CHAPTER 38

Chapter 38: Activity and Exercise

Page 1

• Copyright: 2023 Elsevier Inc. All Rights Reserved.

Page 2: Introduction

• Physical Activity Benefits:

  • Elevates mood and attitude.

  • Enables physical fitness.

  • Assists in quitting smoking and maintaining a tobacco-free lifestyle.

  • Boosts energy levels.

  • Aids in stress management.

  • Promotes better quality of sleep.

  • Improves self-image and self-confidence.

Page 3: Scientific Knowledge Base (1 of 3)

• Nature of Movement:

  • Body Mechanics: Coordinated efforts of musculoskeletal and nervous systems; critical in patient transfers and ambulation.

  • Alignment and Balance:

    • Body alignment indicates stability of center of gravity.

    • Disease, injury, and physical changes (e.g., age, pregnancy) impact balance.

  • Gravity and Friction:

    • Unsteady patients may fall if center of gravity is disrupted.

    • Friction opposes movement.

Page 4: Scientific Knowledge Base (2 of 3)

• Regulation of Movement:

  • Skeletal System: Involves joints, ligaments, tendons, and cartilage.

  • Skeletal Muscle: Involves muscles for movement and posture.

  • Nervous System:

    • Proprioception: Awareness of body position, movement, and muscle stretch.

    • Proper posture is crucial for balance; controlled by inner ear, cerebellum, and vision.

Page 5: Scientific Knowledge Base (3 of 4)

• Balance and Alignment for Nurses:

  • Nurses must maintain body alignment and posture while caring for patients.

  • Steps to achieve balance:

    • Widen base of support by separating feet.

    • Bring center of gravity closer to support base.

    • Bend knees and maintain back alignment.

    • Avoid twisting the spine and adjust bed height as needed.

Page 6: Scientific Knowledge Base (4 of 4)

• Physical Activity (PA): Movement by skeletal muscles resulting in energy expenditure, including various activities (occupational, sports, etc.).

• Types of Exercises:

  • Isotonic: Involves movement (e.g., walking, swimming).

  • Isometric: Muscle activation without movement (e.g., planks).

  • Resistive: Contraction against resistance.

• Pathological Influences:

  • Conditions such as scoliosis, osteoporosis, spinal cord injury, fractures, and obesity affect mobility and alignment.

Page 7: Nursing Knowledge Base

• Safe Patient Handling and Mobility (SPHM):

  • Means improved assessment, mechanical aid use, and safety procedures for patient movements; crucial for caregiver safety and improving patient outcomes.

• Factors Influencing Activity and Exercise:

  • Developmental changes, patient behavior, lifestyle, environmental issues, and family support.

Page 8: Critical Thinking (1 of 2)

• Clinical Judgment: Key for delivering safe interventions that enhance patient activity levels and fitness.

• Integration of Knowledge: Draw on nursing and allied disciplines to understand physical fitness and its effects on patients.

• Problem-Solving Approach: Use critical thinking to guide clinical judgment in nursing processes.

Page 9: Nursing Process Assessment

Patient’s Perspective

• Evaluate Willingness for Exercise: Check if the patient wants to exercise. Ask them how they feel about doing activities.

• Assess Pain Levels: Find out if they are in pain. This will help you understand what activities they can do comfortably.

• Assess Understanding of Activity Needs: Make sure they know why exercise is important for them. Help them understand what type of activities they need to do for their health.

Readiness for Exercise

• Consider Different Factors: Look at things like the patient’s culture (beliefs and practices), income (how much money they have), and physical health (any medical conditions). These can affect whether they are ready to start exercising.

• Pre-Medicate if Necessary: If certain medications can help with pain before exercise, give them if needed. This makes it easier for the patient to start moving.

Body Alignment

• Observe Alignment During Activities of Daily Living (ADLs): Watch how the patient moves during everyday activities, like getting dressed or walking to the bathroom. Good alignment means the body is in a good position, which helps prevent injury and makes it easier to move. You should look for signs that they are leaning or unbalanced, as this can indicate a need for support or modifications in their activities.

• Readiness for Exercise: Consider cultural, socioeconomic, and physical health factors; pre-medicate if necessary.

• Body Alignment: Observe alignment during activities of daily living (ADLs).

Page 10: Nursing Process Assessment

• Mobility Considerations:

  • Assess Ability to Sit: Observe if the patient can sit down safely without losing balance. Check if they can sit up straight or need assistance. Ask them how comfortable or stable they feel when seated.

  • Assess Ability to Stand: Make sure the patient can stand up from a seated position without help. Look for signs of weakness or unsteadiness. Support them if necessary and ensure they can maintain their balance while standing.

  • Assess Ability to Move: Check if the patient can walk or move around safely. Observe their gait (the way they walk) to identify any stumbling or difficulty. Notice if they need walking aids like a cane or walker to help them. It's important to ensure they feel safe and stable while moving, so always be ready to assist them as needed.

  • When caring for patients, it is important to use assistive devices, like walkers or canes, when needed. These tools can help patients move safely and confidently. Do not just rely on what the patient tells you about their abilities; always check their condition yourself. This way, you can ensure they are safe and comfortable while moving.

  • Observing Range of Motion (ROM) and Gait:When caring for patients, it's important to regularly check how well they can move their joints and how they walk.

    • Range of Motion (ROM): This means watching how far and in what directions a patient's joints can move. For example, when checking the arm, you might ask the patient to lift it straight up, move it side to side, and bend it at the elbow. This helps you see if they have any stiffness or pain in their joints.

    • Gait: This refers to how a person walks. You need to observe if they walk steadily or if they seem wobbly or weak. When checking gait, you can ask the patient to walk a short distance and watch for any signs of unsteadiness or difficulty.

    Assessing Daily Activity Levels:It's also important to understand how active the patient is each day. Are they able to do normal activities like brushing their teeth or making a meal? You can ask them questions about what they do during the day and how they feel when doing those activities.

    Assessing Tolerance to Exercise:Lastly, you should check how well they can handle exercise. This means seeing if they feel too tired or short of breath after light activities. For example, you might ask them to take a few steps after a short rest and see if they are breathing normally or if they seem to struggle.

    By observing and talking with them, you can better understand their physical condition and how to help them stay safe and active.

• Environmental Safety:It's very important to make sure that the area around your patient is safe and clear of anything that could cause them to trip or fall. Hazards are objects or situations that can create risks for injuries. Here are a few guidelines to help ensure environmental safety in a healthcare setting:

  • Clear Walkways: Make sure that hallways and paths are free of clutter, like bags, equipment, or loose cables. This helps patients move around without stumbling over things.

  • Good Lighting: Ensure that areas are well-lit so that patients can see where they are walking. If a room is too dark, they might not see obstacles in their way.

  • Non-Slip Floors: Use mats or treatments on the floors to prevent slipping. If the floor is wet, it’s essential to mark this clearly to warn patients.

  • Assistive Devices: Make sure that any walking aids, like canes or walkers, are available for patients who need them. These devices help provide extra support as they move around.Example: For instance, if a patient is struggling to get out of bed, check if there are any items on the floor next to them, like a pile of clothes or equipment. By removing these items, you can lower the risk of them tripping as they try to stand up or walk.

Page 11: Nursing Process - Analysis and Nursing Diagnosis

• Common Diagnoses:

  • Activity Intolerance

  • Risk for Fall-related Injury

  • Impaired Mobility in Bed and General Mobility

  • Acute or Chronic Pain

Page 12: Nursing Process - Planning and Outcomes

• Outcome Setting: Develop realistic, functional goals.

• Prioritization: Identify immediate patient needs and incorporate teamwork (family, PT, OT).

Page 13: Nursing Process - Implementation

• Maintaining Musculoskeletal Mobility:

  • Reposition immobile patients every 2 hours.

  • Encourage or provide ROM exercises multiple times daily.

  • Use assistive devices when necessary; educate patients about integrating ROM in daily routines.

Page 14: Nursing Process - Implementation: Health Promotion

• Acute Care Focus: Minimize risk of deterioration in bed-bound patients.

  • Importance of Early Mobility: Moving patients early is crucial to help them stay strong, and this is especially important for those who might be spending a lot of time in bed or recovering from surgery. Not moving enough can weaken muscles and lead to problems, which is called deconditioning. To prevent this, encourage patients to start moving as soon as they can.

    Types of Exercises:

    1. Isotonic Exercises: These are exercises that involve moving your muscles and body. They can include activities like walking, cycling, or swimming. These exercises help improve muscle strength and circulation. For example, a simple activity like walking down the hallway can be an isotonic exercise.

    2. Isometric Exercises: These exercises involve tensing your muscles without moving. For instance, when a patient is in bed, they can practice pushing their hands against the bed for a few seconds to strengthen their muscles without moving their body.

    Documenting Distances: Keeping track of how far a patient walks is really important. By measuring the distance, they can walk daily, you can see how they are improving. For example, if a patient walks 50 feet the first day, and then 100 feet a few days later, this shows they are getting stronger. By clearly writing down these distances, you can help ensure everyone knows how the patient is progressing and can adjust their care as needed.

  • types of Exercises:

    • Isotonic: Moving your body (like walking or swimming).

    • Isometric: Tensing muscles without moving (like holding a plank).

    • Resistive: Working against something (like weights).

Page 15: Nursing Process - Walking Assistance

• Guidelines for Helping Patients Walk:

  • Always assess strength, coordination, vital signs, and balance.

  • Use a gait belt properly for support; always assist from the weaker side.

  • Monitor for signs of orthostatic hypotension.

Page 16: Nursing Process - Supporting a Patient Fall

• Strategies for Fall Assistance:

  • Provide a stable base of support.

  • Let the patient slide down your leg to the floor safely, protecting their head.

  • Avoid attempting to catch the patient to prevent injury.

Page 17: Nursing Process - Restorative and Continuing Care

• Assistive Devices for Walking:

  • Walker:
    A walker is a supportive device that helps people keep their balance and move safely. It has four legs to provide stability while walking. The handles of the walker are important because they should be at just the right height to make it easy for the person to use it comfortably. Specifically, the top of the handle should line up with the person's wrist when their arms are at their sides. This position allows the person to hold on securely without having to reach up or bend down, making it easier to walk without falling.
    **Example**: If someone is using a walker but the handles are too low, they might have to bend over to grip it. This can make walking difficult and increase the chance of falling. So, it is essential to adjust the walker to the correct height before use, ensuring it's safe and easy for them to walk with it.

  • Cane: A cane is a helpful tool that supports a person while they walk. It is usually made of sturdy materials and helps with balance. When a person uses a cane, it's important to place it on the stronger side of their body. This means if the person has weakness or trouble on one side, they should hold the cane with the other hand to provide extra support.
    
    **Proper Height**: The height of the cane is crucial for comfort and safety. The cane should be adjusted so that when the person stands up straight with their arm at their side, the top of the cane reaches their wrist. This helps ensure the person can use the cane effectively without having to bend over or stretch too much.
    
    **Example**: For instance, if a patient has a weak leg on the right side, they should hold the cane in their left hand (the stronger side). This way, as they walk, the cane can help support their weight. If the cane is too short, they might have to bend down, which can cause discomfort and might lead to falls. So, making sure the cane is the right height is very important for keeping the patient safe and comfortable while they walk.

Page 18: Nursing Process - Restorative and Continuing Care

• Crutches:

  • Used postoperatively or for disabilities.

  • Maintain 2-3 finger space from the axilla; ensure elbow flexion.

Page 19: Nursing Process: Additional Crutch Training Techniques

• Crutch Movement Guidelines:

  1. Adjusting the Crutches

  Before using crutches, they must be set to the correct height:

  • There should be a 2-3 finger space between the crutch pad and the armpit when standing upright.

    • This prevents nerve damage in the underarm (too much pressure can cause pain or numbness).

  • Elbows should be bent at a 15-30° angle when holding the hand grips.

    • This allows for better control and less strain on the arms.

  💡 Tip: If the crutches are too high, they press into the armpits, causing pain. If they're too low, they don’t provide enough support.

  2. Basic Stance – The Tripod Position

  The tripod position is the starting stance for crutch walking:

  • Stand with both crutches slightly in front of you.

  • Feet should be shoulder-width apart for balance.

  • This keeps weight evenly distributed between the crutches and feet.

  💡 Why is this important?

  • It prevents falling and makes it easier to move forward.

  • Keeps good posture so there’s no extra strain on the back or arms.

• Why Are These Steps Important?

  • Too much pressure on the armpits can damage nerves and cause numbness, tingling, or pain in the arms.

  • Bending the elbows slightly helps absorb shock and prevents wrist/arm pain.

  • Using the correct stance helps with balance and prevents falling.

Why Are These Steps Important?

• Too much pressure on the armpits can damage nerves and cause numbness, tingling, or pain in the arms.

• Bending the elbows slightly helps absorb shock and prevents wrist/arm pain.

• Using the correct stance helps with balance and prevents falling.

Page 20: Nursing Process - Crutch Techniques

• Going Up: Up with the Good

  1. Preparation: Make sure the patient feels stable and can stand securely before starting.

  2. Lead with the Strong Leg: The patient should always step up with their uninjured leg first.

  3. Follow with the Other Leg: After the good leg is on the step, they can bring the injured leg up to the same step.

  4. Use the Handrail: If there is a handrail, encourage the patient to use it for extra support.

  5. Take It Slow: Remind the patient to go slowly and carefully to avoid slips.

  Example:

  If a patient has a right leg injury, they should step up with their left leg first. After that, they can bring their right leg up to the same step. This method helps maintain balance and reduces the risk of falling.

  • Down with the Bad: Step down with the injured leg first.

Page 21: Nursing Process - Restoration of Activity and Chronic Illness

• Stair Guidelines:

  • Going Up: Step up first with the stronger leg.

  • Going Down: Step down first with the weaker leg

Chronic Illnesses That Affect Activity

Some medical conditions make movement more difficult, but exercise can still be beneficial:

1. Coronary Artery Disease (CAD)

• This is when the blood vessels that supply the heart get narrow due to plaque buildup.

• Why does this matter? Less blood flow to the heart can lead to chest pain (angina) or heart attacks.

• How does exercise help?

  • Strengthens the heart and improves blood circulation.

  • Lowers cholesterol and blood pressure, reducing the risk of heart attacks.

  • Patients should start with low-intensity exercises like walking and gradually increase activity.

2. Hypertension (High Blood Pressure)

• High blood pressure puts extra strain on the heart and blood vessels.

• How does exercise help?

  • Helps lower blood pressure naturally.

  • Reduces stress, which can also cause blood pressure to rise.

  • Patients should do moderate aerobic exercises like walking, swimming, or cycling.

  • Avoid sudden, intense activity, which can cause blood pressure spikes.

3. Chronic Obstructive Pulmonary Disease (COPD)

• A lung disease that makes it hard to breathe (includes emphysema and chronic bronchitis).

• Why is this important? Patients may feel short of breath even during simple activities like dressing or walking.

• How does exercise help?

  • Improves lung function over time.

  • Helps patients use oxygen more efficiently.

  • Encourages pursed-lip breathing (breathing out slowly through the mouth to control shortness of breath).

  • Low-impact exercises like walking and breathing exercises are recommended.

4. Diabetes Mellitus

• A disease where the body can’t control blood sugar levels properly.

• How does exercise help?

  • Helps lower blood sugar and improves insulin sensitivity.

  • Reduces the risk of complications like nerve damage, kidney disease, and heart problems.

  • Patients should monitor blood sugar before and after exercise to avoid low blood sugar (hypoglycemia).

Nursing Role in Restoring Activity for These Patients

1. Assess patient limitations – How much activity can they handle safely?

2. Encourage safe, gradual exercise – Start slow and increase as tolerated.

3. Educate about benefits – Many patients fear activity will worsen their condition, but the right exercises can help.

4. Monitor vital signs – Watch for signs of distress like shortness of breath, dizziness, or chest pain.

5. Prevent complications – Encourage proper breathing techniques, blood sugar checks, and slow progression of activity.

Why Is This Important?

• Many people with chronic diseases think they shouldn’t exercise, but movement is one of the best treatments for these conditions.

• Regular physical activity improves quality of life, reduces symptoms, and helps prevent further health problems.

• Nurses play a key role in guiding patients to exercise safely and effectively.

Page 22: Nursing Process - Systemic Benefits

• Exercise Benefits:

  • Reduces age-related ailments and sarcopenia; improves vascular health and insulin sensitivity.

  • Affects blood pressure regulation and inflammatory responses positively.

Page 23: Nursing Process - Cardiovascular Benefits

• Exercise Effect:

  • Increases cardiac output and stroke volume; provides protection from ischemic injuries.

  • Enhances vasoreactivity and endothelial function, improving overall cardiovascular health.

Page 24: Nursing Process - Evaluation

Assessment of Outcomes

• Evaluate Patient Satisfaction: Check how happy and satisfied the patient feels about their care and recovery.

• Measures Against Baseline Data: Look at important health measurements such as heart rate (HR), blood pressure (BP), and respiratory rate (RR) at the start of treatment to see if there have been improvements.

• Compare Actual to Expected Outcomes: Compare the current health status of the patient with what was expected from the treatment to see if the health interventions were effective.

Page 25: Safety Guidelines for Nursing Skills

• Pre-Transfer Considerations:

  • Know patient's mobility level and risks for activity intolerance; mentally prepare steps beforehand.

  • Use proper equipment and ensure placement for safety.