Chapter 23 Exercise and Activity All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Exercise and Activity Being active is important for physical and mental well-being. Illness, surgery, injury, pain, and aging cause weakness and some activity limits. Inactivity, whether mild or severe: Affects every body system Affects mental well-being Deconditioning is the loss of muscle strength from inactivity. When not active, older persons become deconditioned quickly. Nurses use the nursing process to promote exercise and activity in all persons to the extent possible. The care plan and your assignment sheet include the person’s activity level and needed exercises. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2

Bedrest To help promote exercise and activity, you need to understand: How to prevent complications from bedrest How to help with exercise The person’s care plan and your assignment sheet tell you the activities allowed. Always ask the nurse what bedrest means for each person. Check with the nurse if you have questions about a person’s activity limits. Review Residents with Dementia: Exercise and Activity on p. 388. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3

Bedrest (Cont’d) Generally bedrest is ordered to: Reduce physical activity Reduce pain Encourage rest Regain strength Promote healing These types of bedrest are common: Strict bedrest Bedrest (some ADL [activities of daily living] allowed) Bedrest with commode privileges Bedrest with bathroom privileges (bedrest with BRP) The doctor orders bedrest to treat a health problem. Sometimes bedrest is a nursing measure if the person’s condition changes. Strict bedrest means that everything is done for the person. No activities of daily living (ADL) are allowed. For bedrest, some activities of daily living (ADL) are allowed. Self-feeding, oral hygiene, bathing, shaving, and hair care are often allowed. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4

Complications of Bedrest Complications of bedrest involve every system and include: Pressure ulcers Constipation and fecal impaction Urinary tract infections and renal calculi Blood clots (thrombi) Pneumonia Contractures Muscle atrophy Orthostatic hypotension (postural hypotension) Syncope A contracture is the lack of joint mobility caused by abnormal shortening of a muscle. The contracted muscle is fixed into position, is deformed, and cannot stretch (Fig. 23-1, p. 389). Atrophy is the decrease in size or the wasting away of tissue. Muscle atrophy is a decrease in size or a wasting away of muscle (Fig. 23-2, p. 389). Orthostatic hypotension is abnormally low blood pressure when the person suddenly stands up. Slowly changing positions is key. When a person moves from lying or sitting to a standing position, the blood pressure drops. Syncope (fainting), a brief loss of consciousness, can occur. Review Box 23-1 on p. 390. Review Focus on Communication: Complications of Bedrest on p. 389. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5

Preventing Complications from Bedrest Good nursing care prevents complications from bedrest. The care plan includes: Good alignment Range-of-motion exercises Frequent position changes Supportive devices are often used. Bed-boards Foot-boards Trochanter rolls Hip abduction wedges Hand rolls or hand grips Splints Bed cradles A foot-board is placed so the soles of the feet are flush against it. Foot-boards prevent plantar flexion that can lead to footdrop. In plantar flexion, the foot (plantar) is bent (flexion). Footdrop is when the foot falls down at the ankle (permanent plantar flexion). Foot-boards also keep top linens off the feet and toes. Hip abduction wedges are common after hip replacement surgery. Bed cradles help prevent footdrop and pressure ulcers. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6

Exercise Exercise helps prevent: Contractures Muscle atrophy Other complications of bedrest A trapeze is used for exercises to strengthen arm muscles. The trapeze is also used to move up and turn in bed. Some exercise occurs with ADL and when turning and moving in bed without help. Range-of-motion exercises and ambulation are needed for muscles and joints. The trapeze hangs from an overbed frame (Fig. 23-11 on p. 392). The person grasps the bar with both hands to lift the trunk off the bed. Review Focus on Rehabilitation: Exercise on p. 391. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7

Range-of-Motion Exercises Active range-of-motion (ROM) exercises are done by the person. With passive range-of-motion exercises, someone moves the joints through their range of motion. With active-assistive range-of-motion exercises, the person does the exercises with some help. Persons on bedrest need more frequent ROM exercises. So do those who cannot walk, turn, or transfer themselves because of illness or injury. OBRA and the CMS require an assessment and care planning process focused on a person’s range of motion: preventing loss of ROM, increasing ROM, preventing further loss of ROM. The movement of a joint to the extent possible without causing pain is the range of motion (ROM) of that joint. Range-of-motion exercises involve moving the joints through their complete range of motion. They are usually done at least two times a day. Review Box 23-2 on p. 392. Review Focus on Communication: Range-of-Motion on p. 392. Review Delegation Guidelines: Range-of-Motion on p. 392. Review Promoting Safety and Comfort: Range-of-Motion on p. 392. Review the Performing Range-of-Motion Exercises procedure on pp. 393-394. Review Figures 23-12 through 23-23 on pp. 395-397. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8

Ambulation (the Act of Walking) Some people need help walking. Some become strong enough to walk alone. Others will always need help. After bedrest, activity increases slowly and in steps. To achieve the goal of walking: Contractures and muscle atrophy must be prevented. Proper positioning and exercises are needed during bedrest. Some people are weak and unsteady from bedrest, illness, surgery, or injury. First the person sits on the side of the bed (dangles). Sitting in a bedside chair follows. Next the person walks in the room and then in the hallway. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9

Walking When helping the person to walk: Follow the care plan. Use a gait (transfer) belt if the person is weak or unsteady. The person uses hand rails along the wall. Check the person for orthostatic hypotension. Always check for orthostatic hypotension (p. 390). Regular walking helps prevent deconditioning. Some persons who use wheelchairs can walk with help. Review Focus on Communication: Ambulation on p. 395. Review Delegation Guidelines: Ambulation on p. 396. Review Promoting Safety and Comfort: Ambulation on p. 397. Review the Helping the Person Walk procedure on pp. 397-398. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10

Walking Aids Walking aids support the body. The need may be temporary or permanent. The type ordered depends on: The person’s condition The amount of support needed The type of disability Crutches are used when the person cannot use one leg or when one or both legs need to gain strength. The doctor, nurse, or physical therapist (PT) orders walking aids. Older persons often need walkers or canes for safety. The PT measures the person and teaches the person to use the device. Some persons with permanent leg weakness can use crutches. They usually use forearm crutches (Fig. 23-26 on p. 399) . Underarm crutches extend from the underarm to the ground (Fig. 23-27 on p. 399). All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 11

Safety Measures for Crutches Follow these safety measures when crutches are used: Check the crutch tips. Check crutches for flaws. Tighten all bolts. Street shoes are worn. Clothes must fit well. Practice safety rules to prevent falls. Keep crutches within the person’s reach. Know which crutch gait the person uses. The person learns to crutch walk, use stairs, and sit and stand. Safety is important. The person on crutches is at risk for falls. Practice safety rules to prevent falls (see Chapter 11). Loose clothes and long skirts may get caught between the crutches and underarms. This clothing can hang forward and block the person’s view of the feet and crutch tips. Discuss the crutch gaits: four-point gait (Fig. 23-28 on p. 399), three-point gait (Fig. 23-29 on p. 399) , two-point gait (Fig. 23-30 on p. 400), swing-to gait (Fig. 23-31 on p. 400), and swing-through gait (Fig. 23-32 on p. 400). All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 12

Canes and Walkers Canes are used for weakness on one side of the body. They help provide balance and support. Single-tip and four-point (quad) canes are common. A cane is held on the strong side of the body. A walker is a four-point walking aid. It gives more support than a cane. There are many kinds of walkers. Baskets, pouches, and trays attach to the walker. The person is taught to use a cane or a walker correctly and safely. Four-point canes give more support than single-tip canes, but they are harder to move (Fig. 23-33 on p. 400). The cane tip is about 6 to 10 inches to the side of the foot. It is about 6 to 10 inches in front of the foot on the strong side. The grip is level with the hip. A standard walker offers the most support (Fig. 23-35 on p. 401). Wheeled walkers are common (Fig. 23-36 on p. 401). Rubber tips on the back legs prevent the walker from moving while the person is standing. Some have a braking action when weight is applied to the walker’s back legs. An additional type of walker is a hemi-walker (Fig. 23-37on p. 402). Hemi-walkers are used for persons who have the use of only one arm or hand; for instance, someone who has had a stroke and has a weak side. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13

Braces Braces support weak body parts. They prevent or correct deformities or prevent joint movement. They are applied over the ankle, knee, or back. You need to keep the skin and bony points under braces clean and dry. You need to report redness, signs of skin breakdown, and complaints of pain or discomfort at once. A brace is applied over the ankle, knee, or back. An ankle-foot orthosis (AFO) is placed in the shoe. Then the foot is inserted. The nurse assesses the skin under braces every shift. The care plan tells you when to apply and remove a brace. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 14

Recreational Activities OBRA requires activity programs for residents. A good activity program improves a person’s quality of life. Activities must meet each person’s interests and physical, mental, and psycho-social needs. Activity ideas are always welcome. Residents may share ideas with you or tell you about favorite pastimes. Or you may have ideas. Share these with the health team. They are given to the resident group that plans activities. Some persons need help getting to an activity. Some persons also need help taking part in them. You must assist as needed. Remember, OBRA (the Omnibus Budget Reconciliation Act) also requires that persons be allowed to take part in resident group activities. Review Teamwork and Time Management: Recreational Activities on p. 402. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 15

Quality of Life You assist residents with exercise and activity. You must protect the rights to privacy and personal choice. The person’s body is not exposed. Choices are allowed whenever safe and possible. You can promote activity by Encouraging the person to be as active as possible. Resisting the urge to do things for the person that he or she can safely do alone or with some help. Focusing on the person’s abilities. Telling the person when he or she is doing well or making progress. Telling the person you are proud of what he or she did or tried to do. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 16