Chapter 27 Exercise and Activity Copyright © 2012 by Mosby, 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 Mental well-being Deconditioning is the loss of muscle strength from inactivity. Some people are in bed for a long time. Some people are paralyzed. Some disorders worsen over time. They cause decreases in activity. When not active, older persons become deconditioned quickly. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Exercise and Activity (cont’d) Nurses use the nursing process to promote exercise and activity in all persons to the extent possible. To help promote exercise and activity, you need to understand: Bedrest How to prevent complications from bedrest How to help with exercise The person works closely with physical therapy and occupational therapists to improve strength and endurance. The care plan and your assignment sheet include the person’s activity level and needed exercises. Review the Focus on Children and Older Persons: Exercise and Activity Box on p. 492 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Bedrest 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 with 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. It 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. Some ADL are allowed with bedrest such as self-feeding, oral hygiene, bathing, shaving, and hair care. The person’s care plan and your assignment sheet tell you the activities allowed. Always ask the nurse what bedrest means for each person. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Bedrest (cont’d) Complications from bedrest include: Pressure ulcers Constipation and fecal impaction Urinary tract infections and renal calculi (kidney stones) Blood clots (thrombi) Pneumonia (inflammation and infection of the lung) Contractures Atrophy Orthostatic hypotension (postural hypotension) Syncope (fainting) Bedrest and lack of exercise and activity can cause serious complications. Every system is affected. 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. Muscle atrophy is a decrease in size or a wasting away of tissue. Orthostatic hypotension is abnormally low blood pressure when the person suddenly stands up. Box 27-1 on p. 493 in the Textbook lists the measures that prevent orthostatic hypotension. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Bedrest (cont’d) Good nursing care prevents complications from bedrest. Important measures included in the care plan include 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 Review the Focus on Communication: Complications of Bedrest Box on p. 493 in the Textbook. A foot-board is placed so the soles of the feet are flush against it. The feet are in good alignment as when standing. This prevents plantar flexion (a bent foot). Foot-boards also help prevent pressure ulcers by keeping linens off the feet and toes. Trochanter rolls prevent the hips and legs from turning outward (external rotation). Hip abduction wedges keep the hips apart. Hand rolls or hand grips prevent contractures of the thumb, finger, and wrist. Splints keep the elbow, wrists, thumbs, fingers, ankles, and knees in normal position. Bed cradles keep the weight of top linens off the feet and toes. The weight of top linens can cause pressure ulcers and footdrop (permanent plantar flexion). Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Bedrest (cont’d) Exercise helps prevent: Some exercise occurs: Contractures Muscle atrophy Other complications from bedrest Some exercise occurs: With ADL When turning and moving in bed without help A trapeze is used: For exercises to strengthen arm muscles To move up and turn in bed Range-of-motion exercises and ambulation also are needed to exercise muscles and joints. The trapeze hangs from an overbed frame. The person grasps the bar with both hands to lift the trunk off the bed. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Range-of-Motion Exercises Range-of-motion exercises (ROM) involve moving the joints through their complete range of motion. They are usually done at least 2 times a day. Active ROM exercises are done by the person. Passive ROM exercises—someone moves the joints through their range of motion. Active-assistive ROM 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. The movement of a joint to the extent possible without causing pain is the range of motion (ROM) of that joint. Review the contents of Box 27-2 on p. 496 in the Textbook. Review the Focus on Children and Older Persons: Range-of-Motion Exercises Box on p. 496 in the Textbook. Review the Focus on Long-Term Care and Home Care: Range-of-Motion Exercises Box on p. 496 in the Textbook. Review the Focus on Communication: Range-of-Motion Exercises Box on p. 496 in the Textbook. Review the Delegation Guidelines: Range-of-Motion Exercises Box on p. 497 in the Textbook. Review the Promoting Safety and Comfort: Range-of-Motion Exercises Box on p. 497 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Ambulation (Walking) After bedrest, activity increases slowly and in steps. 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. Regular walking helps prevent deconditioning. Use a gait (transfer) belt if the person is weak or unsteady. The person also uses hand rails along the wall. Always check for orthostatic hypotension. Some people are weak and unsteady from bedrest, illness, surgery, or injury. They need help walking. Some become strong enough to walk alone. Others will always need help. To walk, contractures and muscle atrophy must be prevented. Proper positioning and exercises are needed during bedrest. Follow the care plan when helping a person walk. Review the Focus on Communication: Ambulation Box on p. 501 in the Textbook. Review the Delegation Guidelines: Ambulation Box on p. 501 in the Textbook. Review the Promoting Safety and Comfort: Ambulation Box on p. 501 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Ambulation (Walking) (cont’d) Walking aids support the body. The need may be temporary or permanent. The type ordered depends on the: Person’s condition Amount of support needed 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 physical therapist or RN measures and teaches the person to use the device. Some persons with permanent leg weakness can use crutches. They usually use forearm crutches. Underarm crutches extend from the underarm to the ground. See Figures 27-26 and 27-27 on p. 504 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Ambulation (Walking) (cont’d) The person on crutches is at risk for falls. Follow these safety measures: Check the crutch tips. Check crutches for flaws. Tighten all bolts. Make sure the person wears street shoes with flat, non-skid soles. Make sure clothes 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. Replace worn or torn crutch tips. Dry wet tips with a towel or paper towels. Crutch tips must not be worn down, torn, or wet. Check wooden crutches for cracks and metal crutches for bends. Loose clothes may get caught between the crutches and underarms. Loose clothes and long skirts can hang forward and block the person’s view of the feet and crutch tips. Discuss the crutch gaits: four-point gait, three-point gait, two-point gait, swing-to gait, and swing-through gait. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Ambulation (Walking) (cont’d) 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 gives more support than a cane. Wheeled walkers are common. Baskets, pouches, and trays attach to the walker. Four-point canes give more support than single-tip canes. However, they are harder to move. Wheeled walkers have wheels on the front legs and rubber tips on the back legs, which 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. Baskets, pouches, and trays attached to walkers are used for needed items and allow for more independence. They also free the hands to grip the walker. Review the Promoting Safety and Comfort: Walkers Box on p. 506 in the Textbook. The person is taught to use a cane or a walker correctly and safely. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Ambulation (Walking) (cont’d) Braces support weak body parts. They also prevent or correct deformities or prevent joint movement. A brace is applied over the ankle, knee, or back. An ankle-foot orthosis (AFO) is placed in the shoe. You need to: Keep skin and bony points under braces clean and dry. Report redness or signs of skin breakdown at once. Report complaints of pain or discomfort. The care plan tells you when to apply and remove a brace. Metal, plastic, or leather is used for braces. An AFO is common after a stroke. Keeping the skin and bony points under braces clean and dry prevents skin breakdown. The nurse assesses the skin under braces every shift. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.