Chapter 38

Activity and Exercise

Scientific Knowledge Base

• Overview of exercise and activity:• Body alignment

• Relationship of one body part to another• Body balance

• Achieved by low center of gravity; enhanced by posture• Coordinated body movement

• A result of weight, center of gravity, and balance

Scientific Knowledge Base (cont’d)

• Overview of exercise and activity:• Friction

• Force that occurs in a direction to oppose movement• Exercise and activity

• A patient’s individualized exercise program depends on the patient’s activity tolerance or the type and amount of exercise or activity that the patient is able to perform.

• Isotonic exercises• Isometric exercises

Case Study

• Mr. Indelicato is a 72-year-old African American who is hospitalized for surgery on his right knee. He relates the problem with his knee to previous sports injuries. He first sought medical advice and treatment 6 years ago.

• He has tried various treatments, including physical therapy, rest, and pain medication. His only preoperative medication is ibuprofen 600 mg every 6 to 8 hours. He and his wife are very active.

Case Study (cont’d)

• Marilyn Sweeney is a 40-year-old nursing student. She has just finished rotating through a general surgical unit and is spending the remaining 6 weeks in the orthopedic/rehabilitation division of the agency. Her assignment is to follow the patient through his surgery and rehabilitation.

• As Marilyn prepares to assess Mr. Indelicato, she reviews anatomy and physiology related to the musculoskeletal system and exercise physiology.

Regulation of Movement

Skeletal system Joints

Ligaments, tendons, cartilage

Skeletal muscle

Muscles concerned

with movement

Muscles concerned

with posture

Muscle groups

Nervous system

Proprioception Balance

Factors Influencing Activity and Exercise

• Developmental changes• Infants through school-aged children• Adolescence• Young to middle adults• Older adults

• Behavioral aspects• Patients are more likely to incorporate an exercise program if those

around them are supportive.

Factors Influencing Activity and Exercise (cont’d)

• Environmental issues• Work site• Schools• Community

• Cultural and ethnic influences• Family and social support

Nursing Process

Assessment Diagnosis Planning Implementation Evaluation

Assessment: Standing

Assessment: Sitting

• Sitting• Head is erect.• Neck and vertebral column are in straight alignment.• Body weight is distributed on the buttocks and thighs.• Thighs are parallel and horizontal.• Feet are supported on the floor.• Forearms are supported on the armrest, in the lap, or on a

table in front of the chair.

Assessment

• Recumbent position• Mobility

• Range of motion• Gait• Exercise

• Activity tolerance

Case Study (cont’d)

• Mr. Indelicato is hesitant to ambulate or use his continuous positive motion machine. He rates his pain as 6 to 7 on a scale of 0 to 10 and is using a patient-controlled analgesia (PCA) pump.

• His degree of knee flexion is now 70 degrees. He is able to ambulate 10 feet with a walker. He further describes his muscle strength in his right leg as feeling weak and tired after walking a short distance.

• Marilyn observes Mr. Indelicato using the walker incorrectly.

Nursing Diagnosis

• Activity intolerance• Ineffective coping• Impaired gas exchange• Risk for injury• Impaired physical mobility• Imbalanced nutrition: more than body requirements• Acute or chronic pain

Planning

• Goals and outcomes• Participates in prescribed physical activity while maintaining

appropriate heart rate, blood pressure, and breathing rate• Verbalizes an understanding of the need to gradually increase

activity based on tolerance and symptoms• Expresses understanding of balancing rest and activity

• Setting priorities• Teamwork and collaboration

Case Study (cont’d)Mr. Indelicato will attain a tolerable level of pain during ambulation.

Mr. Indelicato’s pain will be a 2 to 3 on a scale of 0 to 10 during ambulation.

Mr. Indelicato will gain optimal functioning of the right knee with independent, purposeful movement.

Mr. Indelicato will ambulate 50 to 75 feet with the aid of a walker without reports of increasing fatigue.Mr. Indelicato will gain a minimum of 90-degree flexion in the right knee by the time of discharge.

Mr. Indelicato will demonstrate proper use of a walker while ambulating.

Mr. Indelicato will perform a return demonstration of proper use of a walker.

Implementation

• Health promotion• Teach patients to calculate maximum heart rate.• Body mechanics

• Acute care• Musculoskeletal system• Joint mobility• Walking

• Restorative and continuing care

Controlled Fall

Case Study (cont’d)

• Marilyn wants to help Mr. Indelicato with ambulation and strength training. To implement her plan of care, she:• Encourages Mr. Indelicato to use PCA pump before ambulation• Explains why he should sit in bed and dangle his legs before

standing to ambulate• Establishes realistic increments for Mr. Indelicato to increase

walking distance during ambulation• Talks with him about exercise tolerance

Principles of Transfer and Positioning Techniques

• When moving a patient, knowledge of safe transfer and positioning is crucial.

• Pathological influences on body alignment and mobility:• Congenital defects• Disorders of bones, joints, and muscles• Central nervous system damage• Musculoskeletal trauma

Case Study (cont’d)

• As part of the teaching process, Marilyn consults with a physical therapist on proper use of the walker. She and the physical therapist instruct Mr. Indelicato and family caregivers on the proper use of a walker, and Marilyn provides written material that reinforces these verbal instructions.

Assistive Devices for Walking

• Walkers• Canes• Crutches

• Measuring for crutches• Crutch gait• Sitting in a chair with crutches

Assistive Devices for Walking (cont’d)

Measuring for Crutches

Measuring for Crutches (cont’d)

Crutch Gait

Ascending Stairs

Descending Stairs

Sitting in a Chair

Implementation

• Restoration of activity and chronic illness• Coronary heart disease• Hypertension• Chronic obstructive pulmonary disease• Diabetes mellitus

Evaluation

• Patient outcomes• Reassess the patient for signs of improved activity and exercise

tolerance.• Ask for the patient’s perception of activity and exercise status after

interventions.• Ask if the patient’s expectations are being met.

Case Study (cont’d)

• Marilyn evaluates how effective her plan of care has been. She asks Mr. Indelicato to rate the level of pain from 0 to 10, observes his range of motion and use of the continuous passive motion (CPM) machine, and observes his ambulation with a walker.

• Mr. Indelicato rates his pain as a 3 and is able to perform range of motion (ROM) and use the CPM machine. He has a steady gait with the aid of the walker.

Quick Quiz!

1. A patient with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess

A. Posture.B. Activity tolerance.C. Body mechanics.D. Range of joint motion.

37 - 33

Case Study (cont’d)

• It has been 5 weeks since Marilyn began to care for Mr. Indelicato. Mr Indelicato has progressed steadily to increase both weight bearing and range of joint motion on the affected knee. Mr. Indelicato expected the pain to be completely resolved on hospital discharge and not to follow into physical therapy.

• Marilyn and the physical therapist worked with Mr. Indelicato and his orthopedic surgeon to identify pain control measures.