Chapter 039

Activity and Exercise
Copyright 2017, Elsevier Inc. All Rights Reserved.
Chapter 39
Overview of exercise and activity:
Body alignment
Body balance
Relationship of one body part to another
Achieved by low center of gravity; enhanced by

posture
Coordinated body movement
A result of weight, center of gravity, and balance
2
Scientific Knowledge
Base
Overview of exercise and activity:
Friction
Force that occurs in a direction to oppose movement
Exercise and activity
Activity tolerance
Isotonic exercises
Isometric exercises
Resistive isometric exercises
3
Scientific Knowledge Base

(Cont.)
Case Study
Mr. Smith 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.)

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 Mr. Smith through
his surgery and rehabilitation.
As Marilyn prepares to assess Mr. Smith, she

reviews musculoskeletal anatomy and
physiology and exercise physiology.
Regulation of Movement
Muscles
concerned
with
movement
Skeletal
system
Joints
Ligaments,
tendons,
cartilage
Skeletal
muscle
Muscles
concerned
with posture
Muscle
groups
Nervous
system
Proprioception
Balance
of joints
Types
(Cont.)
(Cont.)
9
Principles of Transfer
and Positioning Techniques
When moving a patient, knowledge of safe transfer and

positioning is crucial.
Pathological influences on body alignment mobility, and

activity:
Congenital defects
Disorders of bones, joints, and muscles
Central nervous system damage
Musculoskeletal trauma
Nursing Knowledge Base
Comprehensive safe patient-handling programs
Ergonomics assessment protocol
Patient assessment criteria
Algorithms for patient handling and movement
Special equipment
Back injury resource nurses
After-action reviews
No-lift policy
Safe patient handling
Transfer techniques
10
Developmental changes
Infants through school-age children
Adolescence
Young to middle-age adults
Older adults
Behavioral aspects
Patients are more likely to incorporate an exercise

program if those around them are supportive
11
Factors Influencing
Activity
and Exercise
Factors Influencing Activity
Work site
Schools
Community
Cultural and ethnic influences
Family and social support
and
Exercise (Cont.)
Environmental issues
12
Critical Thinking
Successful critical thinking
Requires a synthesis of knowledge, experience,

information gathered from patients, critical thinking
attitudes, and intellectual and professional standards
Clinical judgments
Require you to anticipate information, analyze the data, and
make decisions regarding patient care
13
Nursing Process
Diagnosi
s
Plannin
g
Implementati
on
Assessme
nt
14
Evaluatio
n
Assessment
Thoroughly assess:
Body alignment and posture with the patient

standing, sitting, or lying down
Normal physiological changes
Deviations related to poor posture, trauma,

muscle damage, or nerve dysfunction
Patients learning needs
Through the patients eyes
Assess patient expectations concerning activity and

exercise
15
Assessment (Cont.)
Head:
erect, midline
Body:
symmetrical
Spine:
straight with
normal curvatures
Abdomen:
Knees:
tucked
slightly flexed
Feet:
pointed forward
and slightly apart
Arms:
at sides
Standing
16
Assessment (Cont.)
Sitting
Head: erect
Neck and vertebral column: in straight alignment
Body weight: distributed on buttocks and thighs
Thighs: parallel and in a horizontal plane
Feet: supported on the floor
Forearms: supported on the armrest, in the lap, or

on a table in front of the chair
17
Assessment (Cont.)
Recumbent position
Vertebrae: in straight alignment without observable

curves
Mobility
Gait
Exercise
Activity tolerance
18
Case Study (Cont.)

Mr. Smith is hesitant to ambulate or use his
continuous positive motion machine. He rates
his pain as 6-7 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 can ambulate 10 feet with a walker. He
describes the muscle in his right leg as feeling
weak and tired after walking a short distance.
Marilyn observes Mr. Smith using the walker

incorrectly.
19
Nursing Diagnosis
Activity intolerance
Ineffective coping
Impaired gas exchange
Risk for injury
Impaired bed mobility
Impaired physical mobility
Acute or chronic pain
20
Planning
Goals and outcomes
Goal: improve or maintain the patients motor function and

independence
Setting priorities
21
Take into account the patients most immediate needs
Teamwork and collaboration
Physical and occupational therapists
Discharge planning
Case Study (Cont.)
22
Mr. Smith will attain a Mr. Smiths pain will be a 2 to

tolerable level of pain 3 on a scale of 0 to 10 during
during ambulation.
ambulation.
Mr. Smith will gain

Mr. Smith will ambulate 50 to
optimal functioning of 75 feet with the aid of a walker
the right knee with
without reports of increasing
independent,
fatigue.
purposeful
Mr. Indelicato will gain a
movement.
minimum of 90-degree flexion
in the right knee by the time of
discharge.
Mr. Smith will
demonstrate proper
use of a walker while
ambulating.
Mr. Smith will perform a return

demonstration of proper use of
a walker.
Implementation
Health promotion
Body mechanics
Acute care
Musculoskeletal system
Joint mobility
Walking
23
Quick Quiz!
24
A. posture.
B. activity tolerance.
C. body mechanics.
D. range of joint motion.
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:
37 - 24
Implementation (Cont.)
Helping a patient to walk
Assess patients ability to walk safely
Evaluate environment for safety
Assist patient to sitting position, dangle patients

legs over the side of the bed 1 to 2 minutes
before standing
Provide support at the waist so the patients center of

gravity remains midline (gait belt)
Restorative and continuing care
Implement strategies to assist patient with ADLs
25
26
Case Study (Cont.)

Marilyn wants to help Mr. Smith with ambulation
and strength training. To implement her plan of
care, she:
Encourages Mr. Smith to use a PCA pump before

ambulation.
Explains why he should sit in bed and dangle his

legs before standing to ambulate.
Establishes realistic increments for Mr. Smith to

increase walking distance during ambulation.
Talks with him about exercise tolerance.
27
Case Study (Cont.)

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. Smith and family caregivers on the
proper use of a walker, and Marilyn provides
written material that reinforces these verbal
instructions.
28
Assistive Devices for Walking

29
The
patient holds the

handgrips on the
upper bars, takes a
step, moves the
walker forward, and
takes another step.
Walkers
Canes
Keep cane on stronger side

of the body
Place cane forward 6 to 10

inches, keeping body
weight on both legs
Weaker leg is moved

forward, divide weight
between cane and stronger
leg
Stronger leg is advanced

past cane; divide weight
between cane and weaker
leg

30
(Cont.)
Crutches
Measuring
for crutches

31
(Cont.)
32
Measuring for Crutches
33
Crutch Gait
34
Crutch Walking on Stairs:

Ascending Stairs
35
Crutch Walking on Stairs:

Descending Stairs
36
Sitting in a Chair with

Crutches
Restoration of activity and chronic illness
Coronary heart disease
Hypertension
Chronic obstructive pulmonary disease
Diabetes mellitus
37
Evaluation
Through the patients eyes
Are the patients expectations being met?
Patient outcomes
Reassess the patient for signs of improved activity and

exercise tolerance.
Make comparisons with baseline measures
Compare actual outcomes with expected outcomes.
38
Case Study (Cont.)

Marilyn evaluates how effective her plan of care
has been. She asks Mr. Smith to rate his 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. Smith rates his pain as a 3 and is able to

perform range of motion (ROM) exercises and
use the CPM machine. He has a steady gait with
the aid of the walker.
39
Case Study (Cont.)

It has been 5 weeks since Marilyn began to care
for Mr. Smith. Mr. Smith has progressed steadily
to increase both weight bearing and range of
joint motion on the affected knee. Mr. Smith
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. Smith and his orthopedic surgeon to identify
pain-control measures.
40

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Activity and Exercise

Copyright 2017, Elsevier Inc. All Rights Reserved.

Overview of exercise and activity:

Relationship of one body part to another

Achieved by low center of gravity; enhanced by

Coordinated body movement

A result of weight, center of gravity, and balance

Overview of exercise and activity:

Force that occurs in a direction to oppose movement

Exercise and activity

Resistive isometric exercises

Scientific Knowledge Base

He has tried various treatments, including

Copyright 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.)

As Marilyn prepares to assess Mr. Smith, she

Copyright 2017, Elsevier Inc. All Rights Reserved.

Copyright 2017, Elsevier Inc. All Rights Reserved.

Copyright 2017, Elsevier Inc. All Rights Reserved.

Copyright 2017, Elsevier Inc. All Rights Reserved.

When moving a patient, knowledge of safe transfer and

Pathological influences on body alignment mobility, and

Disorders of bones, joints, and muscles

Central nervous system damage

Nursing Knowledge Base

Comprehensive safe patient-handling programs

Ergonomics assessment protocol

Patient assessment criteria

Algorithms for patient handling and movement

Back injury resource nurses

Safe patient handling

Copyright 2017, Elsevier Inc. All Rights Reserved.

Infants through school-age children

Young to middle-age adults

Patients are more likely to incorporate an exercise

Factors Influencing Activity

Cultural and ethnic influences

Family and social support

Copyright 2017, Elsevier Inc. All Rights Reserved.

Requires a synthesis of knowledge, experience,

Copyright 2017, Elsevier Inc. All Rights Reserved.

Copyright 2017, Elsevier Inc. All Rights Reserved.

Body alignment and posture with the patient

Normal physiological changes

Deviations related to poor posture, trauma,

Patients learning needs

Through the patients eyes

Assess patient expectations concerning activity and

Copyright 2017, Elsevier Inc. All Rights Reserved.

Copyright 2017, Elsevier Inc. All Rights Reserved.

Neck and vertebral column: in straight alignment

Body weight: distributed on buttocks and thighs

Thighs: parallel and in a horizontal plane

Feet: supported on the floor

Forearms: supported on the armrest, in the lap, or

Copyright 2017, Elsevier Inc. All Rights Reserved.

Vertebrae: in straight alignment without observable

Copyright 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.)

His degree of knee flexion is now 70 degrees.

Marilyn observes Mr. Smith using the walker

Copyright 2017, Elsevier Inc. All Rights Reserved.

Impaired gas exchange

Risk for injury