Such changes can lead to altered self-concept & lowered self-esteem.
Medical Conditions that can Alter Mobility
Neurological conditions – spinal cord injury, head injury
Degenerative neurological conditions – Myasthenia gravis, Huntington ’ s chorea
Attempt to maintain and/or restore optimal mobility as well as to decrease the hazards assoc. with immobility.
DB & C exercises
Muscle & joint exercises
Frequent repositioning – q 2 hrs
fluid intake/fiber intake
Check activity order
Know client ’ s past medical history & limitations
Baseline vital signs are necessary
Become familiar with assistive devices
Major concern during transfer = Safety of both the client and the nurse
Range of Motion Exercise (ROM)
ROM exercises, in which a body part is moved through a range of motion, are carried out to promote circulation, maintain muscle tone & promote flexibility. In doing this, joint stiffness & debilitating contractures are prevented. Active ROM is range of motion carried out by the patient. It is a form of isotonic exercise & as such, it maintains strength, tone & flexibility. In patients unable to move body parts due to paralysis or extreme illness, ROM is performed by someone else. This is called passive ROM exercise. Passive exercise helps to maintain joint flexibility & prevent stiffness & contractures. Because this type of exercise involves no active movement on the part of the muscles, it does not contribute to muscle tone or strength.
ROM exercises are planned as a regular part of nursing activities. During a bath, for example, the nurse has an excellent opportunity to move the patient ’ s limbs through their full range of motion. The patient is encouraged to exercise actively those muscles that can be used. However, in certain cases, the nurse may need to assist the patient in performing ROM (active assisted ROM), or to perform passive ROM.
The maximum movement that is possible for a joint is it ’ s range of motion.
If a joint is not moved sufficiently it begins to stiffen within 24 hrs & eventually becomes inflexible, flexor muscles contract & pull tight causing contractures or fixed joint flexion.
To prevent joint contractures & muscle atrophy (wasting or decrease in size of a normally developed organ or tissue), exercise must be performed – ROM exercise.
Contracture – abnormal flexion & fixation of joints caused by the disuse, shortening & atrophy of muscle fibers.
Correcting contractures requires intensive therapy over a prolonged period of time, and may be impossible. Prevention is the key.
Two Purposes of ROM
Maintain joint function
Restore joint function
Do not exercise joints beyond the point of resistance or to the point of fatigue or pain
Contraindications to ROM
ROM requires energy & increased circulation, any illness/disorder where increased use of energy or increased circulation is hazardous is contraindicated; puts strain/stress in soft tissues of the joint & bony structures, therefore not done with swollen, inflamed joints.
Perform Exercises in Head to Toe Format
Start with the head and move down, always do bilaterally
Do not grasp the joint directly
Cup the joint gently (prevents pressure)
Do not grasp fingernail or toenail
Important joints – thumb, hip, knee, ankle
Return to correct anatomic position
Move joint through movement 5 times/session
Start at the Neck P&P p. 830 Neck Flexion – look @ the toes Extension – look straight ahead Hyperextension – look up @ ceiling Lateral flexion – look straight ahead, tilt head to shoulder Shoulder Flexion – raise arm forward & overhead Extension – return arm to side of body Abduction – raise arm to side to position above head with palm away from head. Adduction – return arm & bring across chest Internal rotation – elbow flexed, rotate the shoulder by moving arm til thumb is turned inward & toward the back (fingers to the floor) External rotation – elbow flexed, move arm until thumb is upward & lateral to head. (fingers point up) Circumduction – move arm in full circle (arm straight out, move hand as if to draw a circle.
Elbow Elbow Flexion – bend elbow Extension – straighten elbow Hyperextension – bend lower arm back as far as possible Forearm Supination – turn lower hand so palm is up Pronation - turn lower hand so palm is down Wrist Flexion – bend wrist forward Extension – straighten wrist (fingers, wrist & arm in same plane) Hyperextension – bring dorsal surface of hand as far back as possible Abduction (radial flexion) – bring wrist medially towards the thumb Adduction (ulnar flexion) – bend wrist laterally towards 5 th finger
Fingers & Thumb Fingers & thumb Flexion – bend fingers & thumb into palm make a fist Extension – straighten fingers & thumb Hyperextension – bend fingers as far back as possible Abduction – spread fingers apart / extend thumb laterally Adduction – bring fingers together/ thumb back to hand Circumduction – move finger/thumb in circular motion Opposition – touch thumb to each finger of same hand
Hip Hip Flexion – move leg forward (ROM 90-120 deg) Extension – move leg back beside other leg Hyperextension – move leg backwards (ROM 30-50 deg) Abduction – move leg laterally away from body (ROM 30-50 deg) Adduction – move leg back to medial position & beyond if possible (ROM 30-50 deg) Knee Flexion – bring heel toward back of thigh (120-130 deg) Extension – return leg to floor
Ankle Ankle Dorsiflexion – move foot so toes are pointed upward Plantarflexion – move foot so toes are pointed downward Foot Inversion – turn sole of foot medially (ROM 10 deg) Eversion – turn sole of foot laterally (ROM 10 deg) Flexion – curl toes downward (ROM 30-60 deg) Extension – straighten toes (ROM 30-60 deg) Abduction – spread toes apart Adduction – bring toes together
Spine Spine Flexion – when standing – bend forward from the waist Extension – straighten up Hyperextension – bend backward Lateral flexion – bend to the side Rotation – twist from the waist
Types of ROM exercises
Active – exercises the client is able to perform independently.
Passive – exercises performed for the client by someone else.
Active assisted – performed by a client with some assistance – client can move a limb partially through its ROM, but needs help completing the ROM.
In addition to ROM exercises, some immobilized clients may be able to perform muscle-strengthening exercises.
Isotonic – cause muscle contraction & change in muscle length – walking, aerobics, moving arms & legs against light resistance.
Isometric – tightening or tensing of muscles without moving body parts. This increases muscle tension but do not change the length of muscle fibers. Isometric exercises are easily performed by an immobilized patient in bed.
Isotonic and isometric exercises help to prevent muscular atrophy and combat osteoporosis.
Applying Antiembolism Stockings (Elastic) P&P p. 842
Thromobophlebitis – the development of a thrombus or clot along with the inflammation of the vein & may be classified as superficial or deep.
Three elements contribute to the development of a clot.
Hypercoagulability of the bld – clotting disorders, dehydration, pregnancy & 1 st 6 weeks postpartum if the woman was confined to bed, oral contraceptives.
Venous wall damage – local trauma, orthopedic surgeries, major abdominal surgery, varicose veins, arteriosclerosis
Blood stasis – immobility, obesity, pregnancy
Promote venous return by maintaining pressure on superficial veins to prevent venous pooling.
Prevent passive dilation of veins
Application of antiembolism stockings (refer to p. 845 P&P)
A drop in blood pressure that occurs when the client rises from lying to sitting or from sitting to standing. (A decrease in systolic pressure >15 mmHg or decrease diastolic pressure >10 mmHg.)
At risk clients
Prolonged bed red
Measures to minimized Orthostatic Hypotension
Maintain muscle tone
Increase venous return to the heart
Decrease stasis of bld in the lower extremities
ROM/isometric exercises/TED ’ s
Chair – feet flat on floor, footrest if unable to reach floor, knees & hips flexed 90-100 degrees. Buttocks at back of the chair, spine straight, pillows at side to prevent leaning.
High fowlers – same as above, with HOB elevated 45-90 deg. Utilized for clients experiencing difficulty breathing.
Semi fowlers – as above with HOB elevated less than 45 deg.
Orthopneic – sit on side of bed with over bed table across lap, pillow on table, lean forward & rest head & arms on table. Utilized for patients with extreme difficulty breathing – promotes lung expansion.
Therapeutic positions cont.
Lithotomy – supine flex both knees so that feet are close to hips, separate legs, feet in stirrups. Utilized for perineal & vaginal examinations
Trendelenburg – supine, entire bed frame tilted down with head 30 deg below horizontal.
Increase venous return in case of shock
Benefits of Proper Positioning
Maintains body alignment & comfort
Prevents injury to musculoskeletal system, prevents strain
Transferring is a nursing skill that helps the client with restricted mobility attain/maintain mobility & independence.
Benefits of transfers
Maintains & improves joint motion
Relieves pressure on the skin
Improves urinary/respiratory function
Increases social activity
Increased mental stimulation
Transfers - Safety
Safety is a major concern when transferring. Falls are a common hazard. If a patient starts to fall – do not try to stop the fall, instead assist the patient to the floor while protecting the head from injury. This will reduce the risk of patient as well as staff injury.
Complete a thorough nursing assessment before you move the patient to determine if she/he has suffered any injuries.
Prevention of injury is the key, be aware of the client ’ s motor deficit, ability to support their body weight and use effective body mechanics & lifting techniques.
When in doubt regarding the patient ’ s ability- GET ASSISTANCE
Nursing Process - Transfers Assessment Activity orders Client capabilities Planning Decide appropriate transfer technique Explain procedure to the patient Implementation Wash hands Position chair 45 deg angle to bed on clients stronger side Lock bed brakes, lower bed, raise HOB as high as patient tolerates Lower side rail Assist to sitting (lift upper body & swing legs around) Assist with robe & slippers Position feet on floor Take wide stance, bend knees, grasp patient “ 1 2 3 stand ” Pivot to chair
Nursing Process (cont.) Evaluation Of note: Body in alignment, patient comfortable, no injuries Nurse maintains good body alignment Two person lift (same as above) except one nurse is on each side of the patient Never lift under the axilla – can damage nerves Mechanical lifts – enables you to lift heavy patients, or those unable to help. (Use 2 people)
Clients who have been immobile even for a short time may require assistance
A client may require the use of an assistive device to aid in ambulation.
Support a weak extremity
Reduce the load on weight bearing structures; hip, knees
Assisting the patient
Place arm near patient under the arm & at the elbow & grasp pt ’ s hand, synchronize walking with the pt (move inside foot forward at same time as pt ’ s inside foot)
Grasp pt ’ s left hand in nurses ’ left hand & encircle pt ’ s waist with the rt hand & synchronize walking as above
Using a transfer belt (held at the waist from the rear by the belt – helps maintain balance)
Nurse to stand on the pt ’ s weak side. The nurse provides support with his/her leg to the pt ’ s weakened one if necessary. Do not allow the pt. to place their arm around your shoulder.
Walk slowly, even gait, synchronize your steps.
Helps maintain balance by widening the base of support increases a pt ’ s security.
Should be held on stronger side
Should have rubber tip – prevent slipping
Height (from greater trochanter to the floor allowing 15-30 deg of elbow flexion.
Gait – place cane 6-10 inches ahead, move affected leg ahead to cane, place weight on affected leg and cane, move unaffected leg ahead of cane.
Stand from sitting
Cane in hand opposite affected leg, grasp arm of chair & cane in other, push to stand, gain balance
Wide base of support, provides great stability & security. Used for clients who are weak or who has problems with balance.
Patient should have at least one weight bearing leg and arm
Pick up walker is more stable, walker with wheels easier for pt ’ s who have difficulty with lifting or balance, however can roll forward when weight is applied.
Height – upper bar of walker should be slightly below the client ’ s waist with arms flexed 15-30 deg
To stand – walker in front of seat, push up off arms of chair (walker is less stable, chair is lower pt. can push with more force. Hands move to walker one at a time.
To sit – back up to chair, reach back with one arm to arm of chair, then with the other arm and lower to chair.
Gait – walker ahead 6-8 inches, weight on arms. Partial weight on affected leg first.
Wooden or metal staff that reaches from the ground to 11/2 – 2 inches below the axilla. When standing tip of crutch rests 4-6 inches in front & 4-6 inches to side of foot.
Do not rest on top of crutches – pressure on axilla nerves – can lead to paralysis called crutch paralysis (numbness, tingling, muscle weakness)
Crutches (cont.) P&P p.859
3 point gait – able to wt. bear on one foot, full wt. on unaffected leg then on both crutches – begin in tripod position, move crutches & affected leg ahead, move stronger leg forward and repeat.
4 point gait – (most stable crutch walk) weight on both legs and both crutches – muscular weakness, improves balance by providing a wide base of support, lack of coordination, move each independently – rt crutch-lt foot-lt crutch-rt leg