This chapter reviews two skills and four procedures: promoting early activity and exercise; performing range-of-motion exercises; monitoring patient on continuous passive motion machine; applying graduated compression (elastic) stockings and sequential compression device; assisting with ambulation (without assist devices); and assisting with use of cane, walker, and crutches.
Regular physical activity and exercise contribute to patients’ physical and emotional well-being.
This is a principle that you, as a nurse, should apply in the care of patients in all settings.
Functional decline, the loss of the ability to perform self-care or activities of daily living, may result not only from illness or adverse treatment effects, but also can be the result of deconditioning.
Deconditioning is associated with inactivity and can result in generalized weakness and impaired aerobic capacity within a short period of time.
Deconditioning results in numerous physical changes and is a particular risk for hospitalized patients who spend most of their time in bed, even when they are able to walk.
Nurses can play an important role in increasing the overall activity of hospitalized patients to minimize the effects of deconditioning.
In addition to deconditioning, patients with limited mobility are at risk for developing thromboembolic disease and deep vein thrombosis.
[Review Box 12-1: Risk Factors for Deep Vein Thrombosis with the students.]
The promotion of early mobility and exercise in the inpatient setting, and as a daily therapy for patients in outpatient settings, is basic to competent nursing practice.
[Ask students: what do you think a nurse can do to reduce the hazards of immobility? Discuss: frequent repositioning, deep breathing and coughing exercises, muscle and joint exercises, increased fluid intake, and dietary intake of foods containing fiber are examples of measures that help to reduce the hazards of immobility.]
Older adults are at greater risk for a reduction of muscle mass, strength, and power, and for developing orthostatic hypotension, syncope, confusion, increased risk for fractures, and functional incontinence as a result of decreased mobility from bed rest.
Early mobility and activity reduces impairment in cardiovascular and metabolic functioning, reduces risk for pulmonary complications and development of pressure ulcers, and reduces elimination alterations.
Changes in a patient’s mobility and activity can result from a variety of health problems (e.g., musculoskeletal, cardiovascular, and neurological) and therapeutic reasons (e.g., prescribed bed rest or reduced activity from sedation). Direct nursing measures to maintain and/or restore optimal mobility and decrease the hazards associated with immobility.
It is important to act aggressively and implement early activity and mobility once patients are physiologically stable and able to respond to verbal stimulation.
When caring for patients with reduced mobility, consider that there may be profound psychosocial and developmental effects.
Immobilization often leads to emotional, intellectual, sensory, and sociocultural alterations.
For young and older adults, immobility may alter employment, family role functions, and social interactions. Such changes can lead to altered self-concept, lowered self-esteem, and depression.
Respect patient preferences for degree of active engagement in the care process (e.g., activity and exercise).
Assessing each patient’s expectations concerning activity and exercise and determining his or her perception of what is normal or acceptable is of utmost importance.
[Ask students: do you think all patients will want to exercise? What are some of the reasons why patients might not want to exercise? Discuss: freedom from pain and complacency. If exercising is painful or tiresome for a patient, commitment to the desired interventions may be lacking. It is important to consider that some patients are content with their present physical activity and fitness and do not perceive a need for improvement.]
Patients with pain, nausea, or fatigue will have little motivation to engage in physical activity. Patients who are anxious or afraid of injury will often resist participation.
When assisting with exercises or ambulation, keep in mind that these activities may place patients in positions that can be embarrassing.
Provide a garment that protects a patient’s privacy.
Many cultures emphasize modesty, and patients from these cultures may not participate in treatment measures for fear of being exposed.
A study involving 78 adults admitted to a respiratory unit for diagnostic or preoperative evaluation, who were initially able to walk and not confined to bed rest, found that over a 5-day period their functional capacity had decreased in six areas: upper-limb muscle strength, respiratory muscle strength, lung function, chest wall expansion, exercise tolerance, and spinal and trunk mobility. Longer periods of hospitalization inevitably lead to more severe deconditioning.
Zisberg and colleagues (2015) studied 684 patients (age 70 and older) admitted to a hospital with a nondisabling condition. Two-hundred and eighty-two participants (41.2%) reported functional decline at discharge and 317 (46.3%) at 1 month after discharge. In-hospital low mobility accounts for immediate and 1-month posthospitalization functional decline.
These are potentially modifiable hospitalization risk factors for which exercise programs can be targeted.
Participation by older adults in active physical activities (outdoor—e.g., swimming, biking, jogging, vigorous walking; indoor—exercising, dancing, even hour per day, has been shown to significantly lower (15% to 35%) mortality risks compared with no time in such activities.
This evidence shows that exercise and physical activity can help older adults maintain an active lifestyle, improve quality of life, and prevent injury.
Correct answer: D
Rationale: Pain may reduce a patient’s motivation to perform isometric exercises. Pain relief before attempts at exercise may enhance the patient’s participation; it may be appropriate to medicate the patient 30 to 60 minutes before exercise.
1. Knowledge of proper preparation and use of devices is needed to teach patients to use them safely and correctly.
2. Make sure that patients are rested and not fatigued. Obtain extra personnel to assist; use safety devices and flat, nonskid shoes for a patient.
3. [Ask students: what are some ways to address a patient’s fear of falling?]
4. Use appropriate clinical guidelines (see agency protocols) for advancing a patient’s activity level. Consult with a physical therapist.
5. A patient may need to continue the exercise regimen or use an assistive device at home.
Recently concerted effort has been made in hospitals to increase inpatients’ activity and mobility levels as soon as possible to prevent deconditioning and other complications of immobilization.
The American Association of Critical Care Nurses (2015) now recommends an early progressive mobility protocol for critical care patients (refer to agency policy for protocols used by hospital).
However, when patients are transferred out to general nursing units, early mobility protocols should continue. This is often a challenge because staff nurses on general units often have difficulty routinely ambulating patients, because of overall patient care demands, access to equipment, or unfamiliarity with transfer skills.
Healthy People 2020 goals are based on guidelines that suggest regular physical activity can improve the health and quality of life of Americans of all ages, regardless of the presence of a chronic disease or disability.
As a nurse you may work in outpatient settings with the opportunity to plan health promotion activities.
It is crucial to educate patients and family members about the importance of regular physical activity and exercise and how these activities can be incorporated into daily routines.
Record in the inpatient medical record or clinic record results of patient screening, type of exercise implemented, pre- and postexercise assessments, and patient’s tolerance.
Report to health care provider any signs or symptoms indicative of exercise intolerance.
Range-of-motion exercises are active if a patient is able to move the limb against gravity; active assisted is when a caregiver is needed to assist the patient in moving the limb against gravity; and passive is when the exercises are performed by a caregiver.
In every aspect of activities of daily living (ADLs), encourage patients to be as independent as possible.
As a nurse, encourage and supervise patients to perform active and passive range-of-motion (ROM) exercises.
[Ask students: where can you incorporate active ROM exercises in a patient’s ADLs? Discuss: incorporate passive ROM into bathing and feeding activities.]
[Review with students Table 12-1, Incorporating Active Range-of-Motion Exercises into Activities of Daily Living.]
Correct answer: C
Rationale: Reaching sideways to a bedside table is performing ROM activity without putting more stress on the shoulder.
The task of performing ROM exercises can be delegated to nursing assistive personnel (NAP). Patients with spinal cord or orthopedic trauma usually require ROM exercises performed by professional nurses or physical therapists.
The continuous passive motion (CPM) machine is designed to exercise various joints such as the hip, ankle, knee, shoulder, and wrist.
A recent review of studies involving knee arthroplasty surgery show that the CPM probably improves the ability of a patient to bend the knee slightly but may not improve pain or function.
Although the therapy has been questioned, many nurses still find it being used and must be able to monitor patients safely on the device.
CPM is usually prescribed on the day of surgery or on the first postoperative day, depending on the surgeon’s preference and patient’s condition.
An initial setting is typically 20 to 30 degrees of flexion and full extension at two cycles per minute. The purpose of the CPM machine is to keep a joint mobilized to improve ROM, reduce swelling and ultimately prevent contractures and improve function.
The electronically controlled CPM machine flexes and extends a joint to a prescribed degree and at a set speed as ordered by the health care provider.
Velcro straps secure the extremity.
When the device is turned on, the frame slides slowly back and forth, gently moving the joint through a preset range of motion.
The CPM machine can weigh up to 25 pounds.
Using two hospital personnel to lift the machine reduces the risk for caregiver back strain and prevents risk of damage to a patient’s extremity.
[Discuss why the skill of using the CPM machine cannot be delegated to NAP.]
The development of a deep vein thrombosis (DVT) is a hazard of immobility.
[Ask students: do you know what the risk factors are for deep vein thrombosis? Discuss.]
Common risk factors include conditions that influence the Virchow’s triad: Hypercoagulability (e.g., clotting disorders, fever, dehydration); venous wall abnormalities (e.g., orthopedic surgery, varicose veins, atherosclerosis); blood flow stasis (e.g., immobility, obesity, pregnancy). Three factors (known as Virchow’s triad)—hypercoagulability of the blood, venous wall damage, and blood flow stasis—contribute to development of deep vein thrombosis (DVT).
Signs of DVT include swelling in the affected leg (rarely swelling in both legs); warm, cyanotic skin; and pain in the leg which often starts in the calf and can feel like cramping or a soreness.
If a DVT is suspected, keep the patient calm and quiet in bed, and notify the health care provider.
Prevention, which can include anticoagulant medications, is the best approach for DVTs; however, moving the extremities, wearing compression stockings, and using foot pumps are equally important.
All intermittent compression systems have a simple objective, and that is to squeeze blood from the underlying deep veins, which, assuming that the valves are competent, will be displaced proximally.
On deflation of the cuff, the veins will refill, and due to the intermittent nature of the system will ensure periodic flow of blood through the deep veins, as long as there is a supply.
Compression stockings appear to function more by preventing distension of veins. The reduction of edema and pain of the legs during the course of the day is accomplished while wearing elastic stockings.
Sequential compression devices (SCDs) pump blood into deep veins, thus removing pooled blood and preventing venous stasis. Another venous plexus foot pump promotes circulation by mimicking the natural action of walking.
The combination of stockings and foot compression has been shown to be more effective than stockings alone in both DVT and pulmonary embolism incidence.
[Shown is Figure 12-1: Venous plexus foot pump with bedside controls. (Courtesy Tyco Healthcare Group LP.)]
The nurse initially determines the size of elastic stockings needed and assesses the patient’s lower extremities for any signs and symptoms of DVTs or impaired circulation.
[Ask students: what are the signs of an allergic reaction to elastic? Discuss: redness, itching, irritation.]
The nurse directs the NAP to:
Remove the SCD sleeves before allowing a patient to get out of bed.
Report to the nurse if a patient’s calf appears larger than the other or is red or hot, if the patient complains of calf pain, or if there are signs of allergic reactions to elastic (redness, itching, or irritation).
The benefits of ambulation include maintenance of muscle tone, strength and joint flexibility, as well as function of the respiratory, circulatory, and gastrointestinal systems.
Use a gait belt when you assist a patient with ambulation to increase patient safety and decrease a patient’s fall risk.
When assisting a patient up and out of bed or a chair, there is a risk for orthostatic hypotension.
Orthostatic hypotension or postural hypotension is a drop in blood pressure that occurs when a patient changes from a horizontal to a vertical position.
A drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, and fainting indicates orthostatic hypotension.
Dangling on the side of the bed and making sure legs are touching the floor can minimize orthostatic hypotension by allowing the circulatory system to equilibrate.
After dangling, have the patient stand and if he or she tolerates standing without dizziness, proceed with ambulation.
Use safety precautions before and during ambulation to control for orthostatic hypotension and subsequent falling.
The nurse directs the NAP by:
Instructing them to have a patient dangle following lying in bed and checking patient’s blood pressure before ambulation.
Instructing them to immediately return a patient to the bed or chair if he or she is nauseated, dizzy, pale, or diaphoretic and to report these signs and symptoms to the nurse immediately.
Discussing the importance of applying safe, nonskid shoes/socks and ensuring that the environment is free of clutter and there is no moisture on the floor before ambulating patient.
These devices range from standard canes, which provide balance and minimal physical support, to crutches and walkers, which are used by patients with weight-bearing limitations on one or more of their legs.
[Ask students: what are some devices that aid in ambulation? Discuss: these devices range from standard canes, which provide minimal support, to crutches and walkers, which are often used by patients who are unable to bear complete weight on the lower extremities, or who bear weight on only one lower extremity.]
A licensed physical therapist should be consulted to help choose the proper assistive device, fit the device and instruct the patient on the correct technique.
As a nurse, you will assist patients in using their devices correctly during ambulation. When assisting a patient with an assist device to ambulate, always have a gait belt on the patient and stand slightly behind and off to the side of the patient.
Selection of the appropriate device depends on a patient’s age, diagnosis, muscular coordination, and ease of maneuverability.
Canes help to maintain balance by widening the base of support.
Three types of canes are commonly used. The standard crook cane provides the least support and is used by patients who require only minimal assistance to walk. It has a half-circle handle, which allows it to be hooked over chairs. The tripod cane (pyramid cane) has three legs, and the quad cane has four legs; the additional legs provide a wide base of support. These types of canes are useful for patients with unilateral or partial leg paralysis.
Crutches are used by patients who must transfer more weight to their arms than is possible when canes are used.
Two types of crutches are available: the axillary crutch is frequently used by patients of all ages on a short-term basis. The Lofstrand crutch has a handgrip and a metal band that fits around a patient’s forearm and are useful for patients with a permanent disability such as paraplegia.
Walkers provide a wide base of support and the greatest stability and security during walking. A walker can be used by a patient who is weak, has a weight-bearing limitation on a lower extremity or has problems with balance.
Most walkers have two wheels, which makes them easier to use and require less energy, and safer for patients with balance disorders. Standard walkers require balance to be able to lift the walker up to advance it.
Use of assistive devices may be temporary or permanent.
The nurse directs the NAP by:
Instructing them to have a patient dangle following lying in bed before ambulation.
Instructing them to immediately return a patient to the bed or chair if he or she is nauseated, dizzy, pale, or diaphoretic, and to report these signs and symptoms to the nurse immediately.
Discussing the importance of applying safe, nonskid shoes and ensuring that the environment is free of clutter and there is no moisture on the floor before ambulating patient.
[Ask students: why is it important to record the distance walked?]
Teaching
Instruct patient that exercises such as squeezing a rubber ball, raising and lowering both arms in a slow and rhythmic manner while holding weights, push-ups, and pull-ups help to strengthen the upper extremities.
Teach patients using walkers to examine the frame daily. When inspecting a walker, the patient should observe for signs of bending or deformation of the frame, protruding screws that can scratch, and loose or missing screws that weaken the joints of the frame. Assess handgrips for any cracks or signs of being loose.
Instruct patients that if wearing shoes with varying heel sizes, the crutches need to be adjusted to maintain two to three fingers between the axilla and the crutch.
Instruct patients to use the arms of a chair rather than the walker to give them leverage when getting up from a chair; the walker is likely to tip if used for this purpose.
Blistering or soreness of the hands can result from continual pressure between the hand and the handle of a crutch. Advise patient to release pressure intermittently and to wear gloves or pad the handle to reduce friction.
Pediatric
For rehabilitation of a small child who has not yet learned to walk or who is unsteady, special crutches with three or four legs provide needed stability to allow the child to maintain an upright posture and learn to walk.
Another option for children who are just learning to walk would be front- or rear-rolling walkers.
Home care
Teach patient how to use the ambulation aid on various terrains (e.g., carpet, stairs, rough ground, inclines). Teach him or her how to maneuver around obstacles such as doors and how to use the aid when transferring to and from a chair, toilet, and tub.
Teach family caregivers how to assist and what to observe to ensure that an assistive device is used correctly.
Long-term care
Conduct safety and maintenance checks of ambulation devices on a routine basis.
Perform periodic assessments to ensure that the patient is using the ambulation device properly.
Correct answer: A
Rationale: Removing throw rugs would remove an obstacle that the patient could trip over. Elderly patients are at risk for falls, and throw rugs are a hazard. The other items listed are not necessarily hazards for the patient.
