1. Chapter 38
Activity and Exercise

2. 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

3. 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

4. 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.

5. 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.
Marilyn knows that it is important to assist Mr. Indelicato in prompt immediate postoperative recovery and to engage him in a steady, progressive physical therapy program.

6. 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

7. 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.

8. Factors Influencing Activity and Exercise (cont’d)
Environmental issues
Work site
Schools
Community
Cultural and ethnic influences
Family and social support

9. Nursing Process Assessment Diagnosis Planning Implementation
Evaluation

10. Assessment: Standing

11. 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.

12. Assessment Recumbent position Mobility Activity tolerance
Range of motion
Gait
Exercise
Activity tolerance

13. 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.

14. 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

15. Planning Goals and outcomes Setting priorities
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

16. 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.

17. Implementation Health promotion Acute care
Teach patients to calculate maximum heart rate.
Body mechanics
Acute care
Musculoskeletal system
Joint mobility
Walking
Restorative and continuing care

18. Controlled Fall

19. 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

20. 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

21. 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.

22. Assistive Devices for Walking
Walkers
Canes
Crutches
Measuring for crutches
Crutch gait
Sitting in a chair with crutches

23. Assistive Devices for Walking (cont’d)

24. Measuring for Crutches

25. Measuring for Crutches (cont’d)

26. Crutch Gait

27. Ascending Stairs

28. Descending Stairs

29. Sitting in a Chair

30. Implementation Restoration of activity and chronic illness
Coronary heart disease
Hypertension
Chronic obstructive pulmonary disease
Diabetes mellitus

31. 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.

32. 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.

33. 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.

34. 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.