ACTIVITY AND
EXERCISE
ACTIVITY AND EXERCISE
Movement is an activity most people take for granted.
The ability to move and be active benefits health status, whereas
immobility presents a threat to one’s physical, mental, and social well-being. This chapter explores nursing responses to individuals with impaired
ability to move.
OVERVIEW OF MOBILITY
Mobility refers
to the ability to engage in activity and free movement which includes walking,
running, sitting, standing, lifting, pushing, pulling, and performing
activities of daily living (ADLs). Mobility is often considered an indicator of
health status because it influences the correct functioning of many body
systems, especially the respiratory, gastrointestinal, and urinary systems.
Mobility enhances muscle tone, increases energy
levels, and is associated with psychological benefits such as independence and
freedom.
Body Alignment
Body alignment refers to the position of body parts in relation to each other. Proper
body alignment (also called posture) results in balance, which is an
individual’s ability to maintain equilibrium. When the body is in good posture,
the center of gravity (the center point of an object’s mass) is evenly
distributed over the foundation points. Good posture promotes balance, reduces
strain and injury to support structures, facilitates respiratory effort,
enhances gastrointestinal processes, and gives an appearance of confidence and
health. A correct postural stance is maintained by a well-functioning
musculoskeletal system. The normal alignment of the spine has a cervical
concavity, a thoracic convexity, and a lumbar concavity; see Figure 34-1.
Proper standing body alignment (as noted
in Figure 34-2)
is characterized by the following:
• Head
upright
• Face
forward
• Shoulders
squared
• Back
straight
• Abdominal
muscles tucked.
• Arms
straight at side
• Hands
palm forward
• Legs
straight
• Feet
forward
The sitting position in proper alignment
has similar characteristics; however, the hips and knees are flexed. Figure
34-3
shows proper alignment and posture for the sitting position. Proper alignment
and posture of the client lying in bed appear similar to the standing position;
however, the client is supine, as shown in Figure 34-4.
The benefits of proper alignment and
posture include
(1) client
comfort;
(2) prevention of
contractures;
(3) promotion of
circulation;
(4) less stress
on muscle, tendons, nerves, and joints; and
(5) prevention of
foot drop (plantar flexion).
In a person standing upright, the center
of gravity is located in the middle of the pelvis about halfway between the
umbilicus and the symphysis pubis. The line of
gravity (vertical line passing through the center of gravity) is shown in
Figures 34-3 and 34-4.
The base of support is the foundation
on which a person or object rests. Stability of one’s balance is promoted by a
steady base of support and a low center of gravity. Muscle tone and bone
strength allow a person to maintain an erect posture. Muscle contour is
affected by the individual’s exercise and activity patterns. Muscle tone is
the normal state of balanced tension present in the body; it allows a muscle to
respond quickly to stimuli. Two aberrations of muscle tone include hypotonicity (flaccidity), which is a
decrease in muscle tone, and spasticity, which is an increase in muscle
tension and is often noted with extreme flexion or extension. Muscle shape
should be symmetrical. There may be hypertrophy (increased muscle size
and shape due to an increase in muscle fibers) or atrophy (a reduction
in muscle size and shape) which manifests as thin, flabby muscles with
indistinct contour; (Figure 34-5).
Atrophy is usually a result of disuse,
whereas hypertrophy occurs when the muscle is overworked.
Body Mechanics
Functional mobility is governed by body
mechanics, the purposeful and coordinated use of body parts and positions
during activity. Use of proper body mechanics maximizes the effectiveness of
the efforts of the musculoskeletal and neurological systems and reduces the
body’s exposure to strain or injury during movement. Proper body mechanics are
as important to the nurse as to the client. The purpose of proper body
mechanics is prevention of strain and injury to the muscles, joints, and
tendons. Range of motion reflects the extent to which a joint can move.
The ranges vary with each joint and are affected by several factors, including
age, physical condition, and heredity. Parameters for range of motion are
outlined in Tables 34-1 and 34-2. The clinical application of body mechanics is
described later in the implementation section of this chapter.
PHYSIOLOGY OF MOBILITY
Mobility is regulated by the
coordinated effort of the musculoskeletal and neurological systems. The major
functions of the musculoskeletal system are to maintain body alignment and to
facilitate mobility. The musculoskeletal system consists of a framework of
bones, muscles, joints, tendons, ligaments, bursae,
and cartilage.
The Musculoskeletal
System
The musculoskeletal system (comprised
of bones, cartilage, joints, tendons, ligaments, bursa, and muscles) serves
several functions as described in Table 34-1.
Bone is the foundation of the
musculoskeletal system. Mobility and weight-bearing capacity are directly
related to the bone’s size and shape. Joints work with muscles to provide
motion and flexibility. Skeletal muscles overlying the joint exert opposing
forces and, therefore, cause movement. Muscles are basically machines that
convert energy into mechanical work. Contractility is the common property among
the three types of muscles: smooth, cardiac, and skeletal. Skeletal muscle
fibers are innervated by somatic nerves, and, therefore are generally under
voluntary control. The muscles work in cooperation with the nervous system to
maintain body alignment and cause movement. Muscles act in pairs to perform
work. One muscle of the pair produces movement in a single direction. The other
muscle of the pair produces movement in the opposite direction. When one muscle
of the pair is contracted, the other is relaxed. The opposing actions of
contraction and relaxation make motion possible. The position of the tendons
upon the bones and the articulation of the bones make possible types of motion
such as flexion, extension, circumduction, rotation,
and gliding. Muscles that maintain body alignment work together to stabilize
surrounding body parts and to support the body’s weight. Posture is maintained
primarily by the muscles in the back, neck, trunk, and lower extremities.
Nervous System
Muscle contraction is controlled by the
central nervous system (CNS) and is influenced by the transport of nutrients
and oxygen and by the removal of waste products. An intact CNS is essential for
coordinated movement to occur. Nerve impulses stimulate the muscles to
contract. The myoneuronal junction is
the point at which nerve endings come into contact with muscle cells. The
afferent pathway conveys information from sensory receptors to the CNS; these
neurons conduct impulses throughout the body. The CNS processes the sensory
input and determines a response. The efferent pathway transmits the desired
response to skeletal muscles via the somatic nervous system. If the nerve
impulses are interrupted, the muscle is paralyzed and cannot contract.
Proprioception
Proprioception is the awareness of posture, movement, and
changes in equilibrium and the knowledge of posi-tion,
weight, and resistance of objects in relation to the body. Nerve endings in
muscles, tendons, and joints (proprioceptors)
continuously provide input to the brain, which, in turn, regulates smooth
coordinated involuntary movement.
Postural Reflexes
Postural tonus is maintained by postural
or righting reflexes. Table 34-2
describes the major reflexes involved in maintaining posture.
EXERCISE
Exercise
is any physical activity involving muscles that elevates the heart rate above
resting levels. Exercise reduces joint pain and stiffness, and increases
flexibility, muscle strength, and endurance. It also helps with weight
reduction and contributes to an improved sense of well-being (National
Institute of Arthritis and Musculoskeletal and Skin Diseases, 1997). Americans
have become less active in recent years (Bray, 1998). The U.S. Surgeon
General’s Report on Physical Health and Activity (Centers for Disease Control and
Prevention, 1999) lists the following facts about exercise:
• People who are usually inactive can improve their health and well-being
by becoming even moderately active on a regular basis.
• Physical activity need not be strenuous to achieve health benefits.
• Greater health benefits can be achieved by increasing the amount
(duration, frequency, or intensity) of physical activity.
Table
20-
Types
of Exercise
There are several types of exercise
that promote physical and psychologic health; see
Table 34-3.
Range-of-Motion
Exercise
Active
range-of-motion (ROM) activities are performed
independently by the client. During active ROM exercises, the client moves
various muscle groups. Passive ROM exercises are done by the nurse to
help maintain or restore a client’s mobility by achieving several outcomes; see
the accompanying display.
Physical
Fitness
The ultimate outcome of regular
physical activity is physical fitness that affects an individual’s functional
ability. There are four components of physical fitness: endurance and strength,
joint flexibility, cardiorespiratory fitness, and
body composition.
Endurance
and Strength
Endurance is the ability to withstand
movement in terms of duration and absence of fatigue. A physically fit
individual has adequate muscular strength and endurance to accomplish one’s
goals. Muscle strength is the amount of force exerted by the muscles against
resistance. Good muscle strength allows an individual to lift more safely.
Joint
Flexibility
The ability to use a muscle through
its complete range of motion is referred to as flexibility; see Table 34-4
for a complete description of joint movement. People with limited
flexibility are likely to experience shortened muscles and tendons with
resultant imbalance in muscle strength and joint injury. Flexibility can be
improved by stretching exercises such as yoga, tai chi, and dancing.
Performance of ADLs also helps maintain flexibility. Walking, stooping, and
lifting activities can promote and maintain flexibility.
Cardiorespiratory
Fitness
Exercises that improve cardiorespiratory fitness are discussed in Table 34-3. To
improve cardiorespiratory function, physical activity
must be maintained for at least 20 minutes in order to raise the heart rate to
the target level.
Body
Composition
The recommended proportion of fat to
lean body tissue is referred to as body composition. Having a body that falls
within the normal range of body weight and percentage of body fat depends on
balancing caloric intake and expenditure. Any type of physical activity can be
useful in developing and maintaining physical fitness; see Table 34-5.
Fitness
in Older Adults
Approximately 33% of those ages 65
and older fall each year (Lamb & Cummings, 2000). “No one is too old to
enjoy the benefits of regular physical activity. Of special interest to older
adults is evidence that muscle-strengthening exercises can reduce the risk of
fall and fracturing bones and improve the ability to live independently”
(Centers for Disease Control & Prevention, 1999, p. 5). The accompanying
display lists benefits of physical exercise in older adults.
FACTORS AFFECTING MOBILITY
Mobility and activity level can be
influenced by many factors, including overall health status, developmental
stage, environment, attitudes, beliefs, and lifestyle.
Health Status
An individual’s general health status will
influence desire for exercise and activity tolerance. Compromised status of any
of the body systems may affect an individual’s mobility and may, in turn, be
affected by a lack of activity. Physical conditioning will also influence
mobility and stamina. Physical factors interfering with mobility or exercise
include fatigue, muscle cramping, dyspnea,
neuromuscular or perceptual deficits, and chest pain. Mental status is often
manifested as changes in mobility or appearance. For instance, a client who
shuffles into the room, slumps down into a chair, and avoids eye contact may be
sending a message of depression through low activity levels, poor posture, and
a flattened affect.
Developmental Stage
An individual’s developmental stage will
affect the parameters of targeted mobility levels. See Table 34-6
for examples of common age-related musculoskeletal trauma.
Children
Developmental norms related to mobility
have been established for the infant and toddler. Childhood development is
monitored through achievement of milestones such as sitting, crawling, walking,
running, and hopping. For infants, the mobility focus is on gross motor
behavior such as posture, head balance, grasping, sitting, creeping, and standing.
Toddlers are more active, with walking, running, jumping, kicking, and
going up and down stairs. Activity and mobility parameters for the toddler
encompass gross and fine motor behaviors, manual dexterity, and exploration
within environmental safety parameters. The preschooler increases
strength and refines skills by walking, running, and jumping. During middle
childhood (from 6 to 12 years of age) children have improved posture and
locomotion abilities and increased muscle efficiency of the extremities and
trunk; these children also have an increase in muscle tissue with a decrease of
fat. For both preschool and middle childhood, activity and mobility
expectations are centered on development of strength, coordination, and
physical capacities.
Adolescents
The adolescent years (approximately
ages 12 to 18) begin with onset of puberty and end with cessation of somatic
growth. Changes are dramatic at this stage, with physical growth and
development of secondary sex characteristics. Activity and mobility landmarks
are development of muscles plus cardiac, respiratory, and metabolic functions
through physical conditioning.
Adults
Adulthood is divided into young, middle,
and elderly age groups.
The young adult has well-developed myoskeletal and nervous systems which ideally function at
peak efficiency.
The middle-aged adult has a gradual
decrease in muscle mass, strength, and agility. The focus of activity and
mobility for both these groups is on maintaining or developing tone, strength,
and coordination of the musculoskeletal system.
Older adults often have progressive changes in the physiological systems. The rate of
bone reabsorption (which affects bone density)
increases with aging. Bone density loss accelerates in postmenopausal females
due to estrogen deficiency. Decreased bone density makes a person more
vulnerable to fractures, kyphosis, and a reduction in
height. Aging also negatively impacts muscles and connective tissue. The
development of muscle atrophy is a gradual process in which muscle fibers deteriorate
and are replaced by fibrous connective tissue. Muscle atrophy is accompanied by
reduced muscle mass, a loss of muscle strength, and a reduction in overall body
mass. The degree of muscle atrophy will be affected by the person’s activity
level. Staying physically active helps prevent disuse muscle atrophy and helps
maximize muscle strength. Cartilage ages better than bone or muscle; however,
some changes occur that do affect joint flexibility.
Aging leads to a loss of water content of hyaline cartilage and a reduction in
the ability of cartilage to regenerate following trauma. Articulating cartilage
may slightly deteriorate as a result of lifetime wear and tear. Aging also
affects the health of intervertebral disks. For
example, the water content of the disks decreases which leads to less vertebral
flexibility. Thinning of the disks causes older individuals to be more
vulnerable to back pain and injury. As a result of the age-related physical
changes, older people often experience some functional alterations in mobility.
Ambulation may be altered as a result of joint inflexibility and decreased
muscle strength; such alterations are noticed as a reduction in step height and
length as demonstrated in a shuffling gait. Vertebral inflexibility and reduced
muscle strength may cause difficulty with client transfers in and out of a
sitting position. The elderly client may need assistance in rising from a
chair, ambulating, or climbing stairs. Table 34-7
provides an overview of age-related effects on mobility.
Aging also affects the cardiovascular and respiratory systems, which directly
affect endurance and stamina. Activity and mobility goals focus on maintenance
of functional status and safety.
Environment
Environment can influence activity level
in several ways. Home environments, for instance, can be considered safe and
“mobility friendly” if they are free of hazards that can disrupt or endanger
mobility and activity (see the accompanying display). Work environments can
also affect mobility; repetitive handwork, such as keystroking
or sewing, can impair mobility and worsen arthritis. A sedentary lifestyle can
lead to muscle atrophy, weakened bones, and a lack of motivation and energy to
engage in physical activity.
Attitudes and Beliefs
Influential factors related to exercise
are one’s attitudes and beliefs, which are greatly affected by culture and
family. Leisure activities provide a clue to the person’s value system.
Individuals who engage in hiking, bicycle riding, or swimming for recreation value
an active lifestyle. On the other hand, individuals who consider work to be the
dominant area of life may view exercise as “a waste of time.” Does the
individual go everywhere in a car, or is walking a part of normal
transportation? Are elevators routinely used instead of climbing stairs?
Activities enjoyed by the individual are less likely to produce fatigue than
are activities that hold no interest for the person. Thus, preferences should
be matched with capabilities when planning an exercise program.
Lifestyle
Modern lifestyles require little physical
activity; thus, few adults in America are naturally fit. The use
of many convenience items (e.g., fast food, remote controls) encourage
little physical exertion. The sedentary lifestyles of many Americans result in
loss of muscle strength, decreased endurance, inadequate cardiorespiratory
function, and obesity. Individuals with active lifestyles value exercise and,
therefore, are more likely to experience its therapeutic outcomes.
PHYSIOLOGICAL EFFECTS OF
MOBILITY AND IMMOBILITY
Maintaining functional mobility and
desired activity levels is important for both psychological and physiological
reasons. Mobility and lack thereof will both affect the various systems of the
body.
Table 34-8 summarizes the major complications
associated with immobility.
Neurological Effects/
Mental Status
As for mental status, mobility and
activity can increase an individual’s energy levels and sense of well-being.
Activity and exercise are excellent means to relieve tension and reduce stress,
which result in better sleep patterns and an enhanced sense of well-being.
Client inactivity and immobility are stressors that can lead to frustration,
lower self-esteem, anxiety, helplessness, depression, general dissatisfaction,
restlessness, unhappiness, and decreased competency self-rating. Immobility
impacts cognitive abilities, affect, lifestyle, and social and family
responsibilities. The fear of falls, pain, and sensory deficits such as visual
problems, fatigue, and weakness are compounding factors that increase
inactivity and immobility.
Cardiovascular Effects
The cardiovascular system reaps many
benefits from mobility and exercise. The heart becomes more efficient as it
adapts to increased demands for oxygen, and cardiac output increases. A healthy
heart muscle leads to a decreased resting heart rate and decreased resting
blood pressure, which mean that the heart does not have to work as hard in an
individual who exercises regularly as it does in an individual who leads a sedentary
lifestyle. Activity increases the oxygen supply to the heart and muscles and
thereby benefits overall health. Immobility increases the workload on the heart
as the supine position increases the volume of blood circulating to the heart.
This fluid shift increases central venous pressure along with left ventricular
diastolic volume and stroke volume, and the cardiac workload increases. The
cardiovascular system is prone to form thrombi, or blood clots, due to
venous stasis related to lack of muscle contractions of the legs and pressure
on veins, especially the popliteal areas (Figure
34-6).
Thrombi are caused by increased
coagulation of the blood due to free calcium from bone demineralization, stasis
of venous blood, and intimal damage to veins (as from
venipuncture). Another cardiovascular problem related
to immobility is orthostatic hypotension, or a decrease in blood
pressure resulting from sudden position changes, caused by decreased vessel
tone. In orthostatic hypotension, the blood pressure parameters drop at least
• Decreased circulating fluid volume
• Decreased autonomic nervous system response
• Blood pooling in lower extremities
These
factors lead to decreased venous return which negatively affects cardiac
output. Thus, the blood pressure is lowered. Orthostatic hypotension is an
indication that the heart is working harder and less efficiently. Clients who
have experienced immobility (such as with bed rest) need to have blood pressure
checked lying down, sitting, then standing. This is done to establish baseline
parameters to assist in determining the presence of postural-related changes in
blood pressure.
Respiratory Effects
The respiratory system response to
activity and mobility is increased intake of oxygen, which results in increased
overall respiratory capacity and an easing in the work of breathing. The
effects of oxygenation to the tissues are enhanced and pooling of secretions in
the bronchioles is less likely. Immobility from sitting or lying limits chest
expansion, which is compounded by the effects of respiratory muscle atrophy and
ineffective cough (Figure 34-7).
Stasis of respiratory secretions can be
worsened by the use of CNS-depressant medications and dehydration, and can lead
to hypostatic pneumonia and atelectasis.
Musculoskeletal Effects
Musculoskeletal responses to activity
are numerous, including stronger and better-defined muscles, stronger bones,
and increased mobility and range of motion of the joints. Exercise can enhance
endurance and tolerance of the muscle groups. Weight-bearing exercises such as
walking (as opposed to swimming) are especially beneficial in preventing
osteoporosis, or loss of strength and minerals in the bones. Decreased physical
mobility results in gross musculoskeletal impairment, especially when muscular
atrophy occurs. Decreased mobilization alters muscle structure by reducing
muscle mass and decreasing muscle cell diameter and the actual number of muscle
cells. Clients experience rapid fatigue, decreased muscle strength and tone,
decreased endurance, decreased mobility of joints, muscle stiffness, joint
contracture, and negative nitrogen balance due to protein catabolism. Loss of
calcium is a response to immobility and indicates an imbalance between bone
formation and breakdown. The lack of pressure (e.g., weight bearing) on bones
triggers calcium loss. Bone demineralization occurs as early as 2 or 3 days
after onset of immobility and may lead to pathological fractures, renal
calculi, and osteoporosis.
Digestive Effects
Digestive responses to activity
include increased appetite and thirst, which indicate that the body’s rate of
processing nutritional intake is increased. Loss of appetite is commonly
related to lack of activity, negative nitrogen balance, and altered elimination
patterns. Negative nitrogen balance occurs when the nitrogen output exceeds
nitrogen intake. The causes of negative nitrogen balance include the increased
need for protein in situations of extensive tissue damage, such as following
surgery, and extended immobility. Extended periods of immobility cause muscle
atrophy or muscle wasting; thus there is a need for extra protein intake to
provide for muscle repair.
Elimination Effects
Elimination patterns are facilitated
by mobility in that retention of wastes is usually prevented and the risk of
constipation is reduced or avoided. The muscles become stronger and more efficient,
thus enhancing the overall efficiency of elimination. Constipation and fecal
impaction are frequent complications of immobility. Variables contributing to
these elimination problems are:
• Lack of activity, which decreases peristalsis
• Lack of privacy
• Inability to sit upright
• Improper diet
• Inadequate fluid intake
• Use of some medications, especially narcotics
Urinary stasis and urinary infections
are related to the recumbent position of the immobile person. Decreased
peristalsis of the ureters leads to stasis of urine,
which is the etiology of urinary calculi (stones) and infection. Bladder
distention occurs due to difficult relaxation of the external sphincter and
decreased intra-abdominal pressure, thus causing overflow incontinence (loss
of bladder control) and infection. The combination of increased urinary
calcium, urinary stasis, and urinary infection leads to calculi formation.
Integumentary Effects
The integumentary
system benefits from activity and exercise in that increased circulation and
blood flow enhance oxygenation of tissues, maintaining the turgor
and luster of the skin and hair. Pressure ulcers are serious problems related
to immobility. Prolonged pressure, shearing force, friction (rubbing), and
moisture lead to tissue ischemia (impaired blood circulation), causing skin
breakdown and decubiti. Moisture in the form of
urine, feces, perspiration, and wound drainage can also lead to skin softening,
which increases decubiti risk. Secondary factors
contributing to pressure sore development are decreased nutrition, decreased
arterial pressure, increased age, and edema. Refer to Chapter 35 for a
discussion of pressure ulcers.
ASSESSMENT
During the assessment phase of the
nursing process, data regarding activity and mobility of the client are
gathered. Assessment data are used to initiate, individualize, plan, evaluate,
and modify care on the basis of the client’s strengths and limitations.
Assessment of mobility status includes a health history and physical
examination.
Health History
Taking a client’s health history is
the first step in determining the mobility needs and concerns of a client.
Basic information about ADL, exercise patterns (type, frequency), lifestyle
(active, sedentary), activity tolerance, and use of medications should be
discussed. If an alteration or recent change in status is noted, then a
detailed health history is in order. The nurse should ask what impact the
mobility impairment has had on the client’s ADL and should have the client
describe the exact nature of the problem (onset, duration, associated factors,
aggravating factors, alleviating factors). The nurse should ask clients about
the use (past and current) of medications, both prescription and over-thecounter, with the explanation that many drugs negatively
affect the musculoskeletal system; see Table 34-9.
It is also important to ask about the
use of calcium supplements and estrogen replacement medication.
Physical Examination
The physical examination of mobility
status typically covers three basic areas: musculoskeletal assessment,
neurological assessment, and functional assessment.
Musculoskeletal
Assessment
The nurse observes musculoskeletal
functioning during every interaction with the client. Specific factors for
objective assessment include the following:
• Body alignment
• Body mechanics
• Posture (sitting and standing)
• Range of motion of joints
• Strength of muscles
• Endurance
• Muscle tone
• Size and contour of joints
• Inspection of the skin
• Palpation of skin, muscles, and joints
Subjective data include assessment of
client’s pain, joint stiffness, muscle cramping, fatigue, weakness, exercise
habits, and environmental variables. Children should be evaluated by comparing
physical development and abilities with normal values for the age. The elderly
should be evaluated on functional abilities, strengths, weaknesses, joint
limitations, and use of assistive devices such as canes or walkers to assist
the client in ADLs. A complete musculoskeletal assessment needs to include data
related to client weakness, stiffness, and pain related to movement. A 0–10
intensity scale can be used to assess these subjective factors. When assessing
weakness, zero represents complete absence of weakness and 10 represents
weakness requiring complete bed rest. For determining stiffness, zero
represents complete absence of stiffness and 10 represents total inflexibility.
See Chapter 32 for directions on using the 1–10 scale for measuring pain
intensity.
Movement and Gait
Gait, the way that one walks, is
assessed to determine a baseline. Normal gait is characterized by a smooth
rhythmic movement of muscles when walking. Step height and length are
symmetrical for each foot and the arms swing freely at each side of the torso
in opposite movement of the legs. Normally, the lower limbs are able to bear
full body weight during standing and ambulation. Gait is described in terms of
smoothness, balance, arm movement, effectiveness, and the length and width of
the step.
Alignment
When assessing body alignment, the
nurse seeks to determine whether the movement results in fatigue, muscle
stress, or strain. Structural deformities may interfere with body alignment and
functional ability; see Table 34-10.
Endurance
When assessing a client’s endurance
during physical activity, look for reactions such as mood changes, indicators
of pain, presence of fatigue, and changes in respiratory and circulatory
status. Oxygen consumption increases during muscle activity, thus, assessment
of vital signs is essential. The time required for vital signs to return to the
normal (baseline) resting values is a significant factor to include in the
assessment of mobility.
Pathological
Alterations
Assessment to determine the presence
of pathological alterations—such as bone disorders, joint impairment, impaired
muscle development, postural abnormalities, musculoskeletal trauma, and
neurological damage— can offer important data for the determination of mobility
limitations. Muscle Impairments Overuse injuries are a common type of musculoskeletal problem,
especially in people who exercise too much and/or incorrectly. Common overuse
injuries are listed in Table 34-11.
Postural Abnormalities
In addition to the postural
abnormalities described in Table 34-11, contractures may also affect body
alignment.
Contractures A contracture develops when the muscle fibers become unable to flex; see
Figure 34-8.
Each muscle has an antagonist that works in
the opposite direction. If a muscle group is not moved for a period of time or
if proper body alignment is not maintained, the stronger muscle will
predominate, causing contracture deformities. Once a contracture occurs, the
only corrective action is surgery to release the fibrous tissue. Prevention of
contractures is a major nursing focus with immobile clients. Nursing
interventions to prevent a muscle contracture include:
• Encouraging clients to be as active as possible
• Performing ROM exercises
• Positioning to maintain proper body alignment
• Repositioning every 2 hours or more often as needed
Musculoskeletal Trauma
Trauma to musculoskeletal tissues can
result in many types of impairments (such as those described in the display on
overuse disorders). Another common type of musculoskeletal trauma is a fracture
(broken bone). The second type of trauma discussed below is surgical
amputation.
Fractures
According to Lamb and Cummings
(2000), hip fractures are the most disabling for older people. Hip fractures
are usually a result of falls and approximately 24% of those with hip fracture
die from complications within 1 year after the injury. Hip fracture
complications result from immobility and include pressure ulcers, pneumonia,
and sepsis from urinary tract infections. When a fracture is suspected, the
nurse should assess the area for mobility, pain, color, temperature, pulse, and
sensation.
Amputation
Any condition in which circulation is
inadequate to maintain cellular function can necessitate amputation. For
example, lower limb amputations are often required as a result of infection,
peripheral vascular disease (PVD), neoplasm, and trauma. Pressure ulcers, if
inadequately treated, can also lead to the loss of a limb. When the decubiti do not heal, infection and gangrene develop.
Gangrene first manifests as a blackened area and is often accompanied by pain.
Lower limb amputation is either above the knee or below the knee; the level of
amputation depends on the extent of the disease process. Below-the-knee
amputation is the most commonly performed type. The goal of the surgery is to
preserve the length of the extremity in order to assist with prosthetic
fitting. Therefore, as much limb as possible is salvaged.
Central Nervous System
Damage
As movement is a result of
coordination between muscles and nerves, an intact central nervous system is
necessary for mobility. Any disruption in the CNS, such as those occurring with
spinal cord injury, can impair mobility. Spinal cord injury can lead to partial
paralysis or complete loss of mobility.
Spinal Cord Injury
There are 15,000 to 20,000 traumatic
spinal cord injuries each year in the United States (Huston, 1998). Damage to
the spinal cord can be a result of hyperextension and/or compression. With
hyperextension, the spinal cord is overstretched, leading to dislocation of the
vertebrae or discs and possible compression of the spinal cord. Hyperextension
can also completely dissect the spinal cord. In a complete spinal cord injury,
voluntary motor activity, sensory function, and proprioception
below the level of the injury are lacking. Compression injuries occur when the
force of impact fractures the vertebrae or ruptures the discs, forcing bony
fragments or discs into the spinal canal. These particles can lacerate or
compress the spinal cord, resulting in paralysis below the level of the injury.
Prevention of spinal cord injuries is a major concern of nurses and may be
addressed through educating the public on safety precautions related to
driving, participation in sports, and leisure activities.
Neurological Assessment
An intact neurological system is
essential for activity and mobility. Objective neurological assessment includes
(1) cranial
nerves,
(2) motor
system,
(3) sensory
system, and
(4) reflexes.
The nurse assesses the motor system
for the following variables:
• Size, strength, and tone of muscles
• Presence of involuntary movements
• Balance
• Gait
• Coordination
• Proprioception
• Fine motor function
• Gross motor function
The sensory system is assessed for
integrity of peripheral nerves, pain, tactile discrimination (fine touch), and
sensation of vibration. Assessment of deep tendon or stretch reflexes focuses
on the biceps, triceps, brachioradialis, quadriceps,
and Achilles reflexes.
Functional Assessment
Functional assessment focuses on the client’s abilities to perform ADL. The client’s
functional status is assessed in terms of the ability to feed, dress, toilet,
move, transfer, and ambulate self independently or with some degree of required
assistance; see Figure 34-9.
Functional assessment data are used
for initial planning, for discharge planning, for planning continuity of care
in a nursing home or private home, and to provide baseline and ongoing data for
rehabilitation. Clients at high-risk for falls include those with prolonged
hospitalization, those taking sedatives or tranquilizers, confused clients, or
those with a history of physical restraint use.
A great majority of falls:
• Occur in the evening
• Occur in the client’s room
• Involve wheelchairs
• Involve unattended clients
• Involve clients with poor footwear
• Occur with poor lighting
• Involve clients with poor vision
• Occur with clients experiencing neuromuscular impairment
Awareness of these risk factors for
falls allows the nurse to prevent many client injuries. The nurse continually
evaluates the client’s strength and endurance during the entire ambulation
process. The Risk Assessment Tool (RAT) for falls was developed to identify
clients at high risk for falls and to individualize care (Brians,
Alexander, Grota, Chen, & Dumas, 1991). See the
accompanying Nursing Checklist for the RAT and Chapter 31 for further
discussion of fall prevention.
NURSING DIAGNOSIS
Nursing diagnoses related to mobility
focus primarily on activity and mobility levels, and the psychosocial impact that
alterations in mobility can have on a client and the client’s family. Common
NANDA nursing diagnoses related to the physical adaptations or risks resulting
from altered mobility include:
• Activity Intolerance related to bed rest and
immobility, generalized weakness, sedentary lifestyle, and imbalance between
oxygen supply and demand; see the Nursing Process Highlight.
• Impaired Physical Mobility related to
intolerance to activity or decreased strength and endurance, pain, perceptual
or cognitive impairment, neuromuscular impairment, musculoskeletal impairment,
and depression or severe anxiety; see the Nursing Process Highlight.
• Risk for Disuse Syndrome per risk factors
of paralysis, mechanical immobilization, prescribed immobilization, and severe
pain
• Self-Care Deficits related to inability to
wash body or body parts, inability to obtain or get to water source, activity
intolerance, decreased strength and endurance, pain, and impaired transfer
ability
• Ineffective Health Maintenance related
to lack of or significant alteration in communication skills (written,
nonverbal)
• Risk for Falls related
to impaired mobility.
Alterations in family and social
processes may also result from immobility and inactivity. Disruption in
activity and mobility leads to impairment of the ability to perform one’s usual
social, vocational, educational, and family roles. There are often changes in
the client’s perception of role.
Disturbed Body Image and Situational Low Self-Esteem can result from:
1. Changes in physical abilities
2. Changes in family responsibilities
3. Lack of knowledge regarding rehabilitation
4. Denial of abilities and strengths
5. Social insecurity
6. Feelings of worthlessness, hopelessness, or depression
PLANNING AND OUTCOME
IDENTIFICATION
In the development of outcomes for
clients with mobility needs, client involvement is essential. Realistic
outcomes can be targeted by considering the client’s
(1) understanding
of mobility status;
(2) values,
thoughts, and concerns regarding mobility problems;
(3) general
health status; and
(4) ability
to solve problems.
The goal of the interdisciplinary
health team during acute hospitalization and rehabilitation is to restore
function, thus maximizing the level of the client’s independence. Maximal
independence includes the ability to function in ADL (eating, dressing,
bathing, and moving). Independence in these activities contributes to selfreliance, self-care, self-determination,
self-direction, and personal control. Personal client variables determining the
maximal level of independence include extent of disability, competence, age,
self-confidence, cognitive ability, knowledge level, and mood state. It is
important to develop short-term goals that encourage clients to gain a sense of
accomplishment. The nurse should recognize and praise the client’s
accomplishments that increase mobility. The level of independence and ability
for performance of ADL is enhanced or inhibited by the physical environment.
Collaboration of the client, family, caregivers, nurses, physical therapists,
and occupational therapists is essential for individualizing the physical
environment to permit optimal activity and mobilization. Adaptive devices, such
as those that follow, enhance independence for personal activities:
• Eating (e.g., plate guards and hand splints to hold utensils)
• Bathing (e.g., shower chairs and long-handled sponges)
• Dressing (e.g., Velcro closures and zipper pulls)
• Toileting (e.g., elevated toilet seats)
• Mobility (e.g., walkers)
Continued practice in self-care
activities with adaptive devices promotes confidence. Interdisciplinary
cooperation can be used to plan modifications for the home for activity and
mobility, especially in the bathroom and kitchen. Physical modifications with
adaptive equipment in home environments maximize client activity and mobility.
Bed Rest
Bed rest is a therapeutic
intervention that achieves several objectives, including the following:
• Provide rest for clients who are exhausted.
• Decrease the body’s oxygen consumption.
• Reduce pain and discomfort.
The planned duration of bed rest
depends on the client’s physical condition and ability to move. Even though
implemented for therapeutic reasons, bed rest can be counterproductive to a
client’s recovery. The inactivity imposed by bed rest causes structural changes
in joints and shortens muscles. Such changes, which may lead to decreased range
of motion and contractures, can occur within 48 hours of bed rest (Lamb &
Cummings, 2000). To prevent such complications, bed rest should be avoided as
much as possible. For clients whose medical condition necessitates bed rest,
range-of-motion exercises must be implemented. When planning care, it is
important to “prevent immobility if possible; approximately 7 days are needed
for the client to regain the function lost during 1 day of bedrest”
(Eliopoulous, 1999, p. 278).
Restorative Nursing
Care
Being able to move about
independently is an important part of the recovery process and can determine
whether the client is cared for at home or in a health care facility.
Environmental evaluation is particularly important, with the focus on ease and
safety of mobility. Promotion of activity through environmental modification
increases the quality of life for the client whether injured, ill, or aging.
Efforts by the client and the rehabilitation team to promote activity and
mobility can be negated quickly by environmental barriers such as stairs and
narrow passageways. Clients who have limited mobility may be at risk for falls.
To decrease the probability of falls at home, client education should focus on
creating a safe environment for ambulation; see Client Teaching Checklist. The
accompanying display lists some assistive devices for clients receiving care in
the home setting. Other types of assistive devices are available to help
clients perform ADL; see Figure 34-10.
Health Promotion and
Fitness
The client’s long-term goals include
the promotion of activity, mobility, and fitness. Therapeutic exercises
maintain flexibility, strength of muscles, range of motion, and energy and
increase endurance and sense of well-being. Health promotion models stress the
importance of cognitive and perceptual factors on exercise participation.
Factors affecting targeted health promotion outcomes include perceived health
status, perceived benefits of exercise, perceived barriers to exercise, and
attitudes toward exercise. Perceived benefits of exercise and exercise
attitudes held by the client have been identified as critical in goal setting
for a program of health promotion and fitness.
IMPLEMENTATION
Interventions for clients with
impaired mobility include meeting psychosocial needs, using body mechanics,
maintaining body alignment, performing ROM exercises, transferring clients,
assisting with ambulation, promoting wellness, using complementary treatment
approaches, and documentation.
Meeting Psychosocial Needs
Nursing interventions for role change due
to deficits in activity and mobility include
(1) fostering
open family communication,
(2) providing
opportunities for family role resumption,
(3) prioritizing
family roles and responsibilities, and
(4) modifying
family roles and responsibilities.
The accompanying Nursing Process Highlight
lists nursing interventions that encourage socialization.
Applying Principles of
Body Mechanics
Often nurses are required to have
physical strength in order to assist clients in achieving mobility. Carrying,
pulling, pushing, or lifting clients and/or equipment are all activities
involved in the delivery of nursing care. Nurses’ implementation
of correct body mechanics help minimize the following:
• Client injury
• Nurse work-related musculoskeletal injury
• Nurse fatigue “Back injury is mainly caused by lifting unreasonable
loads the most stressful tasks involve the transferring of patients (from a bed
to a chair, for example)” (Owen, 1999, p. 76).
The following variables can increase
the risk of nurse injury:
• Client weight
• Client weight-bearing ability
• Client combativeness and unpredictability
• Height of bed • Confined work space
• Wheelchairs without adjustable arms
Educating staff about the use of proper body
mechanics is essential in preventing injury; see Procedure 34-1.
The U.S. Department of Labor Occupational
Safety & Health Administration (OSHA) has implemented new standards for the
prevention of musculoskeletal injuries. OSHA (2000) defines musculoskeletal
disorders (MSDs) as injuries and disorders of the muscles, nerves, tendons,
ligaments, joints, cartilage, and spinal discs. Examples of MSDs include carpal
tunnel syndrome, tendonitis, sciatica, herniated disc, and low back pain.
Work-related MSDs account for more than one-third of all occupational injuries
and illnesses that are serious enough to result in days away from work (OSHA,
2000). MSDs are preventable by educating the workers and modifying the work
environment. The following recommendations are made by OSHA (2000) to prevent
MSDs:
• Adjust
the height of working surfaces to reduce long reaches and awkward postures.
• Reduce
the weight and size of items that workers must lift.
• Provide
mechanical lifting equipment.
Maintaining Body
Alignment: Positioning
Clients cannot always move
independently and reposition themselves in bed. In such instances, nurses must
use proper turning and positioning techniques in order to achieve the following
outcomes:
• Increase client comfort
• Prevent contractures
• Prevent decubiti (pressure sores)
• Make portions of the client’s body accessible for procedures
• Help clients access their environment
Clients who cannot move independently
must be repositioned every 2 hours. Repositioning must be done more often for
clients who are uncomfortable or incontinent, or who have fragile skin, poor
circulation, fragile skin, decreased sensation, poor nutritional status, or
impaired mental status. Nurses need to be aware of three essential concepts
when positioning clients: pressure, friction, and skin shear. A pressure site
is any skin surface area on which the client is lying or sitting. The force of
the pressure can compromise circulation and lead to skin breakdown
and ulceration. Tissue areas over bony prominences are more likely to
experience impaired skin integrity. It is important to always inspect the skin
and tissue areas under increased pressure for signs of irritation (i.e.,
redness). Friction is caused when the skin is dragged across a rough surface
such as bedsheets or stretcher surfaces. Friction
causes heat, which damages the skin and may lead to decreased skin integrity
with resultant infection and/or skin breakdown.
Skin shear is
the result of dragging skin across a hard surface. The force of resistance to
being dragged tears the deep layers of skin which can lead to skin ulceration.
For clients in bed, limit the number of pillows
under the head in order to avoid neck flexion. Arms should be abducted from the
body and straight with slight flexion. Hands should rest comfortably in a flat
position with fingers open. The knees and hips should be aligned; use sandbags
or pillows to prevent external hip rotation. Avoid flexing the knees by the use
of pillows placed behind the knees. Ankles should be flexed at 90 degrees; use
pillows or footboard if necessary. To maintain proper positioning for a client
seated in a chair, be sure the head is straight without bending the neck or
head dangling. The trunk should be upright without bending or curving. Arms and
hands are to be supported on armrests or the tabletop; avoid dangling the arms.
The hands should be in a flat position with the fingers open. Hips and knees
should be flexed. The feet are to be flat on the floor or footrest with the
ankles at a 90 degree angle. If the legs are supported on leg rests and are
straight, keep the ankles flexed at a 90 degree angle. Table 34-12
provides a
description of the most commonly used positions: Fowler’s (elevated head and
trunk), dorsal recumbent (back-lying with slight elevation of head and
shoulders), prone (face down), lateral (side-lying), and Sim’s
(semi-prone). Assisting clients to comfortable therapeutic positions requires
much skill; see Procedure 34-2.
Often
the client is unable to assist in repositioning; in such cases, it is best to
use two or more staff members to reposition the client in order to prevent
injury. Specialized equipment used for client positioning includes pillows,
foam wedges, trochanter rolls, footboards, bed
boards, hand-wrist splints, traction, side rails, restraints, and trapeze bars.
Table 34-13 describes
devices used to help maintain proper positioning 
Hand-wrist splints can facilitate extension of
the wristhand- fingers, prevent contracture, and
reduce spasticity. The goal for splint use is to maintain a functional hand for
the client. Figure 34-13
shows hand-wrist splints. Clients must be taught the correct way
to put on the
device,
as incorrect use of a splint or brace can cause joint damage, stiffness, or
pain. Falls are common types of injuries in hospitals and long-term care
facilities. Side rails, which are placed on the sides of beds and stretchers to
prevent falls, can be raised, lowered, and locked into place; see Figure 34-14.
For clients who are at risk for falls, side rails
should always be used; however, they should not give nurses a sense of
security. Beds must still be place in the lowest position to reduce the force
of a possible fall, should one occur. Also, clients identified as being at-risk
for falls should be closely monitored. Some clients resist the use of side
rails because they feel their independence is altered. It is important that the
nurse teach clients and families the purpose of side rails, focusing on safety
promotion. Note that some health care agencies require signed notification
consenting to the use of raised side rails. Restraints
are protective devices used to limit physical activity or to immobilize a
client or body part. Restraints are used for the following purposes: to protect
the client from falls; to protect a body part; to prevent the client from
interfering with therapies (i.e., pulling out tubes or catheters); and to
reduce the risk of injury to others. See Chapter 31 for a complete discussion
of restraints and the procedure for applying restraints. Traction may be used
to maintain alignment, especially following injury or surgery. There are several
traction techniques, including manual, skin, and skeletal; Figure 34-15
.
See Table 34-14 for a listing of key assessment data
for clients using skeletal and skin traction. In addition to assessing, the
nurse also documents the findings.
Performing
Range-of-Motion Exercises
Range-of-motion exercises are
performed several times a day by placing each joint through its full functional
motion. The purposes of ROM exercises are to maintain full flexibility,
maintain muscle tone and strength, prevent contractures, and improve
circulation. Refer to Procedure 34-3.
Transfer Techniques
Planning plays a major role in safe
effective client transfers; the nurse must determine to what extent the client
is able to help with the transfer. If the client is totally dependent or is
heavy, the nurse will need other staff members to help. Table 34-15
lists potential hazards involved in client transfers with corresponding
nursing interventions to promote safety.
Moving Clients
Prolonged immobility can cause
discomfort, muscle wasting, clot formation, and skin breakdown. Also, the
client who slides down toward the foot of the bed while the head is elevated
can experience reduced lung capacity and impaired respiratory effort. Nurses
often must move clients up in the bed or reposition them. Moving a client may
sometimes be done by one person, but often requires two staff members to ensure
safe transfer; see Procedure 34-4.
Logrolling the Client
Logrolling is a technique for moving a
client whose body must remain in straight alignment. Situations requiring total
alignment of the spine include spinal injury or recovery from spinal surgery.
Logrolling is accomplished by two or three nurses working in a coordinated
fashion; see Procedure 34-5.
Transferring from Bed
to Chair A client may need to be moved from
the bed to a chair, commode, or wheelchair. Procedure 34-6
describes the steps involved in safely assisting a client from bed to chair. This
procedure discusses moving a client to a wheelchair; however, the process is
the same for transferring to a regular chair or bedside commode.
A wheelchair is a means of
transportation for clients unable to support their weight while standing; see
Figure 34-21.
Safety instructions for use of a
wheelchair include the need to keep the wheels locked when not deliberately
moving and to move the footrests out of the way when getting in and out of the
wheelchair; see the previous Nursing Tip for other recommendations for
wheelchair usage.
Transferring from Bed to
Stretcher
Some clients (e.g., those who are too
weak to sit upright, those who are unconscious, or those with injuries
prohibiting the erect position) must lie flat during transfers. In such
situations, a stretcher (gurney) is used to facilitate client transfer.
Stretchers have several safety features, including side rails, safety
belts/straps, and locking wheels. The nurse should caution clients to move
carefully while on the stretcher as it is more narrow
than the bed. Reassure the client that side rails will be used to prevent
falls. Refer to Procedures 34-7 and 34-8 for instructions on moving clients who
need minimal and maximal assistance
Assistive Devices
There are several devices available
for helping with client transfers. Slide boards or transfer boards assist the
bed-wheelchair transfer by bridging the same level space between the bed and
the wheelchair. Note that specialized wheelchairs with removable armrests are
used with slide boards. As the client becomes more independent, the slide board
can be used to transfer from wheelchair to car. Figure 34-27
shows a slide board transfer to a car. Other transfer appliances include
stretchers (gurneys) and hydraulic lifts. The hydraulic (Hoyer, mechanical)
lift is used for moving immobile clients who are obese; see Procedure
34-9.
A client may be transferred to a
chair, wheelchair, bedside commode, stretcher, or scale using a hydraulic lift.
The manufacturer’s equipment instructions should be followed and the weight
limits must not exceed the manufacturer’s specifications. Two staff members are
needed to safely operate a hydraulic lift. Hydraulic lifts are not for use with
clients who have spinal cord injury as spinal alignment is not maintained
during use of the lift.
Assisting with
Ambulation
Client ambulation (assisted or
unassisted walking) is encouraged soon after the onset of illness or surgery to
prevent the complications of immobility. In planning ambulation, the nurse
assesses the client’s strength, endurance, and mobility status. Can the client
walk alone, or is assistance needed? The presence of equipment (e.g., urinary
catheters, IV infusions, drainage tubes) requires assistance; see the Nursing
Checklist. In order to maintain client safety, ambulation must occur in progressive
stages. First the client should be able to tolerate sitting on the bedside and
dangling the feet. The next step is client tolerance of standing at the side of
the bed. Then progressive ambulation can be initiated; see Procedure 34-10.
As ambulation activities are
initiated, it is important to assess the client’s blood pressure, respiratory
rate, pulse, skin color and moisture, and subjective responses. While the
client is walking, observe for signs of exertion, including diaphoresis,
shortness of breath, or weakness. It is also important to assess for the
presence of orthostatic hypotension in order to prevent falls. Depending on the
client’s physical conditioning and the effects of orthostatic hypotension, the
client may need to slowly progress to independent ambulation. Once the activity
is completed, the nurse evaluates the client evaluation focusing on progression
of activity. Continuous evaluation of the client’s strength and endurance is
performed by the nurse.
Preparing the Client to
Walk
One of the best ways to encourage
ambulation is to help the client become and remain as independent as possible
while lying in bed. This includes urging clients to participate in ROM
exercises and perform self-care activities as much as possible. Independent
mobility, the goal of most clients, is the ability to walk, run, sit, and turn
without mechanical or personal aid. Progressive exercises and activities that
promote independent mobility include:
1. Turning. The client can turn in bed using
side rails for stabilization and leverage.
2. Sitting. The client can raise the head of
the bed and lower the height of the bed. Then the client turns to the side of
the bed and swings legs over the side of the bed to assume the dangling
position. Arms held in the tripod position give balance to the sitting
position.
3. Standing. The client dangles for a few
minutes to assure balance and then bears weight with both feet at the side of
the bed. For additional stability and balance, the client can perch on the edge
of the bed for several minutes.
4. Walking. The client assesses strength and
balance while walking, thus allowing a gradual progression of the duration of
walking. Instruct clients to rest by sitting or standing still stabilized with
a guide rail if fatigued.
Client Education
Prior to ambulation, clients who have
been immobile need to be prepared adequately in order to prevent injury.
Listing the therapeutic outcomes of ambulation is one way to teach clients the
importance of ambulation. Clients should also be taught to sit down or use side
rails if dizziness occurs. Teach clients the technique for safe falling in
order to minimize risk of injury; see Figure 34-37.
Clients should be told that if they
begin to feel faint they should fall toward the affected side of the body and
to use the unaffected side to raise self from the floor or chair.
Preambulatory Exercise
Helping immobile clients to prepare
for ambulation includes instruction of preambulatory
exercises in order to strengthen and tone muscles. The quadriceps femoris is the major muscle used for walking, thus, clients
should be directed to gently contract and release the leg muscles several times
a day. Clients who will be walking with the assistance of walkers and crutches
need upper body strength. Instruction in the safe use of ambulatory assistive
devices is also necessary for many clients with impaired mobility.
Assistive Devices
Clients who are unable to ambulate
independently can use devices designed to help them walk safely. Determination
of which device to use is based on the following:
• Upper arm strength
• Endurance (stamina)
• Presence or absence of one-sided weakness
• Weight-bearing ability; see Table 34-16
See Table 34-17
for a comparison of the three most common devices used to assist in
walking: canes, walkers, and crutches.
Canes
A cane is to be used by clients who can
bear weight on both legs but have some weakness in one leg or hip. The straight
(standard) cane is used most often; canes with three or four legs are used with
clients who need more stability than provided by the straight cane. Quad canes
provide more stability but are sometimes more awkward to use than the straight
cane; see Figure 34-38.
Walkers
A walker is a waist-high metal
tubular device with a handgrip and four legs. Some walkers have rubber tips on
all four legs, whereas others have wheels on the two front legs. The advantages
of using a walker include provision of extra support, provision of a sense of
security, and independence. The client first moves the walker forward and then
takes a step while balancing his or her weight on the walker. A walker is used
by clients who need more support than that provided by a cane. Walkers are
available with and without wheels. The walker without wheels provides more
stability but also requires more client stamina in order to lift the walker.
Walkers with wheels are intended for use by clients with limited upper body
strength. The nurse should determine the following for clients using walkers:
1. Amount of weight bearing allowed on lower limb
2. Appropriateness for client’s height
3. Type of walker (pick-up or rolling)
4. With
pick-up walker: client’s ability to grip, lift, and propel the walker forward
5. With rolling walker: client’s ability to grip and propel the walker
forward
When educating clients about the use
of walkers, inform them when transferring from chair or commode they should
back the walker to the toilet seat and use arms of chair or commode to assist
in standing. Teach clients to always use both hands when using a walker to
transfer from standing to sitting; see Figure 34-39.
Crutches
A crutch is a wooden or metal staff
used to increase client mobility. There are two types of crutches: axillary and forearm. The most commonly used type, the axillary crutch, fits under the axilla
with the weight being placed on the handgrips. The forearm crutch, which has
a handgrip and a metal cuff that fits around the arm, is more convenient but
provides less stability than the axillary crutch. To
prevent slipping, crutches have rubber tips, which must be kept dry. If the
tips are worn or loose, they must be replaced. The crutch must be regularly
inspected; if cracks or bends are present, the person’s weight will not be
properly supported. Crutches can be used by clients who are unable to bear any
weight on one leg, clients who can bear partial weight on one leg, as well as
clients who have full weight bearing on both legs. Several gaits are used with
crutches: the four-point gait, three-point gait, two-point gait, and
swing-through gait. The four-point gait for weight bearing with both
legs follows the pattern of right crutch forward, left foot forward, left
crutch forward, then right foot forward. The four-point gait with crutches is
very stable but slow. The two-point gait for weight bearing with both
legs has the pattern of right crutch and left foot forward together, then left
crutch and right foot forward together. The two-point gait requires more
balance but is a faster gait. The three-point gait for weight bearing
with one leg has the pattern of crutches and weak leg forward together, then
weight-bearing leg forward. The swing-through gait has the pattern of
crutches forward, then legs swing forward together. The swing-through gait has
the advantage of speed; however, it requires good balance. See Procedure 34-11
for a description of crutch-walking techniques
.
Wellness Promotion
Wellness promotion emphasizes the need for
physical fitness, which increases well-being, increases sympathetic nervous
system activity, improves cardiovascular functioning, and produces and
maintains weight loss. “Increasing physical activity is
beneficial for all ages and all groups” (Bray, 1998, p. 238). The nurse
should identify activities enjoyed by the client and encourage increased
participation. When planning an exercise program, the following elements should
be considered:
• Health
status (existing medical conditions)
• Physical
condition
• Age
• Preferences
for types of activities
Complementary Treatment Modalities
EVALUATION
Family support for a client with activity
or mobility deficits is a delicate balance between independence and dependence
that is necessary for positive self-esteem and confidence. This healthy balance
can be influenced by the client’s family and friends. Healthy balance is
fostered through support of the client as requested and needed, and through
encouragement and positive acceptance and affection. Family members are often
unaware of the client’s potential to improve. Thus, they give unnecessary
assistance in activities and mobility rather than allow the client to function
independently. The client then becomes resentful because there is a loss of
self-control. Resentment can also occur with the family who has accepted the
heavy responsibilities of caregiving. For the client
who overestimates his or her own cognitive and physical capabilities and energy
level, safety becomes an important issue. Actual long-term activity and
mobility are the foci of evaluation as the client transfers skills and
knowledge from the acute-care hospital or rehabilitation facility to home.
Common areas of concern regarding activity include:
• Mobility
status
• Activities
of daily living capacity
• Use
of appropriate adaptive devices
• Expansion
of client activities
• Use
of activities as a basis for building areas of competence and achievement
There are numerous complementary
modalities that help improve musculoskeletal health; see the accompanying
display. Also, physical activity and relaxation exercises help reduce muscular
tension and improve functional abilities. Measures of
physical assessment, functional assessment, and performance of ADLs are used
for follow-up evaluation of the client’s status for activity and mobility.
Ongoing assessment of the client’s activity and mobility is important because
compliance with home exercise programs may lessen over time after discharge.
When evaluating long-term activity and mobility goal achievement, the nurse
should observe the client in the home setting to note the client’s ability to
function within his or her own environment.
KEY CONCEPTS
• The
nurse must assess the client on an ongoing basis for activity and mobility
during acute hospitalization, rehabilitation, and postdischarge.
• Collaboration
between client, family, and members of the interdisciplinary health care team
is essential for establishing and modifying goals for activity and mobility.
• Nursing
interventions are individualized to maximize activity, mobility, and
independence for the client and family.
• The
nurse should be aware of the home environment and lifestyle of the client.
• Continuity
of care among nurses and the interdisciplinary health care team is facilitated.
• The
family or caregivers should be included in educational sessions regarding
activity and mobility. Practice sessions of activities and mobility by client,
family, and caregivers under the direction of the nurse are essential.
• The
need for adaptive equipment should be assessed and acquisition of equipment
facilitated.
• The
client, family, and caregiver should be provided instructions in many forms:
demonstrations, videos, pamphlets, handouts.
• The
client and family should be informed of community resources to maximize
activity, mobility, and independence.
• The
nurse should be available to assist the client with problem solving after
discharge.