Activity, Mobility and Exercise

BODY MECHANICS
 efficient, coordinated, and safe use of the body to produce motion and maintain balance
during the activity. It prevents injury to self and clients.

PRINCIPLES OF BODY MECHANICS

1. Balance is maintained, and muscle strain is avoided as long as the line of gravity passes
through the base of support
 Start body movement with proper alignment.
 Stand as close as possible to the object to be moved.
 Avoid stretching, reaching and twisting.

1. The wider the base of support and the lower the center of gravity, the greater the
stability. Before moving objects put your feet apart, flex the hips, knees and ankles.

2. Balance is maintained with minimal effort when the base of support is enlarged in the
direction in which the movement will occur.
 when pushing an object, enlarge the base of support by moving the front foot forward.
 when pulling an object, enlarge the base of support by either moving the rear leg back if
facing the object or moving the front foot forward if facing away from the object.
3. Objects that are close to the center of gravity are moved with least effort.

4. The greater the preparatory isometric tensing or contraction of muscles before moving an
object, the less energy required to move it and the less musculoskeletal strain injury.

5. The synchronized use of as many large muscle groups as possible during an activity
increases overall strength and prevents muscle fatigue and injury.

6. The closer the line of gravity to the center of the base of support the greater its stability.
 When moving or carrying objects, hold them as close as possible to the center of
gravity.
 Pull an object toward self whenever possible rather than pushing it away

7. The greater the friction against the surface beneath an object, the greater the force
required to move the object. Provide a firm, smooth, dry bed foundation when moving the
client.

8. Pulling creates less friction than pushing.

9. The heavier an object, the greater the force needed to move an object.
 encourage the client to assist as much as possible by pushing or pulling.
 use own body weight to counteract the weight of the object.
  obtain the assistance of other persons or use mechanical devices to move objects that
are too heavy.

10. Moving an object along a level surface requires less energy than moving an object up an
inclined surface or lifting it against the force of gravity.

11. Continuous muscle exertion can result in muscle strain and injury. Alternate rest periods
with periods of muscle use to help prevent fatigue.

PHYSIOLOGIC RESPONSES TO IMMOBILITY

 Decrease in muscle strength
 Muscle atrophy
 Disuse osteoporosis
 Fibrosis and ankylosis
 Contracture

PATHOGENESIS OF PRESSURE ULCERS

 also known as Pressure sores, decubitus ulcers, bedsores or distortion sores

 reddened areas, sore or ulcers of the skin occurring over bony prominences
 occurs due to interruption of the blood circulation to the tissue

CAUSES OF PRESSURE SORES

1. Pressure
 primary cause; perpendicular force exerted on the skin by gravity
2. Friction
 parallel force acting on the skin
3. Shearing Force
 combination of friction and pressure
STAGES OF PRESSURE ULCERS

Stage I Pressure Ulcers

 Change in color, consistency, or temperature
of the skin. Possibly only detected by tactile
exam.
 Skin is intact and the underlying tissues are
unaffected.
 Warning sign: Interventions are preventative
of future skin issues.

Stage II Pressure Ulcers

 Involvement of epidermal layer of skin, and
may extend to dermis
 May appear as shallow, open areas or intact
serum-filled or serosanguineous blisters.
 Break of skin integrity
 Often requires serous drainage and localized
dermatologic issues

Stage III Pressure Ulcers

 Extend into the subcutaneous tissue but
there is no involvement of bone, muscle, and
fascia (may be visible)
 If Stage II in appearance but with necrotic
slough in the ulcer
 May involve tunneling and undermining
Stage IV Pressure Ulcers
 Extend into the subcutaneous tissue with
involvement of bone, muscle, and fascia

Unstageable Pressure Ulcers

 If unable to visualize bottom of ulcer due to
covering by thick necrotic tissue or scabbing,
staging is not possible
 Only can stage with debridement

Unstageable Pressure Ulcers

 Surface appears as Stage I or II pressure
ulcer, but there is severe damage to
underlying tissues is severe, with possible
internal necrosis.
 Most common at interface between bone and
soft tissue
 Surface skin can quickly advance to stage II
or IV
High suspicion with large ulcers and low Braden
scores

Areas Commonly Affected by Pressure Ulcers

Areas where the bones are lying superficial to the skin such as
1. Temporal region of the skull
2. Back of the head
3. Shoulder blades
4. Elbows
5. Vertebral column
6. Sacrum
7. Ischial tuberosities
8. Femoral trochanters
9. Lateral and medial malleolus
10. Heels
11. Toes

Vulnerable Groups
 1. Patient with spinal cord injuries
2. Unconsciousness/ coma patients
3. Diabetes due to poor wound healing
4. Patients with orthopedic surgery
5. Intensive care unit patients/ stroke patients/ patients with mechanical ventilators
6. Elderly patients especially those suffering from dementia
7. Malnutrition
8. History of previous ulceration
9. Incontinence
10. Paralyzed

PREVENTING AND TREATING PRESSURE SORES

 Early identification of individual who are susceptible or at risk, using the risk assessment
tool within 6 hours of admission, reassessment should be done weekly.
 Skin inspection should occur regularly.
 During bath, avoid force & friction on the skin, use mild soap, minimize irritation.
 Minimize skin dryness by avoiding cold& low humidity, apply moisturizes after bath
 Keep the skin clean& dry always, free from irritation of urine feces, sweat or incomplete
dryness after bath., use barrier creams when necessary.
 Provide the client with smooth, firm, creases & wrinkle free bed on which to sit or lie.
 Position, transfer & turn clients correctly. Avoid dragging in bed, use a lifting device e. g.
a trapeze.
 Risk level, level of tissue tolerance, medical or physical conditions, comfort level
 Repositioning, even if slight, at least every 2hrs for bed bound persons, chair-bound
persons every hour. A written repositioning schedule should be used. Six (6) positions
can be used. Prone, supine, right &left lateral, right & left sim’s positions.
 Teach chair-bound clients who are able to shift weight every 15minutes.
 Use pressure reducing devices e. g. pillows, air rings, heel protector, foam mattress,
waterbed.
 Give adequate nourishing diet, give nutritional supplements to nutritionally compromised
clients, monitor weight & nutritional status.
 Institute a rehabilitation program to maintain or improve mobility/activity status.
 Encourage active & passive exercises while in bed.
 Avoid massage of bony prominences.
 Monitor and document interventions and outcomes.
 Massage over pressure areas should be avoided, Traditionally, nurses’ massage to
stimulate blood circulation with the intention of preventing pressure ulcer. However,
scientific evidence does not support this belief, vigorous massage may lead to deep
tissue trauma.
 Baby powder & cornstarch are never used as friction or moisture prevention, powders
create harmful abrasive grit damaging to tissues and are considered a respiratory
hazard.
  Avoid the use of petroleum-based creams & ointment as barrier creams as they cause
poor skin protection. Dimethicone based creams, or alcohol-free barrier films in liquid,
spray or moist wipes are better.

TYPES OF EXERCISES

Active ROM

 Active ROM (AROM) is movement of a segment within the unrestricted ROM that is
produced by active contraction of the muscles crossing that joint.
 Done by the patient himself/herself.

Passive ROM

 Passive ROM (PROM) is movement of a segment within the unrestricted ROM that is
produced entirely by an external force; there is little to no voluntary muscle contraction.
 The external force may be from gravity, a machine, another individual, or another part
of the individual’s own body.
 PROM and passive stretching are not synonymous.

Active-Resistive ROM
 Done by the client against a weight or force
Active Assistive ROM
 Active-assistive ROM (A-AROM) is a type of AROM in which assistance is provided
manually or mechanically by an outside force because the prime mover muscles need
assistance to complete the motion.
Isotonic Exercise
 Involves change in muscle strength and tension (running, walking)
Isometric Exercise
 Involves change in muscle tension only (Kegel’s exercise)

COMFORT, REST AND SLEEP

Pain
 Pain is a highly unpleasant and very personal sensation that cannot be shared with
others.
 One of the most complex human experiences; an individual phenomenon influenced by
the interaction of affective, behavioral, cognitive, and physiologic-sensory factors.

Nociceptors
 Sensory pain receptors are free nerve endings in the tissue that respond to tissue-
injuring stimuli (noxious stimuli).
  Receptors that respond to noxious temperature changes(thermoreceptors),
chemicals(chemoreceptor), or pressure (mechanical receptors) transmit the pain if the
noxious stimuli are sufficiently strong.
 Found in the skin, blood vessels, subcutaneous tissue, muscle, fascia, periosteum,
viscera, joints and other structures.
 Nociceptors are located on two types of peripheral nerve cells that are responsible for
transmitting pain from the tissues to the central nervous system.

2 Types of peripheral nerve cells:

1. A – delta fibers – give rise to the bright sharp localized pain that is immediately associated
with injury. (1st pain)
2. C – fibers – cause a second pain sensation that is dull, poorly localized, and persistent after
injury.

Origins & Causes of Pain

1. Cutaneous pain – Originates in the skin or subcutaneous tissue.
e.g., paper cut causing a sharp pain.
2. Deep Somatic pain – arises from ligaments, tendons, bones, blood vessels, and nerves.
It is diffuse and tends to last longer than cutaneous pain.
e.g., ankle sprain
3. Visceral pain – results from stimulation of pain receptors in the abdominal cavity,
cranium, and thorax. Tends to appear diffuse and often feels like deep somatic pain,
that is burning, aching or feeling of pressure.
e.g., ischemia, or muscle spasms.

Types of Pain
1. Acute Pain – may have a sudden or slow onset; it varies from mild to severe, and may
last up to 6 mos and subsides as healing takes place.
 It reflects potential and present tissue damage.
2. Chronic Pain – 6 months or longer and often limits normal functioning.
 usually increases at night.

Concepts Associated with Pain

 Pain Threshold – is the amount of pain stimulation a person requires in order to feel
pain.
 Pain Reaction – ANS & behavioral response to pain; it protects the individual from
further harm. (automatic withdrawal of hand from hot stove)
 Pain tolerance – is the maximum amount & duration of pain that an individual is
willing to endure; influenced by psychologic & socio cultural factor; appears to increase
with age.

Pain Assessment
 An accurate assessment focusing on pain’s cause is essential for determining the proper
therapy. The nurse must obtain a pain history, physical examination that focuses on the
client’s physiologic & behavioral responses to pain.
 Data that should be obtained on Pain Hx
A. Location – “Where is the pain located?”
  This can be measured objectively by using a drawing of a body outline.
B. Intensity - “What is the magnitude or intensity (level) of the pain?”
 Pain intensity is measured with the use of scale
C. Quality – Descriptive adjectives help people to communicate the quality of pain.
 e.g. Hammer like, piercing like a knife
D. Pattern – it includes time of onset, duration, and persistence of or intervals without
pain.
 “when the pain began (onset), how long the pain lasts, if recurrent-the
length of interval without pain; when the pain last occurred.
E. Precipitating factors - activities that sometime precede pain.
F. Alleviating Factors – this will include the analgesics taken, rest, and application of
heat or cold.

Physical Examination
 This will determine the client’s physiologic and behavioral responses to pain.
 The nurse needs to assess the client’s vital signs and observes the skin color, skin
dryness, diaphoresis, facial expression, and body gestures.

1. Physiologic Response -this may vary according to whether the pain is acute or
chronic.
 Acute pain stimulates the sympathetic nervous system, resulting in
increased BP, PR, RR, pallor, diaphoresis, and pupil dilation.
 Chronic pain or visceral pain – parasympathetic stimulation may be
observed: lowered BP, decreased PR, pupil constriction & warm dry skin.
2. Affective Responses - Vary according to the situation, degree & duration of pain.
 The nurse needs to explore the clients feeling (anxiety, fear, exhaustion,
depression)
 People with chronic pain become depressed & tends to be suicidal.
3. Behavior Responses –The very young, aphasic and confused or disoriented persons
often communicate their experience of pain only non-verbally.
 Facial expression is often the first indication of pain.
 (clenched teeth, tightly shut eye, open somber eyes, lip biting & other
facial grimaces)
 Immobilization of the body part, muscle guarding.
 Rhythmic body movement – rubbing of affected body part.
 Speech & vocal pitch –Rapid speech & elevated pitch often reflect anxiety;
slow speech & monotonous tone can signal intense pain.

Pain Management
 It is the alleviation of pain or reduction in pain to a level of comfort that is acceptable to
the client.
 It includes two types of NURSING interventions: Pharmacologic & Non-Pharmacologic.

1. Pharmacologic Pain Management

 It involves the use of Opioids (narcotics), non-opioids/NSAID, adjuvants, or co-analgesic
drugs.
 Opioids Analgesics – include opium derivatives, such as morphine and codeine.
 Non-opioid – include NSAID such as aspirin , acetaminophen, and ibuprofen.
 (decrease or inhibit prostaglandin release)
 Adjuvant analgesics –are medication that developed for uses other than analgesia but
have found to reduce certain types of chronic pain.
e.g. mild sedatives or tranquilizers, diazepam; Antidepressant (Elavil),
2. Nonpharmacologic pain Management.
 Goal of Physical intervention:
 Provide comfort
 Correct physical dysfunction
 Alter physiologic responses
 Reduce fears associated with pain-related immobility or activity restrictions.

A. Cutaneous stimulation – can provide effective temporary pain relief. It distracts the
client & focuses attention on the tactile stimuli, away from the painful sensations, thus,
reducing pain perception.
 Create the release of endorphins that block the pain stimuli.
 Stimulate large diameter A-beta sensory nerve fibers thus decreasing the
transmission of pain impulses through the smaller A-delta & C
fibers

 Example of Cutaneous stimulation:

1) Massage (Effleurage, Tapotement, Petrissage)
2) Application of heat & colds
3) Acupressure – based on the ancient Chinese healing of acupuncture.
4) Contralateral stimulation – stimulating the skin in an area opposite to the
painful area.
B. Immobilization – Immobilizing painful body parts.
C. Transcutaneous Electric Nerve Stimulation (TENS) – same function as cutaneous
stimulation.

 Goals of Cognitive-Behavioral Interventions:

 Alter pain perception
 Alter pain behavior
 Provide clients with greater sense of control over pain.

A. Distraction - it draws the client’s attention away from the pain & lessen the perception
of pain.
- e.g. slow rhythmic breathing, massage & slow-rhythmic breathing, Active listening,
Guided imagery.

B. Hypnosis – is an altered state of consciousness in which an individual’s concentration is

focused and distraction is minimized.

Rest & Sleep

 Rest implies calmness, relaxation without emotional stress, and freedom from anxiety.
 It restores a person’s energy, allowing the individual to resume optimal functioning.
 People deprived of rest are often irritable, depressed, tired and have a poor control of
their emotion.
  Sleep is a state of consciousness which the individual’s perception and reaction to the
environment are decreased. It is characterized by minimal physical activity , variable
levels of consciousness, decreased responsiveness to stimuli.

Stages of sleep
1. NREM
 slow wave sleep
 sleep during night, deep, restful sleep & brings a decrease in physiologic functions.
 Stages & Characteristics of NREM
 People pass through the 4 stages of NREM sleep, usually lasting about 1 hr.
 Sleeper passes from stage I NREM through stages III to IV in about 20 to 30
min.
 Stage IV last for 30 min.
 Followed by III & II; then 1st REM stage occurs for 10 min. (1st sleep cycle)
 Usual sleeper exp 4-6 cycles in 7-8 hrs of sleep.

2. REM Sleep
 Constitutes 25 % of the young adult
 Usually recurs about every 90 minutes & lasts 5-30 min.
 It is not as restful as NREM sleep
 Most dreams takes place and retained in the memory.
 During this stage the brain is more active and brain metabolism increases.

Function of Sleep
 It exerts physiologic effect on the nervous system & other body structures.
 It increases muscle tone
 Necessary for protein synthesis, thus, allow the muscles to repair.

Factors affecting sleep

 Quality of sleep- ability of an individual to stay asleep & to get appropriate REM &
NREM.
 Quantity of sleep – total time the individuals sleeps.
 Age – sleep pattern variation occurs with age.
e.g., Newborn –14 to 18 hours; Infants – 12 to 14 hours; Toddlers –10-12 hours; Pre-
School –11 hours; School age – 10 hours; Adult –8 hours
 Environment – can promote or hinder sleep.
 Fatigue – it is thought that a person who is moderately fatigued usually has a restful
sleep.
 Lifestyle- exercise, work shift
 Psychologic stress – Anxiety & depression disturb sleep.
 Alcohol & stimulants – excessive alcohol disrupts REM sleep. Often experience
nightmares when effect of the alcohol has worn off.
 Diet – dairy products (contains tryptophan)
 Smoking – has a stimulating effect in the body.
 Motivation – the desire of an individual to stay awake.
 Illness – people who are more ill require more sleep.
 Medications – affect the quality of sleep
Common Sleep Disorder

1) Primary Sleep disorders – sleep problem is the main disorder

2) Secondary – sleep disturbances cause by another clinical disorder such as thyroid
dysfunction, depression & alcoholism.
3) Insomnia – the most common sleep disorder
 Inability to obtain an adequate amount or quality of sleep.
 3 types of insomnia:
a. Initial insomnia – difficulty of falling asleep.
b. Intermittent or maintenance – difficulty of staying sleep bec of
frequent waking
c. Terminal insomnia –early morning or premature waking.
 Causes of insomnia
1) Physical discomfort
2) Mental over stimulation due to anxiety.
3) Over consumption of drugs & alcoho
4) Hypersomnia – opposite of insomnia; excessive sleep, particularly in daytime.
 Causes of Hypersomnia
1) Nervous system damage
2) Kidney & liver disorder
3) Diabetic acidosis
4) Hypothyroidsm
5) Coping mechanism
5) Narcolepsy – “Narco”, numbness
 “Lepsis”, seizure
 sudden wave of sleepiness that occurs during the day.
 Also referred as sleep attack
 Cause is unknown, but believed to be a genetic defect of the CNS in w/c REM
can’t be controlled
6) Sleep apnea – it’s the periodic cessation of breathing during sleep.
 Often suspected when a the person has a loud snoring, frequent nocturnal awakenings,
excessive daytime sleepiness, insomnia.
 Last from 10 sec – 2 min; occur during REM or NREMs
 3 types of sleep apnea
a. Obstructive apnea – occurs when the structures of the pharynx or oral cavity
block the air flow.
b. Central apnea – involves a defect in the respiratory center of the brain. All
actions involve in breathing ceased (chest movement, airflow)
c. Mixed apnea –combination of the2.
7) Parasomnias – refers to a cluster of waking behaviors that may interfere with sleep.
A. Somnambulism – sleep walking
- occurs during stages III&IV of NREM
- episodic & occurs 1-2 hafter falling asleep.
B. Sleep talking – occurs during NREM sleep before REM sleep.
- Rarely presents a problem to the person unless it is troublesome to others.
C. Nocturnal enuresis – Bedwetting
- occurs in children over 3 yrs
- often occurs 1 – 2 h after falling asleep,when rousing from NREM stage III - IV
 D. Nocturnal erection / emission – occur during REM sleep.
- begin during adolescence, does not present a problem.
E. Bruxism – clenching & grinding of teeth.
- occurs during stage II NREM

Assessment
 Sleep assessment includes a sleep history, sleep diary & Physical examination.
1. Sleep history
 Usual sleeping pattern, sleeping & waking hours; quality or satisfaction of sleep; time &
duration of naps.
 Bedtime rituals
 Use of medications
 Sleep environment – dark room, temp.
 Recent changes in sleep patterns or difficulty of sleeping.
2. Sleep diary
 Clients with sleeping problem should keep & maintain a SD for at least 1 wk.
 Total number of sleep hours/day
 Activities performed by 2-3 hrs before bedtime (type, duration and time)
 Bedtime rituals – food,fluid medication
 Time of going to bed; trying to fall asleep, instances of waking up, duration;waking up
in the am.
 Any worries that may affect sleep

3. Physical Examination
Observation of the client’s:
 Facial appearance – darkened areas around the eyes, puffy eyelids, reddened
conjunctiva, glazed or dull appearing eyes.
 Behavior – irritability, restlessness, inattentiveness, slowed speech, slumped posture,
hand tremor, yawning, rubbing the eyes, withdrawal, confusion, & incoordination.
 Energy level – physically weak, lethargic, fatigue

Nursing care
 The major goal for the client with sleep disturbance is to develop or maintain a sleeping
pattern that provides sufficient energy for daily activities.
1. Reducing environmental distractions.
2. Promoting bedtime rituals
3. Teaching stress reduction
4. Relaxation techniques
Promoting Comfort & Relaxation
 Provide loose fitting nightwear.
 Assists client’s with hygienic routines.
 Make sure that the bed linen is smooth, clean & dry.
 Assist or encourage the client to void before bedtime.
 Offer to provide a back massage before sleep.
 Position dependent clients appropriately to aid muscle relaxation; provide supportive
devices to protect pressure areas.
 Schedule medications to prevent nocturnal awakenings.
 Administer analgesic 30 min before sleep for patient suffering from pain.
 CHAPTER ASSESSMENT

Read the following situations and answer the questions.

1. A 74-year-ol woman post-stroke has been paralyzed and confined to bed for almost 6
months. Upon assessment, you found that she has little response to verbal
command but has difficulty verbalizing discomforts. She can perform very slight and
occasional changes in position and cannot make movement as frequent as before.
Her skin is often moist but not always, hence her beddings are changed at least once
a day. She rarely eats a complete meal and needs moderate to maximum assistance
even when doing a simple movement.
a. Using the Braden Risk Assessment tool identify the patient’s risk for pressure
ulcer.
b. What are the preventive measures that you need to teach the significant others to
avoid the occurrence of pressure ulcer to the patient?
2. Make your own sleep diary for 1 week. Write your sleep diary in a short cattleya journal
notebook. (Preferably color blue)