Exercise, Transfers &

Ambulation
Nursing 125

Mobility
Mobility refers to a persons ability to move about freely.
Immobility refers to a persons inability to move about
freely.
Mobility & immobility are the endpoints of a continuum with
many degrees of partial immobility in between.

mobility immobility
Some clients move back and forth, some clients remain
absolute.

Ability to Move
The ability to move & function is a function most people take for granted.
The level of mobility has a significant impact on an ind.s physiological,
psychosocial, & developmental well-being (Hamilton & Lyon, 1995).
When there is an alteration in mobility, many body systems are at risk
for impairment.
Cardiovascular functioning orthostatic hypotension
Pulmonary complications pneumonia
Promote skin breakdown, muscle atrophy etc

Such changes can lead to altered self-concept & lowered

self-esteem.

Medical Conditions that can Alter

Mobility
Fractures/sprains
Neurological conditions spinal cord injury,
head injury
Degenerative neurological conditions
Myasthenia gravis, Huntingtons chorea

Nursing Measures
Attempt to maintain and/or restore optimal mobility as well as
to decrease the hazards assoc. with immobility.
DB & C exercises
Muscle & joint exercises
Frequent repositioning q 2 hrs
fluid intake/fiber intake

Guidelines:

Check activity order

Know clients past medical history & limitations
Baseline vital signs are necessary
Become familiar with assistive devices

Major concern during transfer =

Safety of both the client and the
nurse

Range of Motion Exercise

(ROM)
ROM exercises, in which a body part is moved through a
range of motion, are carried out to promote circulation,
maintain muscle tone & promote flexibility. In doing this,
joint stiffness & debilitating contractures are prevented.
Active ROM is range of motion carried out by the patient.
It is a form of isotonic exercise & as such, it maintains
strength, tone & flexibility. In patients unable to move
body parts due to paralysis or extreme illness, ROM is
performed by someone else. This is called passive ROM
exercise. Passive exercise helps to maintain joint flexibility
& prevent stiffness & contractures. Because this type of
exercise involves no active movement on the part of the
muscles, it does not contribute to muscle tone or strength.

ROM(cont.)
ROM exercises are planned as a regular part of
nursing activities. During a bath, for example,
the nurse has an excellent opportunity to
move the patients limbs through their full
range of motion. The patient is encouraged to
exercise actively those muscles that can be
used. However, in certain cases, the nurse
may need to assist the patient in performing
ROM (active assisted ROM), or to perform
passive ROM.

ROM (cont.)
The maximum movement that is possible for a joint is its range of motion.
If a joint is not moved sufficiently it begins to stiffen within 24 hrs &
eventually becomes inflexible, flexor muscles contract & pull tight causing
contractures or fixed joint flexion.
To prevent joint contractures & muscle atrophy (wasting or decrease in
size of a normally developed organ or tissue), exercise must be performed
ROM exercise.
Contracture abnormal flexion & fixation of joints caused by the disuse,
shortening & atrophy of muscle fibers.
Correcting contractures requires intensive therapy over a prolonged period
of time, and may be impossible. Prevention is the key.

Two Purposes of ROM

1. Maintain joint function
2. Restore joint function
Do not exercise joints beyond
the point of resistance or to
the point of fatigue or pain

Contraindications to ROM
ROM requires energy & increased circulation,
any illness/disorder where increased use of
energy or increased circulation is hazardous is
contraindicated; puts strain/stress in soft
tissues of the joint & bony structures, therefore
not done with swollen, inflamed joints.

Perform Exercises in Head

to Toe Format
Start with the head and move down, always do bilaterally
Do not grasp the joint directly
Cup the joint gently (prevents pressure)
Do not grasp fingernail or toenail
Important joints thumb, hip, knee, ankle
Return to correct anatomic position
Move joint through movement 5 times/session

Start at the Neck

P&P p. 830

Neck

Flexion look @ the toes

Extension look straight ahead
Hyperextension look up @ ceiling
Lateral flexion look straight ahead, tilt head to shoulder

Shoulder

Flexion raise arm forward & overhead

Extension return arm to side of body
Abduction raise arm to side to position above head with
palm away from head.
Adduction return arm & bring across chest
Internal rotation elbow flexed, rotate the shoulder by
moving arm til thumb is turned inward & toward the back
(fingers to the floor)
External rotation elbow flexed, move arm until thumb is
upward & lateral to head. (fingers point up)
Circumduction move arm in full circle (arm straight out,
move hand as if to draw a circle.

Elbow
Elbow

Flexion bend elbow

Extension straighten elbow
Hyperextension bend lower arm back as far as
possible

Forearm

Supination turn lower hand so palm is up

Pronation - turn lower hand so palm is down

Wrist

Flexion bend wrist forward

Extension straighten wrist (fingers, wrist & arm in
same plane)
Hyperextension bring dorsal surface of hand as
far back as possible
Abduction (radial flexion) bring wrist medially
towards the thumb
Adduction (ulnar flexion) bend wrist laterally
th

Fingers & Thumb

Fingers &
thumb

Flexion bend fingers & thumb into palm make a

fist
Extension straighten fingers & thumb
Hyperextension bend fingers as far back as
possible
Abduction spread fingers apart / extend thumb
laterally
Adduction bring fingers together/ thumb back
to hand
Circumduction move finger/thumb in circular
motion
Opposition touch thumb to each finger of same
hand

Hip
Hip

Flexion move leg forward (ROM 90-120 deg)

Extension move leg back beside other leg
Hyperextension move leg backwards (ROM
30-50 deg)
Abduction move leg laterally away from body
(ROM 30-50 deg)
Adduction move leg back to medial position &
beyond if possible (ROM 30-50 deg)

Knee

Flexion bring heel toward back of thigh (120130 deg)

Extension return leg to floor

Ankle
Ankle

Dorsiflexion move foot so toes are pointed upward

Plantarflexion move foot so toes are pointed
downward

Foot

Inversion turn sole of foot medially (ROM 10 deg)

Eversion turn sole of foot laterally (ROM 10 deg)
Flexion curl toes downward (ROM 30-60 deg)
Extension straighten toes (ROM 30-60 deg)
Abduction spread toes apart
Adduction bring toes together

Spine
Spine

Flexion when standing bend forward from

the waist
Extension straighten up
Hyperextension bend backward
Lateral flexion bend to the side
Rotation twist from the waist

Types of ROM exercises

Active exercises the client is able to perform
independently.
Passive exercises performed for the client by
someone else.
Active assisted performed by a client with
some assistance client can move a limb
partially through its ROM, but needs help
completing the ROM.

Isometric/Isotonic Exercises
In addition to ROM exercises, some immobilized clients may
be able to perform muscle-strengthening exercises.

1.

Isotonic cause muscle contraction & change in muscle

length walking, aerobics, moving arms & legs against
light resistance.

2.

Isometric tightening or tensing of muscles without moving

body parts. This increases muscle tension but do not
change the length of muscle fibers. Isometric exercises are
easily performed by an immobilized patient in bed.

Isotonic and isometric exercises help to prevent muscular atrophy

and combat osteoporosis.

Applying Antiembolism Stockings

(Elastic) P&P p. 842
Thromobophlebitis the development of a thrombus or
clot along with the inflammation of the vein & may be
classified as superficial or deep.
Three elements contribute to the development of a clot.
1. Hypercoagulability of the bld clotting disorders,
dehydration, pregnancy & 1st 6 weeks postpartum if
the woman was confined to bed, oral
contraceptives.
2. Venous wall damage local trauma, orthopedic
surgeries, major abdominal surgery, varicose veins,
arteriosclerosis
3. Blood stasis immobility, obesity, pregnancy

Antiembolism stockings
Promote venous return by maintaining
pressure on superficial veins to prevent
venous pooling.
Prevent passive dilation of veins
Application of antiembolism stockings
(refer to p. 845 P&P)

Orthostatic hypotension
A drop in blood pressure that occurs when the client rises from lying to
sitting or from sitting to standing. (A decrease in systolic pressure >15
mmHg or decrease diastolic pressure >10 mmHg.)
At risk clients
Immobilized clients
Prolonged bed red
Measures to minimized Orthostatic Hypotension
Maintain muscle tone
Increase venous return to the heart
Decrease stasis of bld in the lower extremities
ROM/isometric exercises/TEDs
Mobilize ASAP

Therapeutic Positions
Chair feet flat on floor, footrest if unable to reach floor, knees & hips
flexed 90-100 degrees. Buttocks at back of the chair, spine straight,
pillows at side to prevent leaning.
Fowlers supine, HOB elevated 45 deg. Promotes lung expansion,
decrease ICP, comfortable for eating.
High fowlers same as above, with HOB elevated 45-90 deg. Utilized for
clients experiencing difficulty breathing.
Semi fowlers as above with HOB elevated less than 45 deg.
Orthopneic sit on side of bed with over bed table across lap, pillow on
table, lean forward & rest head & arms on table. Utilized for patients with
extreme difficulty breathing promotes lung expansion.

Therapeutic positions
cont.
Lithotomy supine flex both knees so
that feet are close to hips, separate
legs, feet in stirrups. Utilized for
perineal & vaginal examinations
Trendelenburg supine, entire bed
frame tilted down with head 30 deg
below horizontal.
Postural drainage
Increase venous return in case of shock

Benefits of Proper
Positioning
Maintains body alignment & comfort
Prevents injury to musculoskeletal system,
prevents strain
Provides sensory, motor & cognitive stimulation
Prevents pressure sore (decubitus ulcer) & joint
contractures

Transfers
Transferring is a nursing skill that helps the client with
restricted mobility attain/maintain mobility & independence.
Benefits of transfers
Maintains & improves joint motion
Increases strength
Promotes circulation
Relieves pressure on the skin
Improves urinary/respiratory function
Increases social activity
Increased mental stimulation

Transfers - Safety
Safety is a major concern when transferring. Falls are a
common hazard. If a patient starts to fall do not try to stop
the fall, instead assist the patient to the floor while protecting
the head from injury. This will reduce the risk of patient as
well as staff injury.
Complete a thorough nursing assessment before you move
the patient to determine if she/he has suffered any injuries.
Prevention of injury is the key, be aware of the clients motor
deficit, ability to support their body weight and use effective
body mechanics & lifting techniques.
When in doubt regarding the patients ability-GET ASSISTANCE

Nursing Process - Transfers

Assessment

Activity orders
Client capabilities

Planning

Decide appropriate transfer technique

Explain procedure to the patient

Implementation

Wash hands
Position chair 45 deg angle to bed on clients stronger
side
Lock bed brakes, lower bed, raise HOB as high as
patient tolerates
Lower side rail
Assist to sitting (lift upper body & swing legs around)
Assist with robe & slippers
Position feet on floor
Take wide stance, bend knees, grasp patient
1 2 3 stand
Pivot to chair

Nursing Process (cont.)

Evaluation

Body in alignment, patient comfortable,

no injuries
Nurse maintains good body alignment

Of note:

Two person lift (same as above) except

one nurse is on each side of the patient
Never lift under the axilla can damage
nerves
Mechanical lifts enables you to lift
heavy patients, or those unable to help.
(Use 2 people)

Ambulation
Clients who have been immobile even for a short time
may require assistance
A client may require the use of an assistive device to aid
in ambulation.
Assistive devices
Increase stability
Support a weak extremity
Reduce the load on weight bearing structures;
hip, knees

Assisting the patient

Simple assist
1.

2.

3.

Place arm near patient under the arm & at the elbow &
grasp pts hand, synchronize walking with the pt (move
inside foot forward at same time as pts inside foot)
Grasp pts left hand in nurses left hand & encircle pts
waist with the rt hand & synchronize walking as above
Using a transfer belt (held at the waist from the rear by the
belt helps maintain balance)

Nurse to stand on the pts weak side. The nurse provides

support with his/her leg to the pts weakened one if
necessary. Do not allow the pt. to place their arm around
your shoulder.

Walk slowly, even gait, synchronize your steps.

Cane
Helps maintain balance by widening the base of support increases a pts
security.
Should be held on stronger side
Should have rubber tip prevent slipping
Height (from greater trochanter to the floor allowing 15-30 deg of
elbow flexion.

Gait place cane 6-10 inches ahead, move affected leg ahead to
cane, place weight on affected leg and cane, move unaffected leg
ahead of cane.

Stand from sitting

Cane in hand opposite affected leg, grasp arm of chair & cane in

other, push to stand, gain balance

Walker
Wide base of support, provides great
stability & security. Used for clients who are
weak or who has problems with balance.
Patient should have at least one weight bearing leg and

arm
Pick up walker is more stable, walker with wheels
easier for pts who have difficulty with lifting or
balance, however can roll forward when weight is
applied.
Height upper bar of walker should be slightly below
the clients waist with arms flexed 15-30 deg

Walker (cont.)
To stand walker in front of seat, push up off
arms of chair (walker is less stable, chair is
lower pt. can push with more force. Hands
move to walker one at a time.
To sit back up to chair, reach back with one
arm to arm of chair, then with the other arm
and lower to chair.
Gait walker ahead 6-8 inches, weight on
arms. Partial weight on affected leg first.

Crutches
Wooden or metal staff that reaches from the
ground to 11/2 2 inches below the axilla.
When standing tip of crutch rests 4-6 inches in
front & 4-6 inches to side of foot.
Do not rest on top of crutches pressure on
axilla nerves can lead to paralysis called
crutch paralysis (numbness, tingling, muscle
weakness)

Crutches (cont.)

P&P p.859

3 point gait able to wt. bear on one foot, full wt.

on unaffected leg then on both crutches begin in
tripod position, move crutches & affected leg
ahead, move stronger leg forward and repeat.
4 point gait (most stable crutch walk) weight on
both legs and both crutches muscular weakness,
improves balance by providing a wide base of
support, lack of coordination, move each
independently rt crutch-lt foot-lt crutch-rt leg

Assisting with Ambulation

Assistive Devices
-Canes
-Walkers

-Crutches