Implementation

Question 1

Acute care

Answer 1

Because patients in acute care are at risk for deconditioning, the
encouragement of early ambulation and performing exercises that involve
stretching and active ROM is important. The level of exercise allowed will
depend on the patient’s physical condition. Physical therapists will
collaborate on an exercise plan, including progressive walking, walking
with assist devices, and isometric exercises. If needed, provide patients
ordered analgesics for pain 30 minutes before exercise. Do not administer
an analgesic that makes the patient feel dizzy.

Question 2

Isometric Exercises

Answer 2

Isometric exercises are prescribed for patients who do not tolerate
increased activity (Chapter 39). A physical therapist will typically
collaborate with the patient’s health care provider in selecting isometric
exercises most beneficial for a patient. As a nurse, your role is to support
patients in knowing how the exercises are to be performed correctly so
that you can observe for any problems or difficulties. For example, an
exercise program that includes isometric exercises of the biceps and triceps
will prepare a patient for crutch walking. Instruct the patient to stop the
activity if pain, fatigue, or discomfort is experienced.During isometrics, a patient tightens or contracts a muscle group for 10
seconds and then completely relaxes for several seconds (Resnick et al.,
2012). Repetitions are increased gradually for each muscle group until the
isometric exercise is repeated 8 to 10 times. Instruct patients to perform the
exercises slowly and to increase repetitions as their physical condition
improves. A patient needs to do isometric exercise for quadriceps and
gluteal muscle groups, which are used for walking, 4 times a day until the
patient is ambulatory.

Question 3

Range of Motion Exercise

Answer 3

The easiest intervention to maintain or improve joint mobility for patients
and one that can be coordinated with other activities is the use of ROM
exercises (see Chapter 39). There are three types of range of motion
exercise: active, active assisted, and passive. In active range of motion
(AROM) exercises patients move specific joints independently based on
their muscular weakness and the type of activity that needs strengthening.
The exercise moves the joint and soft tissues through the available
physiological ranges of motion. AROM exercises are used when a patient
is able to voluntarily contract, control, and coordinate a movement when
such a movement is not contraindicated (Du􀄴on, 2014). As a nurse you
should know the contraindications to AROM, including a healing fracture
site, a healing surgical site, severe and acute soft tissue trauma, and
cardiopulmonary dysfunction (Du􀄴on, 2014). Chapter 39 discusses active
assisted and passive ROM exercises.

Question 4

Walking

Answer 4

Walking increases joint mobility and can be measured by length of time or
distance walked, such as down a hospital hallway or actual number of feet
walked. Measure distances walked in estimated feet or yards instead of
charting “ambulated to nurses’ station and back.” Some hospital or rehab
units will have markers along floorboards designating distances. Illness or
trauma usually reduces activity tolerance, resulting in the need for help
with walking or the use of assistive devices such as crutches, canes, or
walkers. Patients who increase their walking distance before discharge
improve their ability to independently perform basic ADLs, increase
activity tolerance, and have a faster recovery after surgery (AAN, 2015;
Walia et al., 2018).

Question 5

Helping a Patient Walk

Answer 5

Help the patient to a position of si􀄴ing at the side of the bed and
dangling the legs over the side of the bed for 1 to 2 minutes before
standing. Some patients experience orthostatic hypotension (i.e., a drop in
systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at
least 10 mm Hg within 3 minutes of rising to an upright position (Shibao et
al., 2013; Fedorowski and Melander, 2013). Those at higher risk are
patients who are immobilized, patients who are on prolonged bed rest,
older adults, and patients with chronic illnesses such as diabetes mellitus
and cardiovascular disease. Signs and symptoms of orthostatic
hypotension include dizziness, light-headedness, nausea, tachycardia,
pallor, and even fainting. Orthostatic hypotension usually stabilizes
quickly, but if the patient develops dizziness lasting 60 seconds, return the
patient to bed (Myszenski, 2014). Dangling a patient’s legs before standing
is an intermediate step that allows assessment of the patient before
changing positions to maintain safety and prevent injury to the patient. In
some instances you need to take the patient’s blood pressure while he or
she is si􀄴ing on the side of the bed.
Several methods are used to help a patient ambulate - For those who can
bear weight easily provide support at the waist with a gait belt so that the
patient’s center of gravity remains midline. The belt helps you to stabilize
patients if they lose their balance. Don’t place a gait belt over incisions, stitches, tubes, or
intravenous lines, and never use one on a pregnant patient.If the patient has a fainting (syncope) episode or begins to fall, your
natural instinct will be to support or catch the patient. Trying to stop or
minimize a fall can cause you injury. However, an approach used by
physical therapists involves assuming a wide base of support with one
foot in front of the other, thus supporting the patient’s body weight (Fig.
38.10A). While holding the gait belt, try to extend one leg, let the patient
slide against the leg, and gently lower him or her to the floor, protecting
the head. Use caution to prevent your own injury, especially
if the patient is overweight. When the patient attempts to ambulate again,
proceed more slowly, monitoring for reports of dizziness; take the
patient’s blood pressure before, during, and after ambulation.

Question 6

Restoration of Activity and Chronic Illness

Answer 6

Nurses design care plans individualized for increasing activity and
exercise in patients with specific disease conditions and chronic illnesses
such as coronary artery disease (CAD), hypertension, chronic obstructive
pulmonary disease (COPD), and diabetes mellitus.
Regular moderate-intensity aerobic exercise has been shown to reduce the
risk of sudden cardiac death and acute MIIncreasing physical activity is an important modifiable behavior that can
reduce the relative risk of CAD events (such as angina and myocardial
infarction) because of its systemic benefits (Fig. 38.20). Regular moderate
exercise enhances coronary artery blood flow and reduces incidents of
angina by enhancing oxygen delivery to the heart muscle (myocardium). A number of studies have
consistently shown beneficial effects of exercise on hypertension, resulting
in reductions in both systolic and diastolic blood pressure with as much as
5 to 7 mm Hg reductions in those with hypertension.

• Diabetes Mellitus- A number of studies have
  consistently shown beneficial effects of exercise on hypertension, resulting
  in reductions in both systolic and diastolic blood pressure with as much as
  5 to 7 mm Hg reductions in those with hypertension