Chapter 16: Activity and Exercise
Introduction:
●Research evidence supports role of exercise in improving the health status.
○can also reverse many chronic diseases.
●Activity-exercise pattern: person’s routine of exercise, activity, leisure, and recreation.
○ADLS
○type, quality, and quantity of exercise
●Mobility: the ability to move freely, easily, rhythmically, and purposefully in the environment.
○People often define their health and physical fitness by their activity because mental well-being and effectiveness of body function depend largely on mobility.
Normal Movement
●Normal movement and stability are the result of an intact musculoskeletal system, intact nervous system, and intact inner ear structures responsible for equilibrium.
●Requires coordinated muscle activity and neurologic integration.
●Comprised of four basic elements: posture, joint mobility, balance, and coordinated movement. [1]
Posture
●Lecture notes:
○Assess head, shoulder, lower back, hip, knees
●proper body alignment and posture bring the body parts into position that promotes optimal balance and maximal body function.
○Line of gravity: imaginary vertical line drawn through the body’s center of gravity and the base of support.
■as long person maintains balance along this line.
●when a person is well aligned: strain on joints, muscles, tendons, and ligaments are minimized and internal structures and organs are properly supported.
●Proper posture enhances lung expansion and promotes efficient circulatory, renal, and GI functions.
●Posture reflects mood, self-esteem, and personality and vice-versa.
●abdominal and skeletal muscles (extensor “antigravity” muscles)
○functioning continually against the endless downward pull of gravity
■making adjustments to remain erect or seated
Joint Mobility
●Lecture notes:
○Types of Joints
●joints are the functional units of the musculoskeletal system.
●Skeletal muscles are categorized according to the type of joint movement they produce on contraction.
●Flexor muscles stronger than extensor muscles so when the person is inactive, the joints are flexed (bent).
●ROM is the maximum movement that is possible for the joint.
○Joint ROM differs due to several factors:
■genetics, development patterns, disease, and amount of physical activity.
Movement / ActionFlexion / decreasing the angle of the joint
Extension / increasing the angle of the joint
Hyperextension / further extension or straightening of a joint
Abduction / movement of the bone away from the midline of the body
Adduction / movement of the bone toward the midline of the body
Rotation / movement of the bone around its central axis
Circumduction / movement of the distal part of the bone in a circle while the proximal end remains fixed
Eversion / turning the sole of the foot outward from the ankle joint
Inversion / turing the sole of the foot inward from the ankle joint
Pronation / moving the bones of the forearm so that the palm of the hand faces downward
Supination / moving the bones of the forearm so that the palm of the hand faces upward
Balance
●Mechanisms of balance involved maintaining balance and posture involve inputs from: labyrinth (inner ear: vestibule and semicircular canals), vision, and stretch receptors of muscles and tendons.
○Fluid flow from labyrinth stimulate sensory hair cells that initiate reflexes to change position.
○Information from balance receptors go directly to the reflex centers rather than the cerebral cortex.
●Proprioception: awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight, and resistance of objects in relation to the body.
Coordinated Movement
●Balanced, smooth, purposeful movement is the result of proper functioning of the cerebral cortex, cerebellum, and basal ganglia.
○cerebral cortex: operates movements. not muscles.
○cerebellum: coordinates muscles involved in voluntary movement.
■translates the instructions from cortex into action
○basal ganglia: helps maintain posture
Exercise
●Physical activity: bodily movement that enhances health.
●Exercise: type of physical activity defined as a planned, structured, and repetitive bodily movement performed to improve health and maintain fitness to achieve an optimal state of health.
●Functional strength: ability of the body to perform work.
●Activity tolerance: type and amount of exercise or daily living activities an individual is able to perform without experiencing adverse effects.
Types of Exercise[2]
●Isotonic (dynamic) exercises:
○muscle shortens to produce muscle contraction and active movement.
■ex. running, walking, swimming, cycling,
■ADL’s and active ROM.
●ex. pushing or pulling against a stationary object
○using a trapeze to lift body off the bed, lifting buttocks off the bed by pushing with the hands, or pushing the body to a sitting position.
●Isometric (static or setting) exercises:
○muscle contraction without moving the joint (therefore muscle length does not change)
○useful in strengthening abdominals, gluteal, and quadricep muscles.
■ex. squeezing a towel or pillow between knees
●Isokinetic (resistive) exercises
○muscle contraction or tension against resistance.
■ex. resistance training
●Aerobic exercise
○amount of oxygen taken into body is greater than that used to perform the activity.
■ex. CV conditioning and physical fitness.
○Intensity of exercise can be measured in three ways:
■1. Target HR
■2. Talk Test
■3. Borg scale of perceived exertion (1-20)
●Anaerobic exercise
○muscles cannot draw out enough oxygen from bloodstream, and anaerobic pathways are used to provide additional energy for a short time.
■ex. for endurance training of weightlifters and sprinters
Benefits of Exercise
●Musculoskeletal system
○Size, shape, tone, and strength of muscles are maintained with exercise and increased with strenuous exercise.
■Strenuous exercise causes hypertrophy and increased efficiency of muscular contraction.
○Exercise increases:
■joint nourishment
■joint flexibility
■stability
■ROM
○Bone density and strength is maintained through weight-bearing and high-impact movements.
■maintains balance between osteoblasts and osteoclasts.
○prevent atrophy
●CV system
○increases strength of heart muscle contraction
○increases blood supply to the heart and muscles
○lowering BP
○improved O2 uptake
○improved HR variability
○improved circulation
○reduces stress
●Respiratory system
○Benefits:
■improves gas exchange
■increases toxin elimination through deeper breathing
■improves O2 to brain
●enhances problem solving and emotional stability
■prevents pooling of secretions
■decreases breathing effort and risk for infection
■Exercising muscles of respiration:
●enhances oxygenation and stamina
●circulation of lymph
○Special considerations:
■LE exercise forms for treating COPD patients
■yoga breathing and postures with asthma are helpful
●GI system
○Improves appetite
○increases GI tract tone
○facilitates peristalsis
○can help relieve constipation
○Special Considerations:
■rowing, swimming, walking, and sit-ups can help relieve constipation.
■abdominal compressive exercise can help improve symptoms of digestive disorders such as IBS.
●Metabolic/Endocrine system
○increases metabolic rate therefore increased production of body heat, waste products, and calorie use.
○increases use of triglycerides and fatty acids
■resulting in lower serum triglycerides, A1C levels, and cholesterol.
■make cells more responsive to insulin
●GU system
○promotes efficient blood flow = excretion of bodily wastes more effectively.
○prevents stasis of urine and therefore flushes out bacteria = less UTI
●Immune system
○exercise allows for lymph fluid to be more efficiently pumped through the lymphatic system.
○moderate exercise enhances immunity, strenuous exercise may reduce immune function.
●Psychoneurological System
○exercise can elevate mode and relieve stress and anxiety.
○ MoA:
■exercise increases levels of neurotransmitters
■exercise increases levels of endorphins
■increases level of O2 to brain inducing euphoria
■muscular exertion releases stored stress associated with accumulated emotional demands.
○Relaxation response (RR): physiological state that can be elicited through deep relaxation breathing with emphasis on prolonged exhalation.
■Emphasis on exhalation recruits PNS “rest and digest” reflex.
■Progressive contraction and relaxation of muscles throughout body until feels relaxed.
■These can be done by anyone at anytime.
●Cognitive function
○Induces cells in brain to strengthen and build neuronal connections.
○Enhances decision-making, problem-solving, planning, and paying attention.
○Brain Gym and cross-lateral movements helpful to enhance cognitive functions.
■Shown to help ADD< ADHD, learning disorders, and mood disorders.
●Spiritual Health
○Yoga-style exercises improves the mind-body-spirit connection, relationship with God, and physical well-being by establishing balance in the internal and external environment.
○Emphasis of breathing is thought to soothe the Nervous and Cardiorespiratory systems.
○Recitation of the a word or prayer can cause muscle relaxation, decrease in HR and RR.
○Slow breathing enhances heart rate variability and baroreflex sensitivity.
○Walking labyrinths or doing paper labyrinths can cause a meditative state, decreasing HR and RR.
Factors Affecting Body Alignment and Activity[3][4]
Growth & development
●Newborns
○movements are reflexive and random
○all extremities normally flexed, can passively be moved through full range of motion.
●Toddlers (age 1-5)
○Gross motor skills precede fine motor skills.
■Gross motor develops head-to-toe (head movement, crawling, walking)
●Age (6-12)
○refinement of motor skills continues and exercise patterns for later life are determined here.
●Age (12-19)
○growth spurts and behaviors may result in postural changes that often persist into adulthood.
●Age (20-40)
○Pregnancy
○Osteoporosis
■posture changes: leaning forward and stooped
●shift center of gravity causing knees to flex to compensate
○knees flex, support base widens, gait is wide, short stepped, shuffling.
Nutrition
●Undernutrition:
○muscle weakness and fatigue
○Vitamin D deficiency = bone deformity , increases risk of osteoporosis
●Overnutrition:
○obesity = distortion in posture, balance, and joint health
Personal values & attitudes
●People’s values concerning physical activity or type of exercise are affected by:
○family lifestyle and values
○geographic location and cultural role expectations
○personal perception of exercise (recreational vs drudgery)
○motivational states
■individual exercise prescriptions: exercise mode and dose tailored to a specific individual to ensure greater adherence to the exercise program
■nurses must be able to assess each client for motivating factors and give appropriate exercise prescriptions to these factors
External factors
●Climate
●Availability of recreational facilities
○economic situation
●Community safety
Prescribed limitations
●Casts, braces, splints, and traction.
●Bed rest
○meaning may be different per agency, nurses must know the extent of bed rest.
○within 2 weeks of bedrest (20-40% muscle atrophy)
Effects of Immobility
Musculoskeletal system
●disuse osteoporosis
○without exercise, bones demineralize
●Disuse atrophy
●Contractures:
○permanent shortening of the muscle
○foot drop
●Stiffness and pain in the joints
○ankylosed: permanently immobile
○excess calcium deposited in joints.
CV system
●Diminished cardiac reserve
○causes ANS imbalance, increases HR, reduces heart’s capacity to respond to any metabolic demands above basal levels.
■tachycardia with minimal exertion.
●Increase use of the Valsalva maneuver
○Valsalva maneuver: holding breath and straining against a closed glottis.
■builds up intrathoracic pressure causing interferences with return blood flow to the heart.
■When client exhales, pressure released and sudden surge of blood flow back to the heart.
■may cause arrhythmias
●Orthostatic hypotension
●Venous vasodilation and stasis
○Immobile person: skeletal muscles no longer assist in pumping blood back to heart against gravity.
■blood pools and causes vasodilation and engorgement.
■valve incompetence
●Dependent edema
●Thrombus formation
Respiratory system
●Decreased respiratory movement
○intercostal joints become fixed in an expiratory phase of respiration, further limiting the potential for maximal ventilation.
■produces shallow breathing and reduced vital capacity (additional inhalation passed maximum inhalation)
●Pooling of respiratory secretions
●Atelectasis
●Hypostatic pneumonia
GI system
●constipation due to decreased peristalsis + decreased abdominal and perineal muscles = impaction
●embarrassment of using a bedpan leads to postponement of defecation leads to weakened and suppressed defecation reflex
●some clients use Valsalva maneuver excessively which increases intra-abdominal and thoracic pressure and places stress on heart and circulatory system.
Metabolic system
●Decreased metabolic rate
●Negative nitrogen balance
○negative balance between protein anabolism and catabolism
■more catabolism of proteins than intake
●Anorexia
○decreased caloric intake due to decreased metabolic rate (less energy needed)
●Negative calcium balance
○greater amounts of calcium are extracted from bone than can be replaced
GU system
●Urinary stasis
○urine pools due to gravity
●Renal calculi
○calcium salts are no longer in balance and form stones.
●Urinary retention
○bladder distention and occasionally urinary incontinence
○unable to completely void bladder due to decreased muscle tone
●Urinary infection
○static urine
○improper perineal care/ indwelling catheter
○urinary reflex (backward flow)
Integumentary system
●Reduced skin turgor
●Skin breakdown
Psychoneurological
●Decline in mood-elevating substances such as endorphins
●Increased dependence on others
○may lower person’s self-esteem
■frustration and exaggerated emotional reactions
●Decreased variety of stimuli
○time perception deteriorates
○problem-solving and decision making deteriorate due to lack of intellectual stimulation.
●Anxiety
~ Nursing Management ~
Assessing
●Nursing History
●Physical Examination[5] (Table 3 pg.600)
○Body Alignment
■Nurse must identify
●normal development variations in posture
●posture and learning needs to maintain good posture
●Factors contributing to poor posture, such as fatigue, pain compression fractures, or low self-esteem
●muscle weakness or other motor impairments
■Nurse should observe whether:
●shoulder and hips are level
●toes point forward
●spin is straight and not curved to either side.
■Slumped posture:
●neck is flexed forward, abdomen protrudes, pelvis is thrust forward, and knees are hyperextended.
○Lordosis: exaggerated anterior/inward curvature of the lumbar spine.
○Gait
■Stance phase and swing phase.
■Nurse must assess for the following:
●Chin is level, gaze is straight ahead, sternum is lifted, and shoulders are down and back, relaxed away from the ears.
●Heel strikes the ground before the toe. It is here, where both feet are taking some body weight, that the spine is most rotated.
●Feet are dorsiflexed in the swing phase.
●Arm opposite the swing foot moves forward at the same time.
●Gait is smooth, coordinated, and rhythmic, with even weight distribution on each foot. Hips gently sway with spinal rotation; the body moves forward smoothly, stopping and starting with ease.
●Pace (number of steps/min)
○normal 70-100 steps/min
○older person may be 40 steps/min.
●Need for assistive devices.
○compare gait w/ and w/o devices if possible.
○Appearance and Movement of Joints
■Examination of the joints includes: inspection, palpation, assessment of active ROM, and passive ROM.
■Nurse should assess:
●swelling, redness, heat
●deformities
●muscle development (size and symmetry)
●any reported or palpable tenderness
●Crepitation: palpable or audible crackling or grating sensation produced by joint motion.
●degree of joint movement
■ROM shouldn’t be tiring; should be done smoothly, slowly, and rhythmically.
●no joint should be forced.
○Capabilities and Limitations for Movement
■Possible hindrances:
●client’s illness
●obstacles: IV’s, casts, etc.
●ALOC, meds affecting mental status
●balance and coordination
●orthostatic hypotension
●degree of comfort
●visual impairments
■Capabilities of client
○Muscle Mass and Strength
■assess client’s strength and ability to move.
■Providing appropriate degree of assistance lowers risk of muscle strain and body injury to both client and nurse.
■Assessment of UE very important for clients who use assistive devices such as walkers or crutches. [6]
○Activity Tolerance
■Determine appropriate activity level for client and predict whether the client can endure activities that require similar amounts of energy expenditure.
■Useful in encouraging independence in pt’s with:
●CV and respiratory problems
●immobilized for a prolonged period
●decreased muscle mass or musculoskeletal disorder
●inadequate sleep
●pain
●depressed, anxious, or unmotivated
■Most useful measurements of predicting activity tolerance:
●Heart strength, rhythm, and rate
●Respiratory depth, rhythm, and rate
●BP
○measure these before, during, immediately after, 3 minutes after activity
■Activity should be stopped immediately in the event of:[7]
●sudden facial pallor
●dizziness or weakness
●change in LoC
●dramatic change in HR or RR from baseline
●dramatic change in heart or respiratory rhythm
●weakening of pulse
●Dyspnea, SOB, chest pain
●DBP change of 10mmHg or more
■Activity considered safe if client tolerates and vitals return to baseline levels within 5 minutes of activity.
○Problems Related to Immobility
■Take/understand assessment findings and lab values
●establish a baseline and compare with later values
■Clients at risk of developing complications of immobility:[8]
●poorly nourished
●existing CV, pulmonary, or neuromuscular problems
●decreased sensitivity to pain, temperature, or pressure
●ALOC
Diagnosing
●Activity Intolerance
○Level I-IV (1 - independent, 4 - dyspnea and fatigue at rest)
○characteristics:
■abnormal BP response to activity, abnormal HR response, EKG changes (arrhthmias), EKG changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness
■r/t: bed rest; generalized weakness; O2 supply/demand imbalance; immobility; sedentary lifestyle
●Impaired Physical Mobility
○limitation in independent, purposeful physical movement of the body or of one or more extremities
○impaired physical mobility can be the etiology (r/t) for:
■Fear (of falling)
■Ineffective Coping
■Situational Low Self-Esteem
■Powerlessness
■Risk for Falls
○characteristics: