Chapter 16: Activity and Exercise.docx

 Chapter 16: Activity and ExerciseIntroduction: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. ADLStype, quality, and quantity of exerciseMobility: 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 MovementNormal 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. PostureLecture notes:Assess head, shoulder, lower back, hip, kneesproper 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 gravitymaking adjustments to remain erect or seatedJoint MobilityLecture notes:Types of Jointsjoints 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. MovementActionFlexiondecreasing the angle of the jointExtensionincreasing the angle of the jointHyperextensionfurther extension or straightening of a jointAbductionmovement of the bone away from the midline of the bodyAdductionmovement of the bone toward the midline of the bodyRotationmovement of the bone around its central axisCircumductionmovement of the distal part of the bone in a circle while the proximal end remains fixedEversionturning the sole of the foot outward from the ankle jointInversionturing the sole of the foot inward from the ankle jointPronationmoving the bones of the forearm so that the palm of the hand faces downwardSupinationmoving the bones of the forearm so that the palm of the hand faces upwardBalanceMechanisms 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 rmation 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 MovementBalanced, 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 ExercisePhysical 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 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 objectusing 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 kneesIsokinetic (resistive) exercisesmuscle contraction or tension against resistance. ex. resistance trainingAerobic exerciseamount 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 HR2. Talk Test3. Borg scale of perceived exertion (1-20) Anaerobic exercisemuscles 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 sprintersBenefits of ExerciseMusculoskeletal systemSize, 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 nourishmentjoint flexibilitystabilityROMBone density and strength is maintained through weight-bearing and high-impact movements. maintains balance between osteoblasts and osteoclasts. prevent atrophyCV systemincreases strength of heart muscle contractionincreases blood supply to the heart and muscleslowering BPimproved O2 uptakeimproved HR variabilityimproved circulationreduces stressRespiratory systemBenefits: improves gas exchangeincreases toxin elimination through deeper breathingimproves O2 to brainenhances problem solving and emotional stabilityprevents pooling of secretionsdecreases breathing effort and risk for infectionExercising muscles of respiration:enhances oxygenation and staminacirculation of lymphSpecial considerations:LE exercise forms for treating COPD patientsyoga breathing and postures with asthma are helpfulGI systemImproves appetiteincreases GI tract tonefacilitates peristalsiscan 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 systemincreases metabolic rate therefore increased production of body heat, waste products, and calorie use. increases use of triglycerides and fatty acidsresulting in lower serum triglycerides, A1C levels, and cholesterol.make cells more responsive to insulinGU systempromotes efficient blood flow = excretion of bodily wastes more effectively. prevents stasis of urine and therefore flushes out bacteria = less UTIImmune systemexercise allows for lymph fluid to be more efficiently pumped through the lymphatic system. moderate exercise enhances immunity, strenuous exercise may reduce immune function. Psychoneurological Systemexercise can elevate mode and relieve stress and anxiety. MoA:exercise increases levels of neurotransmitters exercise increases levels of endorphinsincreases level of O2 to brain inducing euphoriamuscular 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 functionInduces 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 HealthYoga-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 ActivityGrowth & developmentNewbornsmovements are reflexive and randomall 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 Osteoporosisposture changes: leaning forward and stoopedshift center of gravity causing knees to flex to compensateknees flex, support base widens, gait is wide, short stepped, shuffling. NutritionUndernutrition:muscle weakness and fatigueVitamin D deficiency = bone deformity , increases risk of osteoporosis Overnutrition:obesity = distortion in posture, balance, and joint healthPersonal values & attitudesPeople’s values concerning physical activity or type of exercise are affected by:family lifestyle and valuesgeographic location and cultural role expectationspersonal 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 factorsClimateAvailability of recreational facilitieseconomic situationCommunity safety Prescribed limitationsCasts, 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 ImmobilityMusculoskeletal systemdisuse osteoporosiswithout exercise, bones demineralizeDisuse atrophyContractures: permanent shortening of the muscle foot dropStiffness and pain in the joints ankylosed: permanently immobileexcess calcium deposited in joints. CV systemDiminished cardiac reservecauses 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 maneuverValsalva 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 hypotensionVenous vasodilation and stasisImmobile person: skeletal muscles no longer assist in pumping blood back to heart against gravity.blood pools and causes vasodilation and engorgement. valve incompetenceDependent edema Thrombus formationRespiratory systemDecreased respiratory movementintercostal 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 secretionsAtelectasisHypostatic pneumoniaGI systemconstipation 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 systemDecreased metabolic rateNegative nitrogen balancenegative balance between protein anabolism and catabolismmore catabolism of proteins than intakeAnorexiadecreased 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 systemUrinary stasisurine pools due to gravity Renal calculicalcium 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 toneUrinary infection static urineimproper perineal care/ indwelling catheterurinary reflex (backward flow) Integumentary systemReduced skin turgorSkin breakdownPsychoneurological Decline in mood-elevating substances such as endorphins Increased dependence on others may lower person’s self-esteemfrustration and exaggerated emotional reactions Decreased variety of stimuli time perception deterioratesproblem-solving and decision making deteriorate due to lack of intellectual stimulation. Anxiety ~ Nursing Management ~Assessing Nursing HistoryPhysical Examination (Table 3 pg.600) Body Alignment Nurse must identifynormal development variations in postureposture and learning needs to maintain good postureFactors contributing to poor posture, such as fatigue, pain compression fractures, or low self-esteemmuscle weakness or other motor impairments Nurse should observe whether:shoulder and hips are leveltoes point forwardspin 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. GaitStance 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/minolder person may be 40 steps/min. Need for assistive pare gait w/ and w/o devices if possible. Appearance and Movement of JointsExamination of the joints includes: inspection, palpation, assessment of active ROM, and passive ROM. Nurse should assess:swelling, redness, heatdeformitiesmuscle development (size and symmetry)any reported or palpable tendernessCrepitation: 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 illnessobstacles: IV’s, casts, etc. ALOC, meds affecting mental status balance and coordinationorthostatic hypotensiondegree of comfortvisual impairmentsCapabilities of client Muscle Mass and Strengthassess 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. 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 problemsimmobilized for a prolonged perioddecreased muscle mass or musculoskeletal disorderinadequate sleep pain depressed, anxious, or unmotivatedMost useful measurements of predicting activity tolerance:Heart strength, rhythm, and rateRespiratory depth, rhythm, and rateBPmeasure these before, during, immediately after, 3 minutes after activityActivity should be stopped immediately in the event of:sudden facial pallordizziness or weaknesschange in LoCdramatic change in HR or RR from baseline dramatic change in heart or respiratory rhythmweakening of pulseDyspnea, SOB, chest painDBP change of 10mmHg or moreActivity 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 valuesestablish a baseline and compare with later valuesClients at risk of developing complications of immobility:poorly nourishedexisting CV, pulmonary, or neuromuscular problemsdecreased sensitivity to pain, temperature, or pressureALOCDiagnosingActivity IntoleranceLevel 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 weaknessr/t: bed rest; generalized weakness; O2 supply/demand imbalance; immobility; sedentary lifestyleImpaired Physical Mobilitylimitation in independent, purposeful physical movement of the body or of one or more extremitiesimpaired physical mobility can be the etiology (r/t) for:Fear (of falling)Ineffective CopingSituational Low Self-EsteemPowerlessnessRisk for Fallscharacteristics: decreased reaction time; difficulty turning; engages in substitutions for movement (distractions); exertional dyspnea; gait changes; jerky movements; limited ability to perform gross motor skills; limited ability to perform fine motor skills; limited range of motion; movement-induced tremor; postural instability; slowed movement; uncoordinated movementsr/t: activity intolerance; contractures; deconditioning; decreased muscle control; decreased muscle mass; decreased muscle strength; deficient knowledge regarding physical activity; discomfort; joint stiffness; limited CV endurance; loss of integrity of bone structures; malnutrition; medications; neuromuscular impairment; pain Classification scale:0 = completely independent1 = requires use of assistive device2 = requires helps from another person for assistance, supervision, or teaching3 = requires help from another person and assistive device4 = dependent Sedentary Lifestylecharacteristics: daily routine lacking physical exercise, demonstrates physical deconditioning, verbalizes preference for low energy activitiesr/t: deficient knowledge; lack of training; lack of resources; lack of motivation; lack of interest Self-Care DeficitRisk for InfectionRisk for InjuryRisk for Disturbed Sleep PatternIf immobility is prolonged:Ineffective Airway ClearanceRisk for InfectionRisk for Injury r/t orthostatic hypotensionRisk for Disturbed Sleep Pattern Risk for Situational Low Self-Esteem r/t PlanningIncreased tolerance for physical activityRestored capabilities to ambulate and/or participated in ADL’sself-careAbsence of injury from falling or improper body mechanicsfall preventionEnhanced physical fitnessAbsence of any complications associated with immobilityImproved social, emotional, and intellectual well-being focus on positivesdecreased stress levels Body positioningBowel eliminationJoint movementPROMMobilityenhance mobilityRespiratory statusprevent atelectasis and pneumoniaSleep7hrs, limit napsStress leveltherapeutic communication Weight controlImplementingMaintain or promote body alignment & mobility for nurses and patientsPosition clients appropriatelyMoving & turning clients in bedTransferring clientsROM exercisesAmbulating clientsPrevent complications of immobilityUsing Body Mechanics Body mechanics: efficient, coordinated, and safe use of the body to move objects and carry out the ADL’s. Back belts have not been shown to be effective in reducing back injury. Education alone will NOT prevent job-related injuries. Nurses who are physically fit are at NO less risk of injuryA nurse should not lift weights exceeding 35 lbs.if exceeds 35lbs use assistive devices. Benefits of using proper equipment (ex. Mechanical lifts) outweigh the costs of staff injuries.Balance is maintained when the line of gravity falls close to the base of support. The broader the base of support and lower the center of gravity = greater stability and balance.Body balance can be enhanced by widening base of support and lowering center of gravity.LiftingNurses should not lift more than 35lbs without assistance from proper equipment and/or other persons. Lifted objects must be held close to body’s center of gravity to avoid displacement of the center of gravity and achieve greater stability. Using the bones and joints as levers to lift Pulling and Pushing When pushing or pulling: enlarge the base of support by adjusting foot placement. Easier and safer to pull and object than push because more control over object when pulling.Pivotingplace one foot ahead, raise heels, turn while keeping body aligned. Preventing Back InjuryAvoid twisting and stooping Positioning Clients Reposition client q2h when client is completely dependent, preferred two or more nurses to move or turn the client. make sure mattress if firm yet supports natural body curvatureensure bed is clean and dryavoid placing one body part on top of another (especially those with bony prominences) always obtain info of client comfortUse of supportive devices:Pillows (used for elevation, trochanter rolls)Mattresses (standard or egg-crate)Suspension or heel guard bootFootboardHandroll (rolling a washcloth, prevents hand contractures)Abduction pillow (triangle-shaped that maintains hip abduction to prevent dislocation after total hip replacement. Fowler’s (45-60)careful not to put pillows behind neck due to risk of neck flexion contracturesCorrect measures for Fowler's:Support pillows at: lower back , head, neck, under forearms, under thighs, trochanter roll, lower legsSemi-Fowler’s (15-45)High Fowler’s (60-90) Orthopneic (leaning over bedside table)Dorsal Recumbent (supine with shoulders and head elevated by small pillows)Prone Position (on stomach with head turned)Gravity pulls on trunk causing lordosisLateral PositionSims’ Position (half lateral/half prone; lower arm positioned behind client) Used in clients who are: unconscious (facilitates drainage from mouth), paralyzed (reduces pressure on sacrum), enemas, treatments of perineal area, pregnancy Moving and Turning Clients in BedAssess: client need to function independently and the need for assistance to move.Degree of client condition (surgery, pain, etc.)Need for assistive devicesIV’s or catheters to be cautious for Need for assistance Implementation:Face in direction of movement to prevent spinal twisting.Assume broad stanceLower center of gravityTighten major muscle groups to prepare for actionRock from front to back or vice versa in a smooth motion. Assess client for comfort, body alignment, tolerance, ability to assist. Moving a Client Up in Bed:Adjust HoB so that it is in flattest position tolerable for client. (moving client upward against gravity requires more force and can cause back strain)Moving a client up in bed is not a one-person task especially if care giver is required to lift more than 35lbs. for client over 200lbs requires friction-reducing device AND three assistants..Ask client to flex hips and knees and position feet for effective pushing.keeps entire lower leg off bed to prevent friction during movement, and ensures use of large muscle groups in the client’s legs when pushing. Place client’s arms across chest and flex neck to keep head off bed surface. Position yourself appropriately and move clientface direction of movement to prevent twisting of spinebroad stanceshift weight from back leg to front Turning Client to the Lateral or Prone PositionAdjust bed to both client and caregiver comfortMove client closer to side of bed opposite of desired side the client will be facing. Ensures client is in center of bed after turningPlace client’s arm that is closer to edge across chest.Abduct client’s far shoulder slightly away from the side of the body.For prone position, keep arm alongside body. Help facilitate turning motion and prevents arm from being caught under client’s body during the roll. Place client’s near ankle over and across far ankle to facilitate turning motion. Support the client’s hip and shoulder during turn. Position client on side with their arms and legs positioned and supported properly. NEVER pull a client across the bed while in PRONE. (Can injure a client's breasts or genitals) LogrollingAssisting Client to DanglingTransferring ClientsNurse must determine client’s physical and mental capabilities to perform transfer technique.Gait belts and transfer boards When performing a transfer:Plan what, when, where, and howObtain essential equipment remove obstacles from areaexplain transfer to client other nursing personnel always support or hold the client explain step by step what the client should do. document client tolerance (pain, HR, and RR) Transferring OOB to ChairLower bed to lowest position so client's feet will rest flat on floor. Place wheelchair parallel to the bed. Lock wheels. Assist client to dangling position. Assess for orthostatic hypotension. Assist on proper covering and nonskid footwear. Place gait/transfer belt Have client put stronger leg under edge of bed so it can power the movement and provide a broader base of support. Pivot transferProviding ROM ExercisesActive ROMisotonic exercises in which the client moves each joint in the body through its complete range of movement, maximally stretching all muscle groups within each plane over the joint. these exercises maintain or increase muscle strength and endurance and also prevent deterioration of joint capsules, ankylosis, and contractures. Passive ROManother person moves each of the client’s joints through its complete ROM maximally stretching all muscle groups within each plane over each joint. useful in maintaining joint flexibility, but no value in maintaining muscle strength. only performed when client unable to accomplish the movements activelyPROM should be done systematically and repeated throughout the day. Active-assistive ROMclient uses stronger limb to help support and move weaker limb, while nurses continues the movement passively to its maximal degree. Ambulating ClientsAmbulation - act of walkingif immobilized for 1-2 days, a client can feel weak, unsteady, and shaky when getting out of bed. Preambulatory Exercises:Plan of muscle tone exercises to strengthen the muscles used for walking before ambulation.Most important group to exercise is the quadriceps femoris. Using Mechanical Aids for WalkingClient Teaching Using CanesCane is grasped by hand that is opposite the leg that is the weakestStand with a firm grip on the cane At the same time, step forward with the weaker leg & swing the cane the same distance in front. The tip of the cane & forward foot should be evenTake some of the pressure off of the weaker leg by placing pressure on the caneStep past the cane with the strong legRepeat Turn by pivoting on the strong legClient Teaching Using WalkersIf one leg is weaker Move the walker & the weaker leg ahead togetherWeight is borne by the stronger legMove the stronger leg ahead Weight is borne by the affected leg & both armsWhen maximum support is requiredMove the walker ahead Body weight is borne on both legsMove the right foot up to the walkerBody weight is borne by left leg & both armsMove the left foot up the right footBody weight is borne by right leg & both armsCrutchesCrutch Stance (Tripod Position)Crutches placed about 6in in front of feet and 12 inches or more apart depending on height. Taller client’s need a wider base of support. Hips and knees are extended, back is straight, and the head is held straight and high. No hunching of the shoulders to prevent weight bearing of the axillae. If client unsteady, place gait belt and hold from above. Four-Point Alternate GaitEasiest and safest because has 3 points of support at all times. Does not require much space. To use this gait, client needs to be able to bear weight on both legs. Figure 69 pg 631Three-Point GaitMost common seen.Both crutches and weaker leg move forward.Stronger leg move forwardTwo-Point Alternative GaitFaster than four-point, requires more balance and only two points of support at one time. Requires partial weight bearing on each foot. Move opposite foot and crutch at same time. Swing-to Gaitused in clients with paralysis of legs and hips. prolonged use results in atrophy of unused muscles.Easiest of these two gaits.Move both crutches together, Swing body to crutches using arm strength. Swing-Through GaitMove both crutches together. Swing body beyond crutches using arm strength. Getting in/out of a chairGetting in chair: Stand in front of chair with back of stronger leg against chair.Transfer crutches to hand on the affected side and then grasp the arm of the chair with the unaffected side hand.Lean forward, flex knees and hips, and lower into the chair. Getting out of chair:reverse of getting inassume tripod position before moving Going up StairsTripod position -> unaffected leg -> affected legs (+crutches)Going down StairsoppositeEvaluatingHas the client’s physical or mental condition changed motivation to perform required exercise?Were appropriate ROM exercises implemented?Was the client encouraged to participate in self-care activities as much as possible?Was the client encouraged to make as many decisions as possible when developing a daily activity plan and to express concerns?Did the nurse provide appropriate supervision and monitoring?Was the client’s diet adequate to provide appropriate nourishment for energy requirements? ................
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