ADL	Activities of daily living
CMS	Centers for Medicare & Medicaid Services
ID	Identification
OBRA	Omnibus Budget Reconciliation Act of 1987
PT	Physical therapist
ROM	Range of motion

Being active is important for physical and mental well-being. Most people move about and function without help. Illness, surgery, injury, pain, and aging cause weakness and some activity limits. Some people are in bed for a long time. Some are paralyzed. Some disorders worsen over time. They cause decreases in activity. Examples include arthritis and nervous system and muscular disorders (Chapter 39). Inactivity, whether mild or severe, affects every body system. It also affects mental well-being.

Deconditioning is the loss of muscle strength from inactivity. When not active, older persons become deconditioned quickly. Nurses use the nursing process to promote exercise and activity in all persons to the extent possible. The care plan and your assignment sheet include the person’s activity level and needed exercises.

See Residents With Dementia: Exercise and Activity.

RESIDENTS WITH DEMENTIA

Exercise and Activity

Persons with dementia may resist exercise and activity. They do not understand what is happening and may fear harm. They may become agitated and combative. Some cry out for help. Do not force the person to exercise or take part in activities. Stay calm, and ask the nurse for help. Follow the care plan.

Bedrest

The doctor orders bedrest to treat a health problem. It may be a nursing measure if the person’s condition changes. Generally bedrest is ordered to:

• Reduce physical activity

These types of bedrest are common:

• Strict bedrest. Everything is done for the person. No activities of daily living (ADL) are allowed.

• Bedrest. Some ADL are allowed. Self-feeding, oral hygiene, bathing, shaving, and hair care are often allowed.

• Bedrest with commode privileges. The person uses the commode for elimination.

• Bedrest with bathroom privileges (bedrest with BRP). The person uses the bathroom for elimination.

The person’s care plan and your assignment sheet tell you the activities allowed. Always ask the nurse what bedrest means for each person. Check with the nurse if you have questions about a person’s activity limits.

Complications from bedrest

Bedrest and lack of exercise and activity can cause serious complications. Every system is affected. Pressure ulcers, constipation, and fecal impaction can result. Urinary tract infections and renal calculi (kidney stones) can occur. So can blood clots (thrombi) and pneumonia (inflammation and infection of the lung).

The musculo-skeletal system is affected by lack of exercise and activity. These complications must be prevented to maintain normal movement:

• A contracture is the lack of joint mobility caused by abnormal shortening of a muscle. The contracted muscle is fixed into position, is deformed, and cannot stretch (Fig. 26-1, p. 416). Common sites are the fingers, wrists, elbows, toes, ankles, knees, and hips. They can also occur in the neck and spine. The person is permanently deformed and disabled.

• Atrophy is the decrease in size or the wasting away of tissue. Tissues shrink in size. Muscle atrophy is a decrease in size or a wasting away of muscle (Fig. 26-2, p. 416).

Orthostatic hypotension and blood clots (Chapter 35) occur in the circulatory system. Orthostatic hypotension is abnormally low (hypo) blood pressure when the person suddenly stands up (ortho and static). When a person moves from lying or sitting to a standing position, the blood pressure drops. The person is dizzy and weak and has spots before the eyes. Syncope can occur. Syncope (fainting) is a brief loss of consciousness. (Syncope comes from the Greek word synkoptein. It means to cut short.) Orthostatic hypotension also is called postural hypotension. (Postural relates to posture or standing.) Box 26-1 lists the measures that prevent orthostatic hypotension. Slowly changing positions is key.

Box 26-1

Preventing Orthostatic Hypotension

• Measure blood pressure, pulse, and respirations with the person supine.

• Position the person in Fowler’s position. Raise the head of the bed slowly.

• Ask the person about weakness, dizziness, or spots before the eyes. Lower the head of the bed if symptoms occur.

• Measure blood pressure, pulse, and respirations.

• Keep the person in Fowler’s position for a short while. Ask about weakness, dizziness, or spots before the eyes.

• Help the person sit on the side of the bed (Chapter 17).

• Ask about weakness, dizziness, or spots before the eyes. Help the person to Fowler’s position if symptoms occur.

• Measure blood pressure, pulse, and respirations.

• Have the person sit on the side of the bed for a short while.

• Help the person stand.

• Ask about weakness, dizziness, or spots before the eyes. Help the person sit on the side of the bed if any symptoms occur.

• Measure blood pressure, pulse, and respirations.

• Help the person sit in a chair or walk as directed by the nurse.

• Ask about weakness, dizziness, or spots before the eyes. If the person is walking, help the person to sit if symptoms occur.

• Measure blood pressure, pulse, and respirations.

• Report blood pressure, pulse, and respirations to the nurse. Also report other symptoms or complaints.

Good nursing care prevents complications from bedrest. Good alignment, range-of-motion exercises (p. 419), and frequent position changes are important measures. These are part of the care plan.

See Focus on Communication: Complications of Bedrest.

FOCUS ON COMMUNICATION

Complications of Bedrest

Orthostatic hypotension can occur when the person moves from lying to sitting or standing. Fainting is a risk. To check for orthostatic hypotension, ask these questions:

• “Do you feel weak?”

• “Do you feel dizzy?”

• “Do you see spots before your eyes?”

• “Do you feel like fainting?”

Positioning

Body alignment and positioning were discussed in Chapter 16. Supportive devices are often used to support and maintain the person in a certain position:

• Bed-boards—are placed under the mattress. They prevent the mattress from sagging (Fig. 26-3). Usually made of plywood, they are covered with canvas or other material. There are two sections so the head of the bed can be raised. One section is for the head of the bed. The other is for the foot of the bed.

• Foot-boards—are placed at the foot of mattresses (Fig. 26-4). They prevent plantar flexion that can lead to footdrop. In plantar flexion, the foot (plantar) is bent (flexion). Footdrop is when the foot falls down at the ankle (permanent plantar flexion). The foot-board is placed so the soles of the feet are flush against it. The feet are in good alignment as when standing. Foot-boards also serve as bed cradles. They prevent pressure ulcers by keeping top linens off the feet and toes.

• Trochanter rolls—prevent the hips and legs from turning outward (external rotation) (Fig. 26-5). A bath blanket is folded to the desired length and rolled up. The loose end is placed under the person from the hip to the knee. Then the roll is tucked alongside the body. Pillows or sandbags also keep the hips and knees in alignment.

• Hip abduction wedges—keep the hips abducted (apart) (Fig. 26-6). The wedge is placed between the person’s legs. These are common after hip replacement surgery.

• Hand rolls or hand grips—prevent contractures of the thumb, fingers, and wrist (Fig. 26-7, p. 418). Foam rubber sponges, rubber balls, and finger cushions (Fig. 26-8, p. 418) also are used.

• Splints—keep the elbows, wrists, thumbs, fingers, ankles, and knees in normal position. They are usually secured in place with Velcro (Fig. 26-9, p. 418).

• Bed cradles—keep the weight of top linens off the feet and toes (Fig. 26-10, p. 418). The weight of top linens can cause footdrop and pressure ulcers.

Fig. 26-3 Bed-boards. A, Mattress sagging without bed-boards. B, Bed-boards are under the mattress. No sagging occurs.

Exercise

Exercise helps prevent contractures, muscle atrophy, and other complications from bedrest. Some exercise occurs with ADL and when turning and moving in bed without help. Other exercises are needed for muscles and joints. (See “Range-of-Motion Exercises” and “Ambulation,” p. 424.)

A trapeze is used for exercises to strengthen arm muscles. The trapeze hangs from an overbed frame (Fig. 26-11). The person grasps the bar with both hands to lift the trunk off the bed. The trapeze is also used to move up and turn in bed.

Fig. 26-11 A trapeze is used to strengthen arm muscles.

See Focus on Rehabilitation: Exercise.

FOCUS ON REHABILITATION

Exercise

The person works closely with physical and occupational therapists to improve strength and endurance. Care plan goals for exercise and ambulation (p. 424) may change daily. The goal may be to improve the person’s independence so he or she can go home. Or the goal may be to attain the highest level of function possible. The health team works with the person to meet rehabilitation goals. Follow the care plan carefully.

Range-of-motion exercises

The movement of a joint to the extent possible without causing pain is the range of motion (ROM) of that joint. Range-of-motion exercises involve moving the joints through their complete range of motion (Box 26-2). They are usually done at least 2 times a day.