A program of regular physical activity and exercise has the potential to enhance all aspects of a patient’s biopsychosocial and spiritual model of health. This chapter provides you with knowledge of exercise and activity as they relate to health promotion, the acute phase of illness, and the restorative and continuing care of patients, as well as nursing strategies to help plan an individualized exercise and activity program for a variety of patients with specific disease entities and needs.

Scientific Knowledge Base

Regular physical activity and exercise contribute to both physical and emotional well-being (Edelman and Mandle, 2010; Ferrand et al., 2008). Knowing the physiology and regulation of body mechanics, exercise, and activity helps provide individualized care.

Overview of Exercise and Activity

The coordinated efforts of the musculoskeletal and nervous systems maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living (ADLs). Proper balance, posture, and body alignment reduce the risk of injury to the musculoskeletal system and facilitate body movements, allowing physical mobility without muscle strain and excessive use of muscle energy.

Body Alignment

Body alignment refers to the relationship of one body part to another along a horizontal or vertical line. Correct alignment involves positioning so no excessive strain is placed on a person’s joints, tendons, ligaments, or muscles, thereby maintaining adequate muscle tone and contributing to balance.

Body Balance

Body balance occurs when a relatively low center of gravity is balanced over a wide, stable base of support and a vertical line falls from the center of gravity through the base of support. When the vertical line from the center of gravity does not fall through the base of support, the body loses balance. Proper posture or a body position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones enhances body balance (Patton and Thibodeau, 2010). Nurses use balance to maintain proper body alignment and posture through two simple techniques. First widen the base of support by separating the feet to a comfortable distance. Second, increase balance by bringing the center of gravity closer to the base of support. For example, you raise the height of the bed when performing a procedure such as changing a dressing to prevent bending too far at the waist and shifting the base of support.

Coordinated Body Movement

Coordinated body movement is a result of weight, center of gravity, and balance. Weight is the force exerted on a body by gravity. When an object is lifted, the lifter must overcome the weight of the object and be aware of the center of gravity of the object. In symmetrical objects the center of gravity is located at the exact center of the object. The force of weight is always directed downward. An unbalanced object has its center of gravity away from the midline and falls without support. Because people are not geometrically perfect, their centers of gravity are usually midline, at 55% to 57% of standing height. Like unbalanced objects, patients who are unsteady do not maintain a balance with their center of gravity, which places them at risk for falling. You need to be able to identify these patients and intervene to maintain their safety.

Friction

Friction is a force that occurs in a direction to oppose movement. Reduce friction by following some basic principles. When you move objects, those with a greater surface area create more friction. To reduce friction, you need to decrease the object’s surface area. For example, when helping patients move up in bed, place their arms across the chest. This decreases surface area and reduces friction.

A patient who is passive or immobilized produces greater friction to movement (see Chapter 47). When possible, use some of your patients’ strength and mobility when positioning and transferring them. Explain the procedure and tell your patients when to move. You decrease friction when your patients bend their knees as you help them move up in the bed.

You can also reduce friction by using an air-assisted device when performing lateral patient transfers (Baptiste et al., 2006). Air-assisted devices are commercially available transfer devices that are effective solutions to reducing injury to health care employees and patients.

Exercise and Activity

Exercise is physical activity used to condition the body, improve health, and maintain fitness. Sometimes exercise is also a therapeutic measure. A patient’s individualized exercise program depends on the patient’s activity tolerance or the type and amount of exercise or activity that the patient is able to perform. Physiological, emotional, and developmental factors influence the patient’s activity tolerance.

An active lifestyle is important for maintaining and promoting health; it is also an essential treatment for chronic illnesses (Perez et al., 2009). Regular physical activity and exercise enhance functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being (ACSM, 2007; Edelman and Mandle, 2010).

The best program of physical activity includes a combination of exercises that produces different physiological and psychological benefits. Three categories of exercise are isotonic, isometric, and resistive isometric. The type of muscle contraction involved determines the classification of the exercise. Isotonic exercises cause muscle contraction and change in muscle length (isotonic contraction). Examples are walking, swimming, dance aerobics, jogging, bicycling, and moving arms and legs with light resistance. Isotonic exercises enhance circulatory and respiratory functioning; increase muscle mass, tone, and strength; and promote osteoblastic activity (activity by bone-forming cells), thus combating osteoporosis.

Isometric exercises involve tightening or tensing muscles without moving body parts (isometric contraction). Examples are quadriceps set exercises and contraction of the gluteal muscles. This form of exercise is ideal for patients who do not tolerate increased activity. A patient who is immobilized in bed can perform isometric exercises. The benefits are increased muscle mass, tone, and strength, thus decreasing the potential for muscle wasting; increased circulation to the involved body part; and increased osteoblastic activity.

Resistive isometric exercises are those in which the individual contracts the muscle while pushing against a stationary object or resisting the movement of an object (Hoeman, 2006). A gradual increase in the amount of resistance and length of time that the muscle contraction is held increases muscle strength and endurance. Examples of resistive isometric exercises are push-ups and hip lifting, in which a patient in a sitting position pushes with the hands against a surface such as a chair seat and raises the hips. In some long-term care settings, footboards are placed on the end of beds; patients push against them to move up in bed. Resistive isometric exercises help promote muscle strength and provide sufficient stress against bone to promote osteoblastic activity.

Regulation of Movement

Coordinated body movement involves the integrated functioning of the skeletal, muscular, and nervous systems. Because these three systems cooperate so closely in mechanical support of the body, they are often considered as a single functional unit.

Skeletal System

Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis (blood cell formation). In the discussion of body mechanics, two of these functions (i.e., support and movement) are most important (see Chapter 47). Bones serve as support by providing the framework and contributing to the shape, alignment, and positioning of the body parts. Bones, together with their joints, constitute levers for muscle attachment to provide movement. As muscles contract and shorten, they pull on bones, producing joint movement (Patton and Thibodeau, 2010).

Joints

An articulation, or joint, is the connection between bones. Each joint is classified according to its structure and degree of mobility. On the basis of connective structures, joints are classified as fibrous, cartilaginous, or synovial (Huether and McCance, 2008). Fibrous joints fit closely together and are fixed, permitting little, if any, movement such as the syndesmosis between the tibia and fibula. Cartilaginous joints have little movement but are elastic and use cartilage to unite separate body surfaces such as the synchondrosis that attaches the ribs to the costal cartilage. Synovial joints, or true joints, such as the hinge type at the elbow, are freely movable and the most mobile, numerous, and anatomically complex body joints.

Ligaments, Tendons, and Cartilage

Ligaments, tendons, and cartilage support the skeletal system (see Chapter 47). Ligaments are white, shiny, flexible bands of fibrous tissue that bind joints and connect bones and cartilage. They are elastic and aid joint flexibility and support. Tendons are white, glistening, fibrous bands of tissue that connect muscle to bone. Cartilage is nonvascular, supporting connective tissue with the flexibility of a firm, plastic material. Because of its gristle-like nature, cartilage sustains weight and serves as a shock absorber between articulating bones.

Skeletal Muscle

Contraction of skeletal muscles allows people to walk, talk, run, breathe, or participate in physical activity. There are more than 600 skeletal muscles in the body. In addition to facilitating movement, these muscles determine the form and contour of our bodies. Most of our muscles span at least one joint and attach to both articulating bones. When contraction occurs, one bone is fixed while the other moves. The origin is the point of attachment that remains still; the insertion is the point that moves when the muscle contracts (Patton and Thibodeau, 2010).

Muscles Concerned with Movement

The muscles of movement are located near the skeletal region, where a lever system causes movement (Patton and Thibodeau, 2010). The lever system makes the work of moving a weight or load easier. It occurs when specific bones such as the humerus, ulna, and radius and the associated joints such as the elbow act as a lever. Thus the force applied to one end of the bone to lift a weight at another point tends to rotate the bone in the direction opposite that of the applied force. Muscles that attach to bones of leverage provide the necessary strength to move the object.

Muscles Concerned with Posture

Gravity continually pulls on parts of the body; the only way the body is held in position is for muscles to pull on bones in the opposite direction. Muscles accomplish this counterforce by maintaining a low level of sustained contraction. Poor posture places more work on muscles to counteract the force of gravity. This leads to fatigue and eventually interferes with bodily functions and causes deformities.

Muscle Groups

The nervous system coordinates the antagonistic, synergistic, and antigravity muscle groups that are responsible for maintaining posture and initiating movement. Antagonistic muscles cause movement at the joint. During movement the active mover muscle contracts while its antagonist relaxes. For example, during flexion of the arm the active mover, the biceps brachii, contracts; and its antagonist, the triceps brachii, relaxes. During extension of the arm the active mover, now the triceps brachii, contracts; and the new antagonist, the biceps brachii, relaxes.

Synergistic muscles contract to accomplish the same movement. When the arm is flexed, the strength of the contraction of the biceps brachii is increased by contraction of the synergistic muscle, the brachialis. Thus with synergistic muscle activity there are now two active movers (i.e., the biceps brachii and the brachialis), which contract while the antagonistic muscle, the triceps brachii, relaxes.

Antigravity muscles stabilize joints. These muscles continuously oppose the effect of gravity on the body and permit a person to maintain an upright or sitting posture. In an adult the antigravity muscles are the extensors of the leg, the gluteus maximus, the quadriceps femoris, the soleus muscles, and the muscles of the back.

Skeletal muscles support posture and carry out voluntary movement. The muscles are attached to the skeleton by tendons, which provide strength and permit motion. The movement of the extremities is voluntary and requires coordination from the nervous system.

Nervous System

The nervous system regulates movement and posture. The major voluntary motor area, located in the cerebral cortex, is the precentral gyrus, or motor strip. A majority of motor fibers descend from the motor strip and cross at the level of the medulla. Thus the motor fibers from the right motor strip initiate voluntary movement for the left side of the body, and motor fibers from the left motor strip initiate voluntary movement for the right side of the body.

Transmission of the impulse from the nervous system to the musculoskeletal system is an electrochemical event and requires a neurotransmitter. Basically neurotransmitters are chemicals (e.g., acetylcholine) that transfer the electrical impulse from the nerve across the myoneural junction to stimulate the muscle, causing movement. Several disorders impair movement. For example, Parkinson’s disease alters neurotransmitter production, myasthenia gravis disrupts transfer from the neurotransmitter to the muscle, and multiple sclerosis impairs muscle activity (Huether and McCance, 2008).

Proprioception

Proprioception is the awareness of the position of the body and its parts (Huether and McCance, 2008). Proprioceptors located on nerve endings in muscles, tendons, and joints monitor proprioception. The nervous system regulates posture, which requires coordination of proprioception and balance. As a person carries out ADLs, proprioceptors monitor muscle activity and body position. For example, the proprioceptors on the soles of the feet contribute to correct posture while standing or walking. In standing, pressure is continuous on the bottom of the feet. The proprioceptors monitor the pressure, communicating this information through the nervous system to the antigravity muscles. The standing person remains upright until deciding to change position. As a person walks, the proprioceptors on the bottom of the feet monitor pressure changes. Thus, when the bottom of the moving foot comes in contact with the walking surface, the individual automatically moves the stationary foot forward.

Balance

A person needs adequate balance to stand, run, lift, or perform ADLs. The nervous system controls balance specifically through the cerebellum and the inner ear. The cerebellum coordinates all voluntary movement, particularly highly skilled movements such as those required in skiing.

Within the inner ear are the semicircular canals, three fluid-filled structures that help maintain balance. Fluid within the canals has a certain inertia; when the head is suddenly rotated in one direction, the fluid remains stationary for a moment, but the canal turns with the head. This allows a person to change position suddenly without losing balance.

Principles of Transfer and Positioning Techniques

Using principles of safe patient transfer and positioning during routine activities decreases work effort (Box 38-1). Teach colleagues and patients’ families how to transfer or position patients properly. Teaching a patient’s family to transfer the patient from bed to chair increases and reinforces the family’s knowledge about proper transfer and position techniques.

Box 38-1

Principles of Safe Patient Transfer and Positioning

• Mechanical lifts and lift teams are essential when the patient is unable to assist.

• When a patient is able to assist, remember the following principles:

• The wider the base of support, the greater the stability of the nurse.

• The lower the center of gravity, the greater the stability of the nurse.

• The equilibrium of an object is maintained as long as the line of gravity passes through its base of support.

• Facing the direction of movement prevents abnormal twisting of the spine.

• Dividing balanced activity between arms and legs reduces the risk of back injury.

• Leverage, rolling, turning, or pivoting requires less work than lifting.

• When friction is reduced between the object to be moved and the surface on which it is moved, less force is required to move it.

Whether you are moving a patient who is immobile, assisting a patient from the bed to the chair, or teaching a patient to carry out ADLs efficiently, knowledge of safe patient transfer and positioning is crucial. You also incorporate knowledge of physiological and pathological influences on body alignment and mobility.

Pathological Influences on Body Alignment and Mobility

Many pathological conditions affect body alignment and mobility. These conditions include congenital defects; disorders of bones, joints, and muscles; central nervous system damage; and musculoskeletal trauma.

Congenital Defects

Congenital abnormalities affect the efficiency of the musculoskeletal system in regard to alignment, balance, and appearance. Osteogenesis imperfecta is an inherited disorder that affects bone. Bones are porous, short, bowed, and deformed; as a result, children experience curvature of the spine and shortness of stature. Scoliosis is a structural curvature of the spine associated with vertebral rotation. Muscles, ligaments, and other soft tissues become shortened. Balance and mobility are affected in proportion to the severity of abnormal spinal curvatures (Hockenberry and Wilson, 2011).

Disorders of Bones, Joints, and Muscles

Osteoporosis, a well-known and well-publicized disorder of aging, results in the reduction of bone density or mass. The bone remains biochemically normal but has difficulty maintaining integrity and support. The cause is uncertain, and theories vary from hormonal imbalances to insufficient intake of nutrients (Huether and McCance, 2008).

Osteomalacia is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bone (Lewis et al., 2011). Mineral calcification and deposition do not occur. Replaced bone consists of soft material rather than rigid bone.

Joint mobility is altered by inflammatory and noninflammatory joint diseases and articular disruption. Inflammatory joint disease (e.g., arthritis) is characterized by inflammation or destruction of the synovial membrane and articular cartilage and by systemic signs of inflammation. Noninflammatory diseases have none of these characteristics, and the synovial fluid is normal (Huether and McCance, 2008). Joint degeneration, which can occur with inflammatory and noninflammatory disease, is marked by changes in articular cartilage combined with overgrowth of bone at the articular ends. Degenerative changes commonly affect weight-bearing joints.

Articular disruption involves trauma to the articular capsules and ranges from mild, such as a tear resulting in a sprain, to severe, such as a separation leading to dislocation. Articular disruption usually results from trauma but sometimes is congenital, as with developmental dysplasia of the hip (Hockenberry and Wilson, 2011).

Central Nervous System Damage

Damage to any part of the central nervous system that regulates voluntary movement causes impaired body alignment and immobility. For example, a patient with a traumatic head injury experiences damage in the motor strip in the cerebrum. The amount of voluntary motor impairment is directly related to the amount of destruction of the motor strip. For example, a patient with a right-sided cerebral hemorrhage and permanent damage to the right motor strip has left-sided hemiplegia, whereas a patient with a right-sided head injury experiences cerebral edema around (but not destruction of) the motor strip. The patient with hemiplegia does not regain movement, whereas the second patient’s voluntary movement gradually returns to the left side following extensive physical therapy.

Musculoskeletal Trauma

Musculoskeletal trauma often results in bruises, contusions, sprains, and fractures. A fracture is a disruption of bone tissue continuity. Fractures most commonly result from direct external trauma. They also occur because of some deformity of the bone (e.g., with pathological fractures of osteoporosis) (see Chapter 47).

Nursing Knowledge Base

Application of nursing knowledge allows you to think critically about the holistic needs of patients. Nursing knowledge as it pertains to activity and exercise helps you assess, identify, and intervene when patients have decreased activity tolerance or physical limitation that affects their ability to exercise.

Factors Influencing Activity and Exercise

Factors influencing activity and exercise include developmental changes, behavioral aspects, family and social support, cultural and ethnic origin, and environmental issues. Consider these areas of knowledge and incorporate into the plan of care whether the patient is seeking health promotion, acute care, or restorative and continuing care.

Developmental Changes

Throughout the life span the appearance and functioning of the body undergo change. The greatest change and effect on the maturational process occurs in childhood and old age.

Infants Through School-Age Children

The newborn infant’s spine is flexed and lacks the anteroposterior curves of the adult. The first spinal curve occurs when the infant extends the neck from the prone position. As growth and stability increase, the thoracic spine straightens, and the lumbar spinal curve appears, which allows sitting and standing.

The toddler’s posture is awkward because of the slight swayback and protruding abdomen. As the child walks, the legs and feet are usually far apart, and the feet are slightly everted (turned outward). Toward the end of toddlerhood, posture appears less awkward, curves in the cervical and lumbar vertebrae are accentuated, and foot eversion disappears.

By the third year the body is slimmer, taller, and better balanced. Abdominal protrusion decreases, the feet are not as far apart, and the arms and legs have increased in length. The child appears more coordinated. From the third year through the beginning of adolescence, the musculoskeletal system continues to grow and develop (see Chapter 12).

Adolescence

The period of adolescence usually begins with a tremendous growth spurt. Growth is frequently uneven. As a result, the adolescent appears awkward and uncoordinated. Adolescent girls usually grow and develop earlier than boys. Hips widen; and fat deposits in the upper arms, thighs, and buttocks. The adolescent boy’s changes in shape are usually a result of long-bone growth and increased muscle mass (see Chapter 12).

Young to Middle Adults

An adult with correct posture and body alignment feels good, looks good, and generally appears self-confident. The healthy adult also has the necessary musculoskeletal development and coordination to carry out ADLs (see Chapter 13). Normal changes in posture and body alignment in adulthood occur mainly in pregnant women. These changes result from the adaptive response of the body to weight gain and the growing fetus. The center of gravity shifts toward the anterior. The pregnant woman leans back and is slightly swaybacked; as a result, pregnant women often complain of back pain.

Older Adults

A progressive loss of total bone mass occurs with the older adult. Some of the possible causes of this loss include physical inactivity, hormonal changes, and increased osteoclastic activity (i.e., activity by cells responsible for bone tissue absorption). The effect of bone loss is weaker bones, causing vertebrae to be softer and long shaft bones to be less resistant to bending.

In addition, older adults may walk more slowly and appear less coordinated. They often take smaller steps and keep their feet closer together, which decreases the base of support. Thus body balance is unstable, and they are at greater risk for falls and injuries (see Chapter 14).

Behavioral Aspects

Patients are more likely to incorporate an exercise program into their daily lives if supported by family, friends, nurses, health care providers, and other members of the health care team. The nurse takes into consideration the patient’s knowledge of exercise and activity, barriers to a program of exercise and physical activity, and current exercise habits. Patients are more open to developing an exercise program when they are at a stage of readiness to change their behavior (Prochaska, Norcross, and DiClemente, 1994). Information about the benefits of regular exercise is often helpful to the patient who is not at the stage of readiness to act. Patients’ decisions to change behavior and include a daily exercise routine in their lives sometimes occur gradually with repeated information individualized to patients’ needs and lifestyle (Box 38-2). Once the patient is at the stage of readiness, collaborate with him or her to develop an exercise program that fits his or her needs and provide continued follow-up support and assistance until the exercise program becomes a daily routine.

Box 38-2

General Guidelines for Initiating an Exercise Program

Five steps to beginning an exercise program:

Step 1: Assess fitness level.

• Seek approval from a health care provider to begin. Are there any limitations to consider before determining the exercises in the fitness program?

• Record baseline fitness scores such as pulse rate, how long it takes to walk 1 mile, waist circumference, and body mass index.

Step 2: Design the fitness program.

• Consider fitness goals. Make goals attainable.

• Plan a logical progression of activities (e.g., walk a mile and gradually increase the pace).

• Build the program into a daily routine.

• Plan the fitness program with creativity and different activities.

Step 3: Assemble equipment.

• Choose athletic shoes designed for the chosen exercise.

• Try equipment at a fitness center before purchasing to make sure it fits into the fitness program.

• Buy used fitness equipment.

• Try homemade equipment (e.g., half-gallon milk jugs filled with sand for weights).

Step 4: Get started.

• Start slowly, including a warm-up and cool-down period.

• Divide exercise time throughout day if time or fatigue is a barrier. Ten minutes of exercise 3 times a day instead of a single 30-minute workout may be better for some patients’ schedules and medical conditions.

Step 5: Monitor progress.

• Retake fitness assessment at 6 weeks and then every 3 to 6 months.

• If losing motivation: set new goals, exercise with a friend, or incorporate new activities

Modified from American College of Sports Medicine: Position stand on fitness: the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness and flexibility in healthy adults, 2007, accessed August 2010 from http://www.50plus.org/Libraryitems/1_5positionstandonfitness.htm; and Mayo Clinic Tools for Healthier Lives: Fitness programs: 5 steps to getting started, 2008, accessed August 2010 from http://www.mayoclinic.com/health/fitness/HQ00171/NSECTIONGROUP=2.

Environmental Issues

Work Site

A common barrier for many patients is the lack of time needed to engage in a daily exercise program. Some work sites help their employees overcome the obstacle of time constraints by offering opportunities, reminders, and rewards for those committed to physical fitness (Kuoppala, Lamminpää, and Husman, 2008). Reminders such as signs that encourage employees to use the stairs instead of elevators are useful. Rewards such as free parking or discounted parking fees are also effective for employees who park in distant lots and walk.

Schools

Children today are less active, resulting in an increase in childhood obesity (Harper, 2006; Ward et al., 2010). Schools are excellent facilitators of physical fitness and exercise. Strategies for physical activity incorporated early into a child’s daily routine often provide a foundation for lifetime commitment to exercise and physical fitness.

Community

Community support of physical fitness is instrumental in promoting the health of its members (e.g., providing walking trails and track facilities in parks and physical fitness classes). Success in implementing physical fitness programs depends on a collaborative effort from public health agencies, parks and recreational associations, state and local government agencies, health care agencies, and the members of the community (Bors et al., 2009; Harper, 2006).

Cultural and Ethnic Influences

Exercise and physical fitness are beneficial to all people. When developing a physical fitness program for culturally diverse populations, consider what motivates them and what they see as appropriate and enjoyable. It is also important to know which specific disease entities are associated with different cultural and ethnic origins (Box 38-3).

Box 38-3

Cultural Aspects of Care

Incidence and Challenges of Type 2 Diabetes Among Ethnic Groups in the United States

Studies of ethnic groups indicate that physical inactivity is one of the risk factors associated with type 2 diabetes. In the United States type 2 diabetes is more prevalent in blacks and Native Americans. Physical activity plays an important role in the prevention and treatment of type 2. However, the black and Native American populations have a disproportionate number of individuals who are poor, unemployed, and disadvantaged and who lack access to the health care system (Huang et al., 2009; Maskarinec et al., 2009).

Implications for Practice

• Physical inactivity is a modifiable risk factor for the development of type 2. Prevention and treatment programs need to focus on exercise and be tailored to the activity tolerance and interests of each patient.

• Support promotion of physical activity through formal programs in schools, churches, and government agencies within black and Native American communities.

• Incorporate motivational factors into the exercise program such as providing a healthy snack or meal for the participants and furnishing each patient with a log to monitor weight loss and blood glucose levels.

• Exercise and diabetes prevention programs need to remove potential barriers such as transportation and cost to facilitate commitment to the program.

Family and Social Support

Social support is one motivational tool to encourage and promote exercise and physical fitness. For example, a patient engages a friend or significant other to participate in a “buddy system” where they walk together each day at a specified time. This companionship provides for socialization, increases the enjoyment, and develops a lifelong commitment to physical fitness. Parents support their children in sports and physical activity by providing encouragement, praise, and transportation (Davison and Jago, 2010; Dunton, 2010). Other parents support physical activity by including their children in family outings such as bicycling or a basketball game in the neighborhood schoolyard.

Critical Thinking

Successful critical thinking requires a synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Patients’ conditions are always changing. Clinical judgments require you to anticipate the necessary information, analyze the data, and make decisions regarding patient care.

To understand activity tolerance, physical fitness, and the effect on the patient, you integrate knowledge from nursing and other disciplines, previous experiences, and information gathered from patients. As you plan patient care, consider the relationship among a variety of concepts to provide the best outcome for the patient. For example, you lay the foundation for planning and decision making by understanding the relationship between the musculoskeletal system and health alterations that create problems with activity and exercise, positioning, and transferring. Professional standards such as those developed by the American College of Sports Medicine (ACSM) (2007) and the American Diabetes Association (ADA) (2007) provide valuable guidelines for exercise and physical fitness. In addition, using the recommendations from the American Nurses Association (ANA) (2008) reduces the risk for work-related musculoskeletal disorders.

Any acquired or congenital condition that affects the structure of the musculoskeletal or nervous system impairs activity, body alignment, or joint mobility to some degree. The impairment is sometimes temporary, such as casting of an extremity, or is permanent, such as a contracture. For patients with limited range of motion (ROM) or mobility, the nursing care plan needs to include interventions that maintain the present level of alignment and joint mobility and increase the level of motor function.

Your experiences and critical thinking attitude affect the problem-solving approach with patients and are evaluated with each new patient. Remember that some patients have the capacity for recovery in spite of the loss of some physical function. Restoration of function begins early in the care of patients whose ability to perform self-care is disrupted. Encouragement, support, commitment, and perseverance are important attitudes in critical thinking for these patients.

Perseverance is necessary when caring for patients who depend on you for assistance with positioning, turning, or ambulation. Hourly responsibility for turning often becomes repetitive, and some nurses lose sight of its importance. Perseverance is especially important in delegating these activities to other personnel. Making certain that the task is performed correctly is an essential nursing function. Problems with activity and mobility are often prolonged; creativity is necessary when designing interventions for improving activity tolerance and mobility skills.

Nursing Process

Apply the nursing process and use a critical thinking approach in your care of patients. The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care.