4 Prolonged bedrest
Health care setting
Extended care, acute care, home care
Nursing diagnosis:
Risk for activity intolerance
related to deconditioned status
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess for orthostatic hypotension: Prepare patient for this change by increasing the amount of time spent in high Fowler’s position and moving patient slowly and in stages. | Orthostatic hypotension can occur as a result of decreased plasma volume and difficulty in adjusting immediately to postural change. For more information about orthostatic hypotension, see Risk for Ineffective Cerebral Tissue Perfusion. |
| Assess exercise tolerance: Be alert to signs and symptoms that the cardiovascular and respiratory systems are unable to meet the demands of the low-level range-of-motion (ROM) exercises. | Excessive shortness of breath may occur if (1) transient pulmonary congestion occurs secondary to ischemia or left ventricular dysfunction, (2) lung volumes are decreased, (3) oxygen-carrying capacity of the blood is reduced, or (4) there is shunting of blood from the right to the left side of the heart without adequate oxygenation. If cardiac output does not increase to meet the body’s needs during modest levels of exercise, SBP may fall; the skin may become cool, cyanotic, and diaphoretic; dysrhythmias may be noted; crackles (rales) may be auscultated; or a systolic murmur of mitral regurgitation may occur. |
| Perform ROM exercises 2-4 times/day on each extremity. Individualize the exercise plan based on the following guidelines. | These exercises build stamina by increasing muscle strength and endurance and prevent physiologic problems such as contractures and pressure damage to skin caused by inactivity. |
| Caution: Avoid isometric exercises in cardiac patients. | These exercises can increase systemic arterial blood pressure. |
| Mode or type of exercise: Begin with passive exercises, moving the joints through the motions of abduction, adduction, flexion, and extension. Progress to active-assisted exercises in which you support the joints while patient initiates muscle contraction. When patient is able, supervise him or her in active isotonic exercises, during which patient contracts a selected muscle group, moves the extremity at a slow pace, and then relaxes the muscle group. Have patient repeat each exercise 3-10 times. | Beginning with passive movement, progressing to active-assisted, and continuing with active isotonic takes patient from the least exerting to the most exerting exercises over a period of time, thus enabling gradual tolerance. |
| Caution: Stop any exercise that results in muscular or skeletal pain. Consult a physical therapist (PT) about necessary modifications. | This action prevents injury in a joint too inflamed or diseased to tolerate this type of exercise intensity. |
| Intensity: Begin with 3-5 repetitions as tolerated by patient. | Starting with minimal intensity and progressing step-by-step to more intensity enables gradual tolerance. |
| These assessments help determine tolerance to the exercise. If HR or SBP increases more than 20 bpm or more than 20 mm Hg over resting level, the number of repetitions should be decreased. If HR or SBP decreases more than 10 bpm or more than 10 mm Hg at peak exercise, this could be a sign of left ventricular failure, denoting that the heart cannot meet this workload. For other adverse signs and symptoms, see Assess exercise tolerance. | |
| Duration: Begin with 5 min or less of exercise. Gradually increase the exercise to 15 min as tolerated. | Starting with minimal duration and progressing to greater duration enables gradual tolerance. |
| Frequency: Begin with exercises 2-4 times/day. | As duration increases, the frequency can be reduced. |
| If patient tolerates the exercise, increase intensity or number of repetitions each day. | Tolerance is a sign that cardiovascular and respiratory systems are able to meet the demands of these low-level ROM exercises. |
Ask patient to rate perceived exertion experienced during exercise, basing it on the following scale developed by Borg (1982). | Exercises to prevent deconditioning should be performed at low levels of effort. Patient should not experience an RPE greater than 3 while performing ROM exercises. Intensity of the exercise should be reduced and the frequency increased until an RPE of 3 or less is attained. |
| As patient’s condition improves, increase activity as soon as possible to include sitting in a chair. | To promote optimal conditioning, activity should be increased to correspond to patient’s increased tolerance. |
| Progress activity in hospitalized patients as follows. | Signs of activity intolerance include decrease in BP more than 20 mm Hg, increase in HR to more than 120 bpm (or more than 20 bpm above resting HR in patients receiving beta-blocker therapy), and shortness of breath (discussed earlier). |
| Have patient perform self-care activities as tolerated. | Self-care activities such as eating, mouth care, and bathing may increase patient’s activity level. |
| Teach patient’s significant other the purpose of and interventions for preventing deconditioning. Involve him or her in patient’s plan of care. | Significant others can promote and participate in patient’s activity/exercises once they understand the rationale and are familiar with the interventions. |
| Provide emotional support to patient and significant other as patient’s activity level is increased. | Emotional support helps allay fears of failure, pain, or medical setbacks. |
Nursing diagnosis:
Risk for disuse syndrome
Note:
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess ROM of patient’s joints, paying special attention to the following areas: shoulder, wrist, fingers, hips, knees, and feet. | These areas are especially susceptible to joint contracture. Shoulders can become “frozen” to limit abduction and extension; wrists can “drop,” prohibiting extension; fingers can develop flexion contractures that limit extension; hips can develop flexion contractures that affect the gait by shortening the limb or develop external rotation or adduction deformities that affect the gait; knees may have flexion contractures that can develop to limit extension and alter the gait; and feet can “drop” as a result of prolonged plantar flexion, which limits dorsiflexion and alters the gait. |
| Assess for footdrop by inspecting the feet for plantar flexion and evaluating patient’s ability to pull toes upward toward the head. Document this assessment daily. | Footdrop may occur with prolonged plantar flexion. However, because feet lie naturally in plantar flexion, assess for patient’s inability to dorsiflex (pull the toes up toward the head). This is a sign of footdrop, and it requires prompt intervention to prevent or ameliorate permanent damage. |
| Ensure that patient changes position at least q2h. Post a turning schedule at patient’s bedside. | Position changes not only maintain correct body alignment, thereby reducing strain on the joints, but also prevent contractures, minimize pressure on bony prominences, decrease venostasis, and promote maximal chest expansion. |
| Try to place patient in a position that achieves proper standing. Maintain this position with pillows, towels, or other positioning aids. | A position in which the head is neutral or slightly flexed on the neck, hips are extended, knees are extended or minimally flexed, and feet are at right angles to the legs achieves proper standing alignment, which helps promote ambulation when patient is ready to do so. |
| Ensure that patient is prone or side lying, with hips extended, for the same amount of time that patient spends in the supine position or, at a minimum, 3 times/day for 1 hr. | These positions prevent hip flexion contractures. |
| When the head of bed (HOB) must be elevated 30 degrees, extend patient’s shoulders and arms, using pillows to support the position. | This position maintains proper spinal posture. |
| Allow patient’s fingertips to extend over pillow’s edge. | This position maintains normal arching of the hands. |
| Caution: Ensure that patient spends time with hips in extension (see preceding interventions). | This position helps prevent hip flexion contracture. |
| When patient is in the side-lying position, extend the lower leg from the hip. | This position helps prevent hip flexion contracture. |
| When patient can be placed in the prone position, move him or her to the end of the bed and allow the feet to rest between the mattress and footboard. | This prevents not only plantar flexion and hip rotation, but also injury to heels and toes. |
| Place thin pads under the angles of the axillae and lateral aspects of the clavicles. | These pads help prevent internal rotation of the shoulders and maintain anatomic position of the shoulder girdle. |
| Use positioning devices liberally. | Using pillows, rolled towels, blankets, sandbags, antirotation boots, splints, and orthotics helps maintain joints in neutral position, which helps ensure that they remain functional when activity is increased. |
| When using adjunctive devices, monitor involved skin at frequent intervals. | Assessing for alterations in skin integrity enables prompt interventions that prevent skin breakdown. |
| Teach patient and significant other the rationale and procedure for ROM exercises, and have patient give return demonstrations. Review Risk for Activity Intolerance, p. 58, to ensure that patient does not exceed his or her tolerance. Provide passive exercises for patients unable to perform active or active-assisted exercises. In addition, incorporate movement patterns into care activities, such as position changes, bed baths, getting patient on and off the bedpan, or changing patient’s gown. Ensure that joints especially susceptible to contracture are exercised more stringently. | These actions facilitate adherence to the exercise regimen and help prevent contracture formation. |
| Provide patient with a handout that reviews exercises and lists repetitions for each. Instruct the significant other to encourage patient to perform exercises as required. | These actions facilitate learning and adherence to the exercise program. |
| Perform and document limb girth measurements, dynamography, and ROM, and establish exercise baseline limits. | This assessment of existing muscle mass, strength, and joint motion enables subsequent evaluation and promotes exercise and ROM appropriate for patient. |
| Explain to patient how muscle atrophy occurs. Emphasize the importance of maintaining or increasing muscle strength and periarticular tissue elasticity through exercise. If there are complicating pathologic conditions, consult the health care provider about the appropriate form of exercise for patient. | Muscle atrophy occurs because of disuse or failure to use the joint, often caused by immediate or anticipated pain. This explanation encourages patient to perform exercises inasmuch as disuse eventually may result in decreased muscle mass and blood supply and a loss of periarticular tissue elasticity, which in turn can lead to increased muscle fatigue and joint pain with use. |
| Explain the need to participate maximally in self-care as tolerated. | Self-care helps maintain muscle strength and promote a sense of participation and control. |
| For noncardiac patients needing greater help with muscle strength, assist with resistive exercises (e.g., moderate weight lifting to increase size, endurance, and strength of the muscles). For patients in beds with Balkan frames, provide a means for resistive exercise by implementing a system of weights and pulleys. | Resistance increases the force needed to perform the exercise and promotes the maintenance or rebuilding of muscle strength. |
| First, determine patient’s baseline level of performance on a given set of exercises, then set realistic goals with patient for repetitions (e.g., if patient can do 5 repetitions of lifting a 5-lb weight with the biceps muscle, the goal may be to increase repetitions to 10 within 1 wk, to an ultimate goal of 20 within 3 wk, and then advance to 7.5-lb weights). | Well-planned goals provide markers for assessing effectiveness of the exercise plan and progress made. |
| If the joints require rest, teach isometric exercises. | In these exercises, patient contracts a muscle group and holds the contraction for a count of 5 or 10. The sequence is repeated for increasing counts or repetitions until an adequate level of endurance has been achieved. Thereafter, maintenance levels are performed. |
| Provide a chart to show patient progress, and combine this with large amounts of positive reinforcement. | Attaining progress and having positive reinforcement promote continued adherence to the exercise plan. |
| Post the exercise regimen at the bedside. Instruct the significant other in the exercise regimen, and elicit his or her support and encouragement of patient’s performance of the exercises. | These actions ensure consistency by all health care personnel and involvement and support of significant others. |
| As appropriate, teach transfer or crutch-walking techniques and use of a walker, wheelchair, or cane. Include the significant other in demonstrations, and stress the importance of good body mechanics. | These interventions help ensure that patient can maintain highest possible level of mobility. |
| Provide periods of uninterrupted rest between exercises/activities. | Rest enables patient to replenish energy stores. |
| Seek referral to PT or OT as appropriate. | Such a referral will help patient who has special needs or who is not in a care facility to attain the best ROM possible. |
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