1. 11/23/2010
The gift of exercise
Physical Activity
Produced by muscle contraction that increases energy
expenditure
Exercise
Planned, structured, repetitive
Maintain physical fitness
Functional Strength
Perform work
Nursing 53A The consequences of disuse
Judy Ontiveros, RN, MSN the state in which an individual is at risk for
deterioration of the body systems as the result of
prescribed or unavoidable musculoskeletal inactivity
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Discuss the importance of maintaining Maintain size, shape, Disuse osteoporosis
tone, and strength of
adequate daily physical activity. muscles (including Disuse atrophy
Describe the consequences of disuse on the the heart muscle) Contractures
Nourish joints
major body functions. Stiffness and pain in
Increase joint the joints
Identify and explain preventive nursing flexibility, stability,
and ROM
interventions for the client who is under
Maintain bone density
temporary or prolonged restriction of and strength
physical activity.
Gift of Exercise Immobility and Its Effect
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Effects of Immobility/Disuse
Deterioration of bones, muscles, and joints
Explain the nature of sleep as a form
of rest. Atrophy
Report the effects of sleep Negative nitrogen balance
deprivation. Contractures
Sleep as a major part of Foot drop
daily rest and the characteristics of Osteoporosis
sleep
Explain the need for a balance
between physical activity and rest.
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2. 11/23/2010
Increases HR, Immobility
Increase ventilation Decreased respiratory strength of Diminished cardiac
and oxygen intake movement contraction, and reserve
improving gas Pooling of respiratory blood supply to the Increased use of the
exchange secretions heart and muscles Valsalva maneuver
Prevents pooling of Mediates harmful Orthostatic hypotension
Atelectasis
secretions in the effects of stress Venous vasodilation and
Hypostatic pneumonia stasis
bronchi and
bronchioles Dependent edema
Thrombus formation
Gift of Exercise Immobility and its Effect Gift of Exercise Immobility and its Effect
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Metabolic demands of the cell decrease
CV workload may increase
Difficult to change positions
Difficult to perform ADLs
Valsalva Maneuver
Orthostatic hypotension
falls occur
Emboli formation
DVT
Pulmonary Embolism
Fatty Embolism – broken bones
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red marrow: hematopoietic
yellow marrow: fat, in hollow area of long bones, originates from red marrow,
converts to yellow by 5 y/o, serves as a last resort for body's energy requirements
Lungs function best when upright
Metabolic need for O2 decreases
Inactive
Breathing becomes shallow Person
Muscles weaken
Ability to cough is compromised
Dehydration
Active
Pneumonia Person
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3. 11/23/2010
Elevates the Decreased metabolic Promotes blood flow Urinary stasis
metabolic rate rate to the kidneys causing Renal calculi
Decreases serum Negative nitrogen body wastes to be Urinary retention
triglycerides and balance excreted more
effectively Urinary infection
cholesterol Anorexia
Stabilizes blood sugar Prevents stasis
Negative calcium
and make cells more (stagnation) of urine
balance
responsive to insulin in the bladder
Gift of Exercise Immobility and It’s Effects Gift of Exercise Effects of Immobility
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Improves the appetite Constipation
Increases GI tract
tone
Facilitates peristalsis
Gift of Exercise Effect of Immobility
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Slows Basal Metabolic Rate (BMR)
Slows GI motility
Decreases nutrient absorption
Patient Picture:
Anorexia
Constipation
Increase fat and cholesterol storage
Negative nitrogen balance
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4. 11/23/2010
Upright
Elevates mood Decline in mood
position
elevating substances
Relieves stress and Perception of time
anxiety intervals deteriorates
Improves quality of Problem-solving and
sleep for most decision-making
abilities may
individuals
deteriorate
Loss of control over
Prone Position events can cause
anxiety
Gift of Exercise Effects of Immobility
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Immobility Patient can lose interest in life
Reduced skin turgor Loneliness and social isolation
Prolonged pressure on bony prominences Powerlessness
Skin Breakdown
pressure ulcer
Loss of role
Skin damage from Behavior changes
shear Sensory deprivation/mental confusion
friction
Sleep interference
maceration
infection
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Exercise Exercise
Pumps lymph fluid from tissues Positive effects on decision-making
into lymph capillaries and vessels and problem solving processes,
Increases circulation through lymph planning, and paying attention
nodes Induces cells in the brain to
Strenuous exercise may reduce strengthen and build neuronal
immune function connections
Leaving window of opportunity for
infection during recovery phase
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5. 11/23/2010
A Basic Need: Body position change
Proper alignment
Physiological effect Stimulate circulation
Maximize respirations
Safety and survival
Prevent skin breakdown
Psychosocial effect
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Mobility Alignment:
Essential part of living Support above and below joint
Protection from harm Anatomic or functional
Meet basic needs
Turn q 1 to 2 hours
Independence
Vs vulnerability / dependency Use positioning aides such as:
Mental well-being / effective body functioning Egg crate
All body parts function more efficiently Over bed cradles
Influences self-esteem and body image
Heel protectors
Independence/usefulness/
Pain = difficult coping strategies Hand rolls
Reaction of others to infirmities
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Movement fostered to full extent of ability Change body positioning:
Satisfying life Active, passive or assistive ROM for all joints
Engage in competitions CPM machine for post op orthopedic surgery
Fitness patients
Create Art
Foot boards
Isometrics
ADL’s
OOB
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6. 11/23/2010
Prevent skin breakdown:
Bathing
Remove excess moisture
Use draw sheet to reduce
shear
Be careful with tape
Get help to move patient
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Elevate legs
TED hose
SEQ
Avoid compression of leg vessels
Gradual adjustment to vertical
Dangle
Tilt table
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Encourage lung expansion
Mobilize secretions
Deep breathing 10X q2 hours
Drinking lots of fluids to liquefy
secretions
2 -3 liters of H2O preferably per day
Cough 5 x q 2 hours
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7. 11/23/2010
Nursing History
Physical Examination:
Body alignment
Gait ACTIVITY REST
Appearance and movement of joints
Capabilities and limitations for movement
Muscle mass and strength
SLEEP
Activity tolerance
Problems related to immobility
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Activity tolerance Mobility
Body positioning Respiratory status
Bowel elimination Ventilation and gas
Fall prevention exchange
behavior Self-care
Immobility Sleep
consequences both Stress level
physiological and Weight control
psychocognitive
Joint movement
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Plan what to do and how to do it Sleep is altered state of consciousness where
Obtain essential equipment before starting perception of and reaction to environment
Remove obstacles decreased
Explain transfer to client and assistive Cyclic nature of sleep thought to be
personnel controlled by lower part of brain
Neurons in reticular formation integrate sensory
Support or hold client rather than equipment information from PNS
Explain what client should do Relay to cerebral cortex
Make written plan, including client’s RAS involved in sleep-wake cycle
tolerance
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8. 11/23/2010
Circadian synchronization when biological
clock coincides with sleep-wake cycle
Person awake when body temp highest and
asleep when body temp lowest
By 3-6 months of age have regular sleep-
wake cycle
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Affect sleep-wake cycle Restores normal levels of activity
Serotonin Restores normal balance among parts of the
Thought to lessen response to sensory stimulation
nervous system
GABA Reticular
Thought to shut off activity in neurons of RAS Necessary for protein synthesis
Activating
Wakefulness Psychological well-being
System
RAS – maintains alertness and wakefulness
RAS receives visual and sensory input and auditory
pain and tactile stimuli
Studies support that wakefulness results from neurons
in the RAS releasing catecholamines
Acetylcholine, dopamine, noradrenalin associated with
cerebral cortical arousal
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Sleep & Temperature: sleeping warm/hot interferes with insulin & glucocorticoid stabilization, role in weight loss
Darkness and preparing for sleep cause
decrease in stimulation of RAS
Pineal gland begins to secrete melatonin and
person feels less alert
During sleep GH secreted and cortisol
inhibited
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9. 11/23/2010
Awake
Stage I
Stage I
NREM
Stage II
NREM
Stage III
NREM
Very light sleep and lasts only a
Stage IV
few minutes
NREM
Feels drowsy and relaxed
Repeat III
Eyes roll from side to side
Repeat II HR and RR drop slightly
Stage V Can be readily awakened and may
REM
deny sleeping
Repeat II
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Refers to basic organization of sleep Stage II
Two types that alternate in cycles during
Light sleep lasts only about 10 to 15
sleep
minutes
NREM
REM
Body processes continue to slow down
Eyes are generally still
HR and RR decrease slightly
Body temperature falls
44% to 55% of total sleep
Requires more intense stimuli to
awaken
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Stage III and IV
Occurs when activity in RAS inhibited Deepest stages of sleep (delta sleep or deep
Constitutes 75% - 80% of sleep sleep)
Consists of 4 stages HR and RR drop 20% to 30% below waking hours
Difficult to arouse
Not disturbed by sensory stimuli
Skeletal muscles very relaxed
Reflexes are diminished
Snoring is likely to occur
Swallowing and saliva production reduced
Essential for restoring energy and releasing
important growth hormones
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10. 11/23/2010
Stage I NREM:
BP falls Light sleep Gradual fall in VS /
Few minutes metabolism
Pulse rate decreases
Peripheral blood vessels dilate Stage II NREM: Body functions slow
CO decreases Sound sleep Relaxation progresses
Skeletal muscles relax 10 to 20 minutes
BMR decreases 10% - 30% Muscles completely
Stage III NREM:
GH levels peak [kids & *adolescents* need sleep!] 1st stages of deep sleep relaxed
Intracranial pressure decreases VS decline / WNL
Sleep Cycles Physiological Changes
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Occurs every 90 minute Stage IV NREM: Body restored / rested
VS significant lower than
deepest stage of sleep waking hours
Lasts 5 to 10 minutes 15 to 30 minutes Sleep walking
Enuresis may occur
Acetylcholine and dopamine
increase
Most dreams take place Stage V REM: Loss of skeletal muscle tone
ANS response of rapidly moving
Deep vivid dream eyes
Brain is highly active Sleep lasts 20 minutes Fluctuating BP, HR, RR rate
and cycles Gastric secretions increase
Brain metabolism increases as much Q 50 to 90 minutes Mental restoration occurs
as 20%
Sleep cycles Physiological changes
Distinctive eye movements occur
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Voluntary muscle tone dramatically Newborns
decreased
Toddlers
Deep tendon reflexes absent
May be difficult to arouse or may wake Adolescents
spontaneously Pregnancy
Gastric secretions increase Menopausal
HR and RR often are irregular
women
Regions of brain associated with learning,
thinking, organizing information stimulated Elderly
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11. 11/23/2010
Sleep 16 to 18 hours a Preschool child
(3-5 years)
day requires 11 to 13
Periods of 1 to 3 hours hours of sleep
spent awake Sleep needs fluctuate
in relation to activity
Enter REM sleep and growth spurts
immediately
School-age child
50% NREM and 50% (aged 5 to 12)
REM needs 10-11 hours of
Sleep cycle ~ 50 sleep
Most receive less
minutes
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Awaken every 3 to 4 Require 9-10 hours
hours, eat, and then go of sleep each night
back to sleep Few actually get
Periods of wakefulness that much sleep
gradually increase
Circadian rhythms
By 6 months, most
tend to shift
infants sleep through the
night and establish a Tendency to stay
pattern up later and wake
Establish a pattern of later
daytime naps
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Adults
12 to 14 hours are 7-9 hours of sleep
recommended Individual variations
Most still need an
afternoon nap Elders
Nighttime fears Tendency toward
earlier bedtime and
and nightmares wake times
are also common May show an increase
in disturbed sleep
Need to sleep does
not decrease with age
circadian rhythm variations - 24.2 hour cycle
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12. 11/23/2010
Illness
Hypersomnia
Environment
Sufficient sleep at night but cannot stay awake
Lifestyle during day
Emotional stress Caused by medial or psychological disorders
Stimulants and alcohol Narcolepsy
Diet Caused by lack of hypocretin in CNS that
regulates sleep
Smoking
Clients have sleep attacks
Motivation
Sleep at night usually begins with sleep-onset
Medications REM period
Insufficient sleep
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Insomnia Sleep apnea
Excessive daytime sleepiness Frequent short breathing pauses during night
More than 5 apneic episodes > 10 sec/hr
Parasomnias
considered abnormal
Symptoms
include snoring
frequent awakenings
difficulty falling asleep
morning headaches
memory and cognitive problems
irritability
Types include obstructive, central, mixed
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Signs: reddened uvula, irritation caused by breathing with open mouth
CPAP
Difficulty falling asleep Behavior that may interfere with or occur
Waking up frequently during sleep
Difficulty staying asleep Arousal disorders
i.e., Sleepwalking, sleep terrors
Daytime sleepiness
Sleep-wake transition disorders
Difficulty concentrating
i.e., Sleep talking
Irritability
Associated with REM sleep
Risk factors i.e., Nightmares
Older age Others
Female i.e., Bruxism
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13. 11/23/2010
Helping client to relax When does client usually go to
Teaching cognitive strategies
sleep?
Administering medications
Preparing the environment for sleep Bedtime rituals?
Promoting dietary changes Does client snore?
Scheduling night time care
Can client stay away during day?
Managing Disorders
Managing symptomatology that disturbs sleep Taking any prescribed or OTC
Managing bedtime agitation medications?
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Reducing environmental distractions Rarely yields information unless client
has obstructive sleep apnea
Promoting bedtime rituals
Enlarged and reddened uvula and soft
Providing comfort measures palate
Scheduling nursing care to promote Enlarged adenoids and tonsils
uninterrupted sleep (children)
Teaching stress reduction, relaxation Obesity (adults)
techniques or good sleep hygiene Neck circumference > 17.5 inches
(men)
Deviated septum (occasionally)
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Experience sleepiness and fatigue Altering or eliminating routines can affect
during day sleep
Adults
Attention and concentration deficits
Listening to music
Reduced vigilance Reading
Distractibility Soothing bath
Reduced motivation Praying
Fatigue, malaise, diplopia, dry Children
mouth Need to be socialized into presleep routine
Usually preceded by hygienic ritual
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14. 11/23/2010
Minimal noise
Comfortable room
temperature
Appropriate ventilation
Appropriate lighting
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• Maintain (or develop) a sleeping
pattern that provides sufficient
energy for daily activities
• Enhance feeling of well being
• Improve the quality and quantity of
the client’s sleep
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Sedative-hypnotics (induce
sleep)
Anti-anxiety or tranquilizers
Be aware of actions, effects,
risks of specific medications
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