Exercise, Transfers &

Ambulation

Mobility
Mobility refers to a persons ability to move about freely.
Immobility refers to a persons inability to move about freely.
Mobility & immobility are the endpoints of a continuum with many
degrees of partial immobility in between.

mobility

immobility

Some clients move back and forth, some clients remain absolute.

Ability to Move

The ability to move & function is a function most people take for granted.

The level of mobility has a significant impact on an ind.s physiological,

psychosocial, & developmental well-being (Hamilton & Lyon, 1995).

When there is an alteration in mobility, many body systems are at risk for
impairment.
- Cardiovascular functioning orthostatic hypotension
- Pulmonary complications pneumonia
Promote skin breakdown, muscle atrophy etc

Such changes can lead to altered self-concept & lowered selfesteem.

Medical Conditions that can

Alter Mobility
Fractures/sprains
Neurological conditions spinal cord injury, head injury
Degenerative neurological conditions Myasthenia
gravis, Huntingtons chorea

Nursing Measures

Attempt to maintain and/or restore optimal mobility as well as to decrease

the hazards assoc. with immobility.
- Muscle & joint exercises
- Frequent repositioning q 2 hrs
- Fluid intake/fiber intake

Guidelines:
-

Check activity order

Know clients past medical history & limitations
Baseline vital signs are necessary
Become familiar with assistive devices

 Major concern during transfer = Safety of

both the client and the nurse

Range of Motion Exercise

(ROM)
ROM exercises, in which a body part is moved through a range of
motion, are carried out to promote circulation, maintain muscle
tone & promote flexibility. In doing this, joint stiffness & debilitating
contractures are prevented. Active ROM is range of motion
carried out by the patient. It is a form of isotonic exercise & as
such, it maintains strength, tone & flexibility. In patients unable to
move body parts due to paralysis or extreme illness, ROM is
performed by someone else. This is called passive ROM
exercise. Passive exercise helps to maintain joint flexibility &
prevent stiffness & contractures. Because this type of exercise
involves no active movement on the part of the muscles, it does
not contribute to muscle tone or strength.

ROM(cont.)
ROM exercises are planned as a regular part of nursing
activities. During a bath, for example, the nurse has an
excellent opportunity to move the patients limbs
through their full range of motion. The patient is
encouraged to exercise actively those muscles that can
be used. However, in certain cases, the nurse may
need to assist the patient in performing ROM (active
assisted ROM), or to perform passive ROM.

ROM (cont.)

The maximum movement that is possible for a joint is its range of motion.

If a joint is not moved sufficiently it begins to stiffen within 24 hrs &

eventually becomes inflexible, flexor muscles contract & pull tight causing
contractures or fixed joint flexion.

To prevent joint contractures & muscle atrophy (wasting or decrease in

size of a normally developed organ or tissue), exercise must be performed
ROM exercise.

Contracture abnormal flexion & fixation of joints caused by the disuse,

shortening & atrophy of muscle fibers.

Correcting contractures requires intensive therapy over a prolonged period

of time, and may be impossible. Prevention is the key.

Two Purposes of ROM

1. Maintain joint function
2. Restore joint function

Do not exercise joints beyond the

point of resistance or to the point of
fatigue or pain

Contraindications to ROM
ROM requires energy & increased circulation, any
illness/disorder where increased use of energy or
increased circulation is hazardous is contraindicated;
puts strain/stress in soft tissues of the joint & bony
structures, therefore not done with swollen, inflamed
joints.

Perform Exercises in Head to

Toe Format
Start with the head and move down, always do bilaterally
Do not grasp the joint directly
Cup the joint gently (prevents pressure)
Do not grasp fingernail or toenail
Important joints thumb, hip, knee, ankle
Return to correct anatomic position
Move joint through movement 5 times/session

Start at the Neck

P&P p. 830

Neck

Flexion look @ the toes

Extension look straight ahead
Hyperextension look up @ ceiling
Lateral flexion look straight ahead, tilt head to shoulder

Shoulder

Flexion raise arm forward & overhead

Extension return arm to side of body
Abduction raise arm to side to position above head with
palm away from head.
Adduction return arm & bring across chest
Internal rotation elbow flexed, rotate the shoulder by
moving arm til thumb is turned inward & toward the back
(fingers to the floor)
External rotation elbow flexed, move arm until thumb is
upward & lateral to head. (fingers point up)
Circumduction move arm in full circle (arm straight out,
move hand as if to draw a circle.

Elbow
Elbow

Flexion bend elbow

Extension straighten elbow
Hyperextension bend lower arm back as far as
possible

Forearm

Supination turn lower hand so palm is up

Pronation - turn lower hand so palm is down

Wrist

Flexion bend wrist forward

Extension straighten wrist (fingers, wrist & arm in
same plane)
Hyperextension bring dorsal surface of hand as
far back as possible
Abduction (radial flexion) bring wrist medially
towards the thumb
Adduction (ulnar flexion) bend wrist laterally
th

Fingers & Thumb

Fingers &
thumb

Flexion bend fingers & thumb into palm make a

fist
Extension straighten fingers & thumb
Hyperextension bend fingers as far back as
possible
Abduction spread fingers apart / extend thumb
laterally
Adduction bring fingers together/ thumb back
to hand
Circumduction move finger/thumb in circular
motion
Opposition touch thumb to each finger of same
hand

Hip
Hip

Flexion move leg forward (ROM 90-120 deg)

Extension move leg back beside other leg
Hyperextension move leg backwards (ROM
30-50 deg)
Abduction move leg laterally away from body
(ROM 30-50 deg)
Adduction move leg back to medial position &
beyond if possible (ROM 30-50 deg)

Knee

Flexion bring heel toward back of thigh (120130 deg)

Extension return leg to floor

Ankle
Ankle

Dorsiflexion move foot so toes are pointed upward

Plantarflexion move foot so toes are pointed
downward

Foot

Inversion turn sole of foot medially (ROM 10 deg)

Eversion turn sole of foot laterally (ROM 10 deg)
Flexion curl toes downward (ROM 30-60 deg)
Extension straighten toes (ROM 30-60 deg)
Abduction spread toes apart
Adduction bring toes together

Spine
Spine

Flexion when standing bend forward from

the waist
Extension straighten up
Hyperextension bend backward
Lateral flexion bend to the side
Rotation twist from the waist

Types of ROM exercises

Active exercises the client is able to perform
independently.
Passive exercises performed for the client by
someone else.
Active assisted performed by a client with some
assistance client can move a limb partially through its
ROM, but needs help completing the ROM.

Isometric/Isotonic Exercises

In addition to ROM exercises, some immobilized clients may be

able to perform muscle-strengthening exercises.

1.

Isotonic cause muscle contraction & change in muscle length

walking, aerobics, moving arms & legs against light
resistance.

2.

Isometric tightening or tensing of muscles without moving

body parts. This increases muscle tension but do not change
the length of muscle fibers. Isometric exercises are easily
performed by an immobilized patient in bed.
-

Isotonic and isometric exercises help to prevent muscular atrophy and

combat osteoporosis.

Applying Antiembolism Stockings

(Elastic) P&P p. 842

Thromobophlebitis the development of a thrombus or clot

along with the inflammation of the vein & may be classified as
superficial or deep.

Three elements contribute to the development of a clot.

1. Hypercoagulability of the bld clotting disorders,
dehydration, pregnancy & 1st 6 weeks postpartum if the
woman was confined to bed, oral contraceptives.
2. Venous wall damage local trauma, orthopedic
surgeries, major abdominal surgery, varicose veins,
arteriosclerosis
3. Blood stasis immobility, obesity, pregnancy

Antiembolism stockings
Promote venous return by maintaining
pressure on superficial veins to prevent venous
pooling.
Prevent passive dilation of veins
Application of antiembolism stockings (refer to
p. 845 P&P)

Orthostatic hypotension

A drop in blood pressure that occurs when the client rises from lying to sitting or
from sitting to standing. (A decrease in systolic pressure >15 mmHg or decrease
diastolic pressure >10 mmHg.)

At risk clients
- Immobilized clients
- Prolonged bed red

Measures to minimized Orthostatic Hypotension

- Maintain muscle tone
- Increase venous return to the heart
- Decrease stasis of bld in the lower extremities
ROM/isometric exercises/TEDs
Mobilize ASAP

Therapeutic Positions
Chair feet flat on floor, footrest if unable to reach floor, knees & hips
flexed 90-100 degrees. Buttocks at back of the chair, spine straight, pillows
at side to prevent leaning.
Fowlers supine, HOB elevated 45 deg. Promotes lung expansion,
decrease ICP, comfortable for eating.
High fowlers same as above, with HOB elevated 45-90 deg. Utilized for
clients experiencing difficulty breathing.
Semi fowlers as above with HOB elevated less than 45 deg.
Orthopneic sit on side of bed with over bed table across lap, pillow on
table, lean forward & rest head & arms on table. Utilized for patients with
extreme difficulty breathing promotes lung expansion.

Therapeutic positions cont.

Lithotomy supine flex both knees so that feet
are close to hips, separate legs, feet in stirrups.
Utilized for perineal & vaginal examinations
Trendelenburg supine, entire bed frame tilted
down with head 30 deg below horizontal.
- Postural drainage
- Increase venous return in case of shock

Positions and Uses

Dorsal (supine):
* Place patient on back with head and shoulders are slightly elevated.
* Used for physical assessment , to provide comfort , & change position.

Positions and Uses

Dorsal recumbent:
* Place patient on back, legs flexed and slightly rotated outward
*Used for pelvic examination, female catheterization, perinal care

Positions and Uses

Semi-fowlers position:
* Sitting position with or without positioning pillow at head 45-60
degree. used for eating and facilitate breathing.

Positions and Uses

High fowlers position:
*Head & trunk are raised 60-90 degrees, used for some people
with heart problems or having difficulty breathing.

Positions and Uses

Prone position:
* Lying flat on the abdomen, arm flexed toward head, & head
turned to one side. Useful for some unconscious patients.

Benefits of Proper Positioning

Maintains body alignment & comfort
Prevents injury to musculoskeletal system, prevents
strain
Provides sensory, motor & cognitive stimulation
Prevents pressure sore (decubitus ulcer) & joint
contractures

Transfers
Transferring is a nursing skill that helps the client with restricted
mobility attain/maintain mobility & independence.
Benefits of transfers
- Maintains & improves joint motion
- Increases strength
- Promotes circulation
- Relieves pressure on the skin
- Improves urinary/respiratory function
- Increases social activity
- Increased mental stimulation

Transfers - Safety
Safety is a major concern when transferring. Falls are a common
hazard. If a patient starts to fall do not try to stop the fall, instead
assist the patient to the floor while protecting the head from injury.
This will reduce the risk of patient as well as staff injury.
Complete a thorough nursing assessment before you move the
patient to determine if she/he has suffered any injuries.
Prevention of injury is the key, be aware of the clients motor
deficit, ability to support their body weight and use effective body
mechanics & lifting techniques.
When in doubt regarding the patients ability-GET ASSISTANCE

Nursing Process - Transfers

Assessment

Activity orders
Client capabilities

Planning

Decide appropriate transfer technique

Explain procedure to the patient

Implementation

Wash hands
Position chair 45 deg angle to bed on clients stronger
side
Lock bed brakes, lower bed, raise HOB as high as
patient tolerates
Lower side rail
Assist to sitting (lift upper body & swing legs around)
Assist with robe & slippers
Position feet on floor
Take wide stance, bend knees, grasp patient
1 2 3 stand
Pivot to chair

Nursing Process (cont.)

Evaluation

Body in alignment, patient comfortable,

no injuries
Nurse maintains good body alignment

Of note:

Two person lift (same as above) except

one nurse is on each side of the patient
Never lift under the axilla can damage
nerves
Mechanical lifts enables you to lift
heavy patients, or those unable to help.
(Use 2 people)

Ambulation
Clients who have been immobile even for a short time may require
assistance
A client may require the use of an assistive device to aid in
ambulation.
Assistive devices
- Increase stability
- Support a weak extremity
- Reduce the load on weight bearing structures; hip, knees

Assisting the patient

Simple assist
1. Place arm near patient under the arm & at the elbow &
grasp pts hand, synchronize walking with the pt (move
inside foot forward at same time as pts inside foot)
2. Grasp pts left hand in nurses left hand & encircle pts waist
with the rt hand & synchronize walking as above
3. Using a transfer belt (held at the waist from the rear by the
belt helps maintain balance)

Nurse to stand on the pts weak side. The nurse provides

support with his/her leg to the pts weakened one if necessary.
Do not allow the pt. to place their arm around your shoulder.

Walk slowly, even gait, synchronize your steps.

Cane

Helps maintain balance by widening the base of support increases a pts

security.

Should be held on stronger side

- Should have rubber tip prevent slipping
- Height (from greater trochanter to the floor allowing 15-30 deg of elbow
flexion.

Gait place cane 6-10 inches ahead, move affected leg ahead to
cane, place weight on affected leg and cane, move unaffected leg
ahead of cane.

Stand from sitting

- Cane in hand opposite affected leg, grasp arm of chair & cane in other,
push to stand, gain balance

Walker
Wide base of support, provides great stability &
security. Used for clients who are weak or who
has problems with balance.
- Patient should have at least one weight bearing leg and
arm
- Pick up walker is more stable, walker with wheels easier
for pts who have difficulty with lifting or balance, however
can roll forward when weight is applied.
- Height upper bar of walker should be slightly below the
clients waist with arms flexed 15-30 deg

Walker (cont.)
To stand walker in front of seat, push up off arms of
chair (walker is less stable, chair is lower pt. can push
with more force. Hands move to walker one at a time.
To sit back up to chair, reach back with one arm to
arm of chair, then with the other arm and lower to chair.
Gait walker ahead 6-8 inches, weight on arms. Partial
weight on affected leg first.

Crutches
Wooden or metal staff that reaches from the ground to
11/2 2 inches below the axilla. When standing tip of
crutch rests 4-6 inches in front & 4-6 inches to side of
foot.
Do not rest on top of crutches pressure on axilla
nerves can lead to paralysis called crutch paralysis
(numbness, tingling, muscle weakness)

Crutches (cont.) P&P p.859

3 point gait able to wt. bear on one foot, full wt. on
unaffected leg then on both crutches begin in tripod
position, move crutches & affected leg ahead, move
stronger leg forward and repeat.
4 point gait (most stable crutch walk) weight on both
legs and both crutches muscular weakness,
improves balance by providing a wide base of support,
lack of coordination, move each independently rt
crutch-lt foot-lt crutch-rt leg

Assisting with Ambulation

Assistive Devices
-Canes

-Crutches

-Walkers