Nursing Intervention (Activity and Exercise)

NURSING ASSESSMENT

• Assess patient’s ability to move
• Assess muscle tone, strength
• Assess joint movement and positioning

Nursing Interventions:
1. Position properly to prevent contractures

• Place trochanter roll from the iliac crest to the mid-thigh to prevent EXTERNAL rotation
• Place patient on wheelchair 90 degrees with the foot resting flat on the floor/foot rest
• Place foot board or high-heeled shoes to prevent foot drop

2. Maintain muscle strength and joint mobility

• Perform passive ROME
• Perform assistive ROME
• Perform active ROME
• Move the joints three times TID

3. Promote independent mobility

• Warn patient of the orthostatic hypotension when suddenly standing upright

4. Assist patient with transfer

• Assess patient’s ability to participate
• Position yourself in front of the patient
• Lock the wheelchair or the bed wheel
• Use devices such as transfer boards, sliding boards, trapeze and sheets
• In general, the equipments are placed on the side of the STRONGER , UNAFFECTED body part
• Nurses assist the patient to move TOWARDS the stronger side
• In moving the patient, move to the direction FACING the nurse

5. Assist patient to prepare for ambulation

• Exercise such as quadriceps setting, gluteal setting and arm push ups
• Use rubber ball for hand exercise

6. Assist patient in crutch ambulation
Measure correct crutch length

• LYING DOWN
• Measure from the Anterior Axillary Fold to the HEEL of the foot then:

                     o Add 1 inch (Kozier)
                     o Add 2 inches (Brunner and Suddarth)

• Measure correct crutch length

                    o STANDING (Kozier)
                    o Mark a distance of 2 inches to the side from the tip of the toe (first mark)
                    o 6 inches is marked (second mark) ahead from the first
                    o Measure 2 inches below the axilla to the second mark
                    o Make sure that the shoulder-rest of the crutch is at least 1- 2 inches below the axilla

• Utilizing the patient’s HEIGHT
• Height MINUS 40 cm or 16 inches
• Hand piece should allow 20-30 degrees elbow flexion

Assist patient in Crutch GAIT

• 4 point gait
• three-point gait
• two point gait
• swing to gait
• swing through gait

Assist patient in ambulation with a walker

• Correct height of the walker must allow a 20-30 degrees of elbow flexion

Assist patient in ambulation with a cane

• Correct cane measurement:
• With elbow flexion of 30 degrees, measure the length from the HAND to 6 inches lateral to the tip of the 5th toe