Respiratory

Peak Expiratory Flow Rate (PEFR)

– It refers to the point of highest flow during forced expiration

– It reflects changes in the size of pulmonary airways

– Measured by a peak flow meter

– Measurements are most useful when a person is able to take and compare

measurements on a day-to-day basis.

Peak flow meter

– A hand-held device

– The client stands and exhales into the mouthpiece.

– Commonly used to diagnose and monitor lung diseases such as:

Asthma, Chronic bronchitis, COPD, Emphysema

– Normal range: 300 to 700 L/min (based on age, gender, height, weight &

underlying lung disorder)

Instruction for use:

Instruct patient to inhale as deeply as possible

Then place mouth around mouthpiece, forming a tight seal

If possible, the patient should be in a standing position

Have the patient blow out through mouth as hard and fast as possible

– As patient forcefully exhales, indicator moves up scale to record patient’s peak

expiratory flow (L/min)

Repeat the procedure three times and record the highest value

– Ask the patient to keep record and report if significant changes occur

Instruct patient to clean the unit as least once weekly, following manufacturer's

instructions

Incentive spirometer

– Also referred as sustained maximal inspiration devices (SMIs)

– It is used to:

Promotes deep breathing exercise to expand collapsed alveoli

– To prevent/ resolve pulmonary atelectasis

Helps patients to improve pulmonary ventilation & facilitates respiratory

gaseous exchange

– Especially after thoracic or cardiac surgeries

Helps to loosen respiratory secretion and to minimize the chance of fluid

accumulation in the lungs

Instructions for use:

Better have the patient sitting upright, either in bed or in chair

– To facilitates chest expansion

Hold the spirometer in an upright position. Have the patient to exhale fully

Seal the lips tightly around the mouthpiece. Then take in a slow, deep breath from

the mouthpiece

– Correct placement and effort should elevate the balls and keep them floating

– Slow inspiration can enhance greater lung expansion. Avoid brisk, low-volume

breaths

Sustain the inspiration for ~ 3 seconds after the lungs are fully inflated

– It helps to open up the closed alveoli

– A nose clip can be used if unable to breathe through the mouth only

Instruct the patient to remove the mouthpiece, relax and passively exhale

Patient should take several normal breaths before attempting another one with the

incentive spirometer

At the conclusion of the treatment, encourage the patient to cough

– Deep lung inflation may loosen secretion and enable the patient to expectorate

them

Repeat the procedure several times and then 4-5 times/ hour

Patient Teaching – Use of MDI

Dos

1. Firmly insert the MDI canister into holder

2. Remove mouthpiece cap. Shake for 3-5 seconds

3. Exhale slowly and completely

4. Hold the canister upside down, seal the lips around mouthpiece

5. Press and hold canister down once while inhaling deeply and slowly for 3 to 5

seconds

6. Hold breath for 5 -10 seconds. Release pressure on container and remove

from mouth, then exhale

7. Wait 20 to 30 seconds before repeating for a second puff

8. Rinse mouth/ brush teeth after use

Don’t

Do not block the opening with the tongue or teeth

Never exhale into the mouthpiece

If mist can be seen from the mouth or nose, the device is not used properly

Do not try to float the canister in water to test whether it is empty

Common mistakes in using MDI:

Fail to shake the canister

Hold the inhaler in a wrong way

Inhale through the nose rather then the mouth

Inhale too rapidly

Stop inhalation while feeling the cold propellant is in the throat

Fail to hold the breath after inhalation

Inhale two sprays with one breath

Need very good coordination skills

The patient must activate the device while continuing to inhale

If unable to coordinate, a spacer may be used

If both bronchodilator and anti-inflammatory drugs are ordered by inhaler, the nurse

should instruct the client to take the bronchodilator first **

– Let the bronchioles dilate first, so more tissue is exposed for the

anti-inflammatory drugs to act upon

Rinse mouth/ brush teeth after using anti-inflammatory drugs to prevent complication

– To prevent oral fungal infections

7. Oxygen Therapy

Goals: To prevent or relieve hypoxia (inadequate oxygen supply)

Treated as a drug **

– Can benefit patients with impaired tissue oxygenation

– Can also caused oxygen toxicity

Prescribed by doctors who specifies:

– Concentration or Liter flow/ minute

– Method of delivery

Nurses need to continuously monitor the dosage and concentration used, as well as the

effect and side effect of the therapy

Indications:

Patients with hypoxia

Patients with pulmonary diseases, eg. Chronic obstructive pulmonary disease (COPD);

Asthma, emphysema

Patients with cardiovascular diseases, eg. Myocardial infarction, Anemia, Shock

Patients undergoing cardiopulmonary resuscitation (CPR)

Patients under general anesthesia

Oxygen therapy – Safety Precautions

Oxygen is a highly combustible gas

Do not smoke near the oxygen equipment

Instruct clients and visitors for the hazard of smoking

Make sure all electrical appliance are function properly and are electrically grounded

Avoid materials that generate static electricity

– Advice client to wear cotton fabrics

Avoid use of volatile, flammable materials, such as alcohol, acetone (eg. Nail polish

remover) near clients receiving oxygen

Locate fire extinguishers; know the fire procedure and the route for evacuation

Oxygen Therapy in Client with COPD

Normally, people relies on high serum level of CO2 to signal them to increase their

breathing rate

For COPD patients, they are accustomed to high CO2 concentration

– Low O2 level become the drive.

– i.e. High O2 flow will remove the stimulus for breathing.

Hypoxic Drive

Nursing responsibilities:

• Observe closely on their respiratory status

1. Nasal cannula

Also called nasal prongs

Most commonly used and inexpensive device

Delivery of low to moderate concentration

Can deliver 24% to 44% O2 at the flow rate of 1 to 6 LPM

Using nasal cannula

– Place nasal prongs of cannula into patient’s nares

– Fit cannula tubing around patient’s ears and adjust tubing slide under patient’s

chin

– Adjust flow rate

– For nasal cannula, limit the flow rate to < 6L/min

2. Face Mask

Have both disposable and reusable

Able to fit to patient’s face to avoid leakage

There are 4 different types of face masks, and are used to deliver either low or high

concentration of oxygen:

– Low O2 concentration:

Simple face mask

– High O2 concentration

Partial rebreather mask – rarely used now

Non-rebreather mask

Venturi mask

Simple face mask

It is a transparent mask with simple adaptor

It covers the patient’s mouth and nose for oxygen inhalation

It is connected to oxygen tubing and a flow meter, just like the nasal cannula

The exhalation ports on the sides of the mask allows:

– Room air to leak in, thereby diluting the source oxygen

– Also allows CO2 to escape 13 NURS S103F_14/15_Respiratory Care_Student Handouts

It delivers oxygen concentration from 35% to 60% range (= 6 to 10 LPM).

Never apply the face mask with delivery flow rate < 5 L/min to avoid CO2

retaining

Mask can be replaced with nasal cannula during meal time if no

contraindications

Venturi mask

A high flow oxygen therapy device

It gets its name from the Venturi effect

– Air is entrained from the side port of a plastic oxygen diluter to mix with

the oxygen to achieve a certain concentration of oxygen

– Able to deliver the precise concentration of O2

It delivers O2 concentrations varying from 24% to 40/50% at their

corresponding liter flow of 4 to 10L/minute

Do not occlude the windows of the Venturi mask as this may alter the conc.

Of O2

Non-rebreather mask

It delivers the highest oxygen concentration possible - 95 -100% at liter flows

of 10 to 15 L/min

One way valve (rubber flaps) on the sides of the mask

– Open during exhalation; close during inhalation

– Prevent the patient inhale the room air during inhalation

One way valve between the reservoir bag and the mask

– Open during inhalation; close during exhalation

– Only oxygen is inside the reservoir bag

– Prevent the client’s exhaled air from

entering the bag

– Therefore, only the oxygen in the bag is

inspired

The bag should remain at least one-third

inflated

– To prevent CO2 build up

Grieving & Death

Death

At the moment of Death,

• Cessation of all physiological and brain functions

• No spontaneous breathing movements

• No pulse and heartbeat

• Fixed and dilated pupils; eye may stay open 11

• Cessation all reflexes

• Complete unresponsive to external stimuli

• Waxen colour (pallor) as blood settles to dependent areas

• Body temperature drops

• Release of stool & urine

Body changes after death

• Algor Mortis

• Rigor Mortis

• Livor Mortis

Algor Mortis

• gradual decrease of body temperature after death

• body temperature falls about 1℃(1.8℉)per hour until it reaches room

temperature

Rigor Mortis

• Stiffening of the body about 2 to 4 hours after death because of lack of ATP

(adenosine triphosphate)

• Muscle contracts and immobilizes the joints when it occurs

• It starts in involuntary muscles (eg. heart, bladder), then the head, neck and

trunk, and finally reaches the extremities

• Nurses should position the body, place dentures in the mouth, and close the

eyes and mouth before rigor sets in

Livor Mortis

• Occurs in dependent and lowermost area of the body after 6-8 hours.

• After blood circulation ceases, red blood cell (RBC) will be broke down and

hemoglobin will be released.

• Bluish purple patches thus appear in surrounding tissues.

• The skin loses its elasticity and can easily be broken.

• Be cautious when removing adhesive tape from the body to avoid skin

breakdown.

• Elevates the head to prevent pooling of blood and cause discolouration in head.

Categories of Dead Body

• All dead bodies are potentially infectious

• Classified into 3 categories based on

- mode of transmission of disease

- risk of infection

• Cat.1 : Standard Precautions

• Cat.2 : Additional Precautions

• Cat.3 : Stringent Precautions

3 Categories of dead body

Risk categories Infection

Category 1 :Other than those specified in Cat 2 & Cat 3 below

Category 2: Human Immunodeficiency Virus infection (HIV), Hepatitis C, Severe Acute Respiratory

Syndrome (SARS), Avian Influenza, Creutzfeldt-Jacob disease without necropsy

Category 3 :Anthrax , Plague , Rabies , Creutzfeldt-Jacob disease with necropsy

Categories of dead body: Cat 1

Disposal of dead body: Coffin burial or cremation is optional

Standard Precautions

• Avoid / minimal handle to the body

• No smoking or eating when handling the body

• No touching mouth, eyes and nose when handling the body

• Avoid direct contact with the blood and body fluid of the deceased

• Ensure all wounds dressed with impermeable materials

• Wear disposable gloves and PPE

• Hand wash after removal of gloves or PPE

Categories of dead body: Cat 2

Disposal of dead body: Cremation is mandatory

Additional Precautions

• Dress the deceased with own clothes /disposable gown/ shroud

• Place the body in a robust and leak proof plastic bag of ≧150µm thick, zipped

or closed tightly with tapes and bandage strips, no pins

• If the outside of the plastic bag soiled, wipe with disinfectant solution

• Wrap with mortuary sheet before transport out to mortuary

• Avoid autopsy for cat. 2 & 3 cases

• Applicable to bodies with unknown categories

Categories of dead body: Cat 3

Disposal of dead body: Cremation is advisable

Stringent Precautions

On top of standard and additional precautions,

• The body should not be removed from the plastic bag

• Unzip the plastic bag of the body is not permitted

• Cremation is advisable

• Consult doctor if suspicious being infected

Wound Dressing

Phases of Wound Healing

There are 4 phases of wound healing: Hemostasis, Inflammation, Proliferation &

Maturation

1. Hemostasis

Occurs immediately after injury

Last for about 3 – 6 days

Blood vessels will constrict

To stop bleeding

Platelet activation and clustering

To form blood clot

The same blood vessels will dilate after a brief period of time

Allow plasma to leak out to form exudate, which will cause swelling and pain

2. Inflammation

Follows hemostasis, lasts for ~ 4 – 6 days

White cells, mainly leukocytes, move to the wound first

To ingest bacteria and cellular debris

After ~24 hours, macrophages enter the wound area

To ingest bacteria

To release growth factors for the growth of epithelial cells and new blood

vessels

Characterized by pain, heat, redness, and swelling

Patients might also have an temp. and malaise

3. Proliferation

Also referred as fibroblastic, regenerative, or connective tissue phase

Last for several weeks

New tissue is built to fill the wound space

Connective tissue cells (fibroblast) will synthesis and secrete collagen and produce 5 NURS

S103F_14/15_Wound Care & Dressing_Student Handouts

specialized growth factors

Epithelial cells form across the wound

The new tissue (granulation tissue) forms the scar tissue development

4. Maturation

The final stage, begins about 3 weeks after the injury, continue for months to

years

The collagen that was deposited in the wound is remodeled and contracted,

making the healed wound stronger and more like adjacent tissue

Scar

Scar tissue is strong but less elastic than uninjured tissue

If the scar is over a joint or other body structure, it may limit movement and

cause disability

Sutures, Staples, and Steri-strips

Skin Sutures (stitches)

A suture is a thread used to sew body tissues together

Absorbable – used to attach tissues beneath the skin

Disappear (dissolve) in several days

Non-absorbable – for skin

Made of various materials: silk, cotton, linen, wire, nylon & Dacron

(polyester fiber)

Need to be removed

Removed when enough tensile strength has developed to hold the

wound edges together

Time needed depends on:

Client’s age, Nutritional status, Presence of obesity, and Wound

Location

Different methods of suturing

Plain interrupted

Plain continuous

Blanket continuous

Skin Staples

Instead of using sutures, clips/ staples are also used

Depends on surgeons’ preference

Steri-strips

Adhesive wound closure strips

Usually applied after removal of sutures/ staples

Applied across the healing wound to help hold it together and give additional

support as it continues to heal

Unless otherwise directed, the strips are not removed during regular dressing

change

Nursing Process for Wound Care

Assessment

Wound assessment involves:

Inspection

Palpation

Wound assessment provide data:

Effectiveness of treatment

Wound healing progression

Should be performed at regular interval

Eg. every day during dressing change

Wound Assessment

1. Appearance of the wound

Location

Size

Length, width, depth

Measured in mm/ cm

Measure diameter if wound is circular

Draw the shape if needed

Approximation of wound edges

Signs of dehiscence or evisceration

Presence of drainage/ exudate

Color, consistence, amount, odor

Color of the wound

RED = proliferation stage of healing; need protection with gentle cleansing,

or change dressing only when necessary (Granulation tissue)

Yellow = indicate presence of drainage/ slough; often accompanied with

purulent drainage; requires wound cleansing with wound cleansers (Slough)

Black = indicate presence of eschar; requires debridement (removal) before

the wound can heal (Necrotic tissue)

2. Presence of drains, tubes, staples and sutures

3. Surrounding skin condition

May first appeared bruised

Wound edges may appear reddened and slightly swollen, will return to normal as

blood is reabsorbed

4. Signs of wound infection

Hot on palpation

Increased drainage, possible purulent

Separated wound edges

5. Presence of undermining and tunneling

Measuring of wound tunneling

Determine direction

Insert a sterile applicator into the site

View the direction of the applicator as if it were the hand of a clock

The direction of the client’s head is 12 o’clock

Determine depth

While the applicator is inserted, mark the point on the swab that is even

with the wound’s edge, then measure the depth with ruler

6. Presence of wound pain

Ask the client – subjective feelings

Use pain assessment scale

Measure and document the pain level before, during and after procedure

7. Laboratory data

Leukocyte count

: may delay wound healing, increase possibility of infection

: active infection is going on

Hemoglobin level

: indicates poor oxygen delivery to the tissues

Blood coagulation study

: lead to intravascular clotting

: result in excessive blood loss and prolonged clot absorption

Albumin

: indicates poor nutrition, and may increase risk of poor healing and

infection

Wound Culture

Obtain whenever wound infection is suspected

Helpful in the selection of antibiotic therapy

Nursing Diagnosis

The collection of data from assessment leads to the development of nursing

diagnosis

Examples of nursing diagnosis:

Disturbed body image

Acute pain/ chronic pain

Impaired skin integrity

Activity intolerance

Deficient knowledge related to wound care

Principles of Aseptic Technique

1. All objects used in a sterile field MUST be sterile

Always check sterile package for intactness, dryness and expiry date

Expired sterile packages are considered non-sterile

Check chemical indicators of sterilization before use

Storage area for sterile packages should be clean, dry, off the floor, and away from

sink

2. Sterile objects become unsterile when touched by unsterile objects

Handle sterile objects/ wound only with sterile forceps or sterile gloved hands

Whenever the sterility of an object is questionable, assume the article is unsterile

3. Sterile items that are out of vision or below the waist or table level are considered

unsterile

Once left unattended, a sterile field is considered unsterile

Always keep sterile object in view – do not turn your back on a sterile field

Always keep sterile gloved hands in sight and above waist/ table level

4. Sterile objects can become unsterile by prolonged exposure to airborne

microorganisms

Keep doors closed/ traffic to a minimum

Microorganisms on the hair can make a sterile field unsterile

Refrain from sneezing and coughing over a sterile field

Wear mask during a sterile procedure

Keep talking to a minimum

Refrain from reaching over the sterile field to prevent microorganisms from falling

over to sterile filed

5. Fluids flow in the direction of gravity

Always hold forceps with the tips below the handles

i.e. hold the forceps pointing downwards

6. Moisture that passes through a sterile object draws microorganisms from unsterile

surfaces to sterile surface by capillary action

Use moisture-proof barriers

Pour liquids into container on a sterile field carefully

7. The edges of a sterile field are considered unsterile

Leave a one inch margin

8. The skin cannot be sterilized and is unsterile

Use sterile gloves/ sterile forceps to handle sterile items

Conscientiousness, alertness, and honesty are essential qualities in maintaining

asepsis

Wound Drainage System

Indications:

To help eliminate dead space

To evacuate accumulation of fluid (Blood/ pus) or gas

To prevent potential accumulation of fluid or gas

May drain naturally, or connected to a suction source

Drains are available in different sizes and types

Classifications of Drains

Open drainage system

A drain that does not have a collection device

It empties into absorptive dressing

It promotes drainage passively

Usually not suture in place, but a sterile safety pin may be attached to the outer

portion of the drain to prevent it from slipping back into the wound

Have a higher risk of infection

Eg. Penrose drain

Closed drainage system

It consists of tubes draining into a bag/ bottle

Because the system is closed, have a lower risk of infection

Drains body fluids:

Naturally: by means of gravity or pressure differentials

By suction: compressing the container while the port is open, then closing

the port after the device is compressed

Drains are usually sutured to the skin

Because drainage is collected in a bag/ bottle, it allows accurate measurement of

drainage

Eg. Jackson-Pratt Drain, Hemovac

Other type of Drain

T-tube

For bile drainage after gallbladder surgery

Caring of Drain Site

Clean the drain site during each dressing change

Follow the same aseptic technique principles

Clean with circular motion

Clean the tubing with a upward stroke

Surround the drain site with Y-cut gauze (key-hole dressing)

Cover the opening with absorbable dressing

Assess drainage

Color, characteristics, amount

Record in progress note/ in & out chart

Emptying

Usually once/day

prn whenever the receiving bottle is full

Emptying of Drains

Steps:

– Put on disposable gloves

Body fluid

– Clamp the tubing before opening the cap

– Empty the content completely into container

– Use alcohol pad to clean the outlet

– Fully compress the chamber

Or recharge the suction force by using a suction source (depends on

types of drain)

– Replace the cap, and unclamp the tubing

– Document at appropriate place

– Discard the drainage according to hospital policy

Removal of Sutures and Staples

– Usually skin sutures are removed 7 to 10 days after surgery

– Make sure to check doctor’s prescription

– General guidelines:

Remove alternate sutures

i.e. suture 1, 3, 5, 7, 9

Check approximation of wound edges before proceed to suture 2, 4, 6, 8, 10

Sometimes alternate sutures may remain in place for a few more days before

removal

Clean the wound before and after removal

Method same as simple wound dressing

Removal of Sutures

Prepare extra sterile scissors and forceps

Steps:

Grasp the suture at the knot

Place the scissors under the suture as close to the skin as possible

Cut the suture as close to the skin as possible

Rationales: The visible part of the suture is in contact with bacteria of

the skin and should not be pulled beneath the skin during removal

Removal of staples

Prepare sterile staple remover

Steps:

Place the lower tips of the remover under the staple

Squeeze the handle together until they are completely closed

When both ends of the staple are visible, gently move the staple away

Wound Packing

Indications:

For wounds that require debridement, gauzes are packed in the wound to

absorb exudate

Check wound nurse’s/ doctor’s prescription

Clean wound with the same dressing technique

Depends on manufacturer’s instructor – moisten the packing material

Need to familiar with and follow the manufacturer’s guidelines on special

products

Loosely pack the wound cavity until the wound surfaces and edges are covered

Do not overlap wound edges

To prevent maceration of the surrounding tissues

If tunneling is present, pack the tunneling area first

Cover with appropriate top dressing

Specimen Collection

2. Mid-stream urine (MSU)

• Indication：

- Urine culture for identification of microorganism causing urinary tract infection

(UTI)

• Method:

- Advise client to perform hand washing before procedure

- Ask client to cleanse the genital and perineal areas with 0.9% sodium chloride

soaked gauze by one swab once

- Ambulatory female client: clean from front to back

- Ambulatory male client: use a circular motion

• Inform the client the urination has to be divided into 3 parts

• For client require assistance

- help client cleansing genital and perineal areas

- assist client onto a clean bedpan or commode

• Instruct client to start voiding – the first part of the urine will be discarded

• It helps to flush away any organisms near the meatus, which may affect the

accuracy of the result

• Urine voided at midstream is most characteristic of the urine

• Place the sterile specimen bottle into the stream of urine (ask patient to hold)

and collect ~20-30 ml of urine

• Avoid touching the inside and contaminating the outside of the bottle

• Remove container and continue voiding, the last part of urine is discarded

• Cap the container tightly

• Remove gloves and wash hand

• Label the specimen and documentation

3. Catheterized Specimen urine (CSU)

• Indications：

- For C &ST of urine

- Sterile urine specimen

- Sterile technique

• Method:

Collect from an indwelling Foley catheter within a closed drainage system

Clamp the tube below the access port for 30 minutes

Wear disposable gloves

Wipe the access port on indwelling catheter with alcohol swab

Carefully attach the syringe to the port; if a needle is needed, insert needle

at 30-45 degree angle

Slowly aspirate 10-20ml urine

Detach the needle and syringe from the port

Transfer the urine to specimen bottle without contamination

Unclamp the catheter

Place sharps in sharp container and remove gloves

Label the specimen and deliver the specimen to the lab immediately

Documentation

Special precautions

• Ensure the specimen is free of any barium enema or suppository medications

• Instruct not to urinate or discard toilet paper in the specimen

• Note any current antibiotic regime that may affect result

• Specimen should be sent to lab immediately

• Rectal swab can be alternative if client has diarrhoea

• Infants

− To collect by scraping from the diaper, as long as not contaminated with

urine

− If passing liquid stool, place plastic sheet inside the diaper for collection

• Children

− May need parents’ assistance

− Explain with details, using age appropriate words, no medical jargons.

− Ask the parent the usual words that family normally uses to describe a

bowel movement.

• Elderly

− Elders may need assistance for series of specimens

Exercise and Ambulation

Alignment/ Posture

Alignment and posture are analogous

Referring to the positioning of the joints, tendons, ligaments and muscles while

standing, sitting and lying.

Correct body alignment:

– Reduce strain and risk of injury

– Aids in maintain adequate muscle tone

– Contributes to balance

– Conservation of energy (Potter & Perry, 2005)

Body alignment means that the individual’s center of gravity is stable and body strain is minimized.

Balance

It is:

– center of gravity close to the base of support

– line of gravity goes through the base of support

– a wide base of support

Body alignment contributes to body balance

– Without balance, the center of gravity is displaced, and increase risk of fall

Balance can be compromised by disease, injury, pain, physical development, life

changes (eg pregnancy), medications (eg. Side effect), prolonged immobility...etc

(Potter & P

Types of Exercises

Exercise involves the active contraction and relaxation of muscles

It can be classified according to:

– The type of muscle contraction

1. Isotonic exercise

2. Isometric exercise

3. Isokinetic exercise

The source of energy

Aerobic exercise

2. Anaerobic exercise

(Berman et al, 2008)

Type of Muscle Contraction

1. Isotonic Exercise

• Also referred as dynamic exercises

• The muscles shortens to produce muscle contraction and active movement

• Examples:

– Running, walking, swimming, almost all ADLs, and active ROM

exercise

– Isotonic bed exercise:

• Pushing or pulling against a stationary object

• Using a trapeze to life the body off the bed

• Isotonic exercise increase muscle tone, mass, and strength and maintain

joint flexibility and circulation

• During isotonic exercise, HR & cardiac output quicken to increase blood

flow to all parts of the body

2. Isometric Exercise

• Also refer as static or setting exercise

• There is muscle contraction without moving the joint

– i.e. muscle length does not change/ only a minimum shortening of

muscle fibers

• Examples:

– Isometric bed exercise:

• Squeezing a towel or pillow between the knees while at the

same time tightening the muscles in the fronts of the thighs

by pressing the knees backwards

• Isometric produce a mild increase in HR and cardiac output, but no

appreciable increase in blood flow to other parts of the body

• Can be used to maintain strength in immobilized muscles in casts or

traction, and for endurance training

3. Isokinetic Exercise

• Also refer as resistive exercise

• It involves muscle contraction or tension against resistance; thus it can be

either isotonic or isometric

– The resistance is provided at a constant rate by an external device

• These exercises are used for physical conditioning, and are done to build

up certain muscle groups

• Also seen in rehabilitative exercises for knee and elbow injuries

• Examples:

– The pectorals (chest muscles) may be increased in size and strength

by lifting weights

• An increase in BP and blood flow to muscles occurs with resistance training

Effects of Exercises

Effects of exercise on major body systems

Regular exercise is necessary for human body’s healthy functioning

Cardiovascular system

During exercise, CVS responds by:

– Increasing the HR

– Increasing the contractile strength of the myocardium

– Increasing the stroke volume

– Improving venous return due to the contracting muscles compress

superficial veins and push blood back to the heart

Increase efficiency of the heart

Respiratory system

It works together with the CVS to make increased oxygen available to the

muscles

During exercise, respiratory system respond by:

– Increase rate & depth of respiration

– Increase gas exchange at the alveolar level

– Increase rate of CO2 excretion

Leads to improved pulmonary function

Musculoskeletal System

The rhythmic contraction and relaxation of muscle groups during exercise result

in increased muscle mass, tone, strength, and increased joint mobility.

Regular exercise can:

– Increase muscle efficiency (strength) & flexibility

– Increased coordination

– Increased efficiency of nerve impulse transmission

– Slow aging process

Prevent osteoporosis (process of bone demineralization) - Perform

weight bearing exercise

Metabolic processes

Increase metabolic rate

Increase the efficiency of metabolism and body temperature regulation

Gastrointestinal system

Increase appetite

Increase intestinal tone

Improves digestion and elimination

Control weight

Urinary system

Increase blood circulation, thus improves blood flow to the kidneys

Allows the kidneys to maintain body fluid balance, acid-base balance, and

excrete body waste more efficiently

Skin

Exercise increase circulation to the skin

Improve overall skin condition

Psychosocial outlook

Increase energy

Improve sleep

Improve body image

Improve self concept

Improve positive health behavior

Risks related to Exercise

Precipitation of a cardiac event

– Higher risk on people with known/ suspected CV diseases

– A pre-exercise medical examination may be needed

Orthopedic discomfort and disability

– Common injuries include: irritation to bones, tendons, ligaments & muscles

Resulted from extra weight-bearing stress, or collision with ground,

objects/ person

– Follow safety guidelines during exercise

– When injury occurs, consult doctor; apply “RICE”

Rest, Ice, compression & elevation

Others: heat stroke, exercise-induced asthma, chest pain…etc

Effects of Immobility

Immobility can affect many major body systems, and predispose to many chronic

health problems

– Severity of effects based on patient’s age, & overall health status

Cardiovascular system

Predispose to thrombi formation because of venous stasis

Immobile people are more prone to orthostatic hypotension (BP drop when

change from a supine to a upright position)

– Because the normal neurovascular adjustment that occur to maintain

systemic blood pressure are not used during periods of inactivity and

become inoperative

– Feel weak and faint

Respiratory system

Decreased ventilatory effort

– Decrease rate and depth of respiration

– When areas of lung tissues are not used overtime, atelectasis (incomplete

expansion/ collapse of lung tissues) may occur

Increased respiratory secretions

– Immobility cause decrease movement of secretion in the respiratory tract

Cause pooling of secretion and respiratory congestion

Predispose a person to respiratory tract infection (Pneumonia)

Musculoskeletal System

Immobility leads to decreased muscle size (atrophy), tone, and strength;

decrease joint mobility and flexibility, bone demineralization

– Cause contractures

– Bone demineralization (osteoporosis)

Normal weight bearing activity stimulate bone formation and balance

it with the natural destruction of bone

With immobility, bone formation slows while breakdown increase

Bones become spongy and brittle, which may result in fractures

Metabolic Process

Immobility requires less energy cellular demand for oxygen decrease

decrease metabolic rate

Causing anorexia, decrease appetite

Gastrointestinal System

Immobility leads to decrease in appetite, decrease food intake, altered protein

metabolism and poor digestion

Slow GI tract movement constipation

Urinary System

Urinary stasis cause urinary tract infection

Immobility also predispose patients to have renal calculi (renal stones)

– While bone breakdown, calcium and phosphorus loss via the renal system

Skin

Immobility may cause pressure over bony prominence

may result in skin breakdown, and leads to pressure ulcers

Psychosocial Outlook

Decrease sense of self

– Need constant assistance from others for ADL

Decrease body image

Decrease self concept

– Inability to meet role expectations

– Feeling of worthlessness

Decrease social interaction

Disrupt normal sleep-wake pattern

Produce exaggerated emotional response

Joint Mobility & ROM Exercises

Joints

The functional units of the musculoskeletal system

Most of the skeletal muscles attach to the bones at the joint

– Muscles include flexors, extensors and internal rotators

– Usually the flexor is stronger than the extensor muscles, thus the joints are

pulled into a flexed (bent) position when the person is inactive

– The muscles will be permanently shortened if this tendency is not

counteracted with exercise

Range of Motion (ROM)

ROM of a joint is the maximum movement that is possible for that joint

Varies from individual to individual, determined by genetic makeup,

developmental patterns, the presence or absence of diseases.. etc

Range of Motion Exercise

It is the complete extent of movement of which a joint is normally capable.

Unless contraindicated, active, active-assistive, or passive range-of-motion

exercises should be encouraged.

Active exercise

– Patient is able to move the joints independently through their full range

of motion

Active-assistive exercise

– Nurse provides minimal support

Passive exercise

– The patient is unable to move independently, and the nurse moves each

joint through its range of motion

Both active and passive range of motion exercise

– Improves joint mobility

– Increase circulation to the affected part

BUT

Only active exercise increases muscle tone, mass, and strength; and

improves cardiac and respiratory functioning

Therefore,

Exercise should be as active as the patient's condition permits

Nursing responsibilities:

Assess patient’s ROM

– As baseline measure to compare and evaluate whether loss in joint

mobility has occurred

Assess the patient’s ability

– The type of ROM exercise the patient can perform

– Amount of assistance the patient needs

In general, exercise should be as active as health and mobility allow

Contractures may develop in joints not moved periodically through

their full ROM

Avoid overexertion, and not to exhaust the patient

Avoid to attempt full range of motion in all joints in older adults

– May induce pain

Start gradually and slowly

– All movements should be smooth and rhythmic

– Jerky and irregular movements are uncomfortable

Move each joint until there is resistance, but no pain

Return the joint to a neutral position (the normal position of alignment)

when finishing each exercise

Perform range of motion exercise regularly to build up muscle and joint

capabilities

Use support measures to prevent muscle strain or injury to the patient during

range-of-motion exercises.

(A) Using a cupped hand to support a joint.

(B) Supporting the joint by holding the distal and proximal areas adjacent to

the joint.

(C) Cradling the distal portion of a lower extremity

(Taylor et al, 2011)

Most common ones are:

– Walkers

A lightweight metal frame with a board, four-point base of support

Some walkers have wheels on the front legs

• For patients with a gait that is too fast and for patients who have

difficulty lifting the walker

The walkers should be adjusted to the height of the patient’s hip joint

• So the patient’s elbows are flexed about ~ 30 degree

– Canes

It widens a person’s base of support, providing increased balance

Comes in different variations:

• Half-circle handle: for patient require minimal support

• Straight handle: for patients with hand weakness

• Three (tripod)/ four prongs (quad cane): for patient with poor

balance

Instruct the patient to hold the cane in the opposite hand from the leg

with the most severe deficit

• i.e. the good side

• Lift the cane & move it forward first then the weak leg, then the

good leg

– Crutches

Use crutches to avoid using one leg/ to help strengthen one or both legs

Two types:

Axillary crutches

• For patients who have temporary restriction on ambulation

• Require significant strength to use. Patient must have adequate

upper body and upper arm strength to use this type of crutch

Forearm crutches

• For patient requiring long term support for ambulation

• More likely to be used for patients with permanent limitations and

will always need crutch assistance for ambulation

– Braces

Support weaken muscles

Observe for skin irritation