EXERCISES

Exercises

Exercise is the performance of physical exertion for improvement of the health or the correction of physical deformity.

The beneficial effects of exercise

On the musculo-skeletal system

• Maintains the muscle tone.
• Maintains the joint mobility.(prevent stiff joint)
• Prevents and corrects deformities like foot drop, ankylosis etc.
• Maintains the bone density and prevents osteoporosis.

On the cardio-vascular system

• Stimulates the blood circulation and prevents venous stasis.
• Assists in the exchange of oxygen and nutrients into the tissues and waste products from the tissues.
• Prevents varicose veins.
• Helps to reduce oedema.
• Reduce the work load on the heart.
• Prevents venous thrombosis and pulmonary embolism.

On metabolism

• Prevents obesity.
• Regulates body temperature.
• Oxygen consumption and metabolic rate are increased thus providing good lung expansion to meet the additional requirement of the body.

On the gastro-intestinal system

• Improves appetite and digestion.
• Prevents constipation.
• Prevents flatulence.

On the excretory system

• Promotes urinary functions by stimulating the blood circulation through the kidneys and helps in the elimination of waste products.
• Prevents stagnation of urine and formation of renal calculi.
• Promotes elimination from the skin.

On the respiratory system

• Improves the lung ventilation.
• Prevents atelectasis.(collapse of lung)
• Prevents collection of secretions in the lungs.(hypo static pneumonia)

On the mental process

• Promotes the physical and mental well being.
• Prevents depression and boredom.
• Restore a sense of relaxation and equilibrium.
• Improves the memory.
• Provides an outlet for emotional tension.

Others

• Prevents bed sore.
• Adds to the beauty.

ACTIVE EXERCISE

Active exercises

Active exercise is the type of physical activity accomplished by the patient without assistance. These exercises help he patient to attain the normal physiological functions of the body. Some of the active form of exercises that can be done by the patients on the bed are: deep breathing and coughing exercise for the complete lung expansion usually employed for the post-operative patients.

Exercise of the limbs through full ranges of motion which includes flexion, extension, adduction, abduction and rotation.

• Moving in bed to change the position.
• Foot exercise to prevent foot drop and toe deformities.
• Abdominal and gluteal contraction exercise.
• Exercise to prepare the patient for ambulation eg; patient after amputation of legs needs a variety of exercise before he starts crutch walking.

The ambulatory patients can have both indoor and outdoor exercise. Some of the points to be kept in mind during the exercise are:

• The exercise should be planned according to the age , sex and physical condition of the patient.
• Check for the doctor's orders for any specific precautions taken regarding the movements of the patients.
• The room should be well ventilated.
• Exercise should not be done immediately after a meal.
• Avoid over fatigue.
• Avoid chills and draughts.
• Have loose garments to put on.
• Exercise are to be repeated daily at the same time if possible.

PASSIVE EXERCISE

Passive exercises

In passive exercise, the movements or activity is carried out by another person and the patient makes no voluntary effort to assist or resist the action. The passive exercise are usually carried out by the physiotherapist or the nurse. The performance of certain nursing procedures such as bathing the patient, giving back care and changing the position etc; provide some passive exercise for the patient. Passive exercise are useful for the patients with restricted movements, deformities and unconsciousness.

FOOT DROP

Patients with prolonged rest and restricted movements develop a deformity called foot drop in which the foot is plantar flexed (the ankle bends in the direction of the sole of the foot). If the condition continues without correction, the patient will walk on his toes without touching the ground with the heel of the foot.

The deformity is caused by the contraction of both gastrocnemius ans soleus muscles. Prolonged bed rest, lack of exercise, incorrect positioning in bed and the weight of the bed clothes forcing the toes in the plantar flexion are some of the factors that contribute to this crippling deformity.

The foot drop can be prevented by the use of foot board(foot rest) to maintain the position of the feet at right angles to the legs, flexion and extension exercise to the feet and toes.

SIGNS AND SYMPTOMS OF PRESSURE SORES

The early symptoms of pressure sores are redness, tenderness, discomfort and smarting.The area becomes cold to touch and insensitive. There is local oedema. Later the area becomes blue, purple or mottled. Due to continued pressure, the circulation is cut off, the gangrene develops and the affected area is sloughed off.

PREVENTION OF PRESSURE SORES

1. Identification of patients those who are particularly prone to the development of decubitus ulcer.
2. Daily examination of the decubitus- prone patients for redness, discolouration or blister on the pressure points and they should be reported and treated immediately.
3. Keep the patients clean and dry.
4. Change the position of the patient every 2 hours so that another body surface bears the weight.
5. Use a bed cradle to take off the weight of the bed linen of the patient, so as to enable him to move in the bed.
6. Keep the patients skin well lubricated to prevent cracking by using powder.
7. Protect the damaged skin, damaged skin can be further irritated and macerated by urine, faeces, sweat etc.
8. Provide the patient with adequate fluid and with a nourishing diet that is high in protein and vitamins.
9. Use special mattress and beds to reduce the pressure on the body parts.
10. Use adequate amount of cotton under splints and plaster to reduce friction.
11. Encourage the patient to move in the bed as far it is allowed.
12. Teach the patients and the relatives about the hygienic care of the skin.

DECUBITUS ULCER / PRESSURE / BED SORE

Decubitus ulcer is also known as pressure sore or decubiti, are ulcerated or sloughed area of tissue subjected to pressure from lying on mattress or sitting on a chair for a prolonged period of time resulting in the slowing of circulation and finally death (necrosis) of tissues.

Common sites

Pressure points are those that bear weight, so that the skin over them is subjected to pressure.This may happen more frequently over the bony prominences of the body where there is no rich blood supply or nourishment and also there is a thin layer of skin.The common sites depend upon the position of the patient in the bed.

The pressure points in the supine position are back of the head (occiput), scapula, sacral region, elbows and heels.In a side lying position the pressure points are the ears, acromion process of the shoulder, ribs, greater trochanter of the hip, medial and lateral condyles of the knee and malleolus of the ankle joint.

In a prone position, the pressure points are ears , cheek, acromion process, breast (in the females), genitalia (in males), knees and toes.

CAUSES OF PRESSURE SORE

Direct or immediate causes-

Pressure

Pressure is considered to the primary cause of the pressure sore.In a sick person, the areas of tissue resting against the mattress are vulnerable areas.The pressure in these areas causes depletion of blood supply with the failure of circulation to the weight bearing area resulting in the tissue damage.The pressure over these areas are increased in the following conditions:

• When there is lumps and creases on the bed.
• Incorrect positioning of the body.
• Infrequent change of position.

Friction

Friction of the skin with a rough or hard surface can cause tissue damage. Contact with the rough surface of the bed, wrinkles on the bed clothes, hard surfaces of the plaster casts and splints, presence of foreign bodies on the bed (eg. bread crumbs, orange peelings) careless handling of bed pan, pulling sheets under the patient etc, are frequent cause of friction which cause tissue damage. Friction is also caused due to the rough sponge clothes and prolonged massage without lubricant.

Moisture

The skin contact with moisture for a period of time can lead to maceration of the skin. Patients who are sweating profusely; with incontinence of urine and stools are liable to pressure sores.

Presence of pathogenic organism

Lack of cleanliness harbours pathogenic organisms and infection settles on the skin.

DIFFERENT STAGES OF PRESSURE SORES

Stage 1

Stage 2

Stage 3

Stage 4

Deep injury

Unstageable

Predisposing causes

• Impaired circulation.
• Lowered vitality.
• Emaciation.
• Oedema.
• Obesity.

Patients susceptible to pressure sores

• Acutely ill patients, whose general condition is rapidly deteriorating.
• Elderly bed ridden patients, who make very little movements in bed.
• Obese patients.
• Very thin and emaciated patients, having very little subcutaneous tissue to pad the bony prominences.
• Sedated patients who are not moving readily.
• Paralysed patients, who have suffered spinal coed injuries eg., patients with paraplegia, hemiplegia, and quadriplegia. These patients are not able to make movements in the bed and very often they have incontinence of urine.
• Neurologic patients with lack of sensation that they cannot feel any irritation of the skin.
• Oedematous patient especially those with oedema of the sacrum and buttocks.
• Mal-nourished patients with protein and vitamin deficiencies.
• Agitated patients in restraints.
• Patients on complete bed rest or with limited movements.
• Surgical patients with limited movements.
• Patients with hyper pyrexia who sweat profusely.
• Patients with incontinence of urine and stool.
• Patients with excessive bodily discharges or drainage from the wounds.
• Diabetic patients.

BODY MECHANICS

Body mechanics has been described as the efficient use of the body as a machine and as a means of locomotion. Body mechanics are body posture and balance.The bones, joints, muscles, nerves and brain all function together to maintain posture and balance. Posture is defined as the position in which the various parts of the body are held while sitting, standing, walking and lying.

To understand the body mechanics one has to understand the effects of gravity on balance. The centre of gravity of an object may be defined as the point at which its mass is centered. In man when standing, the centre of gravity is located in the centre of the pelvis approximately mid-way between the umbilicus and the symphysis pubis. The line of gravity is a vertical line which passes through the centre of gravity. There is a constant pull exerted by the earth on every object towards its centre which helps to maintain the good posture and balance.

An object is more stable if:

• Its centre of gravity is close to its base of support.
• The line of gravity goes through the base of support.
• It has a wide base of support.
• The centre of gravity is lower and close to the base of support.

Proper body mechanics are important to the nurses in their work and they are equally beneficial to the patient.

1. The proper body alignment and posture prevent fatigue and deformities.
2. Poor posture causes kyphosis, lordosis, scoliosis and other deformities.
3. Good posture promotes the physiologic functions of the body aids in circulation and digestion.
4. It helps to reduce the expenditure of the energy.
5. It helps to maintain the balance of the body without undue strain on the body parts.
6. It contributes to one's beauty.

BASIC LAWS:

One of the primary factors of musculo-skeletal activity is that the longest and strongest muscles should be used to provide energy needs of the body.When muscles which can not provide the best support and strength are forced into exertion, strain, injury and fatigue of the body tissues.The reason is that in the area of the lower back there are no long muscles.unless the strong and long muscles of the legs are used properly during the periods of strenuous activity. It is likely that back injury will be incurred. Therefore following rules are to be maintained for the good body mechanics:

1. Maintain good posture (anatomical position) in all activities.
2. Use the longest and strongest muscles of the extremities to provide the energy needed in the strenuous activities.
3. Keep the object close to the body to prevent unnecessary strain on the muscles.This brings the centre of gravity of the object close  to the centre of gravity of the body.
4. Place the feet apart to provide a wide base of support. A broader base provide a better body balance.
5. Flex the knees to come close to the object instead of bending the back.
6. Keep work close to the body.
7. Slide, roll, push or pull an object rather than lifting it in order to reduce the energy needed to lift the weight against the pull of gravity.
8. Use the weight of the body to pull or push an object by keeping the body above the object.