Providing appropriate degree of assistance lowers risk of muscle strain and body injury to both client and nurse. Assessment of UE very important for clients who use assistive devices such as walkers or crutches. Activity Tolerance Determine appropriate activity level for client and predict whether the client can endure activities that require similar amounts of energy expenditure. Useful in encouraging independence in pt’s with: CV and respiratory problems immobilized for a prolonged period decreased muscle mass or musculoskeletal disorder inadequate sleep pain depressed, anxious, or unmotivated Most useful measurements of predicting activity tolerance: Heart strength, rhythm, and rate Respiratory depth, rhythm, and rate BP measure these before, during, immediately after, 3 minutes after activity Activity should be stopped immediately in the event of: sudden facial pallor dizziness or weakness change in LoC dramatic change in HR or RR from baseline dramatic change in heart or respiratory rhythm weakening of pulse Dyspnea, SOB, chest pain DBP change of 10mmHg or more Activity considered safe if client tolerates and vitals return to baseline levels within 5 minutes of activity. Problems Related to Immobility Take/understand assessment findings and lab values establish a baseline and compare with later values Clients at risk of developing complications of immobility: poorly nourished existing CV, pulmonary, or neuromuscular problems decreased sensitivity to pain, temperature, or pressure ALOC
Providing appropriate degree of assistance lowers risk of muscle strain and body injury to both client and nurse. Assessment of UE very important for clients who use assistive devices such as walkers or crutches. Activity Tolerance Determine appropriate activity level for client and predict whether the client can endure activities that require similar amounts of energy expenditure. Useful in encouraging independence in pt’s with: CV and respiratory problems immobilized for a prolonged period decreased muscle mass or musculoskeletal disorder inadequate sleep pain depressed, anxious, or unmotivated Most useful measurements of predicting activity tolerance: Heart strength, rhythm, and rate Respiratory depth, rhythm, and rate BP measure these before, during, immediately after, 3 minutes after activity Activity should be stopped immediately in the event of: sudden facial pallor dizziness or weakness change in LoC dramatic change in HR or RR from baseline dramatic change in heart or respiratory rhythm weakening of pulse Dyspnea, SOB, chest pain DBP change of 10mmHg or more Activity considered safe if client tolerates and vitals return to baseline levels within 5 minutes of activity. Problems Related to Immobility Take/understand assessment findings and lab values establish a baseline and compare with later values Clients at risk of developing complications of immobility: poorly nourished existing CV, pulmonary, or neuromuscular problems decreased sensitivity to pain, temperature, or pressure ALOC
chapter16activityandexercise-3.docx