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 patients 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
Dont
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 patients nares
Fit cannula tubing around patients ears and adjust tubing slide under patients
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 patients 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 patients 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 clients 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 150m 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:
Clients 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 clients head is 12 oclock
Determine depth
While the applicator is inserted, mark the point on the swab that is even
with the wounds 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 doctors 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 nurses/ doctors prescription
Clean wound with the same dressing technique
Depends on manufacturers instructor moisten the packing material
Need to familiar with and follow the manufacturers 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 individuals 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 bodys 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 painetc
Effects of Immobility
Immobility can affect many major body systems, and predispose to many chronic
health problems
Severity of effects based on patients 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 patients ROM
As baseline measure to compare and evaluate whether loss in joint
mobility has occurred
Assess the patients 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 patients hip joint
So the patients elbows are flexed about ~ 30 degree
Canes
It widens a persons 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