Voluntary muscles

Voluntary (skeletal) muscles are those in the body that are attached to two bones with a movable joint between them. One of the bones is usually more stationary at a given moment than the other to allow movement to take place between them. Skeletal muscle has a striped appearance under microscopic examination and muscle tissue has four characteristics:

Muscles come in different shapes and sizes depending on their function, and they usually have a thicker belly and a tendon at each end for attachment to bone (Fig. 18.1). The muscles around the mouth are circular, allowing the mouth to open and close fully during eating, whereas the muscles of the forearm are long and thin, allowing the wrist and fingers to flex while making a fist, and to extend during movements such as waving.

Fig. 18.1 A typical skeletal muscle

(reproduced with permission from Greig & Rhind 2002)

Postural muscles help to keep the upright posture or maintain positions for sustained periods of time and do not tire quickly. Examples include the muscles of the abdominal wall, buttocks and thighs. Active muscles are involved in movements such as typing, running and blinking. They allow muscles to respond appropriately to the tasks they perform but tend to tire quickly (Box 18.1). Muscle disorders are outlined in gTable 18.1 and first aid interventions for strains and sprains, and their subsequent neurovascular checks, in Boxes 18.2 and 18.3, respectively.

Table 18.1 Disorders of the musculoskeletal system

Fascia

Fascia is formed from connective tissue, one of the four basic tissues in the body (the others being muscular, nervous and epithelial). Superficial fascia refers to the fatty tissue under the skin and deep fascia refers to the tissue that surrounds muscles, tendons and other organs. The superficial and deep fascias are connected to each other, and the deep fascia that surrounds muscle bellies and tendons is continuous throughout the body. It is incredible to think that the connective tissue surrounding the brain (the meninges) is connected to the fascia in the feet! This is the reason why people with painful knees can be diagnosed with back problems. If the fascia has been damaged in one area, the effects can often be found elsewhere in the body.

Your jumper (see Box 18.1) is a good analogy for the reactions that occur in the fascia when it is shortened or ‘knotted’ through injury. Have you ever felt knots in your shoulder muscles? Did this affect the arm on that side? The effects of postural change may be distant from the original injury. Understanding that fascia is continuous throughout the body helps to understand some of the problems faced by patients/clients who are immobile or trying to regain mobility following illness or injury. The postural characteristics identified earlier have arisen because the muscles and their surrounding fascia have adapted to your habits and protect the shoulder joint from further injury.

These changes are seldom seen in children because their muscles are more elastic and the fascia returns to a near normal position. They also recover more easily from injuries and awkward movements without obvious lasting effect. Fascia stiffens with age. The longer standing a postural habit, the more the fascia adapts to the preferred, habitual position. Understanding that everyone has habits that affect the underlying muscles and tissues also helps to appreciate mobility difficulties that people may have. This knowledge not only helps nurses to move patients/clients more appropriately but also helps them to understand why someone may complain of hip pain when the problem may originate in their shoulder.

Bones

Bones are dynamic, living structures with nerve and blood supplies. The main functions of bones are to:

A typical long bone, such as those of the limbs, has a shaft and two epiphyses (Fig. 18.2). Bone growth takes place at each end of the shaft at the epiphyseal plate. This region consists of cartilage until bone growth is complete when it ossifies. Muscle tendons attach to the outer covering of bone, the periosteum. Hyaline cartilage replaces periosteum at the ends of long bones that form synovial joints.

Before birth the long bones consist mainly of cartilage (Fig. 18.3), which is a tough connective tissue. During pregnancy and early childhood, cartilage is gradually replaced by bone tissue. This process is called ossification and takes place at centres of ossification, initially in the bone shaft and at the epiphyses after birth. Until growth is complete, bones increase in both length and diameter, and a rich blood supply provides the nutrients and energy for the necessary cell division to take place. Several hormones, including growth hormone and thyroid hormones (thyroxine, tri-iodothyronine), are important in growth and development of bones, especially in infancy and childhood, and excessive or impaired secretion results in abnormal bone development. In time, ossification is sufficient to allow walking to be achieved. Although cartilage offers some protection to the vital organs, it behaves like stiff plastic, having a degree of flexibility, as it does not have the rigid hardness of bone. As a result, children’s vital organs are more prone to injury if they fall or are shaken than those of adults and their bones tend to bend, rather than break, causing greenstick fractures (see Fig. 18.4).

Fig. 18.3 Stages of development of a long bone

(reproduced with permission from Waugh & Grant 2006)

Fig. 18.4 Types of simple fracture

At puberty, there is often a sudden increase in bone growth due to the increase in production of the sex hormones testosterone and oestrogen. By the late teenage years, ossification is largely complete. Bones are not fully hardened until their growth stops at about 18 years in females and 25 years in males. Bone mass reaches its peak around 30 years of age. It is important to maintain a lifestyle that maximizes bone density in order to reduce the effects of reduction in later life (Box 18.4). The hardness of adult bone protects vital organs such as the brain, spinal cord, heart and lungs from injury.

Once bone growth is complete, bones continue to replace old bone tissue with new, a process known as remodelling. For example, the lower third of the femur (thigh bone) replaces itself every 4 months in young adults. Following a fracture, new bone tissue is laid down to repair the break. Box 18.5 describes the treatment required for fractures. Bone mass begins to decrease after about 35–40 years of age. In some people the loss of bone mass is excessive and leads to a condition called osteoporosis. Bone disorders are outlined in Table 18.1.

Care of people wearing casts, external fixators or traction

This section introduces the roles of casts, external fixators and traction in immobilizing joints and fractured bones and the principles of nursing care are outlined.

People should be as fully participant in their care as possible, particularly as they will need support and encouragement to adapt to their altered body image, whether it is temporary or permanent and regardless of age. This can be particularly challenging during puberty, which brings about many body changes that can be difficult enough for adolescents to deal with, without the added complication of being ‘different’ from their peers because they have to wear a bulky plaster or stay in bed in traction.

  Page 507 

• Care of patients wearing a cast: Patients who have sustained simple fractures (see Table 18.1 and Fig. 18.4) usually have the fracture immobilized using a lightweight plaster. However, if the plaster needs to be changed after a few days because swelling has reduced, Plaster of Paris (PoP) may be used as it is cheaper and easily removed. It is usually replaced with a harder-wearing, lightweight, waterproof plaster. The principles of care are the same, whichever type of plaster is used (Box 18.6).

• Care of patients with external fixators (Fig. 18.5): External fixation is a method of immobilizing fractures that involves insertion of pins above and below the fracture. The pins are secured to external rods. Pin sites are cared for using the principles shown in Box 18.7. After assembly, neurovascular checks (see Box 18.3) are carried out to ensure local circulation is not impaired and that any swelling is not causing nerve compression. The affected limb is raised to minimize swelling and supported using pillows.

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• Principles of care for patients in traction: Traction is the application of a force (or ‘pull’) on bones that keeps them and their associated joints in correct alignment. It can be applied to either the skin or skeletal system and both types confine the patient to bed. Figure 18.6. shows different types of traction that can be used to treat fractures or joint injuries. In skin traction the pull is applied via adhesive straps attached to the skin of the legs. In skeletal traction, either pins are inserted through the bone below the fracture or a splint is applied to the lower limb and in both cases a system of pulleys is applied. Pin care is outlined in Box 18.7. The skin under a splint needs extra care to prevent development of pressure ulcers. In traction where weights are applied and hang over the end of the bed, the patient’s body provides the countertraction. It is essential to ensure that traction is maintained by keeping the weights hanging free. It is therefore important to ascertain the nursing care required for the particular type of traction in use and to understand how it is maintained. Enforced immobility conferred by traction increases the risk of hazards of immobility (see Box 18.18, p. 525), e.g. pressure ulcers, and patients are assessed for this risk and appropriate interventions carried out to reduce the effects of pressure (see Ch. 25).

Box 18.6 NURSING SKILLS

Care of people wearing casts

• Once a plaster has been applied the affected limb is supported on a waterproof pillow, covered by a towel to absorb moisture. The pillow also provides gentle elevation to reduce swelling.

• Fingers or toes are cleaned to remove any debris so that CSM checks (see Box 18.3) can be carried out at regular intervals and any changes or abnormalities reported.

• The person should be encouraged to change their position hourly so that the plaster dries evenly, on all sides.

• When assisting the person to move their affected limb, only the palms of the hands should be used. This avoids causing indentations from thumbs or fingers on the inside of the plaster that could cause pressure on the skin underneath, leading to a pressure ulcer.

• Nothing should ever be inserted inside a plaster to relieve itching, e.g. knitting needles or rulers. These can damage the skin or become lodged in the plaster, causing ulceration, infection or pressure damage.

• The plaster should be kept dry during personal hygiene activities by covering with a plastic bag. This is also important for waterproof plasters, because the lining material is not waterproof.

• Physiotherapists or experienced nurses supply people with appropriate walking aids if a lower limb is in plaster and teach patients how to use them correctly.

• People wearing plasters can usually be discharged early with an outpatient appointment so that progress can be monitored.

• Education plays a vital role in compliance with treatment as the person must be able to care for their own limb and plaster, and identify early warning signs of complications. It is important to involve people in their care and to provide the necessary information both verbally and in writing. Nurses should check that the person understands what is required of them and that emergency contact numbers are prominently displayed on the information sheets.

Fig. 18.5 An external fixator

(reproduced with permission from Brooker & Nicol 2003)

Box 18.7 NURSING SKILLS

Care of pin sites

External fixators and skeletal traction involve the use of stainless steel pins and the insertion sites require specific care because infection of the bone (osteomyelitis) into which they are inserted is a serious complication.

• Frequent observation is carried out as per local policy to detect early signs of inflammation, e.g. redness or swelling, or movement within the bone.

• Cleaning and dressing is performed according to local policy. The evidence for this is largely inconclusive.

• A small non-adhesive dressing is usually applied if there is leakage and the nature and amount are recorded in the nursing notes.

Student activity

Using the resources below, find out more about the care of pin sites.

[Resources: Smith M 2003 Nursing patients with musculoskeletal disorders. In: Brooker C, Nicol M (eds) Nursing adults: the practice of caring. Mosby, Edinburgh, Chapter 27; Temple J, Santy J 2004 Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database of Systematic Reviews 1:CD004551]

Box 18.3 NURSING SKILLS

Neurovascular checks

These are also sometimes referred to as circulation, sensation and movement (CSM) checks, which are carried out to confirm that a cast, bandage or other intervention does not restrict the local circulation. They are carried out as a first aid measure, following discharge with a new cast and in hospital settings.

The frequency is determined by the type of intervention, the extent of damage, any local policy and reduced over time if observations are within expected levels for the particular patient. Any abnormalities (trends or sudden changes) are reported immediately to the charge nurse. The area, often an extremity, distal to the cast is checked for:

• Temperature: The area should be warm. Cool or cold fingers are abnormal and may be the result of restricted blood supply to the area.

• Colour: The area should be pink. Mottling and white or bluish colour is abnormal and results from impaired blood supply to the affected area.

• Sensation: There should be normal feeling in the area. Any tingling, alteration or loss of sensation is abnormal and may be due to compression of nerves due to local swelling.

• Movement: The amount of movement of the area. Although this may be restricted, any decrease in previous mobility is abnormal.

Fig. 18.6 Types of traction: A. Straight leg skin traction. B. Skeletal traction

(reproduced with permission from Brooker & Nicol 2003)

Box 18.18 Hazards of immobility

• Poor circulation that may predispose to deep vein thrombosis

• Poor respiratory function that may predispose to chest infections

• Development of pressure ulcers (see Ch. 25)

• Loss of bone density (osteoporosis)

• Joint stiffness

• Muscle wasting

• Constipation

• Potential loss of mental well-being, e.g. depression

• Boredom, isolation

• Impaired social interaction

• Loss of independence that may affect all the activities of living.

Joints

Joints, or articulations, occur between bones. They hold the bones securely together but may also allow movement. Some joints hold bones together very tightly and do not permit movement, e.g. the sutures of the skull, whereas others, e.g. the hip and shoulder joints, allow a range of movement. This chapter focuses on synovial joints because they are most involved in body movement. It is these movable (synovial) joints that cause most discomfort and pain, and that most often affect mobility if they become diseased or out of alignment.

Figure 18.7 shows a typical synovial joint. The bone ends are covered in hyaline cartilage, which is smooth and shiny. It aids movement between the bones. The joint cavity is lined with synovial membrane and inside is a small amount of synovial fluid, which lubricates the joint. Ligaments consist of white, fibrous tissue and hold the bones together. They are not very elastic and so restrict the amount of movement available and stabilize the joint. Joints are further supported and protected by surrounding muscles, which prevent dislocation (see p. 504) and help to maintain upright posture. Ligaments attach to the periosteum of bones and cross the joint cavity. Twisting a joint, e.g. the ankle, may stretch and tear the ligaments and is known as a sprain.

Fig. 18.7 Typical synovial joint

(reproduced with permission from Waugh & Grant 2006)

Muscles work together in antagonistic pairs to allow movements to take place at a joint. Contraction of one of a pair of antagonistic muscles brings about one specific movement and the opposite movement is caused by contraction of the opposing muscle, e.g. the biceps and triceps in the upper arm.

Box 18.8 lists the types of movement available at some joints and Figure 18.8. illustrates some of them. Knowing these movements is important for carrying out passive exercises (movements of joints initiated by an external force, e.g. physiotherapist or nurse, to exercise muscles and joints, see p. 525) or encouraging patients/clients to practise active exercises (movements initiated by an individual that exercise muscles and joints, see p. 525). When caring for people with mobility problems it is important to know the range of movements available at different joints so that they are not moved into positions that could be harmful. This is particularly important when caring for unconscious patients, or following joint replacement surgery. Common joint disorders are outlined in Table 18.1.

Fig. 18.8 Main movements possible at synovial joints

(reproduced with permission from Waugh & Grant 2006)

Development of the spinal curves

Babies are born with one ‘C’ shaped spinal curve, which is convex posteriorly. They are unable to control movement of the head, arms or legs and depend on natural reflexes to bring about movement, e.g. the rooting reflex where, in response to lightly touching the side of the cheek, a baby turns its head to that side and begins to suck until the reflex disappears, usually at about 3–4 months of age. The head and spine must be well supported when young babies are moved. At about 6 weeks, babies’ eyes begin to follow colours and movements. This is accompanied by reflex movements in the back of the neck that strengthen the muscles there. Gradually, the neck muscles become bulkier and stronger, and begin to pull the cervical vertebrae and associated muscles into a secondary concave curve, the cervical curve (Fig. 18.9). This enables the head to move from side to side. As babies learn to turn their heads, the muscles around the neck strengthen further and they begin to hold their heads steady on their shoulders for short periods. This is the first stage in developing head control. Gradually thereafter the shoulder muscles strengthen, enabling the muscles of the upper arm to become stronger, leading to more purposeful movements of the upper limbs.

Fig. 18.9 The spinal curves

(reproduced with permission from Waugh & Grant 2006)

At about 3–6 months the baby learns to sit up, but the back is still very rounded. At this age the baby begins to roll from side to side (Box 18.9). This rotational movement around the spine develops the muscles of the lower back, leading to the development of the secondary concave lumbar spine (see Fig. 18.9), which in turn allows the pelvic girdle to be suspended in its correct position at the bottom of the spine.

Only when the spine has achieved the lumbar curve can the child begin to walk and graduate to the toddler stage. Eventually the muscles of the upper and lower legs and feet begin to strengthen and the child develops the upright posture. The spinal curves bring the centre of gravity into a straight line (see Fig. 18.9), which allows the body weight to be evenly distributed and helps to maintain balance in all movements.

The thoracic and sacral curves are known as primary curves because they retain the initial convex ‘C’ shape. The cervical and lumbar curves are known as secondary curves because they develop a concave curvature. A child with severe cerebral palsy, who has poor head control, cannot learn how to make meaningful movements with the rest of their body.

Movement

Movement is brought about by the actions of muscles on joints. Some muscles act on more than one joint and these are the most active in producing movements. Single joint muscles are the deeper, postural muscles (e.g. soleus) and two-joint muscles are the more superficial, active muscles (e.g. gastrocnemius) (Fig. 18.10). This arrangement of muscles helps to produce coordinated movement. For a more detailed explanation of the mechanics and physiology of human movement see, for example, Trew and Everett (2001).

Fig. 18.10 One- and two-joint muscles of the lower leg

(reproduced with permission from Drake et al 2005)

Principles of safer handling and moving

In order to minimize the risk of injury to either practitioners or patients/clients, it is important always to:

The principles of efficient movement are covered in Chapter 13. Carrying out the exercises in Box 18.11 will remind you of these.

Equipment

There are many devices available to assist in moving people (Fig. 18.11). Commonly used equipment and its potential uses are described below. Use of mobility aids such as walking frames, walking sticks and wheelchairs is explained on page 521.

Fig. 18.11 A range of handling and moving equipment: A. Glide sheet. B. Small transfer boards. C. Standing and raising (SARA) hoist. D. Trixie hoist (hoists reproduced with permission from ARJO)

Using equipment to move people

Nurses must familiarize themselves with any equipment used in people’s homes, nursing homes and wards before using it. It is also useful to have experienced being moved using the equipment so that clear explanations can be given to the patient/client. Practical classes at university provide the opportunity to experience being moved in a hoist while under the watchful eye of a trained supervisor and it is a good idea to use these opportunities. They can also be used to discuss with the trainer if a particular piece of equipment is appropriate for a particular care setting. Observing a demonstration using a healthy volunteer who cannot represent your specific patient’s/client’s needs may not necessarily identify problems with equipment that may be encountered in practice.

Handling and moving people

This section addresses key issues of moving people with or without equipment. Details about how to carry out specific manoeuvres can be found in the Guide to the Handling of People (Smith 2005). Nursing patients/clients in bed usually involves handling and moving them to carry out their care, for example:

Helping people to move in bed has been identified as carrying a higher risk of injury than other handling and moving activities (Bertolazzi & Saia 1999). For this reason, it is important that all necessary steps are taken to reduce the risk of injury and to follow the handling and moving guidance given in the nursing care plan.

When moving people in beds or chairs it is important to be aware that the spine is the central axis around which all movement occurs. If a patient/client who has lost power of their arms is required to move one of their hands, the nurse should work from the shoulder girdle. This is because the muscles of the shoulder girdle are postural muscles, built for power, rather than the smaller muscles of the hand, which are built for fine movements. If the hand is moved first, the handlers must bear the load of the whole arm, whereas moving the shoulder first allows the arm and hand to be moved with less effort. Likewise, to move a person’s foot, the move is started from the hip.

It is often necessary to support patients’/clients’ limbs on pillows while they are being moved in bed. This must be carried out in a manner that both supports and protects the limb, and does not cause pain. Limbs should be supported underneath, either in the palm of the hand or across the forearm, while pillows are being positioned. The limbs should be supported in natural positions (Fig. 18.12) that do not put joints into positions that could result in pain or loss of function. Feet should not be left hanging off the ends of pillows and wrists should be supported in neutral positions.

Fig. 18.12 Resting positions of the limbs

(reproduced with permission from Peattie & Walker 1996)

Turning a person in bed

This technique is used to move patients/clients in bed to minimize the risk of twisting their spines while changing bed linen, placing hoist slings in position or turning them (to minimize the risk of pressure damage, see Ch. 25). Box 18.13 (p. 520) describes the principles of turning a patient/client in bed using a glide sheet.

Regaining balance

When a person has been immobile for a period of time, none of the body systems works to their full potential and a programme of gradual mobilization is required to enable them to regain full independence. After a couple of days in bed with a viral illness, even young people may feel quite wobbly on their legs, dizzy and not up to their usual energy levels, and find carrying out even simple tasks makes them feel tired. The feeling of dizziness experienced after a lengthy period of lying down can be due to postural hypotension. For this reason, people who have been nursed in a supine position (lying flat) are sat up gradually, so that the cardiovascular system can adjust to the new position.

If patients/clients are being nursed on a profiling bed, the head of the bed is gently raised a little at a time. Giving the control box to the patient allows them to raise the head of their bed to a position with which they feel comfortable. They may raise the head of the bed further at a rate they can tolerate, until they are able to sit upright. At this stage they will still need to be supported with pillows and backrests. Thereafter they will need to relearn how to sit up unsupported and regain their sitting balance.

Once sitting balance has been regained, the patient/client can progress to standing and walking. The key points to be aware of are whether or not the patient/client can move from sitting to standing unaided and, once standing, whether or not they will have standing balance. Mobility aids and hoists can be used to assist patients/clients to stand and walk (see p. 520).

Helping a person to sit up in bed

The most efficient equipment to assist a patient to move from the lying to the sitting position is an electric powered, height adjustable, profiling bed. If profiling beds are not available, other equipment can be used on non-profiling beds such as:

Patients/clients can be encouraged to move themselves in bed using equipment designed for the purpose, e.g. rope ladders or slides, or a combination of these.

As patients recover and become more mobile, the nursing care plan is altered to reflect their improving mobility. Patients should be encouraged to help themselves to sit up by rolling onto their sides, taking their weight through their elbows and pushing themselves up into a sitting position. During any of the aforementioned procedures, the nurse should initially stay beside the patient to offer support if needed and to give advice and encouragement. Once patients have gained confidence in carrying out the move, and the nurse is satisfied that they are capable of moving themselves safely, observation can be carried out from a distance.

Helping a person to get out of bed

Ensure that there is enough space to work safely, taking into account the size of the chair and the amount of space required for turning the patient/client. Box 18.14 explains how to select a suitable chair for a patient/client; however, in reality, choice may be limited. Initially the bed should be level with the upper thigh while the patient/client is being dressed. Once the person is ready to be moved into a sitting position the bed is lowered to allow their feet to touch the floor. Always check that the brakes are securely applied before helping a person to move. Do not lean against the bed when moving a person as the wheels may slip on the floor.

Well-fitting, lightweight slippers should be put on to prevent the person slipping when their feet reach the floor. Shoes should always be worn with socks, to maintain dignity and to prevent chafing of the feet; however, they can add considerably to the weight of the legs, making them more difficult to move.

The nursing care plan will indicate what equipment to use and how much assistance a patient/client needs to get out of bed and sit in a chair. All equipment requires the assistance of at least one nurse. This includes:

Some patients/clients require only minimal assistance to stand up from the side of the bed. These people must have good sitting balance and be able to support themselves while sitting at the edge of the bed with their feet flat on the floor. Always allow the patient/client to dictate the speed of the move; it is important that people feel in control and that their needs are respected. A person who has had strong analgesics may not be as quick-thinking as usual and needs to be given short, concise instructions that are easily understood. It is also important to be aware that some drugs may cause postural hypotension, a drop in blood pressure that may cause dizziness or fainting when standing upright.

The physiotherapist can provide specific advice to nurses about positioning themselves to help a particular patient/client.

Helping a person to stand up from a chair

Standing a patient up from a chair is different from standing a patient up from a bed. The main differences are that nurses must accommodate the arms of the chair and the height of the chair is usually fixed. Equipment that may be used includes:

Key points to follow when assisting people to stand from chairs are shown in Box 18.15.

Helping people to mobilize

The differences in gait in children, adults and older people (see p. 513) must be taken into account when assisting people to walk. It can be difficult to walk alongside a patient/client who has an altered gait. Helping people with walking carries an increased risk of injuries (Thomas 2005). Allow people with visual impairment to use familiar arm holds for walking, e.g. taking hold of the sighted person’s left arm around the elbow and walking slightly behind. Equipment used to assist people with walking includes walking sticks, walking frames and crutches. These are all measured and fitted to the person’s height by the physiotherapist or registered nurse. Wheeled walkers may be used for children. If a person needs manual assistance with walking, an assessment is carried out and documented in the care plan. This takes account of whether the individual:

The following factors should be also taken into account and assessed prior to mobilizing a person:

Wheelchairs

Wheelchairs offer a degree of independence to some users, but many others are dependent on being pushed around. It is important to understand what a person’s expectations are when discussing the use of a wheelchair. The following general principles are useful:

• If a person is completely dependent on others pushing the wheelchair, then it is best to use one with smaller wheels (Fig. 18.13 A). This makes it easier for the handler to push the wheelchair outside, because the tyres are not inflatable.

• If the patient/client wishes to move the wheelchair independently it is better to have larger, inflatable tyres so that the wheels can be turned more easily, causing less damage to the hands (Fig. 18.13 B).

Fig. 18.13 Wheelchairs: A. Small wheeled. B. Large wheeled

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Choosing the correct width of wheelchair is important to ensure that the patient/client will not slip out of it. It is also necessary to consider the width of doorways if the wheelchair is for home use. Sometimes it is necessary to remove doors to enable access to rooms. All new buildings must comply with national building regulations, e.g. the Scottish Building Standards Agency (2004), to ensure that they have wheelchair access through at least one door and, thereafter, into at least one toilet and one public room on the ground floor.

Wheelchairs can be designed to suit the specific needs of individual patients/clients. Sometimes the whole seat is moulded around the person’s body to accommodate their body shape and offers support in the correct places such as the head, thorax, hips, knees and feet. Back extensions, head extensions, leg extensions and foot plates can all be adapted to meet the individual patient’s/client’s needs. Many younger people have lightweight frames and wheels on their wheelchairs, particularly if they are likely to be involved in sporting and keep fit activities. Different types of padded seat are available to reduce the effects of pressure (see Ch. 25). Box 18.16 provides information about checking and storage of wheelchairs.

Box 18.16 Wheelchairs

Safety checks

Ensure that:

• All tyres are inflated

• Both footplates are attached and in good condition

• Heel straps are correctly fitted to footplates

• Both brakes are working

• The chair is clean

• Any additional attachments such as padding, head support or leg extensions are securely in place and in good condition.

Storage

• Chairs can be folded for storage.

• Empty chairs are easier to move if they are left unfolded and a wheelbarrow action is used. Take hold of the handles from underneath and raise the back wheels slightly from the floor so that only the front wheels are in contact with the floor.

Falls

Cryer and Patel (2001) identified that, in the community, one-third of people over the age of 65 and 50% of people over the age of 80 will fall at some time. Some of these falls will result in fractures. Dealing with a falling patient is challenging. There are many factors that predispose to falls, including:

As falls are common, it is very important to be aware of the main predisposing factors in order to prevent or minimize their occurrence. Prevention of falls is explored in Box 13.9 (p. 326). Older adults who are admitted to hospital following a fall are referred to a gerontologist (a physician who specializes in the care of older adults) for further investigation of their physical health and home circumstances. Falling is often the first indication of an underlying problem. It may be the sign of something simple, e.g. a person requires spectacles, or it may be the result of something more serious such as postural hypotension. Gerontologists carry out physical and psychological investigations to identify the cause of falling and the measures required to remedy the situation.

As part of the multidisciplinary team (MDT), gerontologists work in conjunction with nurses, OTs, physiotherapists and social workers to provide the support needed to enable people to return home. By reducing polypharmacy (see Ch. 22), treating previously undiagnosed conditions and putting appropriate mobility aids into the home, many older adults can be enabled to continue to live at home. The benefits of living at home, in familiar surroundings, far outweigh those of living in supported accommodation, e.g. a nursing home. Moving people from their familiar environment can cause confusion and increase the risk of falls. It is also more cost-effective for health authorities to provide support in people’s homes than in long-term supported care.

Care of people who have fallen

Normally nurses walk to the side and slightly behind patients/clients when they are escorting them (see p. 520). This means that if a patient/client loses their balance, the nurse can move behind them and begin to control their descent to the ground. However, this should only be undertaken if the following criteria are present:

Alternatively, the nurse must clear any furniture if possible and allow the patient/client to fall to the ground, particularly if the person is falling away from the nurse.

Once on the ground the patient/client is safe and the situation must then be assessed to find the best means of assisting them to stand up again. It may be necessary to make a patient comfortable on the ground until the requisite help arrives. People should always be assessed for injuries incurred before being moved.

The patient/client may be able to stand up unaided or be able to follow instructions that will help to do this. Some people will have previously been taught how to do this by the physiotherapist. Small children may be lifted manually, but otherwise inflatable cushions or hoists (see p. 516) should be used if patients cannot assist themselves to stand. An incident form is completed according to local policy (see Ch. 13).

Children

Play normally provides the exercise that children’s body systems need to grow and develop in a coordinated manner. Further intervention is unnecessary in children who are able to play actively by participating in, for example, cycling, running, ball games and other weight-bearing activities. However, children who have sedentary hobbies such as playing computer games and watching television will begin to feel the effects of lack of exercise. In addition to becoming overweight, normal muscle bulk does not build up and there may be changes to the normal curvature of the spine. These may have lasting effects on children’s health, especially the musculoskeletal system, in later life (see p. 511).

Teenagers

Teenagers also need to exercise and should be encouraged to participate in formal exercise in order to develop their bones and muscles. Weight-bearing activities such as walking, running, dancing, skiing, football and rugby help to increase bone mass during adolescence and delay the loss of bone mass thereafter (see p. 506). During exercise, bones accommodate to the stresses that are applied to them, so that those who exercise regularly have denser bones containing more minerals. Bones alter in shape as extra material is laid down at the points of maximum stress. Swimming is an excellent pastime for health in general but, as it is not a weight-bearing activity, it does not affect bone mass. It is, however, very good for developing muscle tissue and the cardiovascular system.

Aerobic, anaerobic and resistance exercises are all good for promoting general health and well-being. Aerobic exercises involve using large muscle groups, rhythmically, over a period of at least 15–20 minutes, and the muscles have sufficient oxygen to fully utilize fuel molecules and release the energy required for contraction. These exercises are generally low in intensity and long in duration such as walking, cycling, jogging or swimming. Anaerobic exercises require muscles to work very hard in the absence of oxygen and are usually high in intensity and short in duration, e.g. sprinting, squash. The limited duration of this type of exercise is due to the accumulation of lactic acid because fuel molecules cannot be fully utilized without oxygen. Resistance exercise – also called strength training or weight training – increases muscle strength, mass and tone.

Cross-training, i.e. training for different events at the same time, such as cycling, swimming and running, develops all the body muscles at the same rate and people report fewer injuries during exercise. In addition, greater body flexibility is present because one group of muscles is not being built up at the expense of others. Cross-training for any sport prevents people from becoming muscle-bound, which can lead to injury (Stamford 1996). For example, runners who only exercise to build up their stamina for running often find their hard-worked muscles become prone to sprains and tendons prone to inflammation. Their other muscles become weaker in comparison and are therefore more prone to injury. This is seen when Olympic athletes, who have spent years training for a particular event, pull up with a calf or hamstring (the posterior thigh muscles) injury in the most important race of their lives.

Adults and older adults

As people age, the benefits of exercise continue to increase (Box 18.17). The more the muscles and fascia have adapted to postural habits, the less flexible people become (see p. 505).

Maintaining healthy joints and muscles

When not used, the joints stiffen and the skeletal muscles waste, and both will limit mobility when mobility can be restarted. It is therefore important to maintain the range of movements available at joints and the condition of skeletal muscles when mobilization is not possible. Active and passive exercises can be carried out in bed in these situations. Active exercises are those initiated by people themselves without aid, e.g. flexing and extending the fingers. Passive exercises are those initiated by carers who move a person’s joints through the normal range of movements. It is important to know the normal movements at joints so that they are not moved into abnormal and potentially harmful positions. They help to:

Prevention of deep vein thrombosis

Deep vein thrombosis (DVT) occurs when the flow of blood through the deep veins of the legs and pelvis is slowed and blood clots form within those veins. Damage to blood vessel walls and coagulation problems are also implicated in DVT formation, which sometimes occurs in healthy people on long haul flights, causing ‘economy class syndrome’. DVT is dangerous because fragments of the clot may become detached and travel in the veins, through the right side of the heart and lodge in a pulmonary artery in lungs causing pulmonary embolism, which can be fatal. The risk of DVT is reduced by carrying out active or passive exercises (see above) and preventing dehydration (see Ch. 19) during periods of immobility.

Preventing chest infection

When mobility is restricted, the benefits of deep breathing that occur during exercise are lost and deep breathing must be actively encouraged. The aim of deep breathing exercises is to improve the flow of air to the bases of the lungs so that they are well ventilated. This helps to prevent the build-up of fluid or respiratory tract secretions within the lungs and the development of a chest infection. Deep breathing (see Ch. 17) also encourages the coughing reflex, which helps to clear the air passages of sputum and potential pathogens (see Ch. 15). Deep breathing exercises are encouraged in patients/clients who are confined to bed or a chair and in those who can walk only short distances.

Pressure ulcers

This complication of immobility, which is almost always preventable, is discussed in depth in Chapter 25. Nursing intervention is key to the prevention of pressure ulcers.

Constipation

Constipation can be prevented by anticipating the dietary and fluid needs of immobile patients/clients and providing an appropriate intake. Peristalsis (the contraction of smooth muscle that moves contents along the digestive tract) is reduced when mobility is limited, predisposing to constipation. The diet should be high in fibre to stimulate peristalsis. In adults, 1.5–2 litres of fluid are required daily to maintain hydration and achieving this can be a nursing challenge (see Ch. 19). Prevention and management of constipation is discussed in Chapter 21.

Maintaining well-being

Limited mobility will often restrict the social interaction that patients/clients are used to and it is necessary to find out the type of activity that will help to pass the time to prevent boredom and isolation and to maintain social interaction. In children this will include therapeutic play, which is essential to achieving developmental milestones when long-term treatment or intervention is necessary. People of all ages may enjoy watching TV, reading and solving crosswords or jigsaw puzzles.

People adapt to restricted mobility in different ways and patients/clients should be assessed for changes in their usual:

Coping mechanisms (see Ch. 11) adapt according to circumstances and changes in these and the features above may indicate difficulty in adjusting to a new situation. People should be encouraged to express their experience of limited mobility and interventions can be provided to minimize its impact. Answering the call bell promptly provides social interaction and will reduce feelings of isolation.

Physiotherapy

Physiotherapists are the key healthcare professionals involved in assessing which aids should be used to improve mobility and which exercises patients/clients should be practising. Many people attend physiotherapy departments (either as in- or outpatients) where a greater range of equipment is available to facilitate active exercising. This may include hydrotherapy (Box 18.20). Much of the equipment within a hospital physiotherapy department is not available in the community although the physiotherapist may recommend going to a local gym that offers suitable activities.

Physiotherapists are also involved in teaching people with mobility problems or a history of falls how to prevent them in future (see Ch. 13) and how to get themselves up from the floor if they do fall (see p. 523).

Following a stroke, patients are often taught to carry out passive exercises (see p. 525) themselves on their affected limb, e.g. a hand and arm, using their unaffected hand. This helps them to regain their awareness of their affected side, which is often lost as a result of the stroke. Enabling patients to carry out passive exercises means that when they are not working directly with the physiotherapist they can continue to exercise the affected limb. This also helps to promote independence and gives people a feeling of involvement in their recovery. Passive exercising improves the blood supply to the affected area, helping to keep the muscle tissue and fascia supple. The repeated movements also provide feedback to the nervous system, thereby improving neuromuscular well-being.

Hot wax can be used for exercising the hands, e.g. to increase movement in rheumatoid arthritis. The heat from the wax helps to relieve pain, and as the wax cools and hardens it provides resistance for the muscles, making them work harder to achieve the same movements of extension and flexion. The hands can also be exercised using soft squeezy objects or a bowl of sand.

Occupational therapy

The OT is a healthcare professional who provides activities and exercises to encourage movement and increase independence. OTs help people to regain independence with activities of living such as personal hygiene and dressing as well as carrying out activities in the home, e.g. making tea, washing up and cooking. OTs also provide advice about communication systems that enable people who are at risk of falls to raise the alarm if they fall at home.

Home assessment

Physiotherapists and OTs often carry out home assessment visits together. Patients are taken home and are observed moving and carrying out normal daily activities in their familiar environment. The OT and/or physiotherapist may recommend home modifications including handrails, raised toilet seats, over-bed tables, trolleys on wheels and other gadgets that enable people to continue to live at home safely and independently.