Chapter 6
Rest and Exercise
• Rest can make clients relax, refresh and relieve mental
stress
• Mobility facilitates pulmonary functioning and
increases peripheral blood flow. Regular exercise
contributes to physiological functioning of each part of
body system.
• Hospitalized clients need adequate rest,but they will
face more physical and mental problems without
adequate exercise
• Nurses should assist clients with rest and exercise
properly.
Section 1 Rest
Rest
Benefits of Rest
Conditions of Thorough Rest
Sleep
觉
Concept of Rest
• Rest
– Rest is a state of decreased mental and physical
activity that leaves a person feeling refreshed,
rejuvenated, and ready to resume the activities of the
day
– Physical comfort
– Freedom from worry
– Comfortable environment
Benefits of Rest
Rest and recovery from diseases
– Promote recovery
①
②
③
④
⑤
relieve tiredness and stress
maintain the normality of physiological regulation.
promote development of body
decrease exhaustion of energy.
promote protein synthesized and tissues
rehabilitated.
Critical
thinking?
1.Forms of rest? What forms of rest
would you like to choose?
2.How do you have a good rest?
Forms of rest
息
摩
Forms of rest
Conditions of Thorough
Rest
•
•
•
•
Physical comfort
Freedom from worry
Comfortable environment
Sufficient sleep
1.Physical comfort
a. Eliminating sources of physical irritation
b. Controlling sources of pain
c. Providing warmth
d. Maintaining hygiene
e.Maintaining proper anatomical alignment
or positioning
2. Freedom from worry
a. Making decisions
b. Participating in personal health care
c.Gaining an understanding
problems and their implications
of
d. Practicing restful activities regularly
health
3. Comfortable environment
a. Removing environmental distractions
b. Providing adequate ventilation
c. Knowing the environment is safe
4. Sufficient sleep
a. Obtaining average hours of sleep needed to
avoid fatigue
b. Following good sleep hygiene habits
sleep
• Concept:
– Sleep is a recurrent, altered state of
consciousness that occurs for sustained
periods, restoring a person’s energy and wellbeing
– first as a discrete state of reduced
responsiveness to external stimuli, from
which a person can be aroused;
– second as a continuous cyclical change in
level of consciousness
sleep
Physiology of Sleep
Normal Sleep Requirements and Patterns
Factors Affecting Sleep
Sleep Disorders
Characteristics of sleep in hospitalized
clients
Implementation
Physiology of Sleep
1.mechanism of sleep
The reticular activating system (RAS) located in the upper brainstem
the bulbar synchronizing region (BSR) in the pons and medical forebrain
work together, alternately activating and suppressing the
brain’s higher centers to control sleep
2.physiological characteristics
of sleep
• Sensory perception
• Skeletal muscle reflex
muscle hypotonicity
• autonomic nervous function ：
– P、R、BP、urine、gastric juice、saliva、
BMR
3. Stages of Sleep
• EEG：
• EOG：
• EMG：
Two stages：
non- rapid eye movement sleep, NREM
sleep(slow wave sleep, SWS or orthodox
sleep,OS)
rapid eye movement sleep, REM sleep(fast
wave sleep, FWS; or paradoxical sleep,PS)。
Characteristic of Sleep Cycle Stages
Stage1: NREM
•The slightest level of sleep
•Lasts a few minutes
•Physiological activity decreases, vital signs fall gradually
and metabolism begins to slow down
•People easily aroused by sensory stimuli such as noise
•If a person awakes, feels as though daydreaming has
occurred
•Reduction in autonomic activities (e.g., heart rate)
Stage2: NREM
•Period of sound sleep
•Relaxation progresses
•Arousal is still easy
•Lasts 10 to 20 minutes
•Body functions still slowing
Stage3: NREM
•Initial stages of deep sleep
•Sleeper difficult to arouse and rarely
moves
•Muscles completely relaxed
•Vital signs decline but remain regular
•Lasts 15 to 30 minutes
Stage4: NREM
•Deepest stage of sleep
•Very difficult to arouse sleeper
•If sleep loss has occurred, sleeper will spend
most of night in this stage
•Restores and rests the body
•Vital signs significantly lower than during
waking hours
•Possible sleepwalking and enuresis
•Hormonal response includes secretion of
growth hormone
REM Sleep
mental
restoration
• Stage of vivid, full-color dreaming (less vivid dreaming
may occur in other stages)
• First occurs approximately 90 minutes after sleep has
begun, thereafter occurs at end of each NREM cycle
• Typified by autonomic response of rapidly moving eyes,
fluctuating heart and respiratory rates, and increased or
fluctuating blood pressure. Secretion of Epinephrine rises.
Angina
pectoris.,
• Loss of skeletal muscle tone except eye
muscle
Asthma, COPD
• Responsible for mental restoration
• Stage in which sleeper is most difficult to arouse
• Duration increasing with each cycle and averaging 20
minutes
睡眠的分期
,正向睡眠）
入睡期
睡眠时相各期特点
15~30min
幼儿神经
发育
20~30min
sleep cycle
NREM and REM alternate,
duration of one cycle: 90min，4～6 cycles
Awakeness
NREM Stage 1
NREM Stage 2
NREM Stage 3
NREM Stage 4
REM
NREM Stage 2
NREM Stage 1
NREM Stage 3
0.5~7min，30~45min begin NREM Stage 3 and 4，
duration a few minutes to 1h。70 ~ 90min，1st REM occurs，
5min(20min), Duration increasing with each cycle and averaging
20 minutes
睡眠周期
睡眠周期
Characteristics of sleep stage
and cycle
• 60~120min, average 90min
• 4~6 cycles,
• If a person awakens from sleep during any
stage, sleep begins again at stage 1
• With each full sleep cycle, stages 3 and 4
shorten, and the period of REM lengthens.
REM sleep may last 30 to 60minutes during
the last sleep cycle.
•
Normal Sleep Requirements
and Patterns
• Requirement amount of sleep varies from
person to person
– Healthy person: Average 7.5h
• Requirement and percentage of sleep
stage in a cycle are related to age.
•Requirements
areof
also
influenced
by other
TotalInverse
hours
sleep
decrease
ratio
with
total hours
Neonates
and
Infants
16～20h，
factors,NREM
such
as
individuality,
health status,
stage
4 decline。
Toddlers
life style,
behavior
habit
and occupation and
Times
of10～14h，
awake
increase
Preschoolers
stage 11～12h
1 and 2 increase
so on. NREM
Adolescents 9～10h，
adults 7～8h，
Older adults ，6～7h。
Factors Affecting Sleep
1．Physiological factors:
– age
– endocrine
– fatigue
– Circadian Rhythms
– habits before sleep
2. pathology factors
– Diseases and
discomfort
– Mental diseases
3.Mental factors
4.Environment factors
5. others：food, medicine
Sleep and Circadian
Rhythms
• circadian rhythm:
• Each person’s life is a series of cyclical rhythms influencing
and regulating physiological function and behavioral
responses.
• The fluctuation and predictability of body
temperature, heart rate, hormone and electrolyte
secretions, and mood depend on the circadian cycle
Sleep and circadian rhythms：The
schedule of
rest and activity should be synchronized with
circadian rhythms.
body temperature: 睡眠最好在节律的低期，而清醒与活动则应在
节律的高期。
睡眠与昼夜节律
Temperature circadian rhythm
高
期
低
期
依据体温变化绘制的昼夜性节律
sleep disorder
器质性睡眠障碍
insomnia
非
器
质
性
睡
眠
障
碍
hypersomnias
睡眠失调
睡眠失常
睡眠觉醒节律障碍
sleep walking
night terrors
nightmare
sleep disorder
• 失眠（insomnia）
• 睡眠剥夺（deprivation）
• 发作性睡眠(narcolepsy) • 梦游症（sleep walking）
• 睡眠过多(hypersomnias) • 梦魇（nightmare）
• 睡眠性呼吸暂停(sleep
apneas)
• 睡惊（night terrors）
• 遗尿（bedwetting）
insomnia
• Has chronic difficulty falling asleep,
difficulty remaining asleep or inability
to resume sleep after awakening
• classifications：
• primary insomnia
• secondary insomnia
• drug dependent insomnia
insomnia
Manifestation：
difficult in falling asleep,睡眠不
稳 (易醒、多梦、睡不深)、早醒。
EEG:NREM stage 3 and 4
decrease,that is,deep sleep decreases
narcolepsy
发作性睡眠
Narcolepsy is a chronic, incurable dysfunction of REM
sleep processes and of mechanisms regulating sleeping
and waking states.
A person may suddenly feel an overwhelming wave of
sleepiness and fall asleep, even in unusual situations
such as while having a conversation
Cataplexy: a brief sudden loss of muscle control
Hallucinations: just when falling asleep
Attacks are most likely to occur in sedentary,
unstimulating situations, such as watching television or
driving
be mistaken for laziness, lack of interest in activities,
or drunkenness
hypersomnia 睡眠过度
度
 Total amount of sleep increase, stage and its
proportion are normal
 Causes: obesity,depress, neural diseases, diabetes,
excess quietive
与脑部疾病.糖尿病.镇
 Daytime drowsy, nighttime disorder
Sleep Apnea
睡眠性呼吸暂停
Upper
respiratory,snore
obesity
cessation of breathing
Classifications:
•obstructive sleep apnea
•Central apnea
brain stem injury, muscular
dystrophy, and encephalitis.
risks: decline in arterial oxygen levels
•cardiac arrhythmias, right heart failure, angina,
stroke, and hypertension
Sleep deprivation
• the amount, quality, and consistency of
sleep decrease
• physiological symptoms
– hand tremors, decreased reflexes, showed
response time, reduced word memory, and
decreased reasoning and judgment
• Psychological symptoms
– mood swings, disorientation, irritability,
decreased motivation, fatigue, sleepiness,
hyperactivity and agitation
梦游、遗尿
Sleep
walking
夜游症
梦行症
睡行症
bedwetting
nightmare
• nightmare
• causes：be terrified in daytime，
excessive agitation，check is
pressed，respiratory is
obstructed,heavy supper
• EEG：REM
Night terrors
• EEG：NREM
• Awakeness obstruction
3.
Sleep
deprivation
Easily awake，fatigue，
discomfort，3天
住院病人的睡眠特点
(resynchronization)
REM，mental andDesynchronization
physical effect，
节律移位：phase
神经官能症及精神障
shift
碍
剥夺：
Sleep
NREM3、4，REM loss，
fragmentation
arrhythmia:如VF，
respiratry dysfunction
NREM3、4，REM
loss，
vulnerability
to
4 is compensated
rebounds
first（Gh），REM is
more inadequate，知
觉人格障碍
Sleep assessment
• Description of sleeping problems
–
–
–
–
–
–
1.Nature of the problem
2.Signs and symptoms
3.Onset and duration
4.Severity
5.Predisposing factor
6.Effect on client
• Normal sleep pattern
Normal sleep pattern
• 1.What time do you usually go to sleep?
• 2.How quickly do you fall asleep?
• 3.What is the average number of hours
you sleep during the night?
• 4.How many times do you awaken at night?
• 5.When do you typically awaken in the
morning?
• 6.Do you rise once you awaken or do you
stay in bed?
implementation
eliminate physical discomfort
Decrease stress
Set good enviroment for sleep
Use Drugs correctly
Form good sleep hygiene and habit
Evening care
Special interventions of Sleep disorder
安眠药
氮
Special interventions of
Sleep disorder
• Insomnia
– improved sleep hygiene measures,
deep breath,massage,biofeedback,
and relaxation techniques
– A gradual withdrawal of hypnotics
– Rejust circadian rhythm
• Hypersomnia
–
–
–
–
Loss of weight
Limit the amount of sleep
Therapy depress
Increase activity
• Narcolepsy
– central nervous system stimulants such as
Ritalin (methylphenidate) and Cylert
(pemoline)
– Brief daytime naps 20min
– Risky factors decrease: liquor or exhausting
activities, long-distance driving, long periods of
sitting, and hot stuffy rooms
– regular exercise
– practicing deep breathing,
– eating light meals high in protein, taking
vitamins and chewing gum
• Sleep apnea
– therapy for underlying cardiac or respiratory
complications and emotional problems.
– Sleep hygiene and weight-loss therapy can
also help.
– nasal continuous positive airway pressure
(CPAP) device
– surgical removal of portions of the pharynx
and palate
• Sleep walking
– Protect ion
• Bedwetting
– drink little water before sleep
– Urine excretion before sleep
– Regular excretion
Section 2 Mobility and
Exercise
Benefits of exercise
 Expressing emotion, self-defense, attaining basic needs,
completing activities of daily living, and performing
recreational activities. maintaining the body’s normal
physiological activities.
 Facilitates pulmonary functioning
 Increases peripheral blood flow.
 Maintain healthy functioning of each part of body
system.
 Influence self-esteem and body image
 relieve stress and relax physically and mentally
Section 2 Mobility and
Exercise
• Mobility and exercises are crucial to physical
fitness.
• Physical activity help maintain physiological function of
every system
• Thinking activity help maintain self-image and develop
intelligence to prevent brain retrogression
illness
Mobility loss or decrease
anchylosis、
constipation、
pressure ulcer
Physical and
mental problem
Self-humiliation、
depression、
susceptivity
contents
Factors Affecting Body Alignment and
Immobility
Effects of Immobility on Major Body Systems
Assessment Mobility of Client
Assisting Clients with Mobility
Factors Affecting Immobility
pain
Neural illness
Pulmonary conditions
Physical disability
Cardiovascular
conditions
Musculoskeletal
conditions
Therapeutic
intervention
Nutritional status
Mental facors
Effects of Immobility
• Physiological effects
• Psychosocial effects
• Developmental effects
Physiological effects
•
•
•
•
•
•
•
Metabolic system
Respiratory system
Cardiovascular system
Musculoskeletal system
Integument
Urinary system
Digestive system
Metabolic system
• Decreased basal metabolic rate (BMR)
• Altered carbohydrate, fat, and protein
metabolism
• Fluid and electrolyte imbalances
• Increased bone resorption
• Gastrointestinal disturbances
Respiratory system
•
•
•
•
•
•
Decreased hemoglobin levels
Reduced lung expansion: Atelectasis
Respiratory muscle weakness
Stasis of secretions:
Hypostatic pneumonia
Stasis of carbon dioxide
Cardiovascular system
• Orthostatic hypotension
• Increased cardiac workload
• Thrombus formation
Musculoskeletal system
•
•
•
•
•
•
Loss of endurance
Decreased muscle mass
Atrophy
Decreased stability
Joint contractures
Disuse osteoporosis
• Integument
– Pressure ulcer formation
• Urinary system
–
–
–
–
Renal calculi
Decreased urinary output
Urinary stasis
Urinary tract infection
Psychosocial effects
•
•
•
•
•
•
Depression
Behavioral changes
Altered sleep-wake cycles
Decreased coping abilities
Increased isolation
Sensory deprivation
Developmental effects
• Decreased
progression
developmental tasks
• Increased dependence
through
Effects of Immobility
对皮肤的影响
对骨骼和肌肉组织的影响
对心血管系统的影响
对呼吸系统的影响
对消化系统的影响
对泌尿系统的影响
对社会心理方面的影响
垂足、垂腕
体位性低血压
深静脉血栓
坠积性肺炎
二氧化碳储留
排尿困难
尿潴留
结石、感染
活动受限的并发症
Assessment Mobility of Client
 Individual information of clients
 Respiratory and cardiovascular function
 Musculoskeletal system: Muscle strength
 Joint structure and function
 Physical mobility:Gordon delineates five
levels
 Problems related to immobility
 Psychosocial condition
Muscle strength:
0: 0% of normal strength; complete paralysis
1: 10% of normal strength; no movement, contraction of
muscle is palpable or visible
2: 25% of normal strength; full muscle movements
against gravity, with support
3: 50% of normal strength; normal full movement
against gravity
4: 75% of normal strength; normal full movement
against gravity and against minimal resistance
5: 100% of normal strength; normal full movement
against gravity and against full resistance
Gordon delineates five levels :
• Level 0: The client is completely independent and can
move freely without assistance.
• Level 1: Requires use of equipment or device.
• Level 2: Requires assistance, supervision, or teaching
from another person
• Level 3: Requires help from another person and
equipment device
• Level 4: Is dependent and does not participate in
movement
Assisting Clients with Mobility
Positioning clients in bed properly
Keeping spinal column physiological bend
Preventing pressure ulcer
Maintaining joint mobility
Reducing immobility hazards
Range of motion exercises
• ROM(range of motion)
– the complete extent of movement of
which a joint is normally capable
• ROM exercise
– Exercises for maintaining and
recovering range of motion of joint
– active
– Passive
Purpose of ROM
exercise
Promote blood circulation and
stimulate nerve
Prevent contracture in muscle,
tendon, ligamenta,joint capsule
Enhance cardiopulmonary function
and physical tolerance
Relieve psychological problem
Contraindications
 acute arthritis, bone fracture, ligament rupture
and joint dislocation
 Clients with cardiovascular diseases do ROM
exercise cautiously.
 For clients with muscle convulsion caused by
CNS，do ROM exercise with the instruction of
physical physical therapist
common types of joint movement
Exercise neck, shoulder, elbow, wrist,
finger,coxa, knee, and ankle ,toe joints in
turn
5~10 times ROM exercises for every joint
common types of joint movement
Movement
Definition
Flexion
Decreasing the angle of the joint (e.g., bending the
elbow)
Increasing the angle of the joint (e.g., straightening the
arm at the elbow)
Movement of the bone away from the midline of the
body
Movement of the bone toward the midline of the body
The state of exaggerated extension. It often results in
an angle greater than 180°
A body part turning on its axis toward the midline of
the body
A body part turning on its axis away from the midline
of the body
Movement of the distal part of the bone in a circle
while the proximal and remains fixed
Extension
Abduction
Adduction
Hyperextension
Internal rotation
External rotation
Circumduction
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
head-neck
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
spinal column
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
水平外展
shoulder
水平内收
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
elbow
arm
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
wrist
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
finger
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
thumb
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
coxa
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
knee
ROM exercise
（broken line denoting start position of motion，arrowhead
denoting direction of exercise)
ankle
Cautions!
• 1. Assess physical condition comprehensively
including body mobility, cardiovascular and
respiratory function, and joint mobility before
exercises and then plan exercise program.
• 2. Keep ward quiet, ventilation, temperature
and moisture proper, and assist the client alter
loose and comfortable dress convenient to
exercise before exercise. Protect privacy of
clients.
• 3.During exercise, observe the reaction
to exercises and activity tolerance, and
observe whether there are negative
effects such as stiff joint, pain, spasm.
When the abnormal reaction is found,
the nurse should inform the physician.
• 4. The client with acute arthritis, bone
fracture, ligament rupture and joint
dislocation does ROM exercise with
instruction of physician.
• 5. Observe changes in heart rate, heart
rhythm, blood pressure when the client with
heart disease does ROM exercises.
• 6. The nurse should introduce the client and
his relatives the importance of joint ROM
exercise and encourage the client participate in
exercises, which can eventually make the client
to exercise from passively to actively.
• 7. After exercises, record time, items, times,
changes in joint mobility and reaction to
exercise of the client timely and properly,
which provide evidence for further plan to be
made.
Types of Exercise__
Muscle contraction
• isometric exercise
• isotonic exercise
• isometric (static) exercise:
– Concepts: those in which there is a change in
muscle tension but there is no movement in
muscle length and no muscle or joint movement
– Examples: quadriceps set exercises and
contraction of the gluteal.
– Purpose: This form of exercises is ideal for
clients who are unable to tolerate an increase in
activity. Isometric exercises are easily
accomplished by an immobilized client in bed
isometric (static) exercise
– The benefits
– increased muscle mass, tone, and strength,
thus decreasing the potential for muscle
wasting;
– increased circulation to the involved body parts;
and increased osteoblastic activity.
– produce a moderate increase in heart rate and
cardiac output, but no appreciable in blood flow
to other part of the body.
• isotonic(dynamic) exercise:
– Concepts: involves muscle shortening and
active movement.
– Benefits: increases muscle tone, mass, and
strength, improves joint mobility, increases
cardiopulmonary function, increases circulation,
and increases osteoblastic activity.
– Examples: walking, swimming, dancing, jogging,
bicycling, and moving arms and legs with light
resistance.
• Isokinetic (resistive) exercises
– Concepts: involve muscle contraction or tension
against resistance, thus they can be either
isotonic or isometric.
– purpose: During isokinetic exercises, the
person moves or tenses against resistance.
Special machines or devices provide the
resistance to movement. These exercises are
used in physical conditions and are often done
to build up certain muscle groups.
– Example: the pectorals may be increased in
size and strength by lifting weights.
• 常用的等张练习方法为“渐进抗阻练习法”
（progressive resistance exercise, PRE）
• 优点
– 是动态运动比较符合大多数日常活动的肌肉运动方式，
同时有利于 改善肌肉的神经控制。
渐进抗阻练习法
• 这种方法是采用逐渐增加阻力进行练习，肌肉工作能
力改进时负荷量也随之增加。采用此法训练前，须先
测定训练肌肉连续作10次等张运动的最大负荷量，即
10RM量。先后用10RM量的1/2、3/4及全量各作10
次抗阻运动，共3组运动，各组间休息1分钟，以便调
整负荷，每日锻炼1次。其中第1、2组练习实为第3
组练习的准备运动。每周复测10RM的值，据以增加
各组负荷量。
教学目标
1.realizing contents:
• benefits of rest and sleep.
• characteristics of every stages of sleep cycle.
• factors affecting sleep.
2.master contents:
• common sleep disorder and their interventions.
• effect of immobility
• interventions promoting clients to exercise