Exercise, Transfers & Ambulation
Nursing 125
Mobility
Mobility refers to a person’s ability to move about freely.
Immobility refers to a person’s inability to move about freely.
Mobility & immobility are the endpoints of a continuum with
many degrees of partial immobility in between.
mobility
immobility
Some clients move back and forth, some clients remain absolute.
Ability to Move
The ability to move & function is a function most people take for granted.
The level of mobility has a significant impact on an ind.’s physiological,
psychosocial, & developmental well-being (Hamilton & Lyon, 1995).
When there is an alteration in mobility, many body systems are at risk for
impairment.
 Cardiovascular functioning – orthostatic hypotension
 Pulmonary complications – pneumonia
 Promote skin breakdown, muscle atrophy etc
Such changes can lead to altered self-concept & lowered selfesteem.
Medical Conditions that can Alter
Mobility
Fractures/sprains
Neurological conditions – spinal cord injury, head
injury
Degenerative neurological conditions – Myasthenia
gravis, Huntington’s chorea
Nursing Measures
Attempt to maintain and/or restore optimal mobility as well as to
decrease the hazards assoc. with immobility.
 DB & C exercises
 Muscle & joint exercises
 Frequent repositioning – q 2 hrs
 fluid intake/fiber intake
Guidelines:
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Check activity order
Know client’s past medical history & limitations
Baseline vital signs are necessary
Become familiar with assistive devices
Major concern during transfer = Safety
of both the client and the nurse
Range of Motion Exercise (ROM)
ROM exercises, in which a body part is moved through a range of
motion, are carried out to promote circulation, maintain muscle
tone & promote flexibility. In doing this, joint stiffness &
debilitating contractures are prevented. Active ROM is range
of motion carried out by the patient. It is a form of isotonic
exercise & as such, it maintains strength, tone & flexibility. In
patients unable to move body parts due to paralysis or extreme
illness, ROM is performed by someone else. This is called
passive ROM exercise. Passive exercise helps to maintain joint
flexibility & prevent stiffness & contractures. Because this type
of exercise involves no active movement on the part of the
muscles, it does not contribute to muscle tone or strength.
ROM(cont.)
ROM exercises are planned as a regular part of nursing
activities. During a bath, for example, the nurse has
an excellent opportunity to move the patient’s limbs
through their full range of motion. The patient is
encouraged to exercise actively those muscles that
can be used. However, in certain cases, the nurse
may need to assist the patient in performing ROM
(active assisted ROM), or to perform passive ROM.
ROM (cont.)
The maximum movement that is possible for a joint is it’s range of
motion.
If a joint is not moved sufficiently it begins to stiffen within 24 hrs &
eventually becomes inflexible, flexor muscles contract & pull tight
causing contractures or fixed joint flexion.
To prevent joint contractures & muscle atrophy (wasting or
decrease in size of a normally developed organ or tissue), exercise
must be performed – ROM exercise.
Contracture – abnormal flexion & fixation of joints caused by the
disuse, shortening & atrophy of muscle fibers.
Correcting contractures requires intensive therapy over a prolonged
period of time, and may be impossible. Prevention is the key.
Two Purposes of ROM
1. Maintain joint function
2. Restore joint function
Do not exercise joints beyond the
point of resistance or to the point
of fatigue or pain
Contraindications to ROM
ROM requires energy & increased circulation, any
illness/disorder where increased use of energy or
increased circulation is hazardous is contraindicated;
puts strain/stress in soft tissues of the joint & bony
structures, therefore not done with swollen, inflamed
joints.
Perform Exercises in Head to
Toe Format
Start with the head and move down, always do bilaterally
Do not grasp the joint directly
Cup the joint gently (prevents pressure)
Do not grasp fingernail or toenail
Important joints – thumb, hip, knee, ankle
Return to correct anatomic position
Move joint through movement 5 times/session
Start at the Neck
P&P p. 830
Neck
Flexion – look @ the toes
Extension – look straight ahead
Hyperextension – look up @ ceiling
Lateral flexion – look straight ahead, tilt head to shoulder
Shoulder
Flexion – raise arm forward & overhead
Extension – return arm to side of body
Abduction – raise arm to side to position above head with palm
away from head.
Adduction – return arm & bring across chest
Internal rotation – elbow flexed, rotate the shoulder by moving
arm til thumb is turned inward & toward the back (fingers to the
floor)
External rotation – elbow flexed, move arm until thumb is upward
& lateral to head. (fingers point up)
Circumduction – move arm in full circle (arm straight out, move
hand as if to draw a circle.
Elbow
Elbow
Flexion – bend elbow
Extension – straighten elbow
Hyperextension – bend lower arm back as far as possible
Forearm
Supination – turn lower hand so palm is up
Pronation - turn lower hand so palm is down
Wrist
Flexion – bend wrist forward
Extension – straighten wrist (fingers, wrist & arm in same
plane)
Hyperextension – bring dorsal surface of hand as far back
as possible
Abduction (radial flexion) – bring wrist medially towards
the thumb
Adduction (ulnar flexion) – bend wrist laterally towards 5th
finger
Fingers & Thumb
Fingers & thumb Flexion – bend fingers & thumb into palm make a fist
Extension – straighten fingers & thumb
Hyperextension – bend fingers as far back as possible
Abduction – spread fingers apart / extend thumb
laterally
Adduction – bring fingers together/ thumb back to hand
Circumduction – move finger/thumb in circular motion
Opposition – touch thumb to each finger of same hand
Hip
Hip
Flexion – move leg forward (ROM 90-120 deg)
Extension – move leg back beside other leg
Hyperextension – move leg backwards (ROM 30-50
deg)
Abduction – move leg laterally away from body (ROM
30-50 deg)
Adduction – move leg back to medial position &
beyond if possible (ROM 30-50 deg)
Knee
Flexion – bring heel toward back of thigh (120-130
deg)
Extension – return leg to floor
Ankle
Ankle
Dorsiflexion – move foot so toes are pointed upward
Plantarflexion – move foot so toes are pointed downward
Foot
Inversion – turn sole of foot medially (ROM 10 deg)
Eversion – turn sole of foot laterally (ROM 10 deg)
Flexion – curl toes downward (ROM 30-60 deg)
Extension – straighten toes (ROM 30-60 deg)
Abduction – spread toes apart
Adduction – bring toes together
Spine
Spine
Flexion – when standing – bend forward from the
waist
Extension – straighten up
Hyperextension – bend backward
Lateral flexion – bend to the side
Rotation – twist from the waist
Types of ROM exercises
Active – exercises the client is able to perform
independently.
Passive – exercises performed for the client by
someone else.
Active assisted – performed by a client with some
assistance – client can move a limb partially through
its ROM, but needs help completing the ROM.
Isometric/Isotonic Exercises
In addition to ROM exercises, some immobilized clients may
be able to perform muscle-strengthening exercises.
1.
Isotonic – cause muscle contraction & change in muscle
length – walking, aerobics, moving arms & legs against light
resistance.
2.
Isometric – tightening or tensing of muscles without moving
body parts. This increases muscle tension but do not change
the length of muscle fibers. Isometric exercises are easily
performed by an immobilized patient in bed.

Isotonic and isometric exercises help to prevent muscular atrophy
and combat osteoporosis.
Applying Antiembolism Stockings (Elastic)
P&P p. 842
Thromobophlebitis – the development of a thrombus or clot
along with the inflammation of the vein & may be classified
as superficial or deep.
Three elements contribute to the development of a clot.
1. Hypercoagulability of the bld – clotting disorders,
dehydration, pregnancy & 1st 6 weeks postpartum if
the woman was confined to bed, oral contraceptives.
2. Venous wall damage – local trauma, orthopedic
surgeries, major abdominal surgery, varicose veins,
arteriosclerosis
3. Blood stasis – immobility, obesity, pregnancy
Antiembolism stockings
Promote venous return by maintaining
pressure on superficial veins to prevent
venous pooling.
Prevent passive dilation of veins
Application of antiembolism stockings (refer
to p. 845 P&P)
Orthostatic hypotension
A drop in blood pressure that occurs when the client rises from lying to sitting or
from sitting to standing. (A decrease in systolic pressure >15 mmHg or
decrease diastolic pressure >10 mmHg.)
At risk clients
 Immobilized clients
 Prolonged bed red
Measures to minimized Orthostatic Hypotension
 Maintain muscle tone
 Increase venous return to the heart
 Decrease stasis of bld in the lower extremities
 ROM/isometric exercises/TED’s
 Mobilize ASAP
Therapeutic Positions
Chair – feet flat on floor, footrest if unable to reach floor, knees
& hips flexed 90-100 degrees. Buttocks at back of the chair,
spine straight, pillows at side to prevent leaning.
Fowlers – supine, HOB elevated 45 deg. Promotes lung
expansion, decrease ICP, comfortable for eating.
High fowlers – same as above, with HOB elevated 45-90 deg.
Utilized for clients experiencing difficulty breathing.
Semi fowlers – as above with HOB elevated less than 45 deg.
Orthopneic – sit on side of bed with over bed table across lap,
pillow on table, lean forward & rest head & arms on table.
Utilized for patients with extreme difficulty breathing – promotes
lung expansion.
Therapeutic positions cont.
Lithotomy – supine flex both knees so that
feet are close to hips, separate legs, feet in
stirrups. Utilized for perineal & vaginal
examinations
Trendelenburg – supine, entire bed frame
tilted down with head 30 deg below
horizontal.
 Postural drainage
 Increase venous return in case of shock
Benefits of Proper Positioning
Maintains body alignment & comfort
Prevents injury to musculoskeletal system, prevents
strain
Provides sensory, motor & cognitive stimulation
Prevents pressure sore (decubitus ulcer) & joint
contractures
Transfers
Transferring is a nursing skill that helps the client with restricted
mobility attain/maintain mobility & independence.
Benefits of transfers
 Maintains & improves joint motion
 Increases strength
 Promotes circulation
 Relieves pressure on the skin
 Improves urinary/respiratory function
 Increases social activity
 Increased mental stimulation
Transfers - Safety
Safety is a major concern when transferring. Falls are a common
hazard. If a patient starts to fall – do not try to stop the fall,
instead assist the patient to the floor while protecting the head
from injury. This will reduce the risk of patient as well as staff
injury.
Complete a thorough nursing assessment before you move the
patient to determine if she/he has suffered any injuries.
Prevention of injury is the key, be aware of the client’s motor
deficit, ability to support their body weight and use effective
body mechanics & lifting techniques.
When in doubt regarding the patient’s ability-GET ASSISTANCE
Nursing Process - Transfers
Assessment
Activity orders
Client capabilities
Planning
Decide appropriate transfer technique
Explain procedure to the patient
Implementation
Wash hands
Position chair 45 deg angle to bed on clients stronger side
Lock bed brakes, lower bed, raise HOB as high as patient
tolerates
Lower side rail
Assist to sitting (lift upper body & swing legs around)
Assist with robe & slippers
Position feet on floor
Take wide stance, bend knees, grasp patient
“1 2 3 stand”
Pivot to chair
Nursing Process (cont.)
Evaluation
Body in alignment, patient comfortable, no
injuries
Nurse maintains good body alignment
Of note:
Two person lift (same as above) except one
nurse is on each side of the patient
Never lift under the axilla – can damage nerves
Mechanical lifts – enables you to lift heavy
patients, or those unable to help. (Use 2
people)
Ambulation
Clients who have been immobile even for a short time may
require assistance
A client may require the use of an assistive device to aid in
ambulation.
Assistive devices
 Increase stability
 Support a weak extremity
 Reduce the load on weight bearing structures; hip, knees
Assisting the patient
Simple assist
1.
2.
3.
Place arm near patient under the arm & at the elbow &
grasp pt’s hand, synchronize walking with the pt (move
inside foot forward at same time as pt’s inside foot)
Grasp pt’s left hand in nurses’ left hand & encircle pt’s
waist with the rt hand & synchronize walking as above
Using a transfer belt (held at the waist from the rear by
the belt – helps maintain balance)

Nurse to stand on the pt’s weak side. The nurse provides
support with his/her leg to the pt’s weakened one if
necessary. Do not allow the pt. to place their arm around
your shoulder.

Walk slowly, even gait, synchronize your steps.
Cane
Helps maintain balance by widening the base of support increases a
pt’s security.
Should be held on stronger side
 Should have rubber tip – prevent slipping
 Height (from greater trochanter to the floor allowing 15-30 deg
of elbow flexion.
Gait – place cane 6-10 inches ahead, move affected leg ahead
to cane, place weight on affected leg and cane, move
unaffected leg ahead of cane.
Stand from sitting
 Cane in hand opposite affected leg, grasp arm of chair & cane
in other, push to stand, gain balance
Walker
Wide base of support, provides great stability
& security. Used for clients who are weak or
who has problems with balance.
 Patient should have at least one weight bearing leg and
arm
 Pick up walker is more stable, walker with wheels easier
for pt’s who have difficulty with lifting or balance,
however can roll forward when weight is applied.
 Height – upper bar of walker should be slightly below the
client’s waist with arms flexed 15-30 deg
Walker (cont.)
To stand – walker in front of seat, push up off arms
of chair (walker is less stable, chair is lower pt. can
push with more force. Hands move to walker one at
a time.
To sit – back up to chair, reach back with one arm to
arm of chair, then with the other arm and lower to
chair.
Gait – walker ahead 6-8 inches, weight on arms.
Partial weight on affected leg first.
Crutches
Wooden or metal staff that reaches from the ground
to 11/2 – 2 inches below the axilla. When standing
tip of crutch rests 4-6 inches in front & 4-6 inches to
side of foot.
Do not rest on top of crutches – pressure on axilla
nerves – can lead to paralysis called crutch paralysis
(numbness, tingling, muscle weakness)
Crutches (cont.)
P&P p.859
3 point gait – able to wt. bear on one foot, full wt. on
unaffected leg then on both crutches – begin in
tripod position, move crutches & affected leg ahead,
move stronger leg forward and repeat.
4 point gait – (most stable crutch walk) weight on
both legs and both crutches – muscular weakness,
improves balance by providing a wide base of
support, lack of coordination, move each
independently – rt crutch-lt foot-lt crutch-rt leg