Chapter 25
Mechanical Immobilization
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Mechanical Immobilization
• Some people are inactive and physically immobile due to
overall debilitating conditions.
• Others have impaired mobility resulting from trauma or
its treatment.
– Orthoses
• Orthopedic devices used to support or align a body
part and prevent/correct deformities
• Splints,immobilizers, braces, slings, casts, etc.
• Caring for individuals with orthopedic devices requires
specialized training
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Purposes
• Most who require mechanical immobilization have
suffered trauma to the musculoskeletal system
• Such injuries are painful and heal slower than injuries to
soft tissue
• Require a period of inactivity to allow new cells to restore
integrity to damaged structures
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Purposes
• Mechanical immobilization of body part is
used to accomplish the following:
– Reduce pain and muscle spasms; support
and align skeletal injuries
– Restrict movement and maintain
functional position while injuries heal;
allow activity while restricting movement
of injured area
– Prevent further structural
damage/deformity
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Mechanical Immobilizing Devices
• The use of various devices can achieve
therapeutic benefits
• Examples include splints, slings, casts, and
traction
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Splints
• Splints
– Device to immobilize/protect an
injured body part
– Used before or instead of casts
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Splints
• Splint types include:
– Emergency
• First aid for suspected sprains/fractures
– Commercial
• More effective than improvised splints
• Variety of designs depending on injury
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Splints
– Inflatable
• Also called “pneumatic splints”
• Become rigid when filled with air
• Limit motion, control bleeding/swelling
• Injured part inserted into deflated splint
• Air infused and splint molds to injured body part
• Fill to point which allows indentation with
fingertips
• Injury should be checked and treated within
30-45 minutes after application
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Splints
– Traction
• Metal devices that immobilize and pull on
contracted muscles
• Not as easy to apply as inflatable splints
• May require special training for application to
prevent further injury
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Emergency Splints
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Inflatable Splints
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Traction Splints
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Other Splints
• Commercial splints
– More effective than improvised splints
– Include:
o Immobilizers
o Molded splints
o Cervical collars
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Commercial Splints
• Immobilizers
– Made from cloth and foam
– Held in place with velcro straps
– Limit motion in the area of a painful but healing
injury such as neck and knee
– Removed for brief periods during hygiene and
dressing
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Commercial Splints
• Molded Splints
– Made of rigid materials and used for chronic
injuries/diseases
– Appropriate for repetitive motion disorders (carpal
tunnel syndrome)
– Provide prolonged support and limit movement to
prevent further injury and pain
– Maintain body part in functional position to prevent
contractures/muscle atrophy during immobility
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Commercial Splints
• Cervical Collars
– Foam or rigid splint placed around neck
– Treat athletic neck injuries/trauma resulting in neck
sprains/strains (whiplash)
• Mild/moderate injury-foam collar
• Severe-rigid collar
– Size based on circumference of neck and distance
between chin and shoulders
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Commercial Splints
• Cervical Collars
– When applying, place head in neutral position with
front of collar positioned well beneath chin and slid
upward until chin supported
– Opening centered at back of neck
– Velcro straps secure collar in position
– Client should be able to breathe and swallow
effortlessly
– Can wear continuously for 10 days-2 weeks
– Remove to do gentle ROM; sooner performed,
quicker recovery
– Assess neuromuscular function during recovery
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Mechanical Immobilizing Devices
• Slings
• Cloth device to elevate, cradle, support body part
• Effectiveness requires proper application
• Braces
• Custom made/custom fitted devices to support
weakened structures
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Mechanical Immobilizing Devices
• Types of braces
– Prophylactic-prevent/reduce severity of injury
– Rehabilitative-protected motion of injured joint that
was treated operatively
– Functional-provide stability for an unstable joint
• Braces usually worn during active periods
• Typically made of metal or leather
• Improper application/ill fitting can cause discomfort,
deformity, skin ulcerations due to friction/prolonged
pressure
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Rehabilitative Brace
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Casts
• Rigid mold placed around injured body
part after realignment
• Casts are used to immobilize injured body
structures
• Made of Plaster of Paris or Fiberglass
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Types of casts
Casts
o Cylinder (may be bivalved)
o Encircles arm/leg leaving toes/fingers exposed
o Extends from joint above and below injury
o Body (may be bivalved)
o Larger form of cylinger; encircles trunk of body
o Spica
o Encircles one/both arms or legs and
trunk/chest
o May have abduction bar; shoulder or hip
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Cast Materials
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Cast Application
Nurse prepares client
Assembles cast materials
Assists physician during cast application
Refer to Skill 25-2 in the textbook
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Casts (cont’d)
• Cast care
– Assess skin integrity (color, motion, sensation; CMS)
– Apply petals to roughened areas
• Cast removal
– Electric cast cutter may frighten clients
due to noise
– Skin care important after cast removal
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Basic Cast Care
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Traction
• Traction: pulling effect exerted on a part
of the skeletal system
– Pull of traction offset by patient’s own body weight
– Involves use of weights connected to patient with
ropes, pulleys, slings, etc.
• Uses
– Reduce muscle spasms; Realign bones
– Relieve pain; Prevent deformities
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Traction (cont’d)
• Traction types include:
– Manual
–
Pulling on body using hands and strength
–
Used frequently to replace dislocation
– Skin
–
Devices applied to skin such as pelvic belt,
Buck’s/Russell’s traction
– Skeletal-pulls directly on bone with wires,
pins, tongs into bone
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Traction (cont’d)
• Traction care
– External fixator
– Pin site care to prevent infection
• Effective traction depends on consistent
application of traction principles
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External Fixators
• Metal devices surgically inserted into or
through one or more broken bones to
stabilize during healing
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Skin Traction
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Principles for Maintaining
Effective Traction
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General Gerontologic Considerations
• Common causes of hip fractures in older
adults
• Longer healing time due to brittle bones
• Stiffer joints due to decreased synovial joint
fluid
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General Gerontologic Considerations
(cont’d)
• Due to diminished tactile sensation, older
adults may be unaware of skin pressure
from cast, brace, etc.
• Remove indwelling catheters as soon as
possible after surgery to prevent
incontinence and urinary tract infections
• Cautious use of narcotics for pain
management to avoid adverse effects
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General Gerontologic Considerations
(cont’d)
• Implement measures to increase bone
density in older adults to prevent fractures:
– Drink liquid supplements high in
nutrients; include protein, calcium, and
zinc in diet to promote healing in a
musculoskeletal injury
– Encourage sun exposure for vitamin D
absorption
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General Gerontologic Considerations
(cont’d)
• Post-orthopedic surgery interventions for
older adults
– Bladder training schedules to maintain
or regain continence
– Appropriate rolling technique when
using fracture-style bedpan
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General Gerontologic Considerations
(cont’d)
• Nonsurgical treatment of fractures of the
upper extremities includes:
– Immobilization
– Occupational and physical therapy to
regain function and range of motion
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Chapter 26
Ambulatory Aids
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• Debilitated clients require physical
conditioning before they can ambulate
again
• Some techniques for increasing strength
and weight bearing include
– isometric exercises for lower limbs
– Isotonic for upper arms
– Dangling at bedside
– Use of a tilt table
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Preparing for Ambulation
• Isometric exercises:
– Promote muscle tone and strength
– 2 types include:
– Quadriceps setting: client alternately tenses and
relaxes the quadriceps muscles
– Gluteal setting: client contracts and relaxes the
gluteal muscles to strengthen and tone them
Easily performed in bed or chair
Initiated long before ambulation begins
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Quadriceps and Gluteal Setting
Exercises
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Preparing for Ambulation
• Upper arm strengthening: flexion and
extension of the arms and wrists; raising and
lowering weights with the hands; squeezing
a ball or spring grip; modified hand push-ups
in bed
• Dangling: normalizes blood pressure
• Using a tilt table
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Assistive Devices
• Devices to support and assist walking:
– Parallel bars (handrails) provide practice
in ambulating
– Walking belt applied around client’s
waist provides secure grip to prevent
injury while ambulating
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Ambulatory Aids
• Crutches: generally used in pairs and made
of wood or aluminum
– Axillary-fit under axilla
– Forearm-cuff for arm; no axillary bar
– Platform-support forearm; for people who cannot
bear weight with hands/wrists
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• Cane: a hand-held ambulation device made of
wood or aluminum
– Rubber tips reduce possibility of slipping
– Different handles and bases
– Handle should be parallel with hip
– Should be on stronger side of body
• Walker: most stable device; has curved aluminum
bars and three-sided enclosure with four legs for
support
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• Crutch-walking gaits: pattern of walking
when ambulating with crutches
– Four-point gait-bilateral weakness; one
crutch opposite foot
– Three-point gait-both crutches followed by
follow through leg
– Two-point gait-same as 4 point but
movement in unison
– Swing-through gait-both crutches and legs
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Using a Cane
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Crutch-Walking Gaits
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Prosthetic Limbs
• Temporary prosthetic limb: immediate
postoperative prosthesis (IPOP)
• Permanent prosthetic components delayed
for several weeks or months to be sure:
– Incision has healed
– Stump size is relatively stable
– Custom-made to conform to stump and meet client
needs
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Prosthetic Limbs (cont’d)
• Prosthetic components include:
– Below the knee: socket, shank,
ankle/foot system
– Above the knee: below-the-knee
components plus a knee system
• Ambulation with a lower limb prosthesis
requires strength and endurance
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General Gerontologic Considerations
• Functional ability involves mobility and
making adaptations to compensate for
changes occurring with aging or disease
processes
• May need encouragement and support
integrating adaptations into their
activities of daily living and maintaining
their self-concept and body image
• Maintaining independence is important
to older adults
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General Gerontologic Considerations
(cont’d)
• Mobility facilitates staying active and
independent
• As a person ages, he or she may develop
flexion of the spine which alters the center of
gravity and may increase falls
• Ensure adequate lighting without laying
electric cords in passageways
• Elevate toilet seats; install grab bars
• Rearrange home furnishings
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Chapter 18
Antiinflammatory, Musculoskeletal, and Antiarthritis
Medications
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53
Muscular and Skeletal Systems
• Bones, joints, muscles, and ligaments
• Antiinflammatory and analgesic drugs
• Skeletal muscle relaxants
• Drugs used to treat arthritis
• Drugs used to treat gout
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The Skeletal System
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The Muscular System
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The Muscular System
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The Inflammatory Response
• Triggers to inflammation
• Phases of the inflammatory response
• Symptoms of inflammation
• Cellular response
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Antiinflammatory and
Analgesic Agents
• Aspirin: acetylsalicylic acid (ASA)
• Acetaminophen
• NSAIDs
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Salicylates
Action
• Analgesic, antipyretic, and antiinflammatory effects
• Stop the production of prostaglandins
• Table 18-1
Uses
• Treatment of mild to moderate pain; reduces the risk of
myocardial infarctions and stroke, as well as transient ischemic
attacks (TIAs) in men
• First-line therapy for various forms of arthritis, fever, myalgia,
neuralgia, arthralgia, headache, and dysmenorrhea
• Systemic lupus erythematosus, acute rheumatic fever
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Salicylates (cont.)
Adverse Reactions
• Tinnitus, visual disturbances, edema, urticaria,
anorexia, epigastric discomfort, and nausea
Drug Interactions
• Alcohol use increases the chance for GI bleeding;
NSAIDs; sulfonamides, sulfonylureas; phenytoin
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Salicylates (cont.)
Nursing Implications
• Assessment, diagnosis, planning, implementation,
and evaluation
Patient Teaching
• Administration time, adverse effects; time for drug
effectiveness; implications for drug interactions and
when to contact the healthcare provider; storage
and safety; other routes of administration if PO is
not tolerated
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Acetaminophen
• Over-the-counter drug used to treat fever and pain;
no antiinflammatory effect
• Action: antipyretic – direct action of the hypothalamic
heat-regulating center; blocks pyogenic cytokines
through vasodilation and sweating
• Use: chronic, nonmalignant pain; osteoarthritis
• Adverse reactions: rare blood response; liver toxicity;
overdosage can be fatal
• Drug interactions and hepatotoxicity
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Nonsteroidal Antiinflammatory Drugs
• Action: unknown; may block prostaglandins;
analgesic, antiinflammatory, and antipyretic effects
• Uses: rheumatic disease, degenerative joint disease,
osteoarthritis, and acute musculoskeletal problems
• Adverse reactions: GI most common
• Drug interactions
• Nursing implications and patient teaching
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Williams' Basic Nutrition & Diet
Therapy
14th Edition
Chapter 15
Weight Management
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
65
Lesson 15.1: Causes of Obesity
and Risks of Food Fads


Underlying causes of obesity include a host of
various genetic, environmental, and psychological
factors.
Short-term food patterns, or fads, often stem from
food misinformation that appeals to some human
psychological need but does not necessarily meet
physiologic needs.
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66
Introduction (p. 280)

Currently in the United States




34.2% of adults are overweight
33.8% are obese
5.7% are extremely obese
16.9% of children and adolescents are obese
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
67
Introduction (cont’d) (p. 280)

Overweight and obesity, by age: United States, 19602004
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68
Obesity and Weight Control
(p. 280)

Body weight and body fat



Definitions
Body composition
Measures of weight maintenance goals


Standard height/weight tables
Healthy weight range
• Individual variation
• Necessity of body fat
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69
Obesity and Health (p. 286)


Weight extremes: clinically severe obesity is health
hazard
Overweight and health problems: hypertension,
diabetes, heart disease, arthritis, cancer
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70
Causes of Obesity (p. 286)



Basic energy balance
Hormonal control: leptin and ghrelin
Genetic and family factors




Genetic control: obesity highly associated with
genetics
Family reinforcement: teach food habits and exert
social pressure
Physiologic factors: number of fat cells in the body
Other environmental factors: availability of energydense, fast foods, convenient foods
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71
Individual Differences and
Extreme Practices (p. 288)


Individual energy balance levels
Extreme practices



Fad diets
Scientific inaccuracies and misinformation
Failure to address the necessity of changing longterm habits
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72
Extreme Practices (p. 289)





Fasting: negative health effects, rebound effect
Specific macronutrient restrictions: no evidence to
support, carry health risks
Clothing and body wraps: cause temporary water
loss
Drugs: FDA regulates, should be combined with
lifestyle changes
Surgery: gastric restriction, malabsorptive
procedures, lipectomy
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73
Surgical Treatments for Obesity
(p. 293)
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74
Lesson 15.2: Weight Management
Tools and Risks of Being
Underweight


Realistic weight management focuses on individual
needs and health promotion, including meal pattern
planning and regular physical activity.
Severe underweight carries physiologic and
psychological risk to the body.
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75
A Sound Weight Management
Program (p. 294)


Essential characteristics: food and exercise
behaviors
Behavior modification


Basic principles
Basic strategies and actions
• Defining problem behavior
• Recording and analyzing baseline behavior
• Planning behavior management strategy
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76
Dietary Principles (p. 294)

Dietary principles

Realistic goals: ½ to 1 lb per week loss
 Negative energy balance: 500 to 1000 kcal/day
 Nutritional adequacy: choose nutrient-dense foods
 Cultural appeal: to allow permanent change in
habits
 Energy readjustment to maintain weight: when
desired weight is reached
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77
Basic Energy Balance
Components (p. 295)


Energy input: food behaviors
Energy output: exercise behaviors
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78
Principles of a Sound Food Plan
(p. 296)





Energy balance: modifications to energy intake and
output
Nutrient balance: carbohydrate, protein, fat
proportions
Distribution balance: spread food throughout the day
Food guide: American Dietetic Association
Preventive approach: overweight children become
obese adults
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79
Food Misinformation and Fads
(p. 300)

Types of claims




Food cures: certain foods cure specific conditions
Harmful foods: certain foods are harmful
Food combinations: specific combinations restore
health
“Natural” foods: only “natural” foods can meet
body needs
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80
Food Misinformation and Fads
(cont’d) (p. 301)


Erroneous claims
Dangers





To health
Often expensive
Perpetuates superstitions
Distrust of modern food market
Vulnerable groups

Elderly, young persons, obese persons, athletes
and coaches, entertainers
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81
Underweight (p. 302)

General causes

Wasting disease
 Poor food intake
 Malabsorption
 Hormonal imbalance
 Energy imbalance
 Poor living situation
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82
Dietary Treatment (p. 303)





High-calorie diet
High protein
High carbohydrate
Moderate fat
Adequate sources of vitamins and minerals
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83
Disordered Eating (p. 303)


Definition of normal eating
Disordered eating





Anorexia nervosa: results in self-imposed
starvation
Bulimia nervosa: binge-and-purge cycle
Binge eating disorder: often follows stress or
anxiety
Significant mortality rates, slow recovery
Treatment
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84
Williams' Basic Nutrition & Diet
Therapy
14th Edition
Chapter 16
Nutrition and Physical Fitness
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85
Lesson 16.1: Physical Activity
and Health



Regular physical activity is an important part of a
healthy lifestyle and relies on healthy muscle
structure.
Different levels of physical activity draw on a variety
of body fuel sources.
Sedentary lifestyles are a contributing factor to poor
health.
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86
Physical Activity Recommendations
and Benefits (p. 311)

Guidelines and recommendations


Technology contributes to sedentary lifestyle
About 39% of Americans do not engage in
physical activity on a regular basis
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87
Guidelines and
Recommendations (p. 311)


Definitions of physical activity and exercise
Physical Activity Guidelines for Americans
based on:



Intensity
Frequency
Duration
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88
Physical Activity Guidelines for
Americans (p. 312)



Children and adolescents: aerobic, musclestrengthening, bone-strengthening
Adults: 150 minutes of moderate-intensity aerobic
physical activity/week
Older adults: same as adults, or, as physically active
as conditions allow
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89
Health Benefits (p. 314)

Coronary heart disease





Heart muscle strengthened
Blood cholesterol levels improved
Oxygen-carrying capacity increased
Hypertension reduced
Diabetes effects reduced
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90
Health Benefits (cont’d) (p. 314)



Weight management: energy output increased
Bone disease: weight-bearing activities increase
osteoblast activity
Mental health: exercise stimulates endorphins,
improves quality of life
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91
Types of Physical Activity
(p. 316)

Activities of daily living



Resistance training



Should be enjoyable
Incorporate into daily life
Builds, maintains muscle and bone strength
Should include 8 to 10 exercises, 2 to 3
days/week for novices
Aerobic exercise


Swimming, running, bicycling, aerobic dancing
Simple form is walking
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92
Types of Physical Activity (cont’d)
(p. 318)

Weight-bearing exercise


Walking, jogging, aerobic dancing
Important for bone structure and strength
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93
Aerobic Exercises for Physical
Fitness (p. 317)
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94
Energy Expenditure During
Various Activities (p. 318)
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95
Meeting Personal Needs (p. 318)

Health status and personal gains



Achieving aerobic benefits



Assess health and resources before starting
Moderation and regularity
Raise pulse to 60% to 90% of maximal heart rate
20 minutes, 3 to 6 times per week
Exercise preparation and care

Warm up before
 Cool down after
 Listen to the body
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96
Dietary Needs During Exercise
(p. 319)

Muscle action and body fuels



Structure and function
Fuel sources: carbohydrates and some fats
Oxygen: body’s ability to deliver oxygen is a
limiting factor in exercise
• Cardiovascular fitness: aerobic capacity
• Body composition: lean body mass, fat, water, bone
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Fluid and Energy Needs (p. 319)

Fluid



Body releases heat through sweating
Water lost must be replaced
Energy and nutrient stores


Exercise raises energy needs
Proper diet choices are essential
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Macronutrient and Micronutrient
Recommendations (p. 320)




Carbohydrate: preferred fuel
Fat: no more than 30% of total daily energy intake
Protein: insignificant contribution during exercise
Vitamins and minerals: intake increases as food
intake increases
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Lesson 16.2: Nutrition for
Training and Competition

A healthy personal exercise program combines both
strengthening and aerobic activities.
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100
Athletic Performance (p. 321)

General training diet


Prevents malnutrition and risk of injury and
infection
Carbohydrate
• General training: 6 to 7 g/kg body weight
• Endurance: 7 to 10 g/kg body weight per day
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101
General Training Diet (p. 321)


Prevents malnutrition and risk of injury and
infection
Carbohydrate

General training: 6 to 7 g/kg body weight
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102
General Training Diet (cont’d)
(p. 322)

Fat



20% to 35% of the total kilocalories
High-fat meal could hinder performance
Protein

1.2 to 1.7 g/kg body weight per day
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103
Competition (p. 323)

Carbohydrate loading



The week before an event
Tapering exercise while increasing carbohydrate
intake
Pregame meal

Usually light meal 3 to 4 hours before event
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104
Competition (cont’d) (p. 324)

Hydration



Fluid needs depend on many factors
Thirst mechanism cannot keep up
Hydrate before, during, after exercise
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105
Hydration (p. 324)
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106
Energy During and After Exercise
(p. 325)

Competition (cont’d)


Energy during exercise
• Activity less than 1 hour: no intake needed
• Longer endurance events: 30 to 60 g/hr carbohydrate
Energy after exercise
• Fluid and carbohydrate replacement beverage
immediately after endurance event
• Not as effective if delayed 2 hours or more
• Protein intake also beneficial
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107
Ergogenic Aids and
Misinformation (p. 326)



Popular but very few have proven effective
Steroid side effects can be devastating
Athletes and coaches susceptible to misinformation
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