6.Endurance: Is patient able to turn in bed,
maintain correct alignment when sitting and
standing, ambulate, and perform self-care
activities?
b.Diagnosis: Activity Intolerance related to
decreased muscle mass, tone, and strength
c. Exercise program: Do range-of-motion exercises
twice a day to build up muscles and joint capa-
bilities. Use quadriceps drills two or three times
an hour, four to six times a day. Do settings twice
a day and pushups three or four times a day.
12.Sample answers:
a.General ease of movement: Normal: Body
movements are voluntarily controlled, fluid,
and coordinated.
Abnormal: Involuntary movements, tremors,
tics, chorea, and so on.
b.Gait and posture: Normal: Head erect, vertebrae
straight.
Abnormal: Spastic hemiparesis, scissors gait
c. Alignment: Normal: In the standing and sitting
position, a straight line can be drawn from the
ear through the shoulder and hip; in bed, the
head, shoulders, and hips are aligned.
Abnormal: Abnormal spinal curvatures, inability
to maintain correct alignment independently
d.Joint structure and function: Normal: Absence
of joint deformities, full range of motion.
Abnormal: Limitations in the normal range of
motion, increased joint mobility
e.Muscle mass, tone, and strength: Normal: Ade-
quate muscle mass and tone. Abnormal:
Atrophy, hypotonicity
f. Endurance: Normal: Ability to turn in bed,
maintain correct alignment.
Abnormal: Weakness, pallorAPPLYING YOUR KNOWLEDGE
REFLECTIVE PRACTICE USING CRITICAL
THINKING SKILLS
Sample Answers
1.What patient teaching might the nurse incorporate
into the plan of care to help Kelsi’s parents minimize
the complications of immobility for their daughter?
The nurse should review the nursing history to
assess Kelsi’s activity level prior to the accident and
develop a teaching plan that maximizes her level of
functioning. The nurse should communicate with
Kelsi and her parents and explain what is happen-
ing to her and the reasoning behind the positioning
and turning schedules and range-of-motion
exercises. The parents could also be taught to assist
with these interventions.
2.What would be a successful outcome for this patient?
By next visit, Kelsi’s parents will demonstrate range-
of-motion exercises to help restore mobility to their
daughter. By next visit, Kelsi will manifest appropri-
ate muscle strength and freedom from skin
alterations.3.What intellectual, technical, interpersonal, and/or
ethical/legal competencies are most likely to bring
about the desired outcome?
Intellectual: knowledge of common problems asso-
ciated with mobility and inactivity
Technical: ability to use correctly the protocols,
products, and equipment necessary to promote
body alignment and to prevent or treat
complications related to immobility
Interpersonal: ability to demonstrate respect for a
patient’s human dignity and autonomy and to
encourage patients and their caregivers to maximize
their mobility and functional status
Ethical/Legal: ability to act as a patient advocate to
promote the maximum level of patient functioning
4.What resources might be helpful for the Lester family?
Home healthcare services, physical rehabilitation
services, printed or AV materials on range-of-
motion exercises
PATIENT CARE STUDY
1.Objective data are underlined; subjective data are in
boldface.
Robert Witherspoon, a 42-year-old university
professor, presents for a checkup shortly after his
father’s death. His father died of complications of
coronary artery disease. Mr. Witherspoon is 5 foot 9
inches, weighs 235 lb, has a decided “paunch,” and
reports that until now he has made no time for
exercise because he preferred to use his free time
reading or listening to classical music. He enjoys
French cuisine, including rich desserts,and has a
cholesterol level of 310 mg/dL (normal is 150 to
250 mg/dL). He admits being frightened by his
father’s death and is appropriately concerned
about his elevated cholesterol level. “I guess I’ve
never given much thought to my health before,
but my Dad’s death changed all that,”he tells
you. “I know coronary artery disease runs in
families, and I can tell you that I’m not ready to
pack it all in yet. Tell me what I have to do to
fight this thing.”He admits that he used to tease a
colleague—who lowered his own cholesterol from
290 to 200 mg/dL by diet and exercise alone—by
accusing him of being a fitness freak. “Now, I’m
recognizing the wisdom of his health behaviors
and wondering if diet and exercise won’t do the
trick for me. Can you help me design an exercise
program that will work?”
2.Nursing Process Worksheet
Health Problem: Altered health maintenance; lack of
exercise program
Etiology:Low value placed on fitness and self-care
behaviors in the past
Signs and Symptoms: 5 foot 9 inches tall; 235 lb;
until now “no time” for exercise; “I’ve never given
much thought to my health before”; “Tell me what
I have to do to fight this thing,” “Can you help me
design an exercise program that will work?”Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:388 ANSWER KEY
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