Chapter 19: Activity and Exercise

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We're embarking on a crucial deep dive today, really getting into activity and exercise in geriatric nursing.

And this isn't just about, you know, going for a run.

It's fundamental.

It's cornerstone of maintaining self -sufficiency, independence,

and, frankly, the quality of life for older adults.

Exactly.

And our mission today, really, is to give you a clear, structured way to think about this.

We're pulling directly from the core chapter.

We need to systematically break down how normal activity patterns change with aging itself,

then look at how disease processes can, unfortunately, accelerate that decline, and, most importantly, how you apply the nursing process, the clinical judgment model, to support the highest possible level of function.

Okay, so let's start with the absolute basics.

What exactly is activity in this context?

Because it's broader than just exercise.

It really is.

We're talking about anything that requires energy expenditure.

Think of it as a spectrum.

At the lowest end, you have basic body functions, just breathing, circulation.

Then maybe sedentary tasks, like reading, moving up.

You've got the activities of daily living, the ADLs, things like dressing, grooming, feeding oneself.

And then at highest energy end, yeah, you have actual physical exercise, like aerobics or running.

And the guiding principle through all of this, it seems to be that mobility is key.

Preventing problems is easier than fixing them.

Absolutely.

That concept mobility is medicine, you could almost say, is crucial.

Because physical activity isn't simple.

It relies on this complex integrated dance involving four primary systems.

You've got the neurological system controlling things, the musculoskeletal system doing the moving, the cardiovascular system supplying the fuel, and the respiratory system providing the oxygen.

Wow.

Okay, so if any one of those is compromised.

Instantly.

Whether it's just from normal aging or an acute illness, activity is altered.

And often, a successful nursing intervention means figuring out which part of that chain is the weakest link and targeting it.

Okay, let's unpack the normal physiological declines then.

What's the first thing you typically notice?

Often, the first thing people notice, or that we observe, is just a decreased speed.

The rate of activity slows down.

Things just take longer.

Why is that?

Primarily, because nerve impulse transmission slows down with age.

It's a subtle change, but it adds up.

And that seemingly small change is why complex, routine tasks, like just getting ready in the morning, suddenly require significantly more time.

And, you know, patience from everyone involved.

Beyond just slowing down, what about the actual structures, muscles, bones?

Oh yeah, big changes there.

We see a predictable loss of muscle mass sarcopenia that directly affects activities needing strength.

Think about lifting a bag of groceries, or even just opening a tight jar.

At the same time, the skeleton changes.

You lose that cushioning cartilage in the joints, which leads straight to arthritic pain.

It inhibits motion.

And the ligaments, the tendons, they stiffen up.

They lose flexibility.

So if you can't bend easily or reach.

Exactly.

Simple self -care becomes a huge challenge.

Washing your back, putting on socks, clipping toenails.

Suddenly these are difficult, maybe impossible without help.

This loss of efficiency, it must impact specific kinds of movement too.

You mentioned key terms we need to know.

Yes, two important ones.

First is agility.

That's the ability to move quickly and smoothly.

As agility decreases, which it does with age, it directly impacts safety.

Think about reacting quickly to avoid tripping over something on the floor.

If that reaction is slow, the fall risk just skyrockets.

Okay, agility.

And the second one.

Dexterity.

This refers to those fine, manipulative skills using your hands and fingers.

What's kind of fascinating here is that dexterity often declines faster than gross motor skills like walking, although there's a caveat.

If someone has maintained a lifelong practice, maybe playing piano or knitting or painting,

those refined skills can often be preserved much longer.

Practice matters.

Interesting.

What else changes?

Stamina?

Definitely see a decline in stamina.

And this is almost always linked back to oxygenation problems.

As we age, the lungs lose some of their natural elasticity.

The chest cavity might even reduce slightly in size.

Both of those things directly impair gas exchange.

Less oxygen getting in and distributed.

So that means getting tired more easily.

Precisely.

The individual requires frequent rest periods or they just have to adopt a much slower pace for everything to avoid getting breathless and exhausted.

And there's a critical safety point here you really have to be aware of.

Any activity that requires coordinating multiple stimuli, like seeing traffic, hearing horns, judging speed, and then making quick physical responses.

Well, driving is the classic example.

It becomes increasingly dangerous because of that decreased reaction time and coordination.

It's a tough conversation to have, but a necessary one sometimes.

Okay, so those are the age -related changes.

But before we get into specific diseases, let's pivot to the positive.

Exercise.

We know it's beneficial.

Hugely beneficial.

Regular activity isn't just nice to have.

It's arguably a non -negotiable part of extending that active independent life.

It helps maintain muscle mass, definitely improves balance and coordination, and significantly reduces the risk of developing disabilities.

So what are the actual guidelines?

What should we be telling people aiming for?

The current guidelines are actually pretty achievable for most people.

They focus on consistency over intensity.

Really.

The aim is for 150 to 300 minutes of moderate intensity aerobic activity each week.

Things like brisk walking, swimming.

Or, if they prefer higher intensity, 70 to 150 minutes of vigorous aerobic activity is the target.

But, and this is critical, you absolutely must couple that aerobic work with muscle strengthening exercise.

Not at all.

Using resistance bands, light hand weights, even just using their own body weight for exercise like chair stands or wall push -ups, it all counts.

Honestly, the biggest barrier we often see isn't physical capacity, it's motivation.

Getting started and sticking with it.

And different types of exercise achieve different goals, right?

Exactly.

So aerobic activity, walking, swimming, maybe cycling that directly promotes cardiorespiratory function.

Yeah.

Keeps heart and lungs healthy.

Strength training, as we said, combats sarcopenia, that age -related muscle loss.

Weight -bearing exercises like walking are absolutely essential for maintaining bone strength, fighting osteoporosis.

And we can't forget flexibility training.

Stretching helps maintain that full range of motion in the joints.

You mentioned swimming good for sore joints.

Oh, excellent.

Water exercise takes the pressure off joints, making it a great option for people with arthritis.

And related to that, we really should champion some of the low -impact, more therapeutic approaches too, like chi gong and tai chi.

Ah, yes, those are becoming more popular.

And for good reason.

These ancient Asian practices are generally less stressful on compromised joints, but they require intense concentration and balance.

The evidence is quite strong now.

They significantly improve balance, flexibility, and strength, particularly in the adaptability.

You can do them standing, sitting, even modified versions lying down, makes them almost universally accessible.

Okay, so lots of options, but safety first.

When someone's starting an exercise program, what are the absolute must -dos from a nursing perspective?

Number one, without question, get a checkup from their primary care provider before starting anything new or increasing intensity, just to clear them for activity.

Number two, and this seems basic, but it's huge, proper supportive footwear.

We so often see older adults shuffling around in loose slippers, worn out shoes, maybe shoes without proper backs.

That is a major, major fall risk.

Right.

Things like bunions or calluses might make finding good shoes tricky, but it's essential.

It is.

We have to educate them and often their families very tactfully about why those comfy old slippers might actually be dangerous.

Also, think about the environment.

Plan exercise around extreme weather.

Older adults are more susceptible to thermal imbalance overheating or getting too cold.

So avoid strenuous activity on very hot or very cold days.

And pacing.

You mentioned needing rest periods earlier.

Crucial.

Teach proper pacing.

Don't try to do too much too soon.

Build up gradually and always, always incorporate a cool -down period after activity.

Stopping vigorous exercise abruptly can cause syncope fainting.

Fainting.

Why does that happen?

Because when you exercise hard, blood rushes to your working muscles.

If you stop suddenly, that blood can pool in the extremities.

It doesn't return quickly enough to the central circulation.

So blood pressure drops.

The brain doesn't get enough oxygen momentarily and down they go.

A gradual cool -down prevents that.

Okay.

That makes sense.

So we've covered normal aging and exercise.

Now let's transition into how specific diseases complicate the picture.

They accelerate these changes, right?

Drastically.

Disease processes layer on top of the normal age -related decline, often making things much worse, much faster.

Take neurological impairment, think stroke, Parkinson's disease, dementia.

These conditions don't just affect physical movement directly by blocking nerve impulses or causing tremors.

Cognitive disorders can impair high -level thinking to the point where the person doesn't even recognize the need to perform an ADL, like bathing or dressing.

Or they might understand the need but be physically unable to initiate or coordinate the action.

That leads to things like a staggering, unsteady gait or freezing mid -movement.

And musculoskeletal problems, arthritis, fractures.

Oh, those create what we often call a vicious cycle.

Conditions like arthritis, gout, or maybe recovering from a hip fracture, they cause significant pain.

That pain naturally makes the person want to restrict their activity to avoid hurting more, but that inactivity then leads to more problems.

Disuse atrophy, where muscles weaken, loss of joint mobility as things stiffen up, often worsening pain because the supporting structures are weaker.

It's this downward spiral that we as nurses have to be really proactive about interrupting.

Early mobilization, pain management, gentle ROM.

And then there are the big ones affecting oxygen supply, heart and lung diseases.

Right, cardiopulmonary diseases like heart failure, COPD, emphysema.

Anything that restricts oxygen intake or its distribution throughout the body.

When oxygen supply is

just walking across the room can be exhausting.

This forces the heart to work much harder to try and compensate, leading to tachycardia, a rapid heart rate.

That's an immediate red flag you need to monitor.

And this lack of oxygen can cause specific types of pain.

Yes, pain that signals tissue, ischemia tissue crying out for oxygen.

Two critical types you absolutely must recognize in geriatric patients.

First is angina, chest pain.

But, and this is key in older adults, it often presents atypically.

It might not be that classic crushing chest pain radiating down the left arm.

It could be vague GI discomfort, indigestion, jaw pain, even shoulder or back pain.

Recognizing those atypical presentations is a really high value clinical skill.

Okay, atypical angina.

And the second one.

Intermittent claudication.

This is a cramping pain almost always felt in the legs, specifically the calves usually.

It comes on during or immediately after walking a certain distance and is caused by inadequate blood flow ischemia to the leg muscles during exertion.

The defining feature is that it's relieved entirely by rest.

Stop walking, the pain goes away.

Start again, it comes back after about the same distance.

That pain is literally the body drawing a line, giving you a clear, measurable boundary of their activity tolerance at that moment.

Rest is mandatory when it occurs.

Wow.

Okay.

Very important distinctions.

So let's move into the structured nursing process now.

How do we assess and intervene for altered mobility?

Right.

When you're assessing for altered mobility, you're looking systematically.

Check their joint range of motion actively if they can, passively if needed.

Is it full?

Is there pain with movement?

Assess muscle strength.

Is it equal on both sides?

Any weakness?

Look at their gait.

Are they steady?

Do they shuffle?

Is it a taxic or uncoordinated?

Observe their posture and alignment.

Do they use assistive devices like walkers or canes?

And crucially, are they using them correctly?

Improper use can be as dangerous as not using one at all.

So assessment is key.

What about interventions?

Preventing problems seems central.

Absolutely.

Our key interventions really prioritize maintaining proper body alignment and positioning.

This is crucial to prevent irreversible contractures like foot drop, where the foot gets stuck pointing downwards, making walking impossible.

Or hip or knee flexion contractures from sitting too much.

Regular repositioning, using supportive pillows or splints as needed.

It's fundamental nursing care.

And range of motion exercises.

It's essential.

Incorporate them into daily care like during bathing.

We need both types.

Passive ROM, where the nurse or therapist moves the patient's joints through their available range.

This keeps the joints flexible, prevents stiffness.

And active ROM, where the patient moves their own joints.

This not only maintains flexibility, but also helps build or maintain muscle strength and tone.

Okay, passive and active ROM.

The source also mentions isometric and isotonic exercises.

What's the difference there?

Good distinction.

These are more specific strengthening exercises.

Isometric exercises involve tightening or contracting a muscle without moving the joint.

Think about pushing against an immovable object, or just consciously tensing your thigh muscle and then relaxing it.

These are useful when a joint is immobilized, maybe in a cast, to maintain some muscle tone.

Then you have isotonic exercise.

This involves muscle movement with joint movement.

Lifting a lightweight, using a trapeze bar to pull yourself up in bed, bending and straightening your knee.

Ah, okay.

Movement versus no movement at the joint.

Is there a safety concern with these?

Yes, a very important one, especially for patients with cardiac conditions.

Both isometric and to some extent isotonic exercises, particularly if they involve straining, can trigger the Valsalva maneuver.

That's when a person holds their breath and bears down while exerting effort.

Like straining to lift something heavy.

Exactly, or straining during a bowel movement.

Or even just pushing hard during an isometric contraction.

This dramatically increases pressure inside the chest, which can impede blood return to the heart and put dangerous stress on a compromised cardiovascular system.

Sudden changes in heart rate and blood pressure can occur.

So you have to teach patients, especially cardiac patients, to breathe through the exertion, never hold their breath.

Crucial safety point, and related to safety and mobility restraints.

A huge topic.

The strong message here is to actively avoid unnecessary restraints or protective devices whenever possible.

We used to think they kept people safe, but the evidence shows the opposite.

Any restraint, even something seemingly benign like raised side rails used improperly, or a lap belt, accelerates the loss of function.

It increases the risk of injury if they try to fight against it, and it absolutely promotes dependence and helplessness.

Our primary goal must always be to adapt the environment to the patient's needs, using bed alarms, lowering beds, keeping pathways clear, rather than restricting the patient themselves.

Adapt the environment, not restrict the person.

Got it.

Let's shift slightly to the nursing diagnosis of altered activity tolerance.

This is when they just don't have enough energy for daily activities, right?

Precisely.

They have insufficient physiological or psychological energy to endure or complete required or desired daily activities.

When assessing for this, you're looking for key signs.

Dyspnea, shortness of breath, unexertion, excessive fatigue, reported weakness, maybe dizziness, and you absolutely must monitor their vital signs.

Pulse, respiration, blood pressure, even oxygen saturation before, during, and immediately after any activity to gauge their physiological response.

How much does their heart rate jump?

How quickly does it recover?

And the main intervention here seems to be pacing.

Pacing is the cornerstone.

It sounds simple, but it's incredibly effective.

Pacing means strictly alternating periods of activity with planned periods of rest throughout the day.

Not pushing until exhaustion hits, but scheduling rest before they get overly tired.

This helps conserve energy, prevents burnout, and actually helps maintain motivation because they don't associate activity only with feeling wiped out.

Makes sense.

What else helps with activity tolerance?

Aggressively teaching energy conservation techniques is vital.

These are the small, practical things that make a big difference.

Like sitting down while dressing or grooming instead of standing.

Using assistive devices like long -handled reachers to avoid bending or stretching.

Organizing their space so frequently used items are within easy reach, minimizing unnecessary steps.

Using slip -on shoes instead of ones with complex laces.

These small adaptations collectively preserve a significant amount of stamina over the course of a day.

So pacing and energy conservation for tolerance.

Now let's talk about basic functional independence, the ADLs.

This is covered under altered self -care ability.

Yes.

This diagnosis addresses deficits in performing those fundamental activities of daily living.

Feeding, bathing, or hygiene, dressing and grooming, and toileting.

We use a systematic grading scale, usually 0 to 4, to assess the level of assistance required for each ADL.

0 means they're completely independent.

4 means they're dependent, requiring full assistance from the caregiver.

Levels 1, 2, and 3 represent varying degrees of needing help, maybe just set up for supervision or some hands -on assistance.

And the inability to do these basic things, that must hit self -esteem hard.

Devastatingly so.

It's deeply tied to feelings of independence, control, and dignity.

Promoting dependence in these areas when it's not absolutely necessary can be really damaging psychologically.

So the intervention goal is always?

The highest possible level of function they can achieve, even if it's slow, even if it's messy sometimes.

This often means collaborating closely with occupational therapists, OTs, and physical therapists, PTs.

They are the experts in recommending and teaching the use of adaptive equipment.

Things like button hooks for people with poor dexterity, sock assists, long -handled sponges or shoe horns,

modified utensils with built -up handles for easier grip, grab bars in the bathroom.

The list is long.

And involving the family is key here too.

Absolutely crucial, especially with families.

We have to actively teach families the importance of allowing the older adult adequate time and opportunity to do as much as possible for themselves.

It's natural for loved ones to want to jump in and help, to do it for them because it's faster or easier.

But we have to explain that rushing them or taking over tasks they could do with more time is actually contributing to a loss of functional ability.

It's custodial care.

Providing the time and encouragement, even if it takes longer, is the rehabilitative approach.

That distinction rushing versus providing time doing for versus doing with seems like a recurring theme.

Okay, one more area before the big picture.

Deficient Diversional Activity.

What does this cover?

This tackles the psychosocial side,

loneliness, boredom, social isolation,

a lack of engagement in meaningful leisure or recreational activities.

Risk factors are pretty clear, limited mobility that prevents getting out, maybe limited financial resources for activities or transportation,

visual or hearing impairments, feelings of anxiety or depression can all contribute.

And why is this so important?

It's not just about keeping busy, is it?

Not at all.

Meaningful activity is vital for maintaining self -esteem, providing a sense of purpose, and fostering social connection.

It combats that sense of isolation that can be so detrimental to mental and even physical health.

The key word is meaningful.

The activities must align with the individual's interests and abilities.

So how do we intervene?

First, assess.

Talk to them about their past hobbies, their current interests, what they used to enjoy, what might they enjoy now, given any limitations.

Focus on their abilities, not just their disabilities.

Maybe they can't garden standing up anymore, but could they manage some container gardening sitting down?

Provide suitable materials.

If they loved reading but struggle with small print, suggest large print books or audio books.

Ensure good lighting.

Encourage participation facility activities if appropriate.

Music therapy, art groups, discussion groups.

And we have to recognize modern challenges, especially highlighted during things like the pandemic lockdowns.

Ah, the isolation aspect.

Exactly.

For older adults who became incredibly isolated, nurses sometimes had to step into a new role, teaching them how to use technology,

showing them how to use video conferencing apps like Zoom or Skype on a tablet or smartphone so they could see and talk to family and friends.

That became a critical intervention for maintaining vital social connection.

And one practical point, always ensure basic physical needs like toileting or having a drink or snack are met before starting an activity to reduce anxiety or potential embarrassment.

That makes perfect sense.

Okay, we've covered a lot of grand duration, the changes, exercise, diseases, specific nursing diagnoses.

Now we arrive at what the source calls the most critical element of all, the nurse's attitude.

This is it.

This is the core message really.

Our underlying attitude, our expectations about aging and about the individual patient fundamentally shapes the care we provide and ultimately the patient's outcomes.

The source draws a very stark contrast between two diametrically opposed philosophies of care.

Okay, let's hear them.

What's the first one?

The first is the custodial focus.

This approach is rooted in negative, almost defeatist view of aging.

It assumes that deterioration, decline, and loss are inevitable and irreversible.

Expectations for the older adult are low.

The focus becomes primarily on meeting only the most basic physiological and safety needs, keeping them clean, fed, safe.

Think the lowest levels of Maslow's hierarchy.

This approach inherently promotes passivity.

The nurse does things for the patient, often because it's quicker or seems easier.

It inadvertently reinforces helplessness and accelerates dependence.

Wow, that sounds bleak.

What's the alternative?

The alternative and the standard we must strive for is the rehabilitative focus.

This operates from a profoundly positive attitude.

It acknowledges age -related changes and diseases, yes, but maintains high yet realistic expectations for the individual's potential.

The goal here is achieving the maximal level of physical, psychosocial, and spiritual health possible for that person.

It's patient -centered.

It's proactive.

It focuses on restoring function

helping the individual adapt positively to irreversible changes and critically supporting their sense of control over their own life.

So this is the doing with approach rather than doing for.

Precisely.

It involves actively engaging the older adult in their care plan, setting challenging but achievable goals together.

It recognizes their intrinsic worth and potential regardless of their physical or cognitive limitations.

It requires the nurse to act as a coordinator, collaborating with the whole team, PT, OT, dietitian, social worker, family, all working towards that shared goal of maximizing function and independence.

This distinction feels incredibly powerful.

If we expect little, we get little.

The source shared a story illustrating this.

Yes, an incredible story about a resident known as the Colonel.

He had multiple strokes, couldn't speak clearly according to his chart, and was largely written off as having severe dementia, non -communicative.

Everyone treated him based on that low expectation.

But then, a nursing instructor, approaching him with respect and assuming competence operating from that rehabilitative mindset, challenged him directly, asking complex questions.

And the Colonel responded.

Clearly.

Coherently.

His mind was sharp, trapped inside a body that made communication difficult but fully capable of comprehension and thought.

His true potential remained hidden simply because everyone before had approached him without limiting custodial focus.

It's a sobering reminder of the power of our expectations.

That's a profound example.

And this rehabilitative idea, it doesn't stop at the hospital or nursing home door, does it?

No, absolutely not.

The source makes a crucial final point here.

Rehabilitation extends into the community.

It argues that nurses have a role, even a responsibility, to become social activists in a sense.

We need to advocate for removing environmental barriers out in the world, campaigning for more ramps, wider doorways in public buildings, accessible public transportation, clear signage.

Making the everyday world accessible is fundamental to allowing older adults, especially those with disabilities, to maintain their independence, their social connections, and their functioning outside the walls of a care setting.

That's part of holistic rehabilitation, too.

So bringing this all together, it's a complex picture.

It is.

Maintaining activity and function in geriatric nursing requires continuous, multi -system assessment.

It demands highly tailored care plans that address not just mobility, but oxygenation status, self -care ability, and those crucial psychosocial needs like meaningful diversion and social connection.

But the single most impactful lesson, it seems, is about mindset.

It's embracing that rehabilitative focus, setting high expectations, actively involving the patient, fostering independence, not just settling for maintenance.

That really has to be the standard of care we strive for every single day.

Absolutely.

And perhaps, as a final thought for you to take away and explore, really reflect on that distinction we discussed, the difference between custodial care doing for the patient and rehabilitative care doing with the patient.

How does internalizing that difference change your approach when you nexus someone with even the simplest tasks, like getting dressed or eating a meal?

How can you shift from doing for to doing with in your daily practice?

That's a powerful question to consider.

This has been a deep dive into the essentials of psychiatric activity and exercise, drawing from that core chapter.

A warm thank you from the Last Minute Lecture Team.