Geriatric 1. Help the mostly immobile client achieve mobility as soon as possible, depending on physical condition.

In the elderly, mobility impairment can predict increased mortality and dependence; however, this can be prevented by physical exercise (Hirvensalo, Rantanen, Heikkinen, 2000). 2. For a client who is mostly immobile, minimize cardiovascular deconditioning by positioning client as close to the upright position as possible several times daily. The hazards of bed rest in the elderly are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998). 3. If client is mostly immobile, encourage him or her to attend a low-intensity aerobic chair exercise class that includes stretching and strengthening chair exercises. Chair exercises have been shown to increase flexibility and balance (Mills, 1994). 4. Initiate a walking program in which client walks with or without help every day as part of daily routine. Walking programs have been shown to be effective in improving ambulatory status and decreasing disability and the number of falls in the elderly (Koroknay et al, 1995). 5. Evaluate client for signs of depression (flat affect, insomnia, anorexia, frequent somatic complaints) or cognitive impairment (use Mini-Mental State Exam [MMSE]). Refer for treatment or counseling as needed. Multiple studies have demonstrated that depression and decreased cognition in the elderly correlate with decreased levels of functional ability (Resnick, 1998). 6. Watch for orthostatic hypotension when mobilizing elderly clients. If relevant, have client flex and extend feet several times after sitting up, then stand up slowly with someone watching. Orthostatic hypotension as a result of cardiovascular system changes, chronic diseases, and medication effects is common in the elderly (Matteson, McConnell, Linton, 1997). 7. Be very careful when getting a mostly immobile client up. Be sure to lock the bed and wheelchair and have sufficient personnel to protect client from falls. The most important preventative measure to reduce the risk of injurious falls for nonambulatory residents involves increasing safety measures while transferring, including careful locking of equipment such as wheelchairs and beds before moves (Thapa et al, 1996). Elderly clients most commonly sustain the most serious injuries when they fall. 8. Help clients assume the prone position three times per week for 20 minutes each time. If clients are unable to do so, help them turn partially over and assume the position gradually. The prone position helps prevent hip deformities that can interfere with balance and walking. This position may be contraindicated in some clients, such as morbidly obese clients, respiratory or cardiac clients who cannot lie flat, and neurological clients. 9. Do not routinely assist with transfers or bathing activities unless necessary. The nursing staff may contribute to impaired mobility by helping too much. Encourage client independence (Mobily, Kelley, 1991). 10. Use gestures and nonverbal cues when helping clients move if they are anxious or have difficulty understanding and following verbal instructions. Nonverbal gestures are part of a universal language that can be understood when the client is having difficulty with communication. 11. Recognize that wheelchairs are not a good mobility device and often serve as a mobility restraint. Wheelchairs can be very effective restraints. In one study, only 4% of residents in wheelchairs were observed to propel them independently; only 45% could propel them, even with cues and prompts; no residents could unlock them without help; the wheelchairs were not fitted to residents; and residents were not trained in propulsion (Simmons et al, 1995). 12. Ensure that chairs fit clients. Chair seat should be 3 inches above the height of the knee. Provide a raised toilet seat if needed. Raising the height of a chair can dramatically improve the ability of many older clients to stand up. Low, deep, soft seats with armrests that are far apart reduce a person's ability to get up and down without help. 13. If client is mainly immobile, provide opportunities for socialization and sensory stimulation (e.g., television and visits). See Deficient Diversional activity. Immobility and a lack of social support and sensory input may result in confusion or depression in the elderly (Mobily, Kelley, 1991). See interventions for Acute Confusion orHopelessness as appropriate.

*PHYSIOLOGY OF OLD AGE* Musculoskeletal M u s c l e m a s s i s a p r i m a r y s o u r c e o f metabolic heat. When muscles contract,heat is generated. The heat generated bym u s c l e c o n t r a c t i o n m a i n t a i n s b o d y t e mp e r a t u r e i n t h e r a n g e r e q u i r e d fo r normal function of its various chemical processes.As early as the third decade of life therei s a g e n e r a l r e d u c t i o n i n t h e s i z e , e l a s t i c i t y a n d s t r e n g t h o f a l l m u s c l e t i s s u e . T h e l o s s o f m u s c l e m a s s co nt inues t hr o ugho ut t he e lde r years. M u s c l e f i b e r s c o n t i n u e t o b e c o m e smaller in diameter due to a decrease in reserves of ATP, glycogen, myoglobina n d t h e n u m b e r of myofibrils. Cues

Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation Reluctance to attempt movement Limited range of motion (ROM) Decreased muscle endurance, strength, control, or mass Imposed restrictions of movement, including mechanical, medical protocol, and impaired coordination Inability to perform action as instructed

Injury . Reduce the risk of environmental harm from clients such as:

Lock the wheels of the bed. Provide adequate lighting. Down from the bed of the eye is not sore and a bed in low position. Pairs of bed in low position. Remove objects that easily falls (such as bins, seats without backrest) Put your tools such as call bell, tissue, telephone, or controller, easily accessible place on the client side is not affected. Encourage clients to use the handle of the bathroom if possible. Clean the floors of small objects such as pins, pencils and needle.

2. Tell the client to change positions slowly. 3. Encourage clients to use adaptive equipment such as canes and walkers for ambulation as needed. 4. Tell the importance of using protective eyewear when performing high risk activities such as ambulation at night or when you are in the midst of children or pets. Rationale 1. Prevent dizziness 2. Prevent falls due to changes in depth perception. Object or objects may not be located in a visible place such as a client, who took over the center of gravity will change which will cause the client to fall. 3. Gave the source of stability. 4. Increase the sense of balance. 5. Prevent injury.

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., Beta-blockers), or emotional states such as depression or lack of confidence to exert one's self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.