FNP WEEK 13:
ACTIVITY AND EXERCISE, SLEEP, PAIN
MANAGEMENT, NUTRITION, & URINARY
ELIMINATION
ACTIVITY AND EXERCISE
INTRODUCTION
 Our ability to move is an essential aspect of our well-
being.
 At 2005-2006 NANDA, Sedentary Lifestyle was
approved.
 Moderate exercise is significant to enhancing
physical fitness. (e.g. reducing the proportion in
adults who engage in no-leisure time)
 Research says that a strong well- developed body
shows improvement in health especially with
cardiovascular diseases, pulmonary dysfunction,
disabilities of aging and depression.
 Numerous research supports the preventive and
therapeutic effects of exercise for individuals with
hypertension, osteoporosis, coronary heart disease,
mental health disorders, diabetes, cancer, arthritis,
chronic fatigue syndrome, HIV/ AIDS, etc.
ACTIVITY EXERCISE PATTERN
 Person’s routine of exercise, activity, leisure, and
recreation
 Includes:
a) ADL that require energy expenditure (hygiene,
cooking, dressing, eating shopping, working,
chores, home maintenance, etc.)
b) The type, quality, and quantity of exercise,
including sports.
MOBILITY
 The ability to move freely, easily, rhythmically, and
purposely in the environment
 Vital to independence
 People must move to protect themselves from
trauma
 The ability to move without pain also influences self-
esteem and body image.
 For those with impaired mobility, movement must
be fostered to the full extent of capability to
facilitate a satisfying life.
 People often define their health by their mobility
status
NORMAL MOVEMENT
 In addition of stability, is the result of INTACT
Musculoskelatal System, an INTACT Nervous System,
INTACT Inner ear structures responsible for
equilibrium.
 INVOLVES 4 BASIC ELEMENTS:
o BODY ALIGNMENT (POSTURE)
o JOINT MOBILITY
o BALANCE
o COORDINATED MOVEMENT
ALIGNMENT AND POSTURE
Bring body parts into position in a manner that promotes
optimal balance and maximal body function (Sitting, Standing
or lying down).
HOW DOES A PERSON MAINTAIN BALANCE?
A persons maintain balance as long as the line of gravity
passes through the center of gravity and base of support.
LINE OF GRAVITY
An imaginary vertical line drawn through the body’s center of
gravity.
CENTER OF GRAVITY
 The point at which all of the body’s mass is centered
 When the body’s well aligned, strain on the joints
muscles, tendons or ligaments is minimized and
internal structures and organs are supported
 Enhances lung expansion and promotes efficient
circulatory renal and gastrointestinal function
 Abdominal and skeletal muscles function almost
continuously, making tiny adjustments that enable
an erect or seated posture despite the endless
downward pull of gravity
 The extensor muscles, often referred to as the
“antigravity muscles” , carry the major loads as they
keep the body upright
JOINT MOBILITY
 Joints – The functional units of the musculoskeletal
system.
 These muscles are categorized according to the type
of joint movement they produce on contraction.
 Called Flexors, extensors, internal rotators, etc.
 The flexor muscles are stronger than extensor
muscles.
RANGE OF MOTION (ROM)
 The maximum movement that is possible for that
joint
 Varies from person to person
 Determined by factors like genetic makeup,
developmental patterns, presence or absence of
disease, the amount of physical activities a person
goes to.
BALANCE
 Mechanisms that helps maintain balance are
complex and involve informational inputs from the
labyrinth (inner ear), vision (vestibulo-ocular input),
and stretch receptors of muscles and tendons
(Vestibulospinal input)
 Sense of balance responds to various head
movements.
  The labyrinth consist of the cochlea, vestibule, and
semicircular canals.
 Proprioception – The reception of stimuli produced
within the body; the awareness of posture,
movement and changes in equilibrium, knowledge of
position and weight and resistance of objects in
accordance with the body.
COORDINATED MOVEMENT
 The cerebral cortex initiates voluntary motor activity,
the cerebellumcoordinates the motor activities of
movement, and the basal gangliamaintain posture.
EXERCISE
 People participate in exercise programs to decrease
risk factors for chronic diseases and to increase their
health and well being
 Functional strength - the ability of the body to
perform work.
 Activity tolerance is the type and amount of exercise
or ADLs an individual is able to perform without
experiencing adverse effects
TYPE OF EXERCISE
 Exercises can be classified according to the type of
muscle contraction (Isotonic, isometric, isokinetic)
and according to the source of energy
TYPES OF EXERCISE THAT INVOLVES CONTRACTION
ISOTONIC (DYNAMIC) EXERCISES
 Are those in which the muscle shortens to produce
muscle contraction and active movement.
 During this type of exercise, both heart rate and
cardiac output quicken to increase blood flow to all
parts of the body
ISOMETRIC (STATIC OR SETTING) EXERCISES
 Are those in which muscle contraction occurs
without moving the joint (muscle length does not
change).
TYPES OF EXERCISE THAT INVOLVES ENERGY SOURCE
AEROBIC EXERCISE
 Activity during which the amount of oxygen taken
into the body is greater than that used to perform
the activity.
 Intensity of exercise can be measured in three ways:
target heart rate, talk test, borg scale of perceived
exertion.
ANAEROBIC EXERCISE
 Involves activity in which the muscles cannot draw
out enough oxygen from the bloodstream, and
anaerobic pathways are used to provide additional
energy for a short time.
THERAPEUTIC MOVEMENT MODALITIES FROM EASTERN
CULTURES
HATHA YOGA
 Developed in ancient Hindu culture, is a series of
physical exercises, breath control, and meditation
that tone and strengthen the whole person – body,
mind, and spirit.
QIGONG
 A Chinese discipline that involves breathing and
gentle movements of mostly arms and torso.
Intended to generate as well as conserve energy to maintain
health or treat illness
T’AI CHI
 Was derived from qigong and combines physical
fitness, meditation, and self defense.
 Developed as a martial art but it is practice today as
a mostly for health promotion.
SLEEP
INTRODUCTION
 important factor in a person’s quality of life, yet
sleep disorders and sleep deprivation are an unmet
public health problem, as reported by CDC.
 It is estimated that 50 million to 70 million
Americans suffer from a chronic disorder of sleep
and wakefulness that hinders daily functioning and
and adversely affects health.
PHYSIOLOGY OF SLEEP
 Sleep has come to be considered an altered state of
consciousness in which the individual’s perception of
and reaction to the environment are decreased. The
cyclic nature of sleep is thought to be controlled by
centers located in the lower part of the brain.
Neurotransmitters, located within neurons in the
brain, affect the sleep/wake cycles.
CICARDIAN RHYTHMS
 Biologic rhythms exist in plants, animals, and
humans. The most familiar biologic rhythm is the
circadian rhythm. It is a sort of 24-hour internal
biologic clock.

TYPES, CYCLES, FUNCTIONS OF SLEEP
SLEEP ARCHITECTURE REFERS TO THE BASIC ORGANIZATION
OF NORMAL SLEEP.
 NREM (non-rapid-eye-movement) sleep occurs when
activity in the RAS is inhibited. Stage 1 is the stage
of very light sleep and lasts only a few minutes.
Stage 2 is the stage of sleep during which body
processes continue to slow down. Stage 3 is the
deepest stage of sleep, differing only in the
percentage of delta waves recorded during a 30-
second period.
 REM (rapid-eye-movement) sleep recurs about
every 90 minutes and lasts 5 to 30 minutes. During
REM sleep, the brain is highly active, and brain
metabolism may increase as much as 20%. This type
of sleep is also called paradoxical sleep because EEG
activity resembles that of wakefulness.
SLEEP CYCLES
 In the first sleep cycle, a sleeper usually passes
through the first two stages of NREM sleep in a
total of about 20 to 30 minutes. Stage 3 lasts about
50 to 60 minutes. After stage 3 NREM, the sleep
passes back through stages 2 and 1 over about 20
minutes. Thereafter, the first REM stage occurs,
lasting about 10 minutes, completing the first sleep
cycle. The healthy adult sleeper usually experiences
four to six cycles of sleep during 7 to 8 hours.
NORMAL SLEEP PATTERNS AND REQUIREMENTS
NEWBORNS
 Newborns sleep 12 to 18 hours a day, on an irregular
schedule with periods of 1 to 3 hours spent awake.
They enter REM sleep immediately (active sleep).
NREM sleep (quiet sleep).
INFANTS
 Infants awaken every 3 or 4 hours, eat, and then go
back to sleep. By 6 months, most infants sleep
through the night and begin to establish a pattern of
daytime naps. An infant usually takes two naps per
day and should get about 9 to 12 hours of sleep in
24 hours
TODDLERS
 Between 12 and 14 hours of sleep are recommended
for children 1 to 3 years of age
PRE-SCHOOLERS
 The preschool-age child (3 to 5 years of age) requires
11 to 13 hours of sleep per night.
SCHOOL AGE CHILDREN
 The school-age child (5 to 12 years of age) needs 10
to 11 hours of sleep per night, but most receive less
because of increasing demands
ADOLESCENTS
 Adolescents (12 to 18 years of age) require 9 to 10
hours of sleep each night; however few actually get
that much sleep.
ADULTS
 Most healthy adults get 7 to 8 hours of sleep per
night, but some adults may be able to function well
with 6 or 10 hours of sleep.
OLDER ADULTS
 Older adults (65 to 75 years) usually awaken 1.3
hours earlier and go to bed approximately 1 hour
earlier than younger adults (ages 20 to 30).
FACTORS AFFECTING SLEEP COMMON SLEEP DISORDERS

 Sleep quality is a subjective characteristic and is INSOMIA

often determined by whether a person wakes up  Described as the inability to fall asleep or remain
feeling energetic or not. Quantity of sleep is the total asleep. Individuals with insomnia do not awaken
time the individual sleeps. feeling rested

ILLNESS
 Causes pain or physical distress can result in sleep
problems. Respiratory conditions, gastric or
duodenal ulcers, and hyperthyroidism can disturb an
individual’s sleep.

ENVIRONMENT
 Promotes or hinders sleep. The absence of usual
stimuli or the presence of unfamiliar stimuli can
prevent people from sleeping.

LIFESTYLE
 Following an irregular morning and night time
schedule can affect sleep
 TYPES OF INSOMIA
EMOTIONAL STRESS o Acute insomnia lasts one to several nights and is
 Stress is considered to be one of the greatest causes often caused by personal stressors. If it persists
of difficulties in falling asleep or staying asleep. for longer than a month, it is considered chronic
insomnia.
STIMULANTS AND ALCOHOL o Intermittent insomnia is a difficulty sleeping for
a few nights, followed by a few nights of
 Caffeine-containing beverages act as stimulates of
adequate sleep before the problem returns
the CNS. People who drink an excessive amount of
alcohol often find their sleep disturbed
 CLINICAL MANIFESTAIONS OF INSOMIA
o Difficulty of falling asleep
DIET
o Waking up frequently during the night
 Weight gain has been associated with reduced total
o Difficulty returning to sleep
sleep time as well as broken sleep and earlier
o Waking up too early in the morning
awakening. Weight loss, on the other hand, seems to
o Unrefreshed sleep
be associated with an increase in total sleep time
o Daytime Sleepiness
and less broken sleep.
o Difficulty concentrating
o Irritability
SMOKING
 Nicotine has a stimulating effect on the body, and
 EXCESSIVE DAYTIME SLEEPINESS
smokers often have more difficulty falling asleep
o Hypersomnia refers too conditions where the
than nonsmokers.
affected individual obtains sufficient sleep at
night but still cannot stay awake.
MOTIVATION
o Narcolepsy is a disorder of excessive daytime
 Motivation can increase alertness in some situations
sleepiness caused by the lack of the chemical
(e.g., a tired person can probably stay alert while
hypocretin in the area of the CNS that regulates
surfing the web late at night)
sleep.
o Sleep apnea is characterized by frequent short
MEDICATION
breathing pauses during sleep.
 Some hypnotics can interfere with deep sleep and o Insufficient sleep causes individuals sleepiness
suppress REM sleep and fatigue during the daytime hours

 PARASOMNIAS
o A behavior that may interfere with sleep and may
even occur during sleep. It is characterized by
physical events such as movements or experiences
that are displayed as emotions, perceptions, or
dreams.
PAIN MANAGEMENT
PAIN
 An unpleasant and highly personal experience that
may be imperceptible to others, while consuming all
parts of an individual’s life.
 According to Margo McCaffery, “pain is whatever
the person says it is, and exists whenever he says it
does”. According to IASP (2012), pain is “an
unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage”.
 Pain management is the alleviation of pain or a
reduction in pain to a level of comfort that is
acceptable to the client
NATURE OF PAIN
 Although pain is a universal experience, the nature
of the experience is unique to the individual based,
in part, on the type of pain experienced, the
psychosocial context or meaning, and the response
TYPES OF PAIN
 Location (e.g., head, back, chest)
 Duration – acute pain (sudden or slow onset) and
chronic pain (prolonged); cancer pain
 Intensity – mild pain (1 to 3 range), moderate pain (4
to 6 range), and severe pain (7 to 10 range)
 Etiology – nociceptive pain (somatic and visceral)
and neuropathic pain (peripheral and central)
CONCEPTS ASSOCIATED WITH PAIN
 Acute pain
 Cancer pain
 Chronic or persistent pain
 Intractable pain
 Neuropathic pain
 Nociceptive pain
 Pain threshold
 Pain tolerance
TYPES OF PAIN
 Pain may be described in terms of location,
duration,intensity and etiology
 LOCATION
 DURATION
 Acute Pain – when in pain, last only through the
expected recovery period, whether it has a asudden
or slow onset, regardless of its intensity. Pain that is
directly related to tissue injury and resolves when
tissue heals.
 Chronic Pain – also known as persistent pain, is
prolonged, usually recurring or lasting 3 months or
longer, and interferes with functioning.
 Cancer Pain – may result from the direct effects of
the disease and it’s treatmentm or mit may be
unrelated.
INTENSITY
 Mild Pain – pain in the range of 1-3
 Moderate Pain – rating of 4-6
 Severe Pain – pain reaching 7-10
ETIOLOGY
 Nocieptive pain – is experienced when an intact,
properly functioning nervous system send signals
that tissues are damaged, requiring attention and
proper care.
 Subcategories of nociceptive somatic and Visceral
Pain
 Somatic Pain – originates in the skin, muscles, bone,
or connective tissue. The sharp sensation of a paper
cut or aching of a sprained ankle are common
examples of somatic pain.
 Visceral Pain – results from activation of pain
receptors in the organs and/ or hollew vescera.
Visceral pain tends to be characterized by cramiping,
throbbing, pressing, or aching qualities. Often
visceral pain is associated with feeling sick (e.g.
sweating, nausea, or vommiting) as in the examples
of labor pain, angina pectoris, or irritable bowel.
 Neuropathic Pain – is associated with damaged or
malfunctioning nerves due to illness (e.g. Phantom
limb pain, spinal cord, injury pain), or undetermined
reasons. Neuropathic pain is typically chroninc it is
descrbed in as burning, ‘electric-shock’ and/or
tingling, dull, and aching. Episodes of sharp, shooting
pain can also be experienced. Neuropathic pain
tends to be difficult to treat. The two subtypes of
neuropathic pain are based on the part of the
nervous system believed to be damaged.
 Peripheral neuropathic pain – (e.g. phantom limb,
post-herpetic neuralgia, carpal tunnel syndrome)
follows damageor sensitization of peripheral nerves.
 Central neuropathic pain – (e.g. spinal cord injury
pain, post stroke pain, multiple sclerosis pain) results
from malfunctioning nerves in the central nervous
system (CNS)
 Sympathetically maintained pain – occurs
occasionally when abnormal conncctions between
pain fibers and the sympathetic nervous system
perpetuate problems with both the pain and
sympathetically controlled functions, e.g. edema,
temperature, and blood flow regulation)
CONCEPTS ASSOCIATED WITH PAIN
 Pain Threshold – is the least amount of stimuli that
is needed for a person to label a sensation as pain.
 Pain tolerance – is the maximum amount of painful
stimuli that a person is willing to withstand without
seeking avoidance of the pain or relief.

ABNORMAL PAIN
 Hyperalgesia- increased sensation of pain in
response to a normally painful stimulus
 Allodynia – includes non painful stimuli that
produces pain
 Dysesthesia – Is an unpleasant abnormal sensation
ABNORMAL NERVE FUNCTIONING
 Allodynia
 Dysesthesia
 Hyperalgesia

REASONS TO PREVENT/ TREAT PAIN

 Sensitization
 Windup

PHYSIOLOGY OF PAIN
NOCICEPTION
 When nociceptors are activated, signals are
transduced and transmitted to the spine and brain
where the signals are modified before they are
ultimately understood and then “felt”

TRANSDUCTION
 stimuli trigger the release of biochemical mediators

TRANSMISSION
 The pain impulses travel from the peripheral nerve
fibers to the spinal cord, and then pain control can
take place

PERCEPTION
 The client becomes conscious of the pain

MODULATION
 “descending system”, neurons in the brain send
signals back down to the dorsal horn of the spinal
cord
GATE CONTROL THEORY
 Small diameter (A-delta or C) peripheral nerve fibers
carry signals of noxious (painful) stimuli to the dorsal
horn, where these signals are modified when they
are exposed to the substantia gelatinosa, which may
be imbalanced in an excitatory or inhibitory
direction.
RESPONSES TO PAIN
 The body’s response to pain is a complex process
rather than a specific action. It has both physiological
and psychosocial aspects.
FACTORS AFFECTING THE PAIN EXPERIENCE
ETHNIC AND CULTURAL VALUES
 Behavior related to pain is a part of the socialization
process. Individuals in one culture may learn to be
expressive about pain, whereas individuals from
another culture may have learned to keep those
feelings to themselves
NUTRITION
 Nutrition is the sum of all the interactions between
an organism and food it consumes.
 Nutrients are organic and inorganic substances
found in foods that are required for body
functioning. Foods differ greatly in their nutritive
value (the nutrient content of a specified amount of
food), and no one food provides all essential
nutrients.
BODY WEIGHT AND BODY MASS STANDARDS
BODY MASS INDEX
 Ideal body weight (IBW) is the optimal weight
recommended for optimal health.
 For people older than 18 years, the body mass index
(BMI) is an indicator of changes in body fat stores
and whether a person’s weight is appropriate for
height, and may provide a useful estimate of
malnutrition.

DEVELOPMENTAL STAGE
 The age and developmental stage of a client is an
important variable that will influence both the
reaction to and the expression of pain

ENVIRONMENT AND SUPPORT PEOPLE

 A strange environment such as a hospital with its
noises can compound pain. Also, the lonely person
who is without a support network may perceive pain
as severe, whereas the person who has supportive
people around may perceive less pain.

PREVIOUS PAIN EXPERIENCES, MEANING OF PAIN, BARRIERS

TO PAIN

PREVIOUS PAIN EXPERIENCE

 People who have personally experienced pain or
who have been exposed to the suffering of someone
close to them are often more threatened by
anticipated pain than people without a pain
experience

MEANING OF PAIN
 A client who associates the pain with a positive
outcome may withstand the pain amazingly well. By
contrast, clients with unrelenting chronic, persistent
pain may suffer more intensely.

BARRIERS TO PAIN
 Regulatory Issues.
 Formulary Issues.
 Management of Acute Pain.
 Management of Chronic Pain.
 Disparities in Pain Management Among Different
Patient Populations.
 Patient Perception of Pain and Pain Medications
FACTORS AFFECTING NUTRITION STANDARDS FOR A HEALTHY DIET

DEVELOPMENT DIETARY GUIDELINES FOR AMERICANS (USDA)

 People in rapid periods of growth have increased  Shift to more plant-based foods
needs for nutrients. Older adults may need fewer  Reduce foods with sugars and fats
calories.  Engage in physical activity
SEX  Consume food full of nutrients
 The larger muscle mass of men translates into a  Keep fat intake within 20% to 35% calories daily
greater need for calories and proteins. Women,  Consume less than 1500 mg of sodium per day
because of menstruation, require more iron than  Drink alcohol in moderation
men do prior to menopause.
ETHNICITY AND CULTURE THE FOOD GUIDE PYRAMID AND MYPLATE
 Ethnicity often determines food preferences. Food  The Food Guide Pyramid is a graphic aid developed
preference probably differs as much among by the USDA as a guide in making daily food choices
individuals of the same cultural background as it
does between cultures.
BELIEFS ABOUT FOOD
 Many people acquire their beliefs about food from
television, magazines, and other media. A fad is a
widespread but short-lived interest or a practice
followed with considerable zeal.
PERSONAL PREFERENCES
 People develop likes and dislikes based on
associations with a typical food. Individual likes and
dislikes can also be related to familiarity
RELIGIOUS PRACTICES
 Some Roman Catholics avoid meat on certain days,
and some Protestant faiths prohibit meat, tea,
coffee, or alcohol.
LIFESTYLE
 Certain lifestyles are linked to food-related
behaviors. Individual differences also influence
lifestyle patterns
ECONOMICS
 What, how much, and how often a person eats are
frequently affected by socioeconomic status

MEDICATIONS AND THERAPY

 The effects of drugs on nutrition vary considerably.
They may alter appetite, disturb taste perception, or
interfere with nutrient absorption. Therapies
RECOMMENDED DIETARY INTAKE
prescribed for certain diseases may also affect eating
 Consumers most commonly learn recommended
patterns
dietary intake information from the US FDA nutrition
HEALTH
labels. Food labeling is required for most prepared
 An individual’s health status greatly affects eating
foods.
habits and nutritional status
ALCOHOL CONSUMPTION
 Excessive alcohol use contributes to nutritional
deficiencies in several ways.
ADVERTISING
 Food producers try to persuade people to change
from the product they currently use to the brand of
the producer
PSYCHOLOGICAL FACTORS
 Some people overeat when stressed, depressed, or
lonely. Others eat very little under the same
conditions
VEGETARIAN DIETS
There are two basic vegetarian diets: those that use only
plant foods (vegan) and those that include milk, eggs, or dairy
products.

URINARY ELIMINATION
ORGANS OF URINARY ELIMINATION

 Kidneys
Remove waste from the blood to form urine
 Bladder
Reservoir for urine until the urge to urinate develops
 Ureters
Transport urine from the kidneys to the bladder
 Urethra
Urine travels from the bladder and exits through the urethral
meatus.

FACTORS AFFECTING VOIDING

 Development factors
o Infants
o Preschools
o School-age children
o Enuresis- involuntary passing of urine
o Nocturnal enuresis or bed wetting – involuntary
passing of urine during sleep
 Older adults
o Nocturnal frequency
 Development factors
 Psychosocial factors
 Fluid and food intake
 Medications
 Muscle Tone
 Pathologic Conditions
 Surgical and Diagnostic Procedure

ALTERED URINE PRODUCTION

 Polyuria – or diuresis, production of abnormally
large of urine by the kidney
 Oliguria – less than 500 ml urine output
 Anuria- lack of urine ouput
 Urinary frequency – voiding four to six times per day
 Nocturia- voiding two or more times at night
 Urgency- sudden strong desire to void
 Dysuria – voiding that is either painful of difficult
 Urinary hesitancy – delay or difficult in initiating
voiding
 Enuresis- involuntary urination in children
 Urinary incontinence- involuntary leakage of urine
or loss of bladder control
 Stress urinary incontinence – weak pelvic floor
muscles or urethral hypermobility
 Urge urinary incontinence- inability to stop
micturition (passage of urine)
 Urinary retention- urine accumulate and the bladder
become distended