Skill 6-2

Teaching Leg Exercises

During surgery, venous blood return from the legs slows (Hinkle et al., 2022). In addition, some patient positions used during surgery decrease venous return (AORN, 2018). Thrombophlebitis , deep vein thrombosis (DVT), and the risk for emboli are potential complications from circulatory stasis in the legs (AORN, 2018). Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscles and should be initiated early in the postoperative period to stimulate circulation (Hinkle et al., 2022). It is important to individualize leg exercises to patient needs, physical condition, health care provider preference, and facility protocol.

Delegation Considerations

Preoperative assessment and teaching are not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, preoperative teaching may be delegated to licensed practical/vocational nurses (LPN/LVNs) after an assessment of education needs by the registered nurse. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

PPE, as indicated

Assessment

It is important to identify patients who are considered at greater risk, such as those with chronic disease; patients who are obese or who have underlying cardiovascular disease; patients who have decreased mobility; older adults; and patients who are at risk for decreased engagement with postoperative activities, such as those with alterations in cognitive function (Hinkle et al., 2022).

Depending on the particular at-risk patient, specific assessments and interventions may be warranted. Assess the patient's current level of knowledge regarding leg exercises.

Outcome Identification and Planning

The expected outcomes to achieve when teaching leg exercises are that the patient verbalizes an understanding of the instructions and is able to demonstrate the activity.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Knowledge deficiency
Anxiety
Impaired mobility

Implementation

Action	Rationale
1. Check the patient's health record for the type of surgery and review the prescribed interventions. Gather the necessary supplies.	This check ensures that the care will be provided for the right patient and any specific teaching based on the type of surgery will be addressed. Preparation promotes efficient time management and an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Place necessary supplies on the bedside stand, overbed table, or other surface within easy reach.	Closing the curtains and door ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Identify the patient's learning needs. Identify the patient's level of knowledge regarding leg exercises. If the patient has had surgery before, ask about this experience.	Identification of baseline knowledge contributes to individualized teaching. Previous surgical experience may impact preoperative/postoperative care positively or negatively, depending on this experience.
6. Explain the rationale for performing leg exercises.	Explanation facilitates patient engagement. An understanding of rationale may contribute to increased engagement.
7. Teach leg exercises and explain their purpose.	Leg exercises assist in preventing muscle weakness, promote venous return, and decrease complications related to venous stasis (Hinkle et al., 2022).
a. Assist or ask the patient to sit up (semi-Fowler's position) (Figure 1) and explain to the patient that you will first demonstrate, and then coach them to exercise one leg at a time.
b. Bend the patient's knee, raise the foot, and keep it elevated for a few seconds. Then, extend the lower leg, and hold this position for a few seconds (Figure 2). Lower the entire leg (Figure 3). Practice this exercise with the other leg.
c. Assist or ask the patient to point the toes of both legs toward the foot of the bed, then relax them (Figure 4). Next, flex or pull the toes toward the chin (Figure 5).
d. Assist or ask the patient to keep legs extended and to make circles with both ankles, first circling to the left and then to the right (Figure 6). Instruct the patient to repeat these exercises three to five times with each leg. Instruct the patient to perform leg exercises every 2 to 4 hours when awake after surgery.
8. Validate the patient's understanding of the information. Ask the patient for a return demonstration. Ask the patient if they have any questions. Encourage the patient to practice the activities and ask questions, if necessary.	Validation facilitates the patient's understanding of information and performance of activities.
9. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has verbalized an understanding of the instructions related to leg exercises and has accurately demonstrated the activities.

Documentation

Guidelines

Document the components of teaching related to leg exercises that were reviewed with the patient and family/caregivers, if present. Record the patient's ability to demonstrate the leg exercises and response to the teaching; note if any follow-up instruction needs to be performed.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient is unable to complete full range of motion of lower extremities due to pain from arthritis or other health issue: Modify exercises based on patient's abilities. Encourage patient to perform to the best of their abilities. Document patient's range of motion and limitations related to exercises.

Special Considerations

All postoperative patients are at some risk for thromboembolism and pulmonary embolism, but some risk factors, including a history of thrombosis, malignancy, trauma, obesity, indwelling venous catheters, and hormone use (e.g., estrogen) increase the risk (Hinkle et al., 2022).
Certain types of surgeries are associated with a higher risk of deep vein thrombosis and pulmonary embolism, including orthopedic, bariatric, cardiothoracic, vascular, abdominal, pelvic, major plastic surgery, and genitourinary surgery involving the abdomen or pelvis (AORN, 2018).

EVIDENCE FOR PRACTICE

Prevention of Deep Vein Thrombosis

American Association of Critical Care Nurses. (2016). AACN practice alert: Preventing venous thromboembolism in adults. Critical Care Nurse, 36(5), e20-e23.

Association of periOperative Registered Nurses (AORN). (2018). Guideline summary: Prevention of venous thromboembolism. AORN Journal, 107(6), 750-754. http://doi.org/10.1002/aorn.12147

These guidelines outline expected nursing practice related to the prevention of venous thromboembolism (VTE) in adults. Depending on the individual patient's level of risk for VTE, appropriate interventions include anticoagulant therapy and mechanical prophylaxis including graduated compression stockings and intermittent pneumatic compression devices as well as daily interprofessional rounds to review each patient's VTE risk factors, current status, and response to treatment.

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Skill 6-2

EVIDENCE FOR PRACTICE