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Copyright © 2015, 2011 by Pearson Education, Inc.All Rights Reserved
Nursing:A Concept-Based Approach to Learning
VOLUME ONE | SECOND EDITION
Nursing: A Concept-Based Approach to Learning Volume One, Second Edition
Mobility
Nursing:A Concept-Based Approach to Learning
MODULE 13
VOLUME ONE | SECOND EDITION
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Physiology Review
• Musculoskeletal system Bones and joints of skeletal system Muscles, ligaments, tendons, and cartilage
of the muscular system
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Alterations to Mobility
• Musculoskeletal system affects nearly every aspect of life. Alterations in muscles, bones, and joints
link a variety of health problems• Arthritis• Fractures• Neurological disorders• Traumatic injuries
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Concepts Related to Mobility
• Comfort• Health, Wellness, and Illness• Stress and Coping• Collaboration• Safety
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Alterations and Manifestations
• Back problems• Fractures• Hip fractures• Multiple sclerosis (MS)• Osteoarthritis (OA)• Parkinson disease• Spinal cord injury
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Alterations and Manifestations, continued
• Abnormalities of the spine Kyphosis Scoliosis Lordosis
• Joint disorders Temperomandibular joint (TMJ) syndrome Wrist, hand Foot
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Genetic Considerations and Nonmodifiable Risk Factors
• Aging is primary risk factor Joint problems decrease mobility
• Osteoarthritis• Gout• Kyphosis• Lower back pain• Inflammatory disorders
Risk of fractures Genetic factors
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Prevention
• Good lifestyle habits• Good nutrition
Adequate calcium intake
• Regular exercise
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Nursing: A Concept-Based Approach to Learning Volume One, Second Edition
Modifiable Risk Factors
• Obesity Excess weight strains joints Increases destruction rate of cartilage and
other tissues Hinders common movements
• Mobility before birth• Well-balanced diet
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Screenings
• Screening tools available for clients with risk factors
• Older clients receive bone density scans• Spinal screenings for children• Genetic testing
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Nursing Assessment
• Structure, function assessed Health assessment interview Physical assessment Diagnostic tests Primary manifestations
• Pain, limited mobility Details of lifestyle Client history
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Physical Assessment
• Part of a total assessment• Sequence
Assessment of gait, posture Inspect, palpate for obvious deformity,
tenderness Measure extremities for length,
circumference
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Physical Assessment, continued
• Sequence Assess muscle mass, strength Muscle function grading scale Assess swelling, pain, redness, warmth,
ROM
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Physical Assessment, continued
• 5 P's neurovascular assessment Pain on a 0–10 scale Pulses comparison between
affected/unaffected extremity Pallor in injured/affected area and overall Parasthesia Paralysis/paresis with fractures to indicate
fracture or muscle weakness
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Lifespan and Cultural Considerations
• Alterations more prevalent in certain age groups Infants, children may have genetic
disorders or congenital malformations Children, Adolescents, young adults prone
to trauma from sports, abuse or accidents Older adults present inflammatory and
"wear-and-tear"
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Diagnostic Tests
• Blood tests• Imaging tests
Bone density scans CT scans MRIs X-rays
• Electrical tests EMG
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Interventions and Therapies
• Independent Promoting safety and comfort Injury prevention Client teaching
• Self-care• Chronic condition
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Independent
• Providing education Body mechanics, proper posture Importance of exercise and nutrition Medications
• Promoting comfort Client positioning Padding of joints can prevent discomfort
and skin breakdown Braces and support devices
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Independent, continued
• Preventing injury Traumatic injury, neurological conditions,
decreased mobility associated with risk of contractures
Exercises and stretches Use braces and splits prescribed by PT, OT Environment screening
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Collaborative
• Rehabilitative nursing Preservative Restorative Goals Hospitalization and immobility
• Exercise Muscles that are not used weaken, shorten Passive, active ROM Resistive exercises
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Collaborative, continued
• Exercise Muscles that are not used weaken, shorten Passive, active ROM Resistive exercises
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Collaborative, continued
• Ambulation Walking Ambulation improves function, well-being,
strength Before assisting client with walking
• Explain purpose, what you are going to do• Prepare client in phases
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Collaborative, continued
• Ambulation Crutches
• Axillary• Lofstrand• Platform
Walkers• Assist client with balance, walking• Arms support all, part of body weight
Canes• Protect clients
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Collaborative, continued
• Pharmacologic therapy Palliative not curative Antispasmodics Muscle relaxants Analgesics NSAIDs, anti-inflammatory
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Exemplar 13.1Back Problems
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Herniated Disk
• Herniated intervertebral disc Ruptured disc Slipped disc Hernitated nucleus pulposus
• Rupture in a spinal disk Allow fluids to leak out and irritate nerves
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Herniated Disk, continued
• Pathophysiology and etiology Intervertebral disks: shock absorbers Rupture of cartilage surrounding disk
• May occur spontaneously or from trauma• Abrupt or gradual
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Herniated Disk, continued
• Nursing process Relieving pain Healing involved disc Regaining mobility
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Herniated Disk, continued
• Assessment Health history
• Employment• Characteristics of pain• History of previous injury• Sport, recreational activities
Physical assessment• Muscle strength, coordination• Sensation• Reflexes
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Herniated Disk, continued
• Diagnostic tests Mobility tests
• Straight-leg raise, gait tests, reflex tests, muscle strength tests
Imaging tests• CT scans, MRIs• Myelogram• Electromyogram
Blood tests
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Herniated Disk, continued
• Diagnosis Risk for injury Risk for reflex urinary incontinence Risk for bowel incontinence Impaired physical mobility Acute pain Chronic pain
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Herniated Disk, continued
• Planning The client will develop no motor deficits. The client will develop no sensory deficits. The client will remain free from infection. The client will demonstrate normal bowel
function.
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Herniated Disk, continued
• Implementation Promoting safety Preventing onset or exacerbation of
neurological deficits Providing adequate pain relief Explain treatment options Nursing care for postsurgical clients
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Herniated Disk, continued
• Surgery Reserved for the most severe cases
• Laminectomy• Discectomy• Spinal fusion• Artificial disc surgery• Laser surgery
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Herniated Disk, continued
• Pharmacologic therapy First line therapy
• Nonsteroidal anti-inflammatory drugs Opioids Antispasmodics Epidural injections of
cortisone/corticosteroids
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Herniated Disk, continued
• Nonpharmacologic therapy Intradiscal electrothermal therapy (IDET) Chiropractic therapy
• Speeds recovery from acute low back pain Massage therapy
• Benefits Acupuncture
• Acute, chronic pain• Motion disabilities
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Scoliosis
• Lateral or sideways curve of the spine• C-shaped or S-shaped• Evident during growth spurt• Most cases are mild• Severe cases can cause spine rotation
Deformities and disabilities
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Scoliosis, continued
• Etiology Idiopathic scoliosis, most common
• Acquired after injury Congenital scoliosis, individual born with
curved spine Neuromuscular scoliosis, medical
conditions that affect nerves and muscles
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Scoliosis, continued
• Risk factors Adolescents at greatest risk
• Growth spurt between ages 9 – 15• Girls are prone to greater curvature
Neuromuscular disorder• Cerebral palsy• Muscular dystrophy
Family history of scoliosis
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Scoliosis, continued
• Assessment Screening
• 5th–7th grades• Visual observation
• From front • From back• Adolescent holding hands together, bent
over slightly• Hands hanging down, not held together
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Scoliosis, continued
• Clinical manifestations Truncal asymmetry Uneven shoulders, hips One-sided rib hump Prominent shoulder blade
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Scoliosis, continued
• Diagnostic tests Adam forward bend test X-ray Scoliometer Additional diagnostic studies
• MRI• CT scan• Bone scan
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Scoliosis, continued
• Diagnosis Risk for Infection related to spinal surgery Impaired Physical Mobility Risk for Impaired Skin Integrity Ineffective Breathing Pattern Readiness for Enhanced Knowledge Disturbed Body Image
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Scoliosis, continued
• Planning Client, family
• Describe selected treatment regimen, roles• Describe condition, stages of treatment
Client requiring surgery can describe procedure to be performed
Pediatric considerations
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Scoliosis, continued
• Implementation Promote understanding, acceptance of
treatment plan• Help client adjust to wearing a brace• Provide reassurance, encouragement• Promote interaction with peers• Provide information about fashionable
clothing to wear with brace
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Scoliosis, continued
• Surgery Mild scoliosis < 20 degrees curvature
• Exercises Moderate scoliosis 20–45 degrees
• Boston (TLSO) or Milwaukee brace• 12–23 hours/day
• Electrical stimulation Severe scoliosis > 50 degrees
• Surgery, spinal fusion
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Scoliosis, continued
• Pharmacologic therapy Usually not treated with medication Clients may take OTC analgesics for pain
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Scoliosis, continued
• Nonpharmacologic therapy Depends on severity of curve
• Observation for worsening curvature in clients with < 20
• Brace to prevent further curvature for clients over 10 years old
Chiropractic treatment, electrical stimulation, biofeedback, nutritional supplements, and exercise are ineffective
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Scoliosis, continued
• Evaluation Client maintains intact skin under brace Client wears brace as directed
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Exemplar 13.5Osteoarthritis
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Overview
• Most common form of arthritis• Develops as wear and tear on joints
breakdown cartilage Bone on bone
• Hands, knees, and hips
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Pathophysiology and Etiology
• Degenerative joint disease Localized Generalized Idiopathic
• Progressive erosion of joint articular cartilage Bone spurs
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Prevention
• Maintain ideal body weight• Participate in moderate exercise program• Inactivity and excessive exercise can lead
to premature degeneration of cartilage
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Assessment
• Health history Symptoms Physical activity, mobility
• Physical examination ROM Swelling
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Clinical Manifestations
• Onset of OA usually gradual, insidious Pain, stiffness in one or more joints Pain may be referred to other parts of body
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Diagnostic Tests
• X-rays• MRI• Ultrasound• Joint fluid analysis• Blood tests to rule out other causes
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Diagnosis
• Chronic Pain• Impaired Physical Mobility• Dressing Self-Care Deficit• Imbalanced Nutrition: More Than Body
Requirements
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Planning
• Client articulates strategies for reducing pain
• Client maintains maximum ROM of involved joints
• Client minimizes impact of osteoarthritis• Client uses assistive devices to maintain
autonomy in performing ADLs
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Collaboration
• No treatment available to stop progression Early treatment beneficial Learn to live with chronic disease
• Nonpharmacologic therapies Education Weight reduction Exercise General, specific rest
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Surgery
• Arthroplasty Total hip replacement Total knee replacement Total shoulder replacement Total elbow replacement
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Surgery, continued
• PT and rehabilitation Focus on building strength, regaining
flexibility Rehabilitation begins in hospital
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Pharmacologic Therapy
• Analgesics Aspirin Acetaminophen NSAIDs
• Topicals Counterirritants Salicylates Capsaicin
• NSAID Cox-2 inhibitors
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Pharmacologic Therapy, continued
• Conservative treatment Apply heat to painful joints Use cold applications to reduce pain,
swelling Use canes, crutches, walkers to protect
joints Use assistive technology
• Viscosupplementation Hyaluronic acid injected into knee joint
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Nonpharmacologic Therapy, continued
• Weight loss Risk factor that can be modified
• Exercise to relieve pain, stiffness Joints dependent on surrounding muscles Lack of use contributes to muscle atrophy Guidelines for older adults with arthritis
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Nonpharmacologic Therapy, continued
• Teaching about rest General Specific joint rest
• Frequent short rest periods• Rest acutely painful, inflamed joint• Acupuncture• Massage therapy• Yoga
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Evaluation
• Client maintains autonomy in performing ADLs
• Client's lifestyle is not significantly impacted by OA
• Client reports pain control adequate for rest, sleep