NSGA 150: Understanding Patient Mobility

• NSGA 150 is about mobility

Course Objectives

• The etiology, pathophysiology, and clinical manifestations of patients with impaired mobility are described
• Nursing care is articulated for patients with disorders related to impaired mobility across the lifespan
• Diagnostic and laboratory findings are interpreted for patients with impaired mobility
• Nursing care associated with pharmacologic and parenteral therapy including nutritional needs for impaired mobility is discussed
• the role of a registered nurse within an interdisciplinary team is identified when caring for patients with impaired mobility

Defining Mobility

• Mobility is about being mobile and/or movable
• Other terms for mobility include: immobility, disuse syndrome, and deconditioned
• Mobility ranges from full to partial, and also complete immobility

Musculoskeletal Anatomy and Physiology Review

• Muscles
• Bones
• Joints
• The neurologic system affects mobility

Fractures: Promoting Health and Preventing Disease

• Health teaching focuses on: osteoporosis screening and self-management education, and fall prevention
• Home safety assessments & modifications are needed
• Substance use and driving are dangerous
• Overuse injuries should be prevented for recreational/professional athletes
• Helmets are important when riding bikes and motorcycles
• Smoking cessation programs
• Smokers are likely to have a fracture, experience severe pain and have longer tissue healing times

Consequences of Immobility

• Cardiovascular, and respiratory complications can occur
• Musculoskeletal complications
• The integument system is affected
• Gastrointestinal complications
• Urinary complications
• Psychological effects

Individual Risk Factors

• Traumatic Injury
• Brain trauma
• Spinal cord trauma
• Bones, joints, muscles trauma
• Neurological conditions
• Chronic conditions or treatment interventions

Musculoskeletal Assessment Elements

• History:
• Past medical history, and family history are obtained
• Current medications
• Lifestyle behaviors, occupation, and social environment
• Problem-based history
• Common symptoms of altered mobility are:
• Pain
• Reduced joint movement, sensation, or loss of sensation
• Falls and fatigue
• Altered gait or imbalance and reduced functional ability

Diagnostic Tests

• Radiographic tests:
• X-rays check bone integrity/joints
• MRIs check soft tissue, vertebral disk, ligaments, or cartilage condition
• CT scans check soft tissue/bony abnormalities/musculoskeletal trauma
• Bone scans are used to detect bone cancer
• Bone mineral density is used to diagnose osteoporosis and osteopenia
• Myelograms use contrast to check the spinal cord/nerve root
• Arthrography uses a radiopaque substance injection to visualize the joint but is for knees and shoulders
• Other diagnostic tests:
• Arthroscopy visualizes the interior joint via endoscopy , usually for the knee
• Electromyography evaluates electrical activity generated within muscles
• Blood tests, analysis of joint fluids, and Pathologic analysis of biopsied tissue

Mobility Exemplar: Fractures

• Fractures disrupt the continuity of a bone, affecting mobility and causing pain
• Fractures have classifications:
• Complete i.e. incomplete fractures
• Open (compound, through the skin) or closed (simple) fractures
• Fragility (pathologic or spontaneous) fractures
• Fatigue or stress fractures
• Compression Fractures

Traumatic Injury in Children

• The weakest point of long bones is the cartilage growth plate (epiphyseal plate)
• Frequent site of damage during trauma
• May affect future bone growth
• Treatments may include open reduction and internal fixation to prevent growth disturbances
• Salter-Harris classification system indicates risk

Stages of Bone Healing (Adults)

• Stage one: occurs within 24-72 hours
• Stage two: occurs within 3 days to 2 weeks
• Stage three: occurs within 3-6 weeks
• Stage four: occurs within 3- weeks
• Stage five: occurs with 4-6 weeks after fracture (up to 1 year)

Stages of Bone Healing (Children)

• Bone Healing and Remodeling is typically rapid in children
• For Neonatal period: 2 to 3 weeks Early childhood: 4 weeks Later childhood: 6 to weeks Adolescence: 8 to 12 weeks
• Includes Diagnostic evaluation Radiographs History is taken Suspicion of fracture considered in a young child who refuses to walk or bear weight
• Fracture management goals are: Reduction and immobilization Restoring function Preventing deformity

Etiology and Genetic Risks of Fractures

• Trauma from motor vehicle accident or falls (especially with elders)
• Fractures are caused by a direct blow to the bone or indirect force from muscle contractions or pulling forces
• Contributing Factors: sports, vigorous exercise, malnutrition, bone diseases (osteoporosis)
• Rib fractures (Adult population and associated with organ injuries); Femoral shaft fracture (young and middle-age adults)
• Fracture common with Children Common injury in children Methods and Treatments treatments are different in children from adults Fractures are rare in infants, warrants investigation Distal forearm break: most frequently broken bone in childhood School age children: are injuries are bike-related and sport injuries

Traumatic Injury Assessment

• Assess the 6 P's for Fractures: Pain and point of tenderness Pallor Pulselessness Paresthesia: sensation distal to the fracture site Paralysis: movement distal to the fracture site Pressure

Emergency Fracture Care

• Trauma is assessed in the community with adults starting with always calling 911
• Assess A, B, C (airway, breathing and circulation), and if CPR is required start with circulation first, then breathing
• Emergency medical team arrives, assess injuries from head-to-toe including pain management
• Hockenberry page 1458 Emergency is for children: Determine cause Assess 6 P's Cover open wounds with sterile or clean dressing Immobilize limb, including joints above & below fracture site: Rigid splint using a pillow/towel or rigid splint using a newspaper/magazine, uninjured leg Reassess neurovascular status Elevate the injured limb if possible Apply cold to the injured area Call 911 or transport to medical facility

Fracture Complications

• VTE (DVT and PE)
• Bone or soft tissue infection (osteomyelitis)
• Fat embolism syndrome
• Complex regional pain syndrome (CRPS): dysfunction of central and peripheral nervous system causes severe persistent pain, usually for the hands/feet (desensitize as needed)
• Acute compartment syndrome

Acute Compartment Syndrome

• Capillaries in muscle dilate causing increased capillary and venous pressure
• Histamine is released by ischemic muscle causes capillaries to become more permeable causing venous drainage to decrease
• Plasma proteins leak into interstitial space causing edema
• Edema causes severe pain and increases pressure on nerves: pain is more than expected injury
• Perfusion is decreased- ischemia and cycle continues
• External pressures also come from outside like a cast etc
• The fix is the removal of cast if an issue is external, or if the issue is internal a fasciotomy will be performed by a surgeon

Fat Embolism Syndrome

• Fat globules are released from the yellow bone marrow into the blood stream (occurs within 12-48 of injury)
• The fat clogs small blood vessels to vital organs usually the lungs and leading to poor perfusion
• Occurs in patient's with pancreatitis, osteomyelitis, blunt trauma or sickle cell anemia
• Earliest S/S: hypoxia (low arterial O2 level), dyspnea & tachypnea followed by: Headache, lethargy, agitation, confusion, decreased level of consciousness (LOC), seizures, vision changes
• Nonpalpable red-brown petechiae appears-- a macular with measle-like rash that may develop over the neck or in the upper arms (CLASSIC MANIFESTATION but last sign)
• Abnormal Lab values: decreased PaO2 level (often below 60 mm hg); increased erythrocyte sedimentation rate (ESR); decreased serum calcium levels; decreased red blood cell and platelet counts, increased serum level of lipids
• Chest x-ray shows: bilateral infiltrates (could be normal) or CT scan showing patchy distribution of opacities
• MRI of brain: shows evidence of neurologic deficits from hypoxemia
• Often diagnosed as PE from a blood clot

Fractures: Recognizing Cues and Performing Patient Assessments

• History:
• Determine cause of fracture
• Events leading up to injury
• Substance use (especially opioids)
• Occupational and recreational activities
• Physical Assessment:
• Trauma to other body systems
• Psychosocial assessment for:
• Children with fractures
• Parents caring for them while in extended hospital stay
• Laboratory assessment includes:
• Hemoglobin: can be low
• Hematocrit: Low
• ESR: elevated, especially if soft tissue injury sprain, or strain is present
• WBC: if elevated during healing & ESR is elevated then consider bone or soft tissue infection are present
• Serum calcium & phosphorus can elevate during healing due to the release of D/t affected bones
• Imaging assessment includes:
• X-rays: visualize the fracture, deformity, malalignment
• CT: complex structures—hip & pelvis are checked
• MRI: amount of soft tissue damage is determined

Fractures: Analyzing Cues and Prioritizing Hypotheses

• Acute pain: related to fractured bone, soft tissue damage, muscle spasms & edema
• Decreased mobility: related to pain, muscle spasm, soft tissue damage
• Potential for, eurovascular compromise: related to perfusion impairment

Fractures: Generating Solutions and Implementing Actions

• Acute pain is managed using:
• Short term IV opioids such as fentanyl, hydromorphone, morphine sulfate, that are transitioned to oral opioids such as Lortab or oxycodone
• NSAIDs & regional nerve blocks are used to decrease opioid dependence
• Fracture management involves reduction & immobilization of the fracture

Nonsurgical Fracture Management

• Bone ends are realigned (reduction) to facilitate proper healing
• Doctor physically moves the bones by pulling or using traction using moderate sedation
• X-rays confirm bone alignment (approximated) before immobilized
• Nurses must prevent neuromuscular compromises: Neurologic assessments are done - every hour for the 1st 24 hours then every 1-4 hours Elevate fractured extremity above the heart Apply ice for the first 24-48 hour hours using 30-minute increments Monitor end-tidal if 30 mm Hg and respiratory rate are 10, rub sternum and encourage breathing

Splints & Orthopedic Boots/Shoes

• Commercial immobilizers used for clavicle or scapula fractures:
• A durable flexible thermoplastic splint materials allows for custom fitting to the patient's body, i.e. lower extremities, then wrapped with elastic bandages
• Splints versus casts:
• Splints are preferred over casts when possible
• Orthopedic boots/shoes for:
• foot/toe fractures
• ankle, or lower limbs

Casts

• For complex fractures and specifically the lower extremity
• Casts:
• Allow for early mobility & reduces pain
• May be applied for deformities (clubfoot) or prevent deformities (rheumatoid arthritis)
• Two types of casts:
• Fiberglass casts: : Waterproof and becomes rigid, decreases risk of impaired tissue if waterproof
• Plaster cast: less commonly used that becomes hot when applied initially, then become damp and cool: not waterproof.
• Teach icing techniques for the first 36 hours.

Traction

• Purposes:
• to relieves fatigue in involved muscles
• position ends of distal and proximal bones
• immobilizes bones at fracture locations, and aids in realignment and healing for casting purposes
• prevents contracture deformity
• immobilizes healing bone and prevents further injury
• reduces muscle spasms Assess pin site/perform the care & document any drainage
• Use pressure reducing measures for tissue integrity
• Weights are never removed
• Think about the child because entertainment is likely required
• Two types: Skin and Skeletal

Drug Therapy

• Severe pain can be treated with:
• opioid combinations (fentanyl, hydromorphone, morphine) with nonopioid for pain (Acetaminophen)
• Alternating the drugs to manage pain both centrally and peripherally
• NSAIDS also help with inflammation but slow down bone healing
• Muscle relaxants

Surgical Management

• Pre-Operative Care:
• The patient/family are educated on what to expect
• NPO is implemented
• Consent is signed
• No issues with anesthesia
• Operative Procedure: Open Reduction Internal Fixation (ORIF) Allows direct visualization of fracture Involves Metal pins, screws, rods, plates or prostheses to immobilize during healing Cast, splint or boot is added after surgery
• Operative Procedure: External Fixation Used for soft tissue injury (open fracture) Pins or wires inserted through skin/bone then connected to rigid external frame outside the body May be used for upper/lower extremities & pelvis Fixator is removed but if needed: an ORIF. boot, cast or splint is used Minimal blood loss Allows for the early ambulation/exercise needed to relief pain Maintains alignment to maintain casts so closed fractures heal Stabilizes comminuted fractures that require bone grafts Disadvantage: increased risk for infection, which can also lead to osteomyelitis

Postoperative Care

• Pain management is aggressive with IV Ketorolac and non-pharmacologic measures (imagery, distraction, and music)
• Pin Site Care:
• Assess drainage (color and odor) and severe redness every 8-12 hours for drainage, color, odor, and severe redness which could indicate inflammation or infection
• Expected: clear drainage and the beginning of the process turns into a crust Protects from infection

Increasing Mobility

• Physical therapy will be ordered for lower extremity fractures versus: occupational therapy for upper extremity fractures
• Devices used for mobility: Crutches: RN reinforces education of PT. Assessment of proper PT practices in the RNs job duties Walkers and Canes: used for elders rather than crutches\
• Mobility must prevent any complications from immobilizing include increasing oral fluid intake and eating high fiber foods Encourage activity as tolerated because administering stool softeners and laxative is part of the PRN process

Preventing and Monitoring for Neurovascular Compromise

• Monitor for:
• Frequent neurovascular checks before/after fixation. If the limbs are unmatched then there MUST be perfusion as that means its distal to the injury.
• Assess pulse, color, temperature, sensation, and movement
• Perfusion distal to injury: increased pain, impaired ability. Decrease sensory perception

Fracture outcomes or the results of fracture analysis

Adequate pain control Ambulates independently with or without assistive device or traction Free of physiologic consequences Adequate blood flow Free from fracture complications

Amputation: Promoting Health and Prevention of Disease

• The plan to get a diabetic patient to adhere to their diabetic disease protocols should help avoid amputations
• Regular exercise and maintaining a healthy weight would help to maintain a good state of being
• Stop behaviours of being risky in any vehicular activity, and use proper safety

Recognizing Cues for Amputation

• Diagnostic Assessment:
• Should be based on blood flow
• Ordered Diagnostic testing should have been done before this stage Ankle-brachial index should be over 0.9, and use Systolic BP Doppler: measures speed of blood flow in limb TCPO2: Measures oxygen pressure to indicate blood flow in limb, predicts healing

Amputation Complications

• Most include :
• Hemorrhage leading to hypovolemic shock Monitor to make sure if bleeding is happening-Infection Osteomyelitis as well as wound
• Phantom limb pain can affect how the brain recovers

Common in Patients with phantom limb pain

• Triggered by temperature/barometer pressure changes, illness, fatigue, stress, anxiety. as that is the main goal.
• Intensely burning that include crushing, or cramping if it is not a numbness sensation Neuroma: tumor of damaged nerve cells, sonography for diagnosis, surgical removal-often grows back; nonsurgical:
• peripheral nerve block, steroid injections, cognitive therapies (hypnosis) May or may not be painful
• Flexion contractures: Hip and knee MUST BE PREVENTED through proper positioning and an active range of motion

Amputation Outcomes

• Includes monitoring the following aspects: Potential or being susceptible to decrease tissue perfusion Acute and/or extreme consistent Pain Decreased ability or movement The way patient's view thierselves

Amputation Outcomes

• Monitoring for decreased tissue perfusion through the following: the usual color of skin or and warmness of the area Patient education of having phantom pain that requires pain management The teaching range of motion which includes a collaborative PT or OT to start performing exercises for the limb that will soon have an assistance to move as needed Actively listening to how the patient views them self is important, as you do not what to assume the way the think, also showing and introducing active amputees would benefit them to being encouraged.

Multiple sclerosis

Most commonly affected with this include: Brain Spinal cord The onset of neurologic disability in the patient with The three most known categories of this is Clinically is a isolated syndrome lasting throughout a whole day is a MRI scan can show what is has in the process and a high number of people 10 year later go through multiple MS at a very fast

Multiple sclerosis

The process includes three factors: Immunity Biological factors Geographical factors Affects Woman age of Twenty and fifty affect by the onset by 2 or a maximum by three

The assessment factors

• The use of patients has the following:
• History of the patient Laboratory information MRI of the brain and evoked the potential of testing.
• Interprofessional team This includes the use of a PT and OT in maintaining exercises Home safety Speech Therapist The administration is is through the use of taking medications

Care Coordination and Transition Management

• Can usually live independently with some assistance Using the multidisciplinary team helps maintain maximum strength, function and independence. Emphasize importance of avoiding: overexertion, stress, extremes of temperatures (fever, hot baths, sauna bath, excessive chilling), humidity, people with infections. Explain all medications, time and route of taking, dosage, purpose and side effects. Teach the patient how to differentiate between expected side effects and adverse/allergic reactions. Make sure they have a resource person to contact with issues or questions. Provide written instructions. Physical therapist develops and exercise program that can be completed at home, emphasize importance of continuing exercise program. They will learn self-care, daily living skills and use of required equipment (walkers, electric carts) Teach bowel and bladder management, skin care, nutrition, and positioning techniques. Teach conservation strategies that balance rest periods with periods of activity including regular social interactions with family and friends. Use assistive devices and modify environment to avoid fatigue. Learn stress management techniques and avoid undo stress Access coping skills of family as well as patient, remind family personality changes can happen with this disease. There needs to be a non-verbal connection they can make to let patient know behavior is inappropriate. National multiple Sclerosis Society, Meal-delivery services, transportation services for disabled and home maker services are all community groups that can help