Musculoskeletal Assessment/Immobility PDF

Musculoskeletal Assessment/Immobility- SLO: Discuss the e ects of immobility on the person. ◦ Metabolic changes: ‣ Physical inactivity can have strong deconditioning e ects on the human body, in particular on bones, muscles, and the cardiovascular system. ‣ Immobility disrupts normal metabolic proce...

Musculoskeletal Assessment/Immobility- SLO: Discuss the e ects of immobility on the person. ◦ Metabolic changes: ‣ Physical inactivity can have strong deconditioning e ects on the human body, in particular on bones, muscles, and the cardiovascular system. ‣ Immobility disrupts normal metabolic processes, decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing uid, electrolyte, and calcium imbalances; and causing GI disturbances such as decreased appetite and slowing of peristalsis. ‣ Older adults often experience decreased stamina, reduced appetite, and increased fatigue. ‣ Negative nitrogen imbalance: when the body excretes more nitrogen than it ingests in proteins. ‣ Calcium loss (resorption) from bones, hypercalcemia ◦ Respiratory changes: ‣ Immobility places patients at risk for respiratory complications. High risk for developing atelectasis (collapse of alveoli) and hypostatic pneumonia (in ammation of the lung from stasis or pooling of secretions) ◦ Cardiovascular changes: ‣ It a ects cardiovascular system, resulting in orthostatic hypotension, increased cardiac workload, and thrombus formation. ‣ It decreases circulation uid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. ◦ Musculoskeletal changes: ‣ Muscle loss. ‣ Loss of endurance, decreased muscle mass and strength, and joint instability place patients at risk for falls. ‣ Impaired calcium metabolism and joint abnormalities. ‣ Osteoporosis, joint contracture (ex:foot drop) ‣ Increased weakness/fragility ◦ Urinary elimination changes: ‣ Since the patient is in a recumbent or at position, gravity is not on their side. So urine enter the bladder unaided by gravity. ‣ Urinary stasis, when the peristaltic contractions of the ureters are insu cient to overcome gravity, the renal pelvis lls before urine enters the ureters. This condition increases UTI and renal calculus (calcium stones) ◦ Integumentary changes: ‣ Major risk factor for pressure injuries. ‣ Any break in the integrity of the skin is di cult to heal. ‣ Pressure ulcers. ◦ Phsychosocial changes: ‣ Immobilization often leads to emotional and behavioral responses, sensory altercations, and changes in coping. ‣ Immobility can cause social isolation and loneliness. ‣ They also experience depression. Propose nursing interventions to minimize complications in each system of the immobilized patient. ◦ Metabolic changes intervention: ‣ Review intake and output records for uid imbalance. ‣ Monitoring laboratory data such as levels of electrolytes, serum protein (albumin and total protein), and blood urea nitrogen (BUN) also helps you to determine metabolic functioning. ‣ Monitoring food intake and elimination patterns and assessing wound healing help to determine altered GI functioning and potential metabolic problems. ‣ The rate of how a wound is healing is a ected by nutritional intake and nutrient absorption. ◦ Respiratory changes intervention: ‣ TCDB: Turn, Cough, and encourage client to take Deep Breaths. ‣ Use of incentive spirometer ‣ Position changes ‣ Oral care, every 2 hours. ◦ Cardiovascular changes intervention: ‣ Medication and uid adjustments. ‣ Use devices: TEDs, SCDs, GCS Use low dose anticoagulants DO NOT MASSAGE CLIENT’S LEGS! ◦ Musculoskeletal changes interventions: ‣ Active and passive ROM exercise ‣ Reposition q 2 hours ‣ Su cient uids ‣ Su cient protein intake/ nutrition ‣ High top sneakers ‣ Floorboard ‣ Isometric contractions- increases energy expenditures. ◦ Urinary elimination changes interventions: ‣ Reposition ‣ Increase uids ‣ Peri care ‣ Monitor “I & O”: Intake: 30ml/kg/day Output:.5-1ml/kg/day ◦ Integumentary changes interventions: ‣ Assess patient’s skin for breakdown and color changes such as pallor or redness ‣ Assess skin integrity during any routine patient contact. ‣ Use Braden Scale for a baseline measure. ‣ Inspect pressure points after the patient has been lying in on position. ‣ Turn every 2 hours ‣ hygiene ‣ Care of bladder and bowels ‣ Air mattresses ‣ Space boots or elevating heels of beds with pillow under calves. ‣ Manage edema ◦ Phsychosocial changes interventions: ‣ Listen to your patients. ‣ Mobilize patients as soon as possible. Discuss safety factors associated with the application of restraints. ◦ Can be used only to ensure the physical safety of the patient or other patients. ◦ Patients who are confused or agitated or who repeatedly try to remove medical devices may temporarily require physical restraints to keep them safe. ◦ Patients who are confused or disoriented, who repeatedly wander or fall may require the temporary use of restraints to keep them safe. ◦ The use of restraints is associated with serious complications resulting from immobilization such as pressure injuries, pneumonia, constipation, and incontinence. ◦ Loss of self-esteem, humiliation, and agitation are also serious problems. ◦ Death has resulted from restraints because of restricted breathing and circulation. ◦ Increase contractures, incontinence and depression. Assess for correct and impaired body alignment and gaits. ◦ Have client walk in a straight line away & back to examiner. ‣ Check for foot dragging ‣ Limping ‣ Shu ing ‣ Position of trunk in relationship to legs ◦ Walking: ‣ Arms swinging freely ‣ Head & face leading the body ‣ How wide is the base of support? ‣ How long are the steps? ◦ Standing: ‣ Upright? ‣ Look at the client sideways Is everything in alignment. Describe the functions of the muscular skeletal system in the regulation of movement ◦ The skeletal system provides attachments for muscle and ligaments and the leverage necessary for mobility. ◦ It is the supporting framework of the body and is made up of four types of bones: long, short, at, and irregular. ◦ Bones are important for movement because they are rm, rigid, and elastic. Describe the sequence of a muscular skeletal assessment. ◦ The basic musculoskeletal physical examination involves inspection, palpation, neurovascular assessment, and range of motion, strength, and re ex testing. ◦ Inspection: ‣ Systemic inspection, starting at the head and neck, then moving to the upper extremities, lower extremities, and trunk. ‣ Note the patient’s general posture and body build, muscle size and symmetry, and symmetry and contour of joints. ◦ Palpation: ‣ Start from head to toe ‣ Note the speci c anatomical location of any abnormal ndings. ◦ ROM: ‣ Simply compare the ROM of 1 extremity with that on the opposite side. ‣ Ask patient if t hey need assistance on ADLs. ‣ 5-12 repetitions per episode ‣ Proxim al to distal ‣ Support joints as needed. ‣ ◦ Muscle-strength testing: ‣ Grade the strength of individual muscles or groups of muscles during contraction on a 5-point scale. ‣ Grade normal muscle strength with full resistance to opposition as a 5/5 bilaterally. ◦ Neurovascular assessment: ‣ 5 P’s: also known as CMST: circulation, movement, sensation, temperature. Pain Pallor: pale appearance Pulselessness: Paresthesia:“pins and needle” sensation. Paralysis: inability to move Assess for correct and impaired body alignment. ◦ Sitting: ‣ The head is erect, and the neck and vertebral column are in straight alignment. ‣ The body weight is distributed evenly on the buttocks and thighs. ‣ The thighs are parallel and in a horizontal plane. ‣ Both feet are supported on the oor, and the ankles are exed comfortably. ‣ It is import ant to asses alignment when sitting if the patient has muscle weakness, muscle paralysis, or nerve damage. ‣ The patient with severe respiratory disease who has orthopnea sometimes assumes a posture of leaning on the table in front of the chair in an attempt to breathe more easily. ◦ Lying: ‣ The vertebrae should normally be aligned, and the position does not cause discomfort. ‣ Patients with impaired mobility (ex: traction or arthritis), decreased sensation (ex: sensory de cits by hemiparesis following a CVA), impaired circulation (ex: peripheral vascular disease caused by diabetes), and lack of voluntary muscle control (ex: spinal cord injury) are at risk for skin damage when lying down. ◦ Standing: ‣ The head is erect and midline. ‣ When observed posteriorly: the shoulders and hips are straight and parallel. The vertebral column is straight. ‣ when observed laterally: The head is erect, and the spinal curves are aligned in a reversed S pattern The cervical vertebrae are anteriorly convex The thoracic vertebrae are posteriorly convex And the lumbar vertebrae are anteriorly convex. The abdomen is comfortably tucked in, and the knees and ankles are slightly exed. ‣ The arms hang comfortably at the sides. ‣ Feet are slightly apart to chive a base support and the toes are pointed forward. ‣ When viewing from behind: The center gravity is in the midline And the line of gravity is from the middle of the forehead to a midpoint between the feet. Laterally the line of gravity runs vertically from the middle of the skull to the posterior third of the foot. OA/Joint Replacement Surgery- SLO: Describe the clinical manifestations, collaborative care, and nursing management of osteoarthritis. ‣ Clinical manifestation: Joint pain Sti ness Limited ROM Throughout peripheral and central joints are a ected. Deformity ‣ Collaborative care: managing pain and in ammation, preventing disability, and maintaining pain and in ammation, preventing disability, and maintaining and improving joint function. PT/ OT Teach the patient to balance rest and activity. Joint protection Good body mechanics Regular Low impact exercise. Apply heat and cold to help reduce pain and sti ness ◦ Heat for sti ness ◦ Ice for in ammation Weight reduction program for overweight patient. Acupuncture, massage, and Tai Chi may reduce arthritis pain and improve joint mobility. Drug therapy: acetaminophen (Tylenol), NSAIDs, Intraarticular corticosteroids. Surgery ‣ Nursing management: Assessment: type, location, severity, and duration of patient’s joint pain and sti ness and how they a ect ADLs, etcv Describe the types of joint replacement surgery associated with arthritis and connective tissue diseases. ◦ Synovectomy: removal of synovial membranes, useful in rheumatoid arthritis. ◦ Osteotomy- removing or adding a wedge or slice of bone to change alignment. ◦ Debridement- removing degenerative debris. ◦ Arthroplasty- reconstruction or replacement of a joint. ◦ Arthrodesis- fusion of a joint. Discuss the preoperative and postoperative management of the client having joint replacement surgery (Hip and Knee Joint) ◦ Preoperative management: ‣ to identify risk factors for postoperative complications so we can implement measures to promote optimal outcome. ‣ History should include, medical diagnoses and complications (diabetes and VTE), pain tolerance and management preferences, current functional level and expectations after surgery, current social support, and home care needs after discharge. ‣ Patient should be free from infection and acute joint in ammation. ‣ Teach about the expected hospital course and postoperative management at home is important for the patient and caregiver. ‣ PT visit to go over postoperative exercises and measurement for assistive devices. ‣ Discuss the safety and accessibility of the home environment. ◦ Postoperative management: ‣ Perform neurovascular assessment. ‣ Give ordered anticoagulant medication, analgesia, and parenteral antibiotics. ‣ Pain management strategies ‣ Assess patient often. ‣ Monitor for complications. ‣ Assess ROM at regular intervals: The a ected joint is exercised and Ambulation is encouraged as early as possible to prevent complications of immobility. ‣ teach patient to report complications, including infection and dislocation. Explain complication associated with joint replacement surgery. ◦ Complication of immobility: dehydration, risk of DVT, cardiac deconditioning, respiratory infections, musculoskeletal deconditioning and contractures, constipation, UTI, pressure ulcers, anxiety and depression. ◦ Infection: fever, increased pain, drainage. ◦ Dislocation of prosthesis: pain, loss of function, shortening or malalignment of an extremity. ◦ Damage to nerves and tissue ◦ Bleeding ◦ Sti ness Apply the nursing process to client needs related to joint replacement surgery. ◦ Manage pain and provide adequate pain relief measures. ◦ Promote wound healing and prevent infection. ◦ Ensure patient safety and prevent falls or complications related to immobility. ◦ Facilitate early mobilization and rehabilitation to regain joint function and prevent complications. ◦ Monitor for signs of complications such as DVT or pulmonary embolism and implement preventive measures. ◦ Provide patient education on self-care, medications, activity restriction, and signs of potential complications. Nursing Process in Care Planning- SLO: Discuss the steps of the nursing process. ◦ “ADPIE” ◦ Assessment: ‣ Involves thorough data collection from multiple sources, accuracy is important. ‣ Objective data: observed Ex: physical exam, vital signs, signs & symptoms, labs, etc. ‣ Subjective data: what client “says” (reports) Ex: stomach ache, chest pain, headache, nausea, etc. ◦ Diagnosis: ‣ Identify problems ‣ Using the assessment data collected, the goal is to address both actual or potential health problems for the client. ‣ It is used to help shape clinical judgment about a client’s physical & psychological status, but may also include the client’s social factors, family, or community experiences. ‣ Can be actual problems or problems the patient is at risk for. ◦ Planning: ‣ Goals, outcome and action plan. ‣ Develop an action plan with speci c goals and desired OUTCOME of the plan and always discuss this plan with the client to assess that perceived needs are being met. Don’t forget about the patient’s opinion here, but make sure patient’s desire is realistic. ‣ SMART: Speci c, Measurable, Attainable, Realistic, Timeframe ‣ Can be short term vs long term. ◦ Implementation: ‣ Nursing actions: Independent: it is ideal, nurse initiated, do not need to consult with other team members, does not require an MD order. Dependent: MD initiated, delegated to RN to implement, still requires nursing judgment. Interdependent: collaborative, actions under direction of MD. ‣ Nursing interventions: assess, monitor, observe, provide ‣ What action will the nurse need to take to be able to evaluate the goal? This is a “required” or mandatory nursing action that must be listed. ‣ Actions nurse plans to do which assist patient towards goal achievement. ‣ Use scienti c rationale. ‣ Must be individualized, speci c to that patient’s needs (culture, developmental stage, etc) ‣ Include frequency, method, etc. ◦ Evaluate: ‣ Objective and measurable. ‣ Reassess the client, were the desired outcomes achieved? ‣ Adapt the plan of care based on new assessment: Identify potential errors or problems in the plan of care. Make adjustments as needed ‣ evaluate progress made towards each outcome (goal) and patient’s response to interventions. ‣ DO NOT EVALUATE INTERVENTIONS/ NURSING ACTIONS! ‣ Evaluation involves a statement for each nursing goal. Apply the nursing process in the development of a care plan. ◦ See previous answer. Discuss the components of critical thinking. ◦ Knowledge base: ‣ Basic and nursing science ‣ Nursing and health care theory ‣ Patient data ◦ Experience: ‣ Personal ‣ Clinical practice ‣ Skill competence ◦ Environment: ‣ Time pressure ‣ Setting ‣ Task complexity ‣ Interruptions ◦ Critical Thinking Attitudes and Standards: ‣ Intellectual ‣ Professional Distinguish between the developmental stages of critical thinking. ◦ Basic: ‣ Answers to complex problems are perceived as either right or wrong. ‣ A single solution usually resolves each problem. ‣ This is an early step in developing critical thinking. ‣ No previous experience. ‣ Thinking is concrete and based on a set of principles or rules. ‣ The experts have the answers. ‣ There is one right answer for every problem and we have to nd it for the test! ‣ Focusing on the narrow concrete. “I’m a good nurse if I can start an IV.” ‣ Ex: Nursing students, anyone in a new clinical situation. ◦ Complex: ‣ Make clinical decision more independently. ‣ Creativity allows nurses to generate many ideas quickly, be able to change viewpoints, and create original solutions to problems. ‣ Thinking abilities and initiative to look beyond expert opinion begin to change. ‣ Learn that alternative and perhaps con icting solutions exist. ‣ Consider di erent options from routine procedures. ‣ Gather additional information and take a variety of di erent approaches for the same therapy. ‣ Analyzes and examines choices/actions more independently. ‣ Examines risks and bene t of solutions before decision is made. ‣ Modi es/customizes the routine procedure or go beyond it to meet unique needs of patient. ‣ Ex: RN utilizing both pharmacological and nonpharmacological pain management; complex IV scenarios. ◦ Commitment: ‣ Able to consider wider array of clinical alternatives for a patient’s situation. ‣ Recognize that sometimes a proper action is the decision to not act or to delay an action until a later time based on experience and knowledge. ‣ Able to apply all elements of clinical judgment model almost automatically. ‣ Chooses an action based on the alternatives available and accept accountability for it and support it. Can justify actions/decisions made. ‣ Knows when it is acceptable or even preferable to break the rules. ‣ Experience provides stronger intuition. Discuss the relationship between the nursing process and critical thinking. ◦ Critical thinking enables you to be deliberate and systematic in collecting data about your patients during the nursing process. ◦ Iterative process which the nurse make clinical judgment to analyze and understand client concerns and form decision to guide care. ◦ Gather data, recognize pattern, synthesize information to guide a nursing care plan. Analyze how socioeconomic factors, growth, and developmental stages, and cultural practices in uence care planning. ◦ Socioeconomic factors: people with low income seek healthcare less often, when they do seek healthcare, it is more likely to be an emergency. ‣ Ex. Unable to miss work. ◦ Cultural practices: there are certain group of people that might decline or refuse treatment in the care plan due to their cultural/spiritual beliefs. ‣ Ex: refusal of blood transfusion. ◦ Think about level of education, family (social) support, types of community