0133427269 Module13 Mobility LectureOutline

Module 13 Mobility The Concept of Mobility Tissues, structures of the musculoskeletal system perform many functions ( support, protection, movement Two subsystemsbones and joints, skeletal muscles Neurologic system ( controls movements of subsystems Alteration in mobility ( severe consequences ADLs Ability to communicate Ability to participate in recreational, occupational activities Normal presentation Physiology review Skeleton Bones form bodys structure, support soft tissues, protect vital organs, move body parts by providing attachment points for muscles, store minerals, hematopoiesis 206 bones Axial skeleton ( bones of skull, ribs, sternum, vertebral column Appendicular skeleton ( bones of limbs, shoulder girdle, pelvic girdle Muscles Types of muscle tissue ( smooth, cardiac, skeletal Skeletal muscles ( thick bundles of parallel multinucleated contractile cells called fibers Typical functional properties of skeletal muscle Excitability Contractibility Extensibility Elasticity Movement triggered ( motor neuron releases acetylcholine ( alters permeability of muscle fiber ( sodium ions enter fiber ( action potential ( causes muscle contraction Prolonged strenuous activity ( continuous nerve impulses ( buildup of lactic acid ( reduced muscle energy Lack of muscle use leads to atrophy Joints ( regions where two or more bones meet Ligaments, tendons, and cartilage Ligaments ( connect bones to other bones to form a joint Tendons ( connect bones to muscles Cartilage ( flexible connective tissue found throughout the body Genetic and lifespan considerations Musculoskeletal differences in children Primary centers of ossification nearly complete at birth ( fibrous membrane between cranial bones ( fontanelles Secondary ossification occurs as long bones grow Cartilage cells at epiphyses ( replaced by osteoblasts Calcium intake during childhood and adolescence essential Long bones of children porous, less dense ( bend, buckle, or break Muscles, tendons, ligaments Muscular system almost completely formed at birth ( muscles increase in length, circumference Ligaments, tendons stronger than bone until puberty Bone remodeling in adults Bone remodeling continues into adulthood at a slower rate Bone resorption occurs when minerals stored in bones are needed for cellular processes Bone formation occurs when excess minerals are available Hormones that regulate bone remodeling are controlled by blood calcium levels Calcium regulation is a vital factor in mobility Musculoskeletal changes in older adults Bone density decreases as bone resorption exceeds bone formation Spinal discs lose fluid and become thinner Muscle fibers atrophy Tendons and ligaments have decreased elasticity Decreased range of motion See Figure 132 NORMAL CHANGES OF AGING IN THE MUSCULOSKETAL, p. 822 Alterations to mobility See CONCEPTS RELATED TO MOBILITY, p. 823 Alterations and manifestations Back problems Causes ( trauma, sudden injury, degenerative disorders, GI causes, pregnancy Fractures ( breaks in the continuity of a bone Impair mobility, pain Hip fractures Fracture of femur at head, neck, or trochanteric regions Multiple sclerosis (MS) Chronic demyelinating neurologic disease of the CNS ( associated with abnormal immune response to environmental factor Osteoarthritis (OA) Most common type ( wear and tear of articular cartilage of weight-bearing joints Parkinson disease Degenerative CNS disorder caused by death of neurons that produce dopamine Primary clients ( older than 50 Symptoms ( tremors, muscle rigidity, postural instability, bradykinesia Spinal cord injuries Typically result in permanent disability, paralysis Motor vehicle crash ( 55 of spinal cord injuries Other alterations that affect mobility Joint disorders Temporomandibular joint syndrome (TMJ) Rotator cuff tears Wrist and hand Joint effusion Rheumatoid nodules Carpal tunnel syndrome Dupuytren contracture Foot Gout Bunion Hallux valgus Hammertoe Traumatic injuries Sprain ( stretching or tearing of ligament Strain ( stretching or tearing of muscle or tendon Usually can be treated at home with RICE (rest, ice, compression, elevation) Genetic considerations and nonmodifiable risk factors Primary risk factor is aging Genetic factors also linked ( see Box 13-1 GENETIC DISORDERS THAT AFFECT MOBILITY, p. 827 Case Study Part 1 ( Darrell Hayes is a 42-year-old Black male who is experiencing lower back pain , p. 827 Prevention Modifiable risk factors Obesity Good maternal nutrition during pregnancy Screenings Bone density scans to detect osteoporosis Genetic testing for those with family history of muscular dystrophy, Marfan syndrome, Parkinson disease Assessment Nursing assessment See ASSESSMENT INTERVIEW MOBILITY, p. 829 Physical assessment See MOBILITY ASSESSMENT, pp. 830 835 Assess 5 Ps of neurovascular status ( pain, pulses, pallor, paresthesia, paralysis/paresis Lifespan and cultural considerations Infants and children ( more likely to have genetic disorders or congenital malformations Children, adolescents, young adults ( sports trauma, abuse motor vehicle crashes Older adults ( inflammatory and wear-and-tear problems Diagnostic tests Blood tests ( see Table 132 BLOOD TESTS FOR MUSCULOSKELETAL DISORDERS, p. 835 Radiologic examinations Bone density examinations Arthroscopy Electromyogram (EMG), somatosensory evoked potential (SSEP) ( tests of electrical activity ofskeletal muscle Case Study Part 2 ( Mr. Hayes is under the care of an orthopedic spine surgeon , p. 836 Interventions and therapies Independent Providing education Body mechanics Proper posture Regular exercise and good nutrition Promoting comfort Client positioning and padding Braces and support devices Preventing injury Encourage clients to perform exercises and stretches Utilize braces and splints Screen clients environment for potential hazards Collaborative Rehabilitative nursing ( process of restoring a persons ability to live, work in as normal a manner as possible Exercise Vital to maintaining muscle strength Range-of-motion ( maintain joint mobility Resistive exercises ( resistance in order to increase muscle strength Isometric exercises ( maintain strength when a joint is immobilized Ambulation Walking ( longer immobilization ( more difficult to regain ambulatory ability Ambulation ( improves function, physical, mental well-being, muscle strength and joint mobility, respiratory exchange, circulation Balance, coordination, good body alignment important for walking Major muscle groups ( thigh, leg Before assisting client with walking Explain what you are going to do Prepare client by completing ambulatory procedure in phases Assist to sit Dangle Remain standing Walk with assistance of one or two nurses Assistive devices Various devices to give client support when ambulating ( used to relieve clients body weight Crutches ( provide support when lower extremities unable to support body weight Axillary, Lofstrand or Canadian, platform Safety factors Type of crutch used depends on ability to ambulate, muscle strength needed for support, individual needs of client Walker Assists client with balance, walking Clients arms used to support all, part of clients body and take weight off lower limbs while ambulating Walker constructed with or without wheels or platforms Cane Protects client from falls, affords client confidence to ambulate, maintain independence Pharmacologic therapy Focus on palliative rather than curative ( anti-inflammatory, relieve muscle spasm See MEDICATIONS Musculoskeletal Disorders, p. 838 Review The Concept of Mobility Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( The epidural cortisone injection that Mr. Hayes received for treatment of his herniated disc helped Exemplar 13.1 Back Problems Overview One of the most common alterations in mobility People typically try to attribute to activity, movement ( most often result from years of improper bending Number of physical conditions can result in back problems Pregnancy, bad posture and sleeping habits, poor physical condition, bad workplace ergonomics Degenerative disorders Referred pain Herniated disk Herniated intervertebral disk ( rupture of cartilage surrounding the intervertebral disk with protrusion of nucleus pulposus See Figure 1320 A HERNIATED INTERVERTEBRAL DISK, p. 840 Pathophysiology and etiology Intervertebral disks ( located between vertebral bodies ( made of inner nucleus pulposus, outer collar Shock absorbers Herniated intervertebral disk occurs when nucleus pulposus protrudes through weakened or torn annulus fibrosus of intervertebral disk Herniation may be abrupt or gradual Etiology As body ages ( nucleus pulposus of intervertebral disk loses fluid content, disks less able to absorb shocks Disks become smaller, slip out of place more easily Risk factors Any adult age ( most common entering middle age, age-related changes occur Prevention Good back care Maintain healthy weight Use proper body mechanics Clinical manifestations Lumbar disks Classic manifestation ( recurrent episodes of pain in lower back, sciatica (result of pressure on nerve roots L4, L5, S1, S2, S3) Other manifestations Postural deformity, motor deficits, sensory deficits, changes in reflexes Cervical disk manifestations Lateral herniation ( pain in shoulder, neck, arm Paresthesia, muscle spasms, stiff neck, decreases, absent arm reflexes Central herniations ( mild, intermittent pain Lower extremity weakness, unsteady gait, muscle spasms, urinary elimination problems, altered sexual function, hyperactive lower extremity reflexes Lifespan and cultural considerations Rare in children Older adults less likely to develop herniated discs than younger adults Collaboration Identifying location, determining treatment See CLINICAL MANIFESTATIONS AND THERAPIES HERNIATED DISC, p. 844 Diagnostic tests X-rays and CT scans Electromyography (EMG) Surgery Indicated for clients who do not respond to conservative management, have serious neurologic deficits Laminectomy ( removal of part of vertebral lamina Discectomy ( remove all or part of the herniated disc Spinal fusion ( insertion of wedge-shaped piece of bone or bone chips betweenvertebrae to stabilize them Artificial disc surgery ( herniated disc is replaced with artificial disc Laser surgery ( vaporizes tissue Pharmacologic therapy Medications to relieve pain, reduce swelling, muscle spasms Non-narcotic analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, sedatives/tranquilizers Nonpharmacologic therapy Hot or cold packs Maintain normal activity Physical therapist Chiropractor Massage therapy Conservative treatment ( usually prescribed for 23 weeks Nursing process Assessment Health history Physical assessment Diagnosis Risk for Injury Risk for Reflex Urinary Incontinence Risk for Bowel Incontinence Impaired Physical Mobility Acute Pain Chronic Pain Disturbed Sleep Pattern Activity Intolerance Deficient Knowledge Ineffective Role Performance Anxiety Planning Client will develop no motor deficits Client will develop no sensory deficits Client will remain free from infection Client will demonstrate normal urinary and bowel function Client will verbalize proper use of medications Client will verbalize emotions and concerns Client will perform job responsibilities without work absences Implementation Prevent injury Avoid bending and twisting Maintain body alignment Use a firm mattress Assist with positioning and ambulation Promote comfort Assess pain frequently Administer pain medications Teach coping techniques Encourage appropriate exercise Education client about procedures and treatments Ease anxiety by explaining procedures and treatments Provide preoperative and postoperative care See Box 13-2 NURSING CARE OF CLIENTS UNDERGOING SURGERY FOR HERNIATED DISC, p. 846 Evaluation Client reports decrease in pain Client is able to maintain acceptable quality of life, including participation in ADLs Client has increased mobility, full ROM, normal sensory perception, and no neurological deficits Scoliosis Pathophysiology and etiology Curvature greater than 10 degrees ( abnormal Etiology Congenital, acquired, idiopathic Idiopathic structural scoliosis ( most common ( spine for unknown reasons begins to curve laterally, with vertebral rotation Congenital diseases involving spinal structure Acquired after injury Risk factors Adolescents at greatest risk Girls more likely to progress to a greater curvature than boys Clinical manifestations Spinal curve to one side Uneven shoulders and hips Differences in leg length Tiredness of the spine Prominent shoulder blade and rib bump Lifespan and cultural considerations Infantile idiopathic scoliosis ( birth to 3 years Juvenile idiopathic scoliosis ( 3 to 9 years of age Adolescent idiopathic scoliosis ( 10 19 years of age Adult idiopathic scoliosis ( may be present from childhood or may develop as a result of aging Collaboration Diagnostic tests School screenings for children age 10 15 ( Adam forward bend test Observation X-ray ( Cobb method Surgery Available for clients with Cobb angle greater than 50 degrees Involves spinal fusion combined with inserting metal rods on either side of the spine See COMMUNITY-BASED CARE Home Care After Surgery, p. 848 Pharmacologic therapy OTC analgesics for mild pain Stronger pain medications for severe scoliosis Nonpharmacologic therapy Early detection essential to successful treatment Mild scoliosis ( less than20 degrees curvature ( monitored every 3 6 months Moderate scoliosis ( 2545 degrees curvature Wearing a TLSO or Milwaukee brace Worn 12 - 23 hours/day Nursing process Assessment Screening ( includes several visual examinations Client in standing position Client in Adam position Diagnosis Risk for Activity Intolerance Deficient Knowledge Impaired Physical Mobility Risk for Impaired Skin Integrity Ineffective Breathing Pattern Risk for Infection Noncompliance Disturbed Body Image Risk for Chronic Low Self-Esteem Anxiety Ineffective Coping Social Isolation Planning Client will demonstrate effective breathing patterns Client, family describe selected treatment regimen, their role in compliance Client, family accurately describe the condition, stages of treatment Client will report compliance with brace wear Client will state important of follow-up care Client will communicate fears and emotions about diagnosis and treatment Clients curvature will not progress during treatment with brace Implementation Promote understanding and acceptance of the treatment plan Provide instructions about exercises Demonstrate exercises, explain their purpose Help client adjust to wearing a brace Provide reassurance, encouragement and promote interaction with peers Provide information about fashionable clothing that can be worn with brace Evaluation Regular assessment of the curvature of the spine Client maintains intact skin under brace Client wears brace as directed Review Back Problems Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 13.2 Fractures Overview Fracture is a break in the continuity of a bone See Table 13-1 COMMON FRACTURES, pp. 854-856 Pathophysiology and etiology Etiology Two main factors contribute to development of a fracture Strength of the force acting against the bone Strength of the bone When the force acting on the bone is greater than bone strength, the bone will fracture The force acting on the bone may be Direct blow Compression Twisting Trauma such as a fall Repetitive force such as running Single large force ( likely to cause fracture at point of impact (direct force) Small repetitive forces ( likely to cause fracture at weakest point of the affected bone (indirect force) Fracture healing Three phases Inflammatory phase ( damage causes bleeding and formation of hematoma around the injury inflammatory cells enter the wound and degrade debris and bacteria Reparative phase ( osteoblasts promote formation of new bone and osteoclasts destroy dead bone, assist in synthesis of new bone ( collagen formation, calcium deposition continue Remodeling phase ( excess callus removed, new bone lain down along fracture line ( site calcified, bone reunited Union ( bone that fractures and undergoes normal healing Nonunion ( fracture that shows no progress toward healing for at least 3 months Delayed union ( when healing process takes longer than expected Malunion ( when bone fragments join in an incorrect position See Table 134 FACTORS INFLUENCING BONE HEALING, p. 857 Risk factors Age Presence of bone disease Poor nutrition Prevention Begins with education Safety equipment Safe living environment See CLIENT TEACHING Fall Prevention in Older Adults, p. 857 Clinical manifestations Symptoms ( pain, visible deformity, swelling, numbness, internal or external loss of blood Complications Compartment syndrome ( occurs when excess pressure in a limited space constricts structures in a compartment ( reducing circulation to muscles, nerves Acute compartment syndrome ( result from hemorrhage, edema in compartment following fracture, crush injury, external compression by cast that is too tight Entrapment of blood vessels limits tissue perfusion ( begins cycle of events that may result in loss of limb Fasciotomy ( surgical intervention ( muscle fascia is cut to relieve pressure Incision left open, passive ROM on extremity Volkmanns contracture ( common complication of elbow fractures Results from unresolved compartment syndrome Arm mobility impaired Deep vein thrombosis (DVT) ( blood clot forms along intimal lining of a large vein Three precursors Venous stasis Injury to blood vessel walls Altered blood coagulation DVT ( may be swelling, leg pain, tenderness, cramping Best treatment ( prevention Early immobilization of fracture Early ambulation Diagnosis ( requires intervention Bed rest for 57 days Fibrinolytic agents Heparin IV to prevent more clots from forming Fat embolism syndrome (FES) ( fat emboli occur when fat globules lodge in the pulmonary vascular bed or peripheral circulation FES ( neurologic dysfunction, pulmonary insufficiency, petechial rash on chest, axilla, upper arms Long bone fractures major trauma Bone is fractured ( pressure in marrow rises, exceeds capillary pressure ( fat globules leave bone marrow, enter the bloodstream Manifestations usually develop within a few hours to a week Early stabilization of long bone fractures is preventive for FES Infection More likely to occur in open fracture than closed Usually result from contamination at time of injury Clostridium may lead to severe gas gangrene and cellulitis Lifespan and cultural considerations Children ( long bone fractures from sports and play, spiral fractures Unexplained midshaft spiral fractures may be indication of child abuse Children often recover quickly from fractures Adolescents ( stress fractures from poor nutrition Athletes ( stress fractures related to repetitive injury Adults ( recovery time is longer due to slower rate of tissue growth Especially true of menopausal women and older adults Older adults ( those with osteoporosis at risk for hip fracture More likely to develop complications Collaboration Stabilize fractured bone ( maintain bone immobilization ( prevent complications and restore function See CLINICAL MANIFESTATIONS AND THERAPIES Fractures and Complications, p. 865 Emergency care Immobilizing fracture ( maintaining tissue perfusion ( preventing infection Open wounds covered, bleeding controlled with pressure dressing Fracture splinted to maintain normal anatomic alignment, prevent from dislocating Relieves pain, prevents further damage Diagnostic tests X-rays MRI and CT scans Blood chemistries, CBC, coagulation studies to assess excessive blood loss Surgery External fixation ( metal pins and screws placed in bone above and below fracture, and then attached to a metal bar outside the skin Internal fixation ( ORIF (open reduction and internal fixation) bone is placed in correct alignment nails, screws, wires, plates or rods are inserted to hold bone in place Pharmacologic therapy Pain relief ( NSAIDS, opioids, PCA Antibiotics to prevent or treat infection Anticoagulants to prevent or treat DVT Nonpharmacologic therapy Casts and splints Cast ( rigid device used to immobilize, support, and protect fractured bones and surrounding soft tissue Usually applied to stable fracture after reduction Custom made to exactly fit the limb Splint ( provides less support than a cast, but easily adjusted to accommodate swelling Often used to stabilize fresh injuries and during reparative phase of healing Traction ( application of straightening or pulling force to return or maintain fractured bones in normal anatomic position ( weights applied to maintain necessary force Skin traction ( splints, bandages, and boots used to control muscle spasm, immobilize part of the body before surgery See Box 134 COMMON TRACTION METHODS, p. 863 Skeletal traction ( application of pulling force through placement of pins into the bone Applied under sterile conditions because of risk of infection See Box 135 NURSING INTERVENTIONS FOR CLIENTS IN TRACTION, p. 864 Nonpharmacologic pain management RICE (rest, ice, compression, elevation) See Box 13-6 NURSING INTERVENTIONS FOR PAIN IN CLIENT WITH A BONE FRACTURE, p. 865 Nursing process Assessment Health history Physical assessment 5 Ps of neurovascular assessment Pain Pulses Pallor Paralysis/Paresis Paresthesia Diagnosis Acute Pain Risk for Peripheral Neurovascular Dysfunction Risk for Ineffective Tissue Perfusion Risk for Infection Impaired Skin Integrity Impaired Physical Mobility Risk for Disuse Syndrome Deficient Knowledge Disturbed Body Image Anxiety Planning Client will obtain pain relief adequate to allow for rest and comfort Client will experience no complications as a result of fracture or treatment Client will experience no ongoing loss of function as a result of fracture Implementation Provide effective pain management Monitor vital signs Ask the client to rate pain on scale of 010 before and after any intervention Move client gently and slowly Encourage distraction and other noninvasive methods of pain relief Administer pain medications as prescribed Maintain proper alignment Casts, traction Promote mobility Physician orders amount of mobility client is allowed Restrictions depend on extent, site of fracture Monitor neurovascular status Assess the 5 Ps every 12 hours Monitor the extremity for edema, swelling Assess for deep, throbbing, unrelenting pain Monitor tightness of cast If cast is tight, be prepared to assist physician with bivalving If compartment syndrome is suspected, assist physician in measuring compartment pressure (normal pressure 1020 mmHg) Elevate injured extremity above the level of the heart Administer anticoagulant per physicians order Prevent infection Monitor vital signs and lab reports of WBCs Use sterile technique for dressing changes Assess wound for size, color, presence of any drainage Administer antibiotics per physicians order Provide discharge instructions Teaching topics include cast care, activity restrictions, taking pain medications, signs of complications, injury prevention Referral to home health care may be needed for older adults Evaluation Client regains prior level of function when fracture resolves Client experiences no complications as a result of treatment Client explains home care Client lists symptoms to report to provider immediately Review Fractures Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 13.3 Hip Fractures Overview Hip fracture refers to fracture of femur at the neck, head, trochanteric regions See Figure 1337 REGIONS WHERE HIP FRACTURES MAY OCCUR, p. 869 Pathophysiology and etiology Types of fractures Intracapsular fractures ( involve head or neck of femur Intracapsular fractures frequently impair flow of blood to femoral head Extracapsular fractures ( involve trochanteric region Extracapsular fractures cause acute blood loss from vascular cancellous bone surfaces Etiology Typically caused by trauma Osteoporosis contributes to tendency of bone to fracture Risk factors Common in older adults ( decreases in bone mass, increased tendency to fall Osteoporosis ( especially for postmenopausal women Chronic medical conditions Medications that weaken bone or cause dizziness Nutritional problems Physical inactivity, especially lack ofweight-bearing exercise Tobacco and alcohol use Prevention Fall prevention Maintaining bone health Mobility assessment Clinical manifestations Symptoms Severe pain in hip, upper thigh, groin, or lower back May be unable to walk, stand, or bear weight Stiffness or bruising and swelling in hip area Leg on injured side may appear shorter and may turn outward Complications DVT Pressure ulcers UTI Pneumonia Muscle atrophy Older adults may lose ability to live independently for up to a year some will remain in long-term care for the rest of their lives Lifespan and cultural considerations Children, adolescents, young adults ( sports injuries or MVCs Treatment for children ( casting or repair surgery rather than hip replacement Collaboration Essential to optimize client outcomes Diagnostic tests X-ray CT and MRI Surgery Goal of surgery ( reduce, stabilize fracture ( increase mobility, decrease pain, prevent complications Type of injury, condition of person, preexisting orthopedic conditions ( determine type of surgical procedure Goal of joint replacement surgery ( decrease pain, increase joint function Pharmacologic therapy Pain medications Anticoagulants Antibiotics Anti-inflammatories Bone density enhancers Nonpharmacologic therapy For those not having surgery ( bed rest, traction or casting Postoperative care includes physical and occupational therapy Nursing process Assessment Health history Age, history of traumatic event, chronic illness, medications Physical assessment Pain, inability to walk, shortening and external rotation of the affected lower extremity 5 Ps of neurovascular assessment Diagnosis Risk for Infection Impaired Physical Mobility Impaired Skin Integrity Risk for Falls Acute Confusion Acute Pain Anxiety Deficient Knowledge Stress Overload Caregiver Role Strain Planning Client achieves adequate pain management to allow for rest and rehabilitation Client ambulates independently after surgery and rehabilitation Client has adequate wound healing Client will not develop infection Client will demonstrate increased muscle strength and balance Client voices impact of hip fracture on lifestyle and begins to make plans for adjusting lifestyle based on residual loss of function Implementation Interventions similar to those for other types of fractures ( managing pain, maintaining proper alignment, promoting mobility, monitoring neurovascular status, monitoring for infection Plan effective pre- and postoperative care Pain management Immobilization Education Prevent complication Assist with ambulation Administer medications as prescribed Promote psychosocial wellness Emotional support is vital Encourage client and family to verbalize feelings Provide information about clients condition and explain treatment plan Provide verbal and written instructions for care Orient client to time, day, place, and situation Refer client and family to home health agency, rehabilitation center, or long-term care facility Promote a trusting relationship Support use of coping mechanisms to decrease stress Provide thorough discharge instructions Proper use of abduction pillow to maintain proper hip alignment Proper sitting and bending techniques Proper use of a cane or walker Explanation of weight-bearing limitations Explanation of all medications Referral to physical therapists, home care agencies, sources for medical equipment Evaluation Attains greatest possible return of mobility Reports pain is controlled, allowing client to rest and attend to rehabilitation needs Copes with loss in mobility by altering lifestyle/living arrangements Review Hip Fracture Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 13.4 Multiple Sclerosis Overview Multiple sclerosis (MS) ( chronic demyelinating neurologic disease of the CNS associated with abnormal immune response to an environmental factor Manifestations vary according to area of CNS affected Characterized by periods of exacerbation when manifestations are highly pronounced followed by periods of remission Pathophysiology and etiology Myelin sheath ( fatty, segmented wrappings that normally protect and insulate nerve fibers, increase the speed of transmission of nerve impulses In MS ( myelin sheaths of the white matter of spinal cord, brain, and optic nerve destroyed in patches, called plaques, along the axon Both plaques and diffuse lesions form as demyelinating lesions Etiology Generally categorized as an autoimmune disorder Triggers are unknown, but links have been found to environmental, infectious, and genetic factors Risk factors Onset usually 2040 years of age Women are twice as likely as men to develop MS Primarily people of northern European ancestry ( occurs in all races Smoking increases risk of MS Clinical manifestations Depend on the location and severity of damage No two clients will present with the same symptoms Symptoms may be persistent, go into remission, or become exacerbated Common symptoms include Fatigue Paresthesia Lack of coordination and balance Unsteady gait Tremors Bladder and bowel dysfunction Visual disturbances Dizziness Sexual dysfunction Pain Cognitive dysfunction Depression and anxiety Muscle spasticity or weakness in one or more limbs See MULTISYSTEM EFFECTS OF MULTIPLE SCLEROSIS, p. 878 Four classifications ( see Box 13-7 CLASSIFICATION OF MS, p. 877 Relapsing-remitting ( most individuals with MS present with this type Primary progressive Secondary progressive Progressive-relapsing Various stressors suggested as triggers ( can also cause relapse of manifestations Lifespan and cultural considerations Children ( 2 5 of individuals with MS experience symptoms prior to age 18 Diagnosis is more challenging in children than in adults Pregnancy considerations ( MS does not affect ability to become pregnant or affect the course of the disease, but medications taken for MS may be harmful to the fetus Cultural differences Whites more susceptible to MS Blacks with MS tend to be older and have more symptoms, especially optic nerve and spinal cord Hispanics usually younger than Whites at age of diagnosis Collaboration Management varies with severity of manifestations Focus on retaining optimal level of functioning Rehabilitation is cornerstone of interdisciplinary approach to treatment Multiple clinicians are needed ( neurologists, immunologists, urologists, ophthalmologists, etc. Diagnostic tests MRI with findings of lesions is most definitive test available Lumbar puncture for CSF analysis Evoked response testing of visual, auditory, or somatosensory impulses may show delayed conduction Blood tests to rule out other infectious or inflammatory diseases Surgery Not a common treatment for MS Sometimes use for specific symptoms such as pain or spasticity Pharmacologic therapy Medication is mainstay of treatment for MS See Box 13-6 MEDICATIONS FOR SYMPTOMS OF MS, p. 881 Medications slow progression, decrease number of attacks Beta interferons Glatiramer Fingolimod Natalizumab Mitoxantrone Dimethyl fumarate Baclofen Nonpharmacologic therapy Physical therapyOccupational therapy Speech/language therapy Cognitive therapy Vocational rehabilitation Maintaining healthy lifestyle See CLINICAL MANIFESTATIONS AND THERAPIES Multiple Sclerosis, p. 882 Nursing process Assessment Health history Physical assessment Diagnosis May have variety of nursing diagnoses depending on the location of myelin damage Impaired Physical Mobility Functional Urinary Incontinence Constipation Fatigue Bathing Self-Care Deficit Hopelessness Disturbed Body Image Caregiver Role Strain Ineffective Role Performance Sexual Dysfunction Ineffective Coping Planning Client will participate in PT, OT, and exercise program Client will state methods to reduce urinary incontinence Client will verbalize understanding of methods to prevent and treat constipation Client will receive 8 hours of sleep per night and rest as needed during the day Client will demonstrate maximum independence in ADLs Client will receive psychological counseling as needed Client will adapt to debilitating symptoms and participate in programs to regain maximal function Caregiver will receive help from home health agency, family, friends Client will participate in vocational rehabilitation Client and partner will verbalize awareness of means to achieve sexual satisfaction and intimacy Client will verbalize understanding of coping techniques Implementation Promote independent mobility Assess for ambulation ability and home safety Help client remain independently mobile for as long as possible Encourage exercise, use of assistive devices Promote self-care Assess extent of clients self-care deficit Help client maintain independence in ADLs Suggest adaptive devices such as arm and wrist braces as needed Teach to use assistive devices to modify food consistency, eat when energy level high Teach interventions related to altered bowel and bladder function Assess emotional status At every visit, assess Depression, anxiety, hopelessness Use and effectiveness of coping mechanisms Stress levels Interference of symptoms with relationships, especially with partner and children Adequate social interaction Feelings of inadequacy in performing home and work responsibilities Changes in self-image Feelings of being a burden to caregivers Facilitate referrals for collaborative care Help integrate care from multiple providers Evaluation Assess for disease exacerbation Client adapts lifestyle to reduce fatigue Client uses assistive devices to optimize autonomy Review Multiple Sclerosis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 13.5 Osteoarthritis Overview Osteoarthritis (OA), a degenerative joint disease ( leading cause of pain, disability in older adults Most common form of arthritis, affecting over 50 million in U.S. Pathophysiology and etiology Characterized by progressive erosion of joint articular cartilage with formation of new bone in the joint space Normal joint cartilage covers the joint and bone ends, provides a cushioning structure to reduce the mechanical force of the joint As cartilage deteriorates ( subchondral bone cells hypertrophy ( eventually cause bony spurs (osteophytes) Etiology Primary, idiopathic ( no single clear cause Secondary arthritis ( underlying condition ( trauma, bone disease, inflammatory joint disease Risk factors Idiopathic OA associated with increasing age Excessive weight contributes to development of OA ( especially in hip and knee Other risk factors linked to OA ( hormonal factors Prevention Maintain ideal body weight Participate regularly in moderate exercise program Use good posture and proper body mechanics Clinical manifestations Symptoms Onset of OA usually gradual, insidious Pain, stiffness in one or more joints Pain is usually worsened with activity and relieved with rest Pain may be associated with prolonger inactivity, such as sleeping at night Other symptoms include tenderness to touch, swelling, crackling or grating, bone spurs, decreased range of motion Complications More complications as condition worsens Joint pain and degeneration, stiffness, unsteady gait, and effects of medication increase risk of falling Decreased ability to perform ADLs Anxiety, depression, feelings of helplessness Collaboration Requires a multidisciplinary team No treatment available to stop progression Learning to live with chronic disease ( attain best quality of life Early treatment ( significantly affect outcomes, improve overall quality of life Diagnostic tests Diagnosis of OA based on history, physical examination, x-rays Characteristic changes of OA visible in x-ray studies Blood tests used to rule out other causes of joint pain Surgery Arthroscopy ( arthroscope inserted into joint for diagnosis and treatment Often combined with joint irrigation Joint resurfacing ( small amount of bone is removed and a metal replacement is inserted Performed instead of total joint replacement in younger clients Osteotomy ( incision into bone Performed to realign an affected joint Joint fusion ( permanently fuses together two or more bones Joint arthroplasty ( reconstruction or replacement of joint Indicated when client has severely restricted joint mobility and pain at rest Damaged joint surfaces are removed and replaced with plastic, metal, or ceramic prostheses Artificial joints last 15 20 years Hip and knee replacements are most common Pharmacologic therapy Analgesics Aspirin Acetaminophen ( preferred for older clients because of fewer side effects NSAIDs Topicals Counterirritants Salicylates Capsaicin NSAID cyclooxygenase-2 (COX-2) inhibitors Nonpharmacologic therapy Heat and cold application Weight reduction to decrease stress on joints Exercise to relieve pain and stiffness General and specific rest as needed to control symptoms Use of canes, crutches, walkers to protect joints Use of assistive technology to help with functional ability Complementary and alternative therapy Acupuncture Massage therapy Tai chi and yoga Stem cell therapy is being studied See CLINICAL MANIFESTATIONS AND THERAPIES Osteoarthritis, p. 892 Nursing process Assessment Health history Physical assessment Diagnosis Chronic Pain Impaired Physical Mobility Sedentary Lifestyle Imbalanced Nutrition More Than Body Requirements Dressing Self-Care Deficit Planning Client will articulate strategies for reducing pain Client will verbalize understanding of the need to rest when pain worsens during physical activity Client will maintain maximum ROM of involved joints Client will begin mild exercise program Client will enroll in nutritional counseling or weight loss program Client will use assistive devices to maintain autonomy in performing ADLs Implementation Promote comfort Monitor level of pain, including intensity, location, quality, aggravating, relieving factors Teach client to take prescribed analgesic, anti-inflammatory medication as needed Encourage rest of painful joints Suggest applying heat to painful joints using the shower Emphasize importance of proper posture and good body mechanics Encourage overweight client to lose weight Encourage the use of nonpharmacologic pain relief measures Optimize physical mobility Assess ROM of affected joints Perform functional mobility assessment Teach active and passive ROM exercises as well as isometric, progressive resistance, low-impact aerobic exercises Promote balanced nutrition Encourage weight loss be decreasing calorie intake and increasing exercise Suggest weight loss support group Evaluation Client maintains autonomy in performing ADLs Clients lifestyle is not significantly affected by OA Client reports pain control adequate to allow for rest and sleep Review Osteoarthritis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 13.6 Parkinson Disease Overview Parkinson disease (PD) ( progressive, neurologic disease characterized by tremors, muscle rigidity, bradykinesia Pathophysiology and etiology Dopamine ( brain neurotransmitter that regulates voluntary movement, reward-seeking behavior, memory and learning, attention, sleep, affect, and other functions In PD ( neurons in cerebral cortex are lost, dopaminergic nigrostriatal pathway degenerated ( number of specific dopamine receptors in the basal ganglia decrease Lewy bodies ( abnormal aggregates of proteins in neurons Usual balance disrupted( dopamine no longer inhibits acetylcholine Etiology Exact cause unknown May be a combination of genetic susceptibility and exposure to environmental factors or toxins Some cases appear to be hereditary but most are sporadic Risk factors Risk increases dramatically with age Men have greater risk than women 15 25 of those with PD have a relative with PD Prevention No definitive prevention Suggestions include eating a healthy diet, avoiding herbicides and pesticides, consuming moderate amounts of caffeine and green tea, taking nutritional supplements Clinical manifestations Symptoms are mild at the beginning and progressively worsen over time Motor symptoms Tremor ( trembling Usually first manifestation experienced One of upper extremities usually affected first Most prominent when individual is at rest Pill-rolling motion of thumb and fingers Trembling of both hands, arms, legs, jaw, and face may occur as disease progresses Rigidity ( resistance to movement Occurs because of involuntary contraction of skeletal muscles Makes active, passive movement difficult Cogwheel rigidity Stiffness, heaviness, aching in muscles Bradykinesia ( slowed movement Difficulty starting, continuing, or coordinating movements ( most common and crippling manifestations Makes ADLs difficult to accomplish Staring gaze with minimal change in expression Difficulty with speech, swallowing, chewing Postural instability ( stooped posture that leads to balance problems Loss of normal postural reflexes Involuntary flexion of head and shoulders Cannot maintain upright position Disorders of equilibrium ( increasing risk of injury from falls Parkinsonian gait Festination Freezing Nonmotor symptoms Cognitive deficits Usually begins with slowed thinking May also develop confusion, memory loss, and eventually dementia Emotional changes Depression Fear Anxiety Panic attacks Social withdrawal and apathy Sleep problems Insomnia Daytime sleep attacks Restless leg syndrome Frequent awakening at night Parkinsonism Individuals with the combination of motor symptoms typically seen in PD are said to have parkinsonism Not everyone with parkinsonism has PD Parkinsonism can result from medications, head trauma, other neurodegenerative disorders Lifespan and cultural considerations 5 10 of individuals with PD have early onset or young onset PD, which begins before age 50 Early-onset PD shares many clinical manifestations with PD but with a slower disease progression and lower rate of dementia Juvenile PD is rare Diagnosed before age 20 Usually begins with dystonia and bradykinesia Most commonly seen in Japan and often runs in families See CLINICAL MANIFESTATIONS AND THERAPIES Parkinson Disease, p. 902 Collaboration Diagnostic tests New test approved by FDA ( DaTscan MRI Blood tests Surgery( reserved for clients with advanced PD Deep brain stimulation Pallidotomy and thalamotomy Pharmacologic therapy See MEDICATIONS Parkinson Disease Motor Symptoms, p. 899 Levodopa Dopamine agonists Dopamine modifiers Other medications Anticholinergics Antivirals Drugs for nonmotor symptoms Antidepressants Anxiolytics Atypical antipsychotics Nonpharmacologic therapy Exercise Physical, occupation, and speech/language therapy Nursing process Assessment Health history including History of brain disorders or trauma Exposure to environmental toxins Medication and drug use Family history of PD Physical assessment Follow Unified Parkinsons Disease Rating Scale Revised scale, MDS-UPDRS Diagnosis Risks for Falls Impaired Physical Mobility Feeding Self-Care Deficit Impaired Swallowing Disturbed Sleep Pattern Impaired Verbal Communication Impaired Urinary Elimination Constipation Fear Impaired Memory Caregiver Role Strain Planning Client will remain free from injury Client will demonstrate progressive improvement on scores for 6-minute walk test Client will participate in daily exercise program Client will participate in PT, OT, SLT Client will maintain autonomy as long as possible Client will employ strategies to promote communication Client will maintain adequate nutrition and fluid intake Client will demonstrate normal urinary and bowel elimination Client will get adequate sleep and rest Client will use positive coping skills to reduce anxiety Implementation Holistic consideration of clients needs ( psychosocial as well as physical needs Prevent injury Safety is a priority Teach use of assistive devices Optimize mobility Encourage clients to walk daily and participate in exercise program Suggest referral to a PT program to develop an individualized exercise program Request that the PT teach caregivers how to do ROM at least twice a day Recommend assistive devices such as lift chairs, canes, splints, braces as indicated Promote independence Encourage clients to take adequate time to perform ADLs Encourage use of assistive devices for ADLs, hygiene activities, maintaining house Provide oral and written information about vocal training and good sleep hygiene Refer to specialists as necessary Determine which ADLs are causing the most difficulty, and design therapies to assist independence Evaluation Client is able to communicate effectively Client maintains optimal and realistic levels of autonomy in performing ADLs Client avoids injury Client maintains adequate nutritional status Review Parkinson Disease Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 13.7 Spinal Cord Injury Overview Spinal cord injury (SCI) (usually results from trauma 12,000 new causes each year in the U.S. Pathophysiology and etiology Spinal cord provides two-way pathway for conduction of impulses and information two and from brain and body, serves as major reflex center, involved in sensory and motor innervation of entire body below the head Ascending pathways carry sensory information Descending pathways carry motor information Pyramidal tracts control skilled voluntary movements Extrapyramidal tracts bring about other body movements When spinal cord injured ( primary injury causes microscopic hemorrhages in gray matter of cord, edema of white matter of cord Microcirculation to cord impaired by edema, hemorrhage When ischemia prolonged ( necrosis of gray and white matter begins within hours Tissue repair occurs over period of 34 weeks ( phagocytes enter area in 3648 hours after initial injury Etiology Result from application of excessive force to spinal column ( accelerationdeceleration forces Hyperflexion ( forcible forward bending Hyperextension ( forcible backward bending Axial loading ( form of compression Rotational injuries ( lateral flexion or twisting Transection ( from gunshot, stabbing that severs spinal cord Common causes Motor vehicle crashes Falling Violence Alcohol Risk factors Age ( 16 - 30 Gender ( males four times more likely to sustain SCI Risky behavior Older adults ( falls Prevention Drive safely using seatbelts, child safety seats Do not drink and drive Do not dive into shallow water Wear proper safety gear when participating in sports Take precautions to prevent falls Clinical manifestations Both level of injury and specific area of spinal cord or spinal nerve that is damaged will determine extent and manifestations of injury All systems below the level of injury will be affected Emergency signs and symptoms include Extreme pain or pressure in the back or neck Weakness Paralysis or lack of sensation in any part of the body Loss of bowel or bladder control Impaired breathing Oddly positioned or twisted back or neck Muscle spasms Half of individuals with SCI develop spinal shock Classification of spinal cord injury Complete ( irreversible ( loss of sensory, motor, autonomic function below level of injury Incomplete ( varying degrees of sensor, motor, autonomic function below level of injury Central cord syndrome Anterior cord syndrome Brown-Sequard syndrome Conus medullaris syndrome Effects of SCI throughout the body Tetraplegia ( paralysis of the upper and lower limbs and trunk usually associated with cervical injury Paraplegia ( paralysis of all or part of the trunk, legs, and pelvic organs usually associated with injury in thoracic or lumbar regions Pain due to neurogenic or physiological causes Urinary and bowel problems ( nerves that innervate the muscles no longer transmit signals properly Loss of control of respiratory muscles ( in those with complete thoracic or cervical injury Cardiovascular problems ( cervical injuries Reproductive problems Complications Cardiovascular system Autonomic dysreflexia DVT Respiratory system Decreased lung capacity Increased respiratory congestion Integumentary system Temporary or permanent loss of mobility High risk for developing pressure sores Lose sensory perception to pain, touch, temperature Urinary system Indwelling or permanent catheter Risk for UTI, kidney or bladder stones Emotional changes Process of grief Lifespan and cultural considerations Children ( not common, tend to have better neurological recovery after SCI compared to adults Pregnancy ( pregnant women with SCI need special care Work closely with healthcare team to prevent complications and prepare for labor and delivery Work with new mothers on breastfeeding issues Collaboration Emergency care All clients with trauma to head or unconsciousness should be treated as if they have an SCI Initial care ( maintaining ability to breathe, preventing further movement that could cause more damage, preventing shock Immediate medical care ( immobilize spine, and transport client to hospital Diagnostic tests X-ray studies CT MRI Myelogram with contrast dye Somatosensory evoked potentials (SSEP) Arterial blood gases (ABGs) Surgery Early vs late decompression ( controversial Stabilize, support spine Bone graft Halo brace Pharmacologic therapy Symptomatic ( decreasing edema from injury, treating hypotension, bradycardia, treating spasticity High-dose methylprednisone within 8 hours of injury Anticoagulants may be given Antibiotics for pneumonia Nonpharmacologic therapy Promote effective ventilation Prevent complications Facilitate rehabilitative and home-based care Nursing process Assessment Health history Time, location, type of event, pain, Physical examination Diagnosis Ineffective Airway Clearance Risk for Aspiration Impaired Physical Mobility Risk for Autonomic Dysreflexia Acute Pain Ineffective Breathing Pattern Urinary Retention Bowel Incontinence Self-Care Deficit Risk for Post-Trauma Syndrome Planning Client will maintain patent airway Client will participate in OT and SLT Client will remain free of complications such as pressure ulcers and contractions Client will maintain clear breath sounds and deny dyspnea Client will verbalize understanding of potential triggers of autonomic dysreflexia Client will participate in PT Client will verbalize adequate pain control Client will maintain adequate nutrition Client will regain bowel and bladder control Client will achieve maximum self-care Client and family will adapt to disability Implementation Manage emergent and urgent problems Immobilizing spine Monitoring vital signs Provide assistance with ADLs Self-care activities Perform respiratory and neurological assessments regularly Help with ROM exercises, turning client, keeping equipment clean Facilitate rehabilitation Once injuries have healed, clients begin aggressive rehabilitation Provide emotional support Perform periodic neurological assessments Bowel and bladder training Evaluation Client attains appropriate bowel and bladder elimination habits Client maintains healthy nutritional status Client optimizes remaining motor and sensory function Client and family accept limitations of disability Caregiver finds adequate support to reduce role strain Review Spinal Cord Injury Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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