Unit 8: Impaired Physical Mobility Class Notes April 23, 2012 Mobility health problems o Spinal cord Herniated

ed nucleus pulposus o Simple trauma Fractures Carpal tunnel o Arthritis Rheumatoid arthritis Osteoarthritis o Metabolic disorders Osteomalacia Pagets disease Gout o Connective tissue disorders SLE Systemic sclerosis o Infectious disorder Lyme disease Low back pain: herniated nucleus pulposus o Displacemtn of intervertebral disc o Biomechanical origin of back pain o Most common area: lumbar 2nd most common: cervical o Lumbar: Assessment: Previous back injury? Repeated stress? Symptoms: Pain: sciatica (largest nerve) o Begins in lower back to butt to thigh to lower leg o May also involve sacral nerves S2: controls bladder function can lead to incontinence or retention Parasthesia Possible loss of bladder control Decreased muscle tone and strength o Cervical Arm weakness, pain, or numbness Neck pain Pain that radiates to the shoulder, upper arm or forearm o Diagnostics

Bone x-rays Bone myogram? (EMG) o Medical management Pharmacologic Muscle relaxants NSAIDs Epidural injection of steroids Opioids: appropriate? Risk of dependence is very high Positioning Exercises, PT Heat/ice o Surgical management Depend on degree of herniation Reserved for those who do not respond to non-surgical treatment Prefer to have neurosurgeon perform cervical surgery instead of orthopedic Percutaneous laser disk decompression Diskectomy Decompressive laminectomy Spinal fusion/arthodesis o Nursing diagnoses Knowledge deficit r/t surgery and post-op care and home care Pain r/t tissue trauma secondary to incision Impaired physical mobility Altered urinary elimination (lumbar) Anatomy and physiology review o Structure of bone Cortex Haversian system Medulla Marrow Periosteum Osteoblasts: build new bone Osteoclasts: destroy existing bone, resorption Approximately equal until mid 30s Can lead to osteoporosis over time o Minerals and hormones Calcium: most abundant mineral in body, 99% in bones, 1% in serum, muscle and nerve transmission, maintain constant level by using bone Absorbed in intestines Phosphorus

o Joints Synovial Bursae o Muscle Skeletal o Ligaments o Tendons o Range of motion Normal aging process o Decreased bone density o Decreased elasticity o Decreased muscle mass and strength o Degenerative changes in spine o Degenerative changes in cartilage o Slower movement o DECLINE RELATED TO LEVEL OF ACTIVITY Assessment o Subjective Pain acute or chronic? Altered sensations Past injuries (even ones from decades ago) Alterations in bones, joints, muscles Risk factors: Weight, occupation, sports, disease Chronic fatigue Psychosocial/lifestyle Comorbidity: tobacco use, diabetes, etc. Prescription medications: ex. Corticosteroids Dietary assessment: calcium deficient? Protein? o Objective General appearance: gross deformities or asymmetry Posture: scoliosis (S shape), lordosis (pregnancy, obesity), kyphosis (angular) Gait: parkisonian (shuffling), waddling (Pagets disease)

Vitamin D: activated by PTH, required to absorb calcium, obtained via sunlight or supplement, deficiency triggers increased release of PTH Calcitonin: decreases bone resorption, helps kidneys to excrete calcium, supplement via nasal spray Parathyroid hormone (PTH): release triggers increased activity of osteoclasts to allow more calcium into serum, blocks the resorption of phosphate in the kidney Estrogen: inhibits PTH activity, stimulates osteoblasts to build bone

Muscles: symmetry, contractures Joint function: ROM, terms used to describe include contracture, inflammation, effusion, crepitus Lovitt? Scale: used by PT to assess strength against resistance Muscle strength and size (bilaterally): degree of atrophy and grading of strength o Diagnostic testing Serum CBC: infection? Alkaline phosphatase (ALP): elevated in osteoblast activity, seen with some cancers Calcium Phosphorus Rheumatoid factor (RF): proteins that are produced by immune system that attack normal healthy tissue Antinuclear antibody (ANA): screening test for Lupus or scleraderma, either positive or negative Sedimentation rate (ESR): elevated=increased inflammation Uric acid: breakdown of purines found in organ meats, shellfish, etc. Bone densitometry (DEXA): very low radiation scan, gold standard to assessing bone density CT, MRI: details of joints, soft tissue, complicated bony structures Arthrocentesis: invasive, sample of synovial fluid is aspirated from joint capsule, used to diagnose infections, gout Arthroscopy: invasive, fibroptic scope inserted into joint, must be able to bend joint (e.g. knee) 40 degrees in order to perform Nursing implications/care o Assess peripheral pulses o Color, motion, sensations in extremity Complications o Infection o Hemorrhage Rheumatoid arthritis REVIEW o Connective tissue disease (CTD) o Chronic, SYSTEMIC, INFLAMMATORY, BILATERAL synovium of the joints o Autoimmune response of connective tissue o May include other organs such as the heart, lungs, and blood vessels o Characterized by remissions and exacerbations o Is PROGRESSIVE in nature Goal is to delay progression and maintain function o Pathophys Antigen-antibody reaction

Synovitis Phagocytosis Breakdown of cartilage Pannus forms: causes bone to further erode Bone erosion occurs Loss of joint motion, decreased elasticity of muscles o Assessment Bilateral and symmetric Pain, warmth, red, stiff, swollen (worse in AM) Fever, weight loss, fatigue, lymphadenopathy Joint deformities: Boutonniere (proximal interphalangeal joint flexes, results in distal hyperextension) Positive rheumatoid factor, +ANA, elevated ESR o Pharmacologic interventions Salicylates (ASA): if able to tolerate NSAIDs/COX-2 inhibitors: inhibit prostaglandin formation Disease modifying antirheumatic drugs Steroids (glucocorticoids) Biologic response modifiers Side effects: GI effects Liver toxicity Bone marrow suppression Dermatitis o Interventions Pain management Rest and exercise Physical therapy Diet Assistive devices o Surgical interventions: joint replacement Osteoarthritis o Degenerative joint disease (DJD) NOT systemic and NOT inflammatory o Localized changes in synovial joints results in damage to bone particularly in large, weight bearing joints (hip, knee), the spine, and hands o Risk factors Age > 60 Genetic predisposition Gender: greater in females Obesity

Excessive use/mechanical injury o Patho Breakdown of cartilage Joint space narrows and ends of bone rub together Bony spurs form Synovial inflammation Joint immobility, joint pain, muscle spasms o Assessment Early signs: pain that increases with activity, but is relieved with rest Stiffness, crepitus (grating sound) Limited ROM stiffness Rarely is joint inflamed or hot to touch; will be enlarged Herberdens nodes within the joint (DIP joint) Bouchards nodes (PIP joint) o Medical interventions Heat Joint rest Physical therapy/orthotic devices Weight reduction Pharmacologic: NSAIDs, Tylenol, muscle relaxers (Flexeril) o Surgical interventions Viscosupplementation: injections into joints, e.g. pig fat, relieves pain Arthroscopi debridement Arthrodesis (surgical fusion) Arthroplasty: joint replacement (TKR and THR) When pain can no longer be managed with meds o Nursing diagnoses Goal: is to maintain or improve mobility and function Chronic pain Fatigue Impaired physical mobility Knowledge deficit Self-care deficits Body image disturbance Ineffective coping Joint replacement: total hip o Most common joint replaced o Preoperative preparation Informed consent Education rehab Assess for support system

IV antibiotics o Types: Minimally invasive Cemented: can be up moving sooner, less preferred Non-cemented: take longer to heal Laminar airflow in surgery o Postoperative client care Prevention of dislocation Abduction pillow: maintain abduction, avoid adduction o Pillow between legs to prevent crossing Prevention of infection Prevention of thromboembolic complications (DVT) Assessment of bleeding/incisional drainage Prevention of anemia Pain management PCA Physical therapy/progressive activity walker o Hip precautions following THR No crossing legs Knees always lower than hips Abduction pillow Ankle pumps Joint replacement: total knee o Preoperative care: same as THR o Postoperative care Heat/ice device Pain management Neurovascular assessment Physical therapy Continuous passive motion (CPM) machine Complications of immobility o Venous stasis o Inability to cough/expectorate secretions o Increased risk for pulmonary infection o Urinary stasis o Decrease in bone and muscle strength o Constipation o Pressure ulcer development Metabolic disorders: osteomalacia (adult rickets) o Softening of the bone that is reversible o Etiology: insufficient dietary intake of vitamin D, lack of sun exposure, malabsorption of vit D

Patho: reduced Ca++ absorption results in hypocalcemia. Hypocalcemia stimulates PTH release which promotes Ca++ resorption from bone. Bones become soft and results in skeletal deformities o Assessment: Ask about dietary intake of vit D Exposure to sun? Back pain? (may indicate fx) Waddling gait Knyphosis Bow legged X-rays with Loosers lines o Interventions Vit D replacement Ages 19-50 = 600 IU daily Ages 51-70 600 IU daily > 70 = 800 IU daily Increase sun exposure o Complications Fractures Bone deformities Pagets Disease o Chronic condition with increased bone resorption and excessive bone formation (with bone that is abnormal) o Patho: unknown o 3 phases: Osteolytic: increased osteoclast activity Mixed: osteoblasts make new bone but it is abnormal Inactive: the new bone becomes sclerosed o Assessment Asymptomatic Bone pain, joint pain, stiffness Skeletal deformity (bowing) Elevated ALP, uric acid, phosphorus levels X-rays show enlarged bone mass o Interventions Pharmacologic NSAIDs Calcitonin ***Alenronate (Fosamax): biphosphonates, drug of choice Surgical: THR

TKR Complications Pathologic fxs Osteoarthritis Skeletal deformity Osteogenic sarcoma

Gout o

o o

SYSTEMIC disease involving overproduction or decreased excretion of uric acid Pain and inflammation results from deposits of urate crystals Characterized by remission and exacerbations Etiology: Primary: uric acid production exceeds excretion Secondary: hyperuricemia secondary to another disease/condition Patho Hyperuricemia Urate crystals (salts) unable to be excreted Deposits of urate salts form: Tophi: deposits of uric crystals in joints or cartilage, appear yellowwhite, can open and drain chalky-white substance Renal calculi: tophi in the kidneys Urate crystals cause inflammation; spikes are pointed and sharp More common in men Acute: PAIN: abrupt, occurs often at night, often in the great toe Erythema, edema, warmth Duration: 2-10 days Colchicines: Decreases uric acid deposits Take until inflammation subsides can cause diarrhea Take at first signs of an attack Administer with food Must stop taking if diarrhea develops NSAIDs corticosteroids Chronic Repeated attacks Deposits of tophi Joint enlargement Renal calculi Uric acid levels > 8.5 mg/dL Elevated WBC, ESR

Arthrocentesis: presence of crystals Allopurinol (Zyloprim) Prevents conversion of xanthine to uric acid Probenecid (Benemid) Increases urinary excretion of uric acid Interacts with ASA (effect decreased) o **FOR BOTH ACUTE AND CHRONIC INCREASE FLUIDS TO 3 L/DAY* o Interventions Use medications early in course of attack Bedrest and/or immobilize joint Use bed cradle to keep sheets off toe Elevate extremity Use cold for pain relief Diet management: restrict/limit high purine content foods; avoid alcohol Stress management o Complications: renal calculi and osteoarthritis Systemic Lupus Erythematosus (SLE) o 2 types: Systemic: is a chronic, progressive, inflammatory disease of connective tissue throughout the body Discoid: typically affects only the skin (90% of the time) o Lupus is an autoimmune disease Characterized by remissions and exacerbations o Women > men; African American race o Ages 15-40 (childbearing years) o *NUMBER ONE CAUSE OF DEATH: KIDNEY FAILURE* o Clinical manifestations Skin: red butterfly facial rash; Discoid: coin like lesions that scar Worsens with sun exposure M/S: myalgia, polyarthritis Joint pain, stiffness, swelling Renal: nephritis Pulmonary: pleural effusions C/V: pericarditis, vasculitits, Raynauds phenomenon (vascular spasms of arterioles in reaction to cold) Neuro: peripheral neuropathy Fever and fatigue (especially during flare) o Diagnosed mostly by observation of at least 4 characteristic symptoms Mimics scleroderma Antinuclear antibodies (ANA) will be +

CBC pancytopenia Erythrocyte sedimentation rate (ESR) will be elevated Serum complement (C3 and C4) elevated o Biopsy Skin for discoid Kidney for the presence of nephritis o Treatment/interventions Pharamacologic Corticosteroids (prednisone, Solu Medrol) Antimalarial (Plaquenil) Immunosuppressants (methotrexate) Lifestyle Avoid sunlight Skin care Hair care Support groups Scleroderma o Chronic progressive connective tissue disease o May be first diagnosed as lupus, as the diseases share characteristics BUT does NOT produce a rash o Progression includes inflammation, fibrosis, sclerosis (abnormal hardening of skin as well as other body systems) o Autoimmune o Women > men (4:1); age of onset 30-50 years o CREST Calcinosis: calcium deposits in the skin Raynauds phenomenon: spasm of blood vessels in response to cold or stress Esophageal dysfunction: acid reflux and decrease in motility of esophagus, causes weight loss Scleodactyly: thickening and tightening of the skin on the fingers and hands, manifests as thin red lines on skin with limited mobility Telegiectasias: dilation of capillaries causing red marks on surface of skin o Nursing management/nursing diagnoses: Administer steroids and immunosuppressantss Acute pain r/t vasospasm Temperature control; stress management Impaired skin integrity r/t inflammatory process Use mild soap Inspect skin daily High risk for aspiration Elevate HOB 1-2 hours after eating

Histamine blockers to decrease acid Avoid spicy foods, alcohol, caffeine o Major cause of death attributed to renal failure o Decreased responsiveness to steroids when compared to lupus Lyme disease o Named after Lyme, CT o Infectious disease caused by the bite of an infected deer tick o Small, young nymph ticks more likely to pass on spirochete o Tick, in order to pass on illness, must remain on person for 24-48 hours o 3 stages: Stage 1: flu-like symptoms; muscle and joint pain, bulls eye rash Chills, fever, myalgia, H/A, localized infection Stage 2: carditis, CNS problems Palsy, similar to bells palsy, muscle weakness Stage 3: chronic arthritis, late disseminated, months to years after initial bite Numbness, tingling, o Western blot antibody assay most reliable blood test o Treatment is with antibiotics: oral doxycycline, or Amoxicillin (early), or Rocephin and Penicillin G IV if treatment if begun later o Diagnosis based on history: woods? Area where it is pandemic? o Prevention is KEY Walk outside away from tall grass and bushes Wear a long sleeved shirt and long pants tucked into socks/boots Use tick repellent Wear light colored clothes (makes it easier to see ticks) Wear a hat Perform a body check after being outdoors especially in areas known to have Lyme/ticks Inspect your pets that may carry ticks into the house