Musculoskeletal Function

On completion of this chapter, the reader will be able to:

1. Describe the normal structure and function of the musculoskeletal system.

2. Discuss the age-related changes in the musculoskeletal system.

3. Discuss the nursing management of clients with fractures of the hip, wrist, clavicle, and vertebra.

4. Distinguish differences among osteoarthritis, rheumatoid arthritis, gout, and polymyalgia rheumatica.

5. Identify the nursing interventions associated with osteoarthritis, rheumatoid arthritis, gout, and polymyalgia rheumatica.

6. Discuss the pathophysiology, treatment, and nursing management of osteoporosis.

7. Describe the indications for amputation in older adults and the nursing management of these clients.

8. Discuss the causes and management of common foot problems in older adults.

http://evolve.elsevier.com/Meiner/gerontologic

Previous authors: Karen Van Dyke Lamb, BS, MS, ND, CS; Marilyn Cummings, MS, RN; and Sue E. Meiner, EdD, APRN, BC, GNP

Musculoskeletal problems are common among older adults. The Administration on Aging (2008) found that 40% of older adults living in the community are given diagnoses of arthritis, and 17% report having other chronic problems of the musculoskeletal system. Complaints in the musculoskeletal system are common because normal aging predisposes people to the development of diseases such as osteoarthritis and osteoporosis. Diseases of the musculoskeletal system are usually not fatal but can lead to chronic pain and disability. Chronic conditions of the musculoskeletal system may contribute to impaired function and disability in older adults in the areas of self-care and mobility. They may suffer impairments in the ability to perform activities of daily living (ADLs), such as bathing, dressing, and eating, and impairments in the ability to perform instrumental activities of daily living (IADLs), such as managing finances, preparing food, managing transportation, and keeping house. Functional impairment of ADLs and IADLs can be devastating to older adults who desire to maintain independence. When dependence occurs, it can result in loss of self-esteem, the perception of decreased quality of life, and depression (see Cultural Awareness Box) (Netz, Wu, Becker, & Tenenbaum, 2005).

Age-Related Changes in Structure and Function

The musculoskeletal system is affected in numerous ways by the aging process. A pronounced decrease in muscle mass and muscle strength occurs gradually over time. The actual number of muscle cells decreases, and they are replaced by fibrous connective tissue. As a result, muscle mass, tone, and strength decrease. The elasticity of ligaments, tendons, and cartilage decreases, as does bone mass, which results in weaker bones. The intervertebral disks lose water, causing a narrowing of the vertebral space. This shrinkage may result in a loss of 1.5 to 3 inches of height. The lordotic or convex curve of the back flattens, and both flexion and extension of the lower back are decreased. Posture and gait change. Posture, as a result of the changes in the spine, assumes a position of flexion. Changes in posture result in a shift in the center of gravity. In men, the gait becomes small stepped with a wider-based stance. Women become bow-legged, with a narrow standing base, and walk with a waddling gait. The articular cartilage erodes in older adults. It is unknown whether this is a direct result of the aging process or the result of wear and tear on the joints.

All the changes mentioned may cause pain, impaired mobility, self-care deficits, and increased risk of falls for older adults. Approximately one third of those age 65 or older have falls each year. About 2% of this group is hospitalized as a result of injuries

CULTURAL AWARENESS

Biocultural Variations in the Musculoskeletal System

BONE	REMARKS
Frontal	Thicker in black men than white men
Parietal/occipital Palate	Thicker in white men than in black men; occipital protuberance palpable in Eskimos Tori (protuberances) along suture line of hard palate, which is problematic for denture wearers Incidence: Blacks: 0% Whites: 24% Asian Americans: up to 50% Native Americans: up to 50%
Mandible	Tori (protuberances) on lingual surface of mandible near canine and premolar teeth, which is problematic for denture wearers Most common in Asian Americans and Native Americans; exceeds 50% in some Eskimo groups
Humerus	Torsion or rotation of proximal end with muscle pull Larger in whites than in blacks Torsion in blacks is symmetric; torsion in whites usually greater on right side than on left
Radius/ulna	Length at wrist variable Ulna or radius may be longer Equal length: Swedish: 61% Chinese: 16% Ulna longer than radius: Swedish: 16% Chinese: 48%
	Radius longer than ulna: Swedish: 23% Chinese: 10%
Vertebrae	24 vertebrae found in 85% to 93% of all people; racial and gender differences reveal 23 or 25 vertebrae in select groups (23 vertebrae in 11% of black women; 25 vertebrae in 12% of Eskimo and Native American men) Related to lower back pain and lordosis
Femur	Convex anterior: Native Americans Straight: blacks Intermediate: whites
Pelvis	Hip width 1.6 cm (0.6 in.) smaller in black women than in white women; Asian American women have significantly smaller pelvises
Second tarsal	Second toe longer than great toe Incidence: Whites: 8% to 34% Blacks: 8% to 12% Vietnamese: 31% Melanesians: 21% to 57%
Height	Clinical significance for joggers and athletes White men 1.27 cm (0.5 in.) taller than black men and 7.6 cm (2.9 in.) taller than Asian American men
	White women equal to black women Asian American women 4.14 cm (1.6 in.) shorter than white or black women
Composition of long bones	Longer, narrower, and denser in blacks than in whites; bone density in whites greater than in Chinese, Japanese, and Eskimos Osteoporosis lowest in black men; highest in white women
Peroneus tertius	Responsible for dorsiflexion of foot Muscle absent: AsianAmericans, Native Americans, and white: 3% to 10% Blacks and Berbers: 10% to 15% (Sahara desert): 24% No clinical significance because tibialis anterior also dorsiflexes the foot
Palmaris longus	Responsible for wrist flexion Muscle absent: Whites: 12% to 20% Native Americans: 2% to 12% Blacks: 5% AsianAmericans: 3% No clinical significance because three other muscles are also responsible for flexion

Data from Overfield T: Biologic variation in health and illness: race, age, and sex differences, ed 2, Boca Raton, Fla, 1995, CRC Press.

incurred during the fall (Gray-Miceli, Strumpf, Johnson,et al, 2006; American Geriatrics Society, 2001; Stevens, Corso, Finkelstein, & Miller, 2006).

It has been estimated that residents have a 50% to 75% incidence of falls in nursing homes. The mean incidence is 1.5 falls per bed per year. Falls are the most common cause of accidental death in older adults. When falls result in injury and hospitalization, the risk of iatrogenic illness and immobility can lead to a downward trajectory, which can ultimately result in death. Falls may also cause a cycle of disuse. This pattern of disuse usually occurs after the individual has experienced repeated falls. The fall experience causes a fear of falling. To avoid falls, the individual decreases mobility; with decreased mobility, muscle strength decreases, joints become stiff, and pain develops, resulting in disability, loss of independence, and frailty (Gray-Miceli et al, 2006).

Current research has documented that some of the diseases and decline in the musculoskeletal system can be decreased or prevented through the use of regular programs of active exercise and resistive muscle strengthening (Stevens et al, 2006).

Common Problems and Conditions of the Musculoskeletal System

Fractures are common problems for older adults that often result in some loss of functional ability. A fracture is a break or disruption in the continuity of the bone. Fractures may occur because of trauma to a bone or joint, or they may be the result of pathologic processes such as osteoporosis or neoplasms. When bones are subjected to more stress than can be withstood, a fracture occurs. Stresses on bones may be from major trauma such as automobile accidents or falls. Falls are the most common cause of fractures in older adults. The most frequently occurring fractures among older adults are hip fractures, fractures of the proximal femur, Colles’ (wrist) fractures, vertebral fractures, and clavicular fractures. Fractures are classified as open or closed by the location and type of fracture (Fig. 27–1).

FIG 27–1 Types of fractures. A, An avulsion is a fracture of bone resulting from a strong pulling effect of tendons or ligaments at the bone attachment. B, A comminuted fracture is a fracture with more than two fragments. The smaller fragments appear to be floating. C, A displaced (overriding) fracture involves a displaced fracture fragment that is overriding the other bone fragment. The periosteum is disrupted on both sides. D, A greenstick fracture is an incomplete fracture with one side splintered and the other side bent. The periosteum is not torn away from the bone. E, An impacted fracture is a comminuted fracture in which more than two fragments are driven into each other. F, An interarticular fracture is a fracture extending to the articular surface of the bone. G, A longitudinal fracture is an incomplete fracture in which the fracture line runs along the axis of the bone. The periosteum is not torn away from the bone. H, An oblique fracture is a fracture in which the line of the fracture extends in an oblique direction. I, A pathologic fracture is a spontaneous fracture at the site of a bone disease. J, A spiral fracture is a fracture in which the line of the fracture extends in a spiral direction along the shaft of the bone. K, A stress fracture is a fracture occurring at the site of a muscle attachment. It is caused by a sudden, violent force or repeated, prolonged stress. L, A transverse fracture is a fracture in which the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis. (From Lewis S, Heitkemper M, Dirksen S, O’Brien B: *Medical-surgical nursing: assessment and management of clinical problems*, ed 7, St Louis, 2007, Mosby.)

The completed process of bone healing is termed union. After fractures occur, regenerative cells (fibroblasts and osteoblasts) move to the fracture site and lay down a fibrous matrix of collagen—the callus. This process usually occurs within 7 days of the injury. As the healing process takes place, the callus bridges the fracture site and the distance between the bone fragments decreases. In the final stage of bone healing, remodeling (absorption of excess cells and calcification) occurs.

The history given by a client with a fracture usually includes trauma followed by immediate local pain. Tenderness, swelling, muscle spasms, deformity, bleeding, and loss of function are also seen with fractures (see Emergency Treatment Box).

Hip Fracture

Hip fractures are the most disabling type of fracture for older adults. They usually are caused by falls and result in direct trauma to the hip. Approximately 24% of clients with hip fractures die within 1 year after the injury (Wolinsky, Fitzgerald, & Stump, 1997). The complications of hip fractures are generally related

EMERGENCY TREATMENT

Fractures

If a fracture is suspected, assess injured area for the following:

If fracture is open and bleeding is present:

• Apply pressure.

• Apply sterile dressing.

• Immobilize the fracture site.

to immobility. They include pneumonia, sepsis from urinary tract infections, and pressure ulcers. With the growing number of older adults, especially those older than 75, it is expected that the incidence of hip fractures will increase.

Hip fractures are classified by their locations. Intracapsular fractures, or subcapital fractures, occur within the hip capsule. Extracapsular fractures occur outside or below the capsule and are referred to as intertrochanteric and subtrochanteric locations (Fig. 27–2).

FIG 27–2 Fractures of the hip. A, Subcapital fracture. B, Transcervical fracture. C, Impacted fracture of the base of the neck. D, Intertrochanteric fracture. E, Subtrochanteric fracture. (From Monahan FD, Neighbors M, Sands J, et al: *Phipps’ medical-surgical nursing: health and illness perspectives*, ed 8, St Louis, 2007, Mosby.)

After the fall or injury that results in the fractured hip, the client has an affected extremity that is usually externally rotated and shortened. Tenderness and severe pain at the fracture site may be present. Immediately after the injury, the joint should be immobilized. Buck’s or Russell’s traction (Fig. 27–3) is used until the client is stabilized. After the client is stabilized, surgical repair, the preferred treatment, is performed. The type of surgical repair depends on the location and type of fracture and can include internal fixation with pins, plates, and screws, or prosthetic replacement of the femoral head (Fig. 27–4).

FIG 27–3 Buck’s extension. Heel is supported off bed to prevent pressure on heel, weight hangs free of bed, and foot is well away from footboard of bed. The limb should lie parallel to the bed unless prevented, as in this case, by a slight knee flexion contracture. (From Monahan FD, Neighbors M, Sands J, et al: *Phipps’ medical-surgical nursing: health and illness perspectives*, ed 8, St Louis, 2007, Mosby.)

Nursing Management

EVIDENCE-BASED PRACTICE

Changes to Home Environment after Idenifying the Location of Home Falls

Sample/Setting

This study reviewed the falls diaries of 124 participants of a randomized controlled trial. A total of 639 falls were reviewed from the diaries over a 6-month period.

Methods

Participants were given a falls diary to maintain for 6 months with questions to complete that described the circumstances around the falls. Participants were mailed the diary each month and received phone call reminders at specific times.

Findings

A total of 124 qualifying participants recorded 639 falls. The locations of 80% of falls were in the home. When falls occurred, clients were walking (45%), standing (32%), transferring (21%), or had slipped out of bed or a chair (2%). Seventeen falls (3%) required treatment and were considered serious. Many combinations of activities were attributed to falling, such as tripping while walking or stepping backward while standing. Also identified were misjudgment, distraction, fatigue, and dizziness as reasons for falls.

Implications

Physical therapy can be specifically designed to address the reasons for an individual’s falls. Nurses caring for clients with Parkinson’s disease must be aware that falls can occur even when standing or reaching out. The home environment can be designed to accommodate reach distances and other individual needs.

From Ashburn A, Stack E, Ballinger C, Fazakarley L, Fitton C: The circumstances of falls among people with Parkinson’s disease and the use of falls diaries to facilitate reporting, Disabil Rehabil 30(16):1205–1212, 2008.

These problems can be prevented if lower initial doses of narcotics than those used with younger adults are used. The individual’s response to the pain medication and the pain are closely monitored. If low doses are tolerated, the dose may be carefully increased. Keeping the affected extremity in alignment during turning also decreases pain. This is done with the use of pillows between the knees or an abduction splint.

Clients who have their fractures repaired with hemiarthroplasty are at risk for dislocation. The nurse should give the client and family instructions on preventing dislocation. Dislocation may occur when the joint is adducted and internally rotated. Activities to avoid include crossing the legs and feet while seated, sitting on low seats, and adducting the legs when lying on the nonoperated side. The client is instructed not to put on socks or shoes without the aid of assistive devices, not to cross the legs, not to lie on the affected side, to use a raised toilet seat and a shower chair, and to use a pillow between the legs while in bed. Activities that can cause dislocation should be avoided for 6 weeks until muscles surrounding the joint are healed and the joint is stabilized. Symptoms of dislocation are sudden severe pain and external rotation of the leg.

After the devastating events of hip fracture and surgery, comprehensive multidisciplinary rehabilitation focuses on returning the client to the prior level of function and preventing disability. Specific areas of treatment are gait and transfer training, muscle strengthening through active assistive exercises, teaching the use of adaptive techniques for dressing, and teaching the correct use of assistive devices. Walkers and canes will be used by the client (Fig. 27–5), and the nurse must ensure that the client uses a safe technique with either device (see Client/Family Teaching Box: Correct Use of Walkers).

FIG 27–5 Walking with a walker. The walker is moved about 6 inches in front of the resident. Both feet are moved up to the walker. (From Potter PA, Perry AG: *Fundamentals of nursing*, ed 7, St Louis, 2009, Mosby.)

The loss of independence and decreased functional ability should also be addressed during rehabilitation. These losses can lead to depression. The nurse’s role is to identify the client’s strengths, give positive feedback, and reinforce the progress made in achieving goals. Discharge planning focuses on using family and social support networks and ongoing therapy programs.

Evaluation

Successful achievement of the expected outcomes after hip fracture will allow the client to return to a preinjury level of function. Those living independently should be successful in meeting goals of therapy and should regain their self-care abilities, which will allow for a return to home. Home health agencies may also be useful in successfully returning the client to the community.

CLIENT/FAMILY TEACHING

Correct Use of Walkers

A walker should always rest on all four legs, never two.

Correct body position should be maintained:

• Posture erect

• Elbows slightly bent

• Wrists extended

• Shoulders relaxed

Sturdy, comfortable, hard-soled shoes should be worn.

Walker and affected leg should be moved together.

Be alert for hazards such as uneven surfaces or wet floors.

Clients who were living in other types of health care facilities before the injury should be expected to return to their previous level of activity. Complications will prolong the recovery period and may lead to long-term changes in the level of independence. Clients should report minimum pain at the fracture or surgical site and intact skin integrity. Muscle strength, joint movement, level of mobility, and degree of safety while performing ADLs should be continually evaluated throughout the recovery period. Continued physical and occupational therapies may be required to achieve goals and expected outcomes (see Nursing Care Plan: Fractured Hip).

Colles’ Fracture

Colles’ fracture is a fracture of the distal radius that is usually a result of reaching out with an open hand to break a fall. This fracture is seen most often in older women with osteoporosis. Clients with a Colles’ fracture have pain at the site of the fracture that begins immediately after the traumatic episode; local edema, swelling, and a visible deformity from the displacement of the distal bone fragment are also present. Treatment of a Colles’ fracture is usually closed reduction and immobilization with a forearm splint or cast. Nursing measures include elevating the extremity to decrease edema and neurovascular assessment to monitor for complications. The client is instructed to actively move the thumb and fingers to improve venous return and decrease edema. Range-of-motion exercises for the elbow and shoulder prevent stiffness of the extremity.

Clavicular Fracture

Fractures of the clavicle, like Colles’ fractures, can occur after a fall on an outstretched hand or on a fall to the shoulder. The majority of these fractures occur in the middle third of the clavicle. The client with a fractured clavicle has point tenderness, local edema, and crepitus. The shoulder is noticeably deformed, dropping downward, forward, and inward. Treatment of a clavicular fracture includes reduction of the fracture and immobilization with a sling or cast. Nursing measures include monitoring for neurovascular complications such as compartment syndrome, elevating the extremity, and instructing the client to actively moving the hand and fingers.

Casts and Cast Care

Casts are one type of device used to immobilize an injured body part. They maintain proper positioning of the injured area, prevent further deformity, protect realigned bones, and promote healing. Used on the lower extremities, they may also allow for earlier weight bearing.

Casting materials include plaster of Paris or synthetic materials such as fiberglass. After application, plaster of Paris casts should be left uncovered to air dry. Drying time depends on the size and thickness of the cast and may take up to 48 hours. The nurse should support this type of cast with the palms of the hands rather than with the fingers to prevent indentations in the cast during the drying time. Synthetic cast materials harden quickly during and after application. The surface of this type of cast may be rough and can be covered with stockinette.

Clients are instructed to keep both types of casts dry; plastic or purchased cast protectors may be used during showering or

NURSING CARE PLAN

Fractured Hip

Clinical Situation

Ms. W is an 86-year-old executive secretary who is admitted to the skilled nursing unit of the local hospital for restorative care after surgical repair of a fractured left hip. The hip was repaired with a femoral head prosthesis. Ms. W fell when getting on the city bus. Before this incident, Ms. W worked 3 days a week. Her general health status is good. She lives alone on the second floor of a two-story building. Her only family is a niece who lives 60 miles away.

On admission, Ms. W is a slender woman who looks younger than her stated age. She is in no acute pain. The left hip incision is clean and dry with the staples intact. Ms. W transfers with the moderate assistance of two people. During the transfer she becomes tense and tells the nurses that she is afraid of falling and that she has to get on her feet so that she can get back to work. Because the surgical procedure has caused decreased range of motion and weakness in her left leg, Ms. W requires assistance with bathing and dressing her lower extremities.

NURSING DIAGNOSES

Impaired physical mobility related to alteration in musculoskeletal function as a result of fracture and surgical repair

Self-care deficit of bathing and dressing lower extremities related to alteration in musculoskeletal function secondary to fracture and surgical repair

Knowledge deficit: home care programs related to limited exposure

OUTCOMES

The client will walk 50 feet with a pickup walker.

The client will bathe and dress her lower extremities with the use of assistive devices.

The client will verbalize knowledge of home care programs.

The client will verbalize satisfaction with the discharge plans.

INTERVENTIONS

Consult with a physical therapist for a program of muscle strengthening, transfer training, and gait training.

Reinforce physical therapy training.

Give positive feedback for gains made.

Instruct the client to take deep breaths and relax before transfers.

Assist with transfers.

Give specific instructions before transfers. Instruct on hip precautions.

Teach the use of a walker.

Give pain medication 30 to 60 minutes before physical therapy.

Consult with the occupational therapist for specific assistive devices.

Teach the use of assistive devices. Allow adequate time for bathing and dressing.

Assess support systems and the need for home services.

Instruct on wound care, home safety, and home exercise programs.

Plan for discharge with the client and team members.

Use community services, visiting nurse, physical therapy, and niece for assistance.

bathing. Synthetic casts are immersed in water only with physician approval and should be dried thoroughly afterward. A hair dryer set at a low temperature may be used for this purpose.

Clients are instructed to keep the extremity elevated to the level of the heart to decrease edema. The client should also be instructed to maintain movement of the extremity to prevent muscle atrophy and joint stiffness above or below the cast (see Client/Family Teaching Box: Cast Care). Nursing care includes assessment for potential areas of skin irritation or breakdown. The client should be instructed to report any redness or discomfort along the edges of the cast and any signs of drainage or odor coming from the cast.

Neurovascular assessment of the extremity is done to determine that the cast is not constrictive. Excessive constriction caused by the cast could result in compartment syndrome, leading to ischemia and tissue destruction of the extremity. Any change in capillary refilling, skin color, skin temperature, or excessive pain not controlled with medication should be immediately reported to the physician.

Casts are generally used to immobilize fractures for 6 to 8 weeks. A variety of assistive devices may be used for clients with lower extremity casts (Fig. 27–6). The nurse prepares the client for self-care and prevention of complications during this treatment period.

FIG 27–6 Assistive devices. A, Cane. B, Quad cane offers more support than a single-stem walker. C, Walker with front wheels allows constant contact with the ground. D, Walker with adjustable front wheels. (From Cameron MH, Monroe L: Physical rehabilitation: evidence-based examination, evaluation, and intervention, St Louis, 2007, Saunders.)

Osteoarthritis

Osteoarthritis, also known as degenerative joint disease, is a noninflammatory disease of joints that is characterized by progressive articular cartilage deterioration and the formation of new bone in the joint space. This is the most common type of arthritis seen in older adults.

CLIENT/FAMILY TEACHING

Cast Care

Keep casted extremity elevated for the first 24 hours.

When cast is wet, lift with palms of hands.

Observe the extremity for swelling, color changes, movement, and sensation.

If any changes occur, contact health care provider.

Do not put anything inside the cast.

Do not get plaster cast wet; cover with plastic for bathing.

The exact cause of osteoarthritis is not well understood. The degeneration of the joint is not caused by aging alone. Age, trauma, lifestyle, obesity, and genetics have been cited as predisposing factors in the development of osteoarthritis.

In osteoarthritis the articular cartilage thins and is lost, particularly in areas of increased stress. As the cartilage deteriorates, there is a proliferation of bone at the margins of the joints. When the joint cartilage is lost, the two bone surfaces come into contact with each other. This results in joint pain. The distal interphalangeals, proximal interphalangeals, knees, hips, and spine are the joints most commonly affected by osteoarthritis.

The most common symptom is a gradual onset of aching joint pain. The pain occurs with activity and is relieved with rest. Stiffness after periods of inactivity that resolves with activity is also seen in osteoarthritis. Crepitus, a grating sound and sensation, may be heard and felt with range of motion in affected joints. Affected joints also have a decreased range of motion. The degeneration of the joint structure may result in muscle spasms, gait changes, and disuse of the joint. Bony enlargements, called Heberden’s nodes (Fig. 27–7), may be seen on the distal interphalangeals.

FIG 27–7 Right hand of a 71-year-old woman with osteoarthritis and Heberden’s nodes. (From Kamal A, Brockelhurst JC: *Color atlas of geriatric medicine*, ed 2, St Louis, 1991, Mosby.)

Nursing Management

Assessment

Nursing assessment of a client with osteoarthritis begins with a thorough history of the problem. Data gathered include information about the onset, location, quality, and duration of the joint pain. Questions about precipitating factors, medications used, and impact on functional abilities should be asked. Affected joints should be inspected for pain, tenderness, swelling, redness, crepitation, and range of motion.

Diagnosis

Nursing diagnoses for the older adult client with osteoarthritis include

• Impaired physical mobility related to lower extremity joint stiffness

• Self-care deficit (specify) related to limitations in joint movement and strength

Planning and Expected Outcomes

The focus of the nursing care plan is to protect and preserve joint motion and function. Expected outcomes for the client are individualized and specific to the joints affected. Outcomes include

1. The client will verbalize an improved level of comfort with activities.

2. The client will be able to successfully use various adaptive devices in maintaining independence in ADLs and IADLs.

3. The client will demonstrate safe use of assistive devices for ambulation.

Intervention

Instructions on joint protection and energy conservation are given. For clients with mild pain, a gentle exercise program that improves muscle tone and prevents joint stiffness may be used. Rest periods between activities are recommended. Heat or cold therapy to the joints may also be used to decrease joint pain. Simple measures such as a warm bath or shower in the morning may help reduce the early morning stiffness that may accompany the pain. Other pain relief interventions may be incorporated into the treatment plan (see Evidence-Based Practice Box: Osteoarthritis and Benefits of Regular Exercise).

The physician may also prescribe various nonsteroidal antiinflammatory drugs (NSAIDs) and nonopioid analgesics to help control the pain. Clients may initially be given over-the-counter medications and then gradually be advanced to a prescription

EVIDENCE-BASED PRACTICE

Osteoarthritis and Benefits of Regular Exercise

Background

Age is the most strongly associated factor in the development of osteoarthritis. It is commonly agreed by health care professionals that physical activity is a major facet to a healthy life at any age. This study examined the relationship between activity (intermittent or lifelong) and the development of osteoarthritis in later life.

Sample/Setting

Data sources to answer the posed research question that physical activity is a factor in the development of osteoarthritis were mapped from Ovid MEDLINE and EMBASE databases. Potential studies were eliminated if the mean age of the subjects was less than 55 years. A total of 15 prospective cohort studies and randomized controlled trials served as the sample for this exploration.

Methods

Information from each portion of the sample was compared for risks, outcomes, subjects involved, and interventions.

Findings

The authors judged that there was too wide a set of variations in how the exercise regimens were conducted to allow for clear comparisons between programs and outcomes. There was no direct association between physical activity as a risk factor for the development of osteoarthritis. Each study that was examined suggests that there may be sufficient supporting evidence on the benefits of some form of exercise regimen in the management of osteoarthritis.

Implications

Nurses can help to impact the overall level of physical activity in those with osteoarthritis by advocating for a routine of some form of regular exercise.

From Hart LE, Haaland DA, Baribeau DA, et al: The relationship between exercise and osteoarthritis in the elderly, Clin J Sport Med 18 (6): 508, 2008.

antiinflammatory agent. Other medical treatment options for more severe pain may include directly injecting the painful joint with steroids. This can be done two or three times yearly for chronic pain. More recent developments in arthritis treatment include the injection of hyaluronic acid into a painful knee joint that has not responded to more conservative measures. The nurse should educate the client about these conservative measures for treating the symptoms of arthritis. Information regarding correct dosing of oral medications, contraindications, side effects, and adverse effects should be provided.

When conservative measures for treating chronic arthritis pain fail and the client becomes more disabled, surgical procedures may be considered. The main indications for surgery are severe pain and increasing disability. The surgical procedure most often used is arthroplasty, a surgical replacement of the involved joint. Joint replacement surgery is currently successful for many joints that may be involved with arthritis, including the shoulders, elbows, fingers, hips, and knees.

Other surgical options include arthroscopic procedures and joint fusion surgery. These procedures do not replace the joint but may result in improved function and reduced pain.

For clients undergoing joint replacement surgery for the hip or knee, the preoperative period focuses on education about the surgical procedure, its risks, any potential complications, and the postoperative course. After surgery the goals of nursing care are to prevent complications, relieve surgical pain, and assist the client in achieving a higher level of function and activity.

Major complications after joint replacement surgery may include thromboembolism (deep venous thrombosis [DVT]), joint or wound infection, blood loss, nerve injury, joint dislocation, and surgical pain. The risk of DVT is highest between the first and second week after surgery. The use of critical pathways or care paths in most institutions has resulted in shortened hospital stays, fewer incidents of complications, and improved outcomes (Branson & Goldstein, 2003; Theis, 1998).

Nursing interventions in the postoperative period include measures to prevent infection, control pain, and assist with daily activities. Aseptic precautions should be taken with surgical wound dressings, urinary catheters, and surgical drains to prevent infection. The client may be given prophylactic antibiotics for a short time (24 hours) after surgery.

Infections of the joint replacement are a serious complication. The incidence of deep infection of joint replacements is 0.5% to 1%. The infection may be a result of contamination during surgery, hematoma formation, or delayed wound healing, or it may be hematogenous from a distant site, such as a urinary tract infection. The most common contaminants are staphylococci and gram-positive aerobic streptococci. Because the new joint is a foreign body, pathogens may be introduced that will persist on the metal or plastic surfaces of the prosthesis, leading to chronic deep infection of the joint.

Clients with rheumatoid arthritis, diabetes mellitus, or poor nutritional status and those receiving long-term corticosteroid therapies are at increased risk for developing joint infections. If infection occurs in a joint replacement, long-term intravenous antibiotic therapy is instituted for at least 6 weeks. In some cases the infected joint may be replaced. Joint infections may lead to increased disability and prolonged rehabilitation. Various prophylactic measures may be used to prevent DVT. These may include various lower extremity compression devices, oral or injectable anticoagulants, and physical therapy to mobilize the client.

Pain control during the first 24 to 48 hours may be accomplished with intravenous or epidural administration of narcotic analgesics. Patient-controlled analgesia is frequently used to provide adequate pain control. As the client’s pain decreases, oral analgesics should be ordered. Mild analgesics may be required for up to 6 weeks postoperatively as the surgical site heals.

Clients who have total hip replacement surgery are at risk for hip dislocation. The hip should be maintained in a position of abduction and neutral alignment. Some physicians may require the use of pillows or abduction splints while the client is in bed. Nurses should reinforce hip precautions as described in the Client/Family Teaching Box: Precautions after Hip Surgery.

The goal of total knee replacement surgery is to restore at least 90 degrees of knee flexion. For clients to achieve this, active and passive physical therapy is instituted. In addition, the physician may order a continuous passive motion device, which continuously moves the knee through a preset range of flexion and extension. Rehabilitation for a client with a joint replacement begins within 24 to 48 hours of the surgical procedure and includes muscle strengthening and range-of-motion exercises. The client is instructed on the use of a cane, walker, or crutches. Occupational therapy provides the client with instructions for

CLIENT/FAMILY TEACHING

Precautions after Hip Surgery

Sit with your hips at a 90-degree or greater angle.

Do not bend forward more than 90 degrees.

Do not lift the knee on the operated side higher than your hip.

Do not cross legs at knees or ankles.

Keep pillows between your legs when lying on your side or your back.

Do not bend to put on shoes; use a long shoehorn.

Do not bend down to reach items on the floor.

Do not sit in low chairs.

independence in daily activities. A short stay in a rehabilitation facility may follow the acute hospital stay. However, many clients are able to quickly return to their own home with continued home therapy services.

Evaluation

The goals in caring for a client with osteoarthritis are to relieve pain and restore function. Clients should report minimum pain and improved ability to perform ADLs. Conservative measures (as outlined earlier) will improve mobility and increase comfort for many older clients. If surgical intervention is used, the client needs to understand the expected outcomes, as well as the risks associated with the procedure. Clients with osteoarthritis may benefit from support groups and group exercise programs especially designed for clients with arthritis. The client’s self-care practices should include regular exercise, the use of adaptive devices if necessary, and adherence to prescribed medication regimens. Understanding the disease process and treatment measures will assist an older adult in maintaining function and independence.

Spinal Stenosis

Symptomatic osteoarthritic changes of the spine leading to functional limitation and pain in older adults are becoming more common. Lumbar spinal stenosis is one of the most frequently encountered, clinically important degenerative spinal disorders in the aging population (Spivak, 1998). Degenerative spinal stenosis is a bony overgrowth of the facet joints of the vertebrae, which leads to narrowing of the spinal canal and possible compression of the nerve roots. Although spinal stenosis can occur at any level of the spine, it is most frequently seen in the lumbar region at levels L3 and L4 (Fig. 27–8). Degeneration of the vertebral joints and disks of the spine, along with nerve compression, leads to progressive back pain and possible weakness of lower extremities. Clients with spinal stenosis may develop claudication-like symptoms of burning and numbness in their lower extremities.