Musculoskeletal Function



Musculoskeletal Function


Ramesh C. Upadhyaya, RN, CRRN, MSN, MBA




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



image CULTURAL AWARENESS


Biocultural Variations in the Musculoskeletal System






















































BONE REMARKS
Frontal Thicker in black men than white men


Mandible
Humerus
Radius/ulna
 
Vertebrae
Femur
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
Height
 
Composition of long bones
Peroneus tertius
Palmaris longus


image



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).


image
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



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).



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).





Nursing Management


image Assessment


Hip fractures are most often related to falls. After any fall or other injury that may cause hip trauma, the nurse assesses the hips and lower extremities for evidence of fracture. This includes inspecting the site for direct evidence of fracture, shortening of the extremity, and abnormal rotation. Also assessed is the presence of pain or tenderness at the site of the injury.




image Planning and Expected Outcomes


Nursing care of a client with a hip fracture involves the perioperative, postoperative, and rehabilitation periods. Each of these stages of treatment and recovery requires specific nursing interventions and includes the following expected outcomes:




image Intervention


On arrival in the acute care setting, the client has his or her medical condition and hip fracture assessed and stabilized. Surgical intervention is usually recommended but is considered elective and therefore requires stability of major health conditions. During this preoperative period the nurse’s main focus is on keeping the client comfortable and hydrated and preventing complications of immobility. Preoperatively, hip fractures can produce severe muscle spasms causing intense pain. Pain medications, traction, or immobilization and proper positioning are used to manage the pain. Preoperative education should include information regarding the surgical procedure, postoperative treatments, potential complications, and expected outcomes for rehabilitation and recovery.


The immediate postoperative period requires monitoring of vital signs and intake and output. Turning, deep breathing, and coughing are used to prevent respiratory complications. The operative site is monitored for signs of infection and bleeding. Movement, circulation, and sensation of the extremity are assessed to determine impaired circulation. Mental status should be assessed and any changes noted. Postoperative delirium may occur in older clients after a hip fracture; the effects of surgery, anesthesia, analgesic medications, loss of familiar surroundings, pain, and immobility may increase the potential for delirium. Care planning should include familiarizing the client with his or her surroundings, providing for safety, instituting comfort measures, decreasing anxiety, and assisting with maintaining a sense of independence and identity (see Evidence-Based Practice: Changes to Home Environment after Identifying the Location of Home Falls).


Pain is managed through careful administration of pain medication. Because of the normal physiologic aging changes that affect pharmacokinetics and pharmacodynamics, older adults are at risk for developing changes in mental status, respiratory depression, and sedative effects with the use of narcotic analgesics.



EVIDENCE-BASED PRACTICE


Changes to Home Environment after Idenifying the Location of Home Falls






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).



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.



image 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.



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



image 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.





image 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.




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.



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.




Nursing Management


image 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.





image 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







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



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.



image 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.




Nursing Management


image Assessment


Goals of nursing assessment focus on the client’s symptoms. The exact location of pain or numbness, the duration of the symptoms, and successful pain relief measures should be identified. Pain caused by degenerative spinal stenosis tends to occur primarily in the back and buttocks, but it may also radiate into the thighs, calves, and feet. The pain may be unilateral or bilateral and generally worsens with prolonged standing or activity. Symptoms are generally relieved with flexion of the spine. Clients can usually report specific positions or activities that aggravate or reduce their symptoms. They may report that activities such as leaning over a grocery cart lessen their pain. Comfort levels during routine ADLs should always be assessed.





image Intervention


Nursing care for an older client with spinal stenosis depends on the severity of spinal cord narrowing, the client’s state of health, and the degree of pain and immobility. For the client being treated conservatively, the nurse should instruct him or her to allow sufficient periods of rest and to limit activities that produce pain. Physical therapy for range of motion and muscle strengthening may be ordered by the physician. Pain relief measures should be initiated and then evaluated for their effectiveness. The physician may order NSAIDs and possibly analgesics for more severe pain. The use of pain assessment scales will help determine pain patterns, the severity of pain, and the effectiveness of pain relief measures.


Other nursing measures to relieve pain include the use of heat or cold applications to the back, massage therapy, relaxation techniques, and position changes for the client while in bed. Older clients with unrelieved chronic pain may be considered for pain team consultation and multidisciplinary treatment efforts. In many clients with chronic pain, depression may accompany and increase the intensity of the pain symptoms. A physician consultant may recommend the use of mild antidepressant medication in addition to the other pain relief measures.

Nov 26, 2016 | Posted by in NURSING | Comments Off on Musculoskeletal Function
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