The skeletal system

The skeletal system is the internal framework that supports, shapes, protects and moves the human body. The bones that form the skeleton serve many functions. These functions include support of body shape, protection of organs, movement, storage of fat and minerals and haematopoiesis or blood cell formation in bone marrow. To understand the importance of the skeletal system, imagine performing a task such as running or throwing. If the bones required in this movement are disabled due to damage or pain, this activity becomes more challenging, if not impossible, to perform (Patton & Thibodeau 2010).

The muscular system

The muscular system enables body movement, joint stabilisation and maintenance of posture. The function of muscle is to contract or shorten (see Clinical Interest Box 26.1). Skeletal muscle attaches to bone and can rapidly contract to exert great power or fine movement under voluntary control. Muscles are supported by a network of connective tissue and tendons that anchor muscle to bone for strength and support. Skeletal muscle is classified by the kind of movement it makes; for example, flexors allow joints to bend or flex, while abductors allow shortening so that joints are straightened or abducted (moved away from the body). When muscle contracts it pulls on a bone or bones and produces movement at a joint, where two bones meet. As joints are weak points in the skeleton, synovial fluid, cartilage, ligaments and tendons add protection and support (Patton & Thibodeau 2010).

The nervous system

Muscle movements occur as a result of stimulation by a motor or efferent nerve. These nerves activate muscles to respond to voluntary signals, such as grasping an object or towel drying hair. Muscle can respond to voluntary control, those movements controlled by human thought, or to involuntary control through the autonomic nervous system (Marieb 2009). Transmission of the impulse from the nervous system to the musculoskeletal system requires a chemical transmitter to cross the myoneural junction. Acetylcholine transfers the electric impulse from the nerve to the muscle to stimulate muscle and initiate movement (Crisp & Taylor 2009). An imbalance in this chemical neurotransmitter can result in impeded nerve transfer which delays the potential for coordinated or rapid musculoskeletal response.

The codependent relationship between the skeletal, muscle and nervous system in body movement can be demonstrated in a client with a spinal cord injury. A lesion in the spinal cord inhibits nerve transmission beyond the point of injury. With no nerve impulse to contract or react, muscle lays dormant. While still providing shape and connection with the underlying bones, the posture cannot be supported and the bones are unable to mobilise due to absence of muscle contraction and voluntary stimulation (Marieb 2009).

Diseases of the bones and skeletal system

Disorders of the joints and tendons

Osteoarthritis

Osteoarthritis is a degenerative non-infectious disease that causes pain and restricted movement of affected joints (Fig 26.2). Cartilage in the joints becomes thinner and eventually the two bones come into contact and begin to degenerate, followed by inflammation and effusion. Thought to be caused by excessive use, it usually develops in late middle age and affects large weight-bearing joints (hips, knees and cervical and lower lumbar spine) (Farrell & Dempsey 2011).

Figure 26.2 Pathological changes in osteoarthritis A: Normal synovial joint. B: An early change in osteoarthritis is destruction of articular cartilage and narrowing of the joint space. There is inflammation and thickening of the joint capsule and synovium. C: With time, there is thickening of subarticular bone caused by constant friction of the two bone surfaces. Osteophytes form around the periphery of the joint by irregular overgrowths of bone. D: In osteoarthritis of the hands, osteophytes on the distal interphalangeal joints of the fingers are termed Heberden’s nodes and appear as small nodules

(Stevens A, Lowe J, Scott I, Core Pathology, 3rd edition, Edinburgh. Mosby, 2008)

Diseases of the muscles

Diseases of the nervous system

Multiple sclerosis, Parkinson’s disease and Huntington’s disease are progressive neurological disorders that affect neurotransmission along motor pathways. With varying aetiology and signs and symptoms, these diseases affect voluntary and involuntary muscle groups and have long-term effects on gait, mobility and ability to independently undertake and complete activities of daily living (Christensen & Kockrow 2011; Crisp & Taylor 2009; Marieb 2009).

Fit versus fat

Obesity and fitness may be considered polar opposites, yet studies reveal that an overweight person can still be physically fit and outlive or outperform their slim peers who live a sedentary lifestyle. Studies performed by Blair and colleagues (ABC Radio National 2007) indicated that those with a body mass index of 30–39.9 (Class 1–2 obesity) who were physically active did not have elevated death rates compared with fit people of normal weight. Additionally, in follow-up 10–12 years later, normal weight unfit people were twice as likely to die compared with obese people who were fit. This study does not promote obesity, but challenges practitioners to look at the complete health profile when determining physical fitness (ABC Radio National 2007).

Exercise and the older adult

As humans age, body systems deteriorate. Research suggests that up to half of the functional decline associated with ageing is the result of disuse and can be reversed with exercise. Exercise improves cardiopulmonary fitness, strength, coordination, mental health, motor control and cognitive function. Improved flexibility, balance and muscle tone can help prevent falls.

The benefits of physical activity can be enjoyed even if regular practice starts late in life (Fig 26.5). Physical activity improves self-confidence and self-sufficiency to enhance psychological wellbeing. Active lifestyles provide occasions to establish new friendships, maintain social networks and interact with people of all ages. Walking, swimming, stretching, dancing, gardening, hiking and cycling are excellent activities for older persons. With the number of people over 60 years of age projected to double in the next 20 years, reducing and postponing age-related disability is an essential public health measure that must be initiated now (WHO 2011).

Figure 26.5 Regular activity creates a sense of health and wellbeing

(© Dorothy Lanyon)

A study by Melov et al (2007) demonstrates the benefits of exercise for older adults. An analysis of tissue samples was taken before and after completion of 6 months of twice-weekly resistance training. Findings revealed a reversal in the genetic profile of cells back to levels similar to those in younger adults, indicating a potential reversal of the ageing process. Additionally, muscle strength measured indicated a 50% improvement in older adults after exercise. This improvement was seen 4 months later in the same adults. Using soup cans and elastic bands, these adults maintained informal resistance training in the home. Despite reduced intensity, those studied remained strong as they still had the same muscle mass developed during the intensive 6-month period (Science Daily 2007).

Exercise attitudes within Indigenous communities

Identified health issues within the Indigenous communities of Australia include hypertension, stroke, diabetes, smoking, obesity and alcohol abuse. High levels of sedentary behaviour were reported in the 15 years and above age group, which accounts for 75% of the Indigenous population in non-remote areas of Australia (ABS 2010). Of those who exercised, the prevalence of arthritis, diabetes, heart and vascular diseases was significantly reduced. Similarly, those who regularly exercised at moderate levels reported good self-assessment of their general health and smoked less than their sedentary counterparts (ABS 2010).

Health concerns among Indigenous New Zealand communities are similar to those of Australian Indigenous communities. Smoking, obesity, poor eating habits and inactivity are identified health issues that lead to long-term chronic health issues such as diabetes mellitus, hypertension, heart disease and stroke (Māori Health 2011).

Finding exercise to suit the individual

Like any activity that humans undertake, exercise must be enjoyable or rewarding if commitment is to be assured. While some are motivated by weight loss or muscle definition, others may be encouraged by improvement in mood, freedom of movement or cardiovascular fitness.

The ideal combination for physical health is a combination of aerobic, flexibility and resistance exercise. Incorporating a daily aerobic walk with resistance exercises that use body weight against gravity (push-ups, weights) are activities that can be done outdoors. For flexibility, combine these with stretching that works the muscle groups that have problems with flexibility, that is, shoulder and chest, hip and knees, back, hamstrings and gluteals (ABC Health & Wellbeing 2007).

Movement and exercise should form part of any treatment program for individuals with neurological disorders. While the exact mechanism of effectiveness is unclear, the benefits can be demonstrated in those suffering symptoms of stroke or Parkinson’s disease. Chen (cited in Fallik 2007) believes voluntary exercise initiated at the right time post stroke can aid rewiring and healing through a ‘use it or lose it’ factor. Repetitive dance steps can help create a pathway to movement in clients with bradykinesia. Dancing uses all muscle groups and creates a sense of achievement and enjoyment. Additionally, Parkinson’s clients who sometimes ‘freeze’ during movement found the beat of the music reduced freezing and enhanced mobility and balance (Fallik 2007).

Barriers to exercise in the elderly were studied by Guerin et al (2008). Many Australian aged care facilities offer in-house exercise programs based on the Easy Moves for Active Ageing program. This chair-based program aims to maintain function and prevent physical decline in older adults by working through a low-impact series of ROM movements. While the benefits of exercise have been discussed, this study revealed factors that can cause resistance in older adults (see Box 26.2). Many residents find these sessions enjoyable, social and empowering; others may experience barriers that inhibit their participation.

Isotonic exercise

Isotonic exercise involves muscle shortening and active contraction and relaxation of muscles. Isotonic activity occurs with movement, such as carrying out activities of daily living, independent range-of-movement (ROM) flexing exercises, swimming, walking, running, cycling or jogging.

Isometric exercise

Isometric exercise involves muscle contraction without shortening of the muscle length. These exercises build muscle bulk and are a popular muscle activity for body builders, for example, lifting weights.

Isokinetic exercise

Isokinetic exercise causes muscle contraction, shortening and relaxation at an even speed. Isokinetic movement occurs during swimming as arms move evenly through water resistance (Marieb 2009).

Encouraging maintenance and restoration of muscle strength

As communities become increasingly sedentary, the cost is reflected in the calibre of clients in the healthcare system. With increasing numbers of cases of osteoporosis and arthritis requiring in-hospital care, nurses may frequently find themselves caring for immobilised or physically disabled clients. To aid return to mobility after the acute care phase, provision of movement activities is essential to prevent long-term complications sustained during immobility. Until this stage, nurses should undertake muscle and joint movement. Using the principles of muscle movement, a range of exercises can be incorporated into everyday situations to enhance client health and recovery (Crisp & Taylor 2009):

Encouraging maintenance of joint mobility

Joints are capable of a wide range of movement (Fig 26.6). ROM or motion exercises are either active, when the clients are able to move the joints themselves, or passive, when the nurse moves clients’ joints within the normal ROM, noting joint flexibility and/or limitations of movement. Joints that are not moved regularly can develop contractures (shortening of a muscle and eventually ligaments and tendons and eventual loss of function). It must be remembered that when a nurse performs passive ROM exercises in which the client’s muscles do not exert effort, some of the potential benefits are reduced in favour of improved joint mobility and circulation (Christensen & Kockrow 2010; Farrell & Dempsey 2011).

Figure 26.6 Range-of-movement joint movements

The frequency with which ROM exercises are performed depends on the client’s condition and medical and nursing management, but they are commonly performed at least twice daily. However, it is important not to overtire the client. ROM exercises may be performed independently or with assistance. Using appropriate movements, all joints are exercised in a logical sequence. Exercise routines are normally individually designed and the intensity and frequency depend upon the client’s general condition, level of fitness and capabilities (Crisp & Taylor 2009).

Gait

Gait describes the manner of walking and, while varying from one person to another, there is normally a certain rhythm to a person’s walk. Gait abnormalities may occur when there is a disorder of the musculoskeletal or nervous system; for example, unilateral hip dislocation produces a distinct ‘waddle’ with each step. A staggering, or ataxic, gait may be caused by a lesion in the brain or spinal cord, and a ‘scissors’ gait is one in which the legs cross each other in progression. An abnormal gait may also result from pain or discomfort due to a lesion on the foot, such as a corn, or from ill-fitting and uncomfortable shoes (Crisp & Taylor 2009).

Pain and nerve (sensory) changes

Pain is a common symptom of musculoskeletal disorders, as a result of trauma, inflammation or degeneration. Clients describe the pain as mild, aching, severe or throbbing, and it may be localised or generalised, depending on the specific disorder. Pain may increase with movement, be exacerbated by changes in external temperature and relieved by rest. It may be worse at certain times; for example, joint discomfort from degenerative disease is often worse in the evenings. Numbness, tingling and lack of sensation are other sensory changes. Swelling from injury or tumours may cause pressure on nerves, resulting in loss of sensation (Farrell & Dempsey 2011).

Swelling, deformity and impaired mobility

Swelling of an affected area may be the result of the formation of inflammatory exudate in response to injury from physical trauma, chemicals or infection. Swelling will also occur when blood is lost from the circulation into surrounding tissues (haematoma); for example, after a fracture. A joint may become swollen if there is an increase in the amount of synovial fluid or if blood or purulent discharge is present in the joint capsule. Deformity may be the result of growths, fractures, dislocations, abnormal curvature of the spine or contractures. The effects of a deformity include changes in range of joint motion, posture and gait. Mobility may be impaired to such an extent that the client is unable to move without pain or unable to carry out activities of daily living, or it may only restrict mobility at certain times, such as after activity or be related to certain positions (Fig 26.7).

Figure 26.7 Knee joint deformity caused by osteoarthritis

(© Dorothy Lanyon)

Sprains

A sprain is an injury to a ligament, caused when a joint is forced beyond its normal ROM. A ligament may be stretched or torn and local bleeding and bruising present with restricted movement. Sprains commonly occur in the wrist and ankle. Treatment is aimed at resting and supporting the area and reducing pain and inflammation with anti-inflammatory medications (Farrell & Dempsey 2011).

Strains

A strain is an injury to a muscle and/or a tendon, resulting from excessive physical effort. Both sprains and strains cause pain and swelling, but strains may cause muscle spasm as well. Nurses can suffer strain injuries from incorrect manual handling techniques (Crisp & Taylor 2009; Christensen & Kockrow 2010).

Fractures

A fracture is a broken bone, often with nearby soft tissue, blood vessel and nerve damage. A stress fracture occurs when a bone is subjected to repeated or prolonged stress such as jogging. A pathological fracture may occur in weakened bone as a result of osteoporosis. Fractures are classified as open or closed, simple or complicated. Open (or compound) fractures are those in which the bone breaks through the skin, while closed fractures are those where the skin is intact. In a simple fracture only the bone is involved, while in complicated fractures nearby blood vessels, nerves or organs are affected. Table 26.2 and Figure 26.8 demonstrate and describe the various types of fractures. Signs and symptoms vary but usually encompass pain, swelling, muscle spasm, bruising, deformity, abnormal mobility and loss of function. Crepitus (grating caused by bone fragments rubbing together) may be heard on examination or experienced and described by the client. Shock may occur as a result of haemorrhage or extensive damage (Farrell & Dempsey 2011; Patton & Thibodeau 2009).

Table 26.2 Types of fractures

Adapted from Crisp & Taylor 2009; Marieb 2009; Patton & Thibodeau 2010

Figure 26.8 A: Closed and open fracture B: Common types of fractures

(A Figure 4.22 from Christensen B L, Krokow E O (2011). Adult Health Nursing, 6th edn. Mosby, Elsevier: St Louis, pp 142–143, modified from the original in Thibodeau, G A & Patton K T (2005). The Human Body in Health and Disease, 4th edn. St Louis, Mosby; B Figure 4.23 from Christensen B L, Krokow E O (2011). Adult Health Nursing, 6th edn. Mosby, Elsevier: St Louis, pp 142–143, modified from the original in Ignatavicius D D & Workman M L (2009). Medical-surgical nursing across the healthcare continuum, 6th edn. Philadelphia: Saunders)

Neurovascular assessment

A neurovascular assessment is performed on clients who have experienced a fracture, who have been fitted with a cast, have undertaken vascular surgery or have had spinal surgery. Neurovascular protocols vary depending on the client diagnosis and treatment undertaken. Nurses should familiarise themselves with neurovascular guidelines within their place of work and employment facility. For example, a client with a fracture should have neurovascular observations undertaken every hour for 24 hours, then every 4–8 hours if fitted with a cast (Berman et al 2012; Farrell & Dempsey 2011).

Assessment must be undertaken by the primary care nurse at the commencement and throughout the shift to identify early changes that can indicate a pathological deterioration. Inability to recognise significant changes in a timely manner may influence a client’s potential for recovery and rehabilitation. A neurovascular assessment might include inspection of:

Dislocation

Dislocation is complete displacement and subluxation to partial displacement of a joint’s articulating surfaces; both processes damage surrounding soft tissue structures. Joint effusion is the accumulation of synovial fluid in a joint and occurs if blood vessels in the synovium are damaged. Joint effusions may result from severe sprains, dislocations or fractures. Signs and symptoms of dislocation and effusion include severe pain, limited movement, joint deformity and swelling. Dislocations may affect fingers, elbows, shoulders, hips, knees and ankles and are often caused by sporting injuries or pressure on the affected area after a fall (Marieb 2009).

Lower back pain

Lower back pain is a common symptom that has a variety of causes, including poor posture, injury, inflammatory conditions, obesity, metabolic bone disorders, degenerative processes and intervertebral disc disease. Discomfort or pain may be mild, severe, continuous or intermittent and be aggravated by certain movements or posture; it may radiate into the buttocks or down the back of the legs. People with lower back pain should not sit for more than 30 minutes at any one time, and frequent stretching (thrusting the hips forwards while the upper body leans back) is recommended. Most lower back pain can be safely and effectively treated after an examination by an orthopaedic surgeon and a prescribed period of activity modification and medication to relieve the pain and diminish the inflammation. Although a brief period of rest may be helpful, most studies show that light activity speeds healing and recovery. It may not be necessary to discontinue all activities, including work. Instead, people may adjust their activity under the guidance of medical officers or physiotherapists (Marieb 2009).

When the initial pain has eased, a rehabilitation program may be suggested to increase muscle strength in the lower back and abdominal muscles, as well as stretching exercises to increase flexibility. If overweight, weight loss is recommended, as this may decrease the chance of recurrence of lower back pain. The best long-term treatment is an active program of maintaining optimal physical condition. This can be achieved by regular exercise, practising correct lifting techniques and assuming good posture (Crisp & Taylor 2009; Hoeman 2008).

Clients with a bone injury

Bone fractures can take weeks or months to heal, and healing occurs in stages:

Figure 26.10 Stages in bone healing A: Bleeding at fractured ends of the bone with subsequent haematoma formation. B: Organisation of haematoma into fibrous network. C: Invasion of osteoblasts, lengthening of collagen strands and deposition of calcium. D: Callus formation: new bone is built up as osteoclasts destroy dead bone. E: Remodelling is accomplished as excess callus is reabsorbed and trabecular bone is laid down

(Fig 62-9 from Brown D & Edwards H (2012) Medical–Surgical Nursing: Assessment and management of clinical problems, 3rd edn. Sydney, Mosby. Redrawn from Phipps W, Monahan F, Sands J, Neighbors M, Marek J (2003) Medical-surgical nursing: Health and Illness Perspectives. St Louis: Mosby, with permission.)

Bone healing is individualised. For most, healing takes place within a standardised time frame; however, some healing is delayed and can be influenced by the following factors:

Surgical repair

For some bone and joint disorders, surgical repair of the affected area is essential to restore alignment, control pain and enhance rehabilitation for full joint mobility. Simple fractures require return of bone fragments to their original position and may be achieved by surgical review and realignment with an internal or external fixature. Compound fractures require surgical debridement to remove dirt, foreign material and necrotic bone fragments (Christensen & Kockrow 2010; Patton & Thibodeau 2010).

Traction

Traction reduces and immobilises fractures. A steady pull from two directions keeps the bone in place. Traction is also used for muscle spasms, to correct or prevent deformities and to relieve pressure on a nerve. Weights, ropes and pulleys are used to create the pull required to stabilise the limb. Traction can be applied to the neck, arms, legs or pelvis. Skin traction is applied to the skin. Tape, a boot or a splint is used. Weights are attached to the device. Skeletal traction is applied directly to the bone with wires or pins are inserted through the bone. Weights are attached to the device (Fig 26.11).

Figure 26.11 Common types of traction

(Fig 63-10, S L Lewis, S Ruff Dirksen, M M. Heitkemper & L Bucher. Medical-Surgical Nursing, 8th edn. St Louis: Mosby, 2011)

Casts

Casts are immobilisation devices made of plaster or fibreglass. They are applied after bone alignment by internal or external fixation. Applying the cast can be painful during manipulation for alignment and clients should be advised of the warmth they will experience as the plaster undertakes its setting process. Clients who have had a cast applied must have neurovascular observations performed as per hospital policy. Clients discharged home wearing a cast should have their cast inspected for rough edges and signs of bleeding or drainage. Clients should be educated to seek medical advice if they notice their cast is cracked, moist or emanating an offensive odour. The limb should be kept elevated to reduce swelling and advice sought if the limb becomes cool, swollen, increasingly painful or changes colour. Casts may remain in place for several weeks to some months, depending on the bone or joint requiring immobilisation (Berman et al 2012; deWit 2009; Farrell & Dempsey 2011).

Promoting rest

Rest helps minimise pain and swelling, promotes healing of injured tissues, relieves muscle spasms and prevents further tissue destruction in inflammatory conditions. Rest may be classified as general, when the individual is confined to bed (e.g. if several joints are inflamed), or local, when a specific body part is immobilised, such as a limb in a splint or cast. General care during the rest phase involves:

Maintaining joint movement

Some joints require movement, not immobilisation post repair. The continuous passive movement (CPM) device provides gentle forward and backward joint movement after knee surgery. Used on clients who are resting in bed, the joint is strapped into the device and moved continuously while the client is immobilised. This movement ensures the joint remains mobile, resulting in reduced pain, swelling and eventual immobility (Crisp & Taylor 2009; Hoeman 2008).

Maintaining skin integrity

Clients who are immobilised for prolonged periods are at high risk of developing pressure sores or decubitus ulcers. Skin must be maintained in good condition and protected from irritation, friction and prolonged pressure (Crisp & Taylor 2009). General care of the skin and prevention of pressure sores are described in Chapter 27.

Positioning techniques

Clients with musculoskeletal disorders who are immobilised require help from nurses to ensure proper body alignment and comfort. Aids to comfort in bed, such as pillows, foot boards, trochanter rolls, trapeze bars, sandbags and slippery-type sheets for ease of movement in bed, are all useful to ensure that an immobilised client is comfortable (Crisp & Taylor 2009; Hoeman 2008).

Various positions and proper positioning are discussed in Chapter 21.

Maintaining or improving nutritional status

Nutrition for clients with a musculoskeletal disorder includes a well-balanced diet and maintenance of recommended body weight. The diet should contain adequate amounts of protein, calcium and vitamin D to promote healing and maintenance of the musculoskeletal system. Adequate fibre and fluids aid elimination. If the client is overweight, a weight-reduction diet is recommended to prevent stress on inflamed or diseased joints (Berman et al 2012; Crisp & Taylor 2009).

Relieving pain

While the general approaches to pain management described in Chapter 31 are relevant to clients with musculoskeletal disorders, specific measures may also be indicated. Clients may experience acute or chronic pain, depending on the specific disorder, and general measures to promote comfort and minimise pain should be implemented; that is, changing position, massage, handling a painful limb gently and rest. If not contraindicated, elevating the limb may relieve discomfort and pain. Specific measures include checking to ensure that splints, casts or dressings are not too tight or rubbing against the skin. Hot or cold packs or treatments may be used to provide relief and increase ROM. Heat is sometimes used in chronic joint disorders, as it relaxes muscles, relieves stiffness and provides analgesia, and is often applied before exercise and massage. Applying a cold pack to a limb or area is useful for acute pain or acutely inflamed joints. When these treatments are used, caution is necessary to prevent tissue damage. Analgesia may be prescribed and administered in accordance with nursing regulations and the institution’s policy (Crisp & Taylor 2009).

Prevention of psychological problems

Management of a musculoskeletal disorder may require a person to be confined to bed, and possibly hospital, for an extended time, and often leads to boredom, frustration or depression. To prevent such problems, clients are encouraged to express their feelings and are allowed to participate in making decisions about their care. Active involvement in all aspects of care and self-care techniques are taught, as this allows clients to take responsibility for some of their care and can help to reduce problems associated with dependence and immobilisation. Regular programs of activity developed with the client and other allied health professionals need to be incorporated into the nursing care plan (Crisp & Taylor 2009; Farrell & Dempsey 2011; Hoeman 2008).

Promoting remobilisation and rehabilitation

As the musculoskeletal system is crucial to activity, a routine of exercise and rehabilitation is developed and implemented. A planned exercise program is generally developed by the physiotherapist, but the nurse is required to encourage and supervise regular exercise. Programs contain exercises designed to prevent muscle atrophy or joint contracture and to prepare for ambulation. Range-of-movement exercises are important during this time. A program of gradated, non-weight-bearing exercises is started, designed to regain or increase muscle tone, build muscle strength and promote joint mobility. When clients are able to bear weight on the affected limb, the exercise program is aimed at restoring as much mobility as possible (Hoeman 2008).

The overall aim of rehabilitation is independence in activities of living, and requires a multidisciplinary team approach consisting of nurses, medical officers, physiotherapists and occupational therapists. Depending on specific needs, a social worker and splint-maker may be involved. (Information on rehabilitation is provided in Ch 38.) Preparation for discharge includes informing clients of the need to continue any exercise program, on the use of splints or braces, about limits of physical activity and the importance of attending any future appointments or ongoing rehabilitation programs (Hoeman 2008).

Nursing care plan of a client requiring prolonged bed rest

Older clients are more prone to problems associated with prolonged bed rest. These clients need careful planning and enactment of care to minimise these potential problems (see Nursing Care Plan 26.1 and Clinical Scenario Box 26.1).

General treatment for exercise-related injuries

Exercise can be the cause of injuries that are mostly orthopaedic in nature and caused by irritation of bones, tendons and ligaments and/or muscle tissue. Injury may be as a result of weight-bearing stress or collision. Nurses can teach clients the acronym PRICE: prevention, rest, ice, compression and elevation, and advise of the need for a medical officer to diagnose the injury. Generally, further injury can be avoided by resting the affected limb (Christensen & Kockrow 2010; Hoeman 2008).

Meeting movement and exercise needs

To plan and implement appropriate nursing actions, a client’s ability to mobilise should be assessed. By observation and obtaining factual information, nurses are able to plan and implement measures to meet client movement and exercise needs. When admitting clients, it is important to note whether a client experiences problems that limit independent movement. Nurses observe and document posture and gait, strength and tone, ROM and other factors such as dyspnoea at rest or on exertion, which may limit exercise (Hoeman 2008).

It is important to identify potential problems that may affect a client’s ability to exercise. Impaired mobility may result from:

Being in hospital is likely to alter a person’s normal movement and exercise routine and, although there is often a degree of restriction in activities, clients able to ambulate should be encouraged to do so, while those who are immobilised may require assistance to move. Nurses promote safety and comfort while encouraging, when possible, a return to independent function (Crisp & Taylor 2009; Farrell & Dempsey 2011).

When planning care to meet a client’s need for movement and exercise the nurse must consider factors such as:

A sample nursing care plan is shown in Nursing Care Plan 26.2.

‘Dangling’ before ambulating

Ambulating, or walking, is encouraged and facilitated to prevent the complications associated with even short-term but especially with long periods of immobility. Certain clients may need to relearn how to walk; for example, after a cerebrovascular accident or leg surgery, clients may need the assistance of aids such as a walking stick, crutches or walking frame. After an extended period of immobility, nurses need to instruct clients to mobilise progressively. Bedridden clients who are able to raise each leg 4–6 cm straight up from the bed usually possess enough strength to walk, provided that they are mentally alert.

Nurses begin re-educating muscle groups by first allowing the client to sit on the edge of the bed for 1–2 minutes with their feet on the floor, a technique called dangling. Clients then progress to standing, then walk a few steps, gradually increasing the distance. Blood pressure can drop dramatically and the client could faint if they were to stand up suddenly. Dangling for a few minutes helps prevent hypotension and dizziness when a previously immobilised client stands for the first time. If a client complains of dizziness or suddenly looks pale when they are standing, quickly return the person to bed or the nearest chair (Hoeman 2008).

When the nurse assists a client who has a one-sided weakness, or hemiplegia, it is important to decide which walking aid or technique has been recommended. Although the method used to assist is individualised, most clients require assistance and support on the affected side. When assisting a person to walk it is helpful if they remain close to a railed wall and are able to rest on a chair before beginning the return walk. If an ambulant client has an intravenous infusion or urinary or wound-drainage bag, the nurse ensures that therapy or drainage is not affected, by checking tubing or drainage bags in case they have become dislodged after exercise.

Well-fitting footwear should always be worn (non-slip soles) and potential hazards eliminated, such as obstacles or liquids on floors. Clients should not be allowed to walk barefoot or with just socks or slippery footwear (e.g. women with nylon hose) on the feet. Clients are encouraged to walk at their own pace and, if they become distressed or complain of pain, faintness, giddiness or undue fatigue, should be seated and the nurse should remain with the client and call for assistance (Hoeman 2008).

Crutches

Crutches enable a person to ambulate by taking the weight of the body off one or both legs. Successful use of crutches requires balance and upper body strength. Selection of crutches and particular type of gait depends on individual needs, but must be appropriate to be safe and effective. The two types commonly used are the underarm and forearm crutches.

Underarm crutches are often used by clients with a sprain or leg cast, while forearm crutches are more commonly used by those with a through gait, as in paraplegia. Underarm crutches must be measured so that the person’s weight is carried on their wrists and palms and not on the axillae. The axilla bar should be 4–5 cm below the axilla, and the hand bar positioned to permit 15–30 degree flexion of the elbow at rest. Forearm crutches must also allow 15–30 degree flexion of the elbow at rest. Before crutches are used they should be assessed for safety, ensuring that all screws and bolts are tightened and rubber tips are in good repair. It is important to ascertain the amount of weight bearing allowed on the affected leg(s); that is, partial or none (Berman et al 2012; Crisp & Taylor 2009; Farrell & Dempsey 2011) (Figs 26.12 to 26.14).

Figure 26.12 Using the goniometer to verify correct degree of elbow flexion for crutch use

(Potter & Perry 2013)

Figure 26.13 Double adjustable forearm crutch

Figure 26.14 Measuring crutch length

(Potter & Perry 2013)

Walking sticks

A walking stick may be used for people with one-sided weakness or injury, occasional loss of balance or to reduce weight bearing on a hip or knee, as well as to provide balance and support for walking, reducing fatigue and strain on weight-bearing joints. Walking sticks should extend from the individual’s greater trochanter to the floor, and be fitted with a rubber tip to prevent slippage. Sticks are available as single-tipped, tripod or four-point, and should permit 15–30 degree flexion of the elbow. Three- and four-point sticks provide a broad base and greater stability and may be used by a client with poor balance or one-sided weakness.

To use a stick the client holds it close to the body on the unaffected side; taking the weight off the affected leg, the client moves the stick and the affected leg simultaneously, followed by the unaffected leg. Sometimes the three- or four-pronged stick is held on the affected side. Clients are encouraged to keep the stride of each leg, and the timing of each step, equal. While a client is learning to use the stick, the nurse stands behind them to support them if they become unsteady. When going up stairs the stick should be held in one hand and clients encouraged to hold the stair rail, leading with the unaffected leg; when going down stairs the affected leg leads (Farrell & Dempsey 2011; Hoeman 2008).

Walking frames

Walking frames consist of a metal frame with hand grips, four legs and one open side (Fig 26.15). A frame may be used by an older adult, as it provides greater support and sense of security than a stick and is useful for those with an unsteady gait, or when partial weight bearing is recommended. The height is selected to allow 15–30 degree flexion of the elbows when the hand grips are held. Attachments such as baskets and trays are available to meet specific needs and to promote greater independence. To safely rise from a chair, the frame is placed in front of the client, who then inches forwards in the seat of the chair and, with both feet firmly on the ground and both hands on the arms of the chair, pushes with their arms to stand and, when standing, grasps the frame. Commonly, the client picks the frame up and moves it 15–20 cm forward, then moves one foot, followed by the other, up to the frame. If a client has a one-sided weakness, the affected leg is moved first (Crisp & Taylor 2009; Hoeman 2008).

Figure 26.15 Walking frame

(© Norman Lanyon)

When clients are learning to use a frame, the nurse stands behind them to support the hips and encourages the client to stand upright and look straight ahead. To sit down, the person stands with the back of their knees against the front of the chair, then reaches behind to securely grip the armrests, bending their arms to lower themselves into the chair. When a walking aid is used, the person is assisted until they are confident in the use of the aid and when unassisted use is decided by their medical officer, physiotherapist or nurse, in consultation with other health professionals (Hoeman 2008).

Pressure sores and decubitus ulcers

Pressure sores result from localised damage to the skin and underlying tissue caused by pressure, shear or friction (for bedridden clients, shear or amount of friction increases as their head is elevated). Pressure, especially on bony prominences, results in poor circulation, so that the area is deprived of essential nutrients and oxygen, and cellular death may occur. Any client with a mobility or activity deficit should be subject to a pressure-sore risk assessment. Pressure sores remain a significant problem in hospitals and residential care settings despite being largely preventable (Crisp & Taylor 2009; Farrell & Dempsey 2011). See Chapter 27 for factors that affect skin integrity.

Effects of immobility upon the musculoskeletal system

Effects of immobility are evident after even short periods of inactivity. People who attempt to walk after several days of bed rest are surprised at how weak their leg muscles have become. Immobilisation and the resultant disuse of muscles lead to decreased joint mobility, bone demineralisation, and atrophy of muscles with decreased size, strength and tone.

Contractures and ankylosis

Contractures are abnormal conditions of a joint. Contractures are characterised by flexion and fixation and caused by atrophy and shortening of muscle fibres. Ankylosis is joint consolidation and immobilisation. Contractures may result from improper support or positioning of a joint, or as a result of inadequate joint movement. For example, if a joint is allowed to remain in one position for an extended length of time, the muscle fibres that normally provide movement shorten to accommodate that position, and lose the ability to contract and relax. Weight-bearing activity stimulates bone formation and balance; however, during immobilisation, bone formation slows, while breakdown of bone increases. With the subsequent loss of bone calcium, phosphorus and matrix, disuse osteoporosis results, and the brittle demineralised bones fracture easily.

For prevention, encourage physical activity and isometric or isotonic active ROM exercises while the client is in correct body alignment. An immobilised person may need direction as well as assistance when they perform ROM exercises. Pressure-relieving devices, such as a bed cradle, may prevent the bedclothes pressing down and forcing joints into abnormal positions (Berman et al 2012; Crisp & Taylor 2009; Hoeman 2008).

Footdrop

Footdrop is another term for plantar flexion, which is caused by damage to the nerve supply of the muscle responsible for dorsiflexion of the foot (Fig 26.16). If a client’s feet are allowed to assume plantar flexion for long periods they become fixed in that position so that, when the client attempts to stand or walk, they will be unable to place their heels on the floor and walk normally.

Figure 26.16 Footdrop

(Potter & Perry 2013)

Prevention includes using a foot board or firm pillow in the bed to maintain the feet in proper alignment, or dorsiflexion, as if in a standing position (if not contraindicated); that is, at a 90-degree angle. Devices and techniques to keep pressure off the feet should be used, such as a bed cradle or foot pleat in the upper bedclothes. The person’s feet should be exercised through their ROM, either actively or passively. If footdrop occurs, management includes use of an orthopaedic brace, intensive physiotherapy or surgical intervention (Crisp & Taylor 2009).

Effects on the cardiovascular and pulmonary systems

The primary negative effects of immobility on the cardiovascular system are increased cardiac workload, postural hypotension and venous thrombosis. An increase in the workload on the heart may be due to less resistance by blood vessels and changes in blood distribution. Heart rate increases and cardiac output falls after prolonged rest. A significant drop in blood pressure on standing (25 mmHg systolic and 10 mmHg diastolic) is termed orthostatic or postural hypotension, and is due to a decrease in neurovascular reflexes and muscle tone. In addition, stasis of blood may precipitate clot formation. A lack of muscular activity that would normally help move blood towards the heart results in calcium exiting the bones to enter the systemic circulation. This action influences clot formation. If a clot or thrombus detaches from the vessel wall and is transported in the bloodstream, it is called an embolus. Emboli that lodge in the pulmonary artery tree are referred to as pulmonary emboli. Depending on the size of the embolus, consequences may be serious (Berman et al 2012; Marieb 2009).

Prevention of deep vein thrombosis (DVT)

Prevention of pulmonary embolus includes exercises to stimulate venous blood circulation in the legs. Active or passive 2-hourly exercises should be performed and consist of rotating the ankles, dorsiflexion and plantar flexion of the feet, flexing and extending the knees and raising and lowering each leg. Clients are advised not to cross their legs while lying in bed or sitting. Prolonged pressure on the backs of the legs should be avoided by careful positioning and repositioning. Upper bedclothes should remain loose to allow movement of the legs.

Antiembolic elastic stockings may be prescribed to facilitate venous return from the lower extremities, prevent venous stasis and venous thrombosis and reduce peripheral oedema. The stockings expose the toes but cover the foot and extend up the leg to the knee or groin. They give firm support to superficial veins in the leg, maintaining adequate venous pressure and reducing the incidence of thrombi. The client’s leg(s) are measured to ensure correct fit, then the stockings applied by rolling them slowly from the foot up the leg. Firm, even pressure is essential, and the toes are exposed to check that they remain warm and pink and blood supply is not impeded by the stockings. For clients requiring surgery, additional preventive measures may include antithrombotic agents pre- and postoperatively (Berman et al 2012; Crisp & Taylor 2009; Farrell & Dempsey 2011).

Prevention of postural hypotension

Prevention involves the gradual reintroduction of ambulation and allowing clients time to adjust to changes such as moving from a lying to a sitting or standing position (see ‘dangling technique’ earlier in this chapter).

Development and management of pulmonary embolus

Management of emboli in the pulmonary system includes administration of oxygen, analgesia and anticoagulant therapy. When immobilised, a person’s pulmonary system declines in function and effects are related to a decrease in the rate and depth of breathing and effort, as well as an increase in bronchial secretions. Lung expansion decreases and breathing deeply is inhibited. In addition, secretions pool in the bronchial tract, which predisposes clients to respiratory tract congestion and infection. Hypostatic pneumonia may result and the risk increases when a person is dehydrated or is given medication that causes respiratory depression, such as morphine.

Atelectasis, or collapse of the lung, may occur and inhibits gaseous exchange at the alveoli. This results in hypoxaemia. Signs and symptoms of lung congestion include a cough and production of sputum, rattling, distressed or painful breathing and increased body temperature (Berman et al 2012; Crisp & Taylor 2009; Farrell & Dempsey 2011).

Prevention of pulmonary stasis

Preventing pulmonary stasis includes nursing clients sitting up when possible and encouraging coughing and deep breathing. Deep breathing exercises are performed with the person in a sitting position. The nurse places one hand on the chest and the other on the abdomen just below the ribs. The client is instructed to inhale slowly and deeply, pushing the abdomen out to promote optimal distribution of air to the alveoli, then breathe out through pursed lips while contracting their abdomen, which forces air out of the lungs. Pursed-lip breathing improves oxygen diffusion, encourages a slow deep-breathing pattern and puts positive back-pressure on the airways so that they stay open longer and expel greater amounts of stale air. Abdominal contraction pushes the diaphragm upwards, exerts pressure on the lungs and helps to empty them. After several breaths, clients are encouraged to cough up sputum.

Additional chest physiotherapy such as postural drainage and chest percussion and vibration may be added. Fluids should be increased (provided there are no contraindications) to help liquefy secretions and facilitate coughing up secretions or phlegm. Oxygen therapy may be necessary, and medications such as antibiotics may be prescribed if infection is present. Analgesia is offered before chest physiotherapy begins. Nebulisation using normal saline can loosen secretions for ease of expectoration (Berman et al 2012; Crisp & Taylor 2009; Farrell & Dempsey 2011).

Urinary stasis

Immobility can lead to retention of urine, urinary tract infection or renal calculi. Difficulty in using the pan or bottle in bed can result in incomplete bladder emptying and stasis of urine. Immobility reduces the amount of circulating lactic acid, which leads to alkaline urine (i.e. high urinary pH values) and, together with excess blood calcium (which is excreted by the kidneys), may result in kidney stones.

Prevention and management of urinary stasis

To prevent stasis of urine, nurses promote an adequate intake of fluids (unless contraindicated), and ensure that clients understand the importance of not postponing urination and of the need to empty the bladder completely. Management depends on the cause and includes increasing fluids and treating any infection (Berman et al 2012; Crisp & Taylor 2009; Farrell & Dempsey 2011). Information on elimination of urine and disorders affecting the urinary system is provided in Chapter 29.

Constipation

Constipation may occur as a result of decreased intestinal peristalsis due to reduced mobility or as a result of difficulty in using the bedpan in bed. Preventing and managing constipation includes promoting adequate fluids, exercise and fibre, as well as the appropriate aperient or suppository when required. Clients are encouraged to maintain as normal a routine as possible to promote normal bowel function. Information on bowel elimination is provided in Chapter 30.

Psychological effects of reduced mobility

Psychological stress, anxiety, depression or boredom can occur when a client is immobilised. Loss of independence occurs when clients have to rely on other people or aids to carry out activities of daily living. It interferes with all aspects of living, and people become bored by the lack of stimulation or variety. A change in the level of independence and physical impairment or isolation from family and friends result in feelings of depression, and people may also be anxious and feel worthless, irritable, apathetic and restless. Nurses need to try to improve clients’ self-esteem.

Clients are encouraged to participate in decisions regarding care, which allows some control over their life. Changes of environment may be beneficial; for example, some time spent in the day room or outside, reading, using the radio, TV or telephones may prevent boredom. Clients are encouraged to pursue hobbies or studies, or the occupational therapy department may be able to provide alternative activities. A social worker may assist with any problems about finance or the home situation. Flexible visiting hours are important, as well as communication with clients showing concern, respect and empathy, active listening and providing information about care and treatment. It is important that clients are allowed to express their emotions (Berman et al 2012; Crisp & Taylor 2009; Farrell & Dempsey 2011).