Musculoskeletal Assessment & Mobility

Health History

• Do you have a condition resulting in curvature of the spine?

• Do you have neurologic disorders such as an injury to the head or spinal cord? h/o stroke? Seizures? Family h/o?

• Have you experienced any recent tremors or inability to control movements?

• Have you had a loss of function or weakness in joint or muscle? Impact on ADL?

• Have you had difficulty with maintaining balance or coordination? Recent falls?

• Do you have daily activities at home or work that involve heavy lifting or repetitive movement?

• Joint pain? Joint swelling, redness, or warmth?

• Numbness or tingling in hands or feet? H/o Diabetes?

• Back pain or spasms?

• Any h/o traumatic bone injury?

Assessment Overview

• What is your goal for your patients with regards to mobility and musculoskeletal function?

• ADLs, highest level of function

• History inquiry/subjective data gathering

• Inspect

• Palpate

• ROM

• Muscle testing: move w resistance, w gravity?

Pertinent health history questions?

• look at notes before

Musculoskeletal Assessment

• Assess for symmetry

• Support joints when assessing

• Take extra care when swollen, red, painful

• Use gentle movement when manipulating joints & always return joint to a neutral position of comfort for the client

• Avoid rapid, jerky movements

• Assess Fall Risk – use scale like Morse or Johns Hopkins

Morse Fall Scale

History of falling within the last three months

• No- 0

• Yes - 25

Secondary Diagnosis

• No- 0

• Yes- 15

Ambulatory Aid

• Bedrest/ Nurse Assist- 0

• Crutches/ Cane/ Walker- 10

• Furniture- 30

IV/ Heparin Lock

• No- 0

• Yes- 20

Gait/ Transferring

• Normal/ Bedrest/ Immobile-0

• Weak- 10

• Impaired- 20

Mental Status

• Oriented to own ability- 0

• Forgets limitations- 15

Just know major risk factors of fall!!! NOTE WHICH IS HIGHER THAN OTHERS!

What interventions can help prevent falls?

Hourly rounding, lowest bed setting, closer to nurses station, alarm, grippy socks, medication management

Morse Fall Scale

• No Risk 0-24

• Low Risk 25-50

• High Risk >50

Do periodically, circumstances change

Inspection & Palpation

Inspection

• Inspect joints, muscles, and bone structure:

• What are you assessing for?

spinal curvature, swelling, discoloration, difference in usage, scarring, skin abnormalities

• Observe client’s gait.

• Postural misalignment

• kyphosis: hunchback

• lordosis: lower, pregnancy

• scoliosis: C or S shape

Palpation

• Palpate for warmth, tenderness, muscle tone, and crepitus (crackling/grinding sound in joints)

• crepitus: arthritis, cartilage issues, aging

UNEXPECTED FINDINGS

Contractures

• Joint deformity from tightening of connective tissue, limiting ROM.

• Results in disuse, atrophy and shortening of muscles – typically legs, arms, hands

• Foot drop – inability to dorsiflex What interventions are required for these patients?

Range of Motion (ROM)

• Active = client moves joint without assistance

• Passive (P ROM) = when we move the muscle/joints for the client

• Do NOT extend muscle further than point of resistance or when painful

• What is the purpose of P ROM?

• prevent atrophy in joint, helps prevent contractures and helps circulation

• What patient populations would require P ROM?

• What would be expected findings when assessing ROM?

Muscle Testing

Muscle Testing

• Testing the STRENGTH of the muscle group

• Perform ROM and apply opposing force

• Should be able to maintain position against resistance bilaterally

• Muscle grading scale (Know this scale):

• Grade 5: Full ROM against gravity, full resistance

• Grade 4: Full ROM against gravity, some resistance

• Grade 3: Full ROM with gravity (diff w heavy lifting)

• Grade 2: Full ROM with gravity eliminated (passive): if supported, patient can move it.

• can move on table but without table, cant know

• Grade 1: Slight contraction

• Grade 0: No contraction

Muscle Testing

• Expected findings:

• Maintain the position of the joint against resistance

• Equal exertion/strength on both sides

• Grade 4-5/5

• Unexpected findings:

• Muscle grade </= 3/5

• Discomfort

• Unequal muscle testing

• Ex: Right arm 4/5, left arm 2/5

Nursing Considerations: MSK Injuries

Nursing Considerations: MSK Injuries

• Collect subjective data regarding injury

•how and when happened?, PQRST

• Assess for pulses, sensation, color, temperature, cap refill, swelling in affected extremity. Compare to opposite extremity.

• For musculoskeletal injury → Think PRICE

• Protect

• Rest

• Ice or intermittent cold therapy

• Compression

• Elevate

Mobility Assessment

 Evaluates how well a client can move, including which specialized equipment or aids are needed to maximize their mobility potential

 Includes an assessment of:

 Normal mobility status

 Ability to sit, stand, walk

 Use or need for assistive devices

 Degree of mobility & immobility

 Condition of skin

 Presence of any manifestations during activity

 Assess tolerance of activity

 Activity intolerance inadequate amount of physical/physiological energy

 How might this present in your patient?

 Activities of daily living (ADL) are basic essential skills that a person does independently every day and are usually related to personal care.

 Dressing, bathing, toileting, feeding oneself, ambulating

 Assistive Devices – walker, wheelchair, shower chair, etc.

 Home assessment: What does pt have vs what does pt need?

 A mobility assessment should be performed prior to initially mobilizing client & repeated every 24 hours

 Standardized mobility assessment tool (MAT) – objectively determine a client’s mobility level

 4 levels

• 1 = Max assistance: cannot bear weight, assist, or maintain seated position.

• Use total mechanical lift or sling. (at least 2 person)

• 2 = Moderate assistance: can maintain seated position, has some upper ex. strength, lacks lower ext. strength; use sit-to-stand powered lifts and assistive devices (at least 2 person)

• 3 = Min assistance: can rise from seated position & stand steady; use gait belt and ambulation devices as needed (1-2 person)

• 4 = No assistance: can stand, march, or step in place; walks without help

LOOK AT ATI MOBILITY TOOL!!!

Generalized Nursing Interventions & Multidisciplinary Care

Generalized Nursing Interventions

• Bedrest – encourage movement of extremities often, sitting client with legs dangling from bed, ROM activities in bed

• Encourage independence as much as possible, but help where pt needs it

• Encourage ambulation (Use ambulation devices)

• Teach and promote weight-bearing activities

• Safety - Protect clients from falls and injuries

• Use splints to support & strengthen joints if joint contractures present

Multidisciplinary Care

• Involve interprofessional health care team members:

 Physical Therapists

 Occupational Therapists

 Speech Therapists/Pathologist

 Dietitian

 Respiratory Therapists

Effects of Decreased Mobility & Nursing Interventions - CV

Effects of Decreased Motility

 Cardiac Deconditioning

 Heart muscle atrophy decreasing cardiac output

 Orthostatic hypotension

 DVT

 Thrombus develops in one or more deep veins (arms, pelvis, thighs, lower legs)

 Increased risk of forming d/t increased blood viscosity & atrophy of muscles that normally pump the blood → venous stasis

Nursing Interventions - CV

 Elevate HOB to promote blood flow

 Educate client about orthostatic hypotension

 Encourage client to change positions slowly

 Antiembolism stockings (TED)/socks to decrease venous pooling

 Sequential Compression Device (SCDs) to promote venous return

 Leg exercises in bed to promote contraction of the LE muscles & venous return

 Ambulate client frequently, when able

 Encourage fluid intake

 Prophylactic anticoagulation if ordered

Effects of Decreased Mobility & Nursing Interventions - Respiratory

Effects of Decreased Mobility - Respiratory

 Reduces the amount of air exchanged & increases risk of infection

 Supine positioning impairs ability of the ribcage to freely expand, shifts abdominal organs toward diaphragm (decreases the depth of breaths & effectiveness of cough)

 Atelectasis (partial or complete collapse of alveoli); decreases number of alveoli available for gas exchange

 Pneumonia – resulting from shallow breathing, thickened mucus, & decreased ability to cough

Nursing Interventions – Respiratory

 Monitor SpO2 levels, RR, lung sounds

 Supplemental O2 when needed

 Elevate HOB at least 30-45 degrees – to encourage deep breathing

 Use of incentive spirometer q 1 h while awake

 Deep breathing & cough exercises

 Turn & reposition client every 2 hours

 Encourage fluid intake

Effects of Decreased Mobility & Nursing Interventions- GI

Effects of Decreased Mobility - GI

 Constipation d/t slower peristalsis. Prolonged transit time increases absorption of water from the feces, causing drier, harder stool

 Fecal impaction (blockage)

 Gastroesophageal reflux – supine positioning places more pressure on the LE sphincter, which causes backflow of gastric fluids and damages the lining of the esophagus

Nursing Interventions - GI

 Early & often ambulation, when able & as client can handle

 Encourage fluid intake

 Monitor appetite and intake

 Assess weight, consider labs related to nutrition (albumin, glucose, electrolytes, etc.)

 Encourage high-fiber foods

 Consult dietitian for malnourished clients; will need extra guidance and special diet considerations

 Elevate HOB after meals to reduce GERD

Effects of Decreased Mobility & Nursing Interventions

Effects of Decreased Mobility - GU

 GU System Effects

 Gravity enhances drainage of urine from kidneys, so lying supine leads to urinary retention

 Incomplete drainage of kidneys & urinary retention often leads to increased risk for renal calculi & UTI

Nursing Interventions - GU

 Encourage fluid intake

 Sitting upright during urination, if possible, to promote bladder emptying

 Get client up to bathroom/BSC as often as possible

 Increase activity to promote voiding

 Pericare

Effects of Decreased Mobility & Nursing Interventions - Skin

Effects of Decreased Mobility - Skin

 Pressure injury – Stage I – IV, unstageable

 Moisture Associated Skin Damage

 Skin that is exposed to moisture are at even greater risk for skin breakdown

Nursing Interventions - Skin

 Reposition q 2

 Use pillows & cushions to support joints/bony prominences

 Use pressure redistribution devices & mattresses to decrease pressure to susceptible areas

 Moisturize dry skin (to prevent cracking/skin breakdown/infection)

 Barrier creams

 Ensure intake of calories, proteins, & micronutrients to promote wound healing

Effects of Decreased Mobility - Psychological

Effects of Decreased Mobility - Psychological

 Increased dependence on others

 Loss of privacy

 Inability to participate in work and hobbies

 All negatively impact self-concept, self-esteem

 Nursing interventions

 Monitor emotional status each shift

 Encourage client to express feelings

 Communicate support & empathy

 Get support system involved

Assisting w/ ADLs & Activity Orders

 Toileting: Bedside Commodes, toilet seat raisers

 Bathing: Shower chairs

 Ambulating: Cane, walker, wheelchair, gait belt

 Oral Care

Activity Orders

 Ad lib

 Bed rest (BR)

 Up to chair

 BR w/ bathroom privileges (BRP)

Mobility Support

Ambulation

 Improves muscle & joint strength

 Prevents complications of immobility

 Decreases client’s LOS in hospital

 Promotes well-being & independence

 Assess mobility PRIOR to ambulating

 Assess for orthostatic hypotension. Instruct pt to change positions slowly, waiting a few mins with each position change & dangle feet

 NON-SKID socks

 Declutter room – nothing blocking client’s path to walk

Assistive Devices for Ambulation

 Gait Belt

 Cane

• Top of cane should be level with inside of the wrist, elbow bent at 15–30-degree angle

• Cane on strong side

• Supporting weight on the stronger leg and the cane, the patient moves weaker foot forward parallel with the cane. Supporting weight on the weaker leg and the cane, the patient brings the stronger leg forward to finish the step.

 Assistive Devices for Ambulation

 Walker

 Top of walker level with wrist, elbows should be bent at 15-degree angle

 Patient lift the walker (without wheels) ahead of themselves and step into it – usually patient will place weaker leg into the walker, keeping walker still. Then step forward with the remaining leg into the walker, keeping walker still. Repeat by moving walker forward

Mobility Support 2

Assistive Devices for Ambulation

 Crutches

 Must be able to use upper body strength

 Crutch pads rest 1–2 inches below axilla

 Hand grips level with hips

 Elbows at 15–30-degree bend when holding grips

 Body weight supported by HANDS on the grip, NOT the axilla  leads to nerve damage

Assistive Devices for Ambulation

 Wheelchair

 When putting pt into wheelchair, footrests are up & brakes on locked. Consider angling wheelchair to bed

 Once pt is in wheelchair, place pt’s feet on footrests; don’t let pt’s feet dangle or force them to hold them up

Proper Positioning

• When adjusting a patient in bed, use a friction-reducing sheet (slide sheet)

• Call for help when possible

Body Mechanics

• Involves the combined effort from the musculoskeletal and nervous systems to maintain posture, alignment, and balance in daily life.

• Proper body mechanics is good posture in motion.

When a person does not move safely and correctly, abnormal stress is placed on the spine resulting in injury or degeneration from wear & tear on the spinal structures

• Proper body mechanics lowers the risk for injury by reducing stress & strain on the body

• Three key principles of body mechanics:

1. Body alignment

2. Balance

3. Body movement

Body Alignment

 Positioning of the body while performing activities

 Optimal posture supports spine, muscles, and joints

 Based on an imaginary line that passes vertically through the body dividing it into two equal halves

 When handling clients or lifting objects, keep back straight, chin level, and tighten abd. muscles throughout task

Balance

 Center of gravity is the central point of weight for an object or the body

 Creating a wide base by spreading the feet shoulder width apart and flexing the knees improves stability and balance

Body Movements

 Reaching, bending, and twisting motions can increase the risk of muscle strain and injury

 Ensure client or object that you are handling is close to your body as possible

RESTRAINTS

RESTRAINTS

• Least restrictive device to achieve the necessary immobility required to protect the client and others

• Correct size

• Correct type

RESTRAINTS SAFETY

• The fastener of the closure strap should be positioned on the outside of the restraint

• Check that one to two fingers can fit between the restraint and the client’s skin

• Do not secure to side rail

• Use a quick-release knot to tie the restraint

RESTRAINTS DOCUMENTATION

• Remove each restraint one at a time for 15 minutes every 2 hours or per facility policy.

• Check the client for skin breakdown, circulatory impairment, and positioning of medical devices (such as peripheral IVs), pain, and ROM. Address the client’s fluid, food, and toileting needs.

• Reapply restraints

• VS and oxygen saturation (per facility policy)

• Circulatory status to restrained extremity: capillary refill, pulse distal to the restraint device, color, and temperature.

• Skin integrity under the restraint device and, if present, under the padding

• IV catheter and site of any other device that may be under the restraint