Gerontological Nursing

(Muskuloskleletal Disorder)
LEARNING OUTCOME 1
Explain normal changes in the musculoskeletal system
associated with aging.
Musculoskeletal System Components
• Muscles
• Ligaments
• Bursae
• Joints
Figure 18-1
Structure of a synovial joint.
Normal Changes of Aging
• Increased complaints of musculoskeletal pain
• Joint limitations
• Increased development of osteoporosis and arthritis
Figure 18-2
Normal changes of aging in the musculoskeletal system.
Significant Alterations Causing Musculoskeletal Changes
in Older Adults
• Human structure
• Function
• Biochemistry
• Genetic patterns
Normal Skeletal Changes of Aging
• Type 1
• Menopausal bone loss
• Rapid bone loss affecting women in the first 5–10 years after menopause
• Type 2
• Senescent bone loss
• Slower phase affecting both sexes after midlife
Normal Skeletal Changes of Aging
• Bones become stiffer, weaker, and more brittle
• Changes in appearance noted after fifth decade
• Loss of height
• Postural changes
Normal Skeletal Changes of Aging
• Disproportionate size of long bones of arm and legs
• Seen in eighth and ninth decades
• Kyphosis
• Backward tilt of the head for eye contact
Normal Muscle Changes of Aging
• Muscle function varies with aging
• Trainable into advanced age
• Regeneration remains normal
• Muscle mass: sarcopenia
• Strength
• Slow decline
• Reduced stamina by age 50
• Decrease of 65% to 85% of mid-twenties stamina by age 80
Normal Joint, Ligament, Tendon, and Cartilage
Changes of Aging
• Erosion of joint linings
• Thinning knee cartilage
• Ligaments, tendons, and joint capsules
• Lose elasticity
• Reduced range of motion
• Stiffening of collagen
LEARNING OUTCOME 2
Identify risk factors for the older person related to
common musculoskeletal problems.
Falls and the Older Person
• Most occur in home during normal routines
• Leading cause of accidental death
• 7th leading cause of death in persons over age 65
• Fall-related deaths increase with age
Falls and the Older Person
• National Center for Injury Prevention and Control (NCIPC, 2006)
Statistics
• Cost of falls over 19 billion
• Costs expected to rise to over 43.8 billion in 2020
• More than 1:3 people over age 65 sustain a serious fall
• Among older adults, falls are most common cause of injury deaths
Falls and the Older Person
• National Center for Injury Prevention and Control (NCIPC, 2006)
Statistics
• Nearly 85% of deaths from falls in 2004 among people 75 and older
• Among older adults, majority of fractures caused by falls
• Osteoporotic fractures of hip, spine, and forearm most common fall-related
injuries
Falls and the Older Person
• National Center for Injury Prevention and Control (NCIPC, 2006)
Statistics
• Risk of aging increase likelihood of hip fracture
• Of all fall-related fractures, hip fractures cause the greatest number of deaths
• After a hip fracture, 1:4 older people are in an institution for at least one year;
many never return home
Falls and the Older Person
• Fall prevention
• Key goal of gerontological nursing practice
• Goals
• Recognition of at-risk persons
• Identify and correct risk factors
• Improve balance, gait, mobility, and functional independence
• Reduce or eliminate environmental factors contributing to fall risk
Hip Fracture
• Responsible for approximately 390,000 hospital admissions
• 95% of hip fractures in older adults caused by falls
Hip Fracture
• Causes
• Low-energy trauma
• Home environment unsafe
• History of falls
• Unable to bear weight
• Hip fractures include upper third of femur
• Intracapsular
• Extracapsular
Hip Fracture
• Assessment
• Injured leg shortened
• Externally rotated
• Extreme pain prevents movement
LEARNING OUTCOME 3
List nursing diagnoses of older persons related to
common musculoskeletal problems.
Impaired Physical Mobility Related to Stiffness, Pain, Joint
Contractures, and Decreased Muscle Strength

• The state in which an individual experiences a limitation of ability for

independent physical movement
• Major defining characteristics
• Inability to purposefully move within the physical environment
• Limited range of motion
Impaired Physical Mobility Related to Stiffness, Pain, Joint
Contractures, and Decreased Muscle Strength

• Minor defining characteristics

• Decreased muscle strength
• Reduced muscle control
• Inability to sit unsupported
• Impaired coordination
Other Nursing Diagnoses
• Acute Pain related to progression of inflammation
• Chronic Pain related to joint abnormalities
• Fatigue related to pain and systemic inflammation
Other Nursing Diagnoses
• Body Image Disturbance related to chronic illness, joint deformities,
impaired mobility
• Ineffective Coping related to personal vulnerability in a situational
crisis
LEARNING OUTCOME 4
Discuss the nonpharmacological management of the
older person with common musculoskeletal problems,
including osteoporosis, osteomalacia, Paget’s disease,
osteoarthritis, rheumatoid arthritis, gout, pseudogout,
and hip fractures.
Diagnostic Tests Used in the Management of
Musculoskeletal Disorders
• Bone mineral density test
• Dual energy X-ray absorptiometry (DEXA)
• Patient lies on table
• Machine passes over body part being tested
• Minimal radiation exposure
• Results measured in standard deviations
• Problems
• Older adults have bone changes due to arthritis complicating results
• Cutoffs to determine diagnosis are arbitrary and must be considered with other factors
Diagnostic Tests Used in the Management of
Musculoskeletal Disorders
• Bone and joint radiography
• Basic imaging technology
• Used to diagnose and stage rheumatic disease and diagnose fractures
• Not sensitive enough to diagnose bone mineral density
Diagnostic Tests Used in the Management of
Musculoskeletal Disorders
• Computerized tomography
• Uses an X-ray machine rotating 180 degrees around body part
• Able to view inflammation and degeneration not visible on a routine X-ray
• Shows occult fractures and articular damage
Diagnostic Tests Used in the Management of
Musculoskeletal Disorders
• Magnetic resonance imaging (MRI)
• Uses large magnet and radio waves to produce energy field that can be
transferred to a visual image
• Does not show calcification or bone mineralization
Diagnostic Tests Used in the Management of
Musculoskeletal Disorders
• Bone scan
• Detects skeletal trauma and disease
• Determines the amount of the matrix the bone “takes up” of a bone-seeking
radioactive isotope
Diagnostic Tests Used in the Management of
Musculoskeletal Disorders
• Blood serum tests
• Rheumatoid factor (RF)
• An antibody that binds to the Fc fragment of immunoglobulin G
• Negative in early stages of disease
• Elevations in titers (> 1.320) predicts an increase in severity of symptoms and greater
disability and extra-articular disease
• Elevated in patients with liver disease, lung disease, and other conditions
• Not diagnostic for RA but can confirm diagnosis
Lifestyle Changes
• Increase exercise
• Weight loss
• Eat healthy diets
• Eliminate alcohol and caffeine intake
• Smoking cessation
Healthy People 2010
(www.health.gov/healthypeople)
• Nation’s goals and objectives for improved health
• Includes an objective for arthritis
Osteoporosis
• Nonpharmacological treatment of osteoporosis
• Assessment of risk factors
• Education
• Prevention
• Lifestyle changes
• Diet
• Exercise
• Risk factor modification
Osteoporosis
• National Osteoporosis Foundation recommendations
• Provide education to all women concerning risk factors
• BMD testing for any women who has had a fracture
• BMD testing for any women under 65 who has any risk factors for disease
development
Osteoporosis
• Lifestyle modification activities to prevent or treat osteoporosis
• Diet with adequate calcium and vitamin D
• Encourage weight-bearing exercise
• Reduce or eliminate smoking
• Reduce or eliminate consumption of beverages containing alcohol, caffeine,
and phosphorus
Nonpharmacological Treatment of
Osteomalacia
• Space activities to conserve energy
• Monitor safety measures for the home
• Evaluate home hazards
Nonpharmacological Treatment of Paget’s
Disease
• Evaluate diet
• Increase exercise
Nonpharmacological Treatment of
Osteoarthritis
• Education about disease process
• Weight reduction
• Exercise to promote pain relief and stiffness
• General and specific rest as needed
• Canes, crutches, and walkers to protect joints
Nonpharmacological Treatment of
Osteoarthritis
• Use of assistive technology to help with functional ability
• Surgical intervention as needed
• Apply heat to painful joints
• Use of cold applications
Nonpharmacological Treatment for
Rheumatoid Arthritis
• Reduction of joint stress
• Maintenance of joint function
• Promotion of independence
• Management of fatigue
Nonpharmacological Treatment for
Rheumatoid Arthritis
• Teaching guidelines
• Refer to local Arthritis Foundation
• Visit government Websites
• Caution concerning advertisements for treatments
• Exercise
Nonpharmacological Treatment for
Rheumatoid Arthritis
• Teaching guidelines
• Avoid positions of deformity
• Rest painful joints
• Weight loss
• Assistive devices
• Scheduled rest periods
Nonpharmacological Treatment for Gout and
Pseudogout
• Rest joint during attacks
• Increase fluid intake
• Apply cold
• Avoid heat if inflammation present
• Avoid high purine foods
• Avoid alcoholic beverages
• Maintain healthy weight
Nonpharmacological Treatment for Bursitis
• Exercise affected area
Nonpharmacological Treatment to Prevent Falls and
Fall-Related Injuries
• Assess for risk factors
• Assess functional mobility
• Education regarding how to recover from a fall
LEARNING OUTCOME 5
Explain the nursing management principles related to
the nursing care of older patients with arthritis.
Nursing Management Principles
• Assessment
• Pain assessment and control
Surgical Intervention
• Type of surgical procedure depends on
• Type of injury
• Patient’s condition
• Preexisting orthopedic conditions