Chapter 22 Mobility and Safety

1. Chapter 22 Mobility and Safety

2. Introduction • Mobility is the most important aspect of physiologic function. • Maintenance for independence • Risks affecting mobility • Falls and fractures • Safety is the integral aspect of mobility.

3. Age-Related Changes That Affect Mobility and Safety • Bones • Framework for musculoskeletal system • Age-related changes • Increased bone resorption, diminished calcium absorption, increased serum parathyroid hormone, impaired regulation of osteoblast activity, impaired bone formation secondary to reduced osteoblastic production, fewer functional marrow cells, and decreased estrogen in women and testosterone in men

4. Age-Related Changes That Affect Mobility and Safety—(cont.) • Muscles • Directly affects all activities of daily living (ADLs) • Age-related changes • Decreased size and number of muscle fibers, loss of motor neurons, replacement of muscle tissue by connective tissue, deterioration of muscle cell membranes, diminished protein synthesis • Sarcopenia: loss of muscle mass, strength and endurance

5. Age-Related Changes That Affect Mobility and Safety—(cont.) • Joints and connective tissues • Harmed by continued use and begin to show wear and tear during early adulthood • Age-related changes • Diminished viscosity of synovial fluid, degeneration of collagen and elastin cells, fragmentation of fibrous structures in connective tissue, outgrowths of cartilaginous clusters, formation of scar tissue and areas of calcification in joint capsules and connective tissue, and degenerative changes in articular cartilage

6. Age-Related Changes That Affect Mobility and Safety—(cont.) • Nervous system • Age-related changes • Central and peripheral nervous system may be primary mechanism in diminished muscle function • Maintenance of balance • Altered visual abilities, slower righting reflex, impaired proprioception, diminished vibratory and positioning sensations in lower extremities • Body sway: measure of motion of the body while standing

7. Age-Related Changes That Affect Mobility and Safety—(cont.) • Osteopenia and osteoporosis • Loss of bone: age-related change • Bone density: amount of minerals in bone • Scored according to standard deviations • T-score: between 1 and 2.5 diagnosis is osteopenia • Lower T-score is diagnosis of osteoporosis • Osteoporosis: silent disease • Fragility fracture: little to no trauma

8. Question Is the following statement true or false? Exercise programs to increase strength and endurance in the older adult population may help delay the onset of the age-related functional consequences of decreased strength and endurance.

9. Answer True Age-related changes in skeletal muscles, which are controlled by motor neurons, directly affect all activities of daily living. The result of these age-related changes is a decline in motor function and a loss of strength and endurance, even in healthy older adults. Exercise programs to increase strength and endurance may help delay the onset of the age-related consequences of disability and loss of function.

10. Question Which statement about osteoporosis is true? • Primary osteoporosis occurs with pathologic problems. • Secondary osteoporosis occurs as a result of age-related changes. • Osteoporosis can cause serious negative functional consequences even in the absence of additional risk factors. • Estrogen levels have a minimal impact on the development of osteoporosis.

11. Answer C. Osteoporosis can cause serious negative functional consequences even in the absence of additional risk factors. Osteoporosis is a gradual loss of bone mass that affects all adults to some degree and is strongly associated with low-trauma fractures in older adults. Osteoporosis is classified as primary when it is associated with age-related changes and as secondary when it is caused by medications or pathologic disturbances.

12. Risk Factors That Affect Mobility and Safety • Risk factors that affect overall musculoskeletal function • Lacking physical activity and nutritional deficits • Vitamin D: essential for the absorption of calcium and bone health • Calcium: essential for good musculoskeletal function • Other dietary factors that increase risk • Low intake of high-quality proteins • Inadequate food sources of vitamin B12 and folic acid

13. Risk Factors That Affect Mobility and Safety—(cont.) • Risk factors for osteoporosis and fragility fractures • Inadequate calcium and vitamin D intake • Lack of weight-bearing activity • Hormonal changes with regard to estrogen in women • Small bones • Increased age • Tobacco use • Excessive alcohol consumption • Certain medications

14. Risk Factors That Affect Mobility and Safety—(cont.) • Risk factors for falls • History of falls • Use of walking aids • Pathologic conditions and functional and cognitive impairments • Medication effects • Environmental factors • Physical restraints

15. Question Which statement related to risk factors for falls and the older adult is true? • Falls are most often the result of an isolated risk factor. • The risk of falling increases in proportion to the number of risk factors. • Risk factors for falls do not vary according to the environment. • Functional abilities of the older adult are not considered a risk factor for falls.

16. Answer B. The risk of falling increases in proportion to the number of risk factors. Falls are the result of a combination of risk factors rather than one isolated risk factor, and the risk of falls increases in proportion to the number of risk factors.

17. Pathologic Condition Affecting Musculoskeletal Function: Osteoarthritis • Osteoarthritis: degenerative inflammatory disease affecting joints and attached muscles, tendons and ligaments • Characterized by pain, swelling and limited movement of joints • Leading cause of disability • Risk factors • Trauma, genetics, obesity and age-related changes • Focus: self-care health education interventions

18. Functional Consequences Affecting Musculoskeletal Wellness • Effects on musculoskeletal function • Diminished muscle strength, endurance and coordination, increased difficulty performing ADLs • Susceptibility to falls and fractures • Osteoporotic fractures, increases with age, serious consequences • Fear of falling • Excessive anxiety about falling

19. Question Which statement related to musculoskeletal function and the older adult population is true? • There is a greater decline in muscle strength in the upper extremities. • Diminished muscle strength is attributed primarily to age-related loss of muscle mass. • Older adults experience muscle fatigue after longer periods of exercise than do younger adults. • Lifelong patterns of exercise and activity have little effect on muscle strength.

20. Answer B. Diminished muscle strength is attributed primarily to age-related loss of muscle mass. Beginning at about the age of 40 years, muscle strength declines gradually, resulting in an overall decrease of 30% to 50% by the age of 80 years, with a greater decline in muscle strength in the lower extremities than in the upper extremities.

21. Nursing Assessment of Musculoskeletal Function • Assessment of overall musculoskeletal performance • Assessing musculoskeletal performance • Identifying risks for osteoporosis • Identifying risks for falls and injury

22. Nursing Diagnoses • Wellness nursing diagnosis: readiness for enhanced self-health management • Related to osteoporosis: health-seeking behaviours, ineffective health maintenance • Related to fall risks: impaired physical mobility, risk for falls • Additional diagnoses that address fear of falling: fear

23. Planning for Wellness Outcomes • Balance, endurance, mobility, activity tolerance • Risk control, risk detection • Safety behavior: fall prevention, home physical environment • Coping, fear control, comfort level

24. Nursing Interventions for Musculoskeletal Wellness • Promoting healthy musculoskeletal function • Teaching about osteoporosis • Preventing falls and fall-related injuries • Addressing intrinsic risk factors • Addressing extrinsic risk factors • Using monitoring devices in institutional settings • Providing assistance in independent settings • Addressing fear of falling • Promoting caregiver wellness

25. Nursing Interventions for Musculoskeletal Wellness—(cont.) • Implementing fall-prevention programs • Eliminating risks • Using monitoring devices • Addressing contributing factors • Preventing fall-related injuries and death • Hip protectors • Environmental interventions • Addressing fear of falling

26. Question Which statement related to adequate calcium supplementation and the older adult is true? • Calcium supplements are rarely necessary. • Calcium supplementation lowers the rate of fractures in older adults. • Calcium supplements have few detrimental effects when taken by older adults. • Absorption of calcium supplements is optimal at 1,500 mg per dose.

27. Answer B. Calcium supplementation lowers the rate of fractures in older adults. A recent report from the U.S. Surgeon General and published on Health Canada’s website recommended a pyramidal treatment approach to osteoporosis that includes physical activity, fall prevention and supplementation with calcium and vitamin D as the foundation for fracture prevention. Absorption of calcium supplements is optimal at not more than 600 mg per dose.

28. Evaluating Effectiveness of Nursing Interventions • Evaluation based on person’s ability to achieve and maintain highest possible level of independence and safe mobility • Incorporation of preventive measures in daily life to ensure safety and prevent osteoporosis • Expressed feelings of safety and improved quality of life • Evaluation of risk factors