Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiological changes to the patient’s musculoskeletal system when in the intensive care unit
- Describe the medical assessments and therapies that apply to the critical care patient’s musculoskeletal system
- Apply nursing concepts and plan associated nursing care for the critical care patient’s musculoskeletal system
When receiving medical care in critical care settings, patients are often confined to their hospital beds for long periods. Although these medical interventions are necessary for sustaining life, musculoskeletal complications may arise from prolonged periods of immobility. These complications include muscle atrophy, or the severe loss of muscle mass, and the development of contractures, resulting in short, stiff joints. Both conditions have the potential to negatively affect the patient’s quality of life and ability to perform activities of daily living long after they are discharged from the hospital. For this reason, thorough musculoskeletal assessments should be performed frequently on critically ill patients, and early mobility is encouraged as tolerated and appropriate for the patient’s condition.
Pathophysiological Insult to the Critical Care Patient’s Musculoskeletal System
Many critically ill patients who survive their acute illness report lingering physical limitations after discharge from the hospital. These limitations often affect both personal and professional aspects of life and can contribute to an overall lower quality of life. Most often, these limitations stem from severe muscle atrophy and contractures caused by prolonged immobilization in the ICU.
When patients are confined to bed for long periods, they are unable to effectively use their upper and lower extremity muscles, resulting in overall loss of muscle tone and subsequent atrophy (Figure 35.14). Immobility may also result in contractures because patients are unable to adequately perform full range of motion and other exercises independently. When patient extremities are held in one position for long periods, a permanent contracture can result. Contractures are especially common in the hands and feet of critically ill patients because of the way they are positioned in bed. The high incidence of muscle atrophy and contractures in critical care settings highlights the need for frequent musculoskeletal assessment and the promotion of early mobility strategies.
Assessment and Early Mobilization
Prevention and treatment of muscle atrophy and contractures in the ICU should be a priority of nursing care to reduce the risk of permanent physical disability after discharge. Prevention and treatment strategies include frequent musculoskeletal assessment, promotion of early mobility, and physical and occupational therapies for critically ill patients. Additionally, other efforts such as optimal nutrition and fluid status help ensure the patient will be able to participate in early mobilization strategies.
Musculoskeletal Assessment
As part of the thorough physical assessment performed at least once per shift, the critical care nurse should assess the musculoskeletal system. This assessment provides baseline information about the patient’s muscular function and can be compared with subsequent assessments to determine if the patient is at risk for developing atrophy or contractures. The components included in this assessment are listed and described in Table 35.13.
| Assessment | Description and Rationale |
|---|---|
| Inspection and palpation |
|
| Range of motion (ROM) |
|
| Muscle strength |
|
Nursing Care for the Prevention of Musculoskeletal Declines
Although the acuity of the critically ill patient may deter progressive interventions to prevent musculoskeletal decline, the status of the patient will determine which interventions can be used. In addition to nutrition, the intent of early movement when clinically tolerated has demonstrated therapeutic effects on musculoskeletal decline of the critically ill patient.
Promotion of Early Mobility
Historically, critically ill patients were kept confined to bed; they were not ambulated or exercised at all for fear that it would negatively affect their healing process or increase their risk of falls. However, in recent years, earlier mobility during hospitalization in the ICU has been promoted. Studies have shown that the implementation of early mobility in critical care settings has greatly reduced the length of hospital stays and decreased the severity of physical disability experienced by patients after discharge (Bergbower et al., 2020).
Early mobilization of a critically ill patient requires collaboration among interdisciplinary teams, principally the nursing staff and physical and occupational therapists. It is important that the therapists have at least a basic knowledge of the invasive equipment the patient will be connected to while ambulating, such as a ventilator or chest tubes. Additionally, it is important that the nurse can effectively physically assist the therapists to help the patient ambulate or move as they are able. Hospitals and specific units will have varying protocols for early mobilization, but it is not uncommon to see critically ill patients walking in the unit hallways while still connected to life-saving medical equipment, to prevent future musculoskeletal complications. An interdisciplinary approach using input from physical and occupational therapists and case managers should guide the discharge planning. Anticipation of care needs is an ongoing evaluation and can be adjusted when the patient’s acuity stabilizes. Above all, keep in mind that readiness to progress to a medical-surgical floor is an ongoing process.
Promotion of Nutrition on Musculoskeletal Health
Critical illness depletes necessary nutrients to combat illness. Because of increased metabolic demands, loss of muscle tone leads to muscle atrophy. A randomized control trial examined the role of nutrition and exercise on decreasing loss of muscle mass in the critically ill population (Chapple et al., 2022). With respect to nutritional modalities, parenteral nutrition consisting of amino acids and protein in that study was found to have prospective benefits of reduced incidence of muscle wasting in the critically ill patient. Ultimately, the benefits of early mobilization and addressing nutritional needs maximize positive outcomes on reducing muscle wasting and preserving caloric reserves. Nurses must advocate for these essential components when considering the musculoskeletal needs of the critically ill patient.