Nursing Care of the Patient with Musculoskeletal System Problems

General Principles

Rest is the essential therapy

Promotes the healing process

Elevation of affected body part above the level of the heart

Decreases Edema

Immobilization and alignment

Complications of rest/immobility

Pneumonia

Temp 101 >

Thrombophlebitis

Demineralization of bone

Muscle atrophy

Urinary stasis

Renal calculi

Constipation

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 Pressure ulcers

General Principles of Nursing Care

Body parts must be in alignment

Prevent foot drop

Logrolling

Body is moved as one unit using two or more individuals, aligning

with pillows, blankets, etc.

General Principles

Circulatory/Neurovascular Checks The 5 Ps

Pulselessness

Pallor

Pain

Parasthesia

Paralysis

Review

Quickly review stages of bone healing

Hematoma

Inflammation and neovascularization

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 Reparative phase

Ossification

Remodeling
Found on page 1766 of text

Managing the Patient in a Cast

Plaster Cast

24-72 hrs to dry completely

Nonplaster fiberglass cast

lighter

relatively waterproof

support earlier mobilization

used when multiple casts not needed & severe edema not present

Bivalve casts

Cast cut in half to allow for inspection of underlying skin, relieve pressure,
change dressings

Resecured with elastic compression bandage to maintain immobilization

Nursing Diagnoses

Knowledge deficit

Pain

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 Impaired physical mobility

Self-care deficit

Risk for impaired skin integrity

Risk for peripheral neurovascular dysfunction (5 Ps)

Potential Complications

Compartment syndrome

associated with extensive soft tissue damage or crush injury.

Forearm & lower leg most common sites

Occurs when there is increased pressure within a limited space

Compromises circulation and tissue function

Compartment syndrome

watch for decreased circulation, pain, motor loss, numbness,

tingling, sensory loss, paleness

Interventions

Notify MD

elevate extremity to heart level

Bivalve the cast

Surgical intervention: fasciotomy

Complications

Pressure ulcer/necrosis

heels, ankles, dorsum of foot, patella, head of fibula

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 pain

heat palpable through cast

tissue breakdown with drainage

odor to cast

Interventions: bivalve, cut a window

Complications

Disuse syndrome

isometric exercises hourly in the cast

quadriceps- & gluteal- setting (see Chart 61-2)

make a fist

exercise fingers and toes

Nursing care review

Check neurovascular

Check integrity of cast (note any rough edges)

Check for drainage and odor

Teach exercises

Instruct patient on what to report

Rest & elevation

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 Management of Fractures with Soft Tissue Damage

External Fixator - provides stable support for comminuted (crushed or

splintered) fracture

metal pins inserted into the bone and attached to external rods

fracture is reduced, aligned, and immobilized by pins inserted in the

bone fragments

Nursing Care

Ensure sharp points are covered

Elevate extremity

Neurovascular checks q 2hr (5 Ps)

Assess pin site for:

redness, drainage, tenderness, pain, loosening of pin

Pin care tid

Isometric exercises

Weight-bearing as ordered

Teach self care

Remember

DO NOT adjust the clamps on the external fixator.

Managing the Patient In Traction

Traction applies a pulling force to establish realignment

Traction Types:

Skin traction
Bucks, Russells, Dunlops, Pelvic belt & pelvic sling, Head halter

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 Skeletal traction applied to bone
Fx of femur, tibia, humerus & cervical spine

traction applies with metal pin or wire

Thomas splint in femur fractures

Nursing Care

Skin Traction

check weights & pulleys

skin breakdown
special mattress if must be supine

circulation checks
pulses, color, temp, capillary refill, DVT

neuro check to extremities

peroneal nerve - dorsiflexion

tibial nerve - plantar flexion

ulnar nerve - little finger movement & sensation

traction exercises
Skeletal traction

Skeletal Traction

check weights and pulleys

check position - pull patient up in bed

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 DO NOT remove weights unless an emergency!

maintain body alignment

skin breakdown

neurovascular checks (5Ps)

isometric exercises & trapeze

pin care
prevent osteomyelitis

Nursing Diagnoses

Knowledge deficit

Anxiety

Pain

Self-care deficit

Impaired physical mobility

*Risk for all problems associated with bedrest: pressure ulcers,

pneumonia, constipation, urinary stasis, DVT

Common problems of the upper extremity

Painful shoulder syndromes

Bursitis

Tendinitis

Loose bodies

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 Impingement syndrome

Rotator cuff tears

Conservative interventions: rest, contrast heat and cold; NSAIDS

Arthroscopic surgery

Joint injections, physical therapy

Upper extremities

Carpal tunnel syndrome entrapment neuropathy of the median nerve at

the wrist due to repetitive hand activities, arthritis, pregnancy

S & S tingling, weakness (thumb, 1st and 2nd fingers), numbness, night
pain

Tx: rest splints, avoidance of repetitive flexion of wrist, NSAIDs, cortisone

injections, surgical release

Upper extremities

Ganglion collection of gelatinous material near the tendon sheaths and

joints

Round, firm, cystic swelling on dorsum of wrist

Tx: aspiration, cortisone injection, surgical excision

Tennis elbow epicondylitis

Tx: RICE
Upper extremities

Dupuytrens contracture inherited autosomal dominant trait in which the

there is a flexion of the 4th and 5th fingers and frequently the middle finger

Due to slowly progressive contracture of the palmar fascia with nodule

development and thickening of palmar skin

Tx: palmar and digital fasciectomy; exercises

Foot problems and deformities

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 Corns hyperkeratoses of small, circumscribed skin with central core

Calluses diffuse hyperkeratoses over weight-prone areas

Ingrown toenail spicule that forms from nail tissue that penetrates soft
tissue around nail

Flatfoot pes planus

Foot problems

Hammer toe deformity of proximal and distal interphalangeal joint

Hallus valgus lateral deviation of the great toe

Pes cavus high arch (clawfoot), prominent metatarsal heads, can be

related to diabetes

Mortons Neuroma swelling of 3rd branch of median plantar nerve

Nursing care

Conservative

proper footwear with high toe box

Inserts

Surgical

Goals of care include adequate tissue perfusion, relief of pain, improved

mobility, absence of infection

Check 5 Ps, dressings, elevation, ice

Metabolic Bone Disorders

Osteoporosis

Reduction in total bone mass and a change in bone structure which

increases susceptibility to fracture.

Incidence of fractures increased along with disability

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 Http://odp.od.nih.gov.consensus/cons/111/111

(March 27-29, 2000, Vol. 17, No. 1)

Websites

http://www.osteo.org

Kyphosis

Gradual collapse of the vertebrae

Loss of height

Postural change results in relaxation of abdominal muscles

Pulmonary insufficiency

Osteoporosis - Risk Factors

Small framed nonobese white women

Inadequate supply of Ca and Vit. D

Smoking

No weight bearing or muscle activity

Cushing's syndrome

Risk factors

Medications affecting calcium

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 Corticosteroids, INH, heparin, furosemide, anticonvulsants, thyroid
supplements affect bodys use and metabolism of calcium

The degree of osteoporosis is related to the duration of medication

therapy

Osteoporosis - Risk Factors

continued

Alcohol Abuse

Liver failure

Renal Failure

Hyperthyroidism

Hyperparathyroidism

Diagnosis

Routine X-rays

25-40% demineralization

Serum Calcium & Phosphate

Ultrasonic heel-density studies

dx osteoporosis & predict fractures

Dual energy x-ray absorptiometry (DEXA)

for spine & hip bone mass

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Diagnosis

Bone mineral density tests (BMD) of spine, wrist, and/or hip (most
common fracture sites)

Detect low bone density before a fracture occurs

Confirm a diagnosis of osteoporosis if Fx present

Predict changes of fracturing in the future

Determine rate of bone loss

Medical Management

Diet, Ca (citrate) & vit. D

Ca Supplement throughout life

ERT???????

Weight-bearing exercise

Medications

Calcitonin - nasal spray, SQ or IM

Fosamax (Alendronate)

Evista (Raloxifene) SERM

Actonel (Risedronate)

Nursing Interventions

Teaching

prevention

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 diet, activity, Ca supplements, ERT

treatment regimen
Meds

Drink adequate fluids

Understand GI side effects of meds

Pain Management

rest, good mattress, heat, back rubs, avoid twisting, assistive

devices

Nursing Interventions
continued

Prevent Constipation

high fiber diet

fluids

stool softeners

** monitor intake & bowel sounds

Ileus may develop if Vertebral collapse involves T10 to L2

Prevent Injury

activity, muscle strengthening, walking, correct body mechanics

Website

www.hiprotector.com

Osteomyelitis

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 Infection of the bone

extension of soft tissue infection

bone surgery

GSW

Blood borne spread from other sites of infection

S. aureus - 70%

Proteus sp.

Pseudomonas sp.

E. Coli

Clinical Manifestations

Chills, fever, rapid pulse, general malaise

Pain

constant pulsing pain

Swelling present

Area is warm

Tender to the touch

Diagnosis

X-rays

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 MRI

Bone Scan

Wound Culture

Blood Cultures

elevated sed. rate & leukocytes

with chronic osteomyelitis may be normal

Medical Management

Immobilize limb

Antibiotics **after culture**

Surgery

bone exposed & irrigated

infection drained

all dead and infected bone removed

wound drain device

Nursing Interventions

Pain Relief

Encourage self-care

Monitor circulation

Monitor infections process

temp, labs, drainage device, dressings

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 Diet

high protein

high Vit. C?????

Contusions, strains, sprains

Contusion soft tissue injury due to blunt force resulting in ecchymosis,

hematoma, pain, swelling, discoloration

Strain muscle pull from overuse

Sprain injury to ligament due to twisting

Intervention: RICE (after 24 to 48 hours, may apply heat), immobilization,

exercise

Fractures

Types

Complete (may be displaced)

Incomplete

Comminuted (fragments)

Closed (no break in skin)

Open (compound/complex)
Grade I clean wound < 1cm

Grade II larger wound w/o extensive soft tissue damage

Grade III highly contaminated w/ extensive soft tissue damage

Clinical Manifestations
(not all present with every Fx)

Muscle Spasm

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 Pain

Loss of Function

Deformity

Shortening

Crepitus

Swelling & Discoloration

Early Complications

Shock

Fat embolism

Compartment syndrome pressure increases within a muscle

compartment

Thromboembolism

Pulmonary embolism

DIC

Infection

DVT

Clinical Manifestations of
Fat Embolus - Lungs

May occur up to 1 week following Fx

**Sudden onset of symptoms**

hypoxia

tachypnea, wheezes, crackles

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 large amount of thick white sputum

precordial chest pain

Tachycardia

pale

mental status changes

Goal: support respiratory system! Life threatening!

Late Complications of fractures

Delayed union slow to heal

Nonunion ends of bone fail to unite

Avascular necrosis pain and limited movement

Reaction to internal fixation devices

Reflex sympathetic dystrophy (RSD) severe burning pain, skin

changes (see page 1839)

Emergency Management of a Closed Fracture

Immobilize the body part

Support body part if need to remove person from a vehicle

Apply padded splints over clothes bandage to chest or place in

sling

Bandage one leg to the other

Asses vascular status

Emergency Management
Open Fracture

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 Cover with clean (sterile) dressing

DO NOT TRY TO REDUCE THE FX

Splint for transport

Move extremity as little as possible

*Call EMS if cannot transport in car

Management of Fracture

Reduction (setting the bone)

Closed - manipulation & manual traction

cast

traction

Open - surgery often with internal fixation devices

Immobilization after reduction

Maintain & restore function

Refer to earlier lecture notes

Nursing Management
Closed Fracture

Watch for S & S of complications

Patient Teaching

Swelling & pain control

REPORT UNCONTROLLABLE PAIN

S & S of complications

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 Exercises

Nutrition

Medications

Crutch walking/transfer techniques

Nursing Management
Open Fracture

Prevent infection

Tetanus prophylaxis

IV antibiotics

Aseptic dressing changes

Nutrition

Patient Teaching

Complications, wound care, neurovascular checks, watch temp.

Review

Fractures of specific sites

Clavicle

Humeral neck

Elbow

Radial

Ulnar

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 Wrist

Pelvic
Gerontologic Considerations

Hip fracture contributor to death >75

Pneumonia

Sepsis

Presence of comorbidity
Cardiovascular

Peripheral Vascular

Pulmonary

Renal

Endocrine / diabetes

Gerontologic Considerations
Continued

Altered mental status

Sleep deprivation

Pain / Medications

Malnutrition / Dehydration

Infection

Blood loss

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 Frail elderly

Hip Fractures

Two major types

Intracapsular
Fx at neck of femur

Extracapsular
Fx of the trochanteric region

** Fractures of the neck of the femur may compromise the blood supply
to the head and neck of the femur.

Non-union & avascular necrosis common

Care for older patient with hip fracture

Get patient in best condition for surgery

Traction while waiting

Open reduction & internal fixation (ORIF) pins, nails, plates, screws

Total hip replacement (femoral head with a prosthesis -

hemiarthroplasty

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 Nursing Care

Traction care - Pre-op

Immobilize & muscle spasm prevention

Post-op

VS - hemorrhage

Neurovascular checks and edema

Prevent complications
DVT (most common)

Pulmonary (deep breathing, spirometry)

Skin breakdown (no tape!!!!)

Incontinence

Infection

Altered mental status (pain)

Discomfort

Do not rely on self report at an indicator of pain and discomfort in the

elderly confused patient

Reposition

Deep breathing

Pain medication frequently

Elimination

Website: Quick reference guide to hip fracture www.sign.ac.uk

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 Amputation

Causes

PVD - most common

Diabetes often root cause of PVD

Gas gangrene

Trauma

Burns

Frostbite

Congenital deformities

Chronic osteomyelitis

Malignant tumor

Level of Amputation

A limb is amputated at the most distal point that will heal

successfully.

Circulation

Functional usefulness
Staged Amputation

Used in gangrenous & infected limbs

Antibiotic

Guillotine amputation

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 Wound debrided and allowed to drain

Further amputation with skin closure

Complications

Hemorrhage

Infection

Skin breakdown

Phantom limb pain

due to severing of nerves

Medical Management

Objective

Healing of the residual limb

non-painful

healthy skin on residual limb

Control of edema
Closed rigid cast

enables early minimum weight-bearing

Elevate foot of bed, do not place residual limb on pillows to avoid

flexion contracture of hip

Soft Dressing w/ or w/o compression

enables viewing may also have a wound drainage device

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Goals of nursing care

Relief of pain

Absence of altered sensory perceptions

Wound healing

Acceptance of altered body image

Resolution of grieving process

Independence in self-care

Restoration of physical mobility

Absence of complications

Nursing Management

Monitor carefully for:

Bleeding
hemorrhage or may develop slowly

Infection
Note any change in drainage, temp, wbc

Skin breakdown

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 Watch for pressure or irritation from dressing

Relieve Pain

change position

analgesics

light sand bag to prevent muscle spasms

Phantom pain may persist for months to years

Relieve Phantom Pain

Early rehab for wound desensitization

Kneading massage

TENS

Distraction

Beta blockers

Promote wound healing

Aseptic technique for dressing changes

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**If the cast or ace wrap comes off, apply an elastic compression
bandage to prevent edema formation

Enhance body image

Encourage to look at, feel, and care for residual limb (stump)

Assist to become independent in functioning

Establish a trusting relationship

Allow to express feelings

Offer information on local and national amputation support groups

Refer to local mental health specialists

Promote independence and self-care

Teach for activities of daily living (ADLs)

Encourage PT exercises

Encourage use of adaptive equipment

Encourage use of temporary prosthesis

Increase physical mobility

Encourage upper body muscle strengthening exercises

Encourage exercises of affected limb

prevents edema

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 increases circulation

Prevent contractures of residual limb

Sitting in chair for short periods only

Move from side to side and lay prone

Assist with ambulation

Rehabilitation

Patient and family teaching

Teach patient and family

Correct method of bandaging

Skin inspection

Skin Care

Massage
circulation & decrease tenderness

Limb toughening in preparation for prosthesis

Push into pillow then firmer surface

Patient and family teaching

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 Residual limb will change shape

Prosthetic adjustments will be made

When not wearing prosthesis will need to use a compression

bandage or shrinking sock to limit edema

Emphasize need to continue therapies

Continued need for good nutrition

Community agencies

Teaching

Instruct patient/family:

*** to call the MD immediately if:

Uncontrolled pain

Signs of infection

Residual limb skin breakdown

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