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Musculoskeletal Problems
NUR 302 Unit IV
Neurovascular Assessment
5 Ps
Pain
Pulses
Pallor
Paresthesia
Paralysis or decr motor strength
Sprains & Strains
Sprain: injury to ligaments around joint
Strain: stretching of a muscle & sheath
S/S: pain, edema, decr function, bruising
Health promotion: warm up exercises
Care: rest, elevate, ice, compression, analgesics, after 24-48hrs heat, PT
Dislocation & Subluxation
Dislocation: complete separation of articular surfaces of joint
Subluxation: partial displacement
Realign & reduce joint ASAP- prevent avascular necrosis
Relieve pain, support & protect joint, prevent contractures
Carpal Tunnel Syndrome
Compression of median nerve under the transverse carpal ligament in wristS/S: weakness esp thumb, pain & numbness, clumsiness, + Phalen’s sign, + Tinel’s signEducate about risks, wrist splint, stop aggravating action, hydrocortisone, surgery, eval of neurovascular status
Repetitive Strain Injury
Cumulative trauma to tendons, ligaments, muscles-> tiny tears, inflammation, scarringS/S: pain, weakness, numbness, impaired functionEducation, approp job design, avoid precipitating activity, PT, careful use of analgesia
Rotator Cuff Injury
Complex of 4 muscles that stabilize & rotate humerus, tear gradual, degenerative or from traumaPain, can’t abduct arm or shoulderMRI, arthrogramRest, ice & heat, NSAID, corticosteroid injections, PTSurgery, shoulder immobilizer, PT
Meniscus Injury
Meniscus- fibrous cartilage in knee, injured by rotational stress when knee is flexed & foot fixed.
Tenderness, pain at abduction & adduction of leg at knee, knee unstable
Arthroscopy, arthrogram, MRI
Ice, immobilize, crutches, PT, surgery
Bursitis
Inflammation of bursae from trauma, friction, gout, rh.arthritis, infection
Warmth, swelling, pain, decr ROM
Rest, ice, immobilize, NSAIDs
Aspiration of bursae fluid, cortisone injections, bursectomy
Muscle Spasms
Pain, palpable muscle mass, tenderness, decr ROM, limited ADL
H&P – R/O CNS problems
PT – heat or ice, exercise, massage, hydrotherapy, ultrasound, bracing
Meds – mild analgesics, NSAIDs, skeletal muscle relaxants
Bone Cancer
Multiple Myeloma- plasma cell cancer invades bone marrow
S/S- back pain , anemia, blding tendencies
Dx- biopsy
Prognosis- poor
Tx- Chemo, radiation, corticosteroids
Bone Cancer
Osteogenic Sarcoma- primary tumor, grows fast, long bones, distal femor
Children & young adults, age 10-25
S/S- gradual pain, swelling, after injury
Tx- pre-op chemo then resection of tumor, amputation
Bone Cancer
Osteoclastoma- destructive, occurs in ends long bonesAge 20-35S/S- swelling pain, joint problemsDx- biopsy, x-ray-> bone destruction & expanded bone endsRx- surg curettage, bone graft, chemoCan reoccur
Ewing’s Sarcoma
Rapid growth of medullary cavity of long boneMetastasis early esp lungsS/S:pain, swelling, paplable soft tissue mass, incr size affected part, fever, leukocytosis Tx: radiation, chemo, resection or amputation
Amputation
Indications- circul impairment, tumors, uncontrolled infection, cong disorders
Assess for potential for revasculariz. therapy by arteriogram
Explain reason for amputation, reassure, rehab, answer questions
Manage underlying diseases
Nursing Care
Assessment- dx tests, labs, swelling, jt function, s/s mets
Pain- medicate, gentle handling extremity, rest
Care of pt receiving chemo, radiation
Psychol support
Care off pt with amputation
Nursing Care
Dsg change- sterile technique, molding limb with compression bandageImmediate post-op fitting in OR or delayed fittingPrevent flexion contractures- avoid sitting in chair with hips flexed or pillow under stump, prone 30min, 3-4X/dayTeach transfer to chair, ROM, arm strength, crutch walking, refer to prosthetics
Nursing Care
H Promotion- teach diabetic, PVD pts & families foot care, assessmentPsychol support- depression, grieving, body image disturbancePre-op- upper extrem strengthening, explain post-op care, phantom painPost-op- hemorrhage- check VS, dsg very thick, notify MD, tourniquet
Osteomyelitis
Enter via arterial bld supply-> stay in area of decr circulation-> infection incr pres in bone-> ischemia-> bone death-> bone separates-> forms sequestra
Acute s/s- systemic- fever chills, nausea, malaise & local- bone pain, swelling, tenderness, warmth, drainage
Chronic- pus -> ischemia-> granulation tissue turns to scar ->infection unreachable by meds
Osteomyelitis
Dx- wound, bld,sequestrum C&S, bone biopsy, elev WBC & sed rate, no s/s on x-rays til 10 days-wks, seen on nuclear bone scans 24-72 hrs, CT& MRI
Rx- antibiotics- central line IV, continue at home 4-6 wks or 3-6 months, surg debridement, wound irrig, hyperbaric O2
Nursing Care
Teach jt replacemt pts s/s infection & prophylactic antibiotics teeth cleaning, procedures etcPain- gentle moving of extremity, elevate, correct alignment, immobilizeDressings- sterile, wet-dry, vac systemTeach meds, care of venous access device, nutrition, follow up care
Acute Low Back Pain
Risk factors- lack of muscle tone, excess wt, poor posture, smoking, job, long sitting, stress
Injury->s/s develop later due to grad increase in muscle spasm
Rx- analgesics, NSAIDs, muscle relaxants, corset. Severe pain- bed rest, epidural corticosteroid & anesthetic
Health Promotion- body mechanics, exercise
Chronic Low Back Pain
Degen disc disease, injury, obesity, posture, lack of exercise, systemic diseaseHern disc- back pain with buttock & leg pain, paresthesia, muscle weaknessDx- x-rays, MRI, CT, myelogram, EMGTx- rest, corset, heat or ice, NSAIDs, muscle relaxants
Chronic Back Pain
Progressive worsening or loss of bladder/bowel control-> surgery
Percutaneous laser diskectomy
Diskectomy or microsurgical diskectomy
Laminectomy
Spinal fusion
Stable Vertebral Fractures
Disrupted ligament -> unstableComplication fx displacement ->spinal cord injuryKeep spine in proper alignment, assess neurovas status, bladder & bowel Log rolling, no trapeze, heat, traction, no turning of torso or upright position, orthotic device, jacket cast, halo vest
Spinal Surgery Nursing Care
Bed rest (flat) 1-2 days, logroll, position
Muscle spasm- meds, correct turning
Leakage CSF->headache, report
Neuro s/s- movement, sensation, strength q2-4h, compare with pre-op
Assess paralytic ileus, bladder emptying
Spinal fusion- orthosis, check donor site
Teach- avoid sit/stand long, body mechanics
Foot Problems
See table 59-22Health Promotion- proper fitting shoesPost-op- elevate, check neuovas status, pins/wires may extend thru toes, dressings, slipper, boot or cast, crutches, don’t walk on heelTeach hygiene, trim toe nails straight across, see podiatrist if poor circulation
Osteoporosis
Low bone mass, structural deterioration of bone tissue-> increased bone fragilityElderly & post-menopausal women fx hip, spine, wristRisk factors- female, incr age, family history, Caucasian or Asian, small, oophorectomy, sedentary, insuf CalciumAlcoholism, rh arthritis, DM, cirrhosis, kidney disease, intest malabsorption
Osteoporosis
Long term meds- corticosteroids, antiseizure, Al antacids, heparin, INH, tetracycline, thyroid replacemt medsGenetic marker- VDR gene S/S: “silent”, bump or fall->fx, vertebrae collapse->back pain, ht loss, kyphosisDx: shows on x-ray only after 25-40% loss, BMD, DEXA, Ca, phos, alk phos
Nursing Care
Prevention- Ca Intake: premenopausal & postmen women taking ERP1000 mg, 1500mg postmenopausal women
Vit D needed for Ca absorption
Exercise builds & maintains bone mass
Keep pts with osteoporosis ambulatory, prevent potential pathological fx
Drug Therapy
Calcitonin- Calcimar-inhibits osteoclastic bone resorption
Biphosphates- Fosamax- inhibits osteoclast mediated bone resorption, incr bone mineral density & bone mass
Evista- mimics estrogen on bone, doesn’t effect uterus or breast tissue
Paget’s Disease
Excessive bone resorption, replacement bone marrow by vascular, fibrous tissue that makes bone largerS/S- skeletal pain, waddling gait, elev alk phos shorter, large head, wt bearing bones curved, complication- patholog fx Tx- Calcitonin, Fosamax, radiation, brace, analgesics, muscle relaxants
Fractures
Types: avulsion, comminuted, displaced, greenstick, impacted, interarticular, longitudinal, oblique, pathologic, spiral, stress, transverseCommunicating or noncommunicating – open or closedLocationStable or unstable
Clinical Manifestations
Determined by history of injury
Pain & tenderness, muscle spasm
Edema, swelling, deformity, ecchymosis
Loss of function, crepitation
Immobilize in position found
Children – epiphyseal plate
Process of Union of Fx
Fracture hematoma
Granulation tissue
Callus formation
Ossification
Consolidation
Remodeling
Age, displacement, site, blood supply
Age
Severity of the trauma
Type of bone Injured
Inadequate immobilization
Infection
Nutrition
Factors that affect bone healing
Fracture Reduction
Manipulation or closed reduction – nonsurgical, manual reduction
Open reduction – surgical, often internal fixation (ORIF) with wires, screws, rods
Complication open reduction- infection
Advantage – early ambulation
Traction – skin or skeletal
Traction
Skin - Buck’s, Russell's, Bryant’s, Pelvic belt
Short term (48-72hrs) til surgery, skel tx
Circumferential – head halter
Skeletal - Overhead arm, lateral arm, balanced suspension traction
See table 59-6
Traction Care
Maintain weight (freely hanging)
Inspect Skin
Pin Site Care
Neurovascular Assessment
External Fixator Device
Metal pins inserted into bone & attached to external rod, stabilizes fx, holds pieces in place
Assess loose pins
s/s infection- exudate, redness, tenderness, pain
Pin care
Cast Materials
Traditional- Plaster of Paris
* Stockinette, Padding, Plaster Rolls
* Feels hot when first applied
* 24-72 hours to dry
* Petal the cast
Synthetic- Fiberglass; Polyester cotton knit
Cast Materials
Traditional- Plaster of Paris
* Stockinette, Padding, Plaster Rolls
* Feels hot when first applied
* 24-72 hours to dry
* Petal the cast
Synthetic- Fiberglass; Polyester cotton knit
Casts
Long arm cast: support & elevate, use sling-> decr edema, encourage finger movement If proximal humerus fx, traction by hanging, aids healingBody jacket cast: assess bowel sounds, “cast syndrome”, resp status, bladder, pres over iliac crest, position q2-3 hrs
Casts
Hip spica cast- femoral fx, children, when drying place in prone position, slightly turn, don’t use support bar to turn, skin care to cast edges, same care as jacket cast
Long leg cast, short leg cast, Jones dressing – elev above heart 24 hrs, initially no wt bearing, later heel or shoe cast, check for pressure areas
Drug Therapy
Pain due to muscle spasms
Soma, Flexaril, Robaxin
S/E: drowsiness, headache, weakness, GI upset, potential abuse
Other belief - Relieve pain, spasm will disappear
Nutritional Therapy
Need protein & vit C for healing
Immobility & callus formation increases Calcium needs
Increase fluids to 2000 – 3000 cc
Hi fiber diet, fruits & veg prevent constipation
Jacket cast – don’t over eat
Health Promotion
Prevention precautions- work sports, home, driving
Seat belts, helmets etc, stretching before exercise
Elderly- look at environment, exercise, vit D & calcium
Nursing Care Fractures
Initial assessment, quick history, to ERGuarding, deformity, laceration, loss of function, rotation, edema, crepitus ecchymosis, compare to uninjured sideFocus on area distal to injury – pulse ?, decreased cap refill, cool vs bluish & warm, decreased or absent sensation, paresthesia
Emergency Management
Priority: ABC, life threatening injuries, control bleeding
Splint above & below fx site
Neurovascular status, elevate, ice
Don’t manipulate protruding bones, tetanus
VS, LOC, O2 sat, pulses, pain
Pre-op Care
Routine pre-op teaching
Explain type of immobilization & activity limits, time
Pain meds
Skin prep
Post-op Care
VS, neurovascular checks
Proper alignment & positioning
Pain meds
Observe for bleeding, report increase
Patency of wound drain
Care of cast or traction, pin care
Prevent constipation & renal calculi
Ambulatory & Home Care
Cast care- do not get wet, remove padding, put things in cast or if synthetic cast – check with MD before wet, dry after
Report: incr pain, swelling, burning under cast, sores or odor, discolored fingers/toes
Elevate, move joints
Follow up with MD
Ambulatory & Home
Short term rehabPT: strengthening, assistive devices, ambulation progressionCrutch walking: two-point gait, four-point gait, swing-to gait, swing-through gaitInvolved limb advanced at same time or immed following the deviceHold cane in hand opposite of involved extremity
Complications of Fractures
Infection- open fx, surgery, irrigation, debridement, left open vs closed, drains
Compartment Syndrome- compression, upper & lower extrem by fascial sheath or bone-> stop venous & arterial bld flow-> ischemia-> cell damage. Tx- fasciotomy
S/S Unrelieved pain distal to injury, numb, tingling, decr-> loss function, cool , no or poor pulse. Check myoglobin in urine & output
Complications of fractures
Venous thrombosis esp with hip fx, due to stasis, immobility Prevent- SCD ,TEDS, ROM, anticoagFat Embolism- fx long bones, pelvis, jt replacement, sp fusion, crush injuriesS/S- chest pain, tachypnea, cyanosis, tachycardia, dyspnea, decr o2 satLittle repositioning til immobilize fx
Types of Fractures
Colles’ fracture –distal radius
Fx of humerus- hanging arm cast, shoulder immobilizer, swathe, elev HOB, axilla skin care
Fx pelvis- check neurovasc status lower extremities, GI & GU function, turn only when ordered, carefully, back care
Types of Fractures
Femoral shaft fx- complications also soft tissue damage, bld lossRx- skel traction 8-12 wks or internal fixation, restricted wt bearing til unionTibial fx- long leg cast, assess neurovas q2h for 48 hrs, need strengthening of quadriceps & upper arms, non wt bearing 6-12 wks, then walking heel
Hip Fracture
S/S- external rotation, muscle spasm, shortened extremity, painBuck’s or Russell’s tx til surgery of pin or femoral head replacementComplications- avascular necrosis, dislocation, nonunion, degen arthritisPre-op- manage pain, care of tx, position, teaching- trapeze, pre-op
Hip Fracture
Post-op- VS, dsg & hemovac, neurovas stasus, pain, abductor pillow
Pinning- OOB by PT, crutches or walker
Prosthesis- hip precautions- no 90 degree flexion, elev tiolet seat, shower chair, chair with arms & elev leg, keep straight when sitting, pillow bet legs when lying on side, turning, do not cross legs
Maxillofacial Fractures
Establish & maintain patent airwayRemove foreign material, blood, prn suction, packing to control hemorrhageTreat as if cervical spine injury & suspect injury to eye esp global ruptureSoft tissue injury-> swelling-> hard to assess, dx CT scanAlteration in body image