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