NCM104 6th Musculo III

7/30/2019 NCM104 6th Musculo III

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jcmendiola_Achievers2013

Care of Clients with Problems In Inflammatory

& Immunologic Response, Perception & Coordination

(NCM 104)

Patients With Musculoskeletal Alterations III

Continuation

Care of Clients with Bone Infections

Osteomyelitis: Infection of the bonesCauses:

1. Staphylococcus aureus = 70% - 80%2. Proteus andpseudomonas3. E. coli

Risk Factors1. Poorly nourished (Common on aged), elderly and obese people2. Impaired immune system3. Chronic Illness (State of health)4. Receiving steroids and immunosuppressant drugs [Prednisone, Decadron] [Imuran]

Pathophysiology Sources of Infection characterized by

1. Inflammation (Swelling)2. Vascularity After 2 3 days (Can create a blood clot) Thrombosis3. Edema Formation

Infection Extends To:1. Medullary Cavity2. Under Periosteum3. Adjacent soft tissues and joints

If in the Event

If goes untreated, it will eventually develop into a bone abscess that contains dead bone tissue(sequestrum) that does not LIQUEFY and DRAIN (The bone therefore cant fully heal)

New bone growth forms (involucrum) that surrounds the sequestrum that produces recurringabscess throughout life

o OSTEOMYELITIS cant fully be treated, because the sequestrum is HARD to penetrateClinical Manifestations

1. Signs of Infection Pain = FIRST SIGN Initially local; later systemic (fever)

2. Pain, swelling and tenderness As infection extends to cortex Pain is constant, pulsating and increases with movement and pressure

3. Signs of Sepsis If it spreads to adjacent tissues CBC will show WBC

Topics Discussed Here Are:

1. Care of Clients with Bone Infectionsa. Osteomyelitis

2. Care of Clients with Musculoskeletal Traumaa. Types of Fracturesb. Castc. Tractiond. Splints / Braces / Orthoses

Sources of Infection:

1. Large Bed Sores2. Surgical Procedure (Amputation)3. Blood Bourne Microorganisms

Definition of Terms:

1. Sequestrum Developed bone abscess that containsdead bone tissue

2. Involucrum Formed new bone growth producingrecurring abscess throughout life

Prognosis

POOR!!


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Diagnostic Tests1. X-Ray

Demonstrates soft tissue swelling In 2 weeks:

Will be Irregular

Will form a Calcification Bone Necrosis New Bone Formation

2. WBC and ESR ESR: Indication of inflammatory processManagement

1. Control of Infection Use of antibiotics (Initially most common route is IV, but later PO)

2. Promotion of Comfort Immobilize affected part (Cast, splint, dont carry weight) Warm Compress To improve circulation at the affected part, (but might not work out

)

3. Surgery Sequestrectomy (After 2 3 years)

Removal of the sequestrumCare of Clients with Musculoskeletal Trauma

Fracture: Break in the continuity of the bones Fragment: Part of a broken bone

Types of FractureI. Simple / Closed Type

Bone broke up into parts, butno part of the bone protruded

out of the skin

Numbers of Injury: 1 1 (FRACTURE)

Examples of Simple / Closed Type of Fracture

1) Greenstick (Incomplete type of fracture) No complete separation of the

bones, theres only

Commonly seen among childrenbecause their bones are still SOFT and PLIABLE

2) Spiral Type The shape of the fracture is not medial, not also transverse, but SPIRAL

3) Comminuted Bone breaks into more than 2 parts :\

II. Compound / Open Type There is a break in the bones and a part of the broken bone protruded outside of the skin


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Anticipate the possibility of bleeding! Numbers of Injuries: 2

1 (FRACTURE) 1 (WOUND)

Categories of Open Fracture1. Grade I

Fracture has protrusion With a clean wound less than 1 cm long

2. Grade II Is a bigger wound than Grade I, but only has a simple wound Larger wound but without extensive soft tissue damage

3. Grade III Highly contaminated Has extensive soft tissue damage MOST SEVERE

Example: Vehicular Accident victimsCauses / Clinical Manifestations

1. Pain More severe with movement, but relieved with immobility Continuous and increases in severity

2. Swelling and Discoloration (Inflammatory Process)3. Deformity and Loss of function of the affected part4. Bruising / Ecchymosis5. Muscle Spasms6. Loss of Function UMULIT XD7. Bleeding Bleeding is only EXPECTED with OPEN / COMPOUND Type8. Crepitus

Grating sound of 2 bones NEVER ELICIT the presence of Crepitus!

9. Shortening of the Affected Extremity Compare the length of the normal and abnormal The fractured one is the SHORTER one

Shortening occurred because of rapid muscular

spasms of the muscles which will shorten the

affected part

Management1. First Aid Done at the site of accident

a. Immobilize With the use of a SPLINT Principle: Splint them where they lie

Rationale: To prevent further traumab. Transportation

Transport to the NEAREST hospitalOnce client is hospitalized, it ENDS the FIRST AID and then continues on to be a

DEFINITE MANAGEMENT

FRACTURES Compressed Fracture

o Affecting the VERTEBRAo Due to a bad fall, one vertebra compresses

another and so forth

Depressed Fractureo Associated with the SKULLo Depression of the SKULL

Patterns of Fracture

90% OF Fractures is Brought About by TRAUMA

1. Sports related2. Falling (From a tree / stairs)3. Violence4. Vehicular Accidents COMMON

10% OF Fractures is Associated with PATHOLOGY

1. Osteomyelitis2. Malignancy

TIPS WHEN SPLINTING

- Scout Around for; Sticks, umbrellas,newspapers / magazines, twigs/branches

- Apply the splint onto the affected part- Any material that can be used to immobilize a

affected part can be a splint!


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2. Definite Management1. Reduction Restoration of broken bones into the NORMAL anatomical alignment

TYPES:a.Closed / Manual

No direct visualization of the broken bone Reduction is done by MANUAL MANIPULATION May be done with the help of the X-ray Plate

b.Open / Surgical Has direct visualization of the affected bone Client can undergo surgery with the use of screws and nails This procedure is no longer done, at present practitioners use an EXTERNAL

FIXATOR (Pins)

Advantage: Puts client to bed for a matter of days and has no weightbearing

2. Immobilization To maintain the NORMAL anatomical alignment Done with: Cast / Traction

Cast- Also called as gypsum, Plaster of Paris, Anhydrous Calcium Sulfate, and Fiber Glass- Rigid immobilizing device that is moulded to the contour of the body (Anatomical Alignment)

Uses of the Cast1. Immobilize a reduced fracture2. Correct Deformity

- Congenital Hip Dislocation- Bow-legged- Clubbed Foot

3. Apply uniform pressure to any underlying soft tissue4. Support and stabilize weakened joints

Types of CastsFor the Upper Extremities

Short Arm Cast (SAC)- Below the ELBOW until the BASE of the THUMB / Middle Part

Long Arm Cast (LAC)- of the Upper Extremity- From the AXILLA (2-3 Inches) until the base of the THUMB Arm Cylinder Cast (ACC)- Similar to the Long Arm Cast- Difference is the PALM / HANDS is not included in the cast

Hanging Cast- Has a support / Rope around the neck

For the Lower Extremities

Short Leg Cast (SLC)- Below the KNEE until the FOOT of the client, it should be OFF THE TOES

Before continuing to DEFINITE MANAGEMENT, the client will:

- Have an X-ray of the affected part- Remind to not do anything not unless x-ray is out!

REMEMBER:

- Fingers and ToesMUST NEVER BE

PART of the CAST!

- Because if can beused to ASSESS the

venous condition of

the client!!


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Leg Cylinder Cast (LCS) / Long Leg Cylindrical Cast (LLCC)- Same up to the thigh but below the groin- Does not include the FOOT, only up to the ANKLES

Long Leg Cast (LLC)- Upper 2/3 of the Thigh- Below the groin but OFF THE TOES

Patellar Tendon Bending Cast (PTB) / Walking Cast (WC)- Similar to the Short Leg Cast, Difference is:

Anteriorly: MID-KNEEPosteriorly: Below the POPLITEAL

- Has black object on the foot :o ??Spica Cast

Cast that includes the MAIN PART of the body PLUS the UPPER and or LOWER EXTREMITY Example:

- Shoulder Spica Cast / Airplane Cast- Hip Spica Cast1. Double Hip Spica Cast

Bilateral long leg hip spica castOne and a half hip spica cast

2. Single Hip Spica CastBody Cast

Examples:1. Full Body Cast (FBC)

The client is somewhat being lifted up as they wrap the cast aroundTakes a lot of personnel to wrap the client with cast

2. Lower Body Cast (LBC)Client is catheterized, the catheter bag is seen!Provide privacy for the client! Because their perineal area is exposed!

Minerva Cast- Uses a Traction- Done to immobilize the CERVICAL AREA

Rissers Cast

Types of Cast Materials1. Non-Plaster Cast (Latest)

- Referred to as Fiber Glass- Water-activated polyurethane materials- Advantage:

a.MUCH MORE POROUS Diminishes skin problems (Good ventilation at affected part)b.Does not soften when wet Allowshydrotherapyc.It is lighter and easily dries up

- Disadvantage is:a.The affected arm has to be already positioned when putting itb.It is also very expensive

2. Plaster- Also known as Traditional Cast(It is emersed into the water to form)

NOTE for DOUBLE HIP SPICA CAST

- There is a piece of wood in between the legs topromote ABDUCTION of the lower extremity!

-

Toes are not included in the cast- The perineal area is opened and also closed


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- Rolls of plaster bandages are wet with cool water Exothermic reaction (Assure the client thatheat/warm will DISAPPEAR as soon as dry)

- Inform the client that they SHOULD NOT COVER the affected extremity, because it will preventheat from coming out Burns / Blisters may occur

- Disadvantage: Client does not have full strength not until the cast is dryCare of Clients in a Cast

1. Knowledge Deficit Explain the treatment regimen

- How long will be the body be placed in a cast?- What would be changed in the ADLs?

2. Acute Pain GOAL: Relieve Pain

a)Elevate the affected part To prevent compression

b)Analgesic PRN (Narcotic / Non-narcotics) Evaluate the pain May be indications of complications

NURSING ALERT!:If in the Event the pain is UNRELIEVED report immediately!!3. Impaired Physical Mobility

Encourage exercise!- To further strengthen the other parts of the body- The fingers are also involved in the exercise- Instruct the client to do ROM exercises

4. Impaired Skin Integrity If in the Event: Open type of fracture

- Assess the condition of the skin Is there an infectious process?

- Assess for the changes in the cast, are there any stains?- If has a stain, encircle it with a pen and comeback after 1 hour to assess changes- May be BLEEDING / DRAINAGE- If it is enlarged, there is the presence of bleeding and INFORM THE DOCTOR!- WINDOWING - The MD will remove a portion of the cast to assess the affected part

5. Risk for Neurovascular Dysfunction Monitor circulation, motion and sensation Assess for any compression of nerves and of blood vesselAssess the 5 Ps

1. Pallor Pale skin / poor capillary refill (Vascular Dysfunction) Blanching Sign Test

- Press on the finger for __ minutes- There should be return of pinkish color within 20 seconds- But if returning but sluggish, it is (+) for Vascular Dysfunction

2. Pain On palpation, there is pain upon movement and is constant (Both Neuro and Vascular

Dysfunction)

- There may be compression of the nerves- Let the client describe the pain


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-If in the event: The pain is not relieved with medications / elevation of leg,it is COMPARTMENT SYNDROME

3. Pulselessness Diminished / absent pulse (Vascular Dysfunction)4. Paresthesia Pins and needles sensation (Neuro Dysfunction)5. Paralysis Neuro Dysfunction

Case: Right hand is with a cast- Sensation: Pinch = Sensation with application of pain- Toes / Fingers is sluggish (Paralysis)

Characteristics of an Ideally Applied Cast1. It should include the joint ABOVE and BELOW the affected part

o Example: Wrist and Elbow Long Arm Cast

2. Made up of 5 7 Layers!o Rationale: So that it would be strong enough for supporto But if Patellar Tendon Bending Cast (PTB) Should be 8 10 Layers

3. It should follow the normal contour of the affected areaNursing Care on Application of Cast

1. Prepare the materialso Rolls of plastero Non-plaster / Traditional A material is first placed on the skin before application of a cast

(Cotton like) = WADING SHEET

Rationale: Wading sheet is used to protect the skin Can be used if Upper Extremity / Lower Extremity

o Body Cast Stockinet is used instead of a Wading Sheeto Prepare a BASIN / PALE of WATER

2. After application of the casto Green Cast The term used in a newly appliedcasto Dry the cast (Traditional) ALLOW NATURE to DRY IT UP!

Expose client to the environment and DO NOT COVER THE CAST The length of time the cast will dry depends on the WEATHER and SIZE of the cast Can use a FAN to help dry the cast

But ROTATE the fan in order to simulate a normal room environment CAST BLOWER / HAIR BLOWER / DRYER

Place the CAST BLOWER 12 15 inches away from the affected areaHow to know if the Cast is Dry??

1. Color Seen from afaro Shiny White DRYo Off White Not Dry

2. Weighto Light in Weight DRYo Green Cast HEAVY

3. Resonant when percussed4. Same temperature with the environment


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5. Smello Odorless DRYo Amoy Lupa Not Dry

Immobilized Client

Traction Application of a pulling force to a part of the body / extremity Uses:

1) Minimize muscle spasms and pain will also be minimized2) Align and immobilize fractures3) Reduce Deformity

Scoliosis Halo Traction

4) Increases the space between two opposing surfaces Vertebral Fracture Relieves pressure on spinal nerves

Types of Traction

1. Skin Typeo Pull / Force is applied to the skin of the cliento Examples:

Bryant Traction For the lower Extremity Used only for INFANTS Congenital Hip Dislocation

Dunlop Traction Applied on the Upper Extremity Head Halter Traction Can be done if client has minimal cervical

destruction

Bucks Extension Traction Similar to the Bryant Traction

Pelvic Traction Done to clients with Low Back Pain Like a Pelvic Girdle and Pulled at the FOOT part Rationale: To create a space between two bones

Cotrel-Dynamic Traction Lower Extremity and Head has weight (Pulls at head and feet) Head Halter Traction + Pelvic Traction Scoliosis

Hammock Traction Similar to Pelvic Traction Cause point of affectation is at the Lower Back

Thomas Splint Traction More considered as a skeletal type of traction Uses _____ wires and _____ pins

2. Skeletal Typeo Examples:

Crutchfield Tong / Vinky Carbuncle


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Counter part of the Head Halter Traction Bores in the skull and pulled at the head part

Halo Traction Used to immobilize the cervical area

Principles in the Care of Clients with Traction1. There should always be a counter traction There should be a pull / force applied at the opposite direction Example:

o Head Halter Traction - Counter-traction: Position of the bed and weight of client2. Should be continuous and uninterrupted; unless an intermittent traction was prescribed

Example:o Head Halter Traction

A cloth is placed under the chin, how will the client eat with the traction on? So, the traction is removed so client can eat, BUT SUBSTITUTE the traction

with the use of Shantz Collar to immobilize the head

3. Should follow a line of pull Thomas Splint

4. It should be free from Friction The traction weights should not touch the bed / floor Example:

o Bryant Traction Buttocks should not touch the bed5. Client should be in a proper position

Splints / Braces / Orthoses Brace / Splint

1. Used if the client does not need a RIGID IMMOBILIZATION Example:

Shoulder-Humeruso Made up ofo Splint which can raise the affected part

Walking Braceo Fractures of ankle and on Short Leg Casto After removing the Short Leg Cast, the Walking Brace is applied

Wrist Fracture Braceo Thumb / Wristo Colles Fracture Wrist Fractureo Before applying the Wrist Fracture Brace, can use Short Arm Cast

2. Conditions wherein swelling may be anticipated due to increased pressure3. Conditions wherein special care is required

Exemplified by: Open / Compound Type of Fracture (Wound + Fracture) DO WOUND CARE

Principles

1. Should immobilize and support the body part in a FUNCTIONAL position2. Must be well padded to prevent skin pressure

Case: Wrist Fracture Brace Carpal Tunnel Syndrome Apply elastic bandage


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The pressure should be uniformly distributed Rationale: To prevent compression on the nerve and blood vessels

3. Should be overlapped with an elastic bandage applied in a spiral fashion and with pressure uniformlydistributed

Rationale: So that circulation in the part is not restricted4. Frequent assessment of the neurovascular condition and skin integrity of the client

External Fixator- Fracture is reduced, aligned and immobilized by a series of pins inserted into the bone- Pin position is maintained through an attachment to a portable frame- Advantages: Facilities

1) Client Comfort Movement is not restricted2) Early Mobility Less complications3) Active Exercises of adjacent uninvolved joints

Client can bend! Not like other castsNursing Care

1. Psychological Support Inform the client that the cast will be SEEN by the public2. Elevate affected part after application (Edema and Swelling)3. Safety Putting of a vial at the ends of the pin (With a stopcock)4. Neurovascular Assessment Every 2- 4 hours5. Assess for Signs and Symptoms of infection

Pin Care Care of the pins inserted on the bonei. Maintenance of cleanliness of site

ii. Strict aseptic techniqueiii. Prescribe topical antibiotics at site of pin

6. Assess for loosening of pins7. Pin care8. Assist to mobilize

With use of crutch With use of a wheel chair


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Stages of Fracture Healing1. Stage I: Impact

(Hematoma / Inflammation Stage)

The period where traumais attained

A.k.a. Hematoma Stage /Inflammation Stage

There is breaking ofsmall blood vessels

Occurs for 1 3 days Immediate formation of

hematoma at the site

Blood forms a blood clotamong the fracture

fragments providing small

amount of stabilization

Vascular dilatation occursin response to

accumulation of dead cell

debris at fracture site

If vascular supply is poor,healing will be impaired

2. Stage II: Induction(Fibrocartilage Forms)

About 3 Days 2 Weeks Fibroblasts, osteoclasts (1st)

and chondroblasts migrate

to the fracture as a result

of inflammation they form a Fibrocartilage Osteoclasts Removes DEAD bone tissue! Osteoblasts Come next, they are the BONE FORMING CELLS

Organization of hematoma offers the FOUNDATION (BLOOD CLOT) for Stage II and tissuehealing

The PERIOSTEUM stimulates the OSTEOBLASTIC ACTIVITY Osteoblastic activity is stimulated by periosteal trauma and bone formation occurs

quickly (To promote bone healing)

3. Stage III: Callus Formation (Hmm iba ung sa notes at iba sa pic XD) Granulation tissue matures into a provisional callus (procallus) as newly formed cartilage (Secures

the bone fragments) and provides a temporary splint, but does not provide adequate strength (So

promote immobilization first!) Procallus Newly formed cartilage!

Proper alignment is essential during this stage This stage Most important in determining if healing is successful - If PROCALLUS is

SECURED

4. Stage IV: Ossification About 5 6 weeks Permanent callus of rigid bone crosses the fracture gap to join the fragments


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Medullary callus formation occurs internally to establish continuity between the marrow cavities***Not only the outside bone is fractured, callused, also the medullary cavity

5. Stage V: Ossification and Remodeling (Some 5 & 6) Because theres only a hairline difference About 6 Weeks 1 Year Unnecessary callus is reabsorbed away from the healing bone (Ossification) Process of bone resorption and deposition along stress line allows the bone to withstand the loads

applied

Remodeling: Actual time of remodeling depends on stresses imposed on the bone by muscles,weight bearing and age

***Unnecessary callus is ___ to the bones with much stress

Factors That Enhances Fracture Healing1. Immobilization of fracture fragments curing time2. Maximize bone fragment contact

In incomplete type of fracture, the healing is FASTER!3. Sufficient blood supply Because blood carries the nutrients4. Proper nutrition Vitamin D5. Exercise Weight bearing for long bones

Osteoblasts Stimulated by WEIGHT6. Hormone Growth hormone, thyroid, calcitonin will affect osteoblastic activity

Factors That Inhibit Fracture Healing1. Extensive local trauma

Open type of fracture: Grade III Because there is much more extensive trauma2. Bone loss Client has comminuted type of fracture, and there is loss of fragments3. Inadequate immobility4. Space / Tissue between bone fragments

If the space is bigger between fractures, there is more space for hematoma and procallus formation The bigger the space, the poorer

5. Infection6. Local Malignancy7. Age8. Irradiated Bones9. Use of steroids

Complications1. Union

Failure of fracture to heal Delayed Union

o Healing is taking place but length of time is longer than expected2. Non Union

Healing is not taking place Seen with X-rays, no improvement

3. Fat Embolism Syndrome Occurs in fracture of long bones / pelvic bones, multiple fractures

***Process of bone healin is about 8 months 1 ea

Infection and Local Malignancy is due to a depressed immune system


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The medullary cavity has Yellow Bone Marrow which contains FATo If the medullary cavity is fractured or has multiple fractures, fats will be distributed to

different parts of the body, so the client is at risk for fat embolism

More on young adults (20 30 years) and elderly adults Rapid onset 24 72 hours of injury Clinical Manifestations (Most often at respiratory system) Cant be explained

a. Presenting Features Hypoxia, HR and RRb. Respiratory Distress Syndrome Use a pulse oximeterc. ABGs - PaO2


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o R Crutch L Foot L Crutch R Foot Swing Two

o Initial position of crutch and foot is sameo Crutch is in fronto Stand on the GOOD FOOTo Good goes to heaven first, and bad goes to hell firsto 1st Step is with the good leg, bad leg is left

Swing Througho Fastest, but if not skillful, the person may fall

Wheel Chairs, Walkers and Strollers Cane

Case:o Right leg is BAD, Left leg is good, what hand should hold the cane?o Answer: Left hand!~o The cane should be held by the hand opposite of the affected leg

Contusion Soft tissue injury produced by BLUNT damage or a kick or fall Small blood vessels rupture into soft tissue (hematoma)Signs and Symptoms

1. Pain2. Swelling / Tenderness

Strain / Pulled Muscles Muscles are AFFECTED Mnemonic ni MAM: sTrain Muscles (TM)

Cause: Due to overuse, overstretching / exercise stress on muscles

Types

1. First Degree Tearing of few muscles only Accompanied by mild / minor discomfort No noticeable loss of function

2. Second Degree Tearing of more muscle fibers With noticeable loss of load bearing strength, edema, muscle and ecchymosis

3. Third Degree Most severe Involves complete disruption of at least one musculotendinous units that

involves separation of:

Muscle from muscle Muscle from tendons Tendons from bones

With significant pain and loss of function Associated with avulsion fracture (Bone fragment is pulled away from above)


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Sprain There is injury to the ligaments and supporting muscle fibers that surround the joints Mnemonic ni MAM: sPrain Ligaments (PL) Cause:

By retching / twistingTypes

1. First Degree Tearing of few ligaments and fibers Mild discomfort No appreciable joint instability

2. Second Degree Tearing of more fibers Edema, tenderness, pain with motion Partial loss of normal joint function

3. Third Degree

Management (RICE)

PRICE Management

P Prevention of Strain and Sprain

RICER Rest affected part to prevent additional injury and to promote healing

I Ice compress / cold compress for 20 30 minutes for 24 48 hours, this will promote

vasoconstriction preventing bleeding

C Compression with use of bandages, controls bleeding, reduces edema and discomfort

E Elevation of affected part

Documents

NCM104 6th Musculo III