Nursing Care of Patients with Musculoskeletal Disorders (I)

Nursing Care of Patients with Musculoskeletal Disorders (I)

Yun-Hsiang Lee PhD, RN. School of Nursing

National Taiwan University

Content

• Basic concepts of musculoskeletal system

• Assessment

• Disorders & Management● Fracture ● Amputation● Arthritis

• Nursing Care

Musculoskeletal System

• The muscular and skeletal systems provide support to the body and allow for movement.

• The bones of the skeleton protect the body’s internal organs and support the weight of the body.

• Musculoskeletal disorders

Injury: Fracture, AmputationDisease: ArthritisHips & Knees ReplacementMalnutrition

1.緻密骨2.海綿骨–紅骨髓：具造血功能，形成血球。–黃骨髓：含脂肪細胞。3.骨骼血液供應

骨骼功能支持運動保護儲存：鈣、磷及脂肪。製造血球：

Prevalence of work related musculoskeletal disorders (WMSDs)

N=232

Hossain, et al. (2018). Prevalence of work related musculoskeletal disorders (WMSDs) and ergonomic risk assessment among readymade garment workers of Bangladesh: A cross sectional study. PLoS One, 13(7), e0200122.

Assessment

Clinical skills• Taking history

– The current symptomsPainStiffnessJoint swelling…

– The evolution of the problem (Acute or Chronic)

– The involvement of other systems– The impact of the disease on the

person’s life

• Physical Examination• X-ray, Sona, CT, MRI, Blood

test (Alk-P, CRP..)– Alk-P: 鹼性磷酸酶 (alkaline

phosphatase)-關節腔鏡檢查(arthroscopy)

關節半月板切除術(診斷+ 治療)-關節穿刺術(arthrocentesis)

Imaging of Bones and Joints

骨贅軟骨下硬化

侵蝕

Disorders & Management-Fracture-

Description

A disruption or break in the continuity of the structure of bone

Traumatic injuries account for the majority of fractures

髋骨骨折好發?肱骨易傷的神經?

Life or Limb Threatening Emergencies• Major pelvic fracture

– Exsanguinations (失血狀況致命)• Compartment syndrome

– Ischaemia, myoglobinuria, renal failure

• Open fracture – Osteomyelitis (骨髓炎)

• Limb injury with vascular injury– Amputation

• Fat Embolism Syndrome


Six PsPain．Paralysis．Paresthesia (感覺

異常)Pulselessness． Poikilothermic (溫度改變)．Pallor

尿中肌紅蛋白

Life or Limb Threatening Emergencies• Fat Embolism Syndrome (happen < 48 hours)


譫妄與昏迷

低血氧、喘

瘀斑

Clinical Manifestations

• Immediate localized pain

• Function decreasing

• Inability to bear weight or use affected part

• May or may not see obvious bone deformity

Fracture Complications


Early Local damageSoft TissuesNervesVesselsInfection

Early generalBleedingFat embolismInfection-Tetanus (破傷風), gangrene

Late LocalAvascular necrosis (骨壞死)OsteomyelitisCRPS-complex regional pain

CRPS: Complex Regional Pain Syndrome


-Fracture-

骨痂肉芽組增(細胞增生)血腫

• Diagnosis– History

– Examination

– Ix -Xrays, CT

– Re-examination of p’t prn if in doubt

– Recognised specific injury

– Ask for advice


• Treatment– Reduction (復位)restore bones and joints to normal anatomical position

(1) Traction (牽引)(2) Closed Reduction

(3) Open Reduction

– Retention (保留)Maintain reduced position-until bone union or healing of soft tissues

– Rehabilitation

• Traction: Application of pulling force to attain realignment– Prevent or reduce

pain – Prevent muscle

spasm– Immobilize a joint or

part of the body– Reduce a fracture or

dislocation– Treat a pathologic

condition


• Skin traction

• 使用膠帶、海棉橡皮或塑膠物貼附於皮膚上，再施以拉力。

1. <2.3～4.5 kg（5～10 lb）牽引力量2. Short time 2~3天

3. 如果需長期或較重的牽引，則應使用骨骼牽引或考量手術。

• Type of Skin traction

- Buck's Traction (布克氏牽引) : It is used preoperatively for patient with a hip fraction to reduce muscle spasms.


• 適用於髖部骨折之暫時固定、下背痛及股骨骨折

• 不適用於糖尿病性壞疽、鬱積性皮膚炎、動脈硬化、嚴重的靜脈曲張的病人。


- Pelvic Traction


45º

間歇

- Cervical Traction


- Russell's Traction

(路斯爾氏牽引)

-股骨幹骨折，

-兩側Traction治療下背痛



• Skeletal traction

• 金屬針及線穿透皮膚、皮下組織及骨頭。

• 牽引繩索應保持離開床鋪和鋪蓋的位置，並應在滑輪輪溝內。

• 所有牽引重力均需懸空，繩索、砂袋不能碰到床或地面。

• 牽引力可達12～15 kg

（25～30 lb）。

• Type of Skeletal traction

- Balanced Skeletal Traction

(平衡骨骼牽引)

- For patient with

femur, hip or lower leg

fracture


• Type of Skeletal traction - Overhead Arm Traction

(高位手臂牽引)

-肱骨骨折

-上臂臂或肘部外傷或骨折，造成腔室症候群，壓迫臂動脈，使得肌肉纖維因缺血而壞死所引起手緊繃僵硬。

-減少弗克曼氏（Volkmann’s）攣縮


• Closed reduction

Nonsurgical, manual realignment

• Open reduction

Correction of bone alignment through a surgical incision

Nursing Care-Fracture-

6PCTMS

• Casts

– Temporary circumferential immobilization device

– Common following closed reduction


合併症:

急性十二指腸阻塞

• Internal fixation

– Pins, plates, intramedullary rods, and screws

– Surgically inserted at the time of realignment


• External fixation

– Metallic device composed of pins that are inserted into the bone and attached to external rods


Pin Care

Nursing Assessment • Brief history of the accident

• Mechanism of injury

• Special emphasis focused on the region distal to the site of injury

• Neurovascular assessment– Color and temperature

• cyanotic and cool/cold: arterial insufficiency

• Blue and warm: venous insufficiency

– Capillary refill (want < 3 sec)

– Peripheral pulses (↓ indicates vascular insufficiency)

– Edema, Sensation, Motor function, Pain


Nursing Diagnosis• Risk for peripheral neurovascular dysfunction

• Acute pain

• Risk for infection

• Risk for impaired skin integrity

• Impaired physical mobility

• Ineffective therapeutic regimen management


• 踝幫浦運動(ankle pumping)• 臀肌收縮• 股四頭等長收縮• 主動或被動ROM• 直舉腿運動• 負重運動

Nursing ImplementationGeneral post-op care

• Assess dressings/casts for bleeding/drainage

• Prevent complications of immobility

• Measures to prevent constipation

• Frequent position changes/ ambulate as permitted

• ROM exercised of unaffected joints

• Deep breathing

• Isometric exercise 等長運動

• Prevent infection (antibiotics)

• Nutrition support


Nursing ImplementationPost-op care for Total Hip Replacement

-Do Not Flex hip greater than 90 degrees.

-Use elevated toilet seat

-Place hip in adduction (外展)

-Prevent external rotation (勿外旋)

-Do Not Cross legs


<90度

Nursing ImplementationPost-op care for

Total Knee Replacement

• Physical Therapy

• Gradually return to normal activities– Walking, climbing stairs

– No running, playing tennis

– Stationary Bicycle – regain strength in knee and leg muscles

– Swimming

-CPM also called continuous passive motion, is a device that is used to gently flex and extend the knee joint.


Control weight

Thank you for your attention

Documents

Nursing Care of Patients with Musculoskeletal Disorders (I)