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Med Surg Musculoskeletal System Chris DeMatteo RN MSN

VIEWS: 12 PAGES: 113


• The branch of medical science dealing
  with prevention or correction of
  disorders and diseases of the
  musculoskeletal system
 Nursing of Pts. with Orthopedic
     Diseases or Disorders
• Objectives:
  –   Maintain body alignment
  –   Preserve muscle tone
  –   Preserve joint mobility
  –   Prevent contractures
• Health History
  –   Major illnesses, surgeries, hospitalizations
  –   Previous injuries
  –   Allergies
  –   Current medications
  –   Family history
  –   Participation in physical exercise/activity
  –   Occupation
• General assessment includes:
  – General appearance: Stature, ht., wt., v.s.,
    nutritional status, apparent age relative to
    chronological age

• Inspection includes:
  – Observation of posture, symmetry, size,
    gait, movement, obvious deformities
• Palpation: Why?

• Range of Motion
• Possible S/Sx r/t Musculoskeletal:

• Muscles

• Bones & Joints

• Other
    Diagnostic Tests see pp. 1056-1061
•   X-Ray
•   Arthrography/Arthroscopy
•   Myelogram
•   Bone Scan
•   CT Scan
•   MRI
•   EMG (Electromyelogram)
•   Synovial Fluid Analysis
•   Biopsy
            Labs: see p. 1056
• Calcium – Increase- Metastatic bone tumor,
  acromegaly, osteoporosis, vit. D deficiency

• Erythrocyte Sedimentation Rate (ESR)
  Increase: inflammation as seen in RA
  Decrease: CHF, OA, Sickle Cell Anemia

• Rheumatoid Factor (RF) – Immunoglobulin
  present in approx. 80% of adults w/ RA

• Uric Acid – Increase: seen with Gout
      Trauma – Soft Tissue
• Contusion
  – Rupture of small blood vessels

• Strain
  – Injury to muscle or tendon from overuse,
    excessive stress or overstretching
  – Rupture of muscle or tendon will require
    surgical repair

• Sprain
  – Injury to ligaments surrounding a joint
  Focused Assessment for Soft
         Tissue Trauma
• History of events and activities
• Position of affected part on injury
• Approximate wt. amt. bearing on
  affected part
• Any cracking, popping, snapping sounds
  heard or felt
• Swelling, discoloration, ltd. or painful
• Comparison with unaffected part
Nursing. Care - Soft Tissue Trauma
 • Relief of pain or muscle spasm
 • Reduction of swelling
 • Restoration of normal wt. bearing &

 • RICE (heat after 1st 36-48 hours)
 • Administration of analgesics &/or
   muscle relaxants
            Severe Trauma
          Focused Assessment
                   7 Ps
1.   Pain
2.   Pallor
3.   Paresthesias
4.   Paralysis
5.   Polar Temperature
6.   Puffiness
7.   Pulselessness
          Severe Trauma
        Focused Assessment
• Limited movement

• Warmth, edema, ecchymosis

• Loss of function

• Signs of shock – What are they?

• Signs of CMS impairment
  Severe Trauma- Dislocation
• Dislocation
  – Joint surfaces are out of contact,
    bone is displaced from normal position
  – Emergency
  – S/Sx: severe pain, decreased
    movement, limb length discrepancy,
    change in contour or shape of joint
  – Medical management: closed
    reduction, surgical intervention
       Severe Trauma- Fractures
• Any break or crack in continuity of bone
• More common in males up to age 45, then
  becomes more common in females. Why?
• More than 150 types- classified in many
  different ways:
  –   Break in skin integrity
  –   Location or appearance
  –   Alignment status
  –   Force that caused fracture
  –   Physician who 1st described
   The Little Old Lady with the
        Fractured Femur
             Fracture: S/Sx
• Deformity            • Normal function loss

• Swelling             • Abnormal mobility

• Tenderness           • Crepitus

• Pain                 • Paralysis

• Impaired Sensation   • Hypovolemic shock
          Diagnostic Tests
• X-Ray

• CT Scan

• Bone Scan
 Common Fracture Classifications
• Greenstick              • Oblique

• In/Complete             • Spiral

• Comminuted              • Linear

• Transverse              • Open or Compound
                            (3 Grades)
• Impacted (telescoped)
                          • Closed
    5 Stages of Bone Healing
1. Hematoma Formation

2. Cellular Proliferation

3. Callus Formation

4. Ossification

5. Consolidation & Remodeling
 Fractures – Medical Treatment

• Realignment (Reduction)

• Establish sturdy union

• Restore function
       Fracture Reduction
Brings ends of broken bone into proper
1. Closed: non-surgical

2. Open: surgical
          Fracture Fixation
Attempts to attach broken bone fragments
Performed during Open Reduction

ORIF: Internal use of rods, pins, nails, screws
 or metal plates to align and hold in place.

OREF: pins in bone attach to external frame.
 Pin track infection occurs in approx. 10%.
 Pin Care – sterile – nursing responsibility.
  Nursing Care Post-Op Open Reduction
• Assess Q1-2h for neurovascular
• Vital Signs Q4h, once stable
• Hemoglobin & Hematocrit
• Observe amount, type & characteristic of
  any drainage. Report amounts >100-150ml/hr
  after the 1st 4 hrs.
• Turn & Reposition @ least Q2h
• Deep Breathing, coughing, incentive
• What kind of meds?
      Fracture Complications
•   Shock
•   Contractures
•   Infection
•   Fat Embolism
•   Compartment Syndrome
•   Avascular Necrosis
•   Gas Gangrene
           Fat Embolism
• Fat globules released from marrow can
  occlude pulmonary vessels and lead to
  respiratory distress

• S/sx include: dyspnea, change in mental
  status (restlessness, agitation,
  confusion, stupor), tachypnea,
  tachycardia, fever (>103°), petecchial
  skin rash, diffuse rales.
       Compartment Syndrome
• Severe interruption of blood flow and
  subsequent muscle damage, most commonly
  w/ tibial, radial or ulnar fractures

• S/Sx: pain disproportionate to injury, pain
  associated w/ pressure over compartment,
  pain w/ passive stretching of involved
  muscle, paresthesias, edema, pallor, weak or
  ≠ pulses, cyanosis

• Treatment: relieve pressure
        Avascular Necrosis
• Occurs whenever blood supply to bone is
• Most often affects head & neck over
  femur and is a gradual process
• Pt. needs to be instructed to report any
  intermittent or constant pain w/ wt.
  bearing and any ROM limitation
• Usual treatment is joint replacement
               Gas Gangrene
• Gram + saprophytic bacterial infection (usually

• S/Sx: change in mental status, fever, chills,
  decreased BP, increased P & R.

• As disease progresses: edema, gas bubbles at
  wound site, and profuse drainage having a
  characteristic fruity odor

• FATAL without treatment
Care of Fractures: Immobilization
• Casts

• Splints

• Immobilizers
                Cast Care
• Depends on casting material used
• Palm only until completely dry
• No removal of padding
• No insertion of objects
• No wt. bearing x 48 hours
• No prolonged plastic covering
• Check circulation @ distal extremity for
  color, pain, motion, and for burning or
  tingling sensations under cast
              Cast Care
• Petaling: cutting edges of cast and
  taping for comfort and extremity

• Window: cut a window into cast to
  relieve pressure
• Provides alignment by exerting a pulling
  force on a fractured extremity.
• Purposes: 1. Alignment
  • Major Types: 1. Skin – no more than 5-10lbs.
                  2. Skeletal – metal pin or wire
  Countertraction: exerting a force that opposes
    the traction already established

           Skin                Skeletal
• Buck’s                • Steinman Pin

• Russell’s             • Kirschner Wire

• Head Halter           • Vincke or
                          Crutchfield Tongs
• Pelvic
                        • Halo Device
• Balanced Suspension
Nursing Care of Pt. in Traction
• Skin assessment
• VS Q4H
• Monitor for s/sx of infection

• Assess for neurovascular complications
• Assess for complications of fractures
• Assess for complications of immobility

• Check that weights are hanging freely
  Nursing Care of Pt. in Traction
• Maintain alignment of pt’s body
• Assess pt’s ability for self movement

• Observe condition of traction cords –
  All knots are Square Knots

• Sheepskin
• Monitor distal pulses
• Monitor for paresthesias
           Crutch Safety
• Proper Measurement w/ wt on hands

• What happens if weight is on axilla?

• Rubber Tips

• Adequate upper body strength

Nursing Care of Pts. w/ Fractures is R/T:
•   Pain
•   Impaired Physical Mobility
•   Impaired Circulation
•   Risk for Impaired Skin Integrity
•   Risk for Infection
•   Activity Intolerance
•   Other: altered nutrition, constipation, self-
    care deficit, ineffective individual coping,
    sleep pattern disturbance, diversional
    activity deficit
  Nursing Interventions r/t Pain
• Immobilization is primary
Nursing Interventions r/t
    Physical Mobility
Nursing Interventions r/t
  Impaired Circulation
   Nursing Interventions r/t
Risk of Impaired Skin Integrity
Nursing Interventions r/t
    Risk of Infection
Nursing Interventions r/t
  Activity Intolerance
          Severe Trauma

Dislocation: ligament gives way and
 bone is displaced from normal
 position in the joint. Can also be
 caused by congenital or acquired
May also damage joint structure:
 ligaments, nerves, & vascular system
 of surrounding tissues
          Severe Trauma

• S/Sx:

• Med Mgmt: closed reduction,
  surgical intervention to restore
  joint articulation is sometimes done
     Severe Trauma: ACL Injury
• Anterior Cruciate Ligament Injury/Tear

• Most common among athletes (basketball,
  soccer, volleyball, football, skiing) 4-6 x
  more common in women

• Complete or partial tear resulting from
  hard twist, sudden stop, jump landing or
  direct blow

• Loud painful pop upon injury f/b swelling
           ACL Tear S/Sx
• A loud “pop” sound

• Severe pain

• Knee swelling within 4-12 hours

• A feeling of instability or knee giving
  way with weight bearing
           ACL Tests & Dx
• History of injury

• Examination of knee in various positions

• Aspiration of fluid in joint space to aid in
  examination and decrease pain

• X-rays to r/o bone fracture

          ACL Tx: Initial
• Short-term: Stop activities that cause
   – RICE
   – Pain relievers such as ibuprofen
   – Splint or crutches if needed
   – PT for ROM & muscle-strengthening
            ACL Tx: Surgical
• Surgery, usually out-patient, arthroscopic
• 1-2 small incisions
• Post-op
   – PT, special knee brace, avoid activities
     that stress knee

  – Return to sports 6-9 months after surgery

  – 9/10 report good – excellent results and
    satisfactory knee stability
           ACL Tx: Non-surgical
• Non-surgical
  – PT
  – Knee bracing
  Consider if:
  - No sports involving cutting, pivoting or jumping
  - Knee not painful or unstable during normal
  - Fairly sedentary lifestyle
  - No damage to knee cartilage
  - Advanced arthritis
          ACL – Nursing Care
•   RICE
•   Pain management
•   Patient education
•   Exercise
•   Use of splints, immobilizers
    Inflammatory Disorders

• Rheumatoid Arthritis

• Bursitis

• Osteomyelitis
• Arthritis is inflammation of the joint

• 50 million Americans affected

• 4 million unable to work, attend school,
  participate in social functions

• Most Common: Rheumatoid, Rheumatoid or
  Ankylosing Spondylitis, Osteoarthritis, Gout
     Rheumatoid Arthritis (RA)
• Systemic, most serious form of arthritis,
  chronic and progressive

• Chronic inflammation of synovial membranes
  of diarthrotic joints leading to destruction
  of joint

• Auto-immune w/ some evidence of genetic

• Peak onset between 30 & 60 y/o. Higher
  incidence in women
                RA S/Sx
• Pain and AM stiffness
• Weakness, fatigue, anorexia, wt. loss
• Muscle Aches
• Joint Deformities, especially in the
  interphalangeal & metacarpophalangeal
• Subj: malaise, muscle weakness, decreased
  grip strength, loss of appetite
• Obj: edema, subcutaneous nodules, fever,
  limited ROM
       RA Clinical Manifestations
•   Elevated ESR
•   + IgM
•   May have elevated IgG
•   Anemia

• Synovial Fluid Analysis: inflammatory
• Radiology:
  Early: soft tissue swelling & osteoporosis
  Late: joint space narrowing, cartilage
  destruction, deformities
     RA: Medical Management

• Medications
  – NSAIDS- Ibuprofen, Naprosyn, etc>
  – DMARDS (Disease Modifying Anti-Rheuma-
    toid Drugs) – Folex, Plaquenil, Azulfidine
  – Glucocorticoids – Cortef, Solu-Cortef
  – Gold Salts – myochrisine IM- long-term anti
    inflammatory- effect takes 3-6 month
         RA: Nursing Care
• Assessment

• Goals of Nursing Care

• Interventions

• Education
• Inflammation of the bursae

• Most commonly affects shoulders & hips

• Caused by repeated use or trauma

• S/Sx: pain, limited ROM, swelling and

• Med Mgmt: NSAIDS, corticosteroid injec.,
  cold & moist heat therapies
      Nursing Care Bursitis
• Assess: Joint involvement for pain,
  swelling, limitation of movement, bil.
  hand grasps

• Goals: Relief of pain & swelling,
  restoration of joint function

• Interventions: Education, med admin.,
  activity modification for 4-6 weeks
• Inflammation of bone and marrow

• Bacterial infection, most commonly staph,
  Gm- and anaerobes are 2nd most common

• Occurs through trauma or surgery or
  bacteria traveling through bloodstream

• Invades bone and degenerates bone tissue
  Osteomyelitis: Sources, S/Sx
• Sources: Hemodialysis, UTI, Bacterial
  Endocarditis, Pressure sores, soft tissue
  trauma, necrosis associated w/ malignancies,
  radiation, burns, sinus & ear infections,
  abcessed teeth, compound fractures,
  surgery, punctures

• S/Sx: Pain, fever, localized tenderness,
  erythema & edema- backache if vertebral
         Osteomyelitis: Clinical
• Elevated WBC & ESR
• Blood cultures may identify causative

• X-ray
• Bone Scan
• CT Scan
Osteomyelitis: Medical Mgmt.
• Antibiotics, usually IV

• Bedrest

• Surgery- What do you think would be
  done surgically?
    Osteomyelitis: Nursing Care
• Assess for predisposing factors. What might
  these be?

• Goals: What do you think the goals of care
  would be?

• What interventions will help reach the goals?

• What would your patient education focus on?
    Degenerative Disorders

• Osteoporosis

• Osteoarthritis (OA) also known as
  Degenerative Joint Disease (DJD)
• Reduction of bone mass
• Females between 55 & 65 y/o

• May be r/t loss of estrogen – connected w/
  increased bone reabsorption & sensitivity to
  parathyroid hormone

• The “silent disease”
• Other factors: low Calcium diet, smoking,
  sedentary lifestyle
Osteoporosis Clinical Manifestations
• CBC, serum Calcium, Alkaline, BUN,
  creatinine, LFTs, TFTs

• Urinalysis

• X-ray

• Bone Density (densitometry or DEXA- Dual
  Emission X-ray Absorbitometer
          Osteoporosis S/Sx
• 1st sx usually

• Dowager’s
  hump, spinal
  deformity, ht.

• Gait
   Osteoporosis Medical Mgmt.
• Bone density promotion & bone loss
• Wt. bearing exercise programs
• Estrogen
• Bone Reabsorption Inhibitors

• Calcium supplements.
  – What vitamin is needed to help Calcium
    absorption and stimulate bone formation?
  – What are some high Calcium foods?
     Osteoporosis Nursing Care
• Assessment: lifestyle (diet, activity, etc.),
  sx, pain, deformity, impact on quality of life

• Goals:

• Interventions: heat application, proper med
  administration, education re: diet & bone
  loss, smoking & bone loss, risks of estrogen

• Safety Issues:
•   Articular cartilage degeneration non-
•   Most common type of arthritis. Leading
    cause of disability over age 65

•   Etiology:
    1. Primary: occurs w/ aging
    2. Secondary:
   Osteoarthritis (DJD) S/Sx
• Large weight bearing
  joints & knuckles
• Variable sx
• Mild to severe pain
• Joint swelling &
• Deformity &
  movement limitation
• Heberden’s nodes &
  Bouchard’s nodes
What causes treatment seeking?
   Osteoarthritis (DJD) Clinical
• No specific lab tests: CBC & ESR
  normal, Rheumatoid factor

• X-ray: narrow joint spaces, bone
  spurs, cysts, joint deformity

• MRI or arthroscopy
    OA/DJD Medical Management
• Physical Therapy
• Weight loss
• ↓ Weight bearing
• Relaxation techniques
• Medication for pain relief: acetaminophen
  recommended by American College of
  Rheumatology. Why do you think? What
  other meds do you think are used?
• Surgery: arthroscopy:
 Osteoarthritis: Nursing Care
• Assessment:

• Goals:

• Interventions: Medications : ASA or
 Total Joint Replacement- Arthroplasty
• Common sites:
• Nursing Interventions & Responsibilities:

  –   Proper positioning
  –   Activity
  –   Wound care
  –   Education/Discharge instructions
  –   ABX Prophylaxis for dental &/or invasive surgical
• Removal of a portion of or entire extremity

• May be necessary due to malignant tumors,
  impaired circulation,, congenital
  deformities, and infections. Most are

• Traumatic amputations can sometimes be
        Amputation -Types
1. Closed – to create a wt. bearing
   residual limb. Uses a skin flap.

2. Open (Staged or Guillotine) – severed
   bone or joint is left uncovered
   (without a skin flap) for 5-10 days,
   then surgically closed.
    Pre-Amputation Assessment
•   Patient understanding of procedure
•   Pain
•   Level of orientation
•   Vital Signs
•   Signs of Infection (fever, tacypnea,
•   Arterial blood flow
•   Wound drainage/wound condition
•   Nutritional status
•   Upper body strength
         Diagnostic Tests


• K+

• Urinalysis

       Medical Management
• Trauma – restore circulating blood
  volume, pain control, infection
  prevention, Maintenance of adequate
  urinary output, and site preparation.

• Elective – antibiotics, any infections
  treated, and, if possible, resolved, prior
  to surgery. Site will have been evaluated
  in advance
          Post-Op Assessment
•   Pain and Phantom Pain
•   S/Sx hemorrhage
•   Hypotension
•   Tachycardia
•   Tachypnea
•   Pallor
•   Decreased urinary output
•   Change in level of consciousness
•   Monitoring drainage & suction
     Nursing Interventions
• Aim care at prevention of deformities

• Prevent flexion hip contractures by:
  raising FOB, side-to-side movement, and
  prone position BID

• Teach how to strengthen remaining
  muscles to facilitate mobility and
  prevent atrophy
        Nursing Interventions
• Shape residual limb into a cone shape

• Observe for pulmonary complications: PE or
  Cardiovascular Collapse

• Bedside suction equipment & Oxygen

• Pt Education re: Phantom pain, rubbing,

• Expression of feelings, permission to grieve
  Common Nursing Diagnoses

• Disturbed Body Image r/t loss of limb

• Impaired Physical Mobility r/t loss of

What do you think might be a nursing
 diagnosis prior to amputation?
     Discharge Teaching Points
• Proper positions, exercises and ambulation
• Residual limb wrapping techniques

• Prolonged phantom pain requires medical
• Skin care to prevent irritation or impairment
  of residual limb

• S/Sx of wound infection
  Persistent Severe Phantom Pain
          Treatment may include:
• Residual limb revision with re-amputation
  at higher level

• Local infiltration of residual limb with
  anesthetic (Procaine)

• Mechanical percussion

• Sympathetic Nerve Block
Temporomandibular Joint (TMJ) Disease/D/O
• Degeneration of joint
• Affects 10 million people
• Causes: Bruxism (clenching or grinding), RA,
  OA, trauma, stress
• S/Sx:
• Dx:
• Moist heat or cold therapy, analgesics,
  NSAIDS, retainer or guard, soft diet,
  Arthroscopy or other surgery last resort
       Carpal Tunnel Syndrome
• Compression of the median nerve

• Highest incidence in obese middle-aged
  women, and in occupations w/ repetitious
  movements of hands or fingers, also in 3rd
  trimester of pregnancy

• 1 of 3 most common work-related conditions
  due to increased computer usage
Carpal Tunnel Clinical Manifestations
• Assessment: deficits in sensory mapping,
  increased tingling w/ gentle tapping on wrist
  (Tinnel’s Sign), forced flexion of wrists for 1
  minute or more produces numbness & tingling
  (+ Phelan’s sign)

• EMG: weakened muscle response to

• MRI: median nerve compression & flattening
         Carpal Tunnel S/Sx
• Burning, pain, numbness or tingling in hand

• Pain intermittent or constant

• Numbness of thumb, index & ring fingers

• Depression of soft tissue @ base of thumb
  on palmar surface
Carpal Tunnel Medical Management
• For Mild Sx:
  – Immobilization- splinting
  – Hydrocortisone acetate suspension
• For Severe Sx
  – Surgery – usually done only if there is
    accompanying muscle atrophy. Standard
    surgical treatment is to decompress the
    median nerve by sectioning the tansvers
    carpal ligament
  Carpal Tunnel Nursing Care
• Proper application of immobilizer


• Education

• Decrease twisting or turning activities
  of wrist
    Carpal Tunnel Nursing Care
For Surgery
• Monitor vs

• Elevate hand and arm x 24 hours

• Check CMS of fingers Q1-2 hours x 24 hrs

• Resumption of normal activities 2-3 days
        Gout (Gouty Arthritis)
• Uric acid in blood due to ineffective
  metabolism of purines. Where do we find

• Affects males 8-9x more than females
• Causes: Primary- hereditary
         Secondary- from medication, other
                     disease or idiopathic

• Occurs in mid-life. Why do you think that is?
                Gout S/Sx
• Excruciating pain, edema and inflammation
• Pain duration is variable
• Attack frequency is variable
• Tophi (calculi or stones made of sodium urate
  that develop in the periarticular tissue) may
  be present at the affected joint – usually
  the Great toe
• Edematous joint w/ red/purple discoration
  and heat
• Increased: temp, BP, P, R
• Complications: Kidney Stones
     Clinical Manifestations: Gout
Uric Acid (blood/urine): significantly elevated

CBC: may reveal anemia & leukocytosis

ESR elevated

X-Ray: cysts, toe bone pockets

Synovial Fluid Analysis: uric acid crystals
     Medical Management of Gout
•   Acute:
    1. Colchicine IV or po
    2. NSAIDS
    3. Corticosteroids
•   Prevention:
    1. allopurinol (Zyloprim) decreases uric acid
    2. probenecid (Benenid) increases uric acid
       excretion by kidneys
    3. sulfinpyrazone (Anturane)- prevent tophi dev.
           Nursing Care Gout
• Assessment:

• Goals:

• Interventions: medication, I&O, check
  for flank pain and hematuria, comfort
  measures, protect affected joint(s),
  encourage fluids, education & dietary
               Lyme Disease
• An infection transmitted through tick bites
• S/Sx: rash/lesion, flu-like illness or
• Diagnosis: ELISA, Western Blot Analysis
• Treatment: Antibiotics
• Complications: neurological, cardiac,
  musculoskeletal type of arthritis

• Nursing: Education aimed at prevention, med
  ed, comfort measures
• How is Lyme Disease prevented?
       Pediatric Musculoskeletal
        Disorder Pesentationss
•   Talipes
•   Scoliosis
•   Congenital Hip Dysplasia
•   Muscular Dystrophy
•   Juvenile Rheumatoid
•   Slipped Epiphysis
•   Legg-Calvé-Perthes
•   Osgood –Schlatter
•   Osteogenesis Imperfecta
Congenital Hip Dysplasia
Muscular Dystrophy
Juvenile Rheumatoid Arthritis
Slipped Epiphysis
Osgood -Schlatter
Osteogenesis Imperfecta

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