MUSCULO-SKELETAL NURSING by hcj

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									 Medical-Surgical Nursing
        NUR 245

MUSCULO-SKELETAL SYSTEM
  Review of Anatomy and Physiology

• The musculo-skeletal system consists of the
  muscles, tendons, bones and cartilage
  together with the joints.

• The primary function of which is to produce
  skeletal movements.
                    Muscles

Three types of muscles exist in the body
• 1. Skeletal Muscles
  – Voluntary and striated
• 2. Cardiac muscles
  – Involuntary and striated
• 3. Smooth/Visceral muscles
  – Involuntary and NON-striated
                  TENDONS

• Bands of fibrous connective tissue that tie
  bones to muscles
                LIGAMENTS

• Strong, dense and flexible bands of fibrous
  tissue connecting bones to another bone
                      BONES

• Variously classified according to shape, location and
  size
• Functions
  1. Locomotion
  2. Protection for vital organs
  3. Support and lever
  4. Blood production
  5. Mineral deposition
                  JOINTS

• The part of the Skeleton where two or more
  bones are connected
               CARTILAGES

• A dense connective tissue that consists of
  fibers embedded in a strong gel-like substance
                  BURSAE

• Sac containing fluid that are located around
  the joints to prevent friction
ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM


 • 1. HISTORY
 • 2. Physical Examination
   – Perform a head to toe assessment
   – Nurses need to inspect and palpate
   – The special procedure is the assessment of joint
     and muscle movement
   – Usually, a tape measure and a protractor are the
     only instruments
ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM

•   Gait: ask the patient to walk
•   Posture: kyphosis, lordosis, scoliosis
•   Muscular palpation
•   Joint palpation
•   Range of motion (ROM): active & passive
•   Muscle strength: examined against the examiner
    hand
          Diagnostic Procedures

1. X-ray studies: to determine bone density,
   texture, erosions, fractures, & joint structure.

2. CT scan: Can reveal tumors of the soft tissues,
   or injuries to the ligaments & tendons.

3. MRI: used to detect abnormalities of soft
   tissues such as muscles, tendons, cartilage &
   nerves.
          Diagnostic Procedures

4. Bone Scan
• Imaging study with the use of a contrast radioactive
  material to detect bone tumors, osteomyelitis.
• Pre-test: Painless procedure, IV radioisotope is used,
  no special preparation, pregnancy is contraindicated
• Intra-test: IV injection, Waiting period of 2 hours
  before X-ray, Fluids allowed, Supine position for
  scanning
• Post-test: Increase fluid intake to flush out
  radioactive material
          Diagnostic Procedures

5. Arthroscopy
  – A direct visualization of the joint cavity done on OR
  – Pre-test: consent, explanation of procedure, NPO

  – Intra-test: Sedative, Anesthesia, incision will be
    made

  – Post-test: maintain dressing, ambulation as soon as
    awake, mild soreness of joint for 2 days, joint rest
    for a few days, ice application to relieve discomfort,
    give analgesic.
         Diagnostic Procedures

6. Bone Marrow Aspiration
  – Usually involves aspiration of the marrow to diagnose
    diseases like leukemia, aplastic anemia

  – Usual site is the sternum and iliac crest

  – Pre-test: Consent form should be obtained.

  – Intra-test: Needle puncture may be painful.

  – Post-test: maintain pressure dressing and watch out for
    bleeding.
         Diagnostic Procedures

7. DXA- (Dual-energy X-ray Absorptiometry):
• Assesses bone density to diagnose osteoporosis.

• Uses LOW dose radiation to measure bone density.

• Painless procedure, non-invasive, no special
  preparation.

• Advise the patient to remove jewelry.
Common musculoskeletal problems


      The Nursing Management
Nursing Management of common musculo-skeletal
                 problems

PAIN

These can be related to joint inflammation, traction,
  surgical intervention.
• 1. Assess patient’s level of pain (intensity, duration)

• 2. Instruct patient alternative pain management like
  meditation, heat and cold application, TENS and
  guided imagery.
PAIN

• 3. Administer analgesics as prescribed
  – Usually NSAIDS
  – Meperidine can be given for severe pain


• 4. Assess the effectiveness of pain measures.
IMPAIRED PHYSICAL MOBILITY

• 1. Instruct patient to perform range of motion
  exercises, either passive or active

• 2. Provide support in ambulation with assistive devices

• 3. Turn and change position every 2 hours

• 4. Encourage mobility for a short period and provide
  positive reinforcements for small accomplishments.
SELF-CARE DEFICITS

• 1. Assess functional levels of the patient

• 2. Provide support for feeding problems
  – Place patient in Fowler’s position
  – Provide assistive device and supervise mealtime
  – Offer finger foods that can be handled by patient
  – Keep suction equipment ready.
SELF-CARE DEFICITS

•3. Assist patient with difficulty bathing and
hygiene
  – Assist with bath only when patient has difficulty
  – Provide ample time for patient to finish activity
   Musculoskeletal Modalities

• Traction

• Cast
                   Traction

Definition:
Pulling force exerted on bones to reduce or
immobilize fractures, reduce muscle spasm,
correct or prevent deformities.

•Used as short term intervention until other
modalities like internal or external fixation are
possible.
                  Traction

• To decrease muscle spasms.

• To reduce, align and immobilize fractures.

• To correct deformities.
Types of Tractions

•Skin traction: applied to the skin to control
muscle spasm. e.g. Buck’s, Bryant

•Skeletal traction: applied directly to the bone
& used occasionally to treat fractures.
   e.g. cervical, tibia, overhead arm traction.
Types of Tractions

• Balanced Suspension traction: supports the
  extremity off the bed.




• Running or Straight traction: apply the pulling
  force in a straight line with the body part
  resting on the bed.
          Nursing Management
Traction: General principles
• 1. ALWAYS ensure that the weights hang freely and
  do not touch the floor.

• 2. NEVER remove the weights.

• 3. Maintain proper body alignment.

• 4. Ensure that the pulleys and ropes are properly
  functioning and fastened by tying square knot.
          Nursing Management

• 5. Observe and prevent foot drop
   – Provide foot plate


• 6. Observe for DVT, skin irritation & breakdown.

• 7. Provide pin site care for clients in skeletal
  traction- use of chlorhexidine is the most
  effective, normal saline can be used also.
     Nursing Management

8. Promote skin integrity
  – Use special mattress if possible
  – Provide frequent skin care
  – Assess pin entrance and cleanse the pin with
    chlorhexidine solution
  – Turn and reposition within the limits of
    traction
  – Use the trapeze
Care of Client in Traction
Temperature
  extremity
  infection
Ropes hang freely
Alignment
Circulation Checks
Type & location of Fx
Increase fluid intake
Overhead Trapeze
No weights on bed or floor
         Nursing Management

CAST
• Rigid immobilizing device made of plaster of
  Paris or fiberglass
• Provides immobilization of the fracture.
       Nursing Management

Cast types:
• Long arm
• Short arm
• Short leg
• Long leg
• Hip Spica
• Body cast
               Casting Materials

• Plaster of Paris
  – Takes 1-3 days to dry completely.
  – If dry, it is SHINY, WHITE, hard and resistant.


• Fiberglass
  – Lighter in weight
  – dries in 20-30 minutes.
  – Water resistant
  – Stronger & more durable than plaster
                 Cast application

•   TO immobilize a body part in a specific position.

•   TO exert uniform compression to the tissue.

•   TO provide early mobilization of UNAFFECTED body
    part.

•   TO correct deformities.

•   TO stabilize and support unstable joints
         Nursing Management

CAST: General Nursing Care
• 1. Allow the cast to air dry (usually 24-72
  hours)

• 2. Handle a wet cast with the PALMS not the
  fingertips to avoid dents.
          Nursing Management

CAST: General Nursing Care
• 3. Keep the casted extremity ELEVATED using
  a pillow to reduce swelling.



• 4. Turn the extremity for equal drying. DO
  NOT USE DRYER for plaster cast
  – Encourage mobility and range of motion exercises
         Nursing Management

CAST: General Nursing Care
• 5. Petal the edges of the cast to prevent
  crumbling of the edges.



• 6. Examine the skin for pressure areas and
  Regularly check the pulses and skin color.
         Nursing Management

CAST: General Nursing Care
• 7. Instruct the patient not to place sticks or
  small objects inside the cast.

• 8. Monitor for the following: pain, swelling,
  discoloration, coolness, tingling or lack of
  sensation and diminished pulses.
         Nursing Management

CAST: General Nursing Care
 • Hot spots (progressively painful areas)
   occurring along the cast may indicate
   infection under the cast
                  Fracture

• A break in the continuity of the bone and is
  defined according to its type and extent.
                 Fracture

Causes:
• Severe mechanical Stress to bone à bone
  fracture
• Direct Blows
• Crushing forces
• Sudden twisting motion
• Extreme muscle contraction
                    Fracture

TYPES OF FRACTURES
• 1. Complete fracture
  – Involves a break across the entire cross-section of
    the bone.
• 2. Incomplete fracture
  – The break occurs through only a part of the cross-
    section of the bone.
                     Fracture

TYPES OF FRACTURE
• 1. Closed fracture
  – The fracture that does not cause a break in the
    skin
• 2. Open fracture
  – The fracture that involves a break in the skin
                    Fracture

TYPES OF FRACTURE
• 1. Comminuted fracture
  – A fracture that involves production of several
    bone fragments.
• 2. Simple fracture
  – A fracture that involves break of bone into two
    parts or one.
                      Fracture

ASSESSMENT FINDINGS (clinical manifestations):

•   1. Pain or tenderness over the involved area
•   2. Loss of function
•   3. Deformity
•   4. Shortening
•   5. Crepitus (crumbling sensation)
•   6. Swelling and discoloration
                 Fracture

ASSESSMENT FINDINGS
1. Pain
• Continuous and increases in severity
• Muscles spasm accompanies the fracture is a
  reaction of the body to immobilize the
  fractured bone
                 Fracture

ASSESSMENT FINDINGS
2. Loss of function
• Abnormal movement and pain can result to
  this manifestation
                  Fracture

ASSESSMENT FINDINGS
3. Deformity
• Displacement, angulations or rotation of the
  fragments in a fracture Causes deformity
                 Fracture

ASSESSMENT FINDINGS
4. Crepitus
• A grating sensation produced when the bone
  fragments rub against each other
               Fracture

• DIAGNOSTIC TEST
• X-ray
                 Fracture
EMERGENCY MANAGEMENT OF FRACTURES

• 1. Immobilize any suspected fracture.

• 2. Support the extremity above and below when
  moving the affected part from a vehicle

• 3. Suggested temporary splints: hard board, stick,
  rolled sheets.
                   Fracture
• 4. Apply sling if forearm fracture is suspected or
  the suspected fractured arm maybe bandaged
  to the chest.

• 5. Open fracture is managed by covering it with
  clean/sterile gauze to prevent contamination

• 6. DO NOT attempt to reduce the facture:
  realignment of the displaced fracture. The
                  Fracture

MEDICAL MANAGEMENT
• 1. Reduction of fracture either open or closed,
  Immobilization and Restoration of function.

• 2. Antibiotics, Muscle relaxants such as
  METHOCARBAMOL and Pain medications.
                   Fracture
General Nursing MANAGEMENT
For CLOSED FRACTURE
• 1. Assist in reduction and immobilization
• 2. Administer pain medication and muscle
  relaxants
• 3. teach patient to care for the cast
• 4. Teach patient about potential complications of
  fracture and to report infection, poor alignment
  and continuous pain
                        Fracture
General Nursing MANAGEMENT
For OPEN FRACTURE
• 1. Prevent wound and bone infection
      - Administer prescribed antibiotics
      - Administer tetanus prophylaxis
      - Assist in serial wound debridement

• 2. Elevate the extremity to prevent edema formation

• 3. Administer care of traction and cast
               Fracture
FRACTURE COMPLICATIONS
Early Complications:
•1. Shock
•2. Fat embolism
•3. Compartment syndrome
•4. Infection
•5. DVT
                  Fracture
• FRACTURE COMPLICATIONS
Late Complications:
• 1. Delayed union
• 2. Avascular necrosis
• 3. Delayed reaction to fixation devices
• 4. Complex regional syndrome
                  Fracture
Fat Embolism
•Occurs usually in fractures of the long bones

•Fat globules may move into the blood stream
because the marrow pressure is greater than
capillary pressure

•Fat globules occlude the small blood vessels of
the lungs, brain kidneys and other organs
                         Fracture

Onset is rapid, within 24-72 hours
ASSESSMENT FINDINGS
•1. Sudden dyspnea and respiratory distress
•2. tachycardia
•3. Chest pain
•4. Crackles, wheezes and cough
•5. Petechial rashes over the chest, axilla and
hard palate
                 Fracture
Nursing Management
•1. Support the respiratory function
Ø Respiratory failure is the most common
cause of death
Ø Administer O2 in high concentration
Ø Prepare for possible intubation & ventilator
support
                  Fracture
2. Administer drugs
•Corticosteroids
•Dopamine
•Morphine
                    Fracture
3. Institute preventive measures

ØImmediate immobilization of fracture
ØMinimal fracture manipulation
ØAdequate support for fractured bone during turning
and positioning
ØMaintain adequate hydration and electrolyte balance
                Fracture
Early complication: Compartment syndrome
•A complication that develops when the
tissue perfusion in the muscles is less than
required for tissue viability as a result of
decreased space for contents within the
compartment
                     Fracture

ASSESSMENT FINDINGS
•Pain- Deep, throbbing and UNRELIEVED by opioids.

•Pain is due to reduction in the size of the muscle
compartment by tight cast.

•Pain is due to increased mass in the compartment
by edema, swelling or hemorrhage.
                   Fracture

• 2. Paresthesia- burning or tingling sensation

• 3. Numbness

• 4. Motor weakness

• 5. Pulselessness, impaired capillary refill time
  and cyanotic skin
                           Fracture
Medical and Nursing management
•1. Assess frequently the neurovascular
status of the casted extremity

•2. Elevate the extremity above the level of
the heart

•3. Assist in cast removal and FASCIOTOMY:
a surgical procedure where the fascia is cut to relieve
tension or pressure (and treat the resulting loss of
circulation to the muscles.

								
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