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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