1. Individuals Experiencing Musculoskeletal Disorders
NURS 2016

2. Musculoskeletal Includes:
Bones
Joints
Muscles
Tendons
Ligaments
Bursae
Complications include:
Trauma
Contusion
Strain
Sprain
Joint dislocation: subluxation & avascular necrosis

3. Musculoskeletal Disorders
Low Back Pain
Most is self-limiting and will improve on its own with time
Sciatica
Osteoporosis
Bone density loss
Small frame, non obese women
Osteomyelitis
Bone infection
Septic Arthritis
Joint infection

4. Musculoskeletal Trauma
Initial Assessment
Circulation
Movement
Sensation

5. Contusions, Strains, and Sprains
Contusion is a soft tissue injury
Strain is a pulled muscle from overuse, overstretching, or excessive stress
Sprain is an injury to ligaments surrounding a joint

6. Treatment: strains, sprains, contusions
Rest
Ice
Compression
Elevate

7. Joint Dislocations
Subluxation is a partial dislocation of the articulating surfaces
Medical Management is immobilization
Nursing Management
provide comfort
neurovascular status
protect joint

8. Fractures
Break in the continuity of the bone

9. Fractures: Break in the continuity of the bone
Make sure you can identify these different fractures

10. Clinical Manifestations
Pain
Loss of function
Deformity
False motion
Shortening
Crepitus
Swelling & discoloration

11. Management Emergency Management: stabilize limb (affected area)
Reduction
Closed
Open
Traction
Emergency treatment always includes assess Airway, Breathing, and Circulation first. From there, stabilizing the affected limb or area is important to prevent further tissue trauma and damage.
Emergency assessment of injured area include Circulation, movement and sensation.
Once a fracture location has been determined, reduction process is planned and implemented (outside of scope of RN). The reduction most often is closed, however with more complext fractures, and open or surgical reduction may be necessary. Often when the fracture is fairly simple, but surrounding muscle is resistant to reduction, persuasive force by the use of traction is implemented to assist relignment of fracture.

12. Complications Shock Fat Embolism Syndrome Compartment Syndrome
Delayed Union/Nonunion
Avascular Necrosis
Infection
It’s important that you understand each of these complications and nursing roles related to each.

13. Nursing Process: Fracture
Assessment
Objective Data: assess clinical manifestations for fx.
Subjective Data
Health Info: past hx, meds, surgery
Functional: motion, weakness, spasm, pain, tingling

14. Nursing Process: Planning
Nursing Diagnosis
Risk for peripheral neurovascular dysfunction related to nerve compression
Acute pain, evidenced by pain descriptors, guarding, crying, related to edema, movement of bone fragments, and muscle spasms.
Risk for infection related to disruption of skin integrity and presence of environmental pathogens secondary to open fracture.
Further examples
Risk for impaired skin integrity related to immobility and presence of cast.
Ineffective therapeutic regimen management related to lack of knowledge regarding muscle atrophy, exercise program, and cast care as evidenced by questioning of longp0term effect of casting and cast care.

15. Nursing Process: Interventions
Expected Outcome: normal neurovascular examination
Nursing Strategies
Assess for S&S peripheral neurovascular dysfunction
Unrelieved pain or pain on passive movement
Paresthesias, cool, pallor, diminished pulses
Elevate extremity above level of heart to reduce edema by promoting venous return
Further nursing strategies
Apply ice compresses as ordered to reduce edema and provide comfort
Notify physician immediately is client complains of increasing pain that is unrelieved by meds because this may indicate neurovascular impairment.
Teach client the signs of peripheral neurovascular dysfunction to enable participation in care.
For each of the other nursing diagnoses ( on previous slide), consider appropriate nursing interventions.

16. The Patient with a Hip Fracture
Surgical repair is preferred method of treatment.
Intra capsular Fx (head and neck of femur): endoprothesis
Extracapsulr Fx (trochanteric): nails, plates, intramedullary devices.
Nursing Management for both is the same.

17. Nursing Interventions
Relieving Pain
Promoting Hip Function & Stability
Promoting Wound Healing
Promoting Normal Urinary Elimination Patterns
Promoting Skin Integrity
Promoting Effective Coping Mechanisms
Promoting Patient Orientation & Participation in Decision Making
Monitoring & Preventing Potential Complications

18. Joint Replacement Arthroplasty: replacement of all parts of the joint
Contributing factors to joint replacement:
Pain
Osteoarthritis
Rheumatoid arthritis
Trauma
Congenital deformity

19. Joint Replacement Cont’
Joints frequently replaced:
Hip
Knee
Finger
Joints sometimes replaced:
Shoulder
Elbow
Wrist
Ankle

20. Special considerations with Hip Fractures/Repair/Replacement
Do NOT
Force flexion >90
Force adduction
Force internal rotation
Cross legs
Put footwear on without assistive device before 8 weeks
Sit on chair without arms to aid in raising to stand DO
Use elevated toilet seat
Place chair inside shower or tub
Use pillow between legs when on side
Keep hip in neutral position
Notify surgeon if severe pain, deformity or loss of function
It is critical that you know these Do’s and Don’ts and that you could implement them into a plan for patient teaching regarding recovery from hip surgery.

21. Continued Strategies for Hip Repair/Replacements
Provide abduction pillow to prevent adduction
Monitor and manage complications
Neurovascular
DVT
Pulmonary
Skin
Bladder control
Delayed complications: infection, nonunion, avascular necrosis, fixation device problems.
Monitor drainage from site (hemovacs)
ml of drainage is common in first day

22. Cast Application Analgesic: admin ordered analgesic
Skin preparation: clean, dry
Support body part during application
Monitor smoothness of cast material
Position limp on pillow to dry, elevated above heart.
Position client comfortably - q2hr
Prepare for discharge

23. 5 P Assessment Pain Pallor Pulselessness Paresthesia Paralysis
Following cast application, monitoring for immediate complications includes assessing the 5 Ps

24. Unexpected Outcomes of Casting
Malunion
Osteomyelitis
Pressure ulcer
Muscle weakness
Cold extremity
Skin irritation
Unable to perform cast care

25. Post Removal Observe underlying skin: colour, temp, integrity
Assess client’s verbal and nonverbal responses
Explain exercise plan and demonstrate exercises
Skin care
Client’s are often disappointed with the appearance of a limb following cast removal – muscle atrophy, skin condition, and even hair growth may impact their response.

26. Traction Maintain established line of pull Prevent friction of skin
Maintain counteraction
Continuous (usually)
Maintain correct body alignment
When casting or open reduction alone are not sufficient for realigning a fracture, traction may be implemented.

28. Skin Traction Non-invasive Assess traction set-up
Assess mobility restrictions
Assess Pain
Assess NV status
Understanding Intermittent release
Patients in traction will experience an extreme limitation in movement and mobility. Nursing measures must focus on this reality.

29. Skeletal Traction
Traction is external and internal (via pins, wires, nails)
Similar care principles as skin traction.
Continuous
Pin Care
Inspect pins every 8 hours at minimum

30. While this may be a drawing of skin or skeletal fracture, the point of including it is to illustrate the forces involved in traction.
Free hanging weights are often used to create the force needed for traction. Part of assessing the traction set-up is ensuring that weights are indeed hanging freely and not subject to interference by activity of patient or others within the room (you don’t want visitors going by and pulling on the weights or swinging them around.--- ouch!!!)

31. Principles of Traction
Weights or traction never removed unless ordered
Patient must be in proper alignment
Ropes unobstructed
Weights hang free
Knots or other devices not hung-up on pulleys or bedframe

32. Amputation Levels: determined by
Circulation and function at most distal end that will heal
Complications: hemorrhage, infection, skin breakdown, joint contracture and phantom pain
Rehabilitation: multidisciplinary
Nursing Management
relieving pain
minimizing altered sensory perception
promoting wound healing
enhancing body image
self-care

33. Amputation Stump Dressing
Promote healing
Residual limb shaping for prosthesis fitting
Control edema
Gentle handling
Aseptic technique
Closed rigid or soft dressing