nursing: Musculoskeletal System Part 1

This nursing lecture briefly discusses the anatomy of the musculoskeletal system.

Musculoskeletal System
- Functions
- Movement and maintains posture
- Support
- Protection
- Hematopoiesis
- Mineral homeostasis
Contusions, Strains, and Sprains
- Contusion- soft tissue injury produced by blunt force.
- Strain - “muscle pull” from overuse, overstretching, or excessive stress.
- Sprain- injury to the ligaments surrounding a joint, caused by a wrenching or twisting motion.
- Treatment : “RICE”
- Rest, Ice, Compression, Elevation
Musculoskeletal Injuries
- Fracture
- Break in the continuity of bone
- Resulting from trauma or various disease processes.
Types
- Complete - fracture extends
- through entire bone,
- producing 2 or more
- fragments.
- 1. Simple or Closed- fractured bone; does not protrude through skin
- 2. Compound or Open- fractured
- bone extends through skin and mucous membranes
- 3. Comminuted fracture- multiple bone fragments
A. Complete Fracture
- 4. Oblique fracture- fracture line at 45-degree angle to long axis of bone
- 5. Spiral fracture- fracture line
- encircling the bone
- 6. Transverse fracture- fracture line perpendicular to long axis
- of bone
B. Incomplete Fracture
- Incomplete- when only part
- of the bone is broken.
- 1. Greenstick fracture- fracture
- of one side of bone; other side
- merely bends; usually seen
- only in children
- 2. Bowing fracture- bending of
- bone.
- 3. Stress fracture- microfracture.
Stress Fracture Bowing Fracture Greenstick Fracture
Fracture
- Clinical Manifestation
- Pain and tenderness
- Soft tissue edema
- Abnormal motion
- Crepitus
- Obvious deformity
- Discoloration or ecchymosis
- Diagnostic Studies
- X-ray
- Objectives of Treatment
- Optimal realignment
- Rigid immobilization
- Restoration of function
Fracture Management
- Treatment Modalities for Fractures
- Closed or Open Reduction
- Casting
- Traction
- Internal or External Fixation Devices
Internal Fixation External Fixation
Fracture Management
- Reduction (“setting” the bone)
Fracture Management
- Closed Reduction (Manipulation)
- Bone ends are realigned w/o surgical exposure of the fracture site
- Anesthesia may or may not be used
- Followed by casting to maintain proper alignment
Fracture Management
- Open Reduction
- Operative procedure utilized to achieve bone alignment
- Pins, wire, nails or rods may be used to secure bone fragments in position
- Prosthetic implants may also be used
Fracture Management
- Immobilization
Fracture Management
- Internal Fixation Devices
- Implanted surgical devices to align and stabilize the fracture site until healing can occur
- Used when closed reduction does not provide stable immobilization
Internal Fixation Devices The advantage of internal fixation is that it often allows early mobility and faster healing.
Fracture Management
- External Fixation Devices
- Two or more rigid bars are placed horizontally above and below the fracture site in the long bones of the extremities
Complication of Fractures
- Early complications
- Shock
- Fat embolism
- Assessment
- (S) dyspnea
- (O) tachypnea, tachycardia, hypoxia, crackles, wheezes, chest pain, cerebral disturbances
- N/I
Complication of Fractures
- Compartment syndrome
- Assessment:
- (S) deep, throbbing, unrelenting pain not controlled by narcotics
- (O) paresthesia (early), swelling, motor weakness
- N/I:
Complication of Fracture
Complication of Fractures
- Infection
- Assessment:
- (S) pain
- (O) ↑ temperature and pulse, edema, sudden local induration, thin, watery, foul-smelling exudate, crepitation (maybe indicative of gas gangrene; with cast-warm area, foul smell
- N/I:
Complication of Fractures
- Delayed complications
- Delayed union/Non-union
- Assessment:
- (S) pain
- (O) callus formation, on X-ray- poor alignment
- N/I:
- Maintain immobilization and alignment
- Maintain adequate nutrition
- Avoid trauma to affected extremity
- Increase calcium in diet
Complication of Fractures
- Avascular Necrosis/Circulatory impairment
- Assessment:
- (S) tenderness, pain, especially on passive motion
- (O) limited movement
- Treatment:
- Revitalize the bone with bone grafts
- Prosthetic replacement
- Arthrodesis
Fracture Care
- Maintain in optimal alignment
- Check all bony prominences for evidence of pressure q4h and prn, depending on amount of pressure
- Monitor: circulation, sensation and motion of affected part
- Assess circulation in the injured limb: warmth and color, capillary refill, peripheral pulses
Fracture Care
- Assessing nerve supply to the limb
- Maintain mobility in unaffected limb and unaffected joints of affected limb by active and passive ROM exercises
- Prevent foot drop by using ankle-top sneakers
Traction
- mechanism by which a steady pull is placed on a part or parts of the body
- 2 Types:
- Skin traction
- Application of wide band of moleskin, adhesive, or commercially available devices directly to the skin and attaching weights to them.
A. Skin Traction
- 1. Buck’s extension
- Exerts straight pull on the affected extremity; to immobilize the leg in patient with a fractured hip
- Has a horizontal weight
- Turn towards unaffected side
- Check for pressure sore at the heel of the foot*
Balance suspension Buck’s extension
A. Skin Traction
- 2. Russel traction
- Knee is suspended in a sling attached to a rope and pulley on a Balkan frame, creating upward pull from the knee
- Weights are attached to the foot of the bed
- Used to treat fracture of the femur
- Allows patient to move about in bed more freely and permits bending of the knee joint
- Assess back of the knee for pressure sores
A. Skin Traction
- 3. Bryant’s traction
- Both legs raised 90 angle to bed
- Used for children under 3 years and 30 lbs to treat fractures of the femur and hip dislocation
- Buttocks must be slightly off mattress
- Knees slightly flexed
The knees should be slightly flexed, and the legs should be extended at a right angle to the body. The body provides a traction mechanism.
A. Skin Traction
- 3. Pelvic traction
B. Skeletal Traction
- Traction applied directly to the bones using pins, wires, or tongs (Crutchfield) that are surgically inserted, used for fractures femur, tibia, humerus, cervical spine
1.Balanced suspension traction
- Produced by a counterforce other than the patient’s weight
- Extremity floats or balances in the traction apparatus
- Patient may change position without disturbing the line of traction
- Used for displaced or overriding fx of femur
- Relieves muscle spasms
- Realigns fx fragments
- Promotes callus formation
Initial weights: 30 to 40 lbs Suspension weights: 7 to 8 lbs Countertraction: 7 to 8 lbs
Pearson attachment Thomas splint
Care of the Clients in Traction
- 5 General Principles in Traction Care:
- 1. Line of pull should be in line with the deformity
- 2. Adequate countertraction present
- 3. Apply traction continuously
- 4. Allow the weights to hang freely
- 5. Avoid friction
Care of the Clients in Traction
- Turn the client as indicated
- Pin site care for skeletal traction:
- Do neurovascular checks
- Prevent complication of immobility
Nursing Intervention
- Promote healing and prevent complications
- diet: high protein, iron, vitamins (tissue repair), moderate carbohydrates (prevent weight gain)
- increase fluid intake
- assess for complications of immobility (pneumonia, constipation, decubitus ulcers, osteoporosis)
- assess casted extremity for presence of foul odor, drainage, paleness or blueness, change in temperature, pulselessness, tingling, numbness
Fracture bedpan
Nursing Intervention
- Prevent injury or trauma
- avoidance of high-risk activities (sky diving, high impact sports, rollerblading)
- avoidance of safety hazards (throw rugs, untreated vision problems)
- regular exercise
- provide care related to ambulation with crutches
- provide safety measures related to possible complications following fracture
Fracture bedpan
CRUTCH WALKING
- The distance between the axilla and the arm piece on the crutches should be at least 3 fingerwidths below the axilla
- The elbows should be slightly flexed, 30 degrees
- When ambulating with the client, stand on the affected side.
CRUTCH WALKING
- Crutch stance: tripod (triangle) position (6-10 inches in front and to the side).
- Instruct the client never to rest the axilla on the axillary bars.
- Instruct the client to look up and outward when ambulating.
- Instruct the client to stop ambulation if numbness or tingling in the hands or arms occurs.
Crutch gaits
- Four-point gait
- Sequence:
- Advance left crutch 4-6 inches
- Advance right foot
- Advance right crutch
- Advance left foot
- Advantages : most stable crutch gait
- Requirements : Partial weight bearing on both legs
Crutch gaits
- Three-point gait
- Sequence:
- Advance both crutches forward with the affected leg and shift weight to crutches.
- Advance unaffected leg and shift weight onto it.
- Advantages: allows the affected leg to be partially or completely free of weight bearing
- Requirements: full weight bearing on one leg, balance and upper-body strength.
Crutch gaits
- Two-point gait
- Sequence:
- Advance left crutch and right foot
- Advance right crutch and left foot
- Advantages: Faster version of the four-point, normal walking pattern.
- Requirements: Partial weight bearing on both legs
- Swing-through gait
- Sequence:
- Move both crutches forward.
- Move both legs farther ahead than crutches.
Amputation of a Lower Extremity
- Removal of a body part, usually an extremity
- 10% of patients experience uncomfortable sensations  phantom limb pain.
- Risk Factors
- Atherosclerosis obliterans
- Uncontrolled DM
- Malignancy
- Extensive and intractable infection
- Severe trauma

nursing

Monday, February 16, 2009

Musculoskeletal System Part 1

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