nursing: Musculoskeletal System

Showing posts with label Musculoskeletal System. Show all posts

Monday, October 19, 2009

Nursing Questions

Here are some sample nursing questions on Cholecystectomy,Appendectomy,Thyroidectomy,CS operation and Gastrectomy. Visit our site often for more Nursing lectures. Subscribe to our RSS feed for instant Email updates.

Monday, February 16, 2009

Musculoskeletal System Part 2

This is the second part of Musculoskeletal System lecture. More nursing lectures about this system at http://nursinglectures.blogspot.com

Below the knee amputation
Nursing Intervention
- Preoperative
Post-operative Care
- Prevent edema
- Prevent hip/knee contractures
- Pain medication as ordered (phantom limb pain)
- Ensure that stump bandages fit tightly and are applied properly to enhance prosthesis fitting
Inflammatory Disorders of the Musculoskeletal System
- Rheumatoid arthritis
- chronic systemic inflammatory disease
- destruction of connective tissue and synovial membrane within the joints
- weakens and leads to dislocation of the joint and permanent deformity
- Risk Factors
- exposure to infectious agents
- fatigue
- stress
Rheumatoid Arthritis
- Signs and Symptoms
- Morning stiffness
- Fatigue
- Weight loss
- Joints are warm, tender, and swollen
- Swan neck deformity-late
- Diagnostic Studies
- X-ray
- Elevated WBC, platelet count, ESR*, and positive RF
- Treatment
- No cure for RA
Swan neck deformity
Rheumatoid Arthritis
Pharmacotherapy
- Aspirin- mainstay of treatment, has both analgesic and anti-inflammatory effects
- Nonsteroidal anti-inflammatory drugs (NSAIDs):
- I mmunosuppressives : Methotrexate
Pharmacotherapy
- Gold compounds
- Injectable form: sodium thiomalate, aurothioglucose; given IM once a week; takes 3-6 months to become effective
- Oral form: auranofin- smaller doses are effective; diarrhea is a common side effect
- Corticosteroids
- Intra-articular injections
Rheumatoid Arthritis
- Treatment
- Surgical Procedures: synovectomy, arthrotomy, arthrodesis, arthroplasty
- Nursing Management
- Advised bed rest during acute pain
- Passive ROM exercise of joints
- Splint painful joints
- Heat & Cold application
- Advised warm bath in the morning
- Protect from infection
- Advised well-balanced diet
Arthrotomy Arthrodesis Arthroplasty
Osteoarthritis (Degenerative Joint Disease)
- Progressive degeneration of the joints as a result of wear and tear
- affects weight-bearing joints and joints that receive the greatest stress, such as the knees, toes, and lower spine .
Osteoarthritis
- Risk Factors
- aging (>50 yr)
- rheumatoid arthritis
- arteriosclerosis
- obesity
- trauma
- family history
- Signs and Symptoms
- Dull, aching pain,* tender joints
- fatigability, malaise
- crepitus
- cold intolerance*
- joint enlargement
- presence of Heberden’s nodes or Bouchard’s nodes
- weight loss
Medications
- Aspirin
- inhibits cyclooxygenase enzyme, diminishes the formation of prostaglandins
- anti-inflammatory, analgesic, antipyretic action
- inhibit platelet aggregation in cardiac disorders
- Adverse effects
- Epigastric distress, nausea, and vomiting
- In toxic doses, can cause respiratory depression
- Hypersensitivity
- Reye’s syndrome
- Ibuprofen
- use for chronic treatment of rheumatoid and osteoarthritis
- less GI effects than aspirin
- Adverse effects
- dyspepsia to bleeding
- headache, tinnitus and dizziness
Medications
- Indomethacin
- inhibits cyclooxygenase enzyme
- more potent than aspirin as an anti-inflammatory agent
- Adverse effects:
- nausea, vomiting, anorexia, diarrhea
- headache, dizziness, vertigo, light-headedness, and mental confusion
- Hypersensitivity reaction
Osteoarthritis
- Nursing Intervention
- Promote comfort: reduce pain, spasms, inflammation, swelling
- Prevent contractures: exercise, bed rest on firm mattress, splints to maintain proper alignment
- Weight reduction
- Isometric and postural exercises
- Nursing Diagnosis
- Pain related to friction of bones in joints
- Risk for injury related to fatigue
- Impaired physical mobility related to stiff, limited movement
Gouty Arthritis
- Metabolic disorder that develops as a result of prolonged hyperuricemia
- Caused by problems in synthesizing purines or by poor renal excretion of uric acid.
- Acute onset, typically nocturnal and usually monarticular, often involving the first metatarsophalangeal joint
- Risk Factors
- Men
- Age (>50 years)
- Genetic/familial tendency
Gouty Arthritis
- Signs and Symptoms
- extreme pain
- swelling
- erythema of the involved joints
- fever
- Tophi
- Laboratory Findings
- elevated serum uric acid (>7.0 mg/dl)*
- urinary uric acid
- elevated ESR and WBC
- crystals of sodium urate aspirated from a tophus confirms the diagnosis*
Treatment
- Allopurinol
- - a purine analog
- - reduces the production of uric acid by competitively inhibiting uric acid biosynthesis which are catalyzed by xanthine oxidase.
- Effective in the treatment of primary hyperuricemia of gout and hyperuricemia secondary to other conditions (malignancies).
- Adverse effects : hypersensitivity reactions, nausea and diarrhea
- Colchicine
- Effective for acute attacks
- Anti-inflammatory activity alleviating pain within 12 hours
- Adverse effects : nausea, vomiting, abdominal pain, diarrhea, agranulocytosis, aplastic anemia, alopecia
- Probenecid/Sulfinpyrazone
- uricosuric agents
- increases the renal excretion of uric acid
- Sulfinpyrazone used as a preventive agent.
- Adverse effects: nausea, rash & constipation
Nursing Implementation
- Maintain a fluid intake of at least 2000 to 3000 ml a day to avoid kidney stone.
- Avoid foods high in purine such as wine, alcohol, organ meats, sardines, salmon, anchovies, shellfish and gravy.
- Take medication with food.
- Have a yearly eye examination because visual changes can occur from prolonged use of allopurinol
- Caution client not to take aspirin with these medication because it may trigger a gout attack and may cause an elevated uric acid levels.
- Encourage rest and immobilize the inflamed joints during acute attacks
- Avoid excessive alcohol intake
- Notify physician if rash, sore throat, fever or bleeding develops.
Osteomyelitis
- Infection of the bone
- Staphylococcus aureus is the most common pathogen.
- Other organisms include Proteus, Pseudomonas and E. Coli
Osteomyeliti s
- Risk Factors
- poorly nourished, elderly or obese
- impaired immune systems
- chronic illnesses
- long term corticosteroid therapy
- Clinical Manifestation
- area appears warm, swollen and extremely painful
- systemic manifestations (fever, chills, tachycardia)
- Diagnostic Studies
- X-ray
- Bone Scan
- Blood and wound culture
Nursing Management
- Promote comfort
- Immobilized affected bone by maintaining splinting.
- Elevate affected leg
- Administer analgesics as needed.
- Control infectious process
- Apply warm, wet soaks 20 min. several times a day.
- Administer antibiotics as prescribed.
- Use aseptic technique when dressing the wound.
- Encourage participation in ADL within the physical limitations of the patient.
Osteoporosis
- reduction of total bone mass
- change in bone structure, which increases susceptibility to fracture
- bone becomes porous, brittle, and fragile
Risk Factors
- Menopause
- aging
- long term corticosteroid therapy
- high caffeine intake
- smoking
- high alcohol intake
- sedentary lifestyle or immobility
- insufficient calcium intake or absorption
- hereditary predisposition
- coexisting medical conditions (hyperparathyroidism, hyperthyroidism)
Osteoporosis
- Clinical Findings
- loss of height
- fractures of the wrist, vertebral column and hip
- lower back pain
- kyphosis
- Respiratory impairment
- Diagnostic Findings
- X-rays
- Dual-energy x-ray absorptiometry (DEXA)
- Serum calcium
- Serum phosphatase
- Urine calcium excretion
Medical Management
- Pharmacologic Therapy
- Hormone replacement therapy
- Alendronate (Fosamax)
- Calcitonin- ↓ plasma levels of Ca, ↑ deposition of Ca in the bone
Nursing Management
- Prevention
- Adequate dietary or supplemental calcium
- Regular weight bearing exercise
- Modification of lifestyle
- Calcium with vitamin D supplements
- Administer HRT, as prescribed
- Relieving pain
- Improving bowel elimination
- Preventing injury
- Nursing Activities
- Encourage use of assistive devices when gait is unstable
- Protect from injury (side rails, walker)
- Encourage active/passive ROM
- Promote pain relief
- Encourage good posture and body mechanics
Bone Tumors
- Osteosarcoma
- Most common primary bone tumor
- Occurs between 10-25 years of age, with Paget's disease and exposure to radiation
- Exhibits a moth-eaten pattern of bone destruction.
- Most common sites: metaphysis of long bones especially the distal femur, proximal tibia and proximal humerus
Osteosarcoma
- Clinical Manifestation
- local signs – pain ( dull, aching and intermittent in nature), swelling, limitation of motion
- palpable mass near the end of a long bone
- systemic symptoms: malaise, anorexia, and weight loss
- Diagnostic Findings
- Biopsy- confirms the diagnosis
- X-ray
- MRI
- Bone Scan
- Increase alkaline phosphatase
Medical Management
- Radiation
- Chemotherapy
- Surgical management
- Prognosis: poor prognosis (rapid growth rate)
Nursing Management
- Promote understanding of the disease process and treatment regimen
- Promote pain relief
- Prevent pathologic fracture
- Assess for potential complications (infection, complications of immobility).
- Encourage exercise as soon as possible (1st or 2nd post-op day)
Total Hip Replacement
- a plastic surgery that involves removal of the head of the femur followed by placement of a prosthetic implant
Nursing Management
- Teach client how to use crutches
- Teach client mechanics of transferring.
- Discuss importance of turning and positioning post-op.
- Place affected leg in an abducted position and straight alignment following surgery
- Prevent hip flexion of more than 90 degrees.
- Apply support stockings
- Advise client to avoid external/internal rotation of affected extremity for 6 months to 1 year after surgery
- Instruct client to avoid excessive bending, heavy lifting, jogging, jumping
- Encourage intake of foods rich in Vitamin C, protein, and iron.
- Administer prescribed medications.
Metallic implant
Complications
- Infection
- Hemorrhage
- Thrombophlebitis
- Pulmonary embolism
- Prosthesis dislocation
- Prosthesis loosening
Dysplasia of the Hip
- condition in which the head of the femur is improperly seated in the acetabulum, or hip socket, of the pelvis.
- Congenital or develop after birth
Assessment
- Neonates: laxity of the ligaments around the hip, allowing the femoral head to be displaced from the acetabulum upon manipulation.
- Implementation:
- Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation (neonatal period)
Pavlik harness
Assessment
- Infants
- Asymmetry of the gluteal and thigh skin folds when the child is placed prone and the legs are extended against the examining table.
- Limited range of motion in the affected hip.
- Asymmetric abduction of the affected hip when the child is placed supine with the knees and hips flexed.
- apparent short femur on the affected side
Congenital Hip Dysplasia
- Implementation
- Traction and/or surgery to release muscles and tendons
- Following surgery, positioning and immobilization in a spica cast until healing is achieved.
Assessment
- The walking child
- minimal to pronounced variation in gait with lurching toward the affected side; positive Trendelenburg sign
- Positive Barlow or Ortolani’s maneuver
Ortolani’s maneuver Barlow maneuver
Scoliosis
- Lateral curvature of the spine
- Surgical and nonsurgical interventions are employed
- The type of treatment depends on the degree of curvature, the age of the child, and the amount of growth that is anticipated.
Assessment
- visible curve fails to straighten when the child bends forward and hangs arms down toward feet.
- asymmetry of hip height
- pelvic obliquity
- inequalities of shoulder height
- scapular prominence
- rib prominence and rib humps
- severe cases, cardiopulmonary and digestive function may be affected because of compression or displacement of internal organs.
Nursing Intervention
- Monitor progression of the curvature
- Prepare the child and parents for the use of a brace if prescribed
- Worn from 23 hours a day
- Inspect the skin for signs of redness or breakdown
- Keep the skin clean and dry, avoiding lotions and powders
- Advise the child to wear soft nonirritating clothing under the brace
- Scoliosis screening: 8 years old*
Nursing Implementation
- Prepare the child and parents for surgery if prescribed.
- Postoperative
- maintain proper alignment; avoid twisting movements
- logroll the child when turning, to maintain alignment
- instruct in activity restrictions
- instruct the child to roll from a side-lying position to a sitting position, and assist with ambulation
Laminectomy
- Surgical incision of part of posterior arch of vertebrae and removal of protruded disc
- Nursing Intervention
- Preoperative
- Postoperative
- Position as ordered
- Lower spinal surgery- flat
- Cervical spine surgery: slight elevation of head of bed
- Proper body alignment- cervical spinal surgery: avoid flexion of neck and apply cervical collar
Laminectomy: Postoperative Care
- Avoid:
- Back- strengthening exercises
- Lie in side- lying with hip flexion
Laminectomy: Postoperative Care
- Patient teaching and Discharge Planning

View more presentations from thinkrn. (tags: musculoskeletal splint)

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