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Nursing Care of the Adult System with Musculoskeletal Stressors Zelne Zamora, DNP, RN Human Skeleton Bone is a Living Tissue Musculoskeletal System Facts Activity = stress→ maintenance of bone strength ↓ mobility → measurable losses in strength and muscle tone within 48 hours Long bones and multiple fractures take longer to heal Effective healing of fractures depends on blood supply, immobilization and alignment Musculoskeletal System Facts Major body systems are impacted by immobility Lungs Renal Cardiovascular Skin Types of Injuries Related to Musculoskeletal System: Fractures Damage to a muscle,ligament, tendon or joint Sprains Soft Tissue Trauma Soft tissue trauma Treatment first aid for soft tissue injuries R – rest I – ice for 48-72 hours C – compression E – Elevation above level of the heart Fracture: Disrupts Bone Continuity CAUSES Blunt force trauma Pressure Accidents that cause above Repetitive stress EPIDEMIOLOGY Very young Very old are most susceptible Types of Fractures Fig. 63-6 Types of Fractures Avulsion – ligament or tendon attached to bone pulls away Comminuted – many small fragments (> 2 pieces) Displaced – displacement of fracture fragments, can be axially displaced, angulated or rotated Greenstick – incomplete fracture in which the bone bends Impacted – one broken end driven and wedged into the other – commonly seen with comminuted fxs Interarticular – related to joints Longitudinal – lengthwise along bone Oblique – across the shaft of the bone, combo of bending and twisting Pathologic – related to disease making bones brittle Spiral – fracture line spirals around the shaft of the bone Stress – bone subjected to repeated stress, AKA fatigue fx Incomplete Fracture Simple (closed) Fracture WARNING! Next slides with graphic photos Compound (open) Fracture What Type of Fracture? What Type of Fracture? What Type of Fractures? What Type of Fracture? What Type of Fracture? Signs and Symptoms of Fractures Pain, especially upon movement Loss of function Deformity - rotation Crepitus Swelling Ecchymosis (may develop later) Diagnostic Tests X-rays MRI CT scan Bone Scan Arthroscopy LABS Serum Calcium (9-11 mg/dl) Phosphorus (2.5-4.5 mg/dl) Alkaline phosphatase (4.313 U/dl) Calcitonin Vitamin D Myoglobin (negative in both urine and serum) How Fractures Heal Hematoma Granulation Callus formation Consolidation Remodeling WARNING! Next slides with graphic photos Factors Impairing Bone Healing Inadequate reduction Increased edema Bone loss due to damage Movement Infection Factors Impairing Bone Healing Bone necrosis Anemia Endocrine imbalances Poor nutrition Treatments for Fractures Closed reduction Open reduction Open reduction internal fixation Pins, plates, screws, nails, grafts, implants Treatments for Fractures Open reduction external fixation Casts, splints, braces, traction Compound fractures may involve cleaning, debriding and infection prevention Traction Casts – Extremities Re-alignment Maintaining alignment Uniform pressure on encased soft tissue Casts Plaster Softer Heat given off during application Hardens over time – easily “dented” Skin irritation/breakdown Usually applied first, then changed to fiberglass Assess CMS – circulation, motion, sensation Casts Non-plaster or fiberglass Lighter weight Stronger – dry thoroughly Durable Water resistant Casts Cast construction and molding may allow movement of a joint while immobilizing a fracture Short vs long Extremity: arm or leg Walking cast Casts Cast construction and molding may allow movement of a joint while immobilizing a fracture Body cast Spica cast Cast Care Elevate, elevate, elevate! Neurovascular checks (CMS) Care of skin Pain management Cast Care Be alert to pressure area formation Good Hygiene Good nutrition Circle drainage marks on cast note date/time Turning Care of External Fixators Wash hands. Gloves must be used. Prepare a clean work surface. Use sterile Q-tips cleaning from the pin working outwards. Agency/unit protocols may vary. Report tenderness, redness, swelling,pus, necrosis, foul odor, fever, pin looseness. S/S of neurovascular impairment Pallor Cyanosis Prolonged capillary refill Edema Increased pain S/S of neurovascular impairment Cool/cold tissue Diminished or absent pulses Changes in sensation Nerve impairment Peroneal nerve Tibial Radial Ulnar Median Fat Embolism Syndrome (FES) Pathophysiology Fat particles enter circulation via fracture site Increase clotting and viscosity Fat Embolism Syndrome (FES) Clinical presentation Hypoxia / hypoventilation ALOC – restlessness, anxiety Petechaie Tachycardia/ chest pain Temp elevated Retinopathy Decreased urine output Fat Embolism Syndrome (FES) Medical Treatment Early immobilization of fx Adequate oxygenation Adequate hydration Nursing interventions Awareness & vigilance – 1224hrs Accurate I&O Compartment Syndrome Increased tissue pressure in small space Compromises circulation Bivalve cast (cast saw) If severe, fasciotomy Compartment Syndrome Commonly caused by: Poor cast care - CMS Compartment Syndrome http://www.youtube.com/watch?v=k1QnE cTP-cY Warning: Graphic slide All rights and images to “Rizzoli & Isles” are courtesy of TNT broadcasting. Fasciotomy Fasciotomy Surgical procedure to release constricting muscle fascia to relieve muscle tissue pressure (Smeltzer et al, 2008) WARNING: Graphic picture coming in next slide Cast syndrome Superior mesenteric artery syndrome: compression due to confinement in body cast Decreased intestinal motility Ileus can occur Can be psychological: claustrophobic-like reaction to cast Cast syndrome Nursing: insert NG tube to decompress stomach IV fluid till GI motility restored Med for nausea / vomiting Worst case: bowel gangrene Disuse Syndrome Muscle atrophy from disuse Prevention: isometric exercises, tense/ relax muscles in cast, ankle exercises, finger exercises, etc Traction Uses To reduce a fracture or dislocation Immobilize and maintain alignment Prevent or reduce muscle spasm Correct or prevent deformity Provide rest and comfort post-op Types of Traction Skin (good for up to 7lbs. of weight). Attaches to skin only Skeletal (pulling force directly to bones, can go up to 30 lbs of weight) Use of pins and screws Traction Must Establish a line of pull Have equal counterforce Be free of friction Be applied with body in correct alignment Buck’s Traction Uses an external pulling force Leg must be fully in boot, heel touching CMS remains priority in care DOES NOT use countertraction Skin breakdown with boot Skeletal Traction Uses an external pulling force Steinman pins or external fixator Priority: CMS and pin care Uses traction and counter-traction Infection can lead to osteomyelitis Nursing care of client in traction No interference with lines of pull Patient is in good alignment Pin assessment, skin assessment, neurovascular checks Nursing care of client in traction Check that correct weights are being used Weights are to be off the floor Position and attachment of weights is safe Check counter-traction Nerves Complications of Immobility Gastrointestinal Genitourinary Constipation Cystitis, retention, calculi Respiratory Pneumonia Complications of Immobility Neurovascular Skin Thrombophlebitis, compartment syndrome Breakdown Psychosocial Boredom, sensory deprivation, altered sense of time Amputations Reasons for amputation Trauma Tumor Infection Advanced PVD Compartment syndrome complications WARNING: graphic picture coming Catagories of Lower limb amputation Foot – toe, midtarsal, Boyd, Symes BKA – transtibial AKA – transfemoral Hip Disarticulation Pre-Op Care Stabilization of diabetes Well nourished and hydrated PT and OT consultations Emotional Support Teaching Pain management, phantom limb Prosthetic preparation Post-op Care VS and respiratory status Wound dressing and drainage Be vigilant of hemorrhage Accurate I&O Pain Management Stump positioning and conditioning Phantom Limb Pain Crutch Walking Points to remember Never rest armpit on the top of the crutch. There should be 2 fingers width between armpit and top of crutch. Points to remember Be sure to ask if patient must navigate stairs Wear tie shoes with low heels Rubber tips clean and in good condition Crutch Gaits: points of contact 2 point 3 point 4 point Swing to Swing through Crutch Gaits: points of contact Skills – wound vacs (Vacuum assisted closure) Negative pressure wound therapy – open wounds Use of Macro- and microstrain Removes infectious materials Promotes perfusion Protected healing environment Reduce edema Wound vac Parts: Machine Sponge Elastic cover Suction end Use of sterile technique Cut sponge to fit Wound vac - Nursing Maintain suction If small leak, can cover with more tegaderm Pamphlet for quick reference Educate patient on wound vac – discharge home with vac