Download Chapter 46 Nursing Care of Patients with Musculoskeletal and

N124IN
Spring 2013
Soft
tissue injury that is due to an
overly stretched muscle or
tendon
Causes: falls, exercise, lifting
Strain classifications:
• Mild strain
• Moderate strain
• Severe strain
Treatment
• RICE
 Rest
 Ice
 Compression
 Elevation
• Apply heat after inflammation diminishes
• Limit activity
• Muscle relaxants
• Surgery if necessary
 Overly
stretched ligament(s)
 Causes: twisting motions with sports,
exercise, falls
 Sprain classifications/treatments:
• Mild sprain
 RICE treatment until swelling/pain decrease
 Anti-inflammatory meds
• Moderate sprain
 Immobilization
• Severe sprain
 Surgery
 Bone
ends forced out of normal position
 Causes: trauma (falls, sports), disease
(RA)
 Symptoms: severe pain, no range of
motion, joint deformity
 Treatment:
• Medical treatment needed immediately!
• Splint extremity the way you find it, place ice on
it, find help
• Do NOT move extremity
 Inflammation
of bursa
 Causes: arthritis, gout, repetitive
movement, sleeping on side
 Prevention is important!
 Symptoms:
• Achy pain, stiffness, burning pain
 Treatment:
• Joint rest, ice application until joint warmth
disappears, heat, joint elevation, ultrasound,
massage, NSAIDs, PT
 Different
injuries can occur
• Ex: chronic impingement syndrome
 Symptoms:
• Aching shoulder
• Pain with arm lifting
• Pain is more severe at night
• Weakness
• Decreased ROM
 Diagnosed
with MRI
Treatment:
• Minor injury
 Rest
 NSAIDs
 Ice
 Physical therapy
• Severe injury
 Arthroscopic surgery
 Small-incision surgery
 Sling/brace after surgery
 Physical therapy
Pathophysiology
• Due to median nerve compression in
carpal tunnel when swelling takes
place in tunnel
• Swelling can occur because of edema,
trauma, RA, repetitive hand movements
Signs/Symptoms
• Slow-onset pain and numbness
• Painful tingling and paresthesias
• Over time, fine motor deficits and
muscle weakness
Diagnostic
Tests
• Signs and symptoms
• Patient history
• Phalen’s test
• Electromyography
(EMG)
Therapeutic Measures
• Decreasing inflammation/pain
 Aspirin, NSAIDs, cortisone injections
• Rest wrist
• Splint
• Surgery
 Open incision or endoscopy
• Physical therapy
Nursing
Considerations
• Educate on prevention
• Give pain medications
• If surgery is completed, give standard
preoperative/postoperative care
 Postop
 Elevate hand
 Splint
 Lifting restrictions
 Signs/Symptoms of neurovascular compromise
 ADLs
Pathophysiology
• Break in a bone
• Cells related to healing process move
to damaged area
• A week after injury, callus forms
• Osteoclasts resorb necrotic bone,
osteoblasts create new bone
 Called bone remodeling
• Proper nutrition (vitamins, minerals,
protein) is needed for fracture healing
 Etiology and Types
• Classifications
 Complete vs. Incomplete
 Complete Fracture: bone breaks into 2 pieces
 Incomplete Fracture: bone doesn’t break into 2 pieces
 Open vs. Closed
 Open Fracture (Compound): bone breaks skin
 Closed Fracture: bone does not break through skin
 Way bone breaks
 Avulsion, comminuted, impacted, greenstick,
interarticular, displaced, pathologic, spiral,
longitudinal, oblique, stress, transverse, depressed
 Signs/symptoms
• Tenderness over injury site
• Severe pain with movement
• Short limb
• Limb rotation
• Limb deformity
• Diminished ROM
• Crepitation
• Ecchymosis over fracture
• Swelling
• Wound
Diagnostic
Tests
• X-ray
• Computed tomography
• Magnetic resonance imaging
• Hemoglobin/Hematocrit Levels
• Erythrocyte sedimentation rate (ESR)
• Serum calcium level
 Emergency
Treatment
• Assess for respiratory distress, bleeding, head/spinal
injury
• Emergency Management of Fractures
 Immobilize limb
 If no bleeding: splint and place padding above/below fracture
 If bleeding: assess where bleeding is coming from; apply
pressure
 If fracture is in leg bone, bandage both legs together
 If fracture is in arm bone, bandage arm to chest or place in
sling
 Assess color, warmth, circulation, movement distal to fracture
 If open fracture, cover bone with clean/sterile dressing
 Minimize movement
 Take patient to ER immediately
Fracture
Management
• Goals:
 Bone end realignment
 Immobilization
 Further injury and deformity prevention
 Function restoration or preservation
 Early healing
 Pain management
Fracture
Management, cont.
• Closed Reduction
 Physician manually pulls on bone and
moves bone ends into realignment
 Analgesia and/or conscious sedation
 X-ray confirms bone ends are in
correct position before immobilizing
area
Fracture
Management, cont.
• Bandages/Splints
 Bandage or splint can immobilize bone
while healing takes place
 Splints may be necessary if:
 Soft tissue damage is present that requires
care
 Swelling is anticipated
 Splints should be well-padded
 Neurovascular assessments
 Fracture Management, cont.
• Casts
 Assist with early mobility
 Help decrease pain
 Support weak joints, correct deformities, restrict
movement
 Type depends on why cast is needed
 Plaster of Paris
 Synthetic (fiberglass)
 Elevate limb for 24-48 hrs and apply ice
 Assess cast for: dryness, tightness, drainage, odor
 If cast is too tight, it should be cut
 If there is a wound, a window opening in cast is made

http://www.youtube.com/watch?v=B6z7tEzVZzc
Fracture
Management, cont.
• Traction
 Pulling force applied to body part to cause
fracture reduction, decrease movement,
decrease pain
 Continuous: used with fracture management
 Intermittent: used with muscle spasms
 Manual traction can be applied for short
time periods
 Fracture
Management, cont.
• Traction, cont.
 Skin traction:
 Used for muscle spasms with fractures; does not assist with
bone aligning
 Types:
 Buck’s traction (velcro boot)
 Russell’s traction/knee sling (sling)
 Pelvic belt
 Halter
 Skeletal traction/balanced suspension
 Pins, screws, wires, or tongs
 Surgically placed in bone
 Helps with alignment
 Countertraction necessary
Fracture Management, cont.
• Traction, cont.
 Nursing care:
 Assess neurovascular status
 Monitor equipment
 Assess skin for pressure points or irritation
 Assess pin sites (redness, drainage, odor, swelling,
warmth)
 Pin site care
 Encourage independence with mobility
 Assess psychosocial health
Fracture
Management, cont.
• Open Reduction with Internal Fixation
(ORIF)
 Surgical incision made, ends of bones are
realigned/reduced
 Metal plates and screws or prosthesis hold
bone ends in place

http://www.youtube.com/watch?v=8dEcsqpqVg8&feature=related
 Fracture Management, cont.
• Eternal Fixation
 Used when multiple fractures present in bone,
crushed bone, splintered bone, open fracture that has
soft tissue damage
 Fracture is reduced, then pins are surgically placed
into bone
 External device holds pins in place to prevent bone
movement
 Complications: pin reaction, altered circulation,
infection
 Nursing considerations:
 Assess pin site
 Pin site care
 Maintain aseptic technique
Fracture
Management, cont.
• Nonunion Modalities
 Malunion: bone doesn’t heal in proper alignment
 Nonunion: bone has delayed or no healing
 Treatment for nonunion
 Electrical bone stimulation
 Bone grafting
 Treatment for slow-healing fractures
 Low-intensity pulsed ultrasound (Exogen therapy)
Fracture Complications
• Altered neurovascular status
 Perform neurovascular checks
Circulation problems:
diminished/absent pulses, cool skin,
dusky color
Neurologic problems: numbness,
tingling, diminished
sensation/mobility
Fracture
Complications, cont.
• Hemorrhage
 Assess bleeding and vital signs
 Bleeding can occur with damage to or
surgery on bone
 Severe hemorrhage can cause
hypovolemic shock
Fracture Complications, cont.
• Infection
 Wound site infection
 Pin site infection
 Drainage tube infection
 Osteomyelitis (bone infections)
 Hospital-acquired infections related to
immobilization (pneumonia, UTIs)
Fracture Complications, cont.
• Thromboembolitic complications
 Related to immobilization
 Deep venous thrombosis (DVT)
 Pulmonary embolus (PE)
 Prevention:
 Leg exercises
 Early ambulation
 Anticoagulant therapy
 Low molecular weight heparin
 Fondaparinux (Arixtra), dalteparin (Fragmin),
enoxaparin (Lovenox)
Fracture
Complications, cont.
• Acute Compartment Syndrome
 Increased pressure in compartment(s)
Circulation impairment
 Can be caused by external device
(cast, dressing)
Fracture
Complications, cont.
• Acute Compartment Syndrome, cont.
 Signs/symptoms
 Early sign:
 Severe, worsening pain
 Severe acute compartment syndrome:
 Pain
 Paresthesia
 Paralysis
 Pallor
 Pulselessness
 Poikilothermia
Fracture Complications, cont.
• Acute Compartment Syndrome, cont.
 Goal: relieve pressure
 Treatment
 Removing pressure source
 Removing cast
 Fasciotomy
 If pressure is not relieved, the following may
occur:
 Tissue necrosis, infection, extremity
contracture, renal failure
http://www.youtube.com/watch?v=xoUzK0Nvmoc
 http://www.youtube.com/watch?feature=fvwp&v=Oz
tTBwYpeOI&NR=1

Fracture
Complications, cont.
• Fat Embolism Syndrome
 Yellow bone marrow releases fat
globules into bloodstream
Move to lung fields
 Results in respiratory distress
 May happen up to 72 hours after initial
injury
Fracture Complications, cont.
• Fat Embolism Syndrome, cont.
 Signs/symptoms:
 Altered mental status
 Tachycardia
 Tachypnea
 Fever
 High BP
 Severe shortness of breath
 Petechiae on upper body
 Pulmonary edema
 Fracture
Complications, cont.
• Fat Embolism Syndrome, cont.
 If suspect fat embolism:
 Give O2 at 2 L/min via nasal cannula
 Position patient in high-Fowler’s position or raise HOB as
patient tolerates
 Keep patient on bedrest
 Minimize extremity movement
 Get patient ready for x-ray or lung scan
 Get patient ready for ABGs
 Give IV fluids per orders
 Give corticosteroids per orders
 Give emotional support
 Ensure calm environment
Nursing
considerations
• Assess neurovascular status
• Assess pain
• Analgesics and anti-inflammatories
• Positioning/alignment
• Promote independence
• Work with interdisciplinary team
• Prevent complications
• Education