1. Musculoskeletal Problems NUR 302 Unit IV

2. Neurovascular Assessment • 5 Ps • Pain • Pulses • Pallor • Paresthesia • Paralysis or decr motor strength

3. Sprains & Strains • Sprain: injury to ligaments around joint • Strain: stretching of a muscle & sheath • S/S: pain, edema, decr function, bruising • Health promotion: warm up exercises • Care: rest, elevate, ice, compression, analgesics, after 24-48hrs heat, PT

4. Dislocation & Subluxation • Dislocation: complete separation of articular surfaces of joint • Subluxation: partial displacement • Realign & reduce joint ASAP- prevent avascular necrosis • Relieve pain, support & protect joint, prevent contractures

5. Compression of median nerve under the transverse carpal ligament in wrist S/S: weakness esp thumb, pain & numbness, clumsiness, + Phalen’s sign, + Tinel’s sign Educate about risks, wrist splint, stop aggravating action, hydrocortisone, surgery, eval of neurovascular status Carpal Tunnel Syndrome

6. Repetitive Strain Injury • Cumulative trauma to tendons, ligaments, muscles-> tiny tears, inflammation, scarring • S/S: pain, weakness, numbness, impaired function • Education, approp job design, avoid precipitating activity, PT, careful use of analgesia

7. Rotator Cuff Injury • Complex of 4 muscles that stabilize & rotate humerus, tear gradual, degenerative or from trauma • Pain, can’t abduct arm or shoulder • MRI, arthrogram • Rest, ice & heat, NSAID, corticosteroid injections, PT • Surgery, shoulder immobilizer, PT

8. Meniscus Injury • Meniscus- fibrous cartilage in knee, injured by rotational stress when knee is flexed & foot fixed. • Tenderness, pain at abduction & adduction of leg at knee, knee unstable • Arthroscopy, arthrogram, MRI • Ice, immobilize, crutches, PT, surgery

9. Bursitis • Inflammation of bursae from trauma, friction, gout, rh.arthritis, infection • Warmth, swelling, pain, decr ROM • Rest, ice, immobilize, NSAIDs • Aspiration of bursae fluid, cortisone injections, bursectomy

10. Muscle Spasms • Pain, palpable muscle mass, tenderness, decr ROM, limited ADL • H&P – R/O CNS problems • PT – heat or ice, exercise, massage, hydrotherapy, ultrasound, bracing • Meds – mild analgesics, NSAIDs, skeletal muscle relaxants

11. Bone Cancer • Multiple Myeloma- plasma cell cancer invades bone marrow • S/S- back pain , anemia, blding tendencies • Dx- biopsy • Prognosis- poor • Tx- Chemo, radiation, corticosteroids

12. Bone Cancer • Osteogenic Sarcoma- primary tumor, grows fast, long bones, distal femor • Children & young adults, age 10-25 • S/S- gradual pain, swelling, after injury • Tx- pre-op chemo then resection of tumor, amputation

13. Bone Cancer • Osteoclastoma- destructive, occurs in ends long bones • Age 20-35 • S/S- swelling pain, joint problems • Dx- biopsy, x-ray-> bone destruction & expanded bone ends • Rx- surg curettage, bone graft, chemo • Can reoccur

14. Ewing’s Sarcoma • Rapid growth of medullary cavity of long bone • Metastasis early esp lungs • S/S:pain, swelling, paplable soft tissue mass, incr size affected part, fever, leukocytosis • Tx: radiation, chemo, resection or amputation

15. Amputation Indications- circul impairment, tumors, uncontrolled infection, cong disorders Assess for potential for revasculariz. therapy by arteriogram Explain reason for amputation, reassure, rehab, answer questions Manage underlying diseases

16. Nursing Care • Assessment- dx tests, labs, swelling, jt function, s/s mets • Pain- medicate, gentle handling extremity, rest • Care of pt receiving chemo, radiation • Psychol support • Care off pt with amputation

17. Nursing Care Dsg change- sterile technique, molding limb with compression bandage Immediate post-op fitting in OR or delayed fitting Prevent flexion contractures- avoid sitting in chair with hips flexed or pillow under stump, prone 30min, 3-4X/day Teach transfer to chair, ROM, arm strength, crutch walking, refer to prosthetics

18. Nursing Care • H Promotion- teach diabetic, PVD pts & families foot care, assessment • Psychol support- depression, grieving, body image disturbance • Pre-op- upper extrem strengthening, explain post-op care, phantom pain • Post-op- hemorrhage- check VS, dsg very thick, notify MD, tourniquet

19. Osteomyelitis • Enter via arterial bld supply-> stay in area of decr circulation-> infection incr pres in bone-> ischemia-> bone death-> bone separates-> forms sequestra • Acute s/s- systemic- fever chills, nausea, malaise & local- bone pain, swelling, tenderness, warmth, drainage • Chronic- pus -> ischemia-> granulation tissue turns to scar ->infection unreachable by meds

20. Osteomyelitis • Dx- wound, bld,sequestrum C&S, bone biopsy, elev WBC & sed rate, no s/s on x-rays til 10 days-wks, seen on nuclear bone scans 24-72 hrs, CT& MRI • Rx- antibiotics- central line IV, continue at home 4-6 wks or 3-6 months, surg debridement, wound irrig, hyperbaric O2

21. Nursing Care • Teach jt replacemt pts s/s infection & prophylactic antibiotics teeth cleaning, procedures etc • Pain- gentle moving of extremity, elevate, correct alignment, immobilize • Dressings- sterile, wet-dry, vac system • Teach meds, care of venous access device, nutrition, follow up care

22. Acute Low Back Pain • Risk factors- lack of muscle tone, excess wt, poor posture, smoking, job, long sitting, stress • Injury->s/s develop later due to grad increase in muscle spasm • Rx- analgesics, NSAIDs, muscle relaxants, corset. Severe pain- bed rest, epidural corticosteroid & anesthetic • Health Promotion- body mechanics, exercise

23. Chronic Low Back Pain • Degen disc disease, injury, obesity, posture, lack of exercise, systemic disease • Hern disc- back pain with buttock & leg pain, paresthesia, muscle weakness • Dx- x-rays, MRI, CT, myelogram, EMG • Tx- rest, corset, heat or ice, NSAIDs, muscle relaxants

24. Chronic Back Pain • Progressive worsening or loss of bladder/bowel control-> surgery • Percutaneous laser diskectomy • Diskectomy or microsurgical diskectomy • Laminectomy • Spinal fusion

25. Stable Vertebral Fractures • Disrupted ligament -> unstable • Complication fx displacement ->spinal cord injury • Keep spine in proper alignment, assess neurovas status, bladder & bowel • Log rolling, no trapeze, heat, traction, no turning of torso or upright position, orthotic device, jacket cast, halo vest

26. Spinal Surgery Nursing Care • Bed rest (flat) 1-2 days, logroll, position • Muscle spasm- meds, correct turning • Leakage CSF->headache, report • Neuro s/s- movement, sensation, strength q2-4h, compare with pre-op • Assess paralytic ileus, bladder emptying • Spinal fusion- orthosis, check donor site • Teach- avoid sit/stand long, body mechanics

27. Foot Problems • See table 59-22 • Health Promotion- proper fitting shoes • Post-op- elevate, check neuovas status, pins/wires may extend thru toes, dressings, slipper, boot or cast, crutches, don’t walk on heel • Teach hygiene, trim toe nails straight across, see podiatrist if poor circulation

28. Osteoporosis • Low bone mass, structural deterioration of bone tissue-> increased bone fragility • Elderly & post-menopausal women fx hip, spine, wrist • Risk factors- female, incr age, family history, Caucasian or Asian, small, oophorectomy, sedentary, insuf Calcium • Alcoholism, rh arthritis, DM, cirrhosis, kidney disease, intest malabsorption

29. Osteoporosis • Long term meds- corticosteroids, antiseizure, Al antacids, heparin, INH, tetracycline, thyroid replacemt meds • Genetic marker- VDR gene • S/S: “silent”, bump or fall->fx, vertebrae collapse->back pain, ht loss, kyphosis • Dx: shows on x-ray only after 25-40% loss, BMD, DEXA, Ca, phos, alk phos

30. Nursing Care • Prevention- Ca Intake: premenopausal & postmen women taking ERP1000 mg, 1500mg postmenopausal women • Vit D needed for Ca absorption • Exercise builds & maintains bone mass • Keep pts with osteoporosis ambulatory, prevent potential pathological fx

31. Drug Therapy • Calcitonin- Calcimar-inhibits osteoclastic bone resorption • Biphosphates- Fosamax- inhibits osteoclast mediated bone resorption, incr bone mineral density & bone mass • Evista- mimics estrogen on bone, doesn’t effect uterus or breast tissue

32. Paget’s Disease • Excessive bone resorption, replacement bone marrow by vascular, fibrous tissue that makes bone larger • S/S- skeletal pain, waddling gait, elev alk phos shorter, large head, wt bearing bones curved, complication- patholog fx • Tx- Calcitonin, Fosamax, radiation, brace, analgesics, muscle relaxants

33. Fractures • Types: avulsion, comminuted, displaced, greenstick, impacted, interarticular, longitudinal, oblique, pathologic, spiral, stress, transverse • Communicating or noncommunicating – open or closed • Location • Stable or unstable

34. Clinical Manifestations • Determined by history of injury • Pain & tenderness, muscle spasm • Edema, swelling, deformity, ecchymosis • Loss of function, crepitation • Immobilize in position found • Children – epiphyseal plate

35. Process of Union of Fx • Fracture hematoma • Granulation tissue • Callus formation • Ossification • Consolidation • Remodeling • Age, displacement, site, blood supply

36. Factors that affect bone healing • Age • Severity of the trauma • Type of bone Injured • Inadequate immobilization • Infection • Nutrition

37. Fracture Reduction • Manipulation or closed reduction – nonsurgical, manual reduction • Open reduction – surgical, often internal fixation (ORIF) with wires, screws, rods • Complication open reduction- infection • Advantage – early ambulation • Traction – skin or skeletal

38. Traction • Skin - Buck’s, Russell's, Bryant’s, Pelvic belt • Short term (48-72hrs) til surgery, skel tx • Circumferential – head halter • Skeletal - Overhead arm, lateral arm, balanced suspension traction • See table 59-6

39. Traction Care • Maintain weight (freely hanging) • Inspect Skin • Pin Site Care • Neurovascular Assessment

40. External Fixator Device • Metal pins inserted into bone & attached to external rod, stabilizes fx, holds pieces in place • Assess loose pins • s/s infection- exudate, redness, tenderness, pain • Pin care

41. Cast Materials Traditional- Plaster of Paris * Stockinette, Padding, Plaster Rolls * Feels hot when first applied * 24-72 hours to dry * Petal the cast Synthetic- Fiberglass; Polyester cotton knit

42. Cast Materials Traditional- Plaster of Paris * Stockinette, Padding, Plaster Rolls * Feels hot when first applied * 24-72 hours to dry * Petal the cast Synthetic- Fiberglass; Polyester cotton knit

43. Casts • Long arm cast: support & elevate, use sling-> decr edema, encourage finger movement • If proximal humerus fx, traction by hanging, aids healing • Body jacket cast: assess bowel sounds, “cast syndrome”, resp status, bladder, pres over iliac crest, position q2-3 hrs

44. Casts • Hip spica cast- femoral fx, children, when drying place in prone position, slightly turn, don’t use support bar to turn, skin care to cast edges, same care as jacket cast • Long leg cast, short leg cast, Jones dressing – elev above heart 24 hrs, initially no wt bearing, later heel or shoe cast, check for pressure areas

45. Drug Therapy • Pain due to muscle spasms • Soma, Flexaril, Robaxin • S/E: drowsiness, headache, weakness, GI upset, potential abuse • Other belief - Relieve pain, spasm will disappear

46. Nutritional Therapy • Need protein & vit C for healing • Immobility & callus formation increases Calcium needs • Increase fluids to 2000 – 3000 cc • Hi fiber diet, fruits & veg prevent constipation • Jacket cast – don’t over eat

47. Health Promotion • Prevention precautions- work sports, home, driving • Seat belts, helmets etc, stretching before exercise • Elderly- look at environment, exercise, vit D & calcium

48. Nursing Care Fractures • Initial assessment, quick history, to ER • Guarding, deformity, laceration, loss of function, rotation, edema, crepitus ecchymosis, compare to uninjured side • Focus on area distal to injury – pulse ?, decreased cap refill, cool vs bluish & warm, decreased or absent sensation, paresthesia

49. Emergency Management • Priority: ABC, life threatening injuries, control bleeding • Splint above & below fx site • Neurovascular status, elevate, ice • Don’t manipulate protruding bones, tetanus • VS, LOC, O2 sat, pulses, pain

50. Pre-op Care • Routine pre-op teaching • Explain type of immobilization & activity limits, time • Pain meds • Skin prep