Musculoskeletal Disorders



Musculoskeletal Disorders





OVERVIEW AND ASSESSMENT



Subjective Data

Much can be learned about musculoskeletal disorders from subjective data. History of injury, description of symptoms, and associated personal health and family history can give clues to the underlying problem and appropriate care for that problem.


Common Manifestations of Musculoskeletal Problems


Pain



  • Where is the pain located?



    • Joints, as in osteoarthritis (OA).


    • Muscles or soft tissue, as in contusions, sprains, or strains.


    • Bone, as in fractures or tumors.


  • Is it sharp, as in a fracture or sprain, or dull, as in a bone tumor?


  • Does the pain radiate?



    • To buttocks or legs, as in lower back pain.


    • To thigh or knee, as in hip fracture.


  • What makes the pain increase? What makes it better?


  • When was the onset of pain?



Limited Range of Motion



  • Is stiffness present? How long does it last?



    • Present in morning for less than 30 minutes or after sitting for long period when due to OA.


    • May persist and is associated with acute pain when due to spasm of lower back strain.


  • Is swelling present and limiting mobility?



    • May be due to fracture.


    • May be soft-tissue injury, such as sprain, strain, or contusion.


  • How does limited mobility affect activities of daily living (ADLs)?


Associated Symptoms



  • Any sensory or motor deficits, such as numbness, paresthesias, or weakness, indicating neurovascular compromise?


  • Any weight loss, fever, or malaise, as in bone tumors?


  • Any bony nodules or deformity, as in rheumatoid arthritis?



Objective Data

Data on current system condition and functional abilities are secured through inspection, palpation, and measurement. Always compare with contralateral side (one side of the body to the other).


Musculoskeletal System


Skeletal Component



  • Note deviation from normal structure—bony deformities, length discrepancies, alignment, symmetry, amputations.


  • Identify abnormal motion and crepitus (grating sensation), as found with fractures.


Joint Component



  • Identify swelling that may be due to inflammation or effusion.


  • Note deformity associated with contractures or dislocations.


  • Evaluate stability, which may be altered.


  • Estimate active and passive range of motion (ROM).


Muscle Component



  • Inspect for size and contour of muscles.


  • Assess coordination of movement.


  • Palpate for muscle tone.


  • Estimate strength through cursory evaluation (ie, handshake) or scaled criteria (ie, 0 = no palpable contraction; 5 = normal ROM against gravity with full resistance).


  • Measure girth to note increases due to swelling or bleeding into muscle or decreases due to atrophy (difference of more than 1 cm is significant).


  • Identify abnormal clonus (rhythmic contraction and relaxation) or fasciculation (contraction of isolated muscle fibers).


Additional Assessment


Neurovascular Component



  • Assess circulatory status of involved extremities by noting skin color and temperature, peripheral pulses, capillary refill response, pain, and edema.


  • Assess neurologic status of involved extremities by the patient’s ability to move distal muscles and description of sensation (eg, paresthesia).


  • Test reflexes of extremities.


  • Compare all to uninjured/unaffected extremity.


Skin Component



  • Inspect traumatic injuries (eg, cuts, bruises).


  • Assess chronic conditions (eg, dermatitis, stasis ulcers).


  • Note hair distribution and nail condition.


  • Inspect for Heberden’s or Bouchard’s nodes.


  • Assess for warmth or coolness of skin.




Radiologic and Imaging Studies

Many radiologic and imaging studies are helpful in evaluating musculoskeletal problems to rule out fracture or skeletal changes and to differentiate soft tissue injury.



X-rays



  • Of bone—to determine bone density, texture, integrity, erosion, changes in bone relationships.


  • Of cortex—to detect any widening, narrowing, irregularity.


  • Of medullary cavity—to detect any alteration in density.


  • Of involved joint—to show fluid, irregularity, spur formation, narrowing, changes in joint contour.


  • Tomogram—special x-ray technique for detailed view of special plane of bone.


Nursing and Patient Care Considerations



  • Tell patient that proper positioning is important to obtain a good x-ray, so cooperation is essential.


  • Advise patient to remove all jewelry, clothing with zippers or snaps, change from pockets, or other items that may interfere with x-ray.


  • Medicate for pain prior to x-ray, as needed.


Bone Scan

A bone scan consists of parenteral injection of bone-seeking radiopharmaceutical (such as gallium); concentration of isotope uptake revealed in primary skeletal disease (osteosarcoma), metastatic bone disease, inflammatory skeletal disease (osteomyelitis); fracture.


Nursing and Patient Care Considerations



  • There is usually no special preparation prior to the scan.


  • Injectable radionuclide is given several hours before the scan.


  • Reassure patient that the procedure will not cause pain and that scan will take 1 to 2 hours.


  • Analgesics or sedatives may be ordered for patients for whom lying immobile for any length of time is difficult.


  • Breastfeeding should be discontinued for at least 4 weeks after test to prevent radionuclide exposure to infant.


  • Inform patient that the exposure to radioactive substances is small (dose of radiation is less than a chest x-ray) and substances are excreted quickly by the body.


Bone Densitometry

Bone densitometry is a noninvasive study that yields an actual measurement of bone density and is diagnostic for osteoporosis (see page 184). It is most often performed on the lower spine and hips; however, simple portable screening tests that analyze the wrist or heel are also available.


Nursing and Patient Care Considerations



  • Calcium supplements should be avoided 24 hours prior to exam.


  • DXA scan should be avoided for 10 to 14 days if patient recently had a barium examination or has been injected with a contrast material for a computed tomography (CT) scan or radioisotope scan.


  • Have patient remove clothing and all jewelry or other metal objects.


  • Advise patient to lie still with hips flexed for about 20 minutes during test; technician will remain in the room.


  • Reassure patient that radiation exposure is minimal.


Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) uses magnetic fields to demonstrate differences in hydrogen density of various tissues. Demonstrates tumors and soft tissue (muscle, ligament, tendon) abnormalities. Although it is more costly than CT scans, the cost is typically validated through the diagnostic accuracy. MRI not only clearly defines internal organs, but also is able to detect nerve damage and changes, such as edema or bruises, of bone. Bone bruises (osseous contusions) with traumatic injuries have some predictive value for future development of posttraumatic arthritis.


Nursing and Patient Care Considerations



  • Prepare patient for need to lie still for about 1 hour; repetitive clanging noise of machine will be heard; patients may feel closed in.


  • Practice relaxation techniques, such as relaxation breathing and imagery, ahead of time.


  • Some patients may need sedation; claustrophobic patients may be unable to undergo procedure or may need open MRI.


  • May be contraindicated for patients with some types of metal implants and devices. Notify the technologist or radiologist of any surgical implants, medical devices, or hardware for evaluation prior to MRI.



    • In general, metal objects used in orthopedic surgery pose no risk during MRI. However, a recently placed artificial joint may require the use of another imaging procedure. If there is any question of their presence, an x-ray may be taken to detect the presence of and identify any metal objects.


    • Patients who might have metal objects in certain parts of their bodies may also require an x-ray prior to an MRI. Notify the technologist or radiologist of any shrapnel, bullets, or other pieces of metal that may be present due to accidents.


    • Dyes used in tattoos may contain iron and could heat up during MRI, but this is rarely a problem.


    • Tooth fillings and braces usually are not affected by the magnetic field but they may distort images of the facial area or brain, so the radiologist should be aware of them.


    • Parents who accompany children into the scanning room also need to remove metal objects and notify the technologist of any medical or electronic devices they may have.





  • Internal (implanted) defibrillator or pacemaker


  • Cochlear (ear) implant


  • Some types of clips used on brain aneurysms


  • Some types of metal coils placed within blood vessels


Other Tests



  • CT scan—narrow beam of x-ray that scans area in successive layers to evaluate disease, bone structure, joint abnormalities, and trauma (fractures).


  • Arthrogram—injection of radiopaque substance or air into joint cavity to outline soft tissue structures (eg, meniscus) and contour of joint.


  • Myelogram—injection of contrast medium into subarachnoid space at lumbar spine to determine level of disk herniation or site of tumor.


  • Diskogram—injection of small amount of contrast medium into lumbar disk abnormalities.


  • Arthrocentesis—insertion of needle into joint and aspiration of synovial fluid for purposes of examination or injection of therapeutic medications.


  • Arthroscopy—endoscopic procedure that allows direct visualization of joint structures (synovium, articular surfaces, menisci, ligaments) through a small needle incision. May be combined with arthrography.


  • Nerve studies—to differentiate nerve root compression, muscle disease (eg, dystrophy, myositis), peripheral neuropathies, central nervous system-anterior horn cell neuropathies, neuromuscular junction problems.



    • Electromyography (EMG)—measures electrical potential generated by the muscle during relaxation and contraction.


    • Nerve conduction velocities—measure the rate of potential generation along specific nerves (speed of impulse conduction).


GENERAL PROCEDURES AND TREATMENT MODALITIES



Crutch Walking

Crutches are artificial supports that assist patients who need aid in walking because of disease, injury, or a birth defect.


Preparation for Crutch Walking

The goals are to develop power in the shoulder girdle and upper extremities that bear the patient’s weight in crutch walking and strengthen and condition the patient.


Strengthening the Muscles Needed for Ambulation

Instruct the patient as follows:



  • For quadriceps setting:



    • Contract the quadriceps muscle while attempting to push the popliteal area against the mattress and raise the heel.


    • Maintain the muscle contraction for a count of 5.


    • Relax for the count of 5.


    • Repeat this exercise 10 to 15 times hourly.


  • For gluteal setting:



    • Contract or pinch the buttocks together for a count of 5.


    • Relax for the count of 5.


    • Repeat 10 to 15 times hourly.


Strengthening the Muscles of the Upper Extremities and Shoulder Girdle

Instruct the patient as follows:



  • Flex and extend arms slowly while holding traction weights; gradually increase poundage of weight and number of repetitions to increase strength and endurance.


  • Do push-ups while lying in a prone position.


  • Squeeze rubber ball—increases grasping strength.


  • Raise head and shoulders from bed; stretch hands forward as far as possible.


  • Sit up on bed or chair.



    • Raise body from chair by pushing hands against chair seat (or mattress).


    • Raise body out of seat. Hold. Relax.


Measuring for Crutches



  • When the patient is lying down (an approximate measurement):



    • Measure from the anterior fold of the axilla to the sole. Then add 2 inches (5 cm).


    • Alternatively, subtract 16 inches (40 cm) from the patient’s height.


  • When the patient is standing erect:



    • Stand the patient against the wall with feet slightly apart and away from the wall.


    • The crutches should be fitted with large rubber suction tips.


    • The elbow is flexed 30 degrees with the hand resting on the grip.


    • There should be a two-finger-width insertion between the axillary fold and the underarm piece grip. A foam-rubber pad on the underarm piece will relieve pressure on the upper arm and thoracic cage.


    • The tip of the crutch is placed 6 to 8 inches (15 to 20 cm) lateral to the forefoot.


Teaching the Crutch Stance



  • Have the patient wear well-fitting shoes with firm soles.


  • Before using the crutches, have the patient stand by a chair on the unaffected leg to achieve balance.


  • Position the patient against a wall with head in a neutral position.


  • Tripod position—basic crutch stance for balance and support.




    • Crutches rest approximately 8 to 10 inches (20 to 25 cm) in front of and to the side of the patient’s toes (see Figure 32-1).


    • Taller patient requires a wider base, whereas shorter patient needs a narrower base.


  • Teach the patient to support weight on hands; weight borne on the axillae can damage the brachial plexus nerves and produce “crutch paralysis.”






Figure 32-1. The tripod position is the basic crutch stance for balance and support.


Teaching the Crutch Gait



  • Crutch walking requires balance, coordination, and a high expenditure of energy; these can be acquired with diligent and regular practice.


  • Practice balancing with crutches while leaning against the wall.


  • Practice shifting body weight in different positions while standing with crutches.


  • The selection of the crutch gait depends on the type and severity of the disability, weight-bearing status, and the patient’s physical condition, arm and trunk strength, and body balance.


  • Teach the patient at least two gaits—a faster gait to be used for swiftness and a slower one to be used in crowded places.


  • Instruct the patient to change from one gait to another—relieves fatigue because a different combination of muscles is used.


Crutch Gaits



Four-Point Gait (Four-Point Alternate Crutch Gait)



  • Four-point gait is a slow but stable gait; the patient’s weight is constantly being shifted.


  • Four-point gait can be used only by patients who can move each leg separately and bear a considerable amount of weight on each of them.


  • Crutch-foot sequence:



    • Right crutch.


    • Left foot.


    • Left crutch.


    • Right foot.






Figure 32-2. Crutch gaits. Shaded areas are weight-bearing. Arrow indicates advance of foot or crutch.



Three-Point Gait



  • Three-point gait is used when one leg is affected.


  • Both crutches and the affected lower leg are moved forward simultaneously.


  • Then the stronger lower extremity is moved forward while most of the body weight is put on the crutches.


Two-Point Gait



  • Two-point gait is a progression from the four-point gait that allows faster ambulation.


  • Weight is borne on both lower extremities and both crutches.


  • Advance left foot and right crutch together.


  • Then advance right foot and left crutch together.


Crutch-Maneuvering Techniques



Ambulation with a Walker

A walker provides more support than crutches or a cane for the patient who has poor balance and cannot use crutches.


Technique for Using a Walker



  • Be aware that a walker gives stability but does not permit a natural reciprocal walking pattern.


  • Rolling walkers may assist the patient who has painful joints in the lower extremities, decreased balance, or decreased cardiopulmonary function.


  • Teach the following sequence for a patient using a stationary (nonrolling) walker:



    • Lift the walker, placing it in front of you while leaning your body slightly forward.


    • Take a step or two into the walker.


    • Lift the walker and place it in front of you again.


  • Teach the following sequence for a patient using a rolling walker:



    • Roll the walker and move it forward about 12 inches.


    • If the patient has an injured leg, a new joint, or a weaker side, step forward with that foot first. Instruct the patient to use the walker to help keep his or her balance as they take the step.


    • Bring the other foot forward to the center of the walker.


    • Repeat the sequence.



Ambulation with a Cane

A cane is used for balance and support. Canes come in a variety of shapes, but the majority have a curved handle and a rubber tip. Quad canes may offer greater support.


Purposes



  • To assist the patient to walk with greater balance and support and less fatigue.


  • To compensate for deficiencies of function normally performed by the neuromuscular skeletal system.


  • To relieve pressure on weight-bearing joints.


  • To provide forces to push or pull the body forward or to restrain the forward motion of the patient while walking.


Principles of Cane Use



  • An adjustable aluminum cane fitted with a 1½-inch (3.8-cm) rubber suction tip to provide traction while walking gives optimal stability to the patient.


  • With bilateral disease, using two canes gives better balance and weight relief.


  • To fit for a cane:



    • Have patient flex elbow at a 30-degree angle and hold the cane 6 inches (15 cm) lateral to the base of fifth toe.


    • Adjust the cane so the handle is approximately level with the greater trochanter.


  • Alternatively, while the patient is standing with arms at side, the handle of the cane should line up with the crease in wrist.


Technique for Walking with a Cane



  • Hold the cane in the hand opposite to the affected extremity (ie, the cane should be used on the good side)—allows partial weight-bearing relief because the cane is in contact with the floor at the same time as the affected extremity.


  • Advance the cane at the same time the affected leg is moved forward.


  • Keep the cane fairly close to the body to prevent leaning.



  • If the patient cannot use the cane in the opposite hand, the cane may be carried on the same side and advanced when the affected leg is advanced.


  • To go up and down stairs:



    • Step up on unaffected extremity.


    • Then place cane and affected extremity on the step.


    • Reverse this procedure for the descending steps.


    • The strong leg goes up first and comes down last.


  • When using a quad cane, ensure that all four tips are touching the ground.


Casts


A cast is an immobilizing device made up of layers of plaster or fiberglass (water-activated polyurethane resin) bandages molded to the body part that it encases. See Procedure Guidelines 32-1. See also Procedure Guidelines 32-2, pages 1109 to 1110, for application and removal of a cast.





Purposes



  • To immobilize and hold bone fragments in reduction.


  • To apply uniform compression of soft tissues.


  • To permit early mobilization.


  • To correct and prevent deformities.


  • To support and stabilize weak joints.


Types of Casts



  • Short-arm cast—extends from below the elbow to the proximal palmar crease.


  • Gauntlet cast—extends from below the elbow to the proximal palmar crease, including the thumb (thumb spica).



  • Long-arm cast—extends from upper level of axillary fold to proximal palmar crease; elbow usually immobilized at right angle.


  • Short-leg cast—extends from below knee to base of toes.


  • Long-leg cast—extends from upper thigh to the base of toes; foot is at right angle in a neutral position.


  • Body cast—encircles the trunk stabilizing the spine.


  • Spica cast—incorporates the trunk and extremity.



    • Shoulder spica cast—a body jacket that encloses trunk, shoulder, and elbow.


    • Hip-spica cast—encloses trunk and a lower extremity.



      • Single hip-spica—extends from nipple line to include pelvis and extends to include pelvis and one thigh.


      • Double hip-spica—extends from nipple line or upper abdomen to include pelvis and extends to include both thighs and lower legs.


      • One-and-a-half hip-spica—extends from upper abdomen, includes one entire leg and extends to the knee of the other.


  • Cast-brace—external support about a fracture that is constructed with hinges to permit early motion of joints, early mobilization, and independence.



    • Cast bracing is based on the concept that some weight-bearing is physiologic and will promote the formation of bone and contain fluid within a tight compartment that compresses soft tissues, providing a distribution of forces across the fracture site.


    • Cast-brace is applied after initial edema and pain have subsided and there is evidence of fracture stability.


  • Cylinder cast—Can be used for upper or lower extremity. Used for fracture or dislocation of knee (lower extremity) or elbow dislocation (upper extremity).


Complications Associated with Casts



  • Pressure of cast on neurovascular and bony structures causes necrosis, pressure sores, and nerve palsies.


  • Compartment syndrome is a condition resulting from increased progressive pressure within a confined space, thus compromising the circulation and the function of tissues within that space. This is a medical emergency and can be limb-threatening. A tight cast, trauma, fracture, prolonged compression of an extremity, bleeding, and edema put patients at risk for compartment syndrome.


  • Immobility and confinement in a cast, particularly a body cast, can result in multisystem problems.



    • Nausea, vomiting, and abdominal distention associated with cast syndrome (superior mesenteric artery syndrome, resulting in diminished blood flow to the bowel), adynamic ileus, and possible intestinal obstruction.


    • Acute anxiety reaction symptoms (ie, behavioral changes and autonomic responses—increased respiratory and heart rate, elevated blood pressure [BP], diaphoresis) associated with confinement in a space.


    • Thrombophlebitis and possible pulmonary emboli associated with immobility and ineffective circulation (eg, venous stasis).


    • Respiratory atelectasis and pneumonia associated with ineffective respiratory effort.


    • Urinary tract infection—renal and bladder calculi associated with urinary stasis, low fluid intake, and calcium excretion associated with immobility.


    • Anorexia and constipation associated with decreased activity.


    • Psychological reaction (eg, depression) associated with immobility, dependence, and loss of control.


Nursing Assessment



  • Assess neurovascular status of the extremity with a cast for signs of compromise.



    • Pain (pain out of proportion to injury is an indication for compartment syndrome).


    • Swelling.



    • Discoloration—pale or blue.


    • Cool skin distal to injury.


    • Tingling or numbness (paresthesia).


    • Pain on passive extension (muscle stretch).


    • Slow capillary refill; diminished or absent pulse.


    • Paralysis.


  • Assess skin integrity of casted extremity. Be alert for:



    • Severe initial pain over bony prominences; this is a warning symptom of an impending pressure ulcer. Pain increases when ulceration occurs.


    • Odor.


    • Drainage on cast.


  • Carefully assess for positioning and potential pressure sites of the casted extremity (see Figure 32-3).



    • Lower extremity—heel, malleoli, dorsum of foot, head of fibula, anterior surface of patella.


    • Upper extremity—medial epicondyle of humerus, ulnar styloid.


    • Plaster jackets or body spica casts—sacrum, anterior and superior iliac spines, vertebral borders of scapulae.


  • Assess cardiovascular, respiratory, and GI systems for possible complications of immobility.


  • Assess psychological reaction to illness, cast, and immobility.







Figure 32-3. Pressure areas in different types of casts.


Nursing Diagnoses



  • Risk for neurovascular injury related to swelling and constrictive bandage or cast.



  • Impaired Physical Mobility related to condition and casting.


  • Risk for impaired gastrointestinal motility related to cast syndrome.


Nursing Interventions


Maintaining Adequate Tissue Perfusion



  • Elevate the extremity on cloth-covered pillow above the level of the heart. Keep the heel off the mattress.


  • Avoid resting cast on hard surfaces or sharp edges that can cause denting or flattening of the cast and consequent pressure sores.


  • Handle moist cast with palms of hands.


  • Turn patient every 2 hours while cast dries.


  • Instruct patient not to place objects into cast. Advise patient of alternative methods of managing itching such as blowing cool air under the cast.


  • Assess neurovascular status hourly during the first 24 hours, then less frequently as condition warrants and swelling resolves.


  • If symptoms of neurovascular compromise occur:



    • Notify health care provider immediately.


    • Bivalve the cast—split cast on each side over its full length into two halves.


    • Cut the underlying padding—blood-soaked padding may shrink and cause constriction of circulation.


    • Spread cast sufficiently to relieve constriction.


  • If symptoms of pressure area occur, cast may be “windowed” (hole cut in it) so the skin at the pain point can be examined and treated. The window must be replaced so the tissue does not swell and cause additional pressure problems at window edge.


Minimizing the Effects of Immobility



  • Encourage the patient to move about as normally as possible.


  • Encourage compliance with prescribed exercises to avoid muscle atrophy and loss of strength.



    • Active ROM for every joint that is not immobilized at regular and frequent intervals.


    • Isometric exercises for the muscles of the casted extremity. Instruct patient to alternately contract and relax muscles without moving affected part.


  • Reposition and turn patient frequently.


  • Avoid pressure behind knees, which reduces venous return and predisposes to thromboembolism.


  • Use anti-embolism stockings and sequential compression devices (SCDs), as indicated.


  • Administer prophylactic anticoagulants, as prescribed.


  • Encourage deep-breathing exercises and coughing at regular intervals to prevent atelectasis and pneumonia.


  • Encourage patient to drink liberal quantities of fluid to avoid urinary infection and calculi secondary to immobility.


  • Facilitate patient participation in care planning and activities. Encourage verbalization of feelings and concerns regarding restriction of activities.


  • Provide and encourage diversional activities.


  • Pay special attention to positioning and turning for patients in spica or body cast (see Box 32-1).



Preventing Gastrointestinal Impairment



  • Encourage balanced nutritional intake.



    • Assess the patient’s food preferences. Serve small meals.


    • Provide natural bowel stimulants (eg, fiber) and good fluid intake.


    • Monitor bowel movements, bowel sounds, and use a bowel program, if necessary.


  • Observe for symptoms of cast syndrome—nausea, vomiting, abdominal distention, abdominal pain, and decreased bowel sounds.


  • If symptoms of cast syndrome develop, report immediately to the health care provider.



    • Place patient in a prone position, if tolerated, to relieve pressure symptoms.


    • Use nasogastric suction as prescribed.


    • Maintain electrolyte balance by intravenous (IV) replacement of fluids, as prescribed.


    • Prepare the patient for removal of the cast or surgical relief of duodenal obstruction, if necessary.



Patient Education and Health Maintenance


Neurovascular Status



  • Instruct patient to check neurovascular status and to control swelling.



    • Watch for signs and symptoms of circulatory disturbance, including blueness or paleness of fingernails or toenails accompanied by pain and tightness, numbness, cold or tingling sensation.


    • Elevate affected extremity and wiggle fingers or toes.


    • Apply ice bags, as prescribed (one third to one half full), to each side of the cast, making sure they do not make indentations in plaster.


    • Call health care provider promptly if excessive swelling, paresthesia, persistent pain, pain on passive stretch, or paralysis occurs.


  • Instruct patient to alternate ambulation with periods of elevation to the cast when seated. Encourage the patient to lie down several times daily with cast elevated.


Skin Irritation

Advise patient to prevent skin irritation at cast edge by padding edges of cast with moleskin or “petaling” cast edges with strips of adhesive tape.





Cast Care



  • Advise to avoid getting cast wet, especially padding under cast—causes skin breakdown as plaster cast becomes soft.


  • Warn against covering a leg cast with plastic or rubber boots because this causes condensation and wetting of the cast.


  • Instruct to avoid weight-bearing or stress on plaster cast for 24 hours.


  • Instruct to report to health care provider if the cast cracks or breaks; instruct the patient not to try to fix it.


  • Teach how to clean the cast:



    • Remove surface soil with slightly damp cloth.


    • Rub soiled areas with household scouring powder.


    • Wipe off residual moisture.


Teaching Safety Measures

To prevent falls, avoid walking on wet floors or sidewalks. To prevent pressure and injury to the skin, do not place objects inside the cast.


After Cast Removal



  • Instruct to clean skin with mild soap and water, blot dry, and apply emollient lotion to dry skin.


  • Warn against scratching the skin.


  • Advise to continue prescribed exercises. Gradually resume activities and elevate extremity to control swelling.


Evaluation: Expected Outcomes



  • No pain, discoloration, or sensory or motor impairment of affected extremity; warm, with good capillary refill.


  • Ambulates with assistance; performing active ROM and isometric exercises every 1 to 2 hours.


  • No signs of cast syndrome.


Traction

Traction is force applied in a specific direction. To apply the force needed to overcome the natural force or pull of muscle groups, a system of ropes, pulleys, and weights is used. See Procedure Guidelines 32-3, page 1114.





Purposes of Traction



  • To reduce and immobilize fracture.


  • To regain normal length and alignment of an injured extremity.


  • To lessen or eliminate muscle spasm.


  • To prevent deformity.


  • To give the patient freedom for “in-bed” activities.


  • To reduce pain.


Types of Traction


Running Traction



  • A form of traction in which the pull is exerted in one plane.


  • May use either skin or skeletal traction.


  • Buck’s extension traction (see Figure 32-4) is an example of running skin traction.


Balanced Suspension Traction



  • Uses additional weights to counterbalance the traction force and floats the extremity in the traction apparatus.


  • The line of pull on the extremity remains fairly constant despite changes in the patient’s position.


Application of Traction

Traction may be applied to the skin or to the skeletal system.


Skin Traction



  • Accomplished by applying a light force that pulls on tape, sponge rubber, or special device (boot, cervical halter, pelvic belt) that is in contact with the skin.


  • The pulling force is transmitted to the musculoskeletal structures.


  • Skin traction is used as a temporary measure in adults to control muscle spasm and pain.


  • It is used before surgery in the treatment of hip fracture (Buck’s extension) and femoral shaft fractures (Russell’s traction).


  • It may be used definitively to treat fractures in children.






Figure 32-4. Buck’s extension traction. (A) Skin traction is accomplished through a boot device in contact with the skin. (B) Weight is applied to exert running traction in one plane, while the body acts as a counterweight. (Courtesy DM Systems Inc., www.dmsystems.com.)


Skeletal Traction




  • Traction applied by the orthopedic surgeon under aseptic conditions using wires, pins, or tongs placed through bones and provides a strong, steady, continuous pull.


  • Skeletal traction is used most frequently in treating fractures of the femur, humerus (supracondylar fractures), tibia, and cervical spine.



Nursing Assessment



  • Assess for pain, deformity, swelling, motor and sensory function, and circulatory status of the affected extremity.


  • Assess skin condition of the affected extremity, under skin traction and around skeletal traction, as well as over bony prominences throughout the body.


  • Assess for alignment of affected body part.


  • Assess for signs and symptoms of complications.


  • Assess traction equipment for safety and effectiveness.



    • The patient is placed on a firm mattress.


    • The ropes and the pulleys should be in alignment.



    • The pull should be in line with the long axis of the bone.


    • Any factor that might reduce the pull or alter its direction must be eliminated.



      • Weights should hang freely.


      • Ropes should be unobstructed and not in contact with the bed or equipment.


      • Patient’s bed should have an overhead trapeze set up to assist the patient to pull self up in bed at frequent intervals.


    • The amount of weight applied in skin traction must not exceed the tolerance of the skin. The condition of the skin must be inspected frequently.


    • Cover exposed sharp ends of skeletal pins with cork or other pin covering to protect patient and caregivers from injury.


  • Assess emotional reaction to condition and traction.


  • Assess understanding of the treatment plan.






Figure 32-5. Balanced skeletal traction using (A) Thomas leg splint and Pearson attachment and (B) slings for support and suspension.



Nursing Diagnoses



  • Impaired Physical Mobility related to traction therapy and underlying pathology.


  • Risk for Impaired Skin Integrity related to pressure on soft tissues.


  • Risk for Infection related to bacterial invasion at skeletal traction site.


  • Risk for Peripheral Neurovascular Dysfunction related to injury or traction therapy.


Nursing Interventions


Minimizing the Effects of Immobility



  • Encourage active exercise of uninvolved muscles and joints to maintain strength and function. Dorsiflex feet hourly to avoid development of footdrop and aid in venous return.


  • Encourage deep breathing hourly to facilitate expansion of lungs and movement of respiratory secretions.


  • Auscultate lung fields at least twice per day.


  • Encourage fluid intake of 2,000 to 2,500 mL daily.


  • Provide balanced high-fiber diet rich in protein; avoid excessive calcium intake.


  • Establish bowel routine through use of diet and stool softeners, laxatives, and enemas, as prescribed.


  • Prevent pressure on the calf and evaluate twice daily for the development of thrombophlebitis.


  • Check traction apparatus at repeated intervals—the traction must be continuous to be effective, unless prescribed as intermittent, as with pelvic traction.



    • With running traction, the patient may not be turned without disrupting the line of pull.


    • With balanced suspension traction, the patient may be elevated, turned slightly, and moved as desired.


  • Use SCDs and compression stockings, as indicated.


  • Administer prophylactic anticoagulants, as prescribed.



Maintaining Skin Integrity



  • Examine bony prominences frequently for evidence of pressure or friction irritation.


  • Observe for skin irritation around the traction bandage.


  • Observe for pressure at traction-skin contact points.


  • Report complaint of burning sensation under traction.



  • Relieve pressure without disrupting traction effectiveness.



    • Make sure that linens and clothing are wrinkle-free.


    • Use lambs’ wool pads, heel and elbow protectors, and special mattresses, as needed.


  • Special care must be given to the back every 2 hours because the patient maintains a supine position.



    • Have patient use trapeze to pull self up and relieve back pressure.


    • Provide backrubs.


Avoiding Infection at Pin Site



  • Monitor vital signs for fever or tachycardia.


  • Watch for signs of infection, especially around the pin tract.



    • The pin should be immobile in the bone and the skin surrounding the wound should be dry. Small amount of serous oozing from pin site may occur.


    • If infection is suspected, percuss gently over the tibia; this may elicit pain if infection is developing.


    • Assess for other signs of infection: heat, redness, fever.


  • If directed, clean the pin tract with sterile applicators and prescribed solution or ointment (ie, normal saline, sterile water, chlorhexidine)—to clear drainage at the entrance of tract and around the pin because plugging at this site can predispose to bacterial invasion of the tract and bone.


Preventing Neurovascular Injury



  • Assess motor and sensory function of specific nerves that might be compromised.



    • Peroneal nerve—have patient point great toe toward nose; check sensation on dorsum of foot; presence of footdrop.


    • Radial nerve—have patient extend thumb; check sensation in web between thumb and index finger.


    • Median nerve—thumb-middle finger apposition; check sensation of index finger.


  • Determine adequacy of circulation (eg, color, temperature, motion, capillary refill of peripheral fingers or toes).



    • With Buck’s traction, inspect the foot for circulatory difficulties within a few minutes and then periodically after the elastic bandage has been applied.


  • Report promptly if change in neurovascular status is identified.


Patient Education and Health Maintenance



  • Teach the patient the purpose of traction therapy.


  • Delineate limitations of activity necessary to maintain effective traction.


  • Teach use of patient aids (eg, trapeze).


  • Instruct the patient not to adjust or modify traction apparatus.


  • Instruct the patient in activities designed to minimize effects of immobility on body systems.


  • Teach the patient necessity for reporting changes in sensations, pain, movement.


Evaluation: Expected Outcomes



  • Exercises as instructed; deep breaths hourly; fluid intake 2,000 to 2,500 mL/24 hours.


  • No signs of skin breakdown under traction bandage or over bony prominences.


  • No drainage, redness, or odor at pin site.


  • No motor or sensory impairment; good capillary refill, color, and warmth of extremity.


External Fixation

External fixation is a technique of fracture immobilization in which a series of transfixing pins is inserted through bone and attached to a rigid external metal frame (see Figure 32-6). The method is used mainly in the management of open fractures with severe soft-tissue damage.


Advantages



  • Permits rigid support of severely comminuted open fractures, infected nonunions, and infected unstable joints.


  • Facilitates wound care (frequent debridements, irrigations, dressing changes) and soft tissue reconstruction (delayed wound closure, muscle flaps, skin grafts).


  • Allows early function of muscles and joints.


  • Allows early patient comfort.


Circular Fixators


Purpose

May be used for limb lengthening, correction of angulation and rotation defects, and in treatment of nonunion.






Figure 32-6. External fixation device used for reduction and immobilization of open fracture, allowing treatment of soft tissue wounds.



Components



  • This fixator apparatus consists of through-the-bone tension wires placed above and below the treatment site.


  • The wires are attached to fixator rings surrounding the limb.


  • The rings are connected to one another by telescoping rods.


Management



  • Adjustments are made daily at about 1 mm/day, stimulating callus and bone formation.


  • Patient compliance is essential.


  • Weight-bearing is encouraged.


  • When the desired length or correction is achieved, the fixator is left in place without further adjustment until bone healing occurs.


Application of External Fixator

Jul 20, 2016 | Posted by in NURSING | Comments Off on Musculoskeletal Disorders

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