Outcomes (NOC)	Interventions (NIC) and Rationales
Bone Healing	Splinting
• Intact peripheral circulation _____ • Return of skeletal function _____ Measurement Scale 1 = None 2 = Limited 3 = Moderate 4 = Substantial 5 = Extensive • Pain _____ • Edema _____ • Infection in surrounding tissue _____ • Infection in bone _____ Measurement Scale 1 = Extensive 2 = Substantial 3 = Moderate 4 = Limited 5 = None Mobility • Balance _____ • Coordination _____ • Joint movement _____ • Moves with ease _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Support the affected body part to avoid fracture displacement and soft tissue injury. • Move the injured extremity as little as possible to avoid additional injury. • Monitor for bleeding at injury site to plan appropriate intervention. • Monitor circulation and sensation in the affected part to detect possible nerve or vascular damage. • Splint an injured leg in an extended position to enhance anatomic positioning. Traction/Immobilization Care • Position in proper body alignment to enhance traction and skeletal function. • Maintain traction at all times to prevent misalignment of bone fragments. • Monitor circulation, movement, and sensation of affected extremity to detect complications of peripheral vascular and nerve function. • Provide trapeze for movement in bed to reduce complications of immobility. • Monitor skin and body prominences for signs of skin breakdown. • Administer appropriate skin care at friction points to prevent skin breakdown. Cast Care: Wet • Handle the casted extremity with palms only until the cast is dry to avoid causing finger indentations that can lead to pressure sores. • Support cast with pillows during the drying period (avoid pillow under heel) to prevent denting and flattening of the cast. • Protect the cast if close to groin to prevent soiling of cast. • Mark the circumference of any drainage as a gauge for future assessments. • Elevate casted extremity at or above heart level to reduce swelling or inflammation, as indicated.

Nursing Diagnosis

Risk for peripheral neurovascular dysfunction related to vascular insufficiency and nerve compression secondary to edema and/or mechanical compression by traction, splints, or casts

Patient Goal

Experiences no peripheral neurovascular dysfunction

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Perfusion: Peripheral	Circulatory Precautions
• Localized extremity pain _____ • Numbness _____ • Tingling _____ • Pallor _____ • Paresthesia _____ • Peripheral edema _____ • Muscle weakness _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	• Perform a comprehensive appraisal of peripheral circulation (e.g., check peripheral pulses, edema, capillary refill, color, temperature of extremity) to monitor for diminished tissue perfusion and plan appropriate intervention comparing to noninvolved extremity. • Prevent infection in wounds to prevent further edema and inflammation, which may contribute further to vascular insufficiency and nerve compression. • Maintain adequate hydration to prevent increased blood viscosity. Positioning • Immobilize or support affected body part to prevent pressure and injury. • Maintain position and integrity of traction to prevent compression of blood vessels and nerves. • Elevate affected limb 20 degrees or greater above the level of heart to reduce edema by promoting venous return. (Note: If compartment syndrome is suspected, elevate extremity no higher than heart level.) Peripheral Sensation Management • Monitor for paresthesia: numbness, tingling, hyperesthesia, and hypoesthesia that indicate nerve compression. • Monitor sharp/dull and/or hot/cold discrimination to ensure early recognition of and intervention for compromised circulation or nerve compression.

Nursing Diagnosis

Acute pain related to edema, movement of bone fragments, and muscle spasm as evidenced by pain descriptors, guarding, crying

Patient Goal

Reports satisfaction with pain relief measures

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control	Pain Management
• Uses preventive measures _____ • Uses nonanalgesic relief measures _____ • Uses analgesics as recommended _____ • Reports uncontrolled symptoms to health care professional _____ • Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, intensity or severity of pain, and precipitating factors to plan appropriate interventions. • Provide patient optimal pain relief with prescribed analgesics to relieve pain and promote muscle relaxation. • Notify physician if measures are unsuccessful or if current complaint is a significant change from patient’s past experience of pain because this may indicate an impending compartment syndrome. • Teach the use of nonpharmacologic techniques (e.g., relaxation, guided imagery, hot/cold application, and massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures to reduce edema and promote comfort.

Nursing Diagnosis

Readiness for enhanced self-health management as evidenced by questions about long-term effect of immobilization, devices, activity restrictions, and expression of desire to prevent complications and return to prior health.

Patient Goals

1. Describes prescribed activities and their rationales

2. Performs activities as prescribed.

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Prescribed Activity	Teaching: Prescribed Activity/Exercise
• Prescribed activity and exercise _____ • Purpose and expected effects of activity _____ • Activity restrictions _____ • Strategies to gradually increase activity _____ • Proper performance of exercise _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge Compliance Behavior • Discusses prescribed treatment regimen with health professional _____ • Performs treatment regimen as prescribed _____ • Monitors treatment response _____ • Modifies treatment regimen as directed by health professional _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Inform the patient of the purpose for, and the benefits of, the prescribed activity/exercise to promote patient compliance. • Instruct the patient how to perform the prescribed activity/exercise. • Observe the patient perform the prescribed activity/exercise to evaluate performance and reinforce the activity. • Instruct the patient how to safely progress activity/exercise. Teaching: Psychomotor Skill • Provide written information/diagrams for continued reference at home. • Provide frequent feedback to patients on what they are doing correctly and incorrectly so that bad habits are not formed. Cast Care: Maintenance • Instruct patient not to scratch skin under the cast with any objects to prevent skin injury and infection. • Instruct patient to direct cool air from hair dryer under cast to decrease itching. • Position cast on pillows to lessen strain on other body parts. • Pad rough cast edges and traction connections to prevent skin irritation and breakdown of cast. • Apply ice for first 24-36 hours to reduce swelling or inflammation. • Address compromised circulation and pain symptoms immediately (e.g., reposition cast, perform range of motion to extremity, immediate cast pressure-relieving action); position cast on pillows to lessen strain on other body parts.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 63-2 Patient Having Orthopedic Surgery *

Nursing Diagnosis**

Impaired physical mobility related to pain, stiffness, and physical deconditioning as evidenced by limited joint movement, difficulty ambulating, inability to participate in physical rehabilitation, guarded movement

Patient Goals

1. Participates in exercise therapy to increase joint mobility

2. Demonstrates ability to transfer, walk with assistive devices, and move with ease

Outcomes (NOC)	Interventions (NIC) and Rationales
Mobility	Exercise Therapy: Joint Mobility
• Coordination _____ • Joint movement _____ • Transfer performance _____ • Moves with ease _____ Ambulation • Bears weight _____ • Walks with effective gait _____ • Walks at slow pace _____ • Walks at moderate pace _____ • Walks moderate distance (>1 block to <5 blocks) _____ • Adjusts to different surface textures _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Determine limitations of joint movement and effect on function to plan appropriate interventions. • Assist patient to optimal body position for passive/active joint movement to prevent dislocation or other complications. • Initiate pain-control measures before beginning joint exercise to decrease discomfort from exercise and increase patient participation. • Perform passive or assisted ROM exercises. • Collaborate with physical therapy in developing and executing an exercise program to increase patient compliance and promote continuity of exercise. Exercise Therapy: Ambulation • Assist patient to sit on side of bed to facilitate postural adjustments. • Apply/provide assistive device (cane, walker, or wheelchair) for ambulation, if the patient is unsteady, to prevent falls. • Assist patient to stand and ambulate specified distance and with specified number of staff to provide adequate staff to safely meet mobility goals. • Assist patient with initial ambulation to promote mobility according to patient’s abilities. • Consult physical therapist about ambulation plan to reinforce plan and to provide unified approach to patient.

Nursing Diagnosis

Acute pain related to tissue trauma, disruption of skin integrity, and edema as evidenced by reluctance to move, guarding of affected area, persistent score of >8 on 10-point pain scale, and/or facial grimacing

Patient Goal

Reports satisfactory relief of pain

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control	Pain Management
• Uses nonanalgesic relief measures _____ • Uses analgesics as recommended _____ • Reports uncontrolled symptoms to health care professional _____ • Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Encourage patient to monitor own pain and to intervene appropriately to increase patient’s control over pain management. • Implement use of patient-controlled analgesia (PCA) to give patient control. • Medicate before an activity to increase participation but evaluate hazard of sedation. • Evaluate effectiveness of pain control measures used through ongoing assessment of pain experience so that pain relief is in accordance with healing process. Positioning • Position in proper body alignment to reduce pressure on nerves and tissues.

Nursing Diagnosis

Risk for peripheral neurovascular dysfunction† related to edema, circulatory stasis, dislocated prosthesis, and/or fixation devices

Nursing Diagnosis

Deficient knowledge related to lack of information and resources for follow-up care as evidenced by expression of concern with ability to care for self after discharge, frequent questioning about follow-up care, and lack of plan for follow-up care

Patient Goals

1. Describes activities related to treatments, activities of daily living, and obtaining assistance if needed

2. Verbalizes confidence in ability to follow prescribed discharge plan

Outcomes (NOC)	Interventions (NIC) and Rationales
Discharge Readiness: Independent Living	Discharge Planning
• Seeks assistance appropriately _____ • Describes prescribed treatments _____ • Describes risks for complications _____ • Manages own medications _____ • Performs activities of daily living (ADLs) independently _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Communicate patient’s discharge plans (e.g., activity limitations, medications, follow-up visit, signs of infection, dislocation) to patient/care giver to prepare for self-care and decision making. • Collaborate with the physician, patient/family/significant others, and other health team members in planning for continuity of health care at home or at next level of care. • Assist patient/family/significant others in planning for the supportive environment necessary to provide the patient’s posthospital care. • Coordinate referrals relevant to linkages among health care providers to monitor long-term rehabilitation program at home.

ROM, Range of motion.

^*This NCP is appropriate for a patient with an open reduction with internal fixation (ORIF) or joint replacement surgery.

^**Nursing diagnoses listed in order of priority.

It is important to teach the public about the basic principles of safety and accident prevention. The morbidity associated with accidents can be significantly reduced if people are aware of environmental hazards, use appropriate safety equipment, and apply safety and traffic rules. In the occupational and industrial setting, teach employees and employers about the use of proper safety equipment and avoidance of hazardous working situations.

Safety Alert

• Falls account for many musculoskeletal injuries in the home environment.

• Provide preventive teaching to high-risk individuals (e.g., people with gait instability or visual or cognitive impairment).

• Stress the importance of wearing shoes with functional and stable soles and heels, avoiding wet or slippery surfaces, and removing throw rugs in the home.

Ways to prevent common musculoskeletal problems in the older adult are listed in Table 63-1.

TABLE 63-1

PATIENT & CAREGIVER TEACHING GUIDE
Prevention of Musculoskeletal Problems in Older Adults

To prevent musculoskeletal problems, include the following instructions when teaching older adults and their caregivers.

1. Use ramps in buildings and at street corners instead of steps to prevent falls.

2. Eliminate scatter rugs in the home.

3. Treat pain and discomfort from osteoarthritis.

• Rest in positions that decrease discomfort.

• Discuss use of medication for pain.

4. Use a walker or cane to help prevent falls.

5. Eat the amount and kind of foods to prevent excess weight gain because obesity adds stress to joints, which may predispose to osteoarthritis.

6. Get regular and frequent exercise.

• Activities of daily living provide range-of-motion exercises. Tai Chi may also be helpful.

• Hobbies (e.g., jigsaw puzzles, needlework, model building) exercise finger joints and prevent stiffness.

• Performing weight-bearing exercise (e.g., walking) is essential and should be done on a daily basis.

7. Use shoes with good support to provide for safety and promote comfort.

8. Gradually initiate activities to promote optimal coordination. Rise slowly to a standing position to prevent dizziness, falls, and fractures.

9. Avoid walking on uneven surfaces and wet floors.

Soft Tissue Injuries

Soft tissue injuries, which include sprains, strains, dislocations, and subluxations, are usually caused by trauma. The increasing number of people involved in a fitness program or participating in sports has contributed to the increased incidence of soft tissue injuries. Common sports-related injuries are summarized in Table 63-2. The most common sports injuries that result in a visit to the emergency department for younger patients are bruises, sprains and strains, tendinitis, and fractures.²

TABLE 63-2

SPORTS-RELATED INJURIES

Injury	Description	Treatment
Impingement syndrome	Entrapment of soft tissue structures under coracoacromial arch of shoulder.	NSAIDs. Rest until symptoms decrease and then gradual ROM and strengthening exercises.
Rotator cuff tear	Tear within muscle or tendinoligamentous structures around shoulder.	If minor tear: Rest, NSAIDs, and gradual mobilization with ROM and strengthening exercises. If major tear: Surgical repair.
Shin splints	Inflammation along anterior aspect of calf from periostitis caused by improper shoes, overuse, or running on hard pavement.	Rest, ice, NSAIDs, proper shoes. Gradual increase in activity. If pain persists, x-ray to rule out stress fracture of tibia.
Tendinitis	Inflammation of tendon as a result of overuse or incorrect use.	Rest, ice, NSAIDs. Gradual return to sport activity. Protective brace (orthosis) may be necessary if symptoms recur.
Ligament injury	Tearing or stretching of ligament. Usually occurs as a result of inversion, eversion, shearing, or torque applied to a joint. Characterized by sudden pain, swelling, and instability.	Rest, ice, elevation of extremity if possible, NSAIDs. Protection of affected extremity by use of brace. If symptoms persist, surgical repair may be necessary.
Meniscus injury	Injury to fibrocartilage of knee characterized by popping, clicking, tearing sensation, effusion, and/or swelling.	Rest, ice, elevation of extremity if possible, NSAIDs. Gradual return to regular activities. If symptoms persist, MRI to diagnose meniscus injury and possible arthroscopic surgery.
Anterior cruciate ligament tear	Traumatic tearing of ligament by deceleration forces together with pivoting or odd positions of the knee or leg.	Physical therapy with rehabilitation, knee brace. If knee instability or continued injuries, reconstructive surgery may be done.

Sprains and Strains

Sprains and strains are common injuries from abnormal stretching or twisting forces that may occur during vigorous activities. These injuries tend to occur around joints and in the spinal musculature.

A sprain is an injury to the ligamentous structures surrounding a joint, usually caused by a wrenching or twisting motion. Most sprains occur in the ankle, wrist, and knee joints.³ A sprain is classified according to the degree of ligament damage. A first-degree (mild) sprain involves tears in only a few fibers, resulting in mild tenderness and minimal swelling. A second-degree (moderate) sprain is partial disruption of the involved tissue with more swelling and tenderness. A third-degree (severe) sprain is complete tearing of the ligament in association with moderate to severe swelling. A gap in the muscle may be apparent or palpated through the skin if the muscle is torn. Because areas around joints are rich in nerve endings, the injury can be extremely painful.

A strain is an excessive stretching of a muscle, its fascial sheath, or a tendon. Most strains occur in the large muscle groups, including the lower back, calf, and hamstrings. Strains may also be classified as first degree (mild or slightly pulled muscle), second degree (moderate or moderately torn muscle), and third degree (severely torn or ruptured muscle).

The clinical manifestations of sprains and strains are similar and include pain, edema, decreased function, and contusion. Pain aggravated by continued use is common. Edema develops in the injured area because of the local inflammatory response.

Mild sprains and strains are usually self-limiting, with full function returning within 3 to 6 weeks. X-rays of the affected part may be taken to rule out a fracture. A severe sprain can result in a concomitant avulsion fracture, in which the ligament pulls loose a fragment of bone. Alternatively, the joint structure may become unstable and result in subluxation or dislocation. At the time of injury, hemarthrosis (bleeding into a joint space or cavity) or disruption of the synovial lining may occur. Severe strains may require surgical repair of the muscle, tendon, or surrounding fascia.

Nursing Management Sprains and Strains

Nursing Implementation

Health Promotion.

Warming up muscles before exercising and vigorous activity, followed by stretching, may significantly reduce the risk of sprains and strains. Strength, balance, and endurance exercises are also important. Strengthening exercises that involve working against resistance build up muscle strength and bone density. Balance exercises, which may overlap with some strengthening exercises, help to prevent falling. Endurance exercises should start at a low level of effort and progress gradually to a moderate level.⁴ Exercise instructions for these types of physical activity are available at www.weboflife.ksc.nasa.gov/exerciseandaging.

Healthy People

Health Impact of Regular Physical Activity

• Assists in weight control.

• Helps maintain bone mass.

• Helps prevent high blood pressure.

• Increases lean muscle and decreases body fat.

• Increases muscle strength, flexibility, and endurance.

• Appears to reduce symptoms of depression and anxiety.

• Reduces the risk of heart disease, diabetes, and colon cancer.

• Enhances psychologic well-being and may reduce risk of depression.

Acute Intervention.

If an injury occurs, the immediate care focuses on (1) stopping the activity and limiting movement, (2) applying ice compresses to the injured area, (3) compressing the involved extremity, (4) elevating the extremity, and (5) providing analgesia as necessary (Table 63-3).

TABLE 63-3

EMERGENCY MANAGEMENT
Acute Soft Tissue Injury

Etiology	Assessment Findings	Interventions
• Falls • Direct blows • Crush injury • Motor vehicle collisions • Sports injuries	• Edema • Ecchymosis, contusion • Pain, tenderness • Decreased sensation with severe edema • Decreased pulse, coolness, and capillary refill >2 sec • Decreased movement • Pallor • Shortening or rotation of extremity • Inability to bear weight when lower extremity involved • Limited or decreased function with upper extremity involvement • Muscle spasms	Initial • Ensure airway, breathing, and circulation. • Assess neurovascular status of involved limb. • Elevate involved limb. • Apply compression bandage unless dislocation present. • Apply ice packs to affected area. • Immobilize affected extremity in the position found. Do not attempt to realign or reinsert protruding bones. • Anticipate x-rays of injured extremity. • Give analgesia as necessary. • Administer tetanus and diphtheria prophylaxis if there is a break in skin integrity or open fracture. • Administer antibiotic prophylaxis for open fracture, large tissue defects, or mangled extremity injury. Ongoing Monitoring • Monitor for changes in neurovascular status. • Eliminate weight bearing when lower extremity involved. • Anticipate compartment pressure monitoring if neurovascular status changes and compartment syndrome suspected.