MUSCULOSKELETAL

SYSTEM
DISORDERS

PYRAMID POINTS
Assessment findings in a fracture
Initial care of a fracture
Various types of traction
Nursing care of the client in traction
Client education for the use of a halo device
Client education related to crutch walking
Client education related to the use of a cane

or walker

PYRAMID POINTS
Assessment findings and interventions for

complications of a fracture
Care of the client following hip pinning and
hip prosthesis
Care of the client following total knee
replacement
Treatment measures for the client with a
herniated intervertebral disc
Care of the client following disc surgery

PYRAMID POINTS
Interventions following amputation
Treatment modalities for the client with

rheumatoid arthritis
Client education related to osteoporosis
Client education related to gout

INJURIES
STRAINS

An excessive stretching of a muscle or tendon

Management involves cold and heat
applications, exercise with activity limitations,
antiinflammatory medications, and muscle
relaxants
Surgical repair may be required for a severe
strain (ruptured muscle or tendon)

INJURIES
SPRAINS
An excessive stretching of a ligament usually
caused by a twisting motion
Characterized by pain and swelling
Management involves rest, ice, and a
compression bandage to reduce swelling and
provide joint support
Casting may be required for moderate sprains
to allow the tear to heal
Surgery may be necessary for severe ligament
damage

INJURIES
ROTATOR CUFF INJURIES
Musculotendinous or rotator cuff of the shoulder
sustains a tear usually as a result of trauma
Characterized by shoulder pain and the inability to
maintain abduction of the arm at the shoulder (drop
arm test)
Management involves nonsteroidal antiinflammatory
drugs (NSAIDs), physical therapy, sling support, and
ice/heat applications
Surgery may be required if medical management is
unsuccessful or for those who have a complete tear

FRACTURES
DESCRIPTION

A break in the continuity of the bone caused

by trauma, twisting as a result of muscle
spasm or indirect loss of leverage, or bone
decalcification and disease that result in
osteopenia

TYPES OF FRACTURES
CLOSED OR SIMPLE

Skin over the fractured area remains intact

GREENSTICK

One side of the bone is broken and the other is

bent; most commonly seen in children

TRANSVERSE

The bone is fractured straight across

OBLIQUE

The break extends in an oblique direction

TYPES OF FRACTURES
SPIRAL
The break partially encircles bone
COMMINUTED

The bone is splintered or crushed, with three or more

fragments

COMPLETE
The bone is completely separated by a break into two
parts
INCOMPLETE

A partial break in the bone

TYPES OF FRACTURES
OPEN-COMPOUND

The bone is exposed to air through a break in

the skin, and soft tissue injury and infection
are common

IMPACTED

A part of the fractured bone is driven into

another bone

DEPRESSED

Bone fragments are driven inward

TYPES OF FRACTURES
COMPRESSION

A fractured bone compressed by other bone

PATHOLOGICAL

A fracture due to weakening of the bone

structure by pathological processes, such as
neoplasia or osteomalacia; also called
spontaneous fracture

TYPES OF FRACTURES

From Ignativicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia:

W.B. Saunders.

FRACTURE OF AN
ASSESSMENT
EXTREMITY
Pain or tenderness over the involved area
Loss of function
Obvious deformity
Crepitation
Erythema, edema, ecchymosis
Muscle spasm and impaired sensation

FRACTURE OF AN
INITIAL CARE
EXTREMITY
Immobilize affected extremity
If a compound fracture exists, splint the
extremity and cover the wound with a sterile
dressing

INTERVENTIONS FOR A
FRACTURE
Reduction
Fixation
Traction
Casts

REDUCTION
DESCRIPTION

Restoring the bone to proper alignment

REDUCTION
CLOSED REDUCTION

Performed by manual manipulation

May be performed under local or general
anesthesia
A cast may be applied following reduction

CLOSED REDUCTION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders.

REDUCTION
OPEN REDUCTION

Involves a surgical intervention

May be treated with internal fixation devices
The client may be placed in traction or a cast
following the procedure

FIXATION
INTERNAL FIXATION

Follows open reduction

Involves the application of screws, plates,
pins, or nails to hold the fragments in
alignment
May involve the removal of damaged bone
and replacement with a prosthesis
Provides immediate bone strength
Risk of infection is associated with the
procedure

INTERNAL FIXATION

From Browner BB et al (1992) Skeletal trauma. Philadelphia: W.B. Saunders.

FIXATION
EXTERNAL FIXATION

An external frame is utilized with multiple pins

applied through the bone
Provides more freedom of movement than
with traction

EXTERNAL FIXATION

From Ignatavicius, D., Workman, M. (2002). Medical-surgical nursing, ed 3, Philadelphia: W.B.

Saunders. Courtesy of Smith and Nephew, Inc., Orthopedics Division, Memphis, TN.

TRACTION
DESCRIPTION

The exertion of a pulling force applied in two

directions to reduce and immobilize a fracture
Provides proper bone alignment and reduces
muscle spasms

TRACTION
IMPLEMENTATION
Maintain proper body alignment
Ensure that the weights hang freely and do not
touch the floor
Do not remove or lift the weights without a
physicians order
Ensure that pulleys are not obstructed and
that ropes in the pulleys move freely
Place knots in the ropes to prevent slipping
Check the ropes for fraying

SKELETAL TRACTION
DESCRIPTION
Mechanically applied to the bone using pins,
wires, or tongs
IMPLEMENTATION

Monitor color, motion, and sensation (CMS) of

the affected extremity
Monitor the insertion sites for redness,
swelling, or drainage
Provide insertion site care as prescribed

SKELETAL TRACTION

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders.

CERVICAL TONGS AND

HALO FIXATION DEVICE
Head and Spinal Cord Injuries

SKIN TRACTION
DESCRIPTION

Traction applied by the use of elastic

bandages or adhesive

SKIN TRACTION: SIDE ARM

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders.

TYPES OF SKIN TRACTION

Cervical traction
Bucks traction
Bryants traction
Pelvic traction
Russells traction

CERVICAL SKIN TRACTION

Relieves muscle spasms and compression in

the upper extremities and neck

Uses a head halter and a chin pad to attach
the traction
Use powder to protect the ears from friction rub
Position the client with the head of the bed
elevated 30 to 40 degrees and attach the
weights to a pulley system over the head of the
bed

CERVICAL SKIN TRACTION

From James, S. Ashwill, R., & Droske, S. (2002). Nursing care of children, ed 2,
Philadelphia: W.B. Saunders.

HEAD HALTER TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BUCKS SKIN TRACTION

Used to alleviate muscle spasms; immobilizes a

lower limb by maintaining a straight pull on the

limb with the use of weights
A boot appliance is applied to attach to the
traction
Weight is attached to a pulley; allow the weights
to hang freely over the edge of bed
Not more than 5 pounds of weight should be
applied
Elevate the foot of the bed to provide the traction

BUCKS SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BRYANTS AND RUSSELLS

SKIN TRACTION
Refer to the module entitled Pediatric

Nursing, Musculoskeletal Disorders for

information related to these types of traction

PELVIC SKIN TRACTION

Used to relieve low back, hip, or leg pain and

to reduce muscle spasm

Apply the traction snugly over the pelvis and
iliac crest and attach to the weights
Use measures as prescribed to prevent the
client from slipping down in bed

PELVIC SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BALANCED SUSPENSION
DESCRIPTION

Used with skin or skeletal traction

Used to approximate fractures of the femur,
tibia, or fibula
Produced by a counterforce other than client

BALANCED SUSPENSION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BALANCED SUSPENSION
IMPLEMENTATION
Position the client in low Fowlers, either on
the side or back
Maintain a 20-degree angle from the thigh to
the bed
Protect the skin from breakdown
Provide pin care if pins are used with the
skeletal traction
Clean the pin sites with sterile normal saline
and hydrogen peroxide or Betadine as
prescribed or per agency procedure

DUNLOPS SKIN TRACTION

DESCRIPTION

Horizontal traction to align fractures of the

humerus; vertical traction maintains the
forearm in proper alignment

IMPLEMENTATION

Nursing care is similar to Bucks traction

DUNLOPS SKIN TRACTION

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

CASTS
DESCRIPTION

Made of plaster or fiberglass to provide

immobilization of bone and joints after a
fracture or injury

CASTS

From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing:

Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.

CASTS
IMPLEMENTATION

Keep the cast and extremity elevated

Allow a wet cast 24 to 48 hours to dry
(synthetic casts dry in 20 minutes)
Handle a wet cast with the palms of the hand
until dry
Turn the extremity unless contraindicated, so
that all sides of the wet cast will dry
Heat can be used to dry the cast

CASTS
IMPLEMENTATION
The cast will change from a dull to a shiny
substance when dry
Examine the skin and cast for pressure areas
Monitor the extremity for circulatory impairment
such as pain, swelling, discoloration, tingling,
numbness, coolness, or diminished pulse
Notify the physician immediately if circulatory
compromise occurs
Prepare for bivalving or cutting the cast if
circulatory impairment occurs

CASTS
IMPLEMENTATION

Petal the cast; maintain smooth edges around

the cast to prevent crumbling of the cast
material
Monitor the clients temperature
Monitor for the presence of a foul odor, which
may indicate infection
Monitor drainage and circle the area of
drainage on the cast
Monitor for warmth on the cast

CASTS
IMPLEMENTATION
Monitor for wet spots, which may indicate a need
for drying, or the presence of drainage under the
cast
If an open draining area exists on the affected
extremity, a cut-out portion of the cast or a window
will be made by the physician
Instruct the client not to stick objects inside the
cast
Teach the client to keep the cast clean and dry
Instruct the client on isometric exercises to prevent
muscle atrophy

COMPLICATIONS OF
FRACTURES
Fat embolism
Compartment syndrome
Infection and osteomyelitis
Avascular necrosis
Pulmonary emboli

FAT EMBOLISM
DESCRIPTION

An embolism originating in the bone marrow

that occurs after a fracture
Clients with long bone fractures are at the
greatest risk for the development of fat
embolism
Usually occurs within 48 hours following the
injury

FAT EMBOLISM
ASSESSMENT
Restlessness
Mental status changes
Tachycardia, tachypnea, and hypotension
Dyspnea
Petechial rash over the upper chest and neck
IMPLEMENTATION

Notify the physician immediately

Treat symptoms as prescribed to prevent
respiratory failure and death

COMPARTMENT SYNDROME
DESCRIPTION

Increased pressure within one or more

compartments causing massive compromise
of circulation to an area
Leads to decreased perfusion and tissue
anoxia
Within 4 to 6 hours after the onset of
compartment syndrome, neuromuscular
damage is irreversible

ANTERIOR COMPARTMENT
SYNDROME

From Black JM, Hawks JH, Keene AM (2001): Medical-surgical nursing: clinical
management for positive outcomes 6th ed., Philadelphia, W.B. Saunders.

COMPARTMENT SYNDROME
ASSESSMENT

Increased pain and swelling

Pain with passive motion
Inability to move joints
Loss of sensation (paresthesia)
Pulselessness

IMPLEMENTATION

Notify the physician immediately

INFECTION AND
DESCRIPTION
OSTEOMYELITIS
Can be caused by the interruption of the
integrity of the skin
The infection invades bone tissue

INFECTION AND
ASSESSMENT
OSTEOMYELITIS

Fever
Pain
Erythema in the area surrounding the fracture
Tachycardia
Elevated white blood cell (WBC) count

IMPLEMENTATION
Notify the physician
Prepare to initiate aggressive IV antibiotic
therapy

AVASCULAR NECROSIS
DESCRIPTION
An interruption in the blood supply to the bony
tissue, which results in the death of the bone
ASSESSMENT

Pain
Decreased sensation

IMPLEMENTATION
Notify the physician if pain or decreased
sensation occurs
Prepare the client for removal of necrotic tissue
because it serves as a focus for infection

PULMONARY EMBOLISM
DESCRIPTION

Caused by immobility precipitated by a

fracture

PULMONARY EMBOLISM
ASSESSMENT
Restlessness and apprehension
Dyspnea
Diaphoresis
Arterial blood gas changes
IMPLEMENTATION

Notify the physician if signs of emboli are

present
Prepare to administer anticoagulant therapy

CRUTCH WALKING
DESCRIPTION

An accurate measurement of the client for

crutches is important because an incorrect
measurement could damage the brachial
plexus
The distance between the axilla and the arm
pieces on the crutches should be two
fingerwidths in the axilla space
The elbows should be slightly flexed 20 to 30
degrees when walking

BRACHIAL PLEXUS

From Crossman AR, Neary D (1995). Neuroanatomy: an illustrated color text. Edinburgh:
Churchill Livingstone.

CRUTCH WALKING
DESCRIPTION

When ambulating with the client, stand on the

affected side
Instruct the client never to rest the axilla on the
axillary bars
Instruct the client to look up and outward when
ambulating
Instruct the client to stop ambulation if
numbness or tingling in the hands or arms
occurs

CRUTCH WALKING

From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2,
St. Louis, 2000, Mosby.

CRUTCH GAITS

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

CANES
DESCRIPTION

Made of a lightweight material with a rubber tip

at the bottom

SINGLE- AND QUAD-FOOT

CANES

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

CANES
IMPLEMENTATION

Stand at the affected side of the client when

ambulating
The handle should be at the level of the
clients greater trochanter
The clients elbow should be flexed at a 25- to
30-degree angle

CANES
CLIENT EDUCATION

Hold the cane close to the body

Hold the cane in the hand on the unaffected
side so that the cane and weaker leg can work
together with each step
Move the cane at the same time as the
affected leg
Inspect the rubber tips regularly for worn
places

HEMICANES OR QUAD-FOOT
CANES
Used for clients who have the use of only one

upper extremity
Hemicanes provide more security than a quadfoot cane; however, both types provide more
security than a single-tipped cane
Position the cane at the clients unaffected side
with the straight nonangled side adjacent to the
body
Position the cane 6 inches from clients side with
the handgrips level with the greater trochanter

WALKERS
Stand adjacent to the client on the affected

side
Instruct the client to put all four points of the
walker flat on the floor before putting weight
on the hand pieces
Instruct the client to move the walker forward
and to walk into it

TYPES OF HIP FRACTURES

Intracapsular
Extracapsular

INTRACAPSULAR HIP
FRACTURE
Bone is broken inside the joint
Skin traction is applied preoperatively to

immobilize and prevent pain

Treatment includes a total hip replacement or
internal fixation with replacement of the
femoral head with a prosthesis
Avoid hip flexion to prevent displacement

EXTRACAPSULAR HIP
FRACTURE
Fracture can occur at the greater trochanter

or can be an intertrochanteric fracture

Trochanteric fracture is outside the joint
Preoperative treatment includes balanced
suspension traction
Avoid hip flexion to prevent displacement
Surgical treatment includes internal fixation
with nail plate, screws, or wires

INTERNAL FIXATION

From Black JM, Matassarin-Jacobs E (1997): Medical-surgical nursing: clinical

management for continuity of care 5th ed., Philadelphia, W.B. Saunders.

HIP REPLACEMENTS

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St.
Louis: Mosby. Courtesy of Zimmer, Inc., Warsaw, IN.

TOTAL HIP REPLACEMENT

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

HIP FRACTURE
POSTOPERATIVE

Maintain leg and hip in proper alignment

Prevent flexion or external or internal rotation
Turn the client from back to unaffected side
Do not position to the affected side unless
prescribed by the physician
Maintain leg abduction to prevent internal or
external rotation

HIP FRACTURE
POSTOPERATIVE
Use a trochanter roll to prevent external
rotation
Ensure that the hip flexion angle does not
exceed 60 to 80 degrees
Elevate the head of the bed 30 to 45 degrees
for meals only
Ambulate as prescribed by the physician
Avoid weight bearing on the affected leg as
prescribed; instruct the client in the use of a
walker to avoid weight bearing

HIP FRACTURE
POSTOPERATIVE

Keep the operative leg extended, supported,

and elevated when getting client out of bed
Avoid hip flexion greater than 90 degrees and
avoid low chairs when out of bed
Monitor the wound for infection or hemorrhage
Monitor circulation and sensation of the
affected side

HIP FRACTURE
POSTOPERATIVE

Maintain the Hemovac or Jackson-Pratt drain

if in place; maintain compression to facilitate
drainage and monitor and record output of
drainage
Drainage should continuously decrease in
amount, and by 48 hours postoperatively,
drainage should be approximately 30 ml in an
8-hour period

HIP FRACTURE
POSTOPERATIVE

Maintain the use of antiembolism stockings

and encourage the client to flex and extend
the feet and ankles
Instruct the client to avoid crossing the legs
and bending over
Physical therapy will begin postoperatively as
prescribed by the physician

TOTAL KNEE REPLACEMENT

DESCRIPTION

Implantation of a device to substitute for the

femoral condyles and the tibial joint surfaces

KNEE PROSTHESIS

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.

TOTAL KNEE REPLACEMENT

POSTOPERATIVE

Monitor the incision for drainage and infection

Maintain the Hemovac or Jackson-Pratt drain
if in place
Begin continuous passive motion (CPM) 24 to
48 hours as prescribed to exercise the knee
and provide moderate flexion and extension
Administer analgesics before CPM to
decrease pain

CONTINUOUS PASSIVE
MOTION

From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills,
St. Louis, 1996, Mosby.

TOTAL KNEE REPLACEMENT

POSTOPERATIVE

The leg should not be dangled to prevent

dislocation
Prepare the client for out-of-bed activities as
prescribed
Avoid weight bearing and instruct the client in
crutch walking

HERNIATION:
INTERVERTEBRAL DISC
DESCRIPTION

Nucleus of the disc protrudes into the annulus

causing nerve compression

TYPES

Cervical
Lumbar

DISC HERNIATION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders.

CERVICAL DISC
DECRIPTION

Occurs at C5 to C6 and C6 to C7 interspaces

Causes pain and stiffness in the neck, top of
the shoulders, scapula, upper extremities, and
head
Produces paresthesia and numbness of the
upper extremities

CERVICAL DISC
IMPLEMENTATION
Provide bed rest to relieve pressure and
reduce inflammation and edema
Provide immobilization as prescribed via
cervical collar, traction, or brace
Apply hot, moist compresses as prescribed to
increase the blood flow and relax spasms
Instruct the client to avoid flexing, extending,
or rotating the neck
Instruct the client to avoid long periods of
sitting

CERVICAL DISC
IMPLEMENTATION
Instruct the client that while sleeping, to avoid the
prone position and keep the head, spine, and hip
in alignment
Instruct the client in the use of analgesics,
sedatives, antiinflammatory agents, and
corticosteroids as prescribed
Prepare the client for a corticosteroid injection
into the epidural space if prescribed
Assist the client with the application of a cervical
collar or cervical traction as prescribed

CERVICAL COLLAR
Used for cervical disc herniation
Holds the head in a neutral or slightly flexed

position
The client may have to wear a cervical collar
24 hours a day
Inspect the skin under the collar for irritation
When the pain subsides, the client is taught
cervical isometric exercises to strengthen the
muscles

CERVICAL COLLAR

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders. Courtesy of Zimmer, Inc., Dover, OH.

LUMBAR DISC
DESCRIPTION
Most often occurs at L4 to L5 or L5 to S1
interspaces
Postural deformity occurs
Produces muscle weakness, sensory loss, and
alteration of the tendon reflexes
The client experiences low back pain and muscle
spasms with radiation of the pain into one hip and
down the leg (sciatica)
Pain is aggravated by bending, lifting, straining,
sneezing, and coughing, and is relieved by bed
rest

LUMBAR DISC
IMPLEMENTATION

Provide bed rest as prescribed

Apply moist heat and massage as prescribed
Instruct the client to sleep on the side with the
knees and hips in a position of flexion and with
a pillow between the legs
Apply pelvic traction as prescribed to relieve
muscle spasms

LUMBAR DISC
IMPLEMENTATION

Begin ambulation gradually as the

inflammation and edema subsides
Instruct the client in the use of muscle
relaxants, antiinflammatory medications, and
corticosteroids as prescribed
Instruct the client in the use of a corset or
brace as prescribed
Instruct the client regarding correct posture
while sitting, standing, walking, and working

LUMBAR DISC
IMPLEMENTATION

Instruct the client to lift objects by bending the

knees and keeping the back straight, avoiding
lifting anything above the elbows
Instruct the client regarding a weight-control
program as prescribed
Instruct the client in an exercise program as
prescribed to strengthen abdominal and back
muscles

DORSOLUMBAR ORTHOSIS

From Mosbys medical, nursing, and allied health dictionary, ed 6, (2002). St. Louis:
Mosby. Courtesy of Truform Orthotics and Prosthetics, Cincinnati, OH.

LOW BACK CARE

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.

TYPES OF DISC SURGERY

CHEMOLYSIS
Injections to dissolve affected disc
DISCECTOMY

Removal of herniated disc tissue and related matter

DISCECTOMY WITH FUSION

Fusion of vertebrae with bone graft
LAMINOTOMY

Division of the lamina of a vertebrae

LAMINECTOMY
Removal of the lamina

DISC SURGERY
PREOPERATIVE

Reassure the client that surgery will not

weaken the back
Instruct the client regarding coughing and
deep-breathing exercises
Instruct the client about logrolling and rangeof-motion exercises

DISC SURGERY: CERVICAL

POSTOPERATIVE
DISC
Monitor for respiratory difficulty
Encourage coughing and deep breathing
Monitor for hoarseness and inability to cough
effectively because this may indicate laryngeal
nerve damage
Use throat sprays or lozenges for sore throat
and do not use those that may numb the
throat to avoid choking

DISC SURGERY: CERVICAL

POSTOPERATIVE
DISC
Monitor the wound for drainage
Provide a soft diet if the client complains of
dysphagia
Monitor for sudden return of radicular pain,
which may indicate that the cervical spine has
become unstable

DISC SURGERY: LUMBAR

POSTOPERATIVE
DISC
Monitor for wound hemorrhage
Monitor sensation and motor ability of the
lower extremities as well as color,
temperature, and sensation of toes
Monitor for urinary retention, paralytic ileus,
and constipation
Initiate measures to prevent constipation such
as a high-fiber diet, increased fluids, and stool
softeners as prescribed

DISC SURGERY: LUMBAR

POSTOPERATIVE
DISC
When turning and repositioning the client,
place the bed in a flat position and a pillow
between the legs; turn the client as a unit
(logroll) without twisting the clients back
When positioning the client, a pillow is placed
under the head with the knees slightly flexed
Avoid extreme knee flexion when the client is
lying on the side

DISC SURGERY: LUMBAR

POSTOPERATIVE
DISC
To assist the client out of bed, raise the head
of the bed while the client lies on the side; the
client's head and shoulders are supported by
the first nurse, the client pushes self to a
sitting position, and the second nurse eases
the legs over the side of the bed
Instruct the client to avoid sitting because it
places a strain on the surgical site

DISC SURGERY: LUMBAR

POSTOPERATIVE
DISC
Administer narcotics and sedatives as
prescribed to relieve pain and anxiety
Encourage early ambulation
Assist the client with the use of a back brace
or corset if prescribed

AMPUTATION OF A LOWER
EXTREMITY
DESCRIPTION

The surgical removal of a lower limb or part of

the limb

LEVELS OF LOWER
EXTREMITY AMPUTATION

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4,

Philadelphia: W.B. Saunders.

AMPUTATION FLAPS

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

AMPUTATION OF A LOWER
EXTREMITY
POSTOPERATIVE

Monitor vital signs

Monitor for infection and hemorrhage
Mark bleeding and drainage on the dressing if
it occurs
Keep a tourniquet at the bedside
Monitor for pulmonary emboli

AMPUTATION OF A LOWER
EXTREMITY
POSTOPERATIVE

Observe for and prevent contractures

Monitor for signs of necrosis and neuroma
Evaluate for phantom limb sensation and pain;
explain sensation and pain to the client, and
medicate the client as prescribed
Check the physicians orders regarding
positioning

AMPUTATION OF A LOWER
EXTREMITY
POSTOPERATIVE
If prescribed, during the first 24 hours, elevate
the foot of the bed to reduce edema, then keep
the bed flat to prevent hip flexion contractures
Do not elevate the stump itself because
elevation can cause flexion contracture of the
hip joint
After 24 and 48 hours postoperatively, position
the client prone if prescribed to stretch the
muscles and prevent flexion contractures of hip

AMPUTATION OF A LOWER
EXTREMITY
POSTOPERATIVE

In the prone position, place a pillow under the

abdomen and stump and keep the legs close
together to prevent abduction
Maintain application of an Ace wrap or elastic
stump shrinker as prescribed to provide stump
shrinkage
Remove and rewrap the Ace bandage or
elastic stump shrinker three to four times daily
as prescribed

AMPUTATION OF A LOWER
EXTREMITY
POSTOPERATIVE
Wash the stump with mild soap or water and
apply lanolin to the skin if prescribed
Massage the skin toward the suture line to
increase circulation
Prepare for a cast application if prescribed to
prepare the stump for prosthesis
Encourage the client to look at the stump
Encourage verbalization regarding loss of the
body part and assist the client to identify
coping mechanisms to deal with the loss

STUMP WRAPPING

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.

BELOW-THE-KNEE
POSTOPERATIVE
AMPUTATION
Prevent edema
Do not allow the stump to hang over the edge
of the bed
Do not allow the client to sit for long periods of
time to prevent contractures

ABOVE-THE-KNEE
POSTOPERATIVE
AMPUTATION
Prevent internal or external rotation of the limb
Place a sandbag or rolled towel along the
outside of the thigh to prevent rotation

AMPUTATION OF A LOWER
EXTREMITY
REHABILITATION

Instruct the client in crutch walking

Prepare the stump for prosthesis
Prepare the client for the fitting of the stump
for prosthesis
Instruct the client in exercises to maintain
range of motion
Provide psychosocial support to the client

RHEUMATOID ARTHRITIS
(RA)
DESCRIPTION
Chronic systemic inflammatory disease; the
etiology may be related to a combination of
environmental and genetic factors
Leads to destruction of connective tissue and
synovial membrane within the joints
Weakens and leads to dislocation of the joint
and permanent deformity
Formation of pannus occurs at the junction of
synovial tissue and articular cartilage projecting
into the joint cavity and causing necrosis

RHEUMATOID ARTHRITIS
(RA)
DESCRIPTION

Exacerbations are increased by physical or

emotional stress
Risk factors include exposure to infectious
agents; fatigue and stress can exacerbate the
condition
Vasculitis can cause malfunction and eventual
failure of an organ or system

RHEUMATOID ARTHRITIS
(RA)
ASSESSMENT

Inflammation, tenderness, and stiffness of the

joints
Moderate to severe pain and morning stiffness
lasting longer than 30 minutes
Joint deformities, muscle atrophy, and
decreased range of motion
Spongy, soft feeling in the joints

RHEUMATOID ARTHRITIS
(RA)
ASSESSMENT

Low-grade temperature, fatigue, and

weakness
Anorexia, weight loss, and anemia
Elevated sedimentation rate and positive
rheumatoid factor
X-ray showing joint deterioration
Synovial tissue biopsy presents inflammation

RHEUMATOID ARTHRITIS
EARLY, MODERATE, AND
ADVANCED STAGE

From Monahan FD, Neighbers M: Medical-surgical nursing: foundations

for clinical practice, ed. 2, Philadelphia, 1998, W.B. Saunders.

RHEUMATOID ARTHRITIS
MUSCLE ATROPHY

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.

RHEUMATOID NODULE

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.

BOUTONNIERE DEFORMITY

From Zitelli BJ, Davis HW: Atlas of Pediatric Physical Diagnosis, ed. 3, St. Louis, 1997, Mosby.

SWAN NECK DEFORMITY

From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts

and clinical practice, ed. 6, St. Louis, 1999, Mosby.

RHEUMATOID (RA) FACTOR

DESCRIPTION

A blood test used to diagnose rheumatoid

arthritis

VALUES

Nonreactive: 0 to 39 IU/ml
Weakly reactive: 40 to 79 IU/ml
Reactive: greater than 80 IU/ml

RHEUMATOID ARTHRITIS
(RA)
PAIN

Salicylates (acetylsalicylic acid [aspirin])

Monitor for side effects including tinnitus,
gastrointestinal (GI) upset, or prolonged
bleeding time
Administer with meals or a snack
Monitor for abnormal bleeding or bruising

RHEUMATOID ARTHRITIS
(RA)
NONSTEROIDAL ANTIINFLAMMATORY

DRUGS (NSAIDs)
May be prescribed in combination with
salicylates if pain and inflammation has not
decreased within 6 to 12 weeks following
salicylate therapy
Monitor for side effects such as GI upset, CNS
manifestations, skin rash, hypertension, fluid
retention, and changes in renal function

RHEUMATOID ARTHRITIS
(RA)
CORTICOSTEROIDS

Administer as prescribed during exacerbations

or when commonly used agents are ineffective

ANTINEOPLASTIC MEDICATIONS

Administer as prescribed in clients with lifethreatening RA

GOLD SALTS

Administer as prescribed in combination with

salicylates and NSAIDs to induce remission
and decrease pain and inflammation

RHEUMATOID ARTHRITIS
(RA)
PHYSICAL MOBILITY

Preserve joint function

Provide ROM exercises to maintain joint
motion and muscle strengthening
Balance rest and activity
Splints during acute inflammation to prevent
deformity
Prevent flexion contractures

RHEUMATOID ARTHRITIS
(RA)
PHYSICAL MOBILITY
Apply heat or cold therapy as prescribed to
joints
Apply paraffin baths and massage as
prescribed
Encourage consistency with exercise program
Instruct the client to stop exercise if pain
increases
Exercise only to the point of pain
Avoid weight bearing on inflamed joints

RHEUMATOID ARTHRITIS
(RA)
SELF-CARE

Assess the need for assistive devices such as

higher toilet seats, chairs, and wheelchairs to
facilitate mobility
Collaborate with occupational therapy to
obtain assistive adaptive devices
Instruct the client in alternative strategies for
providing activities of daily living

RHEUMATOID ARTHRITIS
(RA)
FATIGUE

Identify factors that may contribute to fatigue

Monitor for signs of anemia
Administer iron, folic acid, and vitamin
supplements as prescribed
Monitor for drug-related blood loss by testing
the stool for occult blood
Instruct the client in measures to conserve
energy such as pacing activities and obtaining
assistance when possible

RHEUMATOID ARTHRITIS
(RA)
BODY IMAGE DISTURBANCE

Assess the clients reaction to the body

change
Encourage the client to verbalize feelings
Assist the client with self-care activities and
grooming
Encourage the client to wear street clothes

RHEUMATOID ARTHRITIS
(RA)

SYNOVECTOMY
SURGICAL
INTERVENTIONS

Removal of the synovia to help maintain joint

function

ARTHRODESIS
Bony fusion of a joint to regain some mobility
JOINT REPLACEMENT (ARTHROPLASTY)

Replacement of diseased joints with artificial

joints
Performed to restore motion to a joint and
function to the muscles, ligaments, and other
soft tissue structures that control a joint

OSTEOARTHRITIS
DESCRIPTION

Also known as degenerative joint disease

(DJD)
Cause is unknown but may be caused by
trauma, fractures, infections, or obesity
Progressive degeneration of the joints caused
by wear and tear

OSTEOARTHRITIS
DESCRIPTION

Causes the formation of bony build-up and the

loss of articular cartilage in peripheral and
axial joints
Affects the weight-bearing joints and joints that
receive the greatest stress such as the knees,
toes, and lower spine

JOINT CHANGES IN
OSTEOARTHRITIS

From Ignatavicius DD, Workman ML, Mishler MA, Medical-surgical nursing

across the healthcare continuum, ed. 3, Philadelphia, 1999, W.B.Saunders.

OSTEOARTHRITIS
ASSESSMENT

Joint pain that early in the disease process

diminishes after rest and intensifies after
activity
As the disease progresses, pain occurs with
slight motion or even at rest
Symptoms are aggravated by temperature
change and humidity
Crepitus

OSTEOARTHRITIS
ASSESSMENT
Joint enlargement
Presence of Heberdens nodes or Bouchards
nodes
Limited ROM
Difficulty getting up after prolonged sitting
Skeletal muscle atrophy
Inability to perform activities of daily living
Compression of the spine as manifested by
radiating pain, stiffness, and muscle spasms in
one or both extremities

SEVERE OSTEOARTHRITIS

From Kamal A, Brockelhurst J: Color atlas of geriatric medicine, ed. 2, St. Louis, 1991, Mosby.

HEBERDENS NODES

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.

BOUCHARDS NODES

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.

OSTEOARTHRITIS
PAIN
Administer NSAIDs, salicylates, and muscle
relaxants as prescribed
Prepare the client for corticosteroid injections
into joints as prescribed
Place affected joint in a functional position
Immobilize the affected joint with a splint or
brace
Avoid large pillows under the head or knees
Provide a bed or foot cradle

OSTEOARTHRITIS
PAIN

Position the client prone twice a day

Instruct the client on the importance of moist
heat, hot packs or compresses, and paraffin
dips as prescribed
Apply cold applications as prescribed when
the joint is acutely inflamed
Encourage adequate rest recommending 10
hours of sleep at night and a 1- to 2-hour nap
in the afternoon

OSTEOARTHRITIS
NUTRITION

Encourage a well-balanced diet

Encourage weight loss if necessary

OSTEOARTHRITIS
PHYSICAL MOBILITY
Reinforce the exercise program and the
importance of participating in the program
Instruct the client that exercises should be
active rather than passive and to exercise only
to the point of pain
Instruct the client to stop exercise if pain is
increased with exercising
Instruct the client to decrease the number of
repetitions in an exercise when the
inflammation is severe

OSTEOARTHRITIS
SURGICAL INTERVENTIONS
OSTEOTOMY

The bone is cut to correct joint deformity and

promote realignment

TOTAL JOINT REPLACEMENT (TJR)

Performed when all measures of pain relief

have failed
Hips and knees are most commonly replaced
Contraindicated in the presence of infection,
advanced osteoporosis, and severe
inflammation

RHEUMATOID ARTHRITIS AND

OSTEOARTHRITIS
Assist the
client to identify and correct hazards
CLIENT
EDUCATION

in the home
Instruct the client in the correct use of assistive
adaptive devices
Instruct in energy conservation measures
Review prescribed exercise program
Instruct the client to sit in a chair with a high,
straight back

RHEUMATOID ARTHRITIS AND

OSTEOARTHRITIS
Instruct the
client to use a small pillow, only
CLIENT
EDUCATION
when lying down
Instruct the client in measures to protect the
joints
Instruct the client regarding the prescribed
medications
Stress the importance of follow-up visits with
the health care provider

OSTEOPOROSIS
DESCRIPTION
An age-related metabolic disease
Bone demineralization results in the loss of
bone mass, leading to fragile and porous
bones and subsequent fractures
Greater bone resorption than bone formation
occurs
Occurs most commonly in the wrist, hip, and
vertebral column
Can occur postmenopausal or as a result of a
metabolic disorder or calcium deficiency

OSTEOPOROTIC CHANGES

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.

OSTEOPOROSIS
ASSESSMENT

Back pain after lifting, bending, or stooping

Back pain that increases with palpation
Pelvic or hip pain, especially with weight
bearing
Problems with balance
Decline in height from vertebrae compression

OSTEOPOROSIS
ASSESSMENT

Kyphosis of the dorsal spine

Constipation, abdominal distention, and
respiratory impairment as a result of
movement restriction and spinal deformity
Pathological fractures
Appearance of thin, porous bone on x-ray

DOWAGERS HUMP

From Seidel HM et al: Mosbys guide to physical examination, ed. 4, St. Louis, 1999, Mosby.

SEVERE OSTEOPOROSIS

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.

OSTEOPOROSIS
IMPLEMENTATION

Assess risk for injury

Provide a safe and hazard-free environment
and assist the client to identify hazards in the
home environment
Use side rails to prevent falls
Move the client gently when turning and
repositioning

OSTEOPOROSIS
IMPLEMENTATION
Encourage ambulation; assist with ambulation if
the client is unsteady
Instruct in the use of assistive devices such as a
cane or walker
Provide ROM exercises
Instruct in the use of good body mechanics and
exercises to strengthen abdominal and back
muscles in order to improve posture and provide
support for the spine
Instruct the client to avoid activities that can cause
vertebral compression

OSTEOPOROSIS
IMPLEMENTATION

Apply a back brace as prescribed during an

acute phase to immobilize the spine and
provide spinal column support
Encourage the use of a firm mattress
Provide a diet high in protein, calcium, vitamin
C and D, and iron
Encourage adequate fluid intake to prevent
renal calculi
Instruct the client to avoid alcohol and coffee

MILWAUKEE BRACE

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

OSTEOPOROSIS
IMPLEMENTATION

Administer estrogen or androgens to decrease

the rate of bone resorption as prescribed
Administer calcium, vitamin D, and
phosphorus as prescribed for bone
metabolism
Administer calcitonin as prescribed to inhibit
bone loss
Administer analgesics, muscle relaxants, and
antiinflammatory medications as prescribed

GOUT
DESCRIPTION

A systemic disease in which urate crystals

deposit in joints and other body tissues
Leads to abnormal amounts of uric acid in the
body
Primary gout results from a disorder of purine
metabolism
Secondary gout involves excessive uric acid in
the blood that is caused by another disease

GOUTY JOINT

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations

for clinical practice, ed 2, Philadelphia: W.B. Saunders.

PHASES OF GOUT
ASYMPTOMATIC

No symptoms
Serum uric acid is elevated

ACUTE

Excruciating pain and inflammation of one or

more small joints, especially the great toe

PHASES OF GOUT
INTERMITTENT

Asymptomatic period between acute attacks

CHRONIC

Results from repeated episodes of acute gout

Results in deposits of urate crystals under the
skin and within the major organs, especially
the renal system

GOUT
ASSESSMENT
Excruciating pain in the involved joints
Swelling and inflammation of the joints
Tophi (hard, fairly large, and irregularly shaped
deposits in the skin) that may break open and
discharge a yellow, gritty substance
Low-grade fever
Malaise and headache
Pruritus
Presence of renal stones
Elevated uric acid levels

GOUT

From Clinical Slide Collection of the Rheumatic Diseases, 1991,1995,1997.

Used with permission of the American College of Rheumatology.

GOUT
IMPLEMENTATION

Provide a low-purine diet as prescribed

Instruct the client to avoid foods such as organ
meats, wines, and aged cheese
Encourage a high fluid intake of 2000 ml to
prevent stone formation
Encourage weight-reduction diet if required
Instruct the client to avoid alcohol and
starvation diets because they may precipitate
a gout attack

GOUT
IMPLEMENTATION

Increase urinary pH (above 6) by eating

alkaline-ash foods such as citrus fruits and
juices, milk, and other dairy products
Provide bed rest during the acute attacks
Monitor joint ROM ability and appearance of
joints
Position the joint in a mild flexion position
during acute attack

GOUT
IMPLEMENTATION

Elevate the affected extremity

Protect the affected joint from excessive
movement or direct contact with sheets or
blankets
Provide heat or cold for local treatments to
affected joint as prescribed
Administer NSAIDs and antigout medications
as prescribed