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Musculo-Skeletal (Med.-Surg.)

Musculo-Skeletal (Med.-Surg.)

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Published by: Joseph on Aug 16, 2010
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Care of the Clients with Musculoskeletal Disorders

LABORATORY/ DIAGNOSTIC TESTS ¥ Blood Tests ¹ESR ( elevated in SLE and arthritis) ¹ Rheumatoid factors ( + in rheumatoid arthritis) ¹ Lupus erythematosuscells(Le cells) ¹ Antinuclear antibodies (ANA) (+ in Rheumatoid arthritis) ¹ Anti- DNA (+ in SLE) ¹ C- reactive protein (+ in rheumatoid arthritis) ¹ Uric Acid (elevated in Gout) ¹Mineral s Calcium Decreased levels in osteomalacia , osteoporosis. Increased levels in bone tumors, healing fractures, Paget·s disease Alkaline Phosphatase Elevated level s in bone cancer, osteoporosis, osteomalacia, Paget·s disease Phosphorus Increased levels in healing fractures, bone tumors. ¹ Muscle Enzymes Aldolase Elevated in muscle dystrophy, dermatomyositis AST (aspartate amino transferease) CK (creatinePhospokinase ) Elevated in traumatic injuries LDH (lactic Dehyrogenase) Elevated in skeletal muscle necrosis, extensive cancer ¥ X-Rays(Roentgenography) Done primarily to detect bone fractures ¥ Bone Scan Measures radioactivity in bone 2 hrs.after IV injections of a radio isotope; detects bone tumors, osteomyelitis. ¹Nursing Care Patient must void immediately before procedure Patient must remain still during scan ¥ Arthroscopy

¹ Insertion of fiberopticcs scope into a joint to visualize it, performs biopsies or remove loosesbodies . ¹ Performed in OR under sterile technique ¹ Nursing care Pressure Dressing for 24 hrs. Patient must limit activity for several days ¥ Arthtrocentesis : removal of synovial fluid, blood pus from a joint. ¥ Myelography ¹ Lumbar puncture is done to withdraw a small amount of CSF, which is replaced with a radiopaque dye ; used to detect tumors or herniated intravertebral discs. ¹ Nursing Care Pretest Consent form must be signed Check for iodine allergy Keep on NPO after liquid breakfast ¹ Nursing Care post test If dye has been completely removed (oil Dye), Keep patient flat for 12 hrs. If dye has not been completely removed (water based dye-Amipaque ), keep head of bed elevated( 30_ 45) to prevent causing meningeal s irritations and seizures. If water based dyesused pit patient on seizure precautions and do not administer any phenothiazine ¥ Electromyography (EMG) ¹ Measures and records activity of contracting muscle in response to electrical stimulation; helps differentiate muscle disease from motor neuron dysfunction. ¹ Explain procedure to patient and prepare him for discomfort of needle insertion. COMMON MUCULO-SKELETAL INTERVENTIONs ¥ RANGE OF MOTION EXERCISE ¹ Types Active ² done by the patient. Increase and maintains muscle tone and joint mobility. Passive- Done by the nurse without help from the patient, maintains joint mobility only Active assistive ² patient moves body part as far as possible and nurse completes exercise or stronger arm and leg perform exercise to weaker arm leg. Active resistive ² contraction of muscle against an opposing force; increase muscle power. ¥ Isotonic Exercise Involves change in both muscle length and tension ¥Isometric Exercise Active exercise through contraction/ relaxation of muscle- no joint movement ²length of muscle does not change Patient increase tension in muscle does not change maintains muscle strength and seize ¥ASSISTIVE DEVICE FOR WALKING Cane Types- single, tripod cane, quadripod cane.

Patient must hold cane in hand opposite affected extremity. Advance cane as the affected leg is moved forward Walker Hip level lift and walk Positioned at the back when ongoing down the stirs ¹ Crutches Assure proper length with patient standing: top of the crutch is 2 inches below the axilla and the tip of each crutch is 6 inches in front and to the side of the feet ( 2 inches forward, then 4 inches to the side ). patient·s elbows should be slightly flexed when hand is on bar (30 degree). Weight must not be borne by axillae, but on palms of the hand to prevent crutch palsy. Crutch gaits. Four point gait. Advance right crutch followed by the left foot , then left crutch followed by the right foot Two point gait. Advance right crutch and left foot together , then the left crutch and the right foot together . three point gait . advance the both crutches and affected leg together , followed by the unaffected leg. None or Little weight bearing is allowed . Swing to gait. Advance both crutches, swing the body so that the feet will be at the level of crutches. swing through gait. Advance both crutches , swing the body so that the feet will be past the level of the crutches . Going up and down the stairs Up with the good ( good leg first, then bad leg and crutches ). Down with the bad ( bad Leg and crutches first, then good leg). ¥ CARE OF THE CLIENT WITH CAST Carry with palms of the hand. To prevent indentions and pressure. Elevated wioth pillow support.To prevent edema. Expose to dry .dry cast appears white, shiny, hard and resonant keep clean and dry Observe ´hot spotsµ & musty odor. These are sign and symptoms of infection maintain skin integrity_µpetallingµ Do neurovascular check: skin color Skin temperature sensation Mobility Pulse Windowing- to facilitate observation under cast Bivalving-If Cast is too tight/ Healing process has occurred. It is splitting of the cast. Care of Client With Traction Traction The act of pulling associated with counterpull

Purpose reduce/ immobilize fractures relieve muscle spasm Prevent / correct deformities Types Skin Traction Bucks·s traction exerts straight pull on affected extremity, temporary to immobilize the leg in patient with a fractured hip Shock blocks at the foot of the bed produce counter traction and prevent the patient from sliding down in bed. Has a horizontal weight Turn towards unaffected side, with 2 pillows in between legs. Check for pressure sore at the heel of the feet and signs and symptoms of thrombophlebitis. Russell Traction Knee is suspended in a sling attached to a rope and pulley on a Balkan frame, Creating horizontal traction. Weights are attached to the foot of the bed creating horizontal traction. Used to treat fracture of the femur Allows patient to move about in the bed more freely and permits bending of the knee joint. Hip should be flexed at 20 degree ; foot of bed usually elevated by shock blocks to provide countertraction . Assess back of the knee for pressure sores. Check for signs and symptoms of thrombophlebitis. Bryant Traction Both legs raised at 90 degree angle to bed because the weight of the child is not adequate to provide countertraction. Used for children under 2 years and 30 pounds to treat fractures of the femur and hip dislocation Buttocks must be slightly off the mattress. To enhance efficacy of the weights that hang over head of bed. Knees slightly flexed . To prevent hyperextension deformity. Cervical Traction Cervical head halter attached to weights that hang over head of bed. Used for soft tissue damage ore degenerative disc disease of cervical spine to reduce muscle spasm and maintain alignment. Usually intermittent traction, elevated head of bed to provide countertraction. Pelvic Traction Pelvic girdle with extension straps attached to ropes and weights used for low back to reduce muscle spasm and maintain alignment. Usually intermittent, patient in semi-Fowler·s postion with knee gatched 20-30 degree angle, secure pelvic girdle around iliac crests.

Encourage to use overhead trapeze. Skeletal Traction- traction applied directly to the bones using pins,wire , or tongs (Crutchfield) that are surgically inserted, used for fractures femur , tibis , humerus , cervical spine. Balanced suspension traction produced by a counterforce other than the patients weight. Extremity floats or balances in the traction apparatus. patient may change position without disturv\bing the line of traction. Thomas splint with Pearson attachment Use with skeletal traction in fractures of the femur; hip should be flexed at 20 degree Use footplate to prevent footdrop Check pressure at the inguinal area (groin) PRINCIPLES IN THE CASE OF THE CLIENT WITH TRACTION The line of pull should be in line with the deformity There should be an adequate counteraction Apply traction continuously Allows the weight to hang freely turn the client as indicated Avoid friction Pin site care for skeletal traction Cleanse and apply antibiotic Do neurovascular check Prevent complications of immobility DISORDERS OF THE MUSCULOSKELETAL SYSTEM Trauma Strain. Damage to tendon due to twisting motion Sprain. Damage to ligament due to twisting motion Subluxation. Complete disarticulation Fracture. Any impairment in the bone integrity TYPES OF FRACTURE Cpmplete. The entire circumference of the bone is impaired . Incomplete . Only partial circumference of the bone is impaired Transverse. The line of break is across the bone. Oblique. The line of break goes diagonal along the bone. Spiral. The line of break goes around along the bone. Greenstick. One side of the bone is impaired , the other side is bent . It affects cartilaginous bones: common in children. Comminuted. Bone ends are splintered into 2 or more small pieces. Impacted. One bone enters the intramedullary space of another bone end. Closed or simple ² no break in skin. Open or Compound ² break in skin with or without protrusion of bone .

stress . this is due to other systematic diseases. Pathologic . This is due to other systematic diseases Traumatic. This is due to injury. Assessment pain, aggravated by motion, tenderness Loss Of motion Edema Crepitus Ecchymosis Shortening of the limb Obvious deformity X-ray reveals fracture Collaboration management Traction Reduction Closed reduction through manual manipulation followed by application of cast (with external fixation) (CREF). Open reduction through surgery ( with Internal Fixation) (ORIF) Cast Monitor for disorientation and confusion in the elderly. This may result from stress of fracture , unfamiliar surroundings, coexisting systematic disease, cerebral ischemia, etc. Prevent complications of immobility. Encourage use of trapeze to facilitate movement Analgesics Care of Clients with open reduction Check dressings Empty Hemovac Assess LOC Turn q 2 hour turn to unoperative side only Plac e 2pillows between legs while turning & when lying on side Measures to prevent thrombus formation Elastic Hose Dorsiflexion of foot Anticoagulants such as aspirin encourage quadriceps setting and gluteal setting exercises Observe for adequate bowel and bladder function. Assist patient in getting in and out of bed first and second post-op daqy. Avoid weight bearing until allowed provide care for the patient with a hip prosthesis if necessary (similar to care of patient with total hip replacement) COMPLICATIONS OF FRACTURES Hypovolemic shock. This is due to massive bleeding .

Fat embolism. This usually follows fracture of the long bones , e.g lower extremeties or multiple fractures. Compartment Syndrome. This results from fractures of arms or legs where closed compartment are present. a Compartments contains blood vessels, nerves, muscle which are enclosed by fascia.

Fractures Tight dressings Tight Cast

Edema of contents of the compartment pressure within closed compartment

5Ps Pain Pallor Pulselessness Paresteshia Paralysis

Contractures e.g Volkmann s contracture

Function disability

Collaborative Management of Compartment Syndrome Extremity elevated above the level of the heart Notify Physician remove tight dressing or cast Surgery: Fasciotomy with delayed primary closure of wound, 3-5 days after to allow edema of compartment to subside

Avascular Necrosis. Decreased bone tissue perfusion leads to bone tissue death. Neck of the femur is commonly affected. delayed Union or Nonunion or Malunion. May result from infection, poor circulation, ineffective immobilization, inadequate reducation or poor health condition. TOTAL HIP REPLACEMEnt Replacement of both acetabulum and head of femur with prostheses Indications rheumatoid arthritis or osteoarthritis causing severe disability and intolerance pain. Fractured hip with nonunion Nursing Intervention Provide routine post op care In addition to routine post op care. In addition to routine post op care Maintain abduction of affected limb at all times with abductor splint or 2 pillows between legs. Prevent external rotation by placing trochanter rolls along hip Prevent hip flexion Head of bed flat if ordered Raised head of bed 20 -30 for meals if ordered; use abductor splint or two pillows between knees while turning and lying on side. Get patient out of bed 2-4 days post op Avoid adduction and hip ²flexion- do not use low chair Teach client Prevention of adduction of affected limb and hip flexion Do not cross legs. Used raised toilet seat Do not bend down to put on shoes or socks Do not sit in low chairs. Assess signs of wound infection. Exercise program as ordered. Partial weight bearing only until full weight bearing allowed; used three point crutch gait. RHEUMATOID ARTHRITIS Chronic Systemic disease characterized by inflammatory changes in joints and related structures. Occurs in women more than men(3:1); peak incidence between 20 and 40 years of age. Cause unknown May be autoimmune process/may be genetic. Predisposing factors include fatigue, cold emotional stress, infection Joint distribution is symmetric- most commonly involves wrists, elbow, shoulder, knees, hips, ankles and jaw.

If unarrested, affected joints progress through four stages of deterioration: synovitis, pannus formation, fibrous ankylosis and bony ankylosis. Assessment Fatigue, anorexia, malaise, weight loss, slight temperature elevation. Painful, warm,swollen joints with limited motion, stiff in morning and after periods of inactivity. Crippling deformity in long standing disease. Muscle weakness secondary to inactivity History of remissions and exacerbations. Some patients have other manifestations: subcutaneous nodules, eye, vascular, lung or cardiac problems. Sjoren·s Syndrome Excessive dryness of the eyes, mouth and vagina.

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