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NURS 342

Unit IV
Musculoskeletal
Care Modalities
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Cast
A rigid, external immobilizing device
Uses

Immobilize a reduced fracture


Correct a deformity
Apply uniform pressure to soft tissues
Provide support to stabilize a joint

Materials: nonplaster (fiberglass), plaster


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Cast
A rigid, external immobilizing device
Uses

Immobilize a reduced fracture


Correct a deformity
Apply uniform pressure to soft tissues
Provide support to stabilize a joint

Materials: nonplaster (fiberglass), plaster


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Cast, Splint, Braces, and


Traction Management
Arm

Casts
Leg Casts
Body or Spica Casts
Splints and Braces
External Fixator
Traction
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Pressure Areas in Casts

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Nursing ProcessAssessment of
the Patient With a Cast

Prior to casting

Perform general health assessment


Evaluate emotional status
Determine presenting signs and symptoms and
condition of the area to be casted

Knowledge
Monitor neurovascular status and the potential
for complications
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Nursing ProcessAssessment of
the Patient With a Cast

Prior to casting

Perform general health assessment


Evaluate emotional status
Determine presenting signs and symptoms and
condition of the area to be casted

Knowledge
Monitor neurovascular status and the potential
for complications
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Nursing ProcessDiagnosis of the


Patient With a Cast

Deficient knowledge

Acute pain

Impaired physical mobility

Self-care deficit

Impaired skin integrity

Risk for peripheral neurovascular dysfunction


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Collaborative Problems/Potential
Complications

Compartment syndrome

Pressure ulcer

Disuse syndrome

Delayed union or nonunion of fracture(s)

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Question
Is the following statement True or False?
A patients unrelieved pain should be
reported to the physician 30 minutes after
administered pain medication.

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Answer
False
A patients unrelieved pain must be
immediately reported to the physician to
avoid possible paralysis and necrosis

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Cross Section of Normal Muscle


Compartments and Cross Section With
Compartment Syndrome
Swelling of muscles causes
compression
of nerves and blood vessels

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Nerves and
Blood Vessels

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Nursing ProcessPlanning the


Care of the Patient With a Cast

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Major goals include knowledge of the


treatment regimen, relief of pain, improved
physical mobility, achievement of maximum
level of self-care, healing of any traumaassociated lacerations and abrasions,
maintenance of adequate neurovascular
function, and absence of complications

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Interventions

Relieve pain

Elevate to reduce edema

Apply ice or cold intermittently

Implement position changes

Administer analgesics

Unrelieved pain may indicate compartment syndrome;


discomfort due to pressure may require change of cast

Muscle setting exercises: see Chart 67-3

Patient teaching: see Chart 41-4

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Interventions (cont.)

Heal skin wounds and maintain skin integrity

Treat wounds to skin before the cast is applied

Observe for signs and symptoms of pressure or infection

Pad cast and cast edges

Patient may require tetanus booster

Maintain adequate neurovascular status

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Assess circulation, sensation, and movement

Five Ps

Notify physician at once of signs of compromise

Elevate extremity no higher than the heart

Encourage movement of fingers or toes every hour

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Teaching Needs of the Patient With a


Cast

Prior to cast application

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Explain condition necessitating the cast


Explain purpose and goals of the cast
Describe expectations during the casting process: eg,
the heat from hardening plaster

Cast care: keep dry; do not cover with plastic


Positioning: elevation of extremity; use of slings
Hygiene
Activity and mobility
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Teaching Needs of the Patient


With a Cast

Explain exercises

Do not scratch or stick anything under the cast

Cushion rough edges

Report the following signs and symptoms: persistent


pain or swelling; changes in sensation, movement, skin
color, or temperature; and signs of infection or pressure
areas

Required follow-up care

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Splint and Braces

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Contoured splints of plaster or pliable thermoplastic


materials may be used for conditions that do not
require rigid immobilization, for those in which
swelling may be anticipated, and for those that
require special skin care.
Braces (ie, orthoses) are used to provide support,
control movement, and prevent additional injury.
They are custom fitted to various parts of the body.

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External Fixation Devices

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Used to manage open fractures with soft-tissue damage


Provide support for complicated or comminuted fractures
Reassure patient concerned by appearance of device
Discomfort is usually minimal, and early mobility may be
anticipated with these devices
Elevate to reduce edema
Monitor for signs and symptoms of complications,
including infection
Provide pin care
Patient teaching
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External Fixation Devices (cont.)

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Question
Is the following statement True or False?
The nurse never adjusts the clamps on the
external fixator frame.

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Answer
True
The nurse never adjusts the clamps on the
external fixator frame. It is the physicians
responsibility to do so.

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Traction

The application of pulling force to a part of the


body
Purposes:

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Reduce muscle spasms


Reduce, align, and immobilize fractures
Reduce deformity
Increase space between opposing forces

Used as a short-term intervention until other


modalities are possible
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Direction of Pull with Traction


All traction needs to be
applied in two directions.
The lines of pull are
vectors of force. The
result of the pulling force is
between the two lines of
the vectors of force.

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Principles of Effective Traction

Whenever traction is applied, a counterforce


must be applied; frequently the patients body
weight and positioning in bed supply the
counterforce

Traction must be continuous to reduce and


immobilize fractures

Skeletal traction is never interrupted

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Principles of Effective Traction


(cont.)

Weights are not removed unless intermittent


traction is prescribed

Any factor that reduces pull must be eliminated

Ropes must be unobstructed and weights must


hang freely

Knots or the footplate must not touch the foot of


the bed

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Types of Traction

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Skin traction

Bucks extension traction

Cervical head halter

Pelvic traction

Skeletal traction
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Bucks Extension Traction


SKIN TRACTION
APPLIED TO LOWER
LEG

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Balanced Suspension Skeletal


Traction with Thomas Leg Splint

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Preventive Nursing Care Needs


of the Patient in Traction

Properly apply and maintain traction

Monitor for complications of skin breakdown, nerve pressure,


and circulatory impairment

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Inspect the skin at least 3 times a day

Palpate traction tapes to assess for tenderness

Assess sensation and movement

Assess pulses, color capillary refill, and temperature of


fingers or toes

Assess for indicators of DVT

Assess for indicators of infection


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Preventative Interventions

Promptly report any alteration in sensation or circulation

Provide frequent back care and skin care

Regularly shift position

Special mattresses or other pressure-reduction devices

Perform active foot and leg exercises every hour

Elastic hose, pneumatic compression hose, or anticoagulant


therapy may be prescribed

Trapeze to help with movement for patients in skeletal traction

Pin care

Exercises to maintain muscle tone and strength

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Nursing ProcessAssessment
of the Patient in Traction

Assess neurovascular status and for complications

Assess for mobility-related complications of pneumonia,


atelectasis, constipation, nutritional problems, urinary
stasis, and UTI

Assess for pain and discomfort

Assess emotional and behavioral responses

Assess coping ability

Assess thought processes

Assess knowledge

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Nursing ProcessDiagnosis of the


Patient in Traction

Deficient knowledge

Anxiety

Acute pain

Self-care deficit

Impaired physical mobility

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Collaborative Problems/Potential
Complications
Pressure ulcer
Atelectasis
Pneumonia
Constipation
Anorexia
Urinary stasis and infection
DVT

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Nursing ProcessPlanning the


Care of the Patient in Traction

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Major goals include understanding the


treatment regimen, reduced anxiety,
maximum comfort, maximum level of
self-care within the therapeutic limits of
the traction, and absence of
complications

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Interventions

Prevent skin breakdown, nerve pressure, and


circulatory impairment
Measures to reduce anxiety

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Provide and reinforce information


Encourage patient participation in decision making and
in care
Encourage frequent visits (family and caregivers/ nurse)
to reduce isolation
Provide diversional activities

Use assistive devices


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Interventions (cont.)

Arrange consultation with/referral for physical therapy

Prevention of atelectasis and pneumonia

Auscultate lungs every 4 to 8 hours

Encourage coughing and deep breathing exercises

High-fiber diet

Encourage fluids

Identify and include food preferences and encourage


proper diet

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Joint Replacements

Used to treat severe joint


pain and disability and for
repair and management of
joint fractures or joint
necrosis

Frequently replaced joints


include the hip, knee, and
fingers

Joints including the


shoulder, elbow, wrist, and
ankle may also be replaced

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Needs of Patients After Hip or


Knee Replacement Surgery

Mobility and ambulation


Patients usually begin ambulation within a
day after surgery using walker or crutches
Weight bearing as prescribed by the
physician

Drain use postoperatively

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Assess for bleeding and fluid accumulation

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Needs of Patients After Hip or Knee


Replacement Surgery (cont.)

Prevention of infection

Infection may occur in the immediate


postoperative period (within 3 months), as a
delayed infection (4 to 24 months), or due to
spread from another site (more than 2 years)

Prevention of DVT
Patient teaching and rehabilitation

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Hip Prosthesis

Position the leg in abduction to prevent


dislocation of the prosthesis

Do not flex hip more than 90

Avoid internal rotation

Provide protective positioning

Hip precautions: see Chart 41-9

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ABDUCTION PILLOW USED AFTER


THR TO PREVENT DISLOCATION
OF PROSTHESIS

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Avoiding Hip Dislocation

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Total Knee Replacement

Nursing interventions

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Compression bandage maintained


Ice as ordered
NVS check
Monitor wound suction drain
Continuous Passive Motion (CPM) device
Mobility
Discharge teaching
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Knee Prostheses

Encourage active flexion exercises

Use continuous passive motion (CPM)


device

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CPM Device

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Nursing ProcessPreoperative Care of


the Patient Undergoing Orthopedic
Surgery

Routine preoperative assessment


Hydration status
Medication history, including NSAIDs, Steroids
Possible infection

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Ask specifically about colds, dental problems, urinary


tract infections, other infections within 2 weeks

Knowledge
Support and coping
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Nursing ProcessPostoperative Care


of the Patient Undergoing Orthopedic
Surgery

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Pain
Vital signs, including respirations and breath
sounds
Level of consciousness
Neurovascular status and tissue perfusion
Signs and symptoms of bleeding: wound drainage
Mobility and understanding of mobility restrictions
Bowel sounds and bowel elimination
Urinary output
Signs and symptoms of complications: DVT or
infection
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Nursing ProcessDiagnosis of the


Patient Undergoing Orthopedic Surgery

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Acute pain
Risk for peripheral neurovascular dysfunction
Risk for ineffective therapeutic regimen
management
Impaired physical mobility
Risk for situational low self-esteem and/or
disturbed body image

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Postoperative Collaborative
Problems/Potential Complications
Hypovolemic shock
Atelectasis
Pneumonia
Urinary retention
Infection
Thromboembolism: DVT or PE
Constipation or fecal impaction

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Nursing ProcessPlanning the Care of


the Patient Undergoing Orthopedic
Surgery

Major goals preoperatively and


postoperatively include the relief of pain,
adequate neurovascular function, health
promotion, improved mobility, and
positive self-esteem

Postoperative goals include the absence


of complications

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Relief of Pain

Administration of medications

Use alternative methods of pain relief

Repositioning, distraction, guided imagery, etc.

Specific individualized strategies to control pain

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Patient-controlled analgesia (PCA)


Other medications
Medicate before planned activity and ambulation

Use ice or cold


Elevation
Immobilization
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Interventions

Implement muscle setting and ankle- and calf-pumping


exercises

Take measures to ensure adequate nutrition and hydration

Large amounts of milk should not be given to orthopedic


patients on bed rest

Provide skin care measures including frequent turning and


positioning

Follow physical therapy and rehabilitation programs

Encourage the patient to set realistic goals and perform selfcare care within limits of the therapeutic regimen

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Interventions (cont.)

Prevent atelectasis and pneumonia

Encourage coughing and deep breathing


exercises
Use incentive spirometry

Constipation

Monitor bowel function


Provide hydration
Encourage early mobilization
Use stool softeners

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Patient teaching Chart 41-11


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