MUSCULOSKELETAL PROBLEMS

Outline
• Biology of bones
• Fracture
• Spinal injury & nursing care
• Joints
Biology of bones
 Fracture
• Break of the bone
• Types:
• Closed (simple):
bone does not
penetrate the skin
• Open (Compound):
bone penetrate the
skin
• May be complicated
with soft tissue
injuries
Fracture healing
 Management of fractures
CONSERVATIVE SURGICAL FIXATION
• Casts • Internal / External fixation
 Care of fractures
• Traction, reduction
• Immobilization
– At least 6 to 8 weeks
• Wound care
• Physiotherapy
– Partial weight bearing
gradually to full weight bearing
– Regaining range of motion
– Muscle strengthening
SPINAL INJURY
&
NURSING CARE
 Anatomy
• 5 sections
– Cervical (7)
– Thoracic (12)
– Lumbar (5)
– Sacral (5)
– Coccyx (1)
Anatomy of the Spine
 Functions
• Spine
– Protection
– Motion
• Function of spinal cord:
part of central nervous
system
– Motor
– Sensory
– Autonomic
 Spine Injury
• Bone : fracture,
spondylolisthesis (slipped)
• Soft tissue : ligament
sprain, muscle strain, disc
problems
 Spine injury
• Spinal cord: complete/ incomplete
– contusion/ compression/ severed
– Infections / tumour/ neuron disease/ cord
syndromes etc
 Complications
• Late
– Autonomic dysreflexia (≥ T6 lesions)
– Infection : skin, bladder, lungs
– Decubitus ulcer
– Malnutrition & dehydration
– Deep vein thrombosis
– GI : constipation, cholecystitis, cholelisthiasis
– Contractures, spasticity
 Nursing Care
• Major objectives
– Prevent secondary complications
– Facilitate maximal functional recovery
– Support for patient & family
– Educate patient & family in all aspects of the care
needed to maintain his/her wellbeing
 Nursing care in convalescence home
• Posturing
– Support injured spine
– Maintain limbs & joints in functional position
• Avoid deformity & contractures
• Reducing incidence of spasticity
– Relieve pressure
 Posturing
• How ?
– Many ways – need to
suit patient &
availability and skill of
nursing staff
• Bed
• Pillows
• Balloons / gloves filled
with water
 Lifts and Turns
• Straight lifting
– For transferring & lifting patient to the side of the
bed for nursing care
Lifts and Turns
 Log roll
• For carrying out nursing care
• For lateral positioning
 Pelvic twist
• Suitable for
tetraplegic
• Must NOT be used
in thoracolumbar
lesions
 Posturing
• Important note!
– In all lifts and turns, the person holding the head
is in charge of the timing and coordination
– Frequency of turns – determined by patient’s
tolerance
• Initially 2 to 3 hourly
• With increasing intervals as long as no markings
 Care of the limbs
Legs
i. supine
– Avoid hyperextension of the knees
– Keep feet in line with the hips
– Hold foot at 90o using foot boards/ pillows
• Avoid pressure on the heels
ii. Side
- Lower leg should be extended
- Upper leg slightly flexed
- Lying on pillow & not over the lower leg
 Care of the limbs
• Arms
– Supine
• joints need to be placed in full range of positions
• Hands & arms must always be supported
– Side
• Both arms positioned forward, supported on pillows
• Underlying shoulder protected from pressure by gently
pulled forward/ axillary pillow
 Skin and Pressure
• Examine & relieve pressure regularly
• Skin inspection daily
• Aware of hazards of sensory loss
• Keep clean – bath, fingernails, toe nails, hair
• Avoid damage
• Conscious of pressure
• Risk higher in times of physical/ emotional stress,
depression, tiredness & intercurrentr illnesses
• Treat minor abrasions/ injuries
 Skin and Pressure
• Braden scale : predicting pressure sore risk
– Sensory perception
– Moisture
– Activity
– Mobility
– Nutrition
– Friction & shear
 Bladder management
• Prevent urinary tract infection
• Managing fluid balance
• Patient education – how to care for bladder
 Bladder management – fluid
management
• Intermittent
catheterization
(CIC)
• Aim: output < 500
mls/6 hours
• If volume > 600
mls/6 hours –
reduce intake or
perform more
frequent
catheterization
 Bladder management – fluid
management
• Suprapubic catheterization
(SPC)
• Aim: output of ≥ 3 L/day
• To maintain capacity, clamp
catheter daily to achieve a volume
of 300 mls
• Indwelling catheter (CBD)
• Aim: output of ≥ 3 L/day
• To maintain capacity, clamp
catheter daily to achieve a volume
of 300 mls
 Bowel care
• Upper motor neuron lesion
– Reflex emptying – after suppositories or digital
stimulation
– May not need laxatives if diet appropriate
• Lower motor neuron lesion
– Flaccid
– Manual evacuation & laxatives usually required but
may be able to empty using abdominal muscles
– Suppositories ineffective
 JOINTS
• Formed when two
ends of a bone come
together
• Holds the bones
together and allow
movement
Types of joint
 Arthritis
• Means “joint inflammation”
• Refers to more than 100 rheumatic diseases
and other conditions that can cause pain,
stiffness and swelling in the joints
• Can affect any type of joints, but most
commonly affect synovial joints