Musculoskeletal Disorders Care Of Client With Fall 2005

Care of client with musculoskeletal injury or disorder

What can go wrong 

Fractures  

   

Hip Mandible

Degenerative joint disease Osteoporosis Herniated disc Amputation

CONCEPTS: FRACTURES Reduction/Realignment Immobilization Nursing care Prevention and early detection: 

complication

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Realignment=Reduction 

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Correct bone alignment goal: restore injured part to normal or near-normal function Closed vs. open reduction Open reduction = surgery

Immobilization: to maintain alignment    

Cast Traction External fixation Internal fixation

CASTS

Casts  

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External, circumferential Thermochemical reaction = warmth Nursing care:    

No weight bearing 24-72 hours “flat hands” Elevate Neuro-vascular checks

CASTS

Cast: Client/Family Teaching   

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Keep dry No foreign objects in cast No weight bearing until MD order (at least 48 hour) Elevate above heart (48 hours) Signs of problems to report  

Pain, tingling, burning Sores, odor

External fixation   

Metal pins inserted into bone Pins attach to external rods Nursing care:     

Assess for s/s infection Teach pin care: ½ H2O2+ ½ H2o Open reduction: assess incision Elevate Neurovascular checks

EXTERNAL FIXATION

Internal Fixation 

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Pins, plates, screws surgically inserted Nursing care:  

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Assess incision site MD orders: activity, weight bearing, ROM, Assess s/s infection; temp. q 2-4 hours Neurovascular checks: 

INTERNAL FIXATION

Traction 

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Pulling forces: traction + countertraction Purpose(s):    

Prevent or reduce muscle spasm Immobilization Reduce a fracture Treat certain joint conditions

Types of Traction 

Skin   

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Buck’s Russell’s Bryant’s (“babies cry with Bry”)

Skeletal Balanced suspension (Lewis, 1660-1661) 

Nursing Concerns/Interventions  

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Assess neurovascular status Assess skin (bony prominences, under elastic wraps, etc.) Assess pin sites (skeletal tx) Maintain correct body alignment Weights hang freely Hazards of immobility

TRACTION

SKIN TRACTION

BUCK’S TRACTION

SKELETAL TRACTION

Nursing Diagnoses  

  

Neurovascular dysfunction, risk for Acute pain, R/T edema, muscle spasms, movement of bones Infection, risk for Impaired skin integrity, risk for Impaired physical mobility

Complications of Fractures    

Compartment syndrome Fat embolism Venous thrombosis Infection

COMPARTMENT SYNDROME 

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FACIOTOMY – wound is left open If no improvement, amputation

Hip Fracture 

In 1999 (USA) hip fractures resulted in approximately 338,000 hospital admissions

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Up to 25% of community-dwelling older adults who sustain hip fractures remain institutionalized for at least a year

Hip Fractures 

One-third of older women who fracture their hip will die within a year because of lengthy convalescence that makes them susceptible to complications, like lung and bladder infections.

The Lancet 1999;353:878-82

Fracture of hip Types of hip fractures (Lewis pg. 1675): 

Intracapsular   

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Capital Subcapital Transcervical

Extracapsular  

Intertrochanteric Subtrochanteric

ORIF vs “Total Hip” Open reduction/internal fixation:  pins, screws, plate(s) Total hip:  endoprosthesis – replace femoral head

Internal fixation = immobilization

Nursing Care 

 

Risk for peripheral neurovascular dysfunction Pain Impaired mobility:   

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Prevent thrombus Safety Constipation

Risk for impaired skin integrity:  

Immobility Incision

Femoral head prosthesis (total hip) 

Prevent dislocation:     

Do not flex > 90 degrees No internal rotation (toes to ceiling) Maintain abduction Do not position on operative side Patient teaching:   

Precautions for 6-8 weeks Notify dentist: prophylactic antibiotics Lewis: pg. 1678

Fracture of mandible  

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Trauma vs. Therapeutic Immobilization: wiring, screws, plate(s) Nursing care:    

Airway (Cutter with client) Oral hygiene Nutrition Communication

What can go wrong 

Fractures  

   

Hip Mandible

Degenerative joint disease Osteoporosis Herniated disc Amputation

Degenerative Joint Disease: Osteoarthritis  

Not normal part of aging process Cartilage destruction:     

Trauma Repetitive physical activities Inflammation Certain drugs (corticosteroids) Genetics

Assessment       

Location, nature, duration of pain Joint swelling/crepitus Joint enlargement Deformities Ability to perform ADL’s Risk factors Weight (history of obesity)

Nursing Interventions  

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Pain management Rest with acute pain; exercise to maintain mobility Splint or brace Moist heat Alternative therapies 

TENS, acupuncture, therapeutic touch

Surgical management: total joint arthroplasty (replacement) 

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Elbow, shoulder, hip, knee, ankle, etc. Pre-operative teaching: 

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“What to expect” (CPM, abduction pillow, drains, compression dressing, etc.) Postoperative exercises: quad sets, glute sets, leg raises, abduction exercises Pain management: 

PCA

Total Joint Arthroplasty 

Post-operative care:     

5 P’s Observe for bleeding Pain management Knee: CPM Check incision for s/s infection

Total Joint Arthroplasty 

Postoperative Care Prevent:   

Dislocation Skin breakdown Venous thrombosis (DVT)   

TED/Sequential compression Anticoagulants Exercises: plantar flexion, dorsiflexion, circle feet, glute & quad sets

Osteoporosis  

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Primary – often women postmenopause Secondary – corticosteroids, immobility, hyperparathyroidism Bone demineralization = decreased bone density Fractures:   

Wrist Hip Vertebral column

Silent disease     

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Dowager’s hump (kyphosis) Pain Compression fractures Spontaneous fractures X-ray can not detect until > 25% calcium in bone is lost Diagnosis: bone density ultrasound

Interventions   

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Hormone replacement Calcium & vitamin D Calcitonin, Fosamax, Actonel, Evista Avoid alcohol and smoking Daily weight bearing, sustained exercise (walking, bike) Safety in home (throw rugs, pets,

What can go wrong 

Fractures  

   

Hip Mandible

Degenerative joint disease Osteoporosis Herniated disc Amputation