Musculoskeletal System

Care of Clients with Problems Related to the Musculoskeletal System Earl Francis R. Sumile, RN Instructor, College of Nursing University of Santo Tomas

Diagnostic Procedures •

Radiologic studies X-rays Computed tomography or CT scan – Non- invasive procedure where a body part can be acanned from different angles with an x-raybeam and a computer calculates varrying tissue densities and records a cross section image on paper done to determine extent of fracture in difficult to define areas

Diagnostic Procedures a. Myelography • Injection of radioopaque dye into subarachnoid space at posterior spine to determine level of disc herniation or site of tumor

Diagnostic Procedures Arthrography

1. •

Radioopaque or air injected into joint cavity- outines soft tissue structure and contour of joint

Bone scanning

2. •

Parenteral injection of bone seeking radioactive isotope

Electromyography

3. •

Graphic presentation of the electrical potential of muscles

Diagnostic Procedures Magnetic Resonance Imaging •

Noninvasive scanning technique that uses magnetism and radiofrequency waves to produce cross-sectional images of body tissues on computer screen

2. Arthroscopy • Endoscopic direct visualization of joint, especially knee

Diagnostic Procedures Arthrocentesis

1. •

Needle aspiration of synovial fluid

Bone Biopsy or Muscle biopsy 3. Laboratory 2.

a. Uric acid b. Antinuclear antibody (ANA) for systemic Lupus Erythematosus c. Complement fixation (CF) for Rheumatoid Arthritis d. Calcium, Alkaline Phosphate, Phosphorus

Musculo-Skeletal Therapeutic Modalities Reduction

• •

Realigning an extremity into anatomical position

c. Open- use of surgical methods d. Closed- use of non-surgical methods; manipulation

Musculo-Skeletal Therapeutic Modalities 1.

Immobilization  

Manual Skin- adhesive- plaster or adhesive is applied longitudinally on the lower extremeties and an elastic bamndage applied in an spiral motion

Musculo-Skeletal Therapeutic Modalities 1. Bryant’s traction- indicated for children

aged 0-3 year’s not more than 40 lbs. 1.Traction is always applied on both ends

Nursing Responsibility – Nurse should be able to pass hand between the patient’s buttocks and mattress

Bryant traction

Knee slightly flexed

Buttocks sightly elevetated and clear of bed

Musculo-Skeletal Therapeutic Modalities Buck’s Extension Traction Indicated for older patients to those weighing over 40 lbs.

Nursing Responsibility Only the affected extremity is placed on traction

Buck’s Extension Traction

Musculo-Skeletal Therapeutic Modalities Dunlop Traction Used in affectations of the upper extremities

Dunlop Traction

Nursing Care of Clients with Adhesive Traction • • •

Unwrap and wrap and elastic bandage at least once a shift Check skin integrity for allergic reactions to plaster Note circulation, sensation and mobility of the affected extremities

Skin- non adhesive  Uses canvass or cloth that is applied on the

patient’s skin Pelvic girdle traction

• Applied like a girdle and connected to two ropes with weights that hangs at the foot part of the bed • Indicated for low back pain

Head Halter Traction • Applied on chin and occipital region connected to a hanger with weights that hangs at the head part of the bed • Usually indicated for cervical spine affectations

Skin- non adhesive traction Cotrel Traction • Combination of the head halter and pelvic traction used in scoliosis

Russell Traction • Permits patient to move freely in bed and permits flexion of the knee and hip joint • Buck’s extension and the knee is suspended in a sling to which a rope is attached

Russell Traction

Nursing Care of Clients with nonadhesive traction Rest period are provided

Skeletal Traction  Applied into a bone

Crutchfield Skeletal Traction • Applied into the parietal; bones Indicated for cervical spine affectations

Crutchfield Tong

Skeletal Traction Balanced Skeletal Traction • Applied alone or with skeletal traction to promote patient mobility

Balanced Skeletal Traction

Principles of Care • • • • •

The patient should always be on either supine or dorsal recumbent position The should always be an counteraction (patient’s weight) The line of deformity should be in line with the traction Traction should be continuous There should be no friction within the line of traction

b. Cast- Comparison of Cast Materials Plaster

Synthetic

Material

Plastc of Paris, comprised of powdered calcium sulfate crystals impregnated into the bandages

Polyester and cotton, fiberglass or plastic. Polyester and cotton is impregnated with wateractivated polyurethane resin

Drying time

24-48 hours

7-15 mins of setting 15-30 mins for weight bearing

Advantages

Less costly More effective for immobilizing severely displaced bones Smooth surface Does not require expensive equipment for application

Less likely to indent into skin Lighter in weight Less restrictive Does not crumble Nonabsorbent Can be immersed in water

c. Braces • Knight-taylors • For thoraco-lumbar affectations • Milwaukee • For scoliosis

Nursing Care • Use cotton clothing as barrier

d. Fixators • RAEF • Roger Anderson External Fixator • Ilizarov device • Indicated for comminuted fractures

3. Rehabilitation Active or dynamic program aimed at enabling an ill or disabled to achieve the highest level of physical, mental, social, and economic self-sufficiency of which he is capable

Members of the Rehabilitation team a. b. c. d. e.

Patient • Key member of health team Rehabilitation nurse • Develops plan of patient care Physician • Makes medical diagnosis; directs team Physiatrist • Physician specialist in physical medicine Physical Therapist • Teaches or supervises patient in prescribed exercise program

Members of the Rehabilitation team a. Psychologist • Helps patient or family explore feelings b. Occupational Therapist • Helps develop skills for home and work situations c. Social Worker • Assists patient and family adjust socio-economically d. Vocational Counselor • Tests patient’s interest and aptitudes e. Rehabilitation Engineer • Uses technology in designing or constructing devices to help the handicapped

Transfer and Assistive Devices transferring a client from bed to stretcher

• •

stretcher must be perpendicular to bed

transferring a client from bed to wheelchair

• •

the wheelchair must be parallel to the head of the bed

Canes

• • •

Height of cane is from floor to waist level Cane is held by opposite the affected extremity

Transfer and Assistive Devices 1. Crutches • Height of crutch is from floor to axilla minus 2 inches • Patient’s weight is borne by the palm, of the hand and not on the axilla • When going upstairs, unaffected leg first • When going upstairs, affected leg first

Crutch-walking techniques Two point gait (two alternate gait) Three point gait Four point gait Swinging crutch gaits • Both legs are lifted off the ground simultaneously and swung forward while patient pushes up on crutches

• Swing-to gait • Lift and swing body up to crutches • Swing-through gait • Lift swing body beyond crutches

Exercises a. Isometric • Alternate contraction and relaxation of the muscle without moving the joint b. Done on the affected extremity

Isotonic • •

Range of motion exercises Done on the unaffected extremity

Heat or Cold Application in Trauma Cold Application • first 24 hours • To decrease hemorrhage • To relieve pain • To reduce inflammation

Heat Application – After 24 hours – To relieve pain from muscle spasms – To reduce swelling by increasing circulation – To promote healing by increasing oxygenation

4. Orthopedic Operative Procedures a. Arthrotomy

– Surgical opening into a joint b. Arthrodesis – Fixation of a joint c. Spinal fusion – Surgical removal of 1 or more vertebra and fusing them together

4. Orthopedic Operative Procedures a. Hip replacement

– Placement of prosthesis on the hip joint – Indication Hip fracture Inability to move leg voluntarily Shortening and external rotation of the leg

Nursing Management on Hip Replacement Avoid positioning on the operative site Maintain abduction of hip Pillows between legs Provide chair with firm, non-reclining seat and arms

Nursing Management on Hip Replacement Avoid hip flexion beyond 60 degrees for 10 days Avoid hip flexion beyond 90 degrees from day 10 to 2 months Avoid adduction of the affected leg beyond midline for 2 months Partial weight bearing status for 2 months

Trauma Contusion – Injury to the soft tissue produced by blunt force

Sprain – Injury to the ligamentous structures caused by wrenching or twisting – Forcible hyperextension of a joint with tissue damage like whiplash injury

Trauma Strain – Tearing of musculotendenous unit caused excessive stretching Dislocation – Joint articulating surfaces are partially separated – No longer in anatomical contact Fractures – Break on continuity of bone

Nursing Assessment •

Pain – Increasing until immobilized

Loss of function Localized swelling or discoloration Deformity Crepitus – Grating sound

General Classifications of Fractures •

Simple or closed – Skin is intact over fracture site

•

Compound or open – With an external wound in contact with the underlying fracture

•

Complete – Entire cross section is displaced

•

Incomplete – Portion of cross section undisplaced

General Classifications of Fractures •

Greenstick – One side broken and other bent

•

Transverse – Straight across the bone

•

Oblique – Angle or slanting across the bone

•

Spiral – Twisting or coils around shaft

•

Comminuted – Splintered into several fragments

General Classifications of Fractures Depressed – Fragments are drived-in; facial or skull Compression – Fractured bone compressed by another bone; vertebra Impacted – Fractured bones are pushed into each other (telescoped) Displaced – Fragments are separated from fracture line Linear – Fracture parallel with long axis

COMPARING ARTHRITIS Rheumatoid

Osteoarthritis

Gouty

Etiology

Autoimmune + Rh factor

Degenerative senescence

Metabolic or familial purine metabolism

Incidence

35-45 women

Men or more in women

Men over 40

Signs and symptoms

Subcutaneaous nodules Morning stiffness Swan neck deformity

Heberdens nodule

Tophi

Areas affected

Joints of hands

Weight bearing joint

Great toe

Management

Aspirin, NSAIDs Paraffin bath

Symptomatic

Colchicine Avoid purine diet Allopuyrinol