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Musculoskeletal

Terms in this set (124)

Kyphosis:
Increased curvature of the thoracic spine
Lordosis:
Exaggerated curvature of the lumbar spine
Scoliosis:
Lateral curvature of the spine
MS Assessment - Subjective Data
-Pain
-Altered Sensation (paresthesias)
MS Assessment - Objective Data
-Height & Weight

-Posture (scoliosis, kyphosis, lordosis)

-Gait: Antalgic Gait (gait shortened on injured side)

-Bone Integrity

-Joint Function: Range Of Motion (ROM). Passive (by examiner) or Active (by client).

-Muscle Strength

-Neurovascular Exam (color, temp, movement, sensation)
Laboratory Considerations
-Complete Blood Count (CBC)

-Serum Calcium & Phosphorus levels

-Alkaline Phosphatase (ALP)

-Erythrocyte Sedimentation Rate (ESR)
Imaging Procedures
-X-ray Studies

-Arthrography
•X-ray study of a joint after the injection of a contrast medium; note allergies!!

-CT Scans

-MRI
Nuclear Studies - Bone Scan
-A bone-seeking radioisotope is injected via a vein to visualize the entire skeleton.

-The scan is performed 1-3 hours later

-Assists in identifying bone cancer, bone infections (osteomyelitis), certain fractures

-Nursing Considerations:
•Verify pt is not pregnant pre-scan
•Encourage hydration post-scan
•Instruct client to empty bladder prior to procedure
Arthrocentesis (Joint Aspiration)
-A needle is inserted into joint; synovial fluid aspirated for laboratory test or for relief of pain due to effusions
Arthroscopy
-A fiberoptic scope (arthroscope) is inserted into a joint to allow direct visualization; used to diagnose & treat certain joint disorders

-Nursing Considerations (Post-Procedure)
•Frequent Neurovascular Exams
•Ice may be ordered to reduce edema & discomfort
•Activity restrictions depend on joint & physician's orders
Carpal Tunnel Syndrome
•Compression of the median nerve at the wrist within the carpal tunnel resulting in sensory &/or motor dysfunction
-Highest incidence between 30 & 60 years old
-A serious occupational heath problem

•Causes
-Repetitive hand movements *
-Wrist trauma (i.e. fracture)
-Other
º Pregnancy (later stages), arthritis, hypothyroidism & diabetes mellitus

•Clinical Manifestations
-Pain, numbness, tingling, burning sensations or weakness or difficulty grasping (pinching).
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome - Diagnostic Considerations
•Phalen's Sign
-Complete flexion of the wrists for one minute; Positive = Paresthesias.

•Tinel's Sign
-Light percussion over the median nerve; Positive = Pain & Tingling.
Phalen's Sign
Tinel's Sign
Carpal Tunnel Syndrome - Management
•Primary focus: treat the cause

•Supportive Therapies
-Wrist splints or braces for "rest"
-Ergonomics in the workplace
-Pharmacologic
ºNSAIDs
ºIntra-articular injections of corticosteroids (i.e. cortisone)

•Carpal Tunnel Release Surgery
-Endoscopic or open approach may be utilized to cut the carpal ligament to provide relief from symptoms
Osteoporosis
•Metabolic bone disorder in which the rate of bone resorption exceeds the rate of new bone formation resulting in decreased bone mass
-Bones become porous & brittle → prone to fractures
-A potential health problem for 44 million Americans
-The exact cause is unknown, but numerous risk factors have been established
Risk Factors For Osteoporosis
•Genetics
-Gender: Female
-Ethnicity: Caucasian or Asian
-Body Structure: Small-frame
-Positive Familial History

•Advanced Age (>60 years old)

•Nutrition
-Diet low in calcium & vitamin D
-Diet high in phosphates

•Lifestyle Choices
-Smoking
-Excessive consumption of alcohol or caffeine

•Physical Inactivity
-Sedentary lifestyle
-Prolonged Immobility

•Medications
-Corticosteroids
-Anti-seizure medications
-Aluminum cont. antacids

•Other Disorders
-Cushing's Disease
-Hyperparathyroidism
-Rheumatoid Arthritis
-Malabsorption Syndromes
Osteoporosis - Clinical Manifestations
•Bone Deformity
-Kyphosis (Dowager's hump)
-Diminished height

•Bone Pain

•Pathological Fractures
-Most common sites:
ºVertebral / Spine* (Often compression fractures)
ºHip (head of femur)
ºWrist (distal radius)
* Warmth, redness & new areas of pain may indicate recent fx
Osteoporosis - Diagnostic Considerations
•Bone Densitometry: estimation of bone mineral density (BMD)

1. Dual-energy x-ray absorptiometry (DEXA)
-Measure BMD at the wrist, hip, or spine
-Utilized to estimate extent of osteoporosis, monitor response to treatment

2. Quantitative Ultrasound Studies (QUS)
-Measures BMD from the heel bone
-Utilized to dx osteoporosis, establish the risk for fx (especially hip) for individuals with osteoporosis
Osteoporosis - Medical Management
•Diet
-High in protein, calcium & vitamin D
-Vitamin D & calcium supplements may be helpful

•Lifestyle
-Smoking cessation
-Avoid alcohol & carbonated beverages
-Participate in regular physical activity
ºEncourage weight-bearing activities (i.e. walking or jogging)
ºTeach to avoid high-impact activities

•Pain Management
-Analgesia: Tylenol or NSAIDs

•Hormone Replacement Therapy - controversial!
Osteoporosis - Pharmacology
1. Bisphosphonates
•alendronate (Fosamax) or ibandronate (Boniva)
-antiresorptive medicine, which means they slow or stop the natural process that dissolves bone tissue, resulting in maintained or increased bone density and strength

2. Selective Estrogen Receptor Modulators
•raloxifene (Evista)
-inhibits bone resorption and reduces the risk of vertebral fracture
Osteoporosis - Nursing Considerations
•Client Safety
-Careful handling of client
-Side rails up (maximum x 3)
-Nursing call bell within reach
-Protective devices (i.e. hip protectors)
Osteomyelitis
•An infection of the bone

•Causative Organisms
-Bacteria*, viruses or fungi

•Three modes of infection:

1. Contiguous
-Extension of a soft tissue infection
-Ex: surgical incision, pressure ulcer, gum infection

2. Exogenous
-Infectious organisms enters from outside the body
-Ex: puncture wounds, open fx, orthopedic surgery

3. Endogenous (Hematogenous)
-Infectious organism is carried by the bloodstream from another area of infection within the body.
-Ex: UTI's, long-term I.V. catheters
Individuals at high risk for osteomyelitis
-Children & older adults
-Poor nutrition
-Immunocompromised
-Chronic illness (i.e. DM & rheumatoid arthritis)
Two Types of Osteomyelitis
•Acute Osteomyelitis

•Chronic Osteomyelitis
-Often due to improper treatment of acute osteomyelitis
Clinical Manifestations of Osteomyelitis
1. Acute Clinical Manifestations
-Fever (>101º F)
-Bone Pain
-Tenderness, swelling, redness & warmth over the area

2. Chronic Clinical Manifestations
-Ulceration of skin
•Sinus tract formation
•Drainage
-Localized Pain
Chronic Osteomyelitis
Osteomyelitis - Diagnostic Considerations
•Bone Scan, MRI or Bone biopsy (definitive)

•Lab Studies
-Increased WBC counts
-Positive blood &/or wound cultures
Osteomyelitis - Management
•Osteomyelitis is extremely difficult to treat
-The infected bone becomes walled-off, blocking the body's natural immune responses & decreasing the amount of antibiotic that can penetrate the site
Osteomyelitis - Antibiotic Therapy
•Selected based on blood &/or wound cultures

•Usually I.V. antibiotics for 3 to 6 weeks; once the infection is controlled oral antibiotics are indicated for up to 3 months, possibly longer
-Teach importance of completing the prescribed course of antibiotics
Osteomyelitis - Supportive Therapies
-Ensure adequate hydration

-Encourage a diet high in protein & vitamins

-Immobilization of the affected area to decrease pain and prevent pathological fractures
Osteomyelitis - Surgical Management
•Incision & drainage (I &D) of bone abscess

•Sequestrectomy
-Surgical remove of the dead or infected bone & cartilage to allow for revascularization & healing

•Amputation?
Gout
•A disorder involving altered purine metabolism, resulting in the accumulation of uric acid in the blood

•Eventually leads to deposits of uric acid crystals in joints & other body tissues, causing pain & inflammation

-Causes: failure to excrete uric acid, over-production of uric acid, or a combination of both

-May affect any joint; often in foot or ankle

-Two types of gout:
ºPrimary Gout
ºSecondary Gout
Primary Gout
•Inherited defects in purine metabolism
-25% of all clients have a family history of gout
-Peak onset 30-40 years old
-More common in men than women
Secondary Gout
•Occurs as a result of another condition:

-Renal Disorders

-Hematopoietic Disorders
ºi.e. leukemia, multiple myeloma and some types of anemia

-Certain Medications:
ºi.e. aspirin, diuretics (thiazide) & chemotherapy agents
Gout: Clinical Manifestations
1. Asymptomatic Phase
•Elevated Uric Acid levels (hyperuricemia)
•No Symptoms
•Client may or may not progress to symptomatic disease

2. Acute Phase
•Sustained elevated Uric Acid levels
•Elevated erythrocyte sedimentation rate (ESR) & WBCs
•"Gouty Arthritis Attack"
-Asymmetrical joint pain, redness, warmth, swelling
-Pain is sudden & severe, usually occurs at night
-75% experience inflammation in the great toe (podagra) as an initial manifestation
Gout - Clinical Manifestations
3. Intercritical Phase
•Asymptomatic phase between acute gout attacks; may last for months to years.

4.Chronic Phase
•Occurs after repeated episodes of acute gout.
•Tophi (urate crystals deposits)
-Hard, irregular, yellowish-white nodules
-Most common sites: ears, hands & feet
•Urate kidney stones → May lead to kidney disease
Gout - Diagnostic Considerations
-Elevated serum uric acid levels (hyperuricemia)

-Synovial fluid positive for uric acid crystals
Gout - Management
•Encourage Fluids (2-3 liters/day), if w/o cardiac &/or renal disease

•Low-Purine Diet (controversial)
-Avoid shellfish, oily fish with bones (i.e. anchovies, sardines), red or organ meats (liver & kidney), certain vegetables (peas, lentils, spinach & asparagus)

•Avoid Alcohol

•Maintain a normal body weight; if needed weight loss should be done gradually.
Gout - Pharmacologic Therapies
•**Colchicine (Colsalide)
-Decreases inflammation

•**NSAIDs
-Reduce pain & inflammation

•Allopurinol (Zyloprim)
-Decreases uric acid production

•Probenecid (Benemid)
-Promotes excretion of excess uric acid
Rheumatoid Arthritis (RA)
•A chronic, systemic, progressive, autoimmune disorder causing widespread inflammation & destruction of joints; also can affect any organ or body system. (i.e. heart, lung & blood vessels)

•Women affected 2-3x times more than men

•Can occur at any age; most common in those between 25-50 years old

•Risk Factors
-Genetic Predisposition
-Infectious Factors (i.e. Epstein-Barr Virus)
Rheumatoid Arthritis - Clinical Manifestations
•Joint involvement is bilateral & symmetrical
-Joint Swelling, Redness & Warmth
-Joint Pain
-Joint Stiffness
***Worse in morning or after a period of inactivity; joint stiffness usually lasts more than 30 minutes
-Decreased ROM

•Associated Systemic Symptoms
-Fatigue, anorexia, weight loss, weakness, low-grade fever
RA - Late Clinical Manifestations
•Rheumatoid Nodules: Develop at pressure points; often on the elbows, hands or feet

•Joint Deformities
-Swan Neck
-Ulnar Deviation
-Boutonnière (buttonhole)
Rheumatoid Nodules
Rheumatoid Arthritis - Diagnostic Considerations
•X-rays: reveal demineralization of the bone, soft tissue swelling & extent of cartilage &/or bone erosion

•Lab Findings:
-Serum
ºPositive rheumatoid factor (RF)
ºPositive antinuclear antibody (ANA)
ºElevated erythrocyte sedimentation rate (ESR)

-Synovial Fluid
ºIncreased WBCs, immune complexes including RF
Rheumatoid Arthritis - Non-Pharmacologic Management
1. Diet
•Encourage a diet high in protein, vitamins & iron for tissue building & repair
•Anorexia: small frequent meals; protein supplements

2. Thermal Modalities
•Heat Therapy: To decrease joint stiffness & pain
-Teach: "hot" showers, baths, warm compresses or heating pads.
•Cold Therapy: For acute inflammation
Rheumatoid Arthritis - Non-Pharmacologic Management
3. Encourage Self-Care
•Do not automatically perform ADLs for client
•Be patient & do not hurry the client
•Assistive / Adaptive Devices
-High-toilet seat, long-handled brushes & dressing sticks

4. Physical Activity & Positioning
•Encourage ROM exercises
-Teach to stop exercise if pain increases
•Positioning joints to maintain functional alignment
•Orthotic Devices (splint or braces)
-To immobilize joint during periods of acute inflammation.
-Occupational therapy consult
•Ambulatory Assistive Devices (cane & walkers)
-Physical therapy consult
Rheumatoid Arthritis - Non-Pharmacologic Management
5. Fatigue
•Promote or Ensure Adequate Sleep
•Maintain Rest-Activity Balance
•Energy Conservation
-Pace activities
-Set priorities
-Allow rest periods
-Obtain assistance when needed

6. Body Image
•Assess reactions to body changes
•Encourage the client to verbalize feelings
Rheumatoid Arthritis - Pharmacologic Management
•DMARDs (Disease-modifying antirheumatic drugs)
-Methotrexate (Rheumatrex)
-Sulfasalazine (Azulfidine)

•Anti-malarials
-Hydroxychlooquine (Plaquenil) - watch for visual disturbances; retinopathy can occur even after discharging med

•Biologic/Targeted therapy
-Infliximab (Remicade) - PPD/CXR before starting; at risk for infection
-Etanercept (Enbrel) - risk for infection & HF

•Corticosteroids oral or intra-articular injections

•NSAIDs

•Gold Compounds - oral or parenteral
Rheumatoid Arthritis - Surgical Management
•Synovectomy
-Surgical excision of the damaged synovial membrane to help maintain function

•Total Joint Arthroplasty (TJA)
-AKA Total Joint Replacement Surgery
-A prosthetic system is used to replace the entire diseased joint
Osteoarthritis (OA): Degenerative Joint Disease (DJD)
•A chronic disorder causing slow & progressive deterioration & reformation of cartilage in one or more joints

-Classified as a non-inflammatory arthritis affecting the joint(s) only; no systemic response

-Most often affects weight-bearing joints (spine, hips and knees) & hands

-Most common form of arthritis & leading cause of disability among adults in the U.S.

-Highest incidence in post-menopausal women
Osteoarthritis - Risk Factors
-Advanced Age (> 60 years-old)
-Obesity
-Repetitive Joint Use
-Previous Joint Injury
-Anatomic Deformity
-Genetic Predisposition
Osteoarthritis - Clinical Manifestations
•Unilateral or Single Joint Involvement

•Joint Stiffness
-Worse in morning or after a period of inactivity; joint stiffness usually lasts < 30 minutes

•Joint Pain
-Often relieved by rest; aggravated with activity

•Decreased ROM

•Crepitus (continuous grating sensation)

•Joint Enlargement (boney hypertrophy)

•Boney Nodules
-Heberden's & Bouchard's Nodules (fingers)
Osteoarthritis - Non-Pharmacologic Management
•Weight Reduction
-Dietitian consult

•Thermal Modalities
-Heat Therapy:
ºPrimary thermal treatment in OA
ºDecreases joint stiffness & pain
ºTeach: hot showers, baths, warm compresses or heating pads

-Cold Therapy:
ºReserved for episodes of acute inflammation
Osteoarthritis - Non-Pharmacologic Management
•Rest / Positioning Therapy
-Promote or Ensure Adequate Sleep
-Maintain Rest-Activity Balance
ºTeach to stop exercise if pain increases
ºROM exercises

•Orthotic Devices (splint or braces)
-To immobilize joint during periods of acute inflammation
-Occupational therapy consult

•Ambulatory Assistive Devices (cane and walkers)
-Physical therapy consult helpful

•Positioning joints to maintain functional alignment
Osteoarthritis - Pharmacologic Agents for Pain
•Systemic Agents
-Analgesics: Acetaminophen → NSAIDs → Opioids (severe)
-Muscle Relaxants: i.e. cyclobenzaprine HCL (Flexeril)
-Alternative/complementary: i.e. Glucosamine & chondroitin supplements (check shellfish allergies)

•Topical Agents
-Capsaicin Cream (i.e. Zostrix)

•Intra-Articular Injections
-Corticosteroids (i.e. Cortisone)
-Hyalnuronic Acid (i.e. Hyalgan)
Osteoarthritis - Surgical Management
•Osteotomy
-An excision of a wedge of bone or the cutting of a bone to realign the joint & reduce joint stress

•Total Joint Arthroplasty (TJA)
-AKA Total Joint Replacement
-A prosthetic system is used to replace the entire diseased joint
-Contraindicated during acute inflammation, the presence of infection, or advanced osteoporosis
-Hips & knees most commonly performed
Joint Replacement (Arthroplasty)
•Severe joint pain & disability

•Joint degeneration*
-Osteoarthritis, rheumatoid arthritis, trauma, congenital deformity, avascular necrosis

•Knee, hip, finger most common

•Also shoulder, elbow, wrist, ankle

•Autologous blood transfusions common if elective procedure
Joint Replacement
•Joint implant (aka "prosthesis")
-Metal, high-density polyethylene material

•Cemented w/bone-bonding agent OR cementless (allows pt's bone to grow into the prosthesis)

•Outcomes:
-Excellent pain relief for most
-Return of motion/function depends on preop soft tissue condition & general muscle strength

•Early failure of joint replacement?
-Excessive activity, preop joint/bone pathology
Joint Replacement
•Pre-op: assess limb's neurovascular status
-Necessary to compare post-op

•Increased risk for post-op DVT & PE:
-Age, obesity, preop leg edema, hx of venous thromboemboli, varicose veins
-For total hip replacement pts > 60yrs, the above risk factors = *most common causes of post-op mortality*
Joint Replacement
•Assess pre-op for any s/s infection
-Increases risk for post-op infection

•Infections 2-4 wks before elective surgery may require postponing

•Strict adherence to aseptic technique in OR
-Airborne bacteria can contaminate wound, causing deep infections

•Persistent infection at site usually = removal of implant, joint revision
-May impair function of joint
Joint Replacement Goals
•Relieve pain
•Maintain adequate neurovascular function
•Enhance wound healing, skin integrity
-Watch nutrition, pressure points
•Improve mobility
-Support PT plan of care
•Maintain self-esteem; resume self-care asap
Total Hip Replacement (THR)
•Nursing interventions post-op:
-Prevent dislocation of hip prosthesis**
-Monitor for excessive wound drainage
-Prevent DVT
-Prevent infection
-Prevent skin breakdown (heels*)
-Prevent atelectasis, pneumonia
-Monitor for urinary retention
-Prevent constipation, fecal impaction
THR: Preventing Dislocation
•Maintain femoral head in acetabulum

•Teach pt to keep leg in abduction
-Use pillows, abduction pillow/wedge/splint →
-Maintain abduction with turning

•Never flex affected leg > 90 deg
-Do not ↑ HOB > 60 deg
-Install trapeze to bed
-Maintain while transferring & sitting
-While seated, hips should be higher than knees
THR: Preventing Dislocation
•AVOID:
-Adduction
-Acute flexion
-Internal or external rotation of joint
-Excessive weight-bearing
-Crossing legs
-Hyperextension
-Bending at waist

Above "hip precautions" often (x 4 mo, minimum)
THR: S/S Dislocation
-Increased pain at surgical site + swelling & immobilization

-Acute groin pain or increased discomfort on side of affected hip

-Shortening of affected leg

-Abnormal internal/external rotation

-Restricted ability or inability to move affected leg

-Reported "popping" sensation in affected hip

-Suspected dislocation? Notify surgeon STAT
THR: Other Nursing Intervention
•Monitor wound drainage (JP or Hemovac)
-Up to 500cc w/in 1st 24 hrs expected; should decrease to ~30cc q8h by 48 hrs post-op

•Prevent DVT
-Incidence = 45-70%; peak = 5-7d post-op
-20% develop PE (can be fatal)
-Promote circulation, decrease venous stasis

•Prevent infection (surgical site, osteomylelitis)
-Avoid long use of Foleys, other drains
-Prophylactic antibiotics for any future invasive procedure
-Surgical infections may not appear for up to 24 mo
Total Knee Replacement (TKR)
•Nursing interventions post-op:

-Maintain compression bandage (if ordered)

-Ice may be ordered to control edema, bleeding

-Use of Continuous Passive Motion (CPM) device →
Increases circulation, ROM of affected joint

-Assess neurovascular status of affected leg

-Monitor incisional drainage (JP or Hemovac)
º1st 24 hrs = up to 400 cc
ºMarkedly decreased by 48 hrs
TKR - Other interventions:
•Prevent complications
-Hypovolemic shock
-Thromboembolism
-Peroneal nerve palsy
-Infection (surgical site, osteomyelitis)
-Limited ROM
-Atelectasis, pneumonia
-Urinary retention
-Constipation, fecal impaction
-Joint dislocation?
Shoulder Replacement
•Traditional total shoulder replacement or the newer reverse total shoulder replacement procedure

-Ball/socket: traditional = ball attached to upper humerus, cup is fashioned to the socket

-With reverse procedure, the new joint is created in the opposite fashion, i.e., the ball is attached to the socket and a cup is attached to the upper humerus
-Reverse procedure relies on deltoid muscle, not rotator cuff muscles/tendons, for arm movement
MS Trauma - Contusion
•Soft tissue injury in which small blood vessels rupture & bleed into tissues (ecchymosis)
-If bleed is large enough a hematoma may develop

•Often caused by blunt force i.e. fall, blow, kick

•Clinical Manifestations:
-Pain, swelling, discoloration

•Management
-Intermittent cold applications
-Most resolve in 1 to 2 weeks
Strain
•Excessive stretching or tearing of muscle or a tendon

•Caused by overuse, overstretching or excessive muscle stress

•Clinical Manifestations:
-Soreness, or sudden pain & localized tenderness with muscle use
Sprain
•Injury to a ligament surrounding a joint, caused by excessive stretching
-Wrenching or twisting motion

•Clinical Manifestations:
-Joint instability, pain & swelling

•Degree of disability & pain increases during the first 2 to 3 hours after injury secondary to swelling or bleeding

•X-rays are needed to rule-out bone injury
Management of strains & sprains
•RICE
-Rest, Ice, Compression, & Elevation

•Frequent neurovascular checks

•Heat therapy maybe initiated 48 hours after the injury for 15-30 minutes QID

•Passive & active ROM usually can begin 2-5 days after injury

•Severe strains or sprains may require longer immobilization, splinting or even surgery
Joint Dislocation
•Dislocation
-Bones that meet at a joint become completely separated (or dislocated); = the bones are no longer in their normal anatomical position

•Subluxation
-Partial separation (or dislocation) of joint surfaces

•Clinical Manifestations
-Sudden, severe pain; changes in contour of joint, changes in length of the extremity, loss of normal mobility
Joint Dislocation Management
•Prompt medical treatment is required to prevent neurovascular compromise

-Reduction
ºRealignment of the bones to normal anatomical location; done to preserve joint function

-Immobilization
ºBandages, splints, casts or traction needed to maintain proper positioning

-Nursing Considerations
ºFrequent neurovascular checks!
Fracture (fx)
•A break in the normal continuity of the bone

•Causes
-Trauma: direct blows, crushing forces, sudden twisting motions, extreme muscle contractions

-Pathological fractures: osteoporosis or bone tumor
Manifestations of Fractures
-Pain!
-Loss of function
-Deformity
-Shortening of the extremity
-Crepitus
-Local swelling & discoloration, bruising
-Diagnosis by symptoms & x-ray
-Patient usually reports an injury to the area
Types of Fxs
•Complete
•Incomplete
•Comminuted
•Closed or simple
•Open or compound/complex
-Grade I: clean, < 1cm long
-Grade II: larger, w/o extensive soft tissue damage
-Grade III: highly contaminated, extensive soft tissue damage; the most severe
Fracture picture
Fracture picture
Depression Fx
Avulsion Fx
Compression Fx
Medical Management of Fxs
•Reduction ("setting" the bone)
•Re-align, fixate, immobilize

-Closed: external fixation using bandages, casts, splints, braces, traction, external fixators

-Open: internal fixation: surgical ORIF with metal, implanted internal fixation devices (pins, screws, nails, rods, plates, wires)
Medical Management of Fxs
•Maintain & restore function

•Control edema
-Elevate injured extremity, apply ice

•Assess neurovascular status
-Circulation, movement, sensation

•Isometric exercises
-Activity as ordered (w/ORIF, surgeon will determine how much movement & wt-bearing the bone can take)
Open Fxs
•Prevent infection!!!

-R/t osteomyelitis, tetanus, gas gangrene

-Tetanus prophylaxis, antibiotics, cleaning/debridement of wound

-Closure of the primary wound may be delayed to permit edema, wound drainage, further assessment, debridement if needed
Pins & External Fixators
-Used to manage open fractures with soft-tissue damage

-Provide support for complicated or comminuted fractures

-Discomfort usually minimal

-Early mobility may be anticipated with these devices

-Elevate extremity to reduce edema

-Monitor for signs & symptoms of complications including infection

-Provide pin care

-Patient teaching

-May be used with traction
Casts
•Rigid, external immobilizer: joints proximal & distal to the affected area are immobilized
-Arm, leg
-Spica: body (immobilizes spine); hip, shoulder
-Watch for cast syndrome
ºPsychologic, physiologic changes r/t cast confinement

•Fiberglass, plaster, or "air" casts
-Fiberglass (Non-plaster) Casts
ºWater resistant, lighter, stronger & more durable than plaster
ºDries within minutes

-Plaster Casts
º24-72 hours to dry; while damp ensure the cast is not dented; do not cover with clothing or bed linens

-Air casts = on/off, secures with velcro straps
Cast Care
•Plaster? cushion rough edges

•Assess for pain s/p cast: take seriously
-Could be d/t impaired tissue
perfusion or pressure ulcer

•Instruct
-Keep cast clean, dry
-Nothing in/under cast
-Report persistent pain, swelling
-Report signs of infection or pain over pressure areas
-Report changes in sensation, movement, skin color, skin temperature
Cast Management
•Frequent Neurovascular Exams!

•Relieving Pain
-Elevation of the affected extremity
-Applying cold therapy as prescribed
-Administering analgesics

•Improving Mobility
-ROM of every joint that is not immobilized

•Monitor for Infection
-Watch: odors from cast, purulent drainage stains on cast as well as s/s of systemic infection
Compartment Syndrome (compartment = area of body encased by bone or fascia)
•Increased pressure within a limited space; this could be a muscle compartment or d/t a cast resulting in compromised circulation & loss of tissue function

•Clinical manifestations
-6 Ps: pain, paralysis, paresthesias, pallor, pulselessness, poikilothermia
-**Hallmark sign of acute CS: pain that occurs or intensifies with passive ROM
-Pain is deep, throbbing, unrelenting; usual doses of analgesics/narcotics do not help - call doctor STAT
Compartment Syndrome Treatment
•Do not ↑ affected part above heart level, remove restrictive devices (e.g., a cast), possibly surgery

-Bivalve the cast: cut in half longitudinally to relieve pressure; continue to ensure proper alignment.

-If pressure is not relieved & circulation not restored a fasciotomy may be necessary to relieve pressure from within the muscle compartment
Traction
•Definition: Pulling force that is applied to part of an extremity while a countertraction pulls in the opposite direction.

-Used to reduce, realign & immobilize fractures
-Also reduces deformity, minimizes muscle spasms
-Often a short-term therapy until other modalities such as external or internal fixation are possible
Traction - Key Principles
-Traction must be continuous to be effective
-Skeletal traction is never interrupted
-Weights are not to be removed without an order
-The client must be in the center of the bed & in good body alignment when traction is applied
-Ropes must be unobstructed
-Weights must hang freely & not rest on the bed or floor
-Knots in the rope or footplate must not touch the pulley or the foot of the bed
Straight (Running) Traction
•Applies a pulling force in a straight line with the affected limb resting on the bed
-Body acts as counter-traction; therefore body or bed position changes can alter the counter-traction force
Balanced Suspension Traction
•Exerts pull & support of the affected limb in a hammock held in place by balanced weights attached to overhead bars
-Counter-traction achieved by the system of ropes, pulleys & weights; allows for some client movement without disruption of the line of pull
Skin Traction
•A weight is used to create pull on a device attached to or in contact with the skin
•Cervical Head Halter
•Pelvic Traction

•Buck's Extension Traction
-A type of straight (running) traction
-Unilateral or bilateral skin traction of the lower leg
-Use for proximal hip fractures prior to surgical intervention
-Client's body weight serves as counter-traction
-Weight limited to 5-10 pounds
Buck's Extension Traction
Skeletal Traction
•Traction is applied directly to the bone by means of metal wires, pins or tongs
-Pin site inspection & give pin care Q8h
-Risk of osteomyelitis

•Often balanced suspension traction used
•Weight may be heavier 15-30 pounds
Balanced Skeletal Traction
Traction Complications (for all classifications)
-Pressure Ulcers
-Pneumonia
-Constipation
-Urinary Stasis
-Venous Stasis → Deep Vein Thrombosis (DVT)
Early Complications of Fxs
-Shock: hypovolemic
-Fat embolism (typically w/in 24-72 hrs of injury)
-DVT
-Compartment syndrome
Later Complications of Fxs
•Avascular necrosis
-Bone loses blood supply & dies; may occur after fx, dislocation, prolonged steriod therapy, chronic renal disease

•Delayed union, nonunion

•Reaction to internal fixation devices
-Usually kept in place unless pain & decreased function r/t device

•Complex regional pain syndrome (CRPS)
-Painful SNS problem; more common w/upper extremity trauma & in women; can be chronic

•Heterotrophic ossification
-Abnormal bone formation; adjacent muscle painful; muscular contraction & movement are limited
Amputations
•The removal of all or part of an extremity

•Goals: To provide relief from symptoms, improve function, save life, or improve QOL

•Disorders associated with amputation
-Peripheral vascular disease (PVD), trauma, chronic osteomyelitis, congenital deformities, malignant tumors

•Often performed at the most distal point at which healing will be successful.
•Level of amputation is determined by:
-Circulation
-Functional usefulness
Amputation - Post-Operative Management
•Closed Rigid Casting Dressing
-Provides uniform compression, support to soft tissue, controls pain & prevents contractures
-Lower extremity amputations: cast may be fitted with a prosthesis for early post-op ambulation

•Soft Dressing
-Along with a compression bandage (ACE wrap) may be used if there is significant wound drainage &/or frequent inspection of the stump
-Often with a below-the-knee amputation (BKA) a knee immobilizer is used to prevent flexion contracture; with AKA, prevent contracture through positioning
Amputations: Management
Post-Operative Nursing Considerations:

•Relieve pain
-Pharmacologic & non-pharmacologic interventions
-Phantom pain

•Promote wound healing
-Gentle handing of the residual limb
-Aseptic technique with dressing changes
-Residual limb shaping
-Stump wrapping
-Elevation of the stump

•Prosthesis
-Support the client through fitting, application, utilization & care of prosthesis
Amputations: Management
•Enhance Body Image
-Encourage the client to look at, feel & eventually care for the stump

•Assisting to resolve grief
-Listen, be supportive, encourage expression of feelings, maintain a positive environment

•Promoting independent self-care
-Assist in achieving physical mobility
Daily OT / PT; ROM & strength training exercises
Amputations: Monitor for Complications
Hemorrhage
Infection
Skin Breakdown
Joint Contractures
Phantom Limb Pain
-IT IS REAL PAIN !
Rhabdomyolysis
•The breakdown of muscle fibers that leads to the release of the protein myoglobin (muscle fiber contents) into the bloodstream
-Myoglobin can damage the kidneys

•May be caused by any condition that damages skeletal muscle
-Trauma, crush injuries, severe exertion, seizures, drugs (statin drugs, cocaine, etc)

•Treatment includes increasing fluid intake to flush myoglobin out of kidneys
Rhabdomyolysis S/S
-Abnormal urine color (dark, red, or cola colored)
-Decreased urine production
-General weakness
-Muscle stiffness or aching, tenderness, weakness
-May also see fatigue, joint pain, seizures, weight gain
Blast Injuries
•4 types of blast injuries:
-Primary
-Secondary
-Tertiary
-Quaternary
Primary Blast Injuries
•Typically affect gas-filled organs: auditory^^, pulmonary**, GI systems

•Injuries d/t effect of over-pressurization wave on body
-Includes "spalling" = shock wave travels from one type of tissue to another...waves create tears b/t the 2

•Blast lung injury, tympanic membrane rupture, middle ear injury, abd hemorrhage & perforation; may also see concussion
Secondary Blast Injuries
-Result from flying debris & bomb fragments, other projectiles
-Can affect any body part
-Penetrating ballistic or blunt force injuries, ocular injuries
Tertiary Blast Injuries
-Occur as a result of individuals being thrown by the blast wind
-Victims may tumble along the ground surface or be thrown through the air, striking other objects, resulting in blunt or penetrating trauma
-Can affect any body part
-Typically see fractures, traumatic amputations, closed & open brain injury
Quaternary Blast Injuries
•Any explosion-related injury, illness, or disease not due to primary, secondary, or tertiary mechanisms
-Includes exacerbations/complications of pre-existing illnesses

•Also includes burns (flash, partial, & full thickness) & smoke inhalational injuries
-Temperatures from the explosive gases can reach 3000 deg C.
-Victims close to the detonation can sustain fatal third-degree burns

•Can affect any body part

•Can also see crush injuries; Closed and open brain injury; Asthma, chronic obstructive pulmonary disease, or respiratory illnesses related to dust, fumes, toxic smoke
Blast Injuries: General Management
-Effective triage is essential

-Injuries associated with early mortality, in order:
•Multiple trauma, head trauma, thoracic injury, abdominal injury

-Initially: ABCs of trauma care = airway, breathing, circulation

-Thorough PE, full exposure

-Labs: CBC, lytes, type/cross for blood tx
*Orthopedic Injuries* d/t Explosions
•The result of primary, secondary, or tertiary or combo

•Shrapnel wounds create soft tissue damage, often open fxs
-Combined with environmental debris = contaminated wounds/fxs

•Watch for compartment syndrome, rhabdomyolysis w/musculoskeletal injuries

•High risk for tetanus, gas gangrene
Other Injuries d/t Explosions
•Ocular

•Burns
-Thermal
ºPartial thickness, full thickness
-Caustic chemical burns
-Electrical burns
-Related inhalation injuries

•Human remains shrapnel
-Hep B, HIV
-Infect victims
Systemic Lupus Erythematosus
•SLE is a chronic multisystem inflammatory disease with immune system abnormalities
-The etiology of abnormal immune response is unknown; a genetic influence is suspected

•Extremely variable in its severity, ranging from a relatively mild disorder to one that is rapidly progressive, affecting many organ systems

•Commonly affected organ systems: skin (butterfly rash over nose, cheeks), musculoskeletal (polyarthralgia with morning stiffness), pulmonary (tachypnea), cardiac (dysrhythmias), CNS (seizures), & renal (nephritis)
Systemic Lupus Erythematosus
•Other s/s include anemia, mild leukopenia, thrombocytopenia

•Infection is a major cause of death

•A major treatment challenge is to manage active disease while preventing treatment complications that cause long-term tissue damage

•Meds:
-NSAIDs for mild polyarthralgias or polyarthritis
-Corticosteroids are given for severe SLE
-Antimalarial agents & immunosuppressive drugs may also be used

•Nursing care emphasizes health teaching & patient cooperation for successful home management
Fibromyalgia Syndrome
-FMS is a chronic disorder characterized by widespread, non-articular musculoskeletal pain & fatigue with multiple tender points

-Non-restorative sleep, morning stiffness, irritable bowel syndrome, &/or anxiety may be noted

-A disorder of central nervous processing with neuroendocrine/neurotransmitter dysregulation

-Treatment is symptomatic & requires a high level of patient motivation, including rest, medication, relaxation strategies, & massage
Chronic Fatigue Syndrome
-CFS, also called chronic fatigue & immune dysfunction syndrome, is a disorder characterized by debilitating fatigue

-The etiology & pathology are largely unknown

-Often difficult to distinguish between CFS & FMS, as many of the clinical features are similar

-There is no definitive treatment; supportive management is essential

-Does not appear to progress; most patients recover or at least gradually improve over time
THIS SET IS OFTEN IN FOLDERS WITH...