MUSCULOSKELETAL

Strains and Sprains:

  • Strain involves excessive stretching of a muscle or tendon, while a sprain involves excessive stretching of a ligament.
  • Management includes cold and heat application, exercise with activity limitations, anti-inflammatory medications, and muscle relaxants.
  • Severe strains may require surgical repair, while moderate sprains may need casting.
  • Rest, ice, and compression bandages are used to manage sprains.

Rotator Cuff Injury:

  • Involves tears in the tendons connecting the muscles and bones of the shoulder.
  • Management includes nonsteroidal anti-inflammatory medications, physical therapy, sling support, and ice/heat application.
  • Surgery may be necessary for severe tears.

Fracture:

  • A break in the continuity of a bone.
  • Can result from trauma, muscle spasm, bone disease, or osteopenia.
  • Assessment findings may include:
    • Pain or tenderness over the affected area.
    • Decrease or loss of muscle strength or function.
    • Obvious deformity.
    • Erythema, edema, ecchymosis.
    • Muscle spasm or neurovascular impairment.
  • In children, fractures are often due to increased mobility and inadequate motor and cognitive skills.
  • Fractures in infancy are rare and may require investigation to rule out child abuse.

Abuse:

  • Nonaccidental physical injury or act of omission of care by a parent or caregiver.
  • Includes neglect, physical, sexual, or emotional maltreatment.

Fracture Initial Care:

  • Immobilize the affected extremity.
  • For compound fractures, splint the extremity and cover the wound with a sterile dressing.
  • Treatment options include reduction (closed or open), fixation (internal or external), casting, and traction.

Reduction:

  • Procedure to restore a bone to its proper alignment.
  • Closed reduction: Manual manipulation by a healthcare provider.
  • Open reduction: Surgical intervention with possible use of internal fixation.
  • Monitor for signs of infection if open reduction is performed.
  • Provide pain medication as prescribed.

Internal Fixation:

  • Stabilization of a fracture using screws, plates, pins, or nails.
  • External Fixation: Stabilization with an external frame secured with pins through the bone.
  • Monitor for signs of infection and provide pain medication as prescribed.

Traction:

  • Application of force in two directions to reduce and immobilize a fracture.
  • Types: skin traction and skeletal traction.
  • Skin traction uses elastic bandages or adhesives.
  • Skeletal traction involves pins, wires, or tongs.
  • Nursing considerations include proper body alignment and monitoring for complications.

Types of Skin Traction:

  • Cervical (Head Halter) Skin Traction: Relieves muscle spasms in the upper extremities and neck.
  • Buck’s Skin Traction: Alleviates muscle spasms in the lower extremity.
  • Russell’s Skin Traction: Relieves low back, hip, or leg pain.
  • Ensure proper application and monitor for complications.

Balanced Suspension and Dunlop Traction:

  • Balanced Suspension: Used to approximate fractures of the femur, tibia, and fibula.
  • Dunlop’s Traction: Aligns fractures of the humerus.
  • Maintain proper positioning and provide pin care if used in skeletal traction.

Casts:

  • Plaster or fiberglass device to immobilize a bone or joint.
  • Elevate the cast and extremity.
  • Allow time for drying (24 to 48 hours for wet cast).
  • Handle wet cast with palms until dry, maintain smooth edges.
  • Monitor for circulatory impairment, drainage, and infection.
  • Teach clients about cast care, exercises, and keeping the cast clean and dry.

Fat Embolism:

  • Sudden release of fat into the circulation, potentially obstructing blood flow in a vessel.
  • Often originates in bone marrow after a fracture.
  • Clients with long-bone fractures, especially, are at high risk.
  • Typically occurs within 48 hours of injury.
  • Assessment findings may include:
    • Signs of pulmonary embolism.
    • Restlessness.
    • Mental status changes.
    • Tachycardia.
    • Tachypnea.
    • Hypotension.
    • Hypoxemia.
    • Dyspnea.
    • Petechial rash over the upper chest and neck.
  • Nursing Interventions:
    • Notify the primary healthcare provider immediately if fat embolism is suspected.
    • Provide treatment for signs/symptoms (e.g., administer oxygen) to prevent respiratory failure and death.

Compartment Syndrome:

  • Compartment Syndrome:

    • Condition with increased pressure in a confined anatomical space, leading to reduced blood flow, ischemia, and tissue dysfunction.
    • Early signs: pain, pallor, paresthesia, muscle weakness, loss of pulses.
    • Progression can lead to necrosis and permanent muscle cell damage.
    • Irreversible neuromuscular damage occurs within 4 to 6 hours.
    • Assessment findings:
      • Unrelieved or increased pain and swelling.
      • Pale, dusky, or edematous tissue distal to the affected area.
      • Pain with passive movement.
      • Loss of sensation (paresthesia).
      • Pulselessness (a late sign).
    • Nursing Interventions:
      • Do not elevate the extremity above heart level.
      • Avoid applying compresses to prevent worsening vasoconstriction.
      • Monitor for signs/symptoms of compartment syndrome.
      • Instruct the client to immediately report pain or paresthesia.
      • Notify the primary healthcare provider promptly if suspected.

Infection and Osteomyelitis:

  • Infection of bones can occur after introducing organisms into bone tissue.
  • Assessment findings include fever, erythema, and pain.
  • Aggressive antibiotic therapy, hyperbaric oxygen therapy, and surgery may be required.

Avascular Necrosis:

  • Interruption of blood supply to bone tissue can lead to bone death.
  • Assessment findings include pain and diminished sensation.
  • Removal of necrotic tissue may be necessary.

Hip Fracture:

  • Hip fractures can be intracapsular or extracapsular.
  • Signs/symptoms include severe pain, inability to move the affected leg, and shortening and external rotation of the leg.
  • Treatment options include total hip replacement or internal fixation with a prosthesis.

Hip Fracture Nursing Considerations:

  • Maintain proper alignment and avoid hip flexion.
  • Monitor for signs of infection or hemorrhage.
  • Conduct a neurovascular assessment.
  • Encourage mobility and physical therapy as prescribed.

Total Knee Replacement:

  • Involves implanting a device as a substitute for femoral condyles and tibial joint surfaces.
  • Monitor surgical incision for drainage and infection.
  • Initiate continuous passive motion 24 to 48 hours postoperatively as prescribed.
  • Administer analgesics before continuous passive motion.
  • Prepare the client for out-of-bed activities and avoid weight-bearing.
  • Postoperative blood salvage may be prescribed.

Intervertebral Disk Herniation:

  • Nucleus of affected disk protrudes into annulus, causing nerve compression.
  • Surgical intervention may be necessary.
  • Signs/symptoms depend on the location of the affected disk:
    • Cervical Disk: Pain, stiffness in neck, shoulders, arms, head; paresthesia and numbness in arms.
    • Lumbar Disk: Low back pain, muscle spasms, radiating pain in hip and leg (sciatica); aggravated by certain movements.

Intervertebral Disk Herniation Preoperative Interventions:

  • Provide immobilization with collar, traction, or brace as prescribed.
  • Instruct the client to avoid neck movements.
  • Encourage proper sleeping posture and alignment.
  • For lumbar disk herniation:
    • Apply heat or ice as prescribed.
    • Use pelvic traction as prescribed.
    • Promote side-sleeping with knees and hips flexed, and avoid soft furniture.
    • Emphasize correct posture and safe lifting techniques.
    • Weight-control program and exercises may be prescribed.

Intervertebral Disk Herniation Postoperative Interventions:

  • For cervical disk:
    • Monitor respiratory difficulty.
    • Watch for hoarseness and coughing issues (possible laryngeal nerve damage).
    • Use throat sprays or lozenges for sore throat.
    • Monitor wound for drainage.
    • Offer soft diet if dysphagia occurs.
    • Watch for sudden radicular pain (indicating spine instability).
  • For lumbar disk:
    • Monitor wound for bleeding.
    • Assess leg sensation, motor ability, and toe conditions.
    • Monitor for urine retention, paralytic ileus, and constipation; prevent constipation.
    • Use proper techniques for turning and repositioning.
    • Position the client with a pillow under the head and slightly flexed knees.
    • Discourage sitting; encourage early ambulation.
    • Assist with back brace or corset use.

Leg Amputation:

  • Leg amputation may be necessary due to conditions affecting blood supply.
  • Monitor the wound for signs of infection and hemorrhage.
  • Prevent contracture and evaluate for phantom limb sensation.
  • Follow positioning instructions based on the primary health care provider’s orders.
  • Maintain wound care and prepare the limb for a prosthesis.
  • Instruct the client in crutch walking and range of motion exercises.

Rheumatoid Arthritis:

  • Rheumatoid arthritis is a chronic systemic inflammatory disease affecting joints and connective tissue.
  • Assessment findings include joint inflammation, pain, stiffness, deformities, muscle atrophy, fatigue, and positive rheumatoid factor.
  • Surgical intervention may be considered for joint contractures and deformities.
  • Juvenile idiopathic arthritis (JIA) occurs in children and may lead to unequal extremity growth.
  • Iridocyclitis can be a complication of JIA.
  • Diagnosis of JIA relies on clinical evaluation rather than a definitive test.

Rheumatoid Nodules

Boutonnière Deformity

Swan-Neck Deformity

Rheumatoid Arthritis Nursing Considerations:

  • Pain management using a combination of pharmacological therapies, including NSAIDs, DMARDs, and glucocorticoids.
  • Maintain physical mobility through range-of-motion exercises, rest, and activity balance.
  • Encourage the use of splints during acute inflammation to prevent deformity.
  • Apply heat or cold therapy to joints, along with paraffin baths and massage.
  • Promote a consistent exercise program and the use of joint-protecting devices.
  • Educate the client to avoid bearing weight on inflamed joints.
  • Emphasize proper sitting and lying positions.
  • Stress the importance of follow-up visits with the primary health care provider.
  • Assess the need for assistive devices and collaborate with occupational therapy.
  • Address fatigue by identifying contributing factors and administering supplements.
  • Provide emotional support and assist with self-care activities and grooming.

Osteoarthritis (Degenerative Joint Disease) and Osteoporosis Nursing Considerations:

  • Similar nursing care for osteoarthritis and rheumatoid arthritis.
  • Assess and manage joint pain, swelling, and limitations in range of motion.
  • Pay attention to joint enlargement and nodes (Heberden and Bouchard).
  • Encourage maintaining proper body mechanics and exercise.
  • Promote a healthy diet, especially calcium and vitamin intake.
  • Address risk factors and educate clients on preventive measures.
  • Provide pain management and support for clients with osteoarthritis.

Gout- Nursing Considerations:

urate crystals are deposited in joints and other body tissues

  • Swelling and Inflammation of Joints: Gout often manifests with acute and severe joint inflammation, commonly affecting the joint at the base of the big toe. This inflammation can cause significant pain, redness, warmth, and swelling in the affected joint. Gout attacks can be sudden and extremely painful.
  • Tophi: Tophi are nodular, chalky deposits of urate crystals that can develop in various locations, including joints, cartilage, and soft tissues. These deposits can grow over time and become hard and irregularly shaped. Tophi may also form under the skin, particularly around joints. They can sometimes break open, discharging a gritty yellowish substance.
  • Pruritus (Itching): The presence of urate crystals in the skin can lead to pruritus, which is itching of the affected area. The crystals can irritate the skin and cause discomfort and itching.
  • Increased Level of Uric Acid: Elevated levels of uric acid in the blood, a condition known as hyperuricemia, are a hallmark of gout. Uric acid is a metabolic waste product that, when present in excessive amounts, can form crystals that deposit in joints and tissues, triggering gout attacks.

Gout is a painful and often recurring condition that typically requires medication to manage acute attacks and prevent future episodes. Treatment options include medications to reduce inflammation, lower uric acid levels, and lifestyle modifications such as dietary changes and increased fluid intake to help prevent urate crystal formation.

  • Gout occurs in four phases: asymptomatic, acute, intermittent, and chronic.
  • Management includes pain relief during acute attacks and long-term prevention.
  • Advise clients to follow a low-purine diet, avoid alcohol, and maintain hydration.
  • Encourage weight reduction if needed and discourage alcohol consumption.
  • During acute attacks, provide bed rest with the affected extremity elevated.
  • Offer heat or cold therapy and administer analgesics and uricosurics.

Otito-Umoren