Musculoskeletal System Alterations

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1

The child's skeleton is mostly composed of ___________.

cartilage

2

What are the four bone cells?

Osteogenic

Osteoblasts

Osteocytes

Osteoclasts

3

What are the functions of the bones?

Protect organs

Storage

Hematopoiesis

Remodeling

Reformation

Movable Joints

4

Bone growth and metabolism is affected by several factors. What are they?

Calcium and phosphorus

Calcitonin

Vitamin D

Parathyroid hormones

Growth hormones

Glucocorticoids

Estrogen/Androgens

THyroxine

Insulin

5

When doing an assessment for the musculoskeltal system, what do you want to inquire about?

Pain

Body movements

General inspection (posture and gait)

Family history

Joint function

Peripheral Nerve function

Muscle strength and size

6

Assessment for posture?

Bone integrity, skin, and posture

7

Risk factors for bone disorder/growth problems.

Autoimmune/Metabolic/ Neoplastic disorders

Calcium deficiency

Degenerative conditions

Falls/ trauma/ injury

Hyperuricemia

Infection

Medications

Obesity

Postmenoupausal state

8

Diagnostic Evaluation for bone problems/disorders?

Xrays

Ct

Arthrography

Bone density and bone scan

MRI

Arthrocentesis

Electromyography

Biopsy

9

Musculoskeletal Assessment:

Change in bone alignment

Alteration in length of extremity

Change in shape of bone

Pain upon movement

Decreased ROM

Crepitus

Ecchymotic

Subq emphysema with bubbles under skin

Swelling at fracture site

10

What is a strain?

An excessive stretching of a muscle or tendon.

Management involves cold and heat applications, exercise with limitations, anti-inflammatory meds, and muscle relaxants.

Surgical repair may be required for a severe strain

11

What is a sprain?

An excessive stretching of a ligament usually caused by a TWISTING motion

Characterized by pain and swelling

Management includes RICE

Casting may be required for severe cases

Surgery may be required for severe ligament damage

12

Describe Rotator cuff injuries

Musclotendinous or rotator cuff of the shoulder sustains a tear usually as a result of trauma. Characterized by shoulder pain and inability to maintain abduction of the arm at the shoulder

Management includes NSAIDs, PT, sling support, and ice/heat applications; Surgery may be required

13

Types of fractures:

Complete

Incomplete

Open

Compound

Closed

Simple

Spontaneous (Pathologic)

Fatigue

Stress

Compression

14

What is a fracture?

A break in the continuity of the bone caused by trauma, twisting, or bone decalcification and disease that result in osteopenia

15

What are the stages of bone healing?

Hematoma formation within 48-72 hours after injury

Hematoma to granulation tissue

Callus formation

Osteoblastic proliferation

Bone remodeling

Bone healing completed within about 6 weeks; up to 6 months in the older population

16

Describe Closed or simple and greenstick fractures:

Closed or simple: skin over the fracture area remains intact

Greenstick (mainly in peds)- one side of the bone is broken and the other is bent

17

Describe transverse and oblique fractures:

Transverse: the bone is fractured straight across

Oblique: the break extends in an oblique direction

18

Describe spiral and comminuted fractures:

Spiral: the break partially encircles bone

Comminuted: The bone is splintered or crushed with three or more fragments

19

Describe complete and incomplete fractures:

complete: the bone is completely separated by a break into two parts

incomplete: a partial break in the bone

20

Describe open compound fracture:

the bone is exposed to air through a break in the skin and soft tissue injury and infection are common

21

Described impacted fracture:

a part of the fractured bone is driven into another bone

22

Described depressed fracture:

bone fragments are driven inward

23

Describe compression fracture:

a fractured bone compressed by other bone

24

Describe pathological fracture:

A fracture due to weakening of the bone structure by pathological process such as neoplasia or osteomalacia

Can also be referred to as a spontaneous fracture

25

Assessment for fracture of an extremity:

Pain or tenderness with involved area

Loss of function

Obvious deformity

crepitaion

erythema, edema, and ecchymosis

muscle spasm and impaired sensation

26

Initial care of a fractured extremity:

Immobilize affected extremity

If a compound fracture exists, splint extremity and cover wound with sterile dressing

27

Four interventions for a fracture:

Reduction

Fixation

Traction

Casts

28

Describe compression fractures of the spine:

Most are associated with osteoporosis rather than acute spinal injury

Multiple hairline fractures

29

Management of Compression fractures of the spine:

Bedrest

Analgesics

PT

Or minimally invasive surgeries:

Vertebroplast//kyphoplasty

30

What is reduction?

Restoring the bone to proper alignment

31

Closed reduction

Performed by manual manipulation

May be done under local or general anesthesia

cast may be applied following reduction

32

Open reduction

involves surgical intervention

May be treated with internal fixation devices

the patient may be placed in traction or a cast following the procedure

33

Internal fixation

Follows open reduction

Involves the application of screws, plates, pins, or nails to hold the fragments in alignment

May involve the removal of damaged bone and replaced with prosthesis

Provides minimal bone strength

Risk of infection is associated with procedure

34

External fixation

an external frame is utilized with multiple pins applied through bone

provides more freedom of movement than with traction

35

Acute pain interventions:

Reduction and immobilization of fracture

Assessment of pain

Drug therapy

36

Complementary and alternative therapies for acute pain:

Ice

Heat

Elevation of body part

Massage

Baths

Back rub

Therapeutic touch

Distraction

Imagery

Music therapy

Relaxation techniques

37

Interventions for infection risk:

Apply strict aseptic technique for dressing changes and wound irrigations

Assess for local inflammation

Report purulent drainage immediately to hcp

Assess for pneumonia and UTI

Administer prescribed broad spectrum antibiotics prophylactically

38

Interventions for imbalanced nutrition:

Diet high in protein, calories, and calcium, vitamins B & C

Frequent small feedings and supplemental high protein liquids

Intake of foods high in iron

39

What is traction?

The exertion of a pulling force applied in two directions to reduce and immobilize a fracture

Provides proper bone alignment and reduces muscle spasms

40

What is the implementation of traction:

Maintain proper body alignment

Ensure that the weights hang freely and do not touch the floor

Do not remove or lift the weights without a physician's order

Ensure pulleys are not obstructed and that the ropes move freely

Place knots in the ropes to prevent slipping

Check ropes for fraying

41

What is skeletal traction?

Mechanically applied to the bone using pins, wires, or tongs

Goes through bone to the outside

Monitor color, motion, and sensation of the affected extremity

Monitor for redness, swelling, or drainage

Provide insertion site care as prescribed

42

What is Skin traction:

Does not go through bone; applied by the use of elastic bandages or adhesive

43

Five types of skin traction:

Cervical

Buck's

Bryant's

Pelvic

Russell's

44

Describe cervical skin traction:

Relieves muscle spasms and compression in the upper extremities and neck

Uses a head halter and chin pad to attach traction

Use powder to protect the ears from friction rub

Position the pt with HOB 30-40 degrees and attach weights to a pully system over the HOB

45

Describe Buck's traction:

Used to alleviate muscle spasms; immobilizes a lower limb by maintaining a straight pull on the limb with the use of weights

A boot appliance is applied to attach to the traction

Weight is attached to a pulley and allow the weights to hang freely over the edge of bed

Not more than 5 pounds of weight should be applied

Elevate the foot of the bed to provide the traction

46

Pelvic skin traction:

Used to relieve low back, hip, or leg pain and to reduce muscle spasm

Apply the traction snugly over the pelvis and iliac crest and attach to the weights

Use measures as prescribed to prevent the pt from slipping down in bed

47

When is Balanced suspension used :

Used with skin or skeletal traction

Used to approximate fractures of femur, tibia, or fibula

Produced by a counterforce other than pt

48

How to use balanced suspension:

Position pt in low Fowler's either side or back

Maintain 20 degree angle from thigh to bed

Protect the skin from breakdown

Provide pin care

Clean pin sites with sterile normal saline and hydrogen peroxide or betadine as prescribed

49

Describe Dunlop's skin traction:

Horizontal traction to align fractures of the humerus; vertical traction maintains the forearm in proper alignment

Nursing care similar to buck's traction

50

Describe casts:

Made of plaster or fiberglass to provide immobilization of bone and joints after fracture or injury

51

Nursing care for casts:

Keep cast and extremity elevate

Allow a wet cast 24 to 48 hours to dry (synthetic need 20 mins)

Handle a wet cast with palms of hand until dry

Turn the extremity unless contraindication so that all sides will dry

Heat can be used to dry cast

52

Nursing care with casts:

Cast will go from dull to shiny when dry

Examine for pressure areas

Monitor for circulatory impairment and notify hcp if occurs

Monitor pt temperature

Monitor for presence of foul odor-may indication infection

Monitor for drainage and warmth

53

What are the interventions if circulatory impairment from casts?

Elevation

Then prepare for bivalving or cutting the cast if circulatory impairment occurs

54

What to teach pt about casts?

Keep clean and dry

Do not stick objects in cast

55

What are complications of fractures?

Fat embolism

Shock

Compartment syndrome

Infection or osteomyelitis

Avascular necrosis/ delayed bone healing

Venous thrombosis

Pain

Inadequate nutrition/ impaired mobility

56

What is a fat embolism?

An embolism originating in the bone marrow that occurs after a fracture

Usually occurs within 48 hours following injury

Pts with long bone fractures are at greatest risk

Fat globules are released from yellow bone marrow into bloodstream

57

Assessment for fat embolism:

Restlessness

Mental status changes

Tachycardia, tachypnea, and hypotension

Dyspnea

Petechial rash over upper chest and neck

58

Nursing care for fat embolism:

Notify HCP immediately

Treat symptoms as prescribed to prevent respiratory failure and death

59

Describe compartment syndrome:

Increased pressure within one or more compartments causing massive compromise of circulation to an area

Leads to decreased perfusion and tissue anoxia

Within 4-6 hours after onset neuromuscular damage is irreversible!!!

Sometimes referred to as ischemia-edema cycle

60

Assessment of compartment syndrome:

Increase pain and swelling

Pain with passive motion

Inability to move joints

Loss of sensation (paresthesia)

Pulselessness

61

Nursing care for compartment syndrome:

Notify HCP immediately

Fasciotomy to relieve pressure

62

Possible results of acute compartment syndrome:

Infection

Motor weakness

Volkmann's contractures

Myoglobinuric renal failure (rhabdomyolysis)

Crush syndrome

63

Describe osteomyelitis:

Can be caused by interruption of the integrity of the skin

Infection invades bone tissue

Do culture

64

Assessment for osteomyelitis:

Fever

Pain

Erythema in surrounding area

Tachycardia

Elevate WBC

65

Nursing care for osteomyelitis:

Notify HCP

Prepare to initiate aggressive IV antibiotic therapy

66

Describe avascular necrosis:

An interruption in the blood supply to the bony tissue, which results in the death of a bone

67

Assessment of avascular necrosis:

Pain and decreased sensation

68

Nursing care of avascular necrosis:

Notify HCP if pain or decreased sensation occurs

Prepare pt for removal of necrotic tissue

69

Describe pulmonary embolism:

Caused by immobility precipitated by fracture

70

Assessment of pulmonary embolism:

Restlessness and apprehension

Dyspnea

Diaphoresis

Arterial blood gas changes

71

Nursing care for pulmonary embolism:

Notify HCP if signs of emboli are present

Prepare to administer anticoagulant therapy

72

Describe crutch walking:

An incorrect measurement could damage the brachial plexus

The distance between the axilla and arm pieces on the crutches should be two fingerwidths in the axilla space

Elbows should be slightly flexed 20-30 degrees when walking

73

Nursing care with pts with crutches:

When ambulating with pt stand on affected side

Instruct pt to never rest the axilla on the axillary bars

Instruct pt to look up and out when ambulating

Instruct pt to stop ambulation if numbness or tingling in the hands or arms occurs

74

True or False: Canes are only useful if they can stand alone.

True

75

Nursing care with canes:

Stand on affected side of pt when ambulating

Handle should be at the level of the pts greater trochanter

Pts elbow should be flexed at 25-30 degree angle

76

Pt education for canes:

Hold cane close to body

Hold can in hand of unaffected side

Move cane at the same time as the affected leg

Inspect rubber tips regularly for wear and tear

77

True or False: Hemicanes provide more security than a quad-foot cane?

True

78

What is a hemicane or quad-food cane used for?

For pt who have the use of only one upper extremity

79

Pt education on hemicane or quad-foot cane:

Position on unaffected side

Position 6 inches from pts side with handgrips level with greater trochanter

80

Pt education with walkers:

Stand adjacent to the pt on affected side

Instruct pt to put all four points of the walker flat on the floor before putting weight on the hand pieces

Instruct the pt to move the walker forward and to walk into it

81

What are two types of hip fractures?

Intracapsular and Extracapsular

82

Describe intracapsular hip fracture:

Bone is broken inside the joint

Skin traction is applied pre-op to immobilize and prevent pain

Treatment includes total hip replacement or internal fixation with replacement of femoral head with prosthesis

Avoid hip flexion to prevent displacement

83

Describe extracapsular hip fracture:

Fracture occurs at greater trochanter or can be intertrochanteric fracture

Trochanteric fracture is outside the joint

Pre-op treatment includes balanced suspension traction

Avoid hip flexion to prevent displacement

Surgical treatment includes internal fixation with nail plate, screws, or wires

84

Post-op hip fracture care:

Maintain leg and hip in proper alignment

Prevent flexion or external or internal rotation

Turn the pt from back to unaffected side

DO NOT position to the affected side unless instructed by physician

Maintain leg abduction to prevent internal or external rotation

Use Trochanter roll

Ensure hip flexion does not exceed 60-80 degrees

Elevate HOB 30-45 degrees

Ambulate as prescribed by physician

Avoid weight bearing on affected leg as prescribed (use walker)

Monitor wound for infection or hemorrhage

Monitor for circulation and sensation

Avoid crossing legs and bending over

Maintain use of antiembolism stockings and encourage flexing and extension of feet and ankles

85

Drainage for post-op hip:

Drainage should decrease in amount by 48 hours

Drainage should be approximately 30 ml in a 8 hour period

86

Describe total knee replacement:

Implantation of a device to substitute for the femoral condyles and the tibial joint surfaces

87

Post-op total knee care:

Monitor incision for drainage and infection

Maintain JP drain

Begin continuous passive motion 24-48 hours as prescribed to exercise the knee and provide moderate flexion and extension

The leg should not be dangled to prevent dislocation

Prepare pt for out of bed activities as prescribed

Avoid weight bearing and instruct pt in crutch walking

88

What is the McMurray test?

If pain or "click" is felt, this constitutes a positive McMurray test for a tear in the medial meniscus

89

True or False: A meniscus tear is a common knee joint injury.

True

90

What is the meniscus?

Shock absorber or rubbery cushion of the knee joint

91

Describe herniation of intervertebral disc:

Nucleus of the disc protrudes into the annulus causing nerve compression

Can be cervical or lumbar

92

Describe cervical disc herniation:

Occurs at C5 to C6 and C6 to C7

Causes pain and stiffness in neck, top of shoulders, scapula, upper extremities, and head

Produces paresthesia and numbness of the upper extremities

93

Nursing implementation for cervical disc herniation:

Bed rest

Immobilization

Hot, moist compresses

Instruct pt to avoid flexing, extending, or rotating the neck

Instruct pt to avoid long periods of sitting

Avoid prone postion while sleeping

Use analgesics, sedatives, and anti-inflammatory agents or corticosteroids as prescribed

Assist pt with application of cervical collar or traction

94

6 P's

Pain

Pallor

Paresthesia

Paralysis

Pulses

Poililothermia