chap 33 musculoskeletal

Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders

Chapter 33Care of Patients with Musculoskeletal and Connective Tissue Disorders Theory Objectives State the factors to be assessed for the patient who has a connective tissue injury. Compare the assessment findings of a connective tissue injury with those of a fracture. State the care that is needed for the patient who has an external fixator in place. Identify the “do’s and don’ts” of cast care. Discuss the potential complications related to fractures. Identify the special problems of patients with arthritis and specific nursing interventions that can be helpful. Compare the preoperative and postoperative care of a patient with a total knee replacement with that of a patient with a total hip replacement.Explain the process by which osteoporosis occurs, ways to slow the process, and how the disorder is treated. Describe the care of the patient with a metastatic bone tumor. Identify important postoperative observations and nursing interventions in the care of the patient who has undergone an amputation.Clinical Practice ObjectivesTeach the patient going home with a cast about proper care of the cast and extremity. Provide pin care for a patient with external fixation. Observe a physical therapist who is teaching quadriceps exercise and then assist the patient to practice. Apply a sequential compression device for a patient as ordered.

Sprain

A sprain is a partial or complete tearing of the ligaments that hold various bones together to form a joint

A sprain occurs when a joint may be forced, during trauma, past its normal range of motion, or there may be twisting

The ankle, knee, and wrist are most commonly sprained

Signs and Symptoms

Grade I (mild): Tenderness at site; minimal swelling and loss of function; no abnormal motion

Grade II (moderate): More severe pain, especially with weight-bearing; swelling and bleeding into joint; some loss of function

Grade III (severe, complete tearing of fibers): Pain may be less severe, but swelling, loss of function, and bleeding into joint are more marked

Diagnosis

Physical examination

X-ray to rule out a fracture or other pathology

Treatment and Management

RICE

Rest

Ice after injury and for 24-72 hours

Compression—snug elastic bandage, careful to not to cut off circulation

Elevation

Grade II or III

Rest the joint

Crutches for lower extremity sprain

NSAIDs around the clock for first couple of days

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Strain

Signs, symptoms, and diagnosis

History of overexertion

Soft tissue swelling

Pain

Bleeding if muscle is torn

Etiology and Pathophysiology

A strain is a pulling or tearing of a muscle, a tendon, or both

A strain occurs by trauma, overuse, or overextension of a joint

The most common muscle strain occurs in the back muscles (back problems are discussed in Chapter 23, because they often have a neurologic

component)

Muscle strains do occur in other skeletal muscles—the most common sites are the hamstrings, quadriceps, and calf muscles

Complementary and Alternative Therapies

Soothing sore muscles

Arnica purchased and applied topically as an essential oil is supposed to soothe sore, tired muscles after a long day’s work

Valerian or kava brewed as a tea is also said to relax muscles

Honey or apple juice will make the teas more palatable

Treatment and Nursing Management

Ice and compression should be immediately applied and the part should be rested

The patient is taught to use ice for 20 minutes out of the hour only

When compression is used, the distal parts of the extremity must be checked for sensation and adequate circulation

Heat can be applied after 48 hours

Anti-inflammatory medications are used for discomfort and, when spasm is present, a muscle relaxant may be prescribed

Time is the greatest healer

The patient is cautioned against reinjury and is taught proper ways to lift and move

Surgical repair may be necessary

Dislocation and Subluxation

Etiology and pathophysiology

Signs and symptoms

History of outside force

Severe pain aggravated by movement

Muscle spasm

Abnormal joint appearance

X-ray

Treatment

Reduction of displacement under anesthesia

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Nursing management

Rest

Pain control

Heat or cold applications

Bursitis


Injury or overuse


Mild to moderate aching pain

Swelling

History of injury


Treatment

Rest, ice, and massage

Anti-inflammatory agents

Compression wrap

Bursa cortisone injection

Nursing management

Assess pain and perfusion

Assist with mobilization

Activity limitations

Other Connective Tissue Disorders

Rotator cuff tear

Anterior cruciate ligament injury

Meniscal injury

Achilles tendon rupture

Bunion (hallux valgus)

Carpal Tunnel Syndrome


Compression of the median nerve

Signs and symptoms

Pain

Numbness

Tingling of the hand, particularly at night

Repetitive movements of hands and wrists

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Diagnosis


Compression test

Electromyography

Treatment

Rest and splinting

Changing the angle of the wrist during repetitive movements

Steroid injections

Surgery

Nursing management

Fractures


Definition

Trauma

Osteoporosis and metabolic problems

Mechanism of injury

Signs and symptoms

Minimal to severe pain depending on the type of fracture, the bone(s) involved, and the amount of displacement

Swelling and/or bleeding

Tenderness, deformity of the bone, ecchymoses, crepitation with any movement, and loss of function

Fractures (cont.)

Diagnosis


X-ray

Types of Fractures

Complete ________________________________________________________________________________________________________________

Incomplete_______________________________________________________________________________________________________________

Comminuted _____________________________________________________________________________________________________________

Closed (simple) ___________________________________________________________________________________________________________

Open (compound) _________________________________________________________________________________________________________

Greenstick _______________________________________________________________________________________________________________

Elder Care Points The elderly are more at risk for fractures because of decreased reaction time, failing vision, lessened agility, alterations in balance, and decreased muscle tone

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Proton pump inhibitors (PPIs) increase the risk for fracture of the hip, wrist, and spine

In epidemiologic studies, the risk was highest for people over age 50, who had used PPIs for more than a year

Treatment of Fracture

Emergency care

Prevent shock and hemorrhage

“Splint as it lies”

Tetanus immunization

Prophylactic antibiotics

Primary aim of treatment

Establish union between broken ends to restore bone continuity

Five Stages of Bone Healing and Repair

1. Blood oozes from the torn blood vessels in the area of the fracture; the blood clots and begins to form a hematoma between the two

broken ends of bone (1 to 3 days)

Five Stages of Bone Healing and Repair (cont.)

2. Other tissue cells enter the clot, and granulation tissue is formed. This tissue is interlaced with capillaries, and it gradually becomes firm

and forms a bridge between the two ends of broken bone (3 days to 2 weeks)


3. Young bone cells enter the area and form a tissue called “callus.” At this stage, the ends of the broken bone are beginning to “knit”

together (2 to 6 weeks)


4. The immature bone cells are gradually replaced by mature bone cells (ossification), and the tissue takes on the characteristics of typical

bone structure (3 weeks to 6 months)


5. Bone is resorbed and deposited, depending on the lines of stress. The medullary canal is reconstructed during consolidation and

remodeling (6 weeks to 1 year)

Reduction of Fractures

Closed reduction

Open reduction

Stabilization

Internal fixation

External fixation

Casts, splints, and braces

Traction

Internal Fixation

Pins, nails, or metal plates

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Open reduction and internal fixation

Prosthesis and autotransfusion

IV antibiotics and risk for infection

Nursing care

Maintain good alignment of the affected leg

Prevent complications of immobility

Control pain

Examples of Internal Fixation

External Fixation

Indications

Massive open fractures with extensive soft-tissue damage

Infected fractures that do not heal properly

Multiple trauma such as burns, chest injury, or head injury

Nursing Management

Pin site care and premedicate for pain

Showering

Physical therapy and ADLs

Casts and Fractures

Materials including plaster and synthetic casts

Long-leg and short-leg casts, slings, and spicas

Synthetic Limb Cast

Braces and Splints

Fracture boot, hinged brace, and slab

Patient teaching

Explain the procedure—feel warmth as cast sets and dries

Never put a fresh cast on plastic

Never cover a fresh plaster cast with a blanket

Walking Boot

Skeletal Traction

Pins, wires, or tongs directly through the bone at a point distal to the fracture so that the force of pull from the weights is exerted directly on the

bone

Skeletal traction uses 10 or more pounds of weight and the body acts as the countertraction

Skin Traction

Bandage (moleskin or foam traction boot) is applied to the limb below the site of fracture and then pull is exerted on the limb

No more than 7 to 10 lb of weight are used

Continuous or intermittent

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Common Types of Traction

Points of Care for the Patient in Traction

Traction devices must be assessed to see that they are in correct position and that the weights are hanging free

The patient’s body position should be assessed for proper alignment

Complications of Fractures

The sooner a fracture is fixed, the less likely the chance for complications.

Healing can be impeded by improper alignment and inadequate immobilization

Continued twisting, shearing, and abnormal stresses prohibit a strong, bony union.

Fractures and Infection

Open comminuted fractures and surgery

Antibiotics

Inadequate calcium and phosphorus, vitamin deficiency, and atherosclerosis

Temperature, white blood cells, and wound appearance (redness, swelling, heat, and purulent drainage)

Osteomyelitis

Osteomyelitis is a bacterial infection of the bone

Staphylococcus aureus

Sudden onset with severe pain and marked tenderness at the site, high fever with chills, swelling of adjacent soft parts, headache, and malaise

Diagnosis

The earlier osteomyelitis is diagnosed and treated, the better the prognosis

History of injury to the part, open fracture, boils, furuncles, or other infections

Sedimentation rate and WBC count

X-rays

Biopsy, in which the bone sample exhibits signs of necrosis

Treatment

Antibiotics are prescribed for 4 to 6 weeks, and the abscess is incised and drained

Dead bone and debris are débrided from the site

The affected limb is immobilized for complete rest

Sometimes amputation is the only cure

Nonunion of Fractures

Electrical bone growth–stimulating device

Surgery and bone grafting

Fat Embolism

Signs and symptoms

Change in mental status

Respiratory distress, tachypnea, crackles and wheezes

Rapid pulse, fever, and petechiae (a measles-like rash over the chest, neck, upper arms, or abdomen)

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Nursing Management

Stay with the patient

High Fowler’s position

Use a non-rebreather mask

Establish a peripheral IV

Summon the physician immediately

Anticipate hydration with IV fluids and correction of acidosis

Intubation and mechanical ventilation

Venous Thrombosis

The veins of the pelvis and lower extremities are very vulnerable to thrombus formation after fracture, especially hip fracture

Immobility, traction, and casts may contribute to venous stasis

Compression stockings, sequential compression devices, range-of-motion (ROM) exercises on the unaffected lower extremities are used to help

prevent the problem

Compartment Syndrome

External or internal pressure that restricts circulation in one or more muscle compartments of the extremities

Severe, unrelenting pain unrelieved by narcotics

Assess for 6 “Ps”: pain, pallor, paresthesia, pulselessness, paralysis, and poikilothermia (cold to the touch)

Treatment and Nursing Management

Recognition and immediate notification of the physician can prevent permanent loss of function

If a cast is in place, the cast can be bivalved (split through all layers of the material)

Dressings will be cut or replaced

Surgical fasciotomy (linear incisions in the fascia down the extremity) may be necessary to relieve the pressure on the nerves and blood vessels if

other measures do not relieve the problem

Elevation is the key to preventing compartment syndrome; toes and fingers should be higher than the trunk

Fascial Compartments of the Calf

Nursing Management of Fractures

Assessment (data collection)

Initial assessment (pretreatment)

Mechanism of injury

Physical assessment

Special consideration of open fractures

Daily assessment (posttreatment)

Physical assessment of neurovascular status

Thorough assessment of a patient in a cast

Nutrition for immobile musculoskeletal patients

Nursing Management of Fractures (cont.)

Implementation 8


Cast care—fiberglass and polyester cotton knit casts and plaster casts

Comfort measures

Positioning and repositioning

Itching and skin care

Nursing Management of Fractures (cont.)

Evaluation

Pain should be under control

Progress toward independent ADLs

No problems with immobility (skin breakdown, constipation, atelectasis, or DVT)

No complications (infection, compartment syndrome)

If the goals are not being met, the plan should be revised

Inflammatory Disorders of the Musculoskeletal System

Lyme disease

Osteoarthritis

Rheumatoid arthritis

Gout

Osteoporosis

Paget’s disease

Bone tumors

Lyme Disease

Cause

Spirochete, Borrelia burgdorferi

Signs and symptoms

Flu-like symptoms

Bull’s-eye rash

Pain and stiffness in joints and muscles

Carditis

Meningitis, peripheral neuritis, or facial paralysis

Fatigue, cognition problems, and arthralgia

Treatment

Osteoarthritis


A noninflammatory degenerative joint disease that can affect any weight-bearing joint

Risk factors: Heredity, aging, female gender, obesity, previous joint injury, and recreational/occupational usage

Healthy People 2020 Goals Related to Arthritis

Reducing the mean level of joint pain, activity limitations, care limitations, effect on employment and the proportion of those who find it

very difficult to perform specific joint-related activities

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Increasing health care provider counseling for weight and physical activity; the proportion of those seeing a health care provider for joint

symptoms and effective evidence-based arthritis education as an integral part of managing the condition

Osteoarthritis


Asymmetrical

Typically affects only one or two joints

Chief symptoms

Aching pain with joint movement and stiffness and limitation of mobility

Joints may be deformed and nodules may be present

Treatment of Osteoarthritis

Pain management—including salicylates, acetaminophen, or NSAIDs

Strengthening and aerobic exercise

Weight reduction if the patient is overweight

Maintenance of joint function

Complementary and alternative therapies

Nursing Management of Osteoarthritis

Balance exercise and rest

Moist heat application

Encourage to maintain weight within normal limits

Imagery, relaxation, and diversion

Quadriceps strengthening exercises may relieve pain and disability of the knee

Rheumatoid Arthritis


Rheumatoid factor and small joints

Remissions and exacerbations

Pannus, ankylosis, and damage/atrophy of muscles

Subcutaneous nodules in the pleura, heart valves, or eyes

Rheumatoid Arthritis (cont.)

Signs and symptoms

Joint pain, warmth, edema, limitation of motion, and multiple joint stiffness

Symmetrical—affects joints of the hands, wrists, and feet

Limitations of ADLs

Comparison of Rheumatoid Arthritis and Osteoarthritis

Definition

Pathology

Etiology

Rheumatoid factors (autoantibodies)

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Age at onset

Weight

General state of health

Appearance of joints

Muscles

Other

Rheumatoid Arthritis

Diagnosis

History of morning stiffness that lasts more than one hour or arthritis pain in 3 or more joints that lasts more than 6 weeks

Blood tests for RF, C-reactive protein, and erythrocyte sedimentation rate

X-rays confirm the cartilage destruction and bone deformities

Treatment of Rheumatoid Arthritis

Relieve pain

Minimize joint destruction

Promote joint function

Preserve ability to perform self-care

Medications for Rheumatoid Arthritis

NSAIDs (i.e., ibuprofen) are the first-line agents used for arthritis pain

Other medications include salicylates, corticosteroids, antimalarial drugs, methotrexate, gold compounds, sulfasalazine, d-penicillamine, and

disease-modifying antirheumatic drugs (DMARDs)

Tumor necrosis factor drugs (TNF inhibitors)

Systemic corticosteroids

DMARDs

Medications for Rheumatoid Arthritis (cont.)

The injection of steroids directly into a joint (intra-articular administration) has been used successfully in treating painful flare-ups, shortening the

period of inflammation, and relieving pain and other symptoms

When intra-articular steroid therapy is used, it is recommended that not more than two or three doses be injected into any joint within 1 year’s

time

Clinical Cues

Monitor patients taking NSAIDs for GI intolerance

Assess liver, kidney, and central nervous system function frequently

Watch for signs of blood dyscrasias and check for tinnitus and hearing loss regularly

The side effects of NSAIDs can be serious and sometimes permanent

If early signs of toxicity appear, they should be reported promptly to the physician

Elder Care Points

Elderly arthritis patients must be taught to watch for side effects and promptly report to the physician or nurse

Dizziness, which predisposes to falls, can occur with analgesics for arthritis pain, particularly if the medication contains codeine

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Advise patients to arise slowly, hold on to furniture until steady, and to wait until dizziness passes before trying to walk

Assistive devices for ambulation can also prevent falls

Surgical Intervention and Orthopedic Devices

Casts/braces and splints

Surgery

Synovectomy

Osteotomy

Tendon reconstruction

Joint replacement

Total hip replacement including preoperative and postoperative care

Total knee replacement

Total Hip Replacement Discharge Teaching

It is OK to lay on operated side

For 3 months, you should not cross your legs

Put a pillow between legs when rolling over or lie on your side in bed

It is OK to bend your hip but not beyond a right (90-degree) angle (demonstrate)

Avoid sitting in low chairs

Continue daily exercise program at home

Nursing Management of Rheumatoid Arthritis

Expected outcomes

Patient’s pain will be controlled with medications, heat, and exercise within 2 weeks

Patient’s mobility will improve with the use of assistive devices and physical therapy within 3 weeks

Patient will demonstrate less disturbance of body image by partaking in more social activities within 1 month

Implementation and Evaluation of Rheumatoid Arthritis

Rest and exercise

Instructions for joint protection

Applications of heat and cold

Safety considerations

Patient teaching

Diet

Psychosocial care

Resources for patient and family education

Gout


Uric acid levels

Possible factors

Genetic increase in purine metabolism

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High-purine diets

Big toe

Diuretic therapy and secondary gout

Gout (cont.)

Signs and symptoms

Tight reddened skin over an inflamed, edematous joint accompanied by elevated temperature and extreme pain in the joint

Elevated serum uric acid

Diagnosis

History and physical examination

Serum uric acid

Gout (cont.)

Treatment

NSAIDs for 2-5 days

Colchicine, allopurinol, and probenecid (Benemid)

Febuxostat (Uloric)

Nursing management

Patient teaching and medications

Diet management—weight control and restriction of high-purine foods

Fluid intake

Audience Response Question 1

Dietary management of gout includes which measure(s)? (Select all that apply.)

1. Weight reduction

2. Salt restriction

3. High caloric intake

4. Avoiding foods high in purine

5. High-carbohydrate diet

Osteoporosis


Osteopenia

Risk factors: Age, chronic disease (i.e., liver, lung, kidney), medications (i.e., steroids, anticonvulsants, anticoagulants, proton pump inhibitors,

selective serotonin inhibitors), long-term calcium deficiency, vitamin D deficiency, smoking, excessive caffeine or alcohol intake, and sedentary

lifestyle

Osteoporosis (cont.)

Signs and symptoms

No early signs and symptoms

Height loss, kyphosis, and compression of the spine

Diagnosis

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Bone x-rays

Dual energy x-ray absorptiometry (DXA or DEXA); reported as a T score

Treatment

Goals

Stop bone density loss

Increase bone formation

Prevent fractures

Estrogen replacement therapy

Adequate dietary and supplemental calcium and vitamin D

Weight-bearing exercise

Bisphosphonates

Parathyroid hormones

Osteoporosis and Vertebral Fracture

Pain medication, activity limitation, physical therapy, and bracing

Vertebroplasty

Kyphoplasty

Nursing Management

Promote screening for osteoporosis

Teach the benefits of healthy lifestyle, need for calcium supplement, and weight-bearing exercise

Medications, cautions, and side effects

Upright position for 1 hour after taking bisphosphonate-type drugs to prevent esophageal irritation and erosion

Paget’s Disease

Etiology

Abnormal weak bones

Signs and symptoms

Pain

Diagnosis

X-ray

24-hour urine collection

Serum alkaline phosphatase

Paget’s Disease (cont.)

Nursing management

Firm mattress

Light brace or corset

Avoid lifting and twisting

Bone Tumors


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Benign and malignant tumors

Primary and secondary tumors

Osteosarcoma and Paget’s disease

Bone Tumors (cont.)

Signs and Symptoms

Pain, warmth, and swelling

Diagnosis

X-ray, bone scan, and biopsy

Treatment

Surgery, radiation, and chemotherapy

Amputation

Lower-limb amputations are related to peripheral vascular disease, diabetes mellitus and resultant gangrene, severe trauma, malignancy,

congenital defects, and military injuries from shrapnel and land mines

Upper-extremity amputations are brought on by crushing blows, thermal and electric burns, severe lacerations, vasospastic disease, malignancy,

and infection

Care After Accidental Amputation

Rinse the detached part only enough to remove visible debris

Wrap the part in a clean, damp cloth

Place the part in a sealed plastic bag or in a dry water-tight container

Immerse the bag or container in a mixture of water and ice (3 parts water to 1 part ice). Do not let the part get wet or freeze

Care After Accidental Amputation (cont.)

Alternatively, place the container in an insulated cooler filled with ice

If no ice is available, keep the part cool; do not expose it to heat

Tag the bag or container with the person’s name and the name of the body part and take it to the hospital with the person

Amputation:

Preoperative Care

Patient participation in decision-making

Stages of loss and grieving

Phantom sensations

Physical preparation

Muscle strengthening exercises

Amputation:

Postoperative Care

Hemorrhage and edema of residual limb

Elevation for 24 hours

Monitoring for excessive bleeding

Dressing care

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Phantom limb sensations

Miacalcin IV infusion

Transcutaneous electrical nerve stimulator

Stump stocking

Amputation:

Postoperative Care (cont.)

Alternative modes for managing stump after amputation

Soft dressing with delayed prosthetic fitting

Rigid plaster dressing and early prosthetic fitting

Rigid plaster dressing and immediate prosthetic fitting

Amputation:

Postoperative Care (cont.)

Adequate healing and weight-bearing

Below-the-knee amputation is better to begin walking and weight-bearing than above-the-knee amputation

Abduction contractures and proper positioning

Adjusting to the new center of gravity

Patient teaching: stump care, activity and weight-bearing, and exercise

Rehabilitation

Community care

C-Leg Prosthesis in Action

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chap 33 musculoskeletal

Health & Medicine