chapter twenty-one · a. pavlik harness: a fabric strap harness that is secured around the...

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Musculoskeletal System

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CHAPTER TWENTY-ONE

PHYSIOLOGY OF THE MUSCULOSKELETAL AND CONNECTIVE TISSUE

Skeletal SystemA. Bonestructure.

1. Periosteum: dense fibrous membrane covering thebone;periostealvesselssupplybonetissue.

2. Epiphysis: the widened area found at the end of alongbone.

3. Epiphyseal plate (growth zone): a cartilage area inchildren, which provides for longitudinal growth ofthebone.

4. Articularcartilage:providesasmoothsurfaceovertheendofthebonetofacilitatejointmovement.

5. Redbonemarrow:hemopoietictissuelocatedinthecentralbonecavities.

B. Bonemaintenanceandhealing.1. Regulatory factors determining both formation and

resorption.a. Weight-bearing stress stimulates local bone

resorptionandformation;instatesofimmobilityinwhichweightbearing isprevented, calcium islostfromthebone.

b. VitaminDpromotesabsorptionofcalciumfromthegastrointestinaltractandacceleratesmobiliza-tionofcalciumfromthebonetoincreaseormain-tainserumcalciumlevels.

c. Parathyroidhormoneregulatestheconcentrationofcalciumintheserumpartiallybypromotingthetransferofcalciumfromthebone.

d. Calcitoninandaminobiphosphates(e.g.,alendro-nate [Fosamax], ibandronate [Boniva]) increasetheproductionofbonecells.

2. Bonehealing.a. Whenaboneisdamagedorinjured,ahematoma

precedesnew tissue formation in theproductionofnewbonesubstance.

b. A callus is formed as minerals are deposited toorganizeanetworkforthenewbone.

c. Thecallus forms the initial clinicalunionof thebone and provides enough stability to preventmovementwhenbonesaregentlystressed.

d. Continued bone healing provides for gradualreturnof the injuredbone to its preinjury shape

andstructuralstrength;thisisfrequentlyreferredtoasremodelingofthebone.

ALERT Identify pathophysiology related to an acute or chronic condition (e.g. signs and symptoms).

Connective Tissue: Joints and CartilageA. Joints.

1. Theactionofjointspermitsbonestochangepositionandfacilitatebodymovement.

2. Thediarthrodial(synovial)jointisthemostcommontypeofjointinthebody.a. Cartilage(hyaline)coverstheendofthebone.b. Afibrouscapsuleofconnectivetissuejoinsthetwo

bonestogether.(1) Synovium (synovial membrane) lines the

capsule.(2) Synovialfluidissecretedbythesynoviumand

serves to decrease friction by lubricating thejoint.

B. Articular cartilage is rigid, connective, avascular tissuethatcoverstheendofeachbone;nourishedbycapillariesin adjacent connective tissue; damaged cartilage healsslowlybecauseoflackofdirectbloodsupply.

C. Ligaments and tendons are tough fibrous connectivetissuesthatprovidestabilitywhilecontinuingtopermitmovement.1. Tendonsattachmusclestothebone.2. Ligamentsattachbonestojoints.

Skeletal MuscleA. Lowermotorneuronscontroltheactivityoftheskeletal

muscles.B. Energy is consumedwhen skeletalmuscles contract in

responsetoastimulus.1. Lactic acid, a by-product of muscle metabolism,

accumulatesiftheamountofoxygenavailabletothecellisnotsufficient.

2. Musclefatigueresultsfrom:a. Increased work of the muscle, with inadequate

oxygensupply.b. Depletionofglycogenandenergystores.

C. Musclecontraction.1. Isometric:thelengthofthemuscleremainsconstant;

the force generated by the muscle increases—for

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438 CHAPTER 21 Musculoskeletal System

example, when one pushes against an immovableobject.

2. Isotonic: shortening of the muscle but with noincreaseinmuscletension.

3. Normal activity is a combination of both types ofmusclecontraction.

4. Musclesaccomplishmovementonlybycontraction.a. Flexion:bendingatajoint.b. Extension:straighteningofajoint.c. Abduction:actionmovingawayfromthebody.d. Adduction:actionmovingtowardthebody.

Box 21-1 BODY MECHANICS

Thewiderthebaseofsupport,thegreaterthestability.Positionfeetwideapart.

Thelowerthecenterofgravity,thegreaterthestability.Flextheknees;letthestrongmusclesofthelegsdothework.Positionclosetoclient.

Face the client; keep back, pelvis, and knees aligned; avoidtwisting.

Balanceactivitybetweenarmsandlegs.Avoidbendingtolift;thisdecreasesstrainontheback.

Encourageclienttoassist.Pivoting,turning,rolling,andleveragerequirelesswork.

Personwithheaviestloadshouldcoordinateteamefforts.Obtain assistance or a lift with heavy or difficult transfers or

moves.Teachclientproperbodymechanics.

ALERT Use ergonomic principles when providing care (assistive devices, proper lifting).

Box 21-2 OLDER ADULT CARE FOCUS

Musculoskeletal Changes

• Decreasedbonedensityleadstomorefrequentfractures.• Decreaseinsubcutaneoustissueresultsinlesssofttissueover

bonyprominences.• Degenerative changes in the musculoskeletal system alter

postureandgait.• Degenerative changes in cartilage and ligaments result in

jointstiffnessandpain.• Rangeofmotionofextremitiesdecreases;olderadultmay

needincreasedassistancewithactivitiesofdailyliving.• Slowed movement and decreased muscle strength lead to

decreasedresponsetime.• Loss of height from disk compression, posture changes,

kyphosis.

DISORDERS OF MUSCULOSKELETAL AND CONNECTIVE TISSUE

Congenital Hip DysplasiaCongenital hip dysplasia is a malformation of the hip that occurs as a result of imperfect development of the femoral head, the acetabulum, or both. The structures that support the hip joint and hold the joint together are too loose, or the joint cavity is too shallow.

ALERT Perform a focused assessment and reassessment for changes in client condition. Recognize signs and symptoms of complications and intervene appropriately.

NURSING PRIORITY: Know the terms used in referring to movement of joints.

5. Hypertrophy will occur if muscle is exercisedrepeatedly.

6. Atrophywilloccurwithmuscledisuse.

System AssessmentA. History.

1. History of musculoskeletal injuries, musculoskeletalsurgeries, neuromuscular disabilities, inflammatoryandmetabolicconditionsdirectlyorindirectlyaffect-ingthemusculoskeletalsystem.

2. Familialpredispositiontoorthopedicproblems.3. Level of normal activity, occupation, exercise,

recreation.4. Existenceofotherchronichealthproblems.

B. Physicalassessment.1. Initial inspection for gross deformities, asymmetry,

andedema.2. Nutritionalstatus:appropriatenessofclient’sweight

and body frame; 24-hour diet recall, dietarysupplements.

3. Joints.a. Movement: active and passive; examine active

movementfirst;comparemovementandrangeofmotion (ROM) on one side of the body withmovementandROMontheoppositeside.

b. Inflammation and tenderness: with or withoutmovement.

c. Presenceofjointdeformitiesanddislocations.d. Palpatejointsforcrepitus.

4. Evaluatelimblengthandcircumferenceifhypertro-phyorinconsistencyinbonelengthisevident.

5. Evaluateclient’sspinalalignment,posture,andgait.6. Evaluateskeletalmuscle.

a. Musclestrengthbilaterally.b. Coordinationofmovement.c. Presenceofatrophyorhypertrophy.d. Presenceofinvoluntarymusclemovement.

7. Assessperipheralpulsesandperipheralcirculation.8. Assessforpresenceandcharacteristicsofpain.

a. Specifictypeofpainandexactlocation.b. Identify precipitating and/or alleviating factors

(mostmusculoskeletalpainisrelievedbyrest).c. Askaboutbackpainand/orinjury.

9. Sensory changes: assess for decreased sensation inextremities.

10. Bodymechanics(Box21-1,Appendix3-1).11. Changesintheolderadult(Box21-2).

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CHAPTER 21 Musculoskeletal System 439

AssessmentA. Riskfactors/etiology.

1. Frequently associated with other congenitaldeformities.

2. Prenatalfactors.a. Maternalhormonesecretion.b. Intrauterine posture, especially frank breech

position.B. Clinicalmanifestations(newborn).

1. Ortolani sign: infant supine,kneesflexed,hips fullyabducted;aclickisheardorfeltasthehipisreducedbyabduction.

2. Asymmetricalglutealandthighfolds.3. Shorteningofthelegontheaffectedside;oneknee

islowerthantheother(Galeazzisign).C. Diagnostics(seeAppendix21-1).

TreatmentA. Treatment is initiated as soon as condition is

identified.B. Forthenewborn, thedislocatedhip issecurelyheld in

a full abduction position.This keeps the femur in theacetabulumandstabilizesthearea.1. Abductiondevices.

a. Pavlikharness:afabricstrapharnessthatissecuredaroundtheinfant’sshouldersandchestandiscon-nectedtostrapsaroundthelowerleg.Theharnessmaintains the legs in aflexed, abductedpositionat the hip. The harness may be removed forbathing,buttheinfantwillwearitfulltimeuntilthehipisstable.

b. Hip spica cast:mostoftenusedwhenadductioncontracture is present. After the removal of thecast,aprotectiveabductionbraceisfitted.

2. Closed reduction:performed inolder children,6 to18monthsold.

3. Open reduction: performed if hip is not reduciblewithtractionorclosedreduction.

C. Successfulreductionbecomesincreasinglydifficultaftertheageof4years.

Nursing InterventionsGoal: To identify hip dysplasia in the newborn before

discharge.Goal: Toassistparentstounderstandmechanismtomain-

tainreduction.A. Pavlikbrace: teachparentsproperapplicationofbrace;

undershirts should be worn beneath the brace; checkskinunderbraceforirritationorpressureareas;nooilsor lotions shouldbeapplied to skin thatwillbeunderbrace.

B. Teachparentscastcareifhipspicacastisapplied.

B. Encourageparentstoholdandcuddlechild.C. Maintainnormalhomeroutine.

Clubfoot (Talipes equinovarus)Clubfoot is a deformity of the foot in which adduction, plantar flexion, and inversion of the foot occur in varying degrees of severity. The unilateral form occurs more com-monly than the bilateral form.

AssessmentA. Riskfactors/etiology(inconclusive).

1. Intrauterinecompression.2. Decreasedgrowthofdistaltibia.

B. Assessment.1. Conditionisapparentatbirth.2. In true clubfoot, there is severe limitation of

ROM.C. Diagnostics:clinicalmanifestations.

TreatmentTreatment is begun immediately and most often requiresthreestagesforcorrection.A. Correctionofdeformity: casts are applied in series for

gradualstretchingandstraightening;massageaccompa-niedbyspecialbandagingmayalsobeused.

B. Maintenanceofcorrection:orthopedicshoes.C. Follow-up observations to prevent recurrence of the

deformity.

Nursing InterventionsGoal: Toassistparentstounderstandmechanismoftreat-

menttoachievecorrection.A. Appropriatecareofcastorbraceathome.B. Follow-up care and importance of frequent cast

changes.Goal: Tofacilitatedevelopmentalprogressandadaptnur-

turingactivitiestomeetinfant’sandparents’needs(sameasforcongenitalhipdysplasia).

Herniated Lumbar DiskThe intervertebral disk forms a cushion between the ver-tebral bodies of the spinal column. As stress on an injured or degenerated disk occurs, the cartilage material of the disk (nucleus pulposus) herniates inward toward the spinal column, causing compression or tension on the spinal nerve root. The problem most often occurs in the lumbo-sacral area.


1. Degenerativediskdisease.2. Obesity.3. Injuryorstresstothelowerback.4. Muscle-strengtheningexercises.

B. Clinicalmanifestations(lumbardisk).1. Low back pain, commonly radiating down one

buttockandposteriorthigh.

ALERT Apply, maintain and or remove orthopedic devices (tractions, braces, splints, casts).

Goal: Tofacilitatedevelopmentalprogress.A. Provideappropriatestimuliandactivityfordevelopmen-

tallevel.

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2. Coughing, straining, sneezing, bending, twisting,andliftingexacerbatethepain.

3. Lyingsupineandraisingtheleginanextendedposi-tionwillprecipitatethepain.

C. Diagnostics(seeAppendix21-1).

TreatmentA. Conservative.

1. Analgesics,musclerelaxants.2. Weightreduction,ifappropriate.3. Icemaybeusedforfirst48hoursafter injury;then

moistheatisabetteranalgesic.4. Activity modification, good body mechanics, back

brace.5. Ultrasoundtherapyandmassage.6. Back strengthening exercises once the pain

subsides.B. Surgical.

1. Laminectomy: removal of the herniated portion ofthedisk.

2. Microlaminectomy(diskectomy):removaloftheher-niateddiskwithuseofamicroscope(lesstraumainthe disk area, improved hemostasis, minimal nerverootinvolvement).

C. Alternative:acupressureoracupuncture.

Nursing InterventionsGoal: To relieve pain by means of conservative measures

andpreventrecurrenceofproblem.A. Decrease muscle spasm/pain with analgesics, muscle

relaxants, decreased activity, and cold or heatapplications.

B. Beginambulationslowlyandavoidhavingclientbend,stoop,twist,sit,orlift.

C. Instructtheclientandfamilyregardingtheprinciplesofappropriatebodymechanics.

D. The client will need a firm mattress; sleeping in theprone position, especially with a pillow, should beavoided.

E. Instruct the client and family regarding lower backexercises.

F. Encouragecorrectposture;instructclienttoavoidpro-longedstanding.

G. Clientshouldsitinstraight-backedchairs.H. Semireclining position with forward flexion of lumbar

spine(recliner)maybepositionofcomfort.Goal: Toprepareclientforlaminectomy.A. Perform preoperative nursing interventions, including

educationasappropriate.B. Haveclientpracticelogrolling.C. Haveclientpracticevoidingfromsupineposition.D. Discuss with client postoperative pain and anticipated

methodstodecreasepain.E. Evaluatebowelandbladderfunction.F. Identifyspecificcharacteristicsofpaintobeincludedin

databaseforcomparisonwithpainaftersurgery.G. Establish a baseline neurologic assessment for postop-

erativereference.

Goal: Tomaintainspinalalignmentafterlaminectomy.A. Keepthebedinflatposition.B. Logrollclientwhenturning.C. Keeppillowsbetweenthelegswhenclientispositioned

ontheside.D. The client who has had microdisk surgery will have

fewer limitations on mobility. Often, the client mayassumeapositionofcomfort.

E. Assistwithapplicationofbackbraceifordered.Goal: To maintain homeostasis and assess for complica-

tionsafterlaminectomy.A. Evaluateincisionareaforpossibleleakageofspinalfluid

andbleeding–notifyhealthcareproviderofclearfluidleakingfromincisionalarea.

B. Analgesicsmaybegivenviaapatient-controlledanalge-siapumporepiduralcatheter.

C. Assess pain and determine whether there is any painradiation.

ALERT Assess client’s need for pain management and intervene as needed using non-pharmacologic comfort measures. Use pharmacological pain measures for pain management as needed.

D. Performneurovascularchecksofextremities.E. Normal bladder function returns in 24 to 48 hours;

assesscurrentstatusofvoiding.

NURSING PRIORITY The client who has undergone laminectomy frequently experiences difficulty voiding; this may be due to edema in the area of surgery that interferes with normal bladder sensation.

F. Ambulateassoonasindicated(frequentlyonfirstpost-operativedayifnofusionwasdone).

G. Iffusionwasperformed,mayneedtoapplybodybracebeforeambulation.

H. Theclientwhohasundergonemicrolaminectomyexpe-rienceslesspain,isfrequentlyoutofbedonthedayofsurgery,andhasfewercomplications.

I. Paralytic ileusandconstipationarecommoncomplica-tions;assessfordecreasedbowelsoundsandabdominaldistention.

ALERT Identify factors that interfere with elimination.

ScoliosisScoliosis is a lateral curvature of the spine. If it is allowed to progress without treatment, it will severely affect the shape of the thoracic cavity and impair ventilation.A. Idiopathic(predominanttype)occursprimarilyinado-

lescentgirls.B. Most noticeable at beginning of growth spurt, around

10yearsofage.

AssessmentA. Clinicalmanifestations.

1. Unevenhipsandshoulders.2. Visiblecurvatureofthespinalcolumn;headandhips

arenotinalignment.

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3. When child bends forward from the waist, there isvisible asymmetry of the shoulders. The ribs andshoulderaremoreprominentononeside.

4. Waistlineisuneven;onehipismoreprominent.B. Diagnostics.

1. Clinicalmanifestations.2. X-rayfilm.

TreatmentA. Observationandmonitoringforcurvaturelessthan25

degrees.B. Braceifcurvatureshowsprogression(usedforcurvatures

of25to40degrees).1. Milwaukeebraceforhighthoraciccurvatures.2. Bostonbrace (underarmorthosis) for thoracic-lum-

barcurves.C. Surgery(usedforcurvaturesofmorethan40degrees):

spinalfusionandplacementofarodtopreventdestruc-tionofthefusedsegment;therodmaybeleftinplacepermanently unless it becomes displaced or causesdiscomfort.

Nursing InterventionsGoal: Toidentifydefectsearlyandpromoteeffectivecon-

servativetherapy.A. Promote health programs in school to identify

condition.

B. Characteristics of bones in children affecting fracturesandfracturehealing.1. Presenceofepiphysealplate;iftheepiphysealplateis

damaged inthefracture, thismayaffect thegrowthofthelongbone.

2. Periosteum is thicker and stronger and has anincreased blood supply; therefore healing is morerapid.

3. Bones are more porous and allow for greaterflexibility.

C. Pathologicfracturesoccurasaresultofadiseaseprocess.D. Classificationoffractures(Figure21-1).

1. Type.a. Complete:fracturelineextendsthroughtheentire

bone;theperiosteumisdisruptedonbothsidesofthebone.

b. Incomplete: fracture line extends only partiallythrough the bone (greenstick, hairline-typefractures).

c. Comminuted: fracture with multiple bone frag-ments;morecommoninadults.

d. Greenstick: an incomplete fracturewithbendingand splintering of the bone; more common inchildren.

e. Impacted:complete fracture inwhichbonefrag-mentsaredrivenintoeachother.

2. Classifiedaccording to locationon thebone:proxi-mal,middle,ordistal.

ALERT: Perform targeted screening (scoliosis, vision and hearing).

B. Assistclientandparentstoproperlyusebraces.1. Makesurebraceisproperlyfittedanddoesnotinad-

vertentlyrubbonyprominences.2. MayputlightT-shirtunderbraceforcomfort.3. Initially,thebraceisworn20to23hoursperday.4. Braceisregularlyadjustedtopromotecorrection.5. If progress is good, child is weaned from the brace

duringthedaytimeandwearsitonlyatnight.6. Supplementalexercises.

Goal: To support normal growth and development andassistthechildtodevelopapositiveself-image.

A. Continuetoencouragepeersocialization.B. Encourageindependence.C. Encouragechildtoparticipateinandbeindependentin

schedulingofactivitiesandotheraspectsofcare.D. Emphasizepositivelong-termoutcome.Goal: To maintain spinal alignment after surgical correc-

tion(seeCareofClientAfterLaminectomyandFusion).Goal: To maintain homeostasis and assess for complica-

tionsafter surgical correction (seeCareofClientAfterLaminectomyandFusion).

FracturesA. Afracture isadisruptionorbreak inthecontinuityof

the bone, which occurs most often as the result of atraumaticinjury.

FIGURE 21-1 Types of Fractures. A, Greenstick. B, Transverse. C, Oblique. D, Spiral. E, Comminuted. F, Open. (Courtesy Rocky Shepheard, New London, Ohio. In Monahan FD et al: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St. Louis, 2007, Mosby.)

A B C

D E F

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3. Stableversusunstablefracture.a. Stable:aportionoftheperiosteumusuallyremains

intact; frequently transverse, spiral, or greenstickfractures.

b. Unstable:bonesaredisplacedatthetimeofinjury,withpoorapproximation;frequentlycomminutedorimpacted.

4. Simple,closedfracture:doesnotproduceabreakintheskin.

5. Complex, open, or compound fracture: involves anopenwoundthroughwhichthebonehasprotruded.

2. Types.a. Skeletal: wire or metal pin is inserted into or

throughthebone.b. Skin: forceofpull is applieddirectly to the skin

andindirectlytothebone.D. Castapplicationtomaintainimmobilityofaffectedarea.

1. Cast applied to immobilize joints above and belowtheinjuredarea.

2. Shortorlongarmorlegcast.3. Bodyjacketcastforspinalinjuries.4. Hipspicacastforfemoralfractures.

E. Fixationdevices.1. Externalfixation:applicationofarigidexternaldevice

consistingofpinsplacedthroughtheboneandheldinplacebyametalframe;requiresmeticulouscareofpininsertionsites(Figure21-3).

2. Internal fixation: done through an open incision;hardware(pins,plates,rods,screws) isplacedinthebone.

3. Bothmethodsmaybeusedtotreatafracture.

ComplicationsA. Improperhealing:delayedunion,nonunion,orangula-

tion(bonehealsatadistortedangle).B. Infection:especiallyininjuriesresultinginanopenfrac-

tureandsofttissueinjury.

NURSING PRIORITY Age, displacement of the fracture, the site of the fracture, nutritional level, medications, and blood supply to the area of injury are factors influencing time required for fracture healing to become complete. Be familiar with the terms used to describe fractures.


1. Pathologicfracture.a. Osteoporosis.b. Tumors(multiplemyeloma,osteogenicsarcoma).c. Metabolicdiseases(e.g.,thyroiddisorders).

2. Trauma.B. Clinicalmanifestations.

1. Edema,swellingofsofttissuearoundtheinjuredsite.2. Pain:immediate,severe.3. Abnormalpositioningofextremity;deformity.4. Lossofnormalfunction.5. False movement: movement occurs at the fracture

site;boneshouldnotmoveexceptatjoints.6. Crepitus:palpableor audible crunchingas the ends

ofthebonesrubtogether.7. Discolorationoftheskinaroundtheaffectedarea.8. Sensationmaybeimpairedifthereisnervedamage.


TreatmentA. Immediateimmobilizationofsuspectedfracturearea.B. Fracturereduction.

1. Closed reduction: nonsurgical, manual realignmentofthebones;theninjuredextremityisusuallyplacedinacastforcontinuedimmobilizationuntilhealingoccurs.

2. Openreductionandinternalfixation(ORIF):surgi-calcorrectionofalignment.

C. Traction(Figure21-2).1. Purposes.

a. Immobilizationof fracturesuntil surgicalcorrec-tionisdone;immobilizationoralignmentoffrac-ture until sufficient healing occurs to permitcasting.

b. Decrease,prevent,orcorrectboneorjointdefor-mities associated with muscle diseases and boneinjury.

c. Preventorreducemusclespasm.

FIGURE 21-2 Traction. A, Balanced suspension traction with a Thomas splint and a Pearson attachment. B, Buck’s extension traction. C, 90°-90° traction. (A from Monahan FD et al: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St. Louis, 2007, Mosby. B and C from Hockenberry MJ, Wilson D: Wong’s nursing care of infants and children, ed 8, St. Louis, 2007, Mosby.)

Tibial pin forskeletal tractionA

B

C

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C. Decreased neurovascular status resulting from pressureofcastandedemaformation.1. Decreasedpulsesdistaltoinjury.2. Painunrelievedbyanalgesics.3. Edema,pallor.4. Decreasedsensoryandmotorfunction.

D. Compartmentsyndrome:muscle,nerves,andvesselsarerestrictedtoaconfinedspace(myofascialcompartment)withinanextremity(Figure21-4).1. Etiology.

a. Decreased compartment size from cast, splints,tightbandages,tightsurgicalclosure.

b. Increaseincompartmentcontentscausedbyhem-orrhageand/oredema.

2. Clinicalmanifestationsofcompartmentsyndrome.a. Muscleischemiaoccursasaresultofcompression

ofstructuresinthecompartment.b. Arterial compression may not occur; pulses may

stillbepresent.

g. Volkmann’s ischemic contracture: compartmentsyndrome in the arms that compromises circula-tion;occursmostoftenasaresultofshortarmcastusedtoimmobilizeafractureofthehumerus.

h. Canresult inpermanentdamage inashort time(6-8hours).

i. Paresthesia is frequently the first sign; pulseless-nessisalatesign.

E. Venous stasis and thrombus formation are related toimmobility.

F. Fatembolism.1. Associated with fractures or surgery of long bones

(especiallythefemur);primarilyoccursinadults.2. Clinicalmanifestationsgenerallyoccurwithin12to

48hoursofinjury.3. Fat embolism produces symptoms of acute respira-

torydistressandhypoxia.G. Blisters may be associated with twisting-type fractures

orcompartmentalsyndrome.

Nursing InterventionsGoal: Toimmobilizeafracturedextremityandtoprovide

emergencycarebeforetransportingvictim.A. Evaluatecirculationdistaltoinjury.

FIGURE 21-3 External fixation. (Courtesy Stryker, Kalamazoo, MI.)

ALERT Manage a client with alteration in hemodynamics, tissue perfusion and hemostasis (cerebral, cardiac, peripheral). Recognize signs and symptoms of complications.

c. May cause permanent damage if not relievedimmediately.

d. Clients complainof excessivepainunrelievedbyanalgesics.

e. Occurrenceofcomplicationmaybedecreasedbyelevation of the extremity and application of icepacksafterinitialinjury.

f. Treatmentisdirectedtowardimmediatereleaseofpressure: if theclienthasacast, thecastmaybe“bivalved”—thecastissplitinhalf,andthehalvesaresecuredaroundtheextremitybyawrap,suchasanelasticbandage.

FIGURE 21-4 Compartments of the leg. (From Monahan FD et al: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St. Louis, 2007, Mosby.)

Deep posteriorcompartment

Fibula

Lateralcompartment

Anteriorcompartment

Anterior tibialneurovascular bundle

Posterior tibialneurovascular bundle

Tibia

Interosseousmembrane

Superficialposterior

compartment

Fascia

NURSING PRIORITY: Identify orthopedic situations that can cause compromised circulation and neurologic damage; intervene and obtain assistance.

B. If pulses are not present or if the extremity must berealignedtoapplysplintfortransfer,applyjustenoughtractiontosupportandimmobilizethefracturedextrem-ityinapositionofproperalignment.Oncethetraction

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isinitiated,donotreleaseituntiltheextremityhasbeenproperlysplinted.

C. Splintandimmobilizeextremitybeforetransfer.

5. Trynottogetthecastwet;afterthecastisdryandtheinitialedemaisresolved,mayuselowsettingonhairdryerafterexposuretowater.

NURSING PRIORITY Do not apply traction to compound fractures; traction may cause more damage to tissue and vessels.

D. Elevate the affected extremity, if possible, to decreaseedema.

Goal: To identify complications early, perform frequentperipheral nerve and vascular assessments distal to theareaofinjuryorcast.

A. Impairedbloodflow.1. Pulselessness;skinpaleandcooltotouch.2. Pain,swelling,edemadistaltoinjuryorcast.3. Capillaryrefillgreaterthan3seconds.

B. Nervedamagefromexcessivepressure.1. Paresthesia,numbnessdistaltoinjuryorcast.2. Motorparalysisofpreviouslyfunctioningmuscles.3. Feelingofdeeppainandpressure.

C. Infection:mayoccurwithinthecast.1. Unpleasantodor,drainage(foul,purulent).2. Generalizedbodytemperatureelevation.3. Increasedwarmthovercast,“hotspot.”

ALERT Monitor wound for signs and symptoms of infection; identify adverse response to therapy.

D. Compartmentsyndrome.1. Significant increase in pain, not responsive to

analgesics.2. Lossofmovementandsensationdistaltocast.3. Skinispale,cooltotouch.4. Edemadistaltoinjuryorcast.5. Pulsesmaybepresentinitially.

E. Notify physician immediately if any complications ofcompartmentsyndromeorcompromisedcirculationarepresent.

ALERT Manage care for a client with alteration in tissue perfusion (peripheral circulation). Recognize signs and symptoms of complications and intervene appropriately.

Goal: Tomaintainimmobilizationbymeansofacast.A. Plastercast:allowcasttodryadequatelybeforemoving

theclientorhandlingthecast.1. Encouragedryingofcastbyusingfansandmaintain-

ingadequatecirculation.2. Avoidhandlingwetcasttopreventindentionsinthe

cast,whichmayprecipitatepressureareasinsidethecast;supportcastonpillows.

3. Repositionclientevery2hourstoincreasedryingonallcastsurfaces.

4. “Petaling”acastisdonetocovertheroughedgesandpreventcrumblingofaplastercast;edgesarecoveredwithsmallstripsofwaterproofadhesive.

NURSING PRIORITY Teach client: DO NOT get plaster cast wet, remove any type of padding, insert any objects inside cast, bear weight on new cast for 48 hours (if weight-bearing type), or cover cast with plastic for long periods of time.

B. Synthetic casts (fiberglass, polyester cotton knit) arelighterandrequireaminimalamountofdryingtime.1. Frequentlyusedforupperbodycast.2. Preferableforinfantsandchildren.3. Castdoesnotcrumblearoundtheedgesanddoesnot

soilaseasily.4. Cast dries rapidly if it gets damp, and it does not

disintegrate in water; some synthetic casts can beimmersedforbathing.

C. Continue to assess for compromised circulation andcompartmentsyndrome.

D. Bodyjacketcastandhipspicacast.1. Evaluate for abdominal discomfort caused by cast

compressionofmesentericarteryagainstduodenum.2. Relief of abdominal pressure can be achieved by

meansofnasogastrictubeandsuctionorcastremovalandreapplication.

3. Evaluateforpressureareasoveriliaccrest.E. Elevate casted extremity, especially during the first 24

hoursafterapplication.F. Applyicepacksovertheareaofinjury(keepingcastdry)

duringthefirst24hours.G. Encouragemovementandexerciseofunaffectedjoints.Goal: Tomaintainimmobilizationviatraction(seeFigure

21-2).A. Assume that traction is continuous unless the doctor

ordersotherwise.B. Carefullyassessforskinbreakdown,especiallyunderthe

client.C. Do not change or remove traction weight on a client

withcontinuoustraction.D. The traction ropesandweights shouldhang free from

anyobstructions.E. Tractionappliedinonedirectionrequiresanequalcoun-

tertractiontobeeffective.1. Donotlettheclient’sfeettouchtheendofthebed;

thiswillcausethecountertractiontobelost.2. Donotallowthetractionweightstorestonanything

at the end of the bed; this negates the pull of thetraction.

F. Carefullyassessthepinsitesinclientswithskeletaltrac-tion.Osteomyelitisisaseriouscomplicationofskeletaltraction.

ALERT Recognize client with a condition that increases risk for insufficient vascular perfusion; monitor effective functioning of therapeutic device; prevent complications of immobility. The majority of clients with fractures will experience some level of immobility.

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Goal: To prevent complications of immobility (seeChapter3).

Goal: To prevent complications from external or internalfixation.

A. Inspectexposedskinandpinsitesforinfection.B. Cleansearoundpinsites.C. Performwoundcareonincisionalareaorareaoftrauma.D. Observecarefullyfordevelopmentofaninfection.E. Evaluateforcirculatoryandneurosensoryimpairment.

Home CareA. Teachclientwhatnottodo.

1. Do not bear weight on the affected extremity untilinstructedtodoso.

2. Donotallowthecasttogetwet(discussalternativestotubbaths).

3. Donotinsertanyobjectsintothecastorremoveanypadding.

4. Do not move or manipulate pins on an externalfixatordevice.

B. Clientshouldreportsymptomsassociatedwithswellingor an increase in pain, especially pain unrelieved byanalgesics.

C. Assesspinsitesforevidenceofinfection.

Specific FracturesA. Colles’fracture.

1. Fractureofthedistalradius.2. Primarycomplicationiscompartmentsyndrome.

B. Fracturedpelvis.1. Frequently occurs in older adults and is associated

withfalls.2. Maycauseserious intra-abdominal injuries(hemor-

rhage)andurinarytractinjury.3. Bed rest is prescribed for clients with stable

fractures.4. Combinationoftraction,cast,andsurgicalinterven-

tion may be used for the client with a complexfracture.

5. Turnclientonlyonspecificorders.C. Fracturedhip:maybe repairedbyfixedor slidingnail

plates,replacementprostheses,orhipjointreplacement.1. Common inwomenolder than65yearsbecauseof

lossofposturalstabilityandlossofbonemass.2. Typesoffractures.

a. Intracapsular fracture (femoralneck):morediffi-cult to heal; associated with osteoporosis; morelikelytobeassociatedwithavascularnecrosisduetointerruptionofbloodsupply.

b. Extracapsularfracture:occursoutsidejointcapsule;usuallycausedbyseveredirecttraumaorafall.

3. Clinicalmanifestations.a. External rotation and adduction of the affected

extremity.b. Shortening of the length of the affected

extremity.c. Severepainandtenderness.

4. Treatment.a. Initially, Buck’s traction to immobilize fracture

anddecreasemusclespasms(seeFigure21-2).b. Surgicalrepairassoonasclient’sconditionallows

(permits earlier mobility and prevents complica-tionsofimmobility).

5. Nursinginterventionsaftersurgery(Box21-3).a. Circulatoryandneurologicchecksdistaltoareaof

injury.b. Positiontopreventflexion,adduction,andinter-

nal rotation, which cause dislocation of theprosthesis.

ALERT: Position client to prevent complications.


Musculoskeletal Nursing Implications

• Older adults have difficulty maintaining immobility afterfractures; therefore fractures are frequently repaired withsurgicalintervention(ORIF).

• Older adults heal more slowly, so use of extremity andweightbearingarefrequentlydelayed.

• Complicationsofimmobilityoccurmorefrequently;mobi-lizehospitalizedclientsasearlyaspossible.

• Donotrelyonfeverastheprimaryindicationofinfection;decreasingmentalstatusismorecommon.

• Contracturesaremorecommoninolderadults.• Encourageolderadultstouseassistivedevicessuchascanes

andwalkers.

(1) Donotadducttheaffectedlegpasttheneutralposition.

(2) Maintaintheaffectedleginanabductedposi-tion with an A-frame pillow or pillowsbetweenthelegs.

(3) Avoid flexion of the hip of more than 90degrees.

(4) Preventinternalorexternalrotationbyusingsandbags,pillows,andtrochanter rollsat thethigh.

(5) Extreme external rotation accompanied bysevere pain is indicative of hip prosthesisdisplacement.

c. Checkphysician’sorderregardingpositioningandturning.

d. Evaluatebloodloss.(1) Check under the operative site for hemor-

rhage.(2) Measurethediameterofboththighstoevalu-

ate the presence of internal bleeding in theaffectedextremity.

NURSING PRIORITY: The client is especially prone to complications of immobility (thromboembolism following hip fracture); use nursing interventions to minimize complications.

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D. Totalhipreplacement.1. Hipreplacementmaybedonebecauseofapathologic

fractureoradiseaseprocesssuchasarthritis.2. Preoperativecare.

a. Encourageclienttopracticeusingeithercrutchesor a walker, whichever is anticipated to be usedaftersurgery.

b. Encourageclienttopracticemovingfrombedtoachairinthemannerthatwillbenecessaryaftersurgery.

c. Helptheclientbeginpracticingthepostoperativeexercisessothatheorshewillunderstandandbeabletodothemcorrectlyaftersurgery.

d. ClientshoulddiscontinueuseofNSAIDsand/oraspirinaboutaweekbeforesurgery.

3. Postoperativecare.a. Positionsupinewithheadslightlyelevated,main-

tainabductionofaffectedleg.b. Quadricepsexercises.c. Neurologicandcirculationchecks.d. Client ismobilizedonfirstorsecondpostopera-

tive day to prevent complications of immobility;mayuseantiembolismstockingsand/orsequentialcompressionpumpsonlowerextremitytopreventvenousstasis.

e. Low-molecular-weight heparin (see Appendix16-3)maybegiventopreventthrombophlebitis.

f. Keep client’s heels off the bed to prevent skinbreakdown.

g. Legsshouldnotbecrossed.

2. Painful respirations cause client’s breathing to bemoreshallowandcoughingtoberestrained;thispre-cipitatesbuildupofsecretionsanddecreasedventila-tion,leadingtoatelectasis.

3. Chesttapingorstrappingisnotusuallydonebecauseitdecreasesthoracicexcursion.

4. Multiple rib fractures may precipitate the develop-mentofapneumothoraxoratensionpneumothorax(seeChapter15).

G. Mandiblefracture.1. Wiring of jaws (intermaxillary fixation) is

treatment.2. Postoperativeproblems:airwayobstructionandaspi-

rationofvomitus.3. Wirecuttersatbedsideincaseofemergency(cardiac

orrespiratoryarrest).a. Suctionclientifvomiting.b. Cuttingwiresmaycomplicateproblem.

4. Tracheostomysetatbedside.5. Oralhygieneanduseofpad/pencilorpictureboard

tocommunicatepost-op.6. Discharge teaching: oral care, techniques for han-

dlingsecretions,diet(problemswithconstipationandflatusduetolow-bulk,high-carbohydrateliquidsup-plements),howandwhentousewirecutters.

OsteoporosisOsteoporosis is a metabolic bone disease that involves an imbalance between new bone formation and bone resorption.A. Primaryosteoporosis is themostcommontype;occurs

mostofteninwomenaftermenopausebecauselowlevelsof estrogen are associated with an increase in boneresorption.

B. Bonelossoccurspredominantlyinthevertebralbodiesofthespine,thefemoralneckinthehip,andthedistalradiusofthearm.Bonemassdeclines,leavingthebonesbrittleandweak.


1. Age/ethnicity:incidenceincreasesinwhiteandAsianwomenaftertheageof50years.

2. Estrogendeficit:earlymenopause,estrogen-blockingmedicationssuchastamoxifenoraromasin.

3. Lowpeakbonemass:themaximumamountofboneapersonachievesispeakbonemassachievedbeforeage20.

4. Alcoholintake,sedentarylifestyle.5. Endocrine disorders of the thyroid and parathyroid

glands.6. Nutritional deficits: insufficient intake of dietary

calciumand/orvitaminD.7. Cigarettesmoking,long-termuseofcorticosteroids.

B. Clinicalmanifestations(Figure21-5).1. Maybeasymptomaticuntilx-rayfilmsdemonstrate

skeletal weakening. Bone loss of 25% to 40% must

NURSING PRIORITY After surgery, do not allow the repaired hip to flex greater than 90 degrees; avoid adduction and internal rotation of extremity. Flexion and adduction will dislocate the hip prosthesis.

h. Observeforsignsofpossiblehipdislocation.(1) Increasedhippain.(2) Shorteningofaffectedleg.(3) Externallegrotation.(4) If these symptoms are observed, contact the

surgeonimmediately.E. Femoralshaftfracture.

1. Commoninjuryinyoungadultsandchildren.2. Treatment.

a. Immobilityisachievedbymeansofaspicacastinolderchildren.

b. 90°-90°traction(seeFigure21-2):balancedskel-etaltractionforfracturedfemur.

c. Olderchildandadult.(1) Internalfixation(adults).(2) Balancedskeletaltractionfor8to12weeks.(3) Immobilizationbyapplicationof ahip spica

castaloneorafterbalancedskeletaltraction.F. Ribfractures.

1. Usually heal in 3 to 6 weeks with no residualimpairment.

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occurbeforeosteoporosiscanbe identifiedonstan-dardx-rayfilms.

2. Spinaldeformityand“dowager’shump.”a. Resultsfromrepeatedpathologic,spinalvertebral

fractures.b. Graduallossofheight.c. Increaseinspinalcurvature(kyphosis).

3. Spinal fractures may occur spontaneously or as aresultofminimaltrauma.

4. Chroniclowthoracicandmidlinebackpain.5. Height loss may precipitate thoracic problems,

decreaseinabdominalcapacity,anddecreaseinexer-cisetolerance.

6. Hip fractures and vertebral collapse are the mostdebilitatingproblems.

C. Diagnostics(seeAppendix21-1).1. Serumlaboratoryvaluesofcalcium,vitaminD,phos-

phorus, and alkaline phosphatase may be normalorlow.

2. Computedtomographyorbonedensityscan(DEXA)canbeperformedtoevaluateboneloss.a. Bonemineraldensity(BMD):2.5standarddevia-

tionsbelowmeanofyoungadults is classifiedasosteoporosis.

b. Osteopenia:T-score=1.0to2.5,butnotatlevelofosteoporosis.

TreatmentA. Dietary: increased intake of protein, calcium, and

vitaminD.B. Medications.

1. Calciumsupplements:dailyintakeofcalciumshouldbeapproximately1000mgformenand1500mgforpostmenopausalwomen.

2. Vitamin D supplements to enhance utilization ofcalcium; spending 20 minutes daily in the sun willprovideadequatevitaminD.

3. Medicationstofacilitateincreasedbonedensity(seeAppendix21-2).

C. Exercise:activitiesthatputmoderatestressonbonesbyworking them against gravity (walking, racquet sports,jogging).1. Swimmingandyogamaynotbeasbeneficialbecause

ofdecreasedstressonbonemass.2. Walking for 30 minutes 3-5 times a week is most

effectiveexerciseinpreventingosteoporosis.3. Weight bearing exercise decreases the development

of osteoporosis and possibly increases new boneformation.

D. Compression fractures of the vertebrae usually healwithoutsurgicalintervention.

ComplicationsBone fractures occurring in the vertebral bodies, distalradius,orhip.

Nursing InterventionsGoal: Todecreasepainandpromoteactivitiestodiminish

progressionofdisease.A. Painrelief.

1. Bedrestinitially,firmmattress.2. Narcoticanalgesicsinitially,followedbynonsteroidal

antiinflammatorydrugs(NSAIDs).B. Assessbowelandbladderfunction;clientwillbeprone

to constipation and paralytic ileus if vertebrae areinvolved.

C. Regular daily exercise; encourage outdoor exercises(increasesutilizationofvitaminD).

D. Increasedcalciumintakeandestrogentherapy.

Home CareA. Decreasefallsandinjurybymaintainingsafehomeenvi-

ronment(Box21-4).

FIGURE 21-5 Osteoporotic changes. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 8, Philadelphia, 2009, Saunders.)

Height–5�6�

–5�3�

–5�

–4�9�

–4�6�

–4�3�

40 years 60 years 70 years


Protecting Joints

• If pain lasts longer than 1 hour after exercise, change theexercisesthatinvolvethatjoint.

• Planactivityandworkthatconserveenergy;doimportanttasksfirst.

• Alternateactivities;donotdoallheavytasksatonetime.• Minimizestressonjoints;sitratherthanstand,avoidpro-

longedrepetitivemovements,movearoundfrequently,avoidstairsorprolongedgrasping.

• Uselargestmusclesratherthansmallerones;useshouldersorarmsratherthanhandstopushopendoors;pickupitemswithoutstoopingorbending;uselegmuscles;womenshouldcarrypursesontheirshouldersratherthanintheirhands.

• Painful,acutelyswolleninflamedjointsshouldnotbeexer-cisedbeyondbasicrangeofmotion.

• Regularexercisecanbedoneevenwhen jointsareslightlypainfulandstiff;swimmingandbikeridingmaintainmobil-itywithoutweight-bearing.

• Expectchangesinmentalstatusaftersurgery.• Theremaybearolechangeinthefamilyduetotheclient’s

decreasedmobility.

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B. The client should understand the need to continuetakingmedications,eveniftheydonotmaketheclientfeelbetter. It is important for theclient tounderstandthatthecalciumandvitaminDsupplementsareneces-sarytopreventfurtherboneloss.

C. Donotexerciseifpainoccurs.D. Avoidheavylifting,stooping,andbending.Reviewand

demonstrategoodbodymechanicswiththeclient.

OsteomyelitisOsteomyelitis is an infection of the bone, bone marrow, and surrounding soft tissue.A. ThemostcommoncausativeorganismisStaphylococcus

aureus.B. Inflammatory response occurs initially, with increased

vascularizationandedema.C. Eventhoughthehealingprocessoccurs,thedeadbone

tissue frequently forms a sequestrum, which continuestoretainviablebacteria;thistissuemayproducerecur-rentabscessesforyears.

D. Classifiedaccordingtoacuteorchronicstatus.1. Acute: sudden onset; may heal in 2 to 3 weeks or

progresstochronicstatus.2. Chronic:acontinuous,persistentproblemorexacer-

bationofpreviousproblem.


1. Indirectentryoforganism:hematogenous.a. Morefrequentlyaffectsgrowingbone.b. Injuryandinfectionofadjacentsofttissueindistal

femur,proximaltibia,humerus,andradius.2. Directinjury:canoccuratanyage.

a. Trauma.b. Surgicalprocedures.

B. Clinicalmanifestations.1. Acute.

a. Tenderness,swelling,andwarmthinaffectedarea.b. Drainagefrominfectedsite.c. Systemic symptoms: fever, chills, nausea, night

sweats.d. Constant pain in affected area; worsens with

activity.e. Circulatoryimpairment.

2. Chronic (present longer than 1 month; failed torespondtoinitialcourseofantibiotictherapy).a. Drainagefromwoundorsinustract.b. Recurrentepisodesofbonepain.c. Diminishedsystemicsigns:low-gradefever;local

signsofinfectionmorecommon.d. Remissionandexacerbationofproblem.

C. Diagnostics(seeAppendix21-1).1. Woundand/orbloodculture.

TreatmentA. Intensive intravenous (IV) antibiotics; oral antibiotic

therapyfor6to8weeks.

B. Immobilizationofaffectedarea.C. Surgicaldebridementmaybenecessary.D. Hyperbaricoxygentherapytostimulatecirculationand

healing.

Nursing InterventionsGoal: To decrease pain, promote comfort, and decrease

spreadofinfection.A. Administer IV piggyback antibiotics; frequently assess

statusofIVsite.B. Maintaincorrectbodyalignment.

1. Moveaffectedextremitygentlyandwithsupport.2. Preventcontractures,especiallyofaffectedextremity.

C. If there is an open wound, maintain wound (contact)precautions(seeChapter6).

D. Clientisusuallydischargedwithprescriptionforantibi-oticsandshouldkeepallfollow-upcareappointments.

ALERT Monitor wounds for signs of infection; manage wound care.

Osteogenic SarcomaA. Osteogenicsarcoma(osteosarcoma)isthemostcommon

primary bone cancer; it advances very rapidly withmetastasistothelungsviatheblood(seeChapter8).

B. Most commonly affects the long bones, often thedistal end of the femur, proximal tibia, or proximalhumerus.


1. Peakincidencebetween10and25yearsofage.2. Increasedincidenceinmalesduringadolescence.

B. Clinicalmanifestations.1. Localized pain, swelling at site of tumor usually

aroundknee.2. Client may limp and be unable to function at full

capacity.C. Diagnostics(seeAppendix21-1).

1. Computedtomographyscantodeterminetheextentofthelesion.

2. Radioisotopescanstoevaluateformetastasis.3. Lung evaluation to determine whether metastatic

sitesarepresent.4. Resultsofserumlaboratorystudiesareinconclusive;

client usually has an increase in the serum alkalinephosphataselevel.

5. X-rayfilmwillrevealthetumorlocationandassistindetermininganappropriatebiopsysite.

TreatmentA. Amputationofextremityand/orextensivesurgicalresec-

tionofboneandsurroundingtissue.Limbsalvagepro-ceduremoreoftendone,ifthereisaclearmarginaroundtumorsite.

B. Chemotherapy;radiationtherapy.

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Nursing InterventionsGoal: Tomaintainhomeostasisandpreventcomplications

aftersurgery.A. An extensive pressure dressing with wound drains/

suctionmaybeapplied.B. ROMisusuallybegunimmediately;continuouspassive

motionmaybeusedimmediatelyoronfirstpostopera-tivedayforbothupperandlowerextremitysurgery.

C. Muscletoningisimportantbeforeweightbearing.D. Frequentneurovascularassessmentisnecessarybecause

ofresectionofnervesandvesselsinarea;extremitymayalsobecastedorsplintedforsupport.

Goal: Topreventcomplicationsandpromotemobilityafteramputation(seeAppendix21-3).

Goal: Toassisttheclient/childandfamilytocopewiththediagnosisandbuildbasisforrehabilitation.

A. Provide honest, straightforward information to child/clientandparentsregardingthesituation.

B. Allow the family and client an opportunity to expresstheir concerns and fears; surgery is extensive and mayaffectbodyimage(seeChapter9).

C. Anticipatesenseoflossofcontrolandangeroverchangesinbody.

D. Encouragenormalgrowthanddevelopmentalactivitiesas appropriate; allow client to be as independent aspossible.

Goal: To assist the child and the family to cope withthe side effects of chemotherapy and radiation (seeChapter8).

AmputationsRemoval of part of an extremity at various anatomic locations.

AssessmentA. Indicationsforamputation.

1. Peripheralvasculardisease,especiallyvasculardiseaseoflowerextremities.

2. Severetrauma,congenitaldisorders.3. Acuteorwidespreadinfections(e.g.,gasgangrene).4. Malignanttumors.

B. Diagnostictests:dependentonunderlyingproblem.

Nursing InterventionsGoal: Topreventfurtherlossofcirculationtotheextrem-

ity, promote psychologic stability, promote comfort,promoteoptimumlevelofmobility.

A. Monitorcirculationbeforesurgery.B. Provide preoperative care regarding upper extremity

exercises to promote arm strength for postoperativeactivitiesofcrutchwalkingandgaittraining.

Goal: To manage pain control and residual limb woundcarepostoperatively.

A. Residuallimbmaybeelevatedimmediatepost-op;afterthattime,clientsshouldavoidsittinginachairformorethan1hourwithhipsflexedorhavingpillowundertheresidual limb to prevent flexion contractions. Flexioncontracturehindersuseofprosthesis.

B. Clientshouldlieontheirabdomenfor30minutes3to4 times/day and position the hip in extension whileprone.

C. Discussthephenomenonofphantomlimbsensation.D. Administeranalgesics;phantomlimbpainisveryrealto

theclient.E. Evaluateresiduallimbforbleedingandhealing.F. Arigidcompressiondressing(plastermoldedoverdress-

ing) may be applied to prevent injury and to decreaseswelling. Controlling the edema will enhance healingandpromotecomfort.Changesoftherigiddressingarenecessary;astheresiduallimbheals,italsoshrinks.Thecompression dressing may be changed three or fourtimesbeforeapermanentprosthesisisfitted.Thecom-pressiondressingmaybeformedsothatitcanattachtoaprosthesis.

G. Iftheclientisnotfittedwitharigidcompressiondress-ing,theresiduallimbwillbeshapedwithacompressionbandage.Acebandageelasticwrappingisoftenusedforcompressionofthistype.Itshouldbewornatalltimesexceptduringphysicaltherapyandbathing.

Goal: Toassisttheclienttounderstandmeasuresforresid-uallimbcareafterthewoundhashealed.

A. Continually assess for skin breakdown; visuallyinspect the residual limb for redness, abrasions, orblistering.

B. The residual limb should be washed daily, carefullyrinsed,anddried;residualsoapandmoisturecontributetoskinbreakdown.

C. Do not apply anything to the residual limb (alcoholincreases skin dryness and cracking; lotions keep skinsoftandhinderuseofprosthesis).

Home CareA. Clientshouldputtheprosthesisonwhenheorshegets

upand shouldwear it allday.The residual limb tendsto swell if theprosthesis is not applied.Themore theclient wears the prosthesis; the less swelling will beexperienced.

B. Usingalowerlimbprosthesisrequires40%to60%moreenergyforwalking.

C. Referral to community health nurse for instructionambulation,transfertechniques,pronepositioning,andproperresiduallimbcare.

Rheumatoid ArthritisRheumatoid arthritis is a chronic, systemic autoimmune disease that affects all areas of the body; inflammatory responses occur in all connective tissue. Early symptoms include inflammation of the synovial joints.

ALERT Identify and prevent complications of immobility; use positioning to prevent contractures; provide support for client with unexpected alteration in body image; assist client to ambulate and move with assistive devices; promote wound healing; assist client with use of prosthesis.

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A. Jointinvolvementprogressesinstages;ifdiseaseisdiag-nosed early, permanent joint deterioration may beprevented.1. Thesynoviumbecomesthickenedandinflamed,and

fluid accumulates in the joint space; this causes apannustoform.

2. Thepannus tissueerodes the cartilageanddestroysthejoint.

B. Exacerbationsandremissionsoccur;conditiontendstobeprogressivewitheachexacerbation.

C. Conditionisaproblemoftheconnectivetissue;inflam-matory response may occur in organs throughout thebody(heart,lungs,bloodvessels,muscles).


1. Gender:significantlyincreasedincidenceinwomen.2. Mayoccuratanyageincludingchildhood;peakinci-

denceoccursbetween20and45yearsofage.3. Geneticpredisposition.

B. Clinicalmanifestations.1. Symmetricaljointinvolvement(handsandfeet).

a. Warm,tender,red,painfuljoints;primarilyaffectssmalljoints,wrists,elbows,shoulders.

b. DecreaseinROM.c. Decreaseinstrength.d. Stiffness and pain are worse in the morning

and decrease during the day with moderateactivity.

2. Subcutaneousnodulesoverbonyprominences.a. Nodules are painless; frequently occur on the

elbows.b. Maybepresentforweekstomonths.

3. Systemiceffects.a. Vasculitis.b. Pulmonaryfibrosis.c. Pericarditis.d. Sjögren’ssyndrome(dryeyes,etc.).

4. Chronic deformities develop, most often in thehands.

5. Exacerbation of symptoms may be associated withphysicaloremotionalstress.


TreatmentA. Disease-modifying antirheumatic drugs (DMARDs)

(seeAppendix21-2).B. NSAIDs.

1. Salicylate(aspirin).2. Ibuprofen,naproxen.

C. Corticosteroids(seeAppendix6-7).D. Methotrexate(seeAppendix8-1).E. Heatand/orcoldapplications.F. Assistive devices to preserve joints and prevent

deformity.G. Physicalandrehabilitativetherapy.H. Surgery:jointreplacements.

ComplicationsA. Musculoskeletal.

1. Severejointdeformity,flexioncontracture.2. Diffuseskeletaldemineralization.3. Stressfractures.

B. Systemicinvolvement.

Nursing InterventionsGoal: To relieve pain and preserve joint mobility and

musclestrength(seeBox21-4).A. Use warm compresses to promote relaxation and to

decrease stiffness; use cold compresses to decreaseinflammation.

B. Ifheatincreasespain,coldcompressesmaybebeneficialduringanacuteepisode.

C. Acutely inflamed joints should be immobilized in adevicethatmaintainsafunctionalposition.

D. Positionclienttomaintaincorrectbodyalignmentandpreventcontractures,especiallyflexioncontractures.

ALERT Assess client for complications of immobility, intervene appropriately when providing care.

E. Immobility can increase the pain; ROM exercises andweightbearingmayhelpdecreasepain.

F. Antiinflammatory medications should be taken beforeactivityandwithmealsorfoodtodecreasegastricupset.

G. If client is taking steroids, he or she should wear amedicalidentificationtag.

Goal: To assist client to prevent joint deformity, preservejointfunction,andreduceinflammationandpain.

A. Regularly scheduled rest periods (excessive fatigue is aproblem);balanceactivitieswithrest.

B. Protectjoints(Box21-4).1. Maintainfunctionaljointalignment;avoidpositions

that precipitate joint contraction (sitting too longwithkneesbent).

2. Warmmoistorcoldcompresses to relievepainandmusclespasms.

3. Acutelyinflamedjointsmaybesplinted;splintshouldbe removed periodically and gentle ROM exercisesperformed.

4. Uselargemusclegroups;avoidrepetitivemovementofsmallerjoints.

C. Demonstrate ability to carry out individual exerciseprogram.

D. Identifymedicationsthatareeffectiveinrelievingpain.E. Chronicpainmayleadtofeelingsofpowerlessnessand

make the client more susceptible to false advertisingregardingclaimsofcureandreliefofchronicpain.

F. Encourageclienttobeindependentinactivitiesofdailyliving(ADLs)aslongaspossible.

Home CareA. Encourageclienttoventilatefeelingsregardingchronic

progressionofthediseasestate.B. Evaluatefamilysupportsystem;helpfamilytoidentify

measurestoassistclient.

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C. Modifyhomeroutinetodecreasestressonjoints:ADLs,dressing,etc.

D. Identifymeasurestoassistclienttomaintainself-esteem:What activities can client continue to participate in?Focusonwhatclientcando.

E. Assistclienttosetrealisticgoals.F. Identifyavailablecommunityresources.

B. Activitybalancedwithadequaterest.C. Weightreduction,ifappropriate.D. Physicaltherapyandexercise.E. Surgicalinterventionwithjointreplacement.

Nursing InterventionsGoal: To relieve pain, prevent further stress on the joint,

andmaintainfunction.A. Acutely inflamed joint should be immobilized with

splintorbrace.B. Plan ADLs to prevent stress on involved joints and

provideadequaterestperiods.C. Heat compresses can be used for relief of pain; cold

compressesmaybeusedifjointisinflamed.D. Itisveryimportanttomaintainregularexerciseprogram;

decreaseactivityinacutelyinflamed,painfuljoints.

ALERT Determine client’s ability to perform self-care; assist family to manage care of client with long-term care needs.

Osteoarthritis (Degenerative Joint Disease)Osteoarthritis is a progressive, nonsystemic, noninflam-matory disease that causes a progressive degeneration of synovial joints of weight-bearing long bones.A. Primarilyassociatedwithaging;mayalsobecausedby

musculoskeletalinjuryorconditionsthatcauserepetitivedamagetojoints.

B. Thecartilageattheendsofthelongbonesdeterioratesandleavestheendsofthebonesrubbingtogether;thisproducesapainful,swollenjoint.

AssessmentA. Etiology/predisposingfactors.

1. Excessiveuseofaspecificjoint:kneesinathletes,feetindancers,etc.

2. The hips are more commonly affected in men; inwomen,thehandsaremorecommonlyaffected.

3. Obesity: joints that carry excess weight are morelikelytodegenerateearlier.

4. Frequentlyobservedinolderadults.B. Clinicalmanifestations.

1. Jointsinvolved.a. Primarilyinvolvesweight-bearingjoints;occursas

aresultofmechanicalstress.b. May also involve joints in the fingers and the

vertebralcolumn.2. Symptomsoccurringinthejoint.

a. Pain,swelling,tenderness.b. Crepitation: a grating sound or feeling with

movement.c. Instability,stiffness,andimmobility.

3. Painoccursonmotionandwithweightbearing.4. Painincreasesinseveritywithactivity.5. Heberden’snodes:bonynodulesonthedistalfinger

joints.C. Diagnostics(seeAppendix21-1).

1. No specific lab test to confirm; diagnosis is madeprimarilyonthebasisofsymptomsandhistory.

TreatmentA. Medications for pain relief: salicylates (aspirin), acet-

aminophen (Tylenol), NSAIDs (ibuprofen [Motrin]);COX-2inhibitors(Celebrex).1. Intraarticularinjectionofcorticosteroids,methotrex-

ate,disease-modifyingantirheumaticdrugs,andgoldcompounds.

NURSING PRIORITY More than 4000 mg daily of acetaminophen increase client risk for liver damage.

Goal: To help client understand measures to maintainhealth(seeBox21-4).

A. Identifyactivitiesrequiringincreasedstressoninvolvedjoints.

B. Maintainregularexerciseprogram(e.g.,walking,swim-ming)topromotemusclestrengthandjointmobility.

C. EncourageindependenceinADLs.Goal: To maintain psychologic equilibrium and promote

positiveself-esteem.

Juvenile Idiopathic Arthritis (Juvenile Rheumatoid Arthritis)

Juvenile idiopathic arthritis ( JIA) is a new name for chronic childhood arthritis, previously called juvenile rheumatoid arthritis ( JRA). It is characterized as a chronic inflamma-tory problem of connective tissue; it involves the synovial joints.A. Synovium becomes thick and edematous; granulation

tissueturnstoscartissue,andthejointisdestroyed.B. ReasonfornamechangetoJIAisduetotheminimally

applicablereferenceof“rheumatoid”inchildhoodarthri-tis,whichisrelevantonlyinasmallnumberofaffectedchildren.


1. Possiblyautoimmuneinorigin.2. Peakonsetbetween1and3yearsand8and10years

ofage.B. Clinicalmanifestations.

1. Morningstiffness.2. Mayhavemultiplejointinvolvement,bothlargeand

smalljoints.3. Jointsmaybetenderandpainfultotouchormaybe

relativelyfreeofpain.4. Fever, rash, and development of uveitis (inflamma-

tionoftheirisandciliarybodyoftheeye).

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C. Diagnostics: diagnosis is made by exclusion of otherdiseases;presenceofantinuclearantibodies.

TreatmentA. Medications.

1. NSAIDs,methotrexate.2. Tumornecrosisfactorinhibitors.3. Corticosteroidsinseverecases.

B. Physicaltherapy.C. Moist heat is used to reduce stiffness and relieve

pain.D. Exercise,especiallywaterexercises.

ComplicationsComplicationsincludeseverehipdiseaseandlossofvisionfromiridocyclitis.

Nursing InterventionsChild is usually cared for at home except during severeexacerbations.Goal: Todecreasepainandpromotejointmobility.A. Moistheattorelievejointstiffnessandpain.B. Therapeutic exercises incorporated into play activi-

ties.C. Maintain good body alignment when child is at rest;

preventflexioncontracturesofaffectedjoints.D. Avoidoverexercisingpainfuljoints.Goal: Tohelpchildmaintainnormalgrowthanddevelop-

mentpatternsandtopromoteself-esteem.A. Well-balanceddietwithoutexcessiveweightgain.B. Schedule regular exercise program appropriate to

developmentallevel.C. Encourage independence; allow child to participate in

planningcare.D. Encourage school attendance and socialization with

peers.

GoutGout is an arthritic condition resulting from a defect in the metabolism of uric acid (hyperuricemia).A. Uricacidistheendproductofpurinemetabolism.B. Hyperuricemia may also occur in individuals receiving

chemotherapy(secondarygout).


1. Increased incidence in middle-aged men and withdietshighinpurine-richfood.

2. Obesity,hypertension,diureticuse,excessivealcoholconsumption.

B. Clinicalmanifestations.1. Intensepainandinflammationofoneormoresmall

joints,especiallythoseinthelargetoe.2. Characterized by remissions and exacerbations of

acutejointpain.3. Onsetisgenerallyrapidwithswollen,inflamed,pain-

fuljoints.4. Presence of tophi or uric acid crystals in the area

aroundthelargetoeandtheouterear.5. Tophimaybepresentinsubcutaneoustissue.

C. Diagnostics:persistenthyperuricemia:levelgreaterthan6mg/dL.

TreatmentA. Medications.

1. Antigout(seeAppendix21-2).2. NSAIDs for pain and also to assist in preventing

attacks.B. Decreaseamountofpurineindiet(seeChapter2).

ComplicationsA. Uricacidkidneystones.B. Secondaryosteoarthritis.

Nursing InterventionsGoal: To prevent acute attack, promote comfort, and

maintainjointmobility.A. Medications should be given early in the attack to

decreasetheseverityoftheattack.B. Protectaffectedjoint:immobilize,noweightbearing.C. Coldpacksmaydecreasepain.D. Decreasedamountofpurineindiet.E. Encouragehighfluidintaketoincreaseexcretionofuric

acidandtopreventthedevelopmentofuricacidstones.F. Assistclienttoidentifyactivitiesandaspectsoflifestyle

thatprecipitateattacks.1. Dietaryhabits(decreasepurineintake).2. Decreasealcoholconsumption.

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Serum DiagnosticsRheumatoid factor (RF):Usedtodeterminepresenceofautoan-

tibodies (rheumatoid factor) found in clients with connectivetissuedisease;ifantibodyispresent,itissuggestiveofrheuma-toidarthritis;thehighertheantibodytiter,thegreaterthedegreeofinflammation.

Antinuclear antibody (ANA):Measuresthepresenceofantibod-iesthatdestroythenucleusofbodytissuecells(i.e.,thoseseeninconnectivetissuediseases);apositivetestresultisassociatedwithsystemiclupuserythematosus.

Complement: Essential body protein to measure immune andinflammatory reactions; usually depleted in rheumatoidarthritis.

Alkaline phosphatase:Enzymeproducedbyosteoblasts;elevatedlevels found in osteoporosis, healing fractures, bone cancer,osteomalacia.

Aldolase:Elevatedlevelsinmusculardystrophy.Creatine kinase (CK):Elevatedlevelsfoundinmusculardystro-

phyandtraumaticskeletalmuscleinjury.

Invasive DiagnosticsArthroscopy: Involves the use of an arthroscope inserted into a

jointforvisualizationofthejointstructure;preferably,procedureisconductedintheoperatingroomwithstrictasepsisandper-formedwitheither localorgeneralanesthesia; frequentlyusedtodiagnosestructuralabnormalitiesoftheknee.

Nursing Implications1. Performpreoperativenursinginterventions,asappropriatewith

thelevelofanesthesiatobeused.2. Afterprocedure,woundiscoveredwithasteriledressing.3. Acompressionbandagemaybeappliedfor24hoursafterthe

test.4. Teach client symptoms of vascular compromise, mobility

restrictions,andsteriledressingchangeprocedure.5. Walking is permitted; however, excessive exercise should be

avoidedforafewdays.6. Teachtheclientsignsofinfection(increasedtemperature,local

inflammationatsite).Arthrocentesis: Incision of a joint capsule to obtain samples of

synovialfluid; localanesthesia is induced,andasepticprepara-tion isdonebeforefluidaspiration.Synovialfluid isexaminedforinfectionandbleedingintothejointandtoconfirmspecifictypesofarthritis.

Appendix 21-1 DIAGNOSTIC STUDIES

Nursing Implications1. Explainproceduretoclient.2. Maybedoneatbedsideorinanexaminationroom.3. Compressiondressingisusuallyapplied,andjointisrestedfor

severalhoursaftertest.4. Observedressingforleakageofbloodorfluid.5. Assessthepuncturesiteforevidenceofinfection.Myelogram and CT scan:Used todetermine statusof vertebral

disk.SeeAppendix20-1.Bone biopsy:Maybeperformedinclient’sroomorinatreatment

room. After satisfactory local anesthesia is achieved, a longneedleisinsertedintothebone,orasmallincisionismadetoobtainbonetissue.

Nursing Implications1. Planforanalgesictobeadministeredbeforeprocedure.2. If an incision was made, maintain a pressure dressing over

thesite.3. Extremity iselevatedtodecreaseedemaandmaybe immobi-

lizedforabout12to24hours.4. Assessthepuncturesiteorincisionforevidenceofinfection.Electromyelogram (EMG):Evaluatestheelectricpotentialofthe

musclewithmusclecontraction.Smallneedlesareinsertedintothemuscleandrecordingofelectricalactivityisperformed.

Nursing Implications1. Explaintoclientthatthereisdiscomfortwithprocedure.2. No stimulants (caffeine) or sedatives 24 hours before the

procedure.

Noninvasive DiagnosticsX-ray films:Themostcommondiagnosticproceduretodetermine

musculoskeletalproblems.1. Identifymusculoskeletalproblems.2. Determineprogressofdiseaseorcondition.3. Evaluateeffectivenessoftreatment.Bone scan: Radioisotopes may be injected intravenously, and

bone is scanned to determine where the isotopes are “takenup.” May be used to determine presence of malignancies,arthritis, and osteoporosis. No special precautions before orafter test;need to encouragefluid intake to increase excretionofdye.

Computerized axial tomography (CAT scan): See Appendix20-1.

Magnetic resonance imaging (MRI):SeeAppendix20-1.

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Appendix 21-2 MEDICATIONS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSAntigout Agents Decrease the plasma uric acid levels either by inhibiting the synthesis of uric acid or increasing the excretion of uric acid.

Colchicine:PO Nausea,vomiting,diarrheaToxiceffects:bonemarrow

depression

1. Takemedicationatearliestindicationofimpendinggoutattack.

2. Takemedicationwithfood.3. Promotehighfluidintaketopromoteuricacid

excretion.4. Inacuteattack,administer1tableteveryhouruntil

symptomssubside,untilGIproblemsoccur,oruntilatotalof8mghasbeentaken.

Allopurinol(Zyloprim):PO Rash,GIdistress,fever,headache 1. Administerwithfoodtodecreasegastricupset.2. Discontinuemedicationifrashoccurs.3. Usewithcautioninclientswithrenalinsufficiency.4. Maybeusedtodecreaseserumuricacidlevelsin

clientsreceivingchemotherapy.

Probenecid(Benemid):PO GIdisturbances,headache,skinrash,fever

1. Uratetophidepositsshoulddecreaseinsizewiththerapy.

2. Givewithfood.

Skeletal Muscle Relaxants Relax skeletal muscle by depressing synaptic pathways in the spinal cord.

Methocarbamol(Robaxin):PO,IM,IV

Cyclobenzaprine(Flexeril):POCarisoprodol(Soma): POBaclofen(Lioresal):PO

Drowsiness,dizziness,GIupset,rash,blurredvision

Drowsiness,dizziness,headache,GIupset,orthostatichypotension

Drowsiness,weakness,fatigue,confusion

1. UsedformusclespasmsassociatedwithMSandspinalcordinjury.

2. Cautionclientstoavoidactivitiesthatrequirementalalertnessforsafety(driving,usingpowertools,etc.).

3. Evaluateclientforposturalhypotension.4. AdviseclienttoavoidCNSdepressants(e.g.,

alcohol,opioids,antihistamines).5. AdministerwithmealstodecreaseGIdistress.

Dantrolene(Dantrium):PO,IV Hepatotoxicity,muscleweakness,drowsiness

1. Teachclientssymptomsofliverdysfunction.2. Actsdirectlytorelaxskeletalmuscle.

Calcium Medications Hormones that enhance bone density by preventing the reabsorption of calcium in bone and kidneys.

Calcitonin-salmon(Calcimar, Miacalcin):subQ,IM,nasalspray

GIupset,localinflammationatinjectionsite,flushing

1. Monitorlevelsofserumcalcium.2. Treatmentofestablishedpostmenopausal

osteoporosis.

Bisphosphonates—alendronate(Fosamax),ibandronate,(Boniva):PO,nasalspray

Esophagitis,GIflushing,rash,musculoskeletalpain,fever,chills,jawpain

1. Haveclientswallowtabletwhole;itshouldnotbechewed.

2. Takeinmorningonanemptystomachwithlargeglassofwater(6to8oz)andwaitatleast30minutesbeforeeatingorlyingdown.

3. MakesureclienthasadequateintakeofvitaminD.4. Usedforpreventionandtreatmentof

postmenopausalosteoporosis.5. Clientshouldreportanysignsorsymptomsof

gastricrefluxorpain.

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MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSCorticosteroids See Appendix 6-7.

Nonsteroidal Antiinflammatory Medications (NSAIDs) See Appendix 3-3.

Disease-Modifying Antirheumatic Drugs (DMARDs) Antimetabolite, antirheumatic, and antimalarial drugs that act to decrease inflammation.

Methotrexate(Rheumatrex) Toxiceffects:hepatotoxicity,bonemarrowdepression

Nausea,vomiting,stomatitis

1. Cautionwomenofchildbearingagetoavoidpregnancy.

2. MonitorCBCregularly.3. Avoidalcoholduringtherapy.4. Administerwithfood.

Hydroxychloroquine(Plaquenil) Toxiceffects:retinopathy,skeletalmusclemyopathyorneuropathy

Headache,anorexia,dizziness

1. Recommendeyeexamsevery3months.2. Notrecommendedforchildren.3. Therapeuticeffectmaytake3to6months.

Leflunomide(Arava) Toxiceffects:hepatotoxicity,diarrhea,teratogenesis

1. Notrecommendedforwomenwhomaybecomepregnant.

2. Mayslowtheprogressionofjointdamagecausedbyrheumatoidarthritisandimprovesphysicalfunction.

Biological Therapy Agents that bind TNF to decrease inflammatory and immune responses; used in cases of severe arthritis.

Etanercept(Enbrel):subQ Increasedriskforinfections,injectionsitereactions,heartfailure,headache,nausea,dizziness

1. Usecautiouslyinclientswithheartdisease.2. Rotateinjectionsitesatleast1inchapart.3. Adviseclientsthatinjectionsitereactiongenerally

decreaseswithcontinuedtherapy.4. Donotadministertoclientswithchronicor

localizedinfections.5. Haveclientreportsignsofinfection,bruising,or

bleeding.

Infliximab(Remicade):IVAdalimumab(Humira):subQ

Increasedriskforopportunisticinfections,abdominalpain,nausea/vomiting,headache,rash,injectionsitereactions

1. Avoidinclientswithheartdisease.2. Assessclientsforinfections;administerTBskin

testandchestx-raybeforestartingmedication.3. Rotateinjectionsitesatleast1inchapart.4. PerformperiodicCBCstomonitorforblood

dyscrasias.

CBC, Complete blood count; CHF, congestive heart failure; CNS, central nervous system; GI, gastrointestinal; IV, intravenous; PO, by mouth (orally);subQ,subcutaneous;TNF,tumornecrosisfactor.

Appendix 21-2 MEDICATIONS—cont’d

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FIGURE 21-6 Crutch measurement. (From Harkreader H, Hogan MA, Thobaben M: Fundamentals of nursing: caring and clinical judgment, ed 3, Philadelphia, 2007, Saunders.)

6 in.

6 in.

3 finger widths(1-2 in., 2.5-5 cm)

30 degreesflexion

Appendix 21-3 ASSISTIVE DEVICES FOR IMMOBILITY

CrutchesMeasuring a Client (Figure21-6)• Measurementmaybetakenwithclientsupineorstanding.• Supine:measurethedistancefromtheclient’saxillatoapoint

6incheslateraltotheheel.• Standing: measure the distance from the client’s axilla to a

point 4 to 6 inches to the side and 4 to 6 inches in front ofthefoot.

• Adjusthandbarssothatclient’selbowsareflexedapproximately30degrees.

ALERT Assess client’s use of assistive devices; evaluate correct use; assist client to ambulate with an assistive device.

Canes• Thecaneisusedonthesideoppositetheaffectedleg.• Thecaneandtheaffectedlegmovetogether.

Walkers• Liftthewalkerandplaceitapproximately2feetinfront.• Gainbalancebeforemovingwalkerforwardagain;balancepro-

videsstabilityandequalweightbearing.

• Ifclientwasmeasuredwhilesupine,assistclienttostandwithcrutches. Check the distance between client’s axilla and armpieces.Youshouldbeable toput twoofyourfingersbetweenclient’saxillaandthecrutchbar.

Four-Point Alternate Gait• The four-point alternate gait is used by clients who can bear

partialweightonbothfeet—forexample,clientswitharthritisorcerebralpalsy. It isaparticularly safegait, in that therearethreepointsofsupportontheflooratalltimes.

• This gait provides a normal walking pattern and makes someuseofthemusclesofthelowerextremities.

Three-Point Alternate Gait• Forthethree-pointalternategait,theclientmustbeabletobear

the total body weight on one foot; the affected foot or leg iseitherpartiallyortotallynon-weight-bearing.

• In this gait both crutches are moved forward together withtheaffectedlegwhiletheweightisbeingbornebytheclient’shands on the crutches. The unaffected leg is then advancedforward.

Crutch Walking• Upstairs:Unaffectedlegmovesupfirst,followedbythecrutches

andtheaffectedleg.• Downstairs:Crutchesandaffected legmovedownfirst,body

weight is transferredtothecrutches,andtheunaffected leg ismoveddown.

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Appendix 21-4 AMPUTATIONS

* Removalofpartofabody,usuallyanextremityatvariousana-tomiclocations.

Indications for Amputation1. Peripheralvasculardisease,especiallyvasculardiseaseof lower

extremities.2. Severetrauma.3. Acutechronicinfection.4. Malignanttumors.Nursing Implications1. Preventfurtherlossofcirculationtotheextremity.2. Promotepsychologicstability.3. Promotecomfort.4. Promoteoptimumlevelofmobility.

Postoperative Care

ALERT Identify and prevent complications of immobility; use positioning to prevent contractures; provide support for client with unexpected alteration in body image; assist client to ambulate and move with assistive devices; promote wound healing; assist client with use of prosthesis.

3. Phantom limbpain is very real to the client.Handle residuallimbcarefullywhenassessingsiteorchangingdressing.

4. Evaluateresiduallimbforbleedingandhealing.5. Arigidcompressiondressingmaybeappliedtopreventinjury

and todecrease swelling.Controlling theedemawill enhancehealing and promote comfort. Changes of the rigid dressingarenecessary; as the residual limbheals, it also shrinks. Jobstair splint, a plastic inflatable device, is used and inflated to20mmHgfor22ofevery24hours.

6. Iftheclientisnotfittedwitharigidcompressiondressing,theresiduallimbwillbeshapedwithacompressionbandage.Acebandageelasticwrappingisoftenusedforcompressionofthistype.

7. Discouragea semi-Fowler’sposition in theclientwithabove-the-kneeamputation;thispositionencouragesflexioncontrac-tionatthehip.

Residual Limb Care after Wound Has Healed1. Continually assess for skin breakdown; visually inspect the

residuallimbforredness,abrasions,orblistering.2. Theresiduallimbshouldbewasheddaily,carefullyrinsed,and

dried.Soapandmoisturecontributetoskinbreakdown.3. Donotapplyanything to the residual limb (alcohol increases

skindrynessandcracking;lotionskeepskinsoftandhinderuseofprosthesis).

4. Clientshouldputtheprosthesisonwhenheorshegetsupandshouldwear it allday.The residual limb tends to swell if theprosthesis isnotapplied.Themoretheclientwears thepros-thesis,thelessswellingwillbeexperienced.

Residual Limb Wound Care1. Theresiduallimbmaybeelevatedforapproximately24to48

hours; after that time, keep the joint immediately above theresidual limb in an extended position. Flexion contracturehindersuseofprosthesis.

2. Recognize the difference between phantom limb pain (PLP)and residual limb pain (RLP). Opioid analgesics are not aseffectiveforPLPasforRLP.

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Study Questions Musculoskeletal System

1. Afteralumbarlaminectomy,aclientcontinuestocom-plain of the same low back pain that he had beforesurgery.Thenurseknowsthatthisfindingiscausedbywhatproblem?1 Failureofthesurgeontoremovetheclient’sherni-

ateddisk2 Swellingintheoperativeareathatcompressesadja-

centstructures3 Twisting of the client’s spine when he turns from

sidetoside4 Limitation of movement resulting from spinal

fusion2. The nurse is assessing a client who had a fractured

femur repairedwithanexternalfixatordevice.Whichassessment findings would cause the nurse concernregarding the development of compartmental syn-drome?Selectallthatapply.______ 1 Decreaseinpulserateinaffectedleg______ 2 Paresthesiadistaltoareaofinjury______ 3 Toes on affected leg cool to touch and

edematous______ 4 Complaintsthatpinsarehurting______ 5 Complaintsof legpainunrelievedbyanal-

gesicsorrepositioning______ 6 Clientangryandcallingloudlytothenurse

every10minutes3. In taking the health history of a client with severe

painfulosteoarthritis,thenursewouldexpecttheclienttoreportwhichofthefollowing?1 Agradualonsetofthedisease,withinvolvementof

weight-bearingjoints2 Asuddenonsetofthedisease,withinvolvementof

alljoints3 Nocomplaintsofmorningstiffness4 Jointpainthatisnotaffectedbyexercise

4. Aclienthasa fracturedhipand iscurrently inBuck’stractionbeforesurgery.HowisthecounterattractioninBuck’stractionachieved?1 Byapplyinga10-poundcounterweightattheknee2 Byplacingshockblocksundertheheadofthebed3 Byelevatingthekneegatchandelevatingthehead

ofthebedabout30degrees4 Byelevatingthefootofthebedframeandallowing

theweightstohangfreely5. Thepostoperativenursingcareplanforaclientwhohas

hadarightlegamputationincludes:1 Applying ice packs to the residual limb for 72

hours2 Havingtheclientlieonhisorherabdomenfor30

minutes3-4times/day3 Wrapping the residual limb with Ace bandages

fromproximaltodistalends4 Managing client’s pain with antiinflammatory

medications.

6. Aclienthasalonglegplastercastapplied.Whatnursingactionsareimplementedwhilethecastisstillwet?1 Useonlythefingertipswhenmovingthecast.2 Keeptheclientandcastcoveredwithblankets.3 Supportthecastonplastic-coveredpillows.4 Placeaheatlampdirectlyoverthecast.

7. AclientisbeingtreatedwithBuck’straction.Whatareimportantnursinginterventionsforthisclient?1 Removethetractionbootevery6hourstoprovide

skincare.2 Check and clean the pin sites at least three times

daily.3 Checktheareaaroundthehipwherethetractionis

applied.4 Verifythatweightsareintheamountsorderedand

arehangingfreely.8. Foraclientwithseverepainfulosteoarthritis,aregimen

ofheat,massage,andexercisewill:1 Helprelaxmusclesandrelievepainandstiffness.2 Restorerangeofmotionpreviouslylost.3 Preventtheinflammatoryprocess.4 Helptheclientcopewithpaineffectively.

9. A client is confined tobedwith a fracture of the leftfemur.Hebeginsreceivingsubcutaneousheparininjec-tions.Whatisthepurposeofthismedication?1 Topreventthrombophlebitisandpulmonaryemboli

associatedwithimmobility2 Topromotevascularperfusionbypreventingforma-

tionofmicroemboliintheleftleg3 Toprevent venous stasis,whichpromotes vascular

complicationsassociatedwithimmobility4 Todecrease the incidenceof fat emboli associated

withlongbonefractures10. What is important assessment information to obtain

fromaclientwithafracturedhip?1 Circulationandsensationdistaltothefracture2 Amountofswellingaroundthefracturesite3 Degreeofbonehealingthathasoccurred4 Amount of pain that the fracture and healing are

causing11. What evaluation is important in the preoperative

nursingassessmentofaclientwithaseverelyherniatedlumbardisk?1 Movementandsensationinthelowerextremities2 Legpainthatradiatestobothlowerextremities3 Reflexesintheupperextremities4 Pupillaryreactiontolight

More questions on companion CD!

Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: Answers and Rationales.

chapter twenty-one · a. pavlik harness: a fabric strap harness that is secured around the...

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