Post on 13-Nov-2014
Care of Clients with Problems Care of Clients with Problems Related to the Musculoskeletal Related to the Musculoskeletal
SystemSystem
Earl Francis R. Sumile, RNEarl Francis R. Sumile, RNInstructor, College of NursingInstructor, College of Nursing
University of Santo TomasUniversity of Santo Tomas
Diagnostic ProceduresDiagnostic Procedures
1.1. Radiologic studiesRadiologic studiesa.a. X-raysX-raysb.b. Computed tomographyComputed tomography or CT scan or CT scan
– Non- invasive procedure where a body part Non- invasive procedure where a body part can be acanned from different angles with can be acanned from different angles with an x-raybeam and a computer calculates an x-raybeam and a computer calculates varrying tissue densities and records a varrying tissue densities and records a cross section image on paper done to cross section image on paper done to determine extent of fracture in difficult to determine extent of fracture in difficult to define areasdefine areas
Diagnostic ProceduresDiagnostic Procedures
c.c. MyelographyMyelography• Injection of radioopaque dye into Injection of radioopaque dye into
subarachnoid space at posterior spine to subarachnoid space at posterior spine to determine level of disc herniation or site of determine level of disc herniation or site of tumortumor
Diagnostic ProceduresDiagnostic Procedures
2.2. ArthrographyArthrography• Radioopaque or air injected into joint cavity- outines Radioopaque or air injected into joint cavity- outines
soft tissue structure and contour of jointsoft tissue structure and contour of joint
3.3. Bone scanningBone scanning• Parenteral injection of bone seeking radioactive Parenteral injection of bone seeking radioactive
isotopeisotope
4.4. ElectromyographyElectromyography• Graphic presentation of the electrical potential of Graphic presentation of the electrical potential of
musclesmuscles
Diagnostic ProceduresDiagnostic Procedures
5.5. Magnetic Resonance ImagingMagnetic Resonance Imaging• Noninvasive scanning technique that uses Noninvasive scanning technique that uses
magnetism and radiofrequency waves to magnetism and radiofrequency waves to produce cross-sectional images of body produce cross-sectional images of body tissues on computer screentissues on computer screen
6.6. ArthroscopyArthroscopy• Endoscopic direct visualization of joint, Endoscopic direct visualization of joint,
especially kneeespecially knee
Diagnostic ProceduresDiagnostic Procedures
7.7. ArthrocentesisArthrocentesis• Needle aspiration of synovial fluidNeedle aspiration of synovial fluid
8.8. Bone Biopsy or Muscle biopsyBone Biopsy or Muscle biopsy
9.9. LaboratoryLaboratorya.a. Uric acidUric acid
b.b. Antinuclear antibody (ANA) for systemic Lupus Antinuclear antibody (ANA) for systemic Lupus ErythematosusErythematosus
c.c. Complement fixation (CF) for Rheumatoid ArthritisComplement fixation (CF) for Rheumatoid Arthritis
d.d. Calcium, Alkaline Phosphate, PhosphorusCalcium, Alkaline Phosphate, Phosphorus
Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic Modalities Modalities
1.1. ReductionReduction• Realigning an extremity into anatomical Realigning an extremity into anatomical
positionposition
a.a. Open- use of surgical methodsOpen- use of surgical methods
b.b. Closed- use of non-surgical methods; Closed- use of non-surgical methods; manipulationmanipulation
Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic ModalitiesModalities
2.2. ImmobilizationImmobilization ManualManual Skin- adhesive- plaster or adhesive is Skin- adhesive- plaster or adhesive is
applied longitudinally on the lower applied longitudinally on the lower extremeties and an elastic bamndage extremeties and an elastic bamndage applied in an spiral motionapplied in an spiral motion
Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic ModalitiesModalities
2.2. Bryant’s traction- indicated for children Bryant’s traction- indicated for children aged 0-3 year’s not more than 40 lbs.aged 0-3 year’s not more than 40 lbs.1.1.Traction is always applied on both endsTraction is always applied on both ends
Nursing ResponsibilityNursing Responsibility– Nurse should be able to pass hand between Nurse should be able to pass hand between
the patient’s buttocks and mattressthe patient’s buttocks and mattress
Bryant tractionBryant traction
Buttocks sightly elevetated and clear of bed
Knee slightly flexed
Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic ModalitiesModalities
Buck’s Extension TractionBuck’s Extension TractionIndicated for older patients to those weighing Indicated for older patients to those weighing
over 40 lbs.over 40 lbs.
Nursing ResponsibilityNursing ResponsibilityOnly the affected extremity is placed on Only the affected extremity is placed on
tractiontraction
Buck’s Extension TractionBuck’s Extension Traction
Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic ModalitiesModalities
Dunlop TractionDunlop TractionUsed in affectations of the upper extremitiesUsed in affectations of the upper extremities
Dunlop TractionDunlop Traction
Nursing Care of Clients with Nursing Care of Clients with Adhesive TractionAdhesive Traction
1.1. Unwrap and wrap and elastic bandage at Unwrap and wrap and elastic bandage at least once a shiftleast once a shift
2.2. Check skin integrity for allergic reactions Check skin integrity for allergic reactions to plasterto plaster
3.3. Note circulation, sensation and mobility Note circulation, sensation and mobility of the affected extremitiesof the affected extremities
Skin- non adhesiveSkin- non adhesive
Uses canvass or cloth that is applied on the Uses canvass or cloth that is applied on the patient’s skinpatient’s skinPelvic girdle tractionPelvic girdle traction• Applied like a girdle and connected to two ropes with Applied like a girdle and connected to two ropes with
weights that hangs at the foot part of the bedweights that hangs at the foot part of the bed• Indicated for low back painIndicated for low back pain
Head Halter TractionHead Halter Traction• Applied on chin and occipital region connected to a Applied on chin and occipital region connected to a
hanger with weights that hangs at the head part of the hanger with weights that hangs at the head part of the bedbed
• Usually indicated for cervical spine affectationsUsually indicated for cervical spine affectations
Skin- non adhesive tractionSkin- non adhesive traction
Cotrel TractionCotrel Traction• Combination of the head halter and pelvic Combination of the head halter and pelvic
traction used in scoliosistraction used in scoliosis
Russell TractionRussell Traction• Permits patient to move freely in bed and Permits patient to move freely in bed and
permits flexion of the knee and hip jointpermits flexion of the knee and hip joint• Buck’s extension and the knee is suspended Buck’s extension and the knee is suspended
in a sling to which a rope is attachedin a sling to which a rope is attached
Russell TractionRussell Traction
Nursing Care of Clients with non-Nursing Care of Clients with non-adhesive tractionadhesive traction
Rest period are providedRest period are provided
Skeletal TractionSkeletal Traction
Applied into a boneApplied into a bone
Crutchfield Skeletal TractionCrutchfield Skeletal Traction• Applied into the parietal; bonesApplied into the parietal; bones
Indicated for cervical spine affectationsIndicated for cervical spine affectations
Crutchfield TongCrutchfield Tong
Skeletal TractionSkeletal Traction
Balanced Skeletal TractionBalanced Skeletal Traction• Applied alone or with skeletal traction to Applied alone or with skeletal traction to
promote patient mobilitypromote patient mobility
Balanced Skeletal TractionBalanced Skeletal Traction
Principles of CarePrinciples of Care
1.1. The patient should always be on either The patient should always be on either supine or dorsal recumbent positionsupine or dorsal recumbent position
2.2. The should always be an counteraction The should always be an counteraction (patient’s weight)(patient’s weight)
3.3. The line of deformity should be in line The line of deformity should be in line with the tractionwith the traction
4.4. Traction should be continuousTraction should be continuous5.5. There should be no friction within the line There should be no friction within the line
of tractionof traction
b. Cast- Comparison of Cast Materialsb. Cast- Comparison of Cast MaterialsPlaster Plaster Synthetic Synthetic
Material Material Plastc of Paris, comprised Plastc of Paris, comprised of powdered calcium of powdered calcium sulfate crystals sulfate crystals impregnated into the impregnated into the bandages bandages
Polyester and cotton, Polyester and cotton, fiberglass or plastic. fiberglass or plastic. Polyester and cotton is Polyester and cotton is impregnated with water- impregnated with water- activated polyurethane activated polyurethane resin resin
Drying time Drying time 24-48 hours 24-48 hours 7-15 mins of setting7-15 mins of setting
15-30 mins for weight 15-30 mins for weight bearing bearing
Advantages Advantages Less costly Less costly
More effective for More effective for immobilizing severely immobilizing severely displaced bonesdisplaced bones
Smooth surfaceSmooth surface
Does not require Does not require expensive equipment for expensive equipment for application application
Less likely to indent into Less likely to indent into skinskin
Lighter in weightLighter in weight
Less restrictiveLess restrictive
Does not crumbleDoes not crumble
NonabsorbentNonabsorbent
Can be immersed in water Can be immersed in water
c. Bracesc. Braces
• Knight-taylorsKnight-taylors• For thoraco-lumbar affectationsFor thoraco-lumbar affectations
• MilwaukeeMilwaukee• For scoliosisFor scoliosis
Nursing CareNursing Care• Use cotton clothing as barrierUse cotton clothing as barrier
d. Fixatorsd. Fixators
• RAEFRAEF• Roger Anderson External FixatorRoger Anderson External Fixator
• Ilizarov deviceIlizarov device• Indicated for comminuted fracturesIndicated for comminuted fractures
3. Rehabilitation3. Rehabilitation
• Active or dynamic program aimed at Active or dynamic program aimed at enabling an ill or disabled enabling an ill or disabled to achieve the to achieve the highesthighest levellevel of physical, mental, social, of physical, mental, social, and economic self-sufficiency of which he and economic self-sufficiency of which he is capableis capable
Members of the Rehabilitation teamMembers of the Rehabilitation team
a.a. PatientPatient
• Key member of health teamKey member of health team
b.b. Rehabilitation nurseRehabilitation nurse
• Develops plan of patient careDevelops plan of patient care
c.c. PhysicianPhysician
• Makes medical diagnosis; directs teamMakes medical diagnosis; directs team
d.d. PhysiatristPhysiatrist
• Physician specialist in physical medicinePhysician specialist in physical medicine
e.e. Physical TherapistPhysical Therapist
• Teaches or supervises patient in prescribed exercise Teaches or supervises patient in prescribed exercise programprogram
Members of the Rehabilitation teamMembers of the Rehabilitation team
f.f. PsychologistPsychologist• Helps patient or family explore feelingsHelps patient or family explore feelings
g.g. Occupational TherapistOccupational Therapist• Helps develop skills for home and work situationsHelps develop skills for home and work situations
h.h. Social WorkerSocial Worker• Assists patient and family adjust socio-economicallyAssists patient and family adjust socio-economically
i.i. Vocational CounselorVocational Counselor• Tests patient’s interest and aptitudesTests patient’s interest and aptitudes
j.j. Rehabilitation EngineerRehabilitation Engineer• Uses technology in designing or constructing Uses technology in designing or constructing
devices to help the handicappeddevices to help the handicapped
Transfer and Assistive DevicesTransfer and Assistive Devices
1.1. transferring a client from bed to stretchertransferring a client from bed to stretcher• stretcher must be perpendicular to bedstretcher must be perpendicular to bed
2.2. transferring a client from bed to wheelchairtransferring a client from bed to wheelchair• the wheelchair must be parallel to the head of the the wheelchair must be parallel to the head of the
bedbed
3.3. CanesCanes• Height of cane is from floor to waist levelHeight of cane is from floor to waist level• Cane is held by opposite the affected extremityCane is held by opposite the affected extremity
Transfer and Assistive DevicesTransfer and Assistive Devices
4.4. CrutchesCrutches• Height of crutch is from floor to axilla minus Height of crutch is from floor to axilla minus
2 inches2 inches• Patient’s weight is borne by the palm, of the Patient’s weight is borne by the palm, of the
hand and not on the axillahand and not on the axilla• When going upstairs, unaffected leg firstWhen going upstairs, unaffected leg first• When going upstairs, affected leg firstWhen going upstairs, affected leg first
Crutch-walking techniquesCrutch-walking techniques
• Two point gaitTwo point gait (two alternate gait) (two alternate gait)• Three point gaitThree point gait• Four point gaitFour point gait• Swinging crutch gaitsSwinging crutch gaits
• Both legs are lifted off the ground simultaneously and Both legs are lifted off the ground simultaneously and swung forward while patient pushes up on crutchesswung forward while patient pushes up on crutches
• Swing-to gaitSwing-to gait• Lift and swing body up to crutchesLift and swing body up to crutches
• Swing-through gaitSwing-through gait• Lift swing body beyond crutchesLift swing body beyond crutches
ExercisesExercises
a.a. IsometricIsometric• Alternate contraction and relaxation of the Alternate contraction and relaxation of the
muscle without moving the jointmuscle without moving the joint
a.a. Done on the affected extremityDone on the affected extremity
b.b. IsotonicIsotonic• Range of motion exercisesRange of motion exercises• Done on the unaffected extremityDone on the unaffected extremity
Heat or Cold Application in TraumaHeat or Cold Application in Trauma
Cold ApplicationCold Application• first 24 hoursfirst 24 hours• To decrease To decrease
hemorrhagehemorrhage• To relieve painTo relieve pain• To reduce To reduce
inflammationinflammation
Heat ApplicationHeat Application– After 24 hoursAfter 24 hours– To relieve pain from To relieve pain from
muscle spasmsmuscle spasms– To reduce swelling To reduce swelling
by increasing by increasing circulationcirculation
– To promote healing To promote healing by increasing by increasing oxygenationoxygenation
4. Orthopedic Operative 4. Orthopedic Operative ProceduresProcedures
a.a. ArthrotomyArthrotomy
– Surgical opening into a jointSurgical opening into a joint
b.b. ArthrodesisArthrodesis
– Fixation of a jointFixation of a joint
c.c. Spinal fusionSpinal fusion
– Surgical removal of 1 or more Surgical removal of 1 or more vertebra and fusing them togethervertebra and fusing them together
4. Orthopedic Operative 4. Orthopedic Operative ProceduresProcedures
d.d. Hip replacementHip replacement– Placement of prosthesis on the hip Placement of prosthesis on the hip
jointjoint– IndicationIndication
Hip fractureHip fractureInability to move leg voluntarilyInability to move leg voluntarilyShortening and external rotation of Shortening and external rotation of the legthe leg
Nursing Management on Hip Nursing Management on Hip ReplacementReplacement
Avoid positioning on the operative siteAvoid positioning on the operative site
Maintain abduction of hipMaintain abduction of hip
Pillows between legsPillows between legs
Provide chair with firm, non-reclining Provide chair with firm, non-reclining seat and armsseat and arms
Nursing Management on Hip Nursing Management on Hip ReplacementReplacement
Avoid hip flexion beyond 60 degrees Avoid hip flexion beyond 60 degrees for 10 daysfor 10 daysAvoid hip flexion beyond 90 degrees Avoid hip flexion beyond 90 degrees from day 10 to 2 monthsfrom day 10 to 2 monthsAvoid adduction of the affected leg Avoid adduction of the affected leg beyond midline for 2 monthsbeyond midline for 2 monthsPartial weight bearing status for 2 Partial weight bearing status for 2 monthsmonths
TraumaTrauma
ContusionContusion– Injury to the soft tissue produced by Injury to the soft tissue produced by
blunt forceblunt force
SprainSprain– Injury to the ligamentous structures Injury to the ligamentous structures
caused by wrenching or twistingcaused by wrenching or twisting
– Forcible hyperextension of a joint with Forcible hyperextension of a joint with tissue damage like whiplash injurytissue damage like whiplash injury
TraumaTrauma
StrainStrain– Tearing of musculotendenous unit caused Tearing of musculotendenous unit caused
excessive stretchingexcessive stretching
DislocationDislocation– Joint articulating surfaces are partially Joint articulating surfaces are partially
separatedseparated– No longer in anatomical contactNo longer in anatomical contact
FracturesFractures– Break on continuity of boneBreak on continuity of bone
Nursing AssessmentNursing Assessment
1.1. PainPain– Increasing until immobilizedIncreasing until immobilized
2.2. Loss of functionLoss of function
3.3. Localized swelling or discolorationLocalized swelling or discoloration
4.4. DeformityDeformity
5.5. CrepitusCrepitus– Grating soundGrating sound
General Classifications of General Classifications of FracturesFractures1.1. Simple or closedSimple or closed
– Skin is intact over fracture siteSkin is intact over fracture site
2.2. Compound or openCompound or open– With an external wound in contact with the With an external wound in contact with the
underlying fractureunderlying fracture
3.3. CompleteComplete– Entire cross section is displacedEntire cross section is displaced
4.4. IncompleteIncomplete– Portion of cross section undisplacedPortion of cross section undisplaced
General Classifications of General Classifications of FracturesFractures1.1. GreenstickGreenstick
– One side broken and other bentOne side broken and other bent
2.2. TransverseTransverse– Straight across the boneStraight across the bone
3.3. ObliqueOblique– Angle or slanting across the boneAngle or slanting across the bone
4.4. SpiralSpiral– Twisting or coils around shaftTwisting or coils around shaft
5.5. ComminutedComminuted– Splintered into several fragmentsSplintered into several fragments
General Classifications of General Classifications of FracturesFractures
DepressedDepressed– Fragments are drived-in; facial or skullFragments are drived-in; facial or skull
CompressionCompression– Fractured bone compressed by another bone; Fractured bone compressed by another bone;
vertebravertebraImpactedImpacted– Fractured bones are pushed into each other Fractured bones are pushed into each other
(telescoped)(telescoped)DisplacedDisplaced– Fragments are separated from fracture lineFragments are separated from fracture line
LinearLinear– Fracture parallel with long axisFracture parallel with long axis
COMPARING ARTHRITISCOMPARING ARTHRITIS
RheumatoidRheumatoid OsteoarthritisOsteoarthritis GoutyGouty
EtiologyEtiology AutoimmuneAutoimmune
+ Rh factor+ Rh factor
DegenerativeDegenerative
senescencesenescence
Metabolic or Metabolic or familial purine familial purine metabolismmetabolism
IncidenceIncidence 35-45 women35-45 women Men or more in Men or more in womenwomen
Men over 40Men over 40
Signs and Signs and symptomssymptoms
Subcutaneaous Subcutaneaous nodulesnodules
Morning stiffnessMorning stiffness
Swan neck deformitySwan neck deformity
Heberdens noduleHeberdens nodule TophiTophi
Areas Areas affectedaffected
Joints of handsJoints of hands Weight bearing jointWeight bearing joint Great toeGreat toe
ManagementManagement Aspirin, NSAIDsAspirin, NSAIDs
Paraffin bathParaffin bath
SymptomaticSymptomatic ColchicineColchicine
Avoid purine Avoid purine dietdiet
AllopuyrinolAllopuyrinol