Medical-Surgical Nursing: An Integrated Approach, 2E

Chapter 24

NURSING CARE OF THE CLIENT: MUSCULO-SKELETAL SYSTEM

Orthopedics

The branch of medicine that deals with the prevention and correction of the disorders and diseases of the musculo-skeletal system.

Involves the muscles, skeleton, joints, and supporting structures such as ligaments and tendons.

Orthopedic Nursing

The primary goal of the nurse caring for a client with locomotor disorders is the prevention of contractures (permanent shortening of a muscle) or deformities.

Skeletal Functions

To provide the body with a structural framework.

To act as a protective casing for internal organs ( the brain, heart, lungs,etc.).

To allow movement by muscles attached to the skeleton.

To store calcium, phosphorus, and magnesium.

To manufacture blood cells in the red bone marrow.

Types of Bones

Two types of bone: Cancellous, which resembles a sponge

with spaces. Cortical, which is compact bone found

in the shaft of long bones.

Muscle Characteristics Muscles act as motors controlled by

nerve fibers from the cerebral cortex. Muscles and skeleton work together to

permit movement. Muscles are attached to bones by

tendons. Movement of the muscles may be

voluntary or involuntary.

Joints

A joint is a junction of two or more bones. Three types:

Diarthosis: freely movable such as hinge (elbow, knee); ball and socket (hip, shoulder), pivot (skull, first vertebrae), gliding (wrist) and saddle (thumb).

Synarthosis: joints are immovable. Amphiarthosis: slightly movable (vertebrae

and pelvic bones).

Assessment of the Bony Skeleton Notation on any deformities. Body alignment. Abnormal growths due to bone tumors. Shortened extremities. Amputations. Abnormal angulation other than at joints. Crepitus (a grating or crackling sensation

or sound).

Assessment of Spine

Scoliosis (crooked back; lateral curving deviation).

Kyphosis (hump back; increased roundness of the thoracic spinal curve).

Lordosis (sway back; exaggeration of the lumbar spine curvature as seen in pregnancy).

Three common spinal curvatures:

Musculoskeletal Trauma

Strains. Sprains. Dislocations. Fractures. Compartment Syndrome.

Strain

An injury to a muscle or tendon due to overuse or overstretching.

May be acute or chronic.

Sprain

An injury to ligaments surrounding a joint caused by a sudden twist, wrench, or fall.

Symptoms include pain, edema, loss of motion, and ecchymosis.

Dislocation

What occurs when articular surfaces of a joint are no longer in contact. The bones are literally “out of joint.”

Fracture

A break in the continuity of a bone. More than 90 different classifications.

Most common are: Greenstick, or incomplete. Simple, or closed. Compound, or open. Impacted, or telescoped. Spiral. Comminuted.

Compartment Syndrome

A form of neurovascular impairment that may lead to permanent injury of an affected limb caused by the progressive constriction of blood vessels and nerves.

Casts Since plaster casts dry from the inside out, they

should not be covered or dried with a hairdryer or heat lamp.

Moisture and heat from the drying cast should be allowed to evaporate naturally.

To avoid indentation, a drying cast should be placed on pillows and not on a hard surface.

When handling the cast, only the palms of the hands should be used.

Synthetic casts dry in minutes.

Traction

The principle of traction is to have two forces pulling in opposite directions. Traction consists of weights and counterweights.

Traction may be used to reduce a fracture, immobilize an extremity, lessen muscle spasms, or correct or prevent a deformity.

Rehabilitation

Physical Therapy. Learning the proper use of equipment

such as crutches, canes, or walkers.

Surgical Methods:Open Reduction

A surgical procedure that enables the surgeon to reduce (repair) the fracture under direct visualization.

Major disadvantage is chance of infection.

Circulation, Movement, and Sensation Assessments: The Five P’s

Pain. Pallor (slow capillary return). Paresthesia (unrelieved tingling or

numbness). Puffiness (edema). Pulselessness.

Inflammatory Diseases Rheumatoid Arthritis. Bursitis (an inflammation of the bursa, a

sac filled with synovial fluid that facilitates joint movement. Major bursae are found in the shoulder, knee, hip, and elbow).

Polymyositis (involves striated muscle). Osteomyelitis (inflammation of the bone

and bone marrow).

Degenerative Disorders

Osteoporosis. Degenerative joint disease. Total joint arthoplasty.

Osteoporosis

An increase in the porosity of bones causing an increased susceptibility to fractures of the hip, spine, and wrist.

Of those affected, 80% are women.

Degenerative Joint Disease

Also called osteoarthritis. Considered a “wear and tear” disease,

characterized by slow and steady progressive destructive changes of the joint.

The most common type of arthritis.

Total Joint Arthroplasty

Joint replacement or arthroplasty is the replacement of both articular surfaces within a joint capsule.

The hip, knee, shoulder, and fingers are the joints most frequently replaced.

Joint replacement is usually an elective procedure and clients may wish to have autologous blood transfusions.

Musculoskeletal Disorders

Amputations. Temporomandibular joint

disease/disorder. Carpal Tunnel syndrome.

Amputations

Removal of all or part of an extremity. Done in response to injuries resulting in

extensive laceration of arteries or nerves, or diseases such as malignant tumors, infections, and peripheral vascular disorders.

Temperomandibular Joint Disease/Disorder (TMD) Commonly referred to as TMJ by general

population, this is a collection of conditions affecting the temperomandibular joint and/or the muscles of mastication.

Causes include trauma, stress, teeth clenching or grinding (bruxism), and joint diseases such as arthritis.

Common symptoms include limited jaw movement, clicking or crepitus when jaw moves, popping when chewing or talking, and radiating pain in the face, neck, or shoulders.

Carpal Tunnel Syndrome

Occurs when the median nerve in the wrist is compressed by inflamed, edemetous flexor tendons.

Symptoms include pain, paresthesia, and weakness of the thumb, index finger, middle and part of the ring finger but never the pinky.

Caused by repetitive motion.

Systemic Disorders with Musculoskeletal Manifestations

Gout. Lyme Disease.

Gout

A metabolic disease of ineffective purine metabolism resulting from deposits of needlelike crystals of uric acid in connective tissue, join spaces, or both.

Attack generally begins with severe constant pain.

Clients should avoid foods high in purine (e.g. liver, sardines, sweetbreads, anchovies, gravies, and asparagus).

Lyme Disease

Caused by a spirochete Borrelia burgdorferi carried by deer ticks.

First symptom in most cases is a red rash. Other symptoms include headache, neck stiffness, fever, and pain.

Untreated Lyme Disease can result in arthritis, fatigue, facial palsy, meningitis, and encephalitis.