Nursing Care of Clients with Musculoskeletal System Disorders Flashcards by Kelsey Klipfel

Bruises
Contusions
Types
Treatment

Soft tissue injuries

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Strain:
Sprain:

Types

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Pulled muscle injury to the muscle/tendon unit
Painful
Edema
Muscle spasma
Joint tender

Strain:

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Injury to ligaments and supporting muscle fiber around a joint
In gen: more severe for pts; longer to heal; less blood flow in area
Joint tender; movement painful; edema factor; affect mobility

Sprain:

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Immobilize area as much as possible
NSAIDS - reduce inflammation causing the pain
RICE
Rest
Ice - pain and reducing swelling in area; 20 min on and off
Compression - braces and ace bandages keep swelling down
Elevation

Treatment

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Fall, heavy lifting, aging (older adults), repetitive motions
Multiple risk factors

Risk Factors: - muscle/tendon tears: rotator cuff tear

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Pain & limited use of joint

Clinical Manifestations - muscle/tendon tears: rotator cuff tear

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Arm drop test - abduct arm and tell pt to hold at same level; if cannot and arm drops - indicates potential rotator cuff tear
MRI - BEST; little time to approve this; sometimes cannot go in this

Diagnosis - muscle/tendon tears: rotator cuff tear

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Physical therapy - as area heals; regain ROM
NSAIDS
Surgery - if severe; recovery and PT longer

Treat: - muscle/tendon tears: rotator cuff tear

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RICE
SURGERY: gen POST-OP Care (incision clear and dry, symptoms of infection, when can resume activities); teach home care

Nursing: - muscle/tendon tears: rotator cuff tear

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Inflammation - not comfy
swollen, warm, painful, and tender
Necrosis (tissue death)/abscess
Bone doe not liquefy and not go into lymph sys drainage as other sys easily - takes longer; get formation new bone around infected area - get reoccuring infections
Formation of new bone around infection may occur

Infection of bone results in - Metabolic: infection: osteomyelitis

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Staphylococcus aureus
MRSA
Any bacteria inside body

Common organisms - Metabolic: infection: osteomyelitis

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Acute
Fever greater than 101F, edema, erythema (red and angry looking tissue), drainage, pain
Chronic - after body tried heal self; infection always there
Low grade fever in evening (99-100)
Drainage some, pain in area
Vascular insufficiency - where infection was - bones very vascular - infection killed blood vessels so not good blood flow
Ulcerations/ sinus tract formation (fistula draining from site of infection)
Nerve damage-may have no pain if vascular damage

Clinical manifestations: - Metabolic: infection: osteomyelitis

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Adv age
DM
Immunodeficiency
Skin infections
Poor infusion - peripheral vascular disease or peripheral arterial disease
Injury - huge - some way bacteria introduced; not only way but most common way
Systemic infection
Smoking
Previous surgery

Risk factors- Metabolic: infection: osteomyelitis

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Diagnostics
Biopsy
Swab culture/sensitivity - organism - antibiotics effective
X-Ray - tissue involvement/MRI
Elevated WBC, ESR, C-reactive protein
Treatment:
Pain control - VERY PAINFUL
PICC line - take awhile for infection to go away; long course antibiotics
IV antibiotics 3-6 wks - not leave pt in hospital; home with PICC line; home health and know how care for it
Hyperbaric oxygen (HBO) - pressurized O2 3x atmospheric levels: more O2 available for blood stream - heal faster and completely; anaerobic bacteria causing infection not like infection so kill off those (digestive tract often)
Surgical debridement - get rid dead tissue attached - higher risk infection
Surgical reconstruction - if possible consider for pt
Avoid loss of limb - treating infection and goal for this; bones deep internal structures and lot vascularity which can spread infection and high risk for sepsis on these pts - if bone to blood stream

Medical - Metabolic: infection: osteomyelitis

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History and Physical
Story from what happened
Patient reports
acute onset of signs and symptoms (e.g., localized pain, edema, erythema, fever) or recurrent drainage of an infected sinus with associated pain, assess for edema/erythmia, and low-grade fever.
Drainage - culture and send off esp if nasty
Assesses patient for risk factors
Acute pain related to inflammation and edema - NSAIDS; prob require opioids (morphine/diluadid)
Impaired physical mobility related to pain, use of immobilization devices, and weight-bearing limitations - no weight bearing or cannot weight bearing; teach immobility devices
Risk for infection: bone abscess formation - worried about spreading or abscess forming causing recurring infection
Deficient knowledge related to the treatment regimen - teaching about PICC line, IV antibiotics; adminstering them in home - home health - lots edu

N. assessment/diagnosis - Metabolic: infection: osteomyelitis

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Relief of pain or acceptable level
Improved physical mobility within therapeutic limitations - non-weight bearing abide by that
Control and eradication of infection - keep from spreading and get rid of it
Adequate Knowledge of treatment regimen - know expect and when seek help if not going like supposed to
Transition care-home
Monitor skin and neurovascular status - check pulses
Gentle manipulation of limb - move pt - will hurt; make sure not grabbing hold and treat gently
Pain meds as prescribed
Elevate limb as much possible/non-weight bearing
Monitor:
Response to antibiotics - s/s of infections; temp
good IV access - PICC line patent and correctly located
Secondary infection (candida - yeast - heavy antibiotics secondary organisms can take over)
Aseptic technique-dressing changes; pt do dressing changes teach how do aseptic dressing changes

N. goals/plan/interventions - Metabolic: infection: osteomyelitis

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Expected patient outcomes may include: - over time
Experiences pain relief - controlled pain at acceptable level
Increases in safe physical mobility
Shows absence of infection
Adheres to therapeutic plan

N. eval - Metabolic: infection: osteomyelitis

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N. diagnosis: Ineffective health maintenance r/t continued immobility at home, PICC line care, continued antibiotics, dressings, casts/splints ….
Goal: Client will follow a mutually agreed upon plan of care and be compliant to plan of care - FU care, PICC line maintained, call when something looks off
Interventions:
Long-term management of home IV administration
PICC line care
Mobility limitations
Postoperative and follow-up care
Manifestations of deteriorating condition - when call for help
No smoking (or reduce - inferes with vascular sys)/nutrition - good healing want adquate nutrition: adequate protein to help body heal
Referral for home care
Safety and prevention of injury - safety cont factor for pt

N. Home care - Metabolic: infection: osteomyelitis

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Injury to pt where have Multiple fractures and muscle damage - crushed by something
Pt has Life-threatening systemic injury
Major shock and renal failure - huge concerns for pt

Crush syndrome

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Hypovolemia - from shock; crushed - circulating fluid volume depleted - bleeding out or internally bleeding
Hyperkalemia - renal failure huge possibility; when muscles get crushed release K - too high tall peaked T waves on EKG - not excess K in timely fashion and progress to v-tach - fatal arrhythmia
Acute tubular necrosis /Renal failure (myoglobinuric)
Rhabdomyolysis (myoglobin from muscle in circulation) - common with crush injuries; striated muscle that dies due to crush injury get myoglobin protein released into systemic circ - kidneys work really hard to process proteins - excess protein - can lead to acute tubular necrosis and renal failure
Muscle weakness and pain - lactic acid also present rhabdomyolysis and creating pain

Major shock and renal failure - huge concerns for pt - Crush syndrome

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Twisting injuries - potentially tear/lyse muscle tissue
Natural disaster victims
Industrial accidents
Overdose: pt passes out due to overdose and laying on part body and causes compression and damage; limb compressed by body wt.; body weight compressing limb causing muscle and tissue damage for longer period of time
Age: Older adults fall/immobile - same position for extended period of time

Risk factors - Crush syndrome

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Prevent renal failure
Cardiac dysrhythmias

Medical Management - Crush syndrome

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Surgical emergency - react to quickly to preserve patient’s limb; life-threatening if not addressed quick enough
Swelling inside a limb - swelling so much that compresses
Internal or external causes
Compression of muscle, nerves and blood vessels-ischemia- tissue infarction/death in 4-12 hours - intervene before tissue death
Commonly in lower leg and forearm
S/S: Edema, pain, paresthesia (numbness, tingling, pins and needles), pale, pulseless, cool to touch (poikilothermia)
Not corrected Necrosis/high risk for infection/not resolved causes loss of function or limb/life - HCPs attention quickly - get VS first
Emergency surgery; prep for surgery

Acute compartment syndrome

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Fasciotomy - large incision down tissue to relieve fascia - make room for swelling - takes pressure off muscle so can swell without compressing blood vessels and relieve pressure which is the goal

Medical - Acute compartment syndrome

Monitor at risk patients: trauma, fracutres Report signs and symptoms to HCP in timely manner Monitor development of crush syndrome - compartment and crush syndrome found together Care of surgical site as would for any other surgical pt

Nursing - Acute compartment syndrome

Urate crystal deposits in the joints and other body tissues causes inflammation. Primary - most common type; errors in purine metabolism; purine: product of protein breakdown and end product uric acid; normally uric acid excreted by kidneys; primary: not excrete uric acid in same level as those without gout; Males more likely to get than females - females most likely after menopause Secondary - too much uric acid produced in bloodstream

Pathophysiology - Gout

Renal insufficiency - kidney issue Diuretic therapy Some Chemotherapy Older adults - postmenopausal women; peak for men 40-50 yrs CV problems - vascular component: PVD, DM - affected small blood vessels Obesity Postmenopausal women

Risk factors - Gout

Asymptomatic hyperuricemia - may be unaware of it until experiencing symp Client usually unaware Higher than normal levels uric acid in blood stream Elevated uric acid levels No treatment - lifestyle changes; not detected at this point of time Acute gouty arthritis - seek treatment Pain and inflammation - terrible pain - no weight on affected pain Podagra – pain in great toe; big toe most common area where pain manifests itself Chronic/tophaceous gout - Chronic - Repeated gout attacks Tophaceous - not in US; if not compliant with med regimen Urate kidney stone formation; uric acid crystals lodge self in small vessels where start see them through skin - small fessels and fingers and toes - also in organs so higher risk for kidney stones

Stages - Gout

Joint pain - LOT PAIN; pain rated high Joint inflammation - swollen Hyperuricemia - high uric acid levels Uric Acid levels - high Elevated BUN (10-20 mg/dL) Elevated Creatinine (0.6-1.3) mg/dL) Kidney stones - urate acid crystals build up

CM - Gout

Medications Indomethacin Works in about 12 hours Ibuprofen Other NSAIDS can be used as well Work quickly Decreases inflammation - reduces pain Allopurinol Great med - reduces uric acid level in body; not work quickly; be on qday; goal reduce chances further attacks in future; maintenance med

Treatment - Gout

Strict low-purine diet - purines break down into urice acid so avoid as much as possible: avoid red meats, pork, shellfish, organ meats (liver), sweet breads, grain-based liquids Teach client fad diets may cause attack- eat nothing but one sort of food for extended period of time Avoid Aspirin - acetylcyclic acid; want reduce acidity level for pts Avoid Diuretics Stress reduction - spurred by stressful events Assess for kidney stones

N. interventions - Gout

Impaired physical mobility r/t musculoskeletal impairment - not put weight on affected extremity Chronic Pain r/t inflammation of affect joint Readiness for enhanced Knowledge: expresses an interest in learning - educating pt on med adherence and ways reduce future attacks

Nursing Diagnosis - Gout

Bone is both destroyed and reconstructed at a rapid pace. This causes bone fragility Bones break down and remodeled over time - for these pts happens quick pace; bone rebuilt not same quality over bone slow pace that people who don’t have this

Pathophysiology - Paget’s disease of the bone

Increased age greater than 40 Genetic predisposition Men greater than women - attached to X chromosome since boys have one and girls have 2

Risk Factors - Paget’s disease of the bone

Broken bones - main one; larger bones affected in gen Hearing loss - skull affected risk for this Pinched nerves - as bones develop and not usual shape nerves can be pinched; get paresthesias and pain with that

Clinical Manifestations - Paget’s disease of the bone

Larger bones Pelvis Skull Spine Leg

What bones are generally affected? - Paget’s disease of the bone

X-ray Bowing of bones Bones forming irregular shapes Bone scans Shows open bones fragments Increased alkaline phosphatase in labs alkaline phosphatase - goes with liver; phosphorus and Ca have inverse relationship; extra phosphate shows active disease in bloodstream Shows active disease

Diagnosis - Paget’s disease of the bone

Medications - not curative; help slow do down progression of the disease for the pt Alendronate - most frequently given Ibandronate Pamidronate Risedronate Zoledronic acid Surgery Help fractures heal in a way that more conducive for movement for pts Joint replacements possibility if bone structures in hips/knees where grown where joint articulation is painful may need to replace whole joint Bone realignment Relieve pressure on nerves - pinched nerves

Treatment - Paget’s disease of the bone

Disturbed body image - bones growing in diff ways than someone who does not have disease Deficient Knowledge Chronic Sorrow Risk for Trauma Risk for Injury - weak, brittle bones Fear - when going to break again

Nursing Diagnosis - Paget’s disease of the bone

Prevent falls – provide safe passage; not fall Promote activity - strengthen bones; weight-bearing activity; do so in safe manner Dietary plan – Calcium and Vit. D; adequate stores of both; breakdown bones and build-up bones go through lot Ca Educate client on disease process

Nursing Interventions - Paget’s disease of the bone

Peripheral vascular disease Diabetes Infection Malignant tumor Traumatic - car accident

Amputation may be congenital or traumatic or caused by conditions such as - Amputation

Amputation is used to relieve symptoms, improve function, and improve quality of life Can be diff: Health care team needs to communicate a positive attitude about this as much as possible to facilitate acceptance and participation in rehabilitation; put in place of pt; losing functionality can be devastating for pt - why necessary; get them participate in rehab Goal – preserve as much functional length as possible Regain more normal function -prosthesis - if possible; and help Improve quality of life Amputation-leg either above (AKA/transfemoral) or below knee (BKA/transtibial) -- most common amputation surgery

Amputation

Hemorrhage - result in blood loss Infection - incision site for redness, purulent drainage Phantom limb pain - amputated limb still hurts; nerves once attached still sending pain signals through NS and still hurting; aching, tingling, itching; gen fades over time; do treat pain Flexion contracture Loss of strength Assess: perfusion edema, good pulses, color adequate, temp, monitor suture/incision line, monitor for edema, Wound heals 4-8 weeks - varies Control Pain control Phantom limb pain – absent limb pain; some hesitant to report but let them know is norm Alternative methods: imaging Treat PAIN No pillows under stump/residual limb (contractures - scar tissue developing that limits ROM) Overhead trapeze to help with mobility with LE amputation; exercises Pt out of bed 12 – 24 hours after surgery - up ASAP

Complications and nursing - post amputation and post-surg - Amputation

PT and/or OT Psychological support - assess support sys; not understand how must feel; will have grieving process; get in support groups for those who have experienced the same or sim feelings r/t amputations very beneficial Prostheses appropriate fitting and educated on how to use Physical therapy Vocational or occupational training and counseling Use a multidisciplinary team approach - all professions to care for pts Patient teaching - LOTS EDU

Rehab - Amputation

Acute pain Impaired skin integrity Disturbed body image Grieving Self-care deficit Impaired physical mobility Major goals include: Most likely long-term goals; not really short0term Relief of pain - phantom limb pain Absence of altered sensory perceptions Wound healing Acceptance of altered body image - takes a while Resolution of grieving processes Restoration of physical mobility Absence of complications

N. diagnosis/goals - Amputation

Relief of pain Administer analgesic or other medications as prescribed Changing position frequently Putting a light sand bag on residual limb Alternative methods of pain relief: distraction, TENS unit Promoting wound healing Handle limb gently - will be sore and in pain Residual limb shaping - brace helps with this Resolving Grief/Enhancing Body Image Do with what can to help with this - does take time; ok that going through grieving process and norm for situation Encourage communication and expression of feelings Accepting, supportive atmosphere Provide support and listen (VERY THERAPEUTIC TO LISTEN) Encourage patient to look at, feel, and care for the residual limb - coping mechanism not want acknowledge it Help patient set realistic goals Help Resume self-care and independence Referral to counselors/support groups can be beneficial to pts

N. interventions - Amputation

Limb shaping brace helpful Proper positioning of limb; avoid abduction for pts - goal: keep contractures from forming so appropriate ROM, external rotation and flexion Turn frequently; prone positioning if possible Use of assistive devices - get trained how use appropriately ROM exercises Muscle strengthening exercises “Preprosthetic care”: involves proper bandaging to help with shaping of them and also get toughening/calloused to where pat can put on prosthesis and not have any blisters as a result, massage, and “toughening” of the residual limb

N. interventions: achieving phys mobility - Amputation

Encourage active participation in care - as independent as possible; gradually increase overtime Continue support in rehabilitation facility or at home Focus on safety and mobility

N. interventions: self-care home - Amputation

Contusion - bruise Trauma resulting in bleeding and brusing to lung tissue; bruising in lungs Frequently caused by/Common - rapid deceleration - car accident - steering wheel and not wearing a seatbelt

Pulmonary contusion - Musculoskeletal - chest trauma

Immediate Over time - time to develop

Risk for Respiratory failure - Pulmonary contusion - Musculoskeletal - chest trauma

Between alveoli - in and around alveoli - vessels around alveoli where gas exchange occurs and if those vessels surrounded by fluid gas exchange cannot occur and no gas exchange no O2 to blood stream

Blood and edema - Pulmonary contusion - Musculoskeletal - chest trauma

Crackles Wheezes - potential - narrowing airway Cough Tachycardia Tachypnea Dullness to percussion - excess fluid from contusions/bruises in lung

Clinical manifestations - Pulmonary contusion - Musculoskeletal - chest trauma

Early – CXR negative; bleeding in and around alveoli not happened or actively happening may not see it present Late – CXR hazy opacity over affected area; day or two later - see this; more white and gray - more opaque; see blood leak and edema in lungs

Diagnosis - Pulmonary contusion - Musculoskeletal - chest trauma

Need to ensure to Maintain airway and monitor breathing - assistance as needed Maintain IV fluids - losing fluid where having fluid volume deficit need fluid support; trauma pt tend get lot fluids Moderate-Fowler's position - trouble breathing sit up - not tolerate high up BiPAP (positive airway pressure) or PEEP (positive and expiratory pressure) - help keep alveoli open - alveoli surrounded in fluid collapse which not do job effectively and so extra airway pressure help stay open

Nursing implications - Pulmonary contusion - Musculoskeletal - chest trauma

Impaired gas exchange - need alveoli to do their job

Nursing Diagnosis - Pulmonary contusion - Musculoskeletal - chest trauma

Condition can lead to acute respiratory distress syndrome (ARDS) Not corrected or happens anyway despite best try

Outcome - Pulmonary contusion - Musculoskeletal - chest trauma

Common – direct blunt trauma to chest If not drive further into check care supportive; given adequate pain med - avoid meds that suppress resp drive (morphine, dilaudid) - lidocaine, xylocaine, pivocaine - splint area and not take deep breaths - want them to take deep breaths so adequately oxygenated and not get pneumonia Simple rib fractures - no splinting; take easy; deep breathing exercises; manage pain until ribs repair self Rib fracutre driven into chest and lungs - pulm contusion, pneumothorax, hemothorax Bone ends are driven into chest Risk for pulmonary contusion, pneumothorax (collapsed lung), hemothorax (blood put pressure on lung where not able to expand full) Pain causes client to splint which causes decreased lung volume - not want take deep break Deeper injury equals poorer prognosis

Rib fracture - Musculoskeletal - chest trauma

Assist with gas exchange Treat pain, but avoid medications that suppress the respiratory drive than more have Assess for pneumothorax (hallmark sym for bad one: tracheal deviation - lung collapsed and air in chest cavity putting pressure on lungs where not able expand like should and go towards one side and trachea shifts away from midline; most often use chest tubes insertion to relieve for pt), hemothorax (most often use chest tubes insertion to relieve for pt), respiratory failure

Nursing implications - Rib fracture - Musculoskeletal - chest trauma

Impaired gas exchange Pain

Nursing Diagnosis - Rib fracture - Musculoskeletal - chest trauma

Neighboring rib fractures occurring and rib fracture in more than one location on same rib causing paradoxical chest wall movement; results in free floating portion of the chest wall Common – blunt chest trauma Look for other injuries because flail chest requires a great deal of force to happen Common after fall in elderly pts; typ car accidents Common after ACLS - CPR on pts; can happen in bone actually separates from cartilage get odd chest wall movement Most time pts go to surgery - intubated and on ventilator and fractures stabilized

Flail chest - Musculoskeletal - chest trauma

Paradoxical chest movement - HALLMARK; section of chest with broken bones move opp direction should; causes imbalance whenever breathing and increases work breathing and lungs unable to expand fully; reduces total SA lungs able to expand reducing oxygenation for pt Dyspnea Cyanosis - been awhile since initial trauma Tachycardia Hypotension SOA Anxiety Pain

Manifestations - Flail chest - Musculoskeletal - chest trauma

Pain management - rib fractures hurt esp if lot of them Oxygen - getting adequate oxygen and frequently end up on ventilator Lung expansion Expanding fully Ventilator - positive airway pressure for full expansion Remind them to do deep breathing exercises and have good positioning for pts Deep breathing Positioning Respiratory assessment Mechanical ventilation - PEEP - keep lungs inflated Frequent ABG’s on pts; monitor acid-base balance and pO2 levels Surgery only in extreme cases - big enough trauma to fracture multiple ribs are severe enough

Nursing Interventions - Flail chest - Musculoskeletal - chest trauma

Impaired gas exchange Pain Impaired communication - particularly for pts on ventilator

Nursing Diagnosis - Flail chest - Musculoskeletal - chest trauma