Week 9: Musculoskeletal Disorders Flashcards
Structure and Function Bone
-Support: to keep the body from collapsing
-Movement: work as levers with attached muscles
-Protection: of the body’s internal structures
-Blood cell production
-Mineral storage
Structure and Function Joints
-Place where the ends of two bones are in proximity and move in relation to each other
-Classified according to the degree of movement they allow
Structure and Function Cartilage
-Rigid connective tissue
-Serves as a support for soft tissue & provides the articular surface for joint movement
Structure and Function Muscles
Skeletal
-movement of the skeleton and other organs
-half of a person’s body weight
Smooth
-walls of hollow structures (airways, arteries, GI tract, bladder, uterus)
Cardiac
-pumps the heart
Structure and Function Ligaments & Tendons
-Dense, fibrous connective tissue
-Ligaments: connect bones to bones, elastic and flexible
-Tendons: attach muscles to bones; stronger than ligaments
-Both have poor blood supply: longer healing time
Structure and Function Fasciae
-Layers of connective tissue
-Surrounds muscles allowing them to act independently and glide over each other during contraction
Structure and Function Bursae
-Small sacs of connective tissue lined with synovial membrane and containing synovial fluid
-Located at bony prominences to relieve pressure and prevent friction between moving parts
Skeletal Muscle
Structural Unit = muscle fibre (cell)
-Myofibrils
-Contractile units (sarcomeres)
Neuromuscular Junction
-Where the axon of the neuron meets the muscle fibre (cell)
-Requires a nerve impulse to contract the muscle
-Acetylcholine released triggers the release of Ca+
-Contraction occurs
Age Related Considerations
Many functional problems experienced by the aging adult relate to changes of the MSK system
*Decreased Ability to perform ADL
-Chronic pain and immobility
*Loss of muscle mass & strength, change in balance & in proprioception
-Increased potential for falls
*Increased bone resorption & decreased bone formation
-Loss of bone density, osteoporosis
*Tendons & ligaments become less flexible
-Joints & limbs become more rigid
Assessment- Subjective Data
Current Health:
-Joints,muscles, bones
-Functional abilities (ADLs)
-Self care behaviours
-Consider aging adult issues
Symptoms:
-Pain, weakness
-Deformity
-Limitation of movement
-Stiffness, joint crepitation
Past health Hx, Illness, Hospitalization:
-Physical trauma
-Arthritic and connective tissue diseases
-Previous MSK surgeries or treatments
Medications
-Prescribed
-OTC
-Herbal, nutritional supplements
-Use of corticosteroids
-Analgesics
-Estrogen replacement
Assessment- Objective Data
Normal Physical Assessment of the MSK
- Full range of motion of all joints without pain or laxity (hypermobility)
-No joint swelling, deformity, or crepitation
-Normal spinal curvatures
-No tenderness on palpation of spine
-No muscle atrophy or asymmetry
-Muscle strength of 5
Diagnostics
Radiology: x-ray, CT, MRI
Arthroscopy: fibre optic examination the interior of joint cavity
Muscle Enzymes: Creatine kinase r/t muscle damage
Bone Mineral Density: measure bone mass
Electromyogram: measures electrical system of the muscle
Fractures
-The nurse has an important role in the prevention of complications, and promotion of function in patients with fractures and orthopaedic surgery
-The most common cause of MSK injuries is a traumatic event resulting in fracture, dislocation, & associated soft tissue injury
Fractures Classifications
Open: skin broken & soft tissue exposed
Closed: skin intact
Complete: break is completely through bone
Incomplete: bone is still in one piece but break occurs across the bone shaft
Displaced: two ends separated from one another
Nondisplaced: bone is aligned and periosteum is intact
Greenstick Fracture
Occurs when a bone bends and cracks, instead of breaking completely into separate pieces
Fracture Clinical Manifestations
-Immediate localized pain, edema, swelling
-Decreased or loss of function
-Client guards and protects the area
-Deformity is a cardinal sign of fracture
(may not be obvious)
Fracture Healing 1.) Fracture Hematoma
-First 72 hours
-Bleeding creates a hematoma surrounding the ends of the fragments
Fracture Healing 2.) Granulation Tissue
-3 to 14 days post injury
-Hematoma converts to granulation tissue consisting of new blood vessels, fibroblasts, & osteoblasts
-Promotes healing
Fracture Healing 3.) Callus Formation
-Appears by the end of 2nd week
-Minerals and new bone matrix are deposited & woven around fracture parts
-Callus is composed of cartilage, osteoblasts, calcium, & phosphorus
Fracture Healing 4.) Ossification
-3wks to 6mos
-The bone is knitting together & stronger
-Cast may be removed
-# is still evident
Fracture Healing 5.) Consolidation
-Ossification continues
Fracture Healing 6.) Remodelling
Gradual return to pre-injury structural strength
Collaborative Care Goals
Reduction-
anatomical realignment of bone fragments
Immobilization-
to maintain realignment
Restoration-
of normal or near-normal function of the injured part
Fracture Reduction- Closed
-Nonsurgical, manual realignment of bone fragments to previous anatomical position
-Traction & countertraction applied to restore position, length, and alignment
-Under local or general anesthesia
-Immobilize the injured part to maintain alignment until healing occurs
Fracture Reduction- Open
-Surgical correction of bone alignment
-Often includes internal fixation (ORIF) using wires, screws, pins, plates, rods, or nails
-May involve external fixation of metal pins inserted into the bone & fixated to external rods
Main disadvantages:
-Possibility of infection
-Complications associated with anaesthesia
-Effects of pre-existing medical conditions
Nursing Diagnoses & Goals
-Impaired physical mobility r/t joint stiffness & pain
-Risk for peripheral neurovascular dysfunction r/t fracture
-Acute pain r/t physical injury
-Readiness for enhanced self-health management
Overall Goals
-Have physiological healing with no associated complications
-Obtain satisfactory pain relief
- Achieve maximal rehabilitation potential
Nursing Management- Pre OP
Inform Clients of:
-Immobilization
-Assistive devices that will be used
-Expected activity limitations after surgery
Assure clients that their needs will be met
Assure clients that pain medication will be available
*Antibiotics are used prophylactically before surgery
Nursing Management- Post OP
Apply general principles of post-op nursing care & infection prevention:
-Pin care cleaning: 1⁄2 strength H2O2 with normal saline is often used
Perform neurovascular assessments of affected extremity:
-Peripheral vascular: colour, temp, cap refill, pulses, edema
-Peripheral neurological: sensation, motor function, pain
Minimize Pain & Discomfort
-Through proper alignment & positioning
-Analgesics as ordered
On Discharge
-Instruct pt & family on meticulous skin care
During the post-op phase, the client will have antibiotics administered intravenously for 3–7 days
Collaborative Care- Nutrition
Protein:
Ample protein
1g/kg of body weight
Vitamins:
Vitamins B, C, D
Protein & vitamin C deficiencies interfere with tissue healing
Minerals:
Calcium, phosphorus, magnesium
Immobility & callus formation increase calcium needs
Meals:
3 meals/day
Provides necessary nutrients
Prevent constipation with high-fibre diet incl fruit & veggies
Fluids
Adequate fluid intake 2000–3000ml/day
Fracture Reduction- Traction
Traction applies a pulling force on a fractured extremity to attain realignment, while countertraction pulls in the opposite direction – two types:
SKIN TRACTION:
-Short term
-Tape, boots, or splints
SKELETAL TRACTION:
-Long term pull
-Inserts pin or wire into the bone
Forces must be pulling in opposite direction to prevent client from sliding to end or side of bed
Countertraction commonly supplied by client’s body weight or augmented by elevating end of bed
Nursing Management- Traction
-Inspect exposed skin regularly when slings are
used with traction
-Ulcers may result from pressure over bony prominence created by wrinkled sheets or bedclothes
-Persistent skin pressure may impair blood flow & cause injury to peripheral neurovascular structures
-Imperative that the nurse maintains traction constantly & does NOT interrupt weight applied to traction
-Position changes, ROM exercises on unaffected joints, deep breathing
Nursing Management
Rapid deconditioning of cardiopulmonary system:
-Results from prolonged bed rest
-Orthostatic hypotension & diminished lung capacity
-Monitor for DVT
Renal Calculi
-Can develop as a result of bone demineralization
-Encourage fluid intake of 2500 mL/day
Fracture Immobilization- Cast
-Temporary circumferential immobilization device commonly applied following a closed reduction
-Allows client to perform many normal ADLs
-Plaster or fiberglass (used more often)
-Application incorporates joints above and below fracture
-Restricts tendon and ligament movement
-Assisting with joint stabilization while fracture heals
Casts- Nursing Care
-Frequent neurovascular assessments are critical
-Teach pt about signs of cast complications and to report them
-Elevate the extremity above the level of the heart to promote venous return & prevent edema (NOT if compartment syndrome)
-Encourage pt to move fingers & non-immobilized joints of the upper extremity
Ambulation
-Reinforce physiotherapist’s instructions
-The nurse should know the patient’s weight-bearing status and the correct technique if the patient is using an assistive device
-Decision about what device to use is made by health care provider: cane, crutches, walker
-The involved limb is usually advanced at the same time or immediately after advance of the device
-A cane is held in the hand opposite the involved extremity (serves role of unstable leg)
Ambulation
-Transfer belt should be placed around client’s waist to provide stability during learning stages
-Discourage client from relying on furniture or another person for support
-With inadequate upper limb strength or poorly fitted crutches, the client bears weight at the axilla rather than at the hands, endangering the neurovascular bundle that passes across the
axilla
Fractures- Complications
-Majority heal without complications
-Damage to underlying organs & vascular structures
-Complications of fracture or immobility
DIRECT COMPLICATIONS:
-Problems with bone infection, bone union, avascular necrosis (AVN)
INDIRECT COMPLICATIONS:
-Blood vessels and nerve damage
-Compartment syndrome
-Venous thromboembolism
-Fat embolism
-Rhabdomyolysis (breakdown of skeletal muscle)
-Hypovolemic shock
Complications- Compartment Syndrome
-A condition in which swelling & increased pressure within a limited space (compartment) press on and compromise the function of blood vessels, nerves, and tendons that run through that compartment
-Causes capillary perfusion to be reduced below the level necessary for tissue viability
-Two types of compartment syndrome
Decreased Compartment Size
Resulting from restrictive dressing, splints, casts, excessive traction, or premature closure of fascia
Increased Compartment Contents
-Related to bleeding, edema, IV filtration
Edema
Compromised arterial flow
Ischemia
Muscles & nerve cells are destroyed
Loss of function
Compartment Syndrome- Assessment
Pain:
-distal to injury not relieved by opioids
-Pain on passive stretch of muscle through compartment
Pressure:
-Increase in compartment
Paresthesia
-Numbness and tingling
Pallor:
-Coolness and loss of normal colour of extremity
Paralysis:
-Loss of function
Pulselessness:
-Diminished/absent peripheral pulses
Compartment Syndrome- Collab Care
Early recognition & treatment essential
-Ischemia can occur within 4–8 hours after onset
Regular neurovascular assessments
Urine output must be assessed for possibility of muscle damage
-Myoglobin
Myoglobin released from damaged muscle cells precipitates as a gel-like substance
Causes obstruction in renal tubules
May result in acute tubular necrosis
May result in AKI
Common Signs of Myoglobinuria
-Dark reddish brown urine
-Signs and symptoms of AKI
Compartment Syndrome- Collab Care
Extremity should NOT be elevated above heart level
-Elevation may raise venous pressure and slow arterial perfusion
May be necessary to remove or loosen bandage or split cast
Reduction in traction weight may reduce external circumferential pressures
Surgical decompression (fasciotomy) may be necessary
-Left open for several days
-Ensures adequate soft tissue decompression
Complications- Venous Thrombo-Embolism
-Veins of lower extremities and pelvis are highly susceptible to thrombosis, esp. hip fractures
-Venous stasis is aggravated by inactivity of muscles that normally assist in the pumping
action of venous blood
-Prophylactic anticoagulant drugs may be ordered
-Wear compression gradient stockings
Complications- Fat Embolism Syndrome (FES)
- Presence of systemic fat globules from fractures that are distributed into tissues
& organs after a traumatic skeletal injury
-FES is fatal in 5% to 15% of patients
-May follow total joint replacement, spinal fusion, crash injury
-Fractures most often causing FES are those of long bones, ribs, tibia, and pelvis
FES Collaborative Care
-Early recognition crucial in preventing potentially lethal course
-Most clients manifest symptoms 24– 48 hours after injury
-Fat globules move to the lungs causing pneumonitis
-Look for acute respiratory distress syndrome (ARDS)
-S&S of hypoxia
-Pt expresses feeling of impending disaster
-Skin colour changes from pallor to cyanosis
-Client may become comatose
FES Treatment
-Treatment is directed at prevention
-Careful immobilization of a long bone fracture is the most important element
-Management is symptom related and supportive
-Fluid resuscitation to prevent hypovolemic shock
-Encourage deep breathing & coughing
-Reposition the client as little as possible before fracture immobilization r/t danger of dislodging fat droplets into the general circulation
-Oxygen to treat hypoxia
Hip Fracture
-Refers to a fracture of the proximal third of the femur
Intracapsular (within the joint):
-osteoporosis & minor trauma
Extracapsular (outside the joint):
-severe direct trauma or fall
Common among the elderly and serious
-Particularly women aged 75+
Requires one of the longest hospital stays
-Averaging > 12 days
Hip Fractures
-Displaced femoral neck #s cause serious disruption of the blood supply to the femoral head (can result in vascular necrosis)
-Risk for life-threatening post-op complications:
(pneumonia, thrombi, UTIs)
-Also at risk for:
(constipation, confusion, pressure ulcers)
Nursing Management (Hip Fracture)
-In planning tx of the hip fracture, consider the pt’s chronic health problems
(diabetes, cardiac, and pulmonary disease)
-Surgery within 48h or risk ↑ mortality in pts 85+
Hip Fracture- Log Rolling
-Keep affected leg abducted and prevent external rotation of hip
Amputation
-Removal of all or part of the extremity by trauma or surgery
-Severe damage due to trauma
-To prevent spread of cancer
-To prevent spread of gangrene r/t PVD
-Majority are aged 55+
GOAL: to preserve extremity length & function
Amputation
-Tremendous psychological & social implications for the pt
-Pt should be warned about phantom limb sensation and pain
Amputation
-Proper residual limb bandaging fosters shaping and moulding for eventual prosthesis fitting
Applied immediately after surgery to:
-support the soft tissues
-Reduce edema
-Hasten healing
-Minimize pain
-Promote residual limb shrinkage and maturation
Arthritis
-Inflammation of a joint or joints
-Most forms of arthritis affect women more frequently than men
-Osteoarthritis is the most common chronic condition of the joints
-Rheumatoid arthritis is the most serious and most disabling
Osteoarthritis (OA)
-Slowly progressive non-inflammatory disorder of the synovial joints
-Gradual loss of articular cartilage with
formation of bony outgrowths (spurs) at the
joint margins
-Pain & stiffness r/t cartilage loss and joint surfaces rubbing against each other
Osteoarthritis (no cure)
Focus of Care:
-Managing pain and inflammation
-Preventing disability
-Maintaining and improving joint function
Treatments:
-rest & splints
-Heat applications to relieve stiffness
-Weight reduction and exercise
-Acupuncture and massage
MEDS:
-Acetaminophen
-ASA
-Topical salicylates, capsaicin, diclofenac
-NSAIDs
-Corticosteroids
-Methotrexate
-Humira, Remicade
Rheumatoid Arthritis (RA)
-Chronic, systemic autoimmune disease characterized by inflammation of connective tissue in the synovial joints
(diagnosis by RF in bloodwork)
-Marked by periods of remission and exacerbation
-Pain, stiffness, limitation of motion, and signs of inflammation
-Joint symptoms occur symmetrically and frequently affect the small joints of the hands & feet
RA can affect nearly every system in the body
Rheumatoid Arthritis Treatment
Medication is the cornerstone of RA tx
-Methotrexate preferred for early tx
-Other meds s/a OA
Other Treatments:
-Rest
-Joint protection
-Heat (for stiffness) and cold (for inflammation)
-Gentle ROM exercises; aquatic exercise
Pressure Injuries
-Localized injury to the skin or underlying soft tissue, usually over a bony prominence, as a result of excessive or prolonged pressure, shear, and tissue deformation
-Pressure injuries are generally considered an indicator of the quality of care, and most are regarded as avoidable
-Financial burden on health care system
-Impact on mortality, morbidity, & quality of life
Common Sites Pressure Injuries
Sacrum
Ischium
Trochanter
Coccyx
Heels
Malleolus
Pressure Injury Factors
-Amount of pressure
-Duration of pressure
-Pt’s tissue tolerance to pressure and/or shearing
Nursing Assessment
-Assess for pressure risk on admission
-Thorough head-to-toe skin assessment
-Use an assessment tool: Braden Scale
Dx: reduced skin/tissue integrity
Braden Scale
The higher the score the better
Sensory: perception of pressure discomfort
Moisture: degree to which skin is exposed to moisture
Activity: degree of physical activity
Mobility: ability to change and control body position
Nutrition: usual food intake pattern
Friction & Shear: ability to move without sliding
Pressure Injuries
-Staged according to the deepest level of tissue damage
-When slough or eschar present, not possible to stage until debrided
-When full-thickness pressure injuries heal, fat, muscle, and dermis are replaced with granulation tissue
(original integrity of the tissue is lost)
Pressure Injury- Deep Tissue
-Intact or nonintact skin with localized area of persistent non- blanchable, deep red, maroon, purple discoloration
-Pain & temperature change often precede skin
colour changes
-Discoloration may appear differently in darkly pigmented skin
Pressure Injury- Stage 1
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin
Pressure Injury- Stage 2
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also appear as an intact or ruptured serum-filled blister
Pressure Injury- Stage 3
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.
Slough or eschar, or both, may be visible
Pressure Injury- Stage 4
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough, eschar, or both may be visible
Pressure Injury- Unstageable
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury is revealed
Nursing Management (Pressure Injury)
-Pressure relief
-Pain management
-Wound Care
-Adequate nutrition
Pressure Injury- Assess & Measure
*Measure in cm
-Head to toe
-Side to toe
-Depth
*Tunnelling or undermining
-Assess with cotton swab
*Chart it like a clock
