2 Overview of Anatomy and Physiology Functions of the skeletal systemSupportProtectionMovementMineral storageHemopoiesisStructure of bonesFour classifications based on form and shapeLong, short, flat, and irregularThe skeletal system performs five vital functions in the body. These functions include support, protection, movement, mineral storage, and hemopoiesis.Review the minerals that play a role in the functioning of the skeletal system.How does the body compensate for alterations in dietary intake of these minerals?
3 Skeleton, anterior view. Figure 44-2Review the types of bones discussed in the previous slide. What are specific examples of each of the different types of bones in the skeleton?(From Thibodeau, G.A., Patton, K.T. . The human body in health and disease. [4th ed.]. St. Louis: Mosby.)Skeleton, anterior view.
4 Skeleton, posterior view. Figure 44-3(From Thibodeau, G.A., Patton, K.T. . The human body in health and disease. [4th ed.]. St. Louis: Mosby.)Skeleton, posterior view.
5 Overview of Anatomy and Physiology Articulations (joints)Allow movementThree types according to degree of movementSynarthrosis—no movementAmphiarthrosis—slight movementDiarthrosis—free movementDivisions of the skeletonAxial skeletonAppendicular skeletonWhat are examples of each of the joint types?Provide examples of bones in the axial skeleton.What are some of the bones in the appendicular skeleton?
6 Structure of a freely movable (diarthrotic) joint. Figure 44-1(From Thibodeau, G.A., Patton, K.T. . Structure and function of the body. [13th ed.]. St. Louis: Mosby.)Structure of a freely movable (diarthrotic) joint.
7 Overview of Anatomy and Physiology Functions of the muscular systemMotionMaintenance of postureProduction of heatSkeletal muscle structureEpimysiumPerimysiumEndomysiumContraction and relaxation provides the motion needed for muscular movement.Review how tendons and ligaments differ.How do muscles provide posture for the body?Approximately 85% of the body’s heat is produced by the muscles. What processes are responsible for this vital function?
8 Anterior view of the body. Figure 44-5The body contains more than 600 muscles.(From Thibodeau, G.A., Patton, K.T. . The human body in health and disease. [4th ed.]. St. Louis: Mosby.)Anterior view of the body.
9 Posterior view of the body. Figure 44-6Nearly 40% to 50% of the body’s weight is due to its muscles.(From Thibodeau, G.A., Patton, K.T. . The human body in health and disease. [4th ed.]. St. Louis: Mosby.)Posterior view of the body.
10 Overview of Anatomy and Physiology Nerve and blood supplyBlood vessels provide a constant supply of oxygen and nutrition, and nerve cells/fibers supply a constant source of informationMuscle contractionMuscle stimulus—when a muscle cell is adequately stimulated, it will contractMuscle tone—skeletal muscles are in a constant state of readiness for actionTypes of body movements—flexion, extension, abduction, adduction, rotation, supination, pronation, dorsiflexion, and plantar flexionNutrition and oxygenation are chief requirements for muscle health. Optimal muscle health is needed to maintain the constant state of readiness of the body for action and reaction.How will disease processes of the muscles impact the body’s ability to move?
11 Laboratory and Diagnostic Examinations Radiographic studiesMyelogramNuclear scanningMagnetic resonance imaging (MRI)Computed axial tomography (CT or CAT scan)Bone scanEndoscopic examinationArthroscopyEndoscopic spinal microsurgeryRadiographic studies are the most common type of diagnostic testing done for the musculoskeletal system.What special precautions and nursing implications are needed for patients undergoing radiographic studies?How is arthroscopy both diagnostic and therapeutic in nature?
12 Laboratory and Diagnostic Examinations AspirationSynovial fluid aspirationElectrographic procedureElectromyogram (EMG)Laboratory testsCalciumErythrocyte sedimentation rate (ESR)Lupus erythematosus (LE) preparationRheumatoid factor (RF)Uric acid (blood)Needle aspiration is used to obtain body fluids from joint cavities. Review the nursing interventions when caring for a patient having this type of examination.When caring for a patient undergoing diagnostic musculoskeletal testing, what education should be provided to the patient?
13 Inflammatory Disorders of the Musculoskeletal System Rheumatoid arthritisEtiology/pathophysiologyMost serious form of arthritisChronic, systemic diseaseMost common in women of childbearing ageAutoimmune disorder, but may also be geneticMay affect lungs, heart, blood vessels, muscles, eyes, and skinChronic inflammation of the synovial membrane of the diarthrodial joints (movable)An estimated 50 million Americans are victims of arthritis. Arthritis is a costly disease resulting in lost wages and health care expenses.Review the autoimmune reaction that is suspected when rheumatoid arthritis strikes.
14 Inflammatory Disorders of the Musculoskeletal System Rheumatoid arthritis (continued)Clinical manifestations/assessmentCharacterized by periods of remission and exacerbationMalaiseMuscle weaknessLoss of appetiteGeneralized achingEdema and tenderness of jointsLimited range of motion (morning stiffness)
15 Rheumatoid arthritis of hands. Figure 44-7Notice how the patient’s fingers are affected by rheumatoid arthritis.(From Kamal, A., Brocklehurst, J.C. . Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.)Rheumatoid arthritis of hands.
16 Inflammatory Disorders of the Musculoskeletal System Rheumatoid arthritis (continued)Diagnostic testsRadiography studies show loss of articular cartilage and change in bone structureLaboratory testsErythrocyte sedimentation rate (ESR)Rheumatoid factor (RF)Latex agglutination testSynovial fluid aspirationA single definitive diagnostic tool for rheumatoid arthritis is not available. A diagnosis involves a complete physical examination and patient history.Review the anticipated findings in the erythrocyte sedimentation rate, Rheumatoid factor, latex agglutination test, and synovial fluid aspiration when a diagnosis of rheumatoid arthritis is confirmed.What other disorders could have similar diagnostic test results?
17 Inflammatory Disorders of the Musculoskeletal System Rheumatoid arthritis (continued)Medical management/nursing interventionsPharmacological managementSalicylates, NSAIDs, COX-2 inhibitors, anti-inflammatory agents, disease-modifying antirheumatoid drugsRest: 8 to 10 hours of sleep a nightExercise: Range of motion two to three times per dayHeat: Hot packs, heat lamp, and/or hot paraffinRehabilitationRheumatoid arthritis is a chronic disease with no known cure.“Quiet” exercise is recommended. What are examples of quiet exercise?What are the goals of disease management?Given the age of the most commonly stricken population and the absence of a complete cure, what are potential psychosocial implications for a family after a member is diagnosed with rheumatoid arthritis?
18 Inflammatory Disorders of the Musculoskeletal System Ankylosing spondylitisEtiology/pathophysiologyChronic, progressive disorder of the sacroiliac and hip joints, the synovial joints of the spine, and the adjacent soft tissuesMost common in young menStrong hereditary tendencyClinical manifestations/assessmentPain and stiffness in back; decreased ROMElevated temperature; tachycardia; hyperpneaAnkylosing spondylitis is a progressive inflammatory disorder. Although both men and women are affected, it is typically milder in women.How does ankylosing spondylitis differ from rheumatoid arthritis?
19 Inflammatory Disorders of the Musculoskeletal System Ankylosing spondylitis (continued)Diagnostic testsHemoglobin, hematocrit, ESR, alkaline phosphataseRadiographicMedical management/nursing interventionsPharmacological managementAnalgesics, NSAIDsExercise program: swimming and walkingSurgery: replace fused jointsMaintain spine alignmentTurn, position, and breathing exercises every 2 hoursReview the diagnostic tests used to confirm the presence of anklyosing spondylitis. What findings for each test are used in the confirmation process?
20 Inflammatory Disorders of the Musculoskeletal System Osteoarthritis (degenerative joint disease)Etiology/pathophysiologyNonsystemic, noninflammatory disorder that progressively causes bones and joints to degeneratePrimaryCause is unknownSecondaryCaused by trauma, infections, previous fractures, rheumatoid arthritis, stress on weight-bearing jointsOsteoarthritis is the most common type of arthritis. It is a chief cause of disability.What risk factors are associated with the development of osteoarthritis?Differentiate between the modifiable and nonmodifiable risk factors.What impact does aging have on the development of osteoarthritis?REMEMBER-osteo due to wear and tear, rhematoid due to aUTOIMMUNE
21 Figure 44-9 Heberden’s nodes. Heberden’s nodes are nodules on the distal sides of the fingers’ joints.Explain how Heberden’s nodes differ from Bouchard’s nodes.(From Kamal, A., Brocklehurst, J.C. . Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.)Heberden’s nodes.
22 Inflammatory Disorders of the Musculoskeletal System Osteoarthritis (degenerative joint disease) (continued)Clinical manifestations/assessmentJoint edema, tenderness, instability, and deformityHeberden’s nodesBouchard’s nodesDiagnostic testsRadiographic studiesArthroscopySynovial fluid examinationBone scansThere are no definitive tests available for osteoarthritis.What findings can be anticipated when a diagnosis of osteoarthritis is confirmed?Compare and contrast osteoarthritis and rheumatoid arthritis.
23 Inflammatory Disorders of the Musculoskeletal System Osteoarthritis (degenerative joint disease) (continued)Medical management/nursing interventionsPharmacological managementSalicylates, NSAIDs, corticosteroids, glucosamine supplementsExercise balanced with restHeat applicationsGait enhancers (canes, walkers, etc.)SurgeryOsteotomyJoint replacementWhat are the goals of disease management for osteoarthritis?What is the role of the nurse in the care of a patient diagnosed with osteoarthritis?
24 Inflammatory Disorders of the Musculoskeletal System Gout (gouty arthritis)Etiology/pathophysiologyMetabolic disease resulting from an accumulation of uric acid in the bloodCaused by an ineffective metabolism of purinesPrimary: hereditary factorsSecondary: use of certain drugs, complication of other diseases, or idiopathicAffects men more frequently than womenDoes not occur before puberty in males or before menopause in females
25 Inflammatory Disorders of the Musculoskeletal System Gout (gouty arthritis) (continued)Clinical manifestations/assessmentExcruciating painEdemaInflammation (most common in the great toe)TophiDiagnostic testsSerum and uric acid level, CBC, ESRRadiography studiesSynovial fluid aspirationDiscuss the characteristics of the pain experienced by the patient having gout.What subjective data should be collected by the nurse from the patient suspected of having gout?
26 Inflammatory Disorders of the Musculoskeletal System Gout (gouty arthritis) (continued)Medical management/nursing interventionsPharmacological managementColchicine, phenylbutazone (Butazolidin), indomethacin (Indocin), corticosteroids, allopurinol (Zyloprim), sulfinpyrazone (Anturane)Encourage fluid intakeMonitor intake and outputBed rest and joint immobilizationDietary restrictionsDevelop a list of foods that should be avoided by the patient diagnosed with gout.What is the importance of monitoring kidney function in the patient with gout?Purines are restricted in the patient with gout. What foods should be avoided?
27 Other Disorders of the Musculoskeletal System OsteoporosisEtiology/pathophysiologyReduction of bone massMost common in women ages 55 to 65Contributing factors: immobilization; steroids; high intake of caffeine; diet low in calcium, high in protein; smoking; sedentary lifestyleClinical manifestations/assessmentBackachePorous and brittle bonesDowager’s humpOsteoporosis is a disorder in which the skeleton’s function is impaired because of the loss of bone mass.Explore reasons that support the development of osteoporosis in high-risk populations. Why are women affected more often than men? How does immobility or a sedentary lifestyle influence the onset of osteoporosis?
28 Other Disorders of the Musculoskeletal System Osteoporosis (continued)Diagnostic testsCBC, serum calcium, phosphorus, alkaline phosphatase, blood urea nitrogen, creatinine level, urinalysis, liver and thyroid function testsRadiography studiesMedical management/nursing interventionsPharmacological managementCalcium supplements, vitamin DEstrogen, alendronate (Fosamax)Weight-bearing exercisesDietary recommendationsWhat laboratory findings support a diagnosis of osteoporosis?Develop a list of calcium-rich foods.Review the nursing implications for the administration of Fosamax.
29 Other Disorders of the Musculoskeletal System OsteomyelitisEtiology/pathophysiologyLocal or generalized infection of the bone and bone marrowStaphylococci are the most common causeIntroduced through trauma (injury or surgery) or via the bloodstream from another site in the body to the boneBacteria invade the bone and degeneration of bone occursWhat other organisms are associated with osteomyelitis?Identify patient populations at increased risk for the development of osteomyelitis. What behaviors or pathophysiology increase their risk of developing the infection?
30 Other Disorders of the Musculoskeletal System Osteomyelitis (continued)Clinical manifestations/assessmentPersistent, severe, and increasing bone painWound draining purulent fluidSigns and symptoms of infection: temperature, tachycardia, and tachypneaEdema of affected areaDiagnostic testsRadiography studies; bone scanCBC; ESR; cultures of blood and drainageWhat subjective data will be collected by the nurse?What objective data will be collected by the nurse?Review diagnostic findings supportive of a diagnosis of osteomyelitis.
31 Other Disorders of the Musculoskeletal System Osteomyelitis (continued)Medical management/nursing interventionsPharmacological managementAntibiotic therapySurgery: removal of necrotic boneAbsolute rest of affected extremityWound careIrrigate with hydrogen peroxide or antibiotic solution; cover with sterile dressingDrainage and secretion precautionsDietary recommendations: high in calories, protein, and vitaminsThe treatment regimen prescribed for osteomyelitis is lengthy.Parenteral antibiotics are needed for several weeks.What broad-spectrum antibiotics could be used to treat osteomyelitis?When planning patient education, what elements concerning safety should be included for the patient diagnosed with osteomyelitis?
32 Other Disorders of the Musculoskeletal System Fibromyalgia syndrome (FMS)Etiology/pathophysiologyMusculoskeletal chronic pain syndromeUnknown etiologyClinical manifestations/assessmentGeneralized achingIrritable bowel syndromeTension headacheParesthesia of upper extremitiesSensation of edematous handsFibromyalgia syndrome is a disorder associated with chronic pain. The vague complaints often make diagnosis challenging.In what population is fibromyalgia syndrome most commonly seen?
33 Other Disorders of the Musculoskeletal System Fibromyalgia syndrome (FMS) (continued)Diagnostic testsNo specific laboratory or radiographic tests diagnose FMSMedical management/nursing interventionsPharmacological managementTricyclic antidepressantsPatient education and reassuranceExerciseRelaxation techniquesGiven the often lengthy period of illness that precedes a diagnosis, what are some psychological concerns that could be experienced by a patient suspected of having fibromyalgia syndrome?What is the impact of tricyclic antidepressants on the patient with fibromyalgia?
34 Surgical Interventions for Total Knee or Total Hip Replacement Knee arthroplasty (total knee replacement)Replacement of the knee jointRestore motion of the joint, relieve pain, or correct deformityHip arthroplasty (total hip replacement)Replacement of the hip jointWhat patients can be helped/treated by undergoing a hip or knee replacement?
35 Figure 44-11(from Monahan, F.D., et al. . Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.)A, Tibial and femoral components of total knee prosthesis. B, Total knee prosthesis in place.
36 Hip arthroplasty (total hip replacement). Figure 44-14Hip arthroplasty (total hip replacement).
37 Surgical Interventions for Total Knee or Total Hip Replacement ArthroplastyNursing interventionsIntake and outputDrainage from operative drainsOral and intravenous intakeUrinary outputPromote respiratory functionGive oxygen 2 to 3 L/minIncentive spirometer; cough and deep-breatheBed rest for 24 to 48 hoursChange dressing as orderedDiet as orderedNeurovascular checks and vital signs every 4 hoursWhat are the patient goals for the patient undergoing a total joint replacement?Outline the priorities for nursing care during the postoperative period following a total joint replacement.
38 Surgical Interventions for Total Knee or Total Hip Replacement Arthroplasty (continued)Nursing interventions (continued)Physical therapy will initiate ambulation and prescribe routineAntiembolisim stockingsAvoid dislocation of prosthesisAvoid adduction and hyperflexion of hipUse toilet riser to prevent hyperflexion of hip
39 Fractures Fracture of the hip Etiology/pathophysiology Most common type of fractureWomen at higher risk due to osteoporosisTypes: intracapsular and extracapsularClinical manifestations/assessmentSevere pain at siteInability to move the leg voluntarilyShortening or external rotation of the legThe elderly are at risk for hip fractures. What factors associated with aging promote this population’s increased risk?How can hip fractures in the elderly be prevented?Review the 7-Ps that must be reviewed when completing a neurological assessment in a patient suspected of having a fractured hip.How should abnormal findings in the “7-P” assessment be handled?
40 Figure 44-16 Fractures of the hip. (from Monahan, F.D., et al. . Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.Fractures of the hip.
41 Fractures Fracture of the hip (continued) Diagnostic tests Radiographic examinationHemoglobinMedical management/nursing interventionsBuck’s or Russell’s traction until surgerySurgical repairInternal fixationNeufeld nail and screws, Kuntscher nailProsthetic implantsAustin Moore prosthesis, bipolar hip replacementIn an effort to prevent further damage, the leg and hip must be kept as still as possible. Review the role of traction in the care of a patient who has suffered a fracture to the hip. How is this traction applied?What laboratory test results can be seen when evaluating the hemoglobin and blood glucose of a patient whose hip is fractured?
42 Fractures Fracture of the hip (continued) Medical management/nursing interventions (continued)Postoperative interventionsWound and drain assessmentVital signsIncentive spirometer and turning every 2 hoursAntiembolic stockings; anticoagulation therapyMaintain leg abductionLimit weight-bearing on affected sideChairs and commode seats should be raised to prevent flexion of hip beyond 60 degreesWhat are the goals of nursing care for the patient who has undergone a total hip or knee replacement?Review the parameters for abnormal and normal findings in the postoperative period.
43 Fractures Fracture of the hip (continued) Medical management/nursing interventions (continued)Patient teaching for open reduction internal fixation (ORIF)Assess ability to understandAssist to dangle at bedsideNo weight on operative sideTurn every 2 hours, maintain abductionPhysical therapy will instruct as to ambulation and weight-bearingAs patient progresses, encourage continuing ambulation only with assistanceList the potential complications associated with total hip and knee replacement surgeries.
44 Fractures Fracture of the hip (continued) Medical management/nursing interventions (continued)Patient teaching for hip prosthetic implantAvoid hip flexion beyond 60 degrees for approximately 10 days; beyond 90 degrees for 2 to 3 monthsAvoid adduction of the affected leg beyond midline for 2 to 3 months (maintain abduction)Maintain partial weight-bearing for approximately 2 to 3 monthsAvoid positioning on the operative sideDemonstrate positioning options for the patient who has had a total hip replacement surgery. Define abduction and adduction.What positions are contraindicated? Why? Review alternative positions that can be used by the patient.
45 Fractures Other fractures Etiology/pathophysiology A traumatic injury to a bone in which the continuity of the tissue of the bone is brokenPathological or spontaneous fracturesTypes of fractures: open, closed, greenstick, complete, comminuted, impacted, transverse, oblique, spiral, Colle’s, and Pott’sFractures occurring as a result of an injury or trauma are termed “spontaneous.”Pathological fractures happen due to a disease process.Give examples of both spontaneous and pathological fractures.
46 Fractures Other fractures (continued) Clinical manifestations/assessmentPainLoss of normal functionObvious deformityChange in the curvature or length of boneCrepitus (grating sound with movement)Soft tissue edemaWarmth over injured areaEcchymosis of skin surrounding injured areaLoss of sensation distal to injury
47 Fractures Other fractures (continued) Diagnostic tests Radiographic examinationMedical management/nursing interventionsSplinting to prevent edemaBody alignmentElevation of body partApplication of cold packs, first 24 hoursAdministration of analgesicsAssess for change in color, sensation, or temperatureObserve for signs of shockReview the rationale for the interventions to manage a fracture.
48 Fractures Other fractures (continued) Medical management/nursing interventions (continued)Closed (simple)Closed reduction; immobilization; tractionOpen reduction with internal fixation deviceOpen (compound)Surgical debridement and culture of woundAdministration of tetanus toxoidObservation for signs of infectionClosure of woundReduction and immobilization of fractureAn open fracture is one in which the bone has broken through the skin. A closed fracture has not protruded through the skin.When caring for a closed fracture, a cast can be employed to immobilize the fracture. Review the nursing responsibilities when caring for a newly casted extremity.An open fracture has a unique set of potential risk factors. What medical concerns are raised when an open fracture occurs?
49 Fractures Fracture of the vertebrae Etiology/pathophysiology Diving accidentsBlows to the head or bodyOsteoporosisMetastatic cancerMotorcycle and car accidentsDisplaced fracture may place pressure on or sever the spinal cord nervesVertebral fractures happen due to a variety of causes. Injuries can involve the vertebral body, articulating processes, and lamina.What factors will determine if permanent paralysis will occur as a result of the injury?
50 Fractures Fracture of the vertebrae (continued) Clinical manifestations/assessmentPain at site of injuryPartial or complete loss of mobility or sensationEvidence of fracture/fracture dislocation on x-rayMedical management/nursing interventionsStable injuriesPain medication, muscle relaxantsBack support, brace, or castUnstable fracturesTraction, open reductionThe patient might or might not experience pain after a vertebral fracture. How can a lack of discomfort be explained?Assessment of neurological function is vital when caring for the patient who has suffered a vertebral fracture. What should be included in the neurological assessment?Review the medication therapy that will accompany the postinjury care of a patient who has experienced a vertebral fracture.
51 Fractures Fracture of the pelvis Etiology/pathophysiology Falls, automobile accidents, crushing accidentsClinical manifestations/assessmentUnable to bear weight without discomfortPelvic tenderness and edemaSigns of shockMedical management/nursing interventionsBed rest—More severe fractures may require surgery and/or spica or body castA fracture of the pelvis may be accompanied with injuries to other parts of the body.What other body systems can be involved?Review signs and symptoms that indicate additional trauma to the area.
52 Complications of Fractures Compartment syndromeCauseProgressive development of arterial vessel compression and reduced blood supply to an extremityClinical manifestations/assessmentSharp pain with movement, numbness or tingling in the affected extremity, cool and pale or cyanotic, slow capillary refillMedical management/nursing interventionsFasciotomy (incision into the fascia)Review the presence of compartments in the body’s extremities.What prognosis accompanies the development of compartment syndrome?Identify factors that affect this prognosis.
53 Figure 44-26 Compartment syndrome. (From Beare, P.G., Myers, J.L. . Adult health nursing. [3rd ed.]. St. Louis: Mosby.)Compartment syndrome.
54 Complications of Fractures ShockCauseBlood loss, pain, fearClinical manifestations/assessmentAltered level of consciousness, restlessnessHypotension, tachycardia, and tachypneaPale, cool, moist skinMedical management/nursing interventionsRestore blood volume; shock trousersOxygenShock related to a bone fracture can occur for one of two reasons. Bone is vascular and can experience blood loss. Severed blood vessels from the injury can also cause significant blood loss followed by shock.Review the early and late clinical manifestations of shock.Prioritize the interventions associated with treatment and management of shock.What precautions should be taken during management of the patient experiencing shock?
55 Complications of Fractures Fat embolismCauseEmbolization of fat tissue with plateletsClinical manifestations/assessmentIrritability, restlessness,disorientation, stupor, coma, chest pain, and dyspneaMedical management/nursing interventionsIV fluidsSteroids, digoxinOxygenDevelopment of a fat embolism is rare.Identify at-risk populations for the occurrence of a fat embolism.In what time frame is the typical fat embolism seen in the patient?Prioritize care and treatment interventions for the management of a patient who has experienced a fat embolism.
56 Complications of Fractures Gas gangreneCauseInfection of skeletal muscle by ClostridiumClinical manifestations/assessmentPain at site of injurySigns of infection; gas bubbles under the skinNecrotic skin at site; foul odor from woundMedical management/nursing interventionsExcision of gangrenous tissueAntibiotics; strict aseptic techniqueHow can a patient be exposed to the Clostridium toxin associated with gas gangrene?
57 Complications of Fractures ThromboembolusCauseBlood vessel is occluded by an embolusClinical manifestations/assessmentArea tingles and is cold, numb, and cyanoticPulmonary embolus causes a sharp thoracic painMedical management/nursing interventionsAnticoagulantsA clot carried through the bloodstream from the site of formation to another site, resulting in an occluded vessel, is known as a thromboembolism.Identify fractures that are at higher risk for developing this complication.Demonstrate an assessment for the Homan’s sign.What nursing implications accompany the administration of anticoagulation therapy?What diagnostic tests can be anticipated with the development of this complication?
58 Complications of Fractures Delayed fracture healingHealing is delayed but will eventually occurNonunionThe ends of the fracture fail to stabilize and heal after 6 to 9 monthsIdentify populations at an increased risk for delayed fracture healing or nonunion.Review the prognosis for these diseases.
59 Skeletal Fixation Devices External fixation devicesSkeletal pin external fixationImmobilizes fractures by the use of pins inserted through the bone and attached to a rigid external metal frameCasts/cast braceMade of layers of plaster of Paris, fiberglass, or plastic roller bandagesStockinette applied, then a sheet of wadding, and casting materialNumerous options are available to manage fractures. What information will be used to determine the best option for an individual patient?When a cast is used to immobilize a fracture, what postapplication assessments will the nurse perform?How should a cast be cared for?Discuss care of the extremity after the cast is removed.
60 Nonsurgical Interventions for Musculoskeletal Disorders TractionThe process of putting an extremity, bone, or group of muscles under tension by means of weights and pulleys to:Align and stabilize a fracture siteRelieve pressure on nervesMaintain correct positioningPrevent deformitiesRelieve muscle spasmsSkeletal or skinCompare and contrast skeletal and skin traction.
61 Traumatic InjuriesContusion: A blow or blunt force that causes local bleeding under the skinSprains: Wrenching or hyperextension of a jointWhiplash: Injury at cervical spine caused by hyperextensionStrains: Microscopic muscle tears as a result of overstretching muscles and tendonsInjuries to the musculoskeletal system’s supportive structures result from a variety of actions including sports, exercise, and accidents.What types of activities would result in contusions, sprains, whiplash, and strains?What do sprains, whiplash, and strains have in common?
62 Traumatic Injuries Contusions, sprains, whiplash, strains Medical management/nursing interventionsElevate injured areaCold compresses for 15 to 20 minutes intermittently for 12 to 36 hoursWarm compresses for 15 to 30 minutes four times a day after 24 hoursCompressive dressings and/or splintSurgeryThe care given to contusions, sprains, whiplash, and strains is initially supportive in nature. What are the primary goals of treatment?Review the rationale for the use of cold and warm compresses. Why is cold therapy used initially?When does surgery become needed?
63 Traumatic Injuries Dislocations Etiology/pathophysiology Temporary displacement of bones from their normal positionClinical manifestations/assessmentErythema; discolorationEdemaPainLimitation of movementDeformity or shortening of the extremityDislocations can result from the following: congenital causes, trauma, or disease processes.What are some of the more common locations affected by dislocations? What do these locations have in common?
64 Traumatic Injuries Dislocations (continued) Medical management/nursing interventionsClosed reductionOpen reductionCold compresses first 24 hours and warm compresses after 24 hoursElevate injured extremityElastic bandageImmobilizeAnalgesicsTreatment of dislocations can be noninvasive or surgical.What are the primary goals of the nursing care for dislocations?Identify examples of analgesics that are to be used to treat dislocations.
65 Traumatic Injuries Carpal tunnel syndrome Etiology/pathophysiology Compression of the median nerve between the carpal ligament and other structuresPredisposing factorsObese, middle-aged womenEmployment in occupations involving repetitious motions of the fingers and handsCompression of the median nerve within the wrist results in a syndrome known as carpal tunnel. It is a painful disorder.Populations at risk for development of the disorder include obese, middle-aged women, occupations using repetitive wrist and hand movements, and pregnancy. Why do the people in these categories develop this disorder?
66 Figure 44-38(From Thompson, J.M., et al. . Mosby’s clinical nursing. [5th ed.]. St. Louis: Mosby.)A, Wrist structures involved in carpal tunnel syndrome. B, Decompression of median nerve.
67 Traumatic Injuries Carpal tunnel syndrome (continued) Clinical manifestations/assessmentParesthesiaHypoesthesiaBurning pain or tingling in the handsInability to grasp or hold small objectsEdema of the hand, wrist, or fingersMuscle atrophyDepressed appearance at the base of the thumb on the palmar side
68 Traumatic Injuries Carpal tunnel syndrome (continued) Diagnostic tests Physical exam—Tinel’s signElectromyogramMRIMedical management/nursing interventionsImmobilizerElevate extremityROM exercisesHydrocortisone injectionsSurgeryThe diagnosis of carpal tunnel includes an electromyogram and an MRI. What findings from these tests are indicative of carpal tunnel syndrome?What is the role of the nurse in the provision of care for the patient undergoing surgical management of carpal tunnel syndrome?
69 Traumatic Injuries Herniation of intervertebral disk Etiology/pathophysiologyRupture of the fibrocartilage surrounding an intervertebral disk, releasing the nucleus pulposus that cushions the vertebrae above and belowLumbar and cervical herniations are most commonMay occur from lifting, twisting, trauma, or degenerative changesAny portion of the spine can be affected with disk herniation. Herniation could occur suddenly or over time as a result of a disease process.Provide examples of disorders that could cause a herniation.Lumbar and cervical herniations are seen most frequently. What about their location predisposes for this condition?
70 Sagittal section of vertebrae showing both normal and herniated disks. Figure 44-39(From Thibodeau, G.A., Patton, K.T. . The human body in health and disease. [4th ed.]. St. Louis: Mosby.)Sagittal section of vertebrae showing both normal and herniated disks.
71 Traumatic Injuries Herniation of intervertebral disk (continued) Clinical manifestations/assessmentLumbarLow back pain that radiates over the buttock and numbness and tingling in affected legCervicalNeck pain, headache, and neck rigidityDiagnostic testsCAT scan, myelography, and electromyelographyWhen the patient seeks treatment for the herniated disk, pain is one of the common complaints. What questions should the nurse ask when gathering the health history relating to this situation?Diagnostic tests employed to diagnose a herniated disk include a CT scan, myelography, and electromyelography. What findings are supportive of a diagnosis of disk herniation?
72 Traumatic Injuries Herniation of intervertebral disk (continued) Medical management/nursing interventionsPharmacological managementAnalgesicsMuscle relaxantsBed restPhysical therapyTractionSurgeryLaminectomy, spinal fusion, diskectomy, chemonucleolysisTypically conservative management interventions are implemented in the care of the herniated disk. Rest, pharmacological therapies, and physical therapy are implemented first.What is the desired outcome of physical therapy?Discuss the medications prescribed in the management of herniated disks.
73 Tumors Tumors of the bone Etiology/pathophysiology May be primary or secondaryBenign or malignantOsteogenic sarcomaOsteochondromaClinical manifestations/assessmentSpontaneous fracturesAnemiaPain especially with weight-bearingEdema and discoloration of skin at siteOsteogenic sarcoma is a rapidly growing malignant tumor. The involved bones are usually the femur, tibia, and humerus. It is most commonly seen in males 10 to 25 years old.Osteochondroma is the most common benign tumor. Like osteogenic sarcoma, it is most commonly seen in the femur, tibia, and humerus. Again, males are the most commonly involved population.Why do spontaneous fractures accompany bone tumors?Review the etiology of anemia that can occur with a bone tumor.
74 Tumors Tumors of the bone (continued) Diagnostic tests Radiography studiesBone scan; bone biopsyCBC; platelet count; serum protein levelsSerum alkaline phosphatase levelMedical management/nursing interventionsSurgeryChemotherapy and radiationWhen bone tumors are suspected, serum blood levels may be assessed. What findings are expected on complete blood counts, platelet counts, and serum protein levels when a diagnosis of a bone tumor is present?What factors will determine the treatment regimen employed?Discuss the prognosis that accompanies a diagnosis of bone cancer.
75 Amputation Amputation of a portion of or an entire extremity Malignant tumors, injuries, impaired circulation, congenital deformities, infectionsPostoperative nursing interventionsRaise foot of bed to elevate extremityEncourage movementPlace in prone position at least two times a dayTeach strengthening exercisesElastic wraps to shape residual extremityAssess for respiratory complicationsPhantom-limb pain is normalAmputation is the removal of all or a portion of an extremity. The amputation can be traumatic or surgical.Amputation is done for differing purposes. It might be done to promote function, to treat a disease process, or for cosmetic functions.The loss of a body part is accompanied with psychological anguish. What concerns and feelings might be voiced by a patient who has had an amputation?What is the role of the nurse during the period preceding the amputation?Identify the role of the nurse in the postoperative period.
76 Correct method of bandaging amputation stump. Figure 44-40Following an amputation, the extremity is usually wrapped using elastic bandages. What purpose does this serve? How long are the elastic bandages used?(From Beare, P.G., Myers, J.L. . Adult health nursing. [3rd ed.]. St. Louis: Mosby.)Correct method of bandaging amputation stump.
77 Nursing Process Assessment Scoliosis Kyphosis Lordosis Blanching test Lateral curvature of the spineKyphosisA rounding of the thoracic spineHump-backed appearanceLordosisAn increase in the curve at the lumbar regionBlanching testCapillary nail refill
78 Nursing Process Nursing diagnoses Mobility, impaired physical Mobility, impaired bedCoping, ineffectiveAnxietyPainKnowledge, deficientWhen developing a care plan for the patient experiencing complications of the musculoskeletal system, potential nursing diagnoses involve mobility, coping, anxiety, pain, and knowledge deficit.What patient outcomes can accompany these diagnoses? How are they best evaluated?