3Musculoskeletal Disorders Low Back PainMost is self-limiting and will improve on its own with timeSciaticaOsteoporosisBone density lossSmall frame, non obese womenOsteomyelitisBone infectionSeptic ArthritisJoint infection
9Fractures: Break in the continuity of the bone Make sure you can identify these different fractures
10Clinical Manifestations PainLoss of functionDeformityFalse motionShorteningCrepitusSwelling & discoloration
11Management Emergency Management: stabilize limb (affected area) ReductionClosedOpenTractionEmergency treatment always includes assess Airway, Breathing, and Circulation first. From there, stabilizing the affected limb or area is important to prevent further tissue trauma and damage.Emergency assessment of injured area include Circulation, movement and sensation.Once a fracture location has been determined, reduction process is planned and implemented (outside of scope of RN). The reduction most often is closed, however with more complext fractures, and open or surgical reduction may be necessary. Often when the fracture is fairly simple, but surrounding muscle is resistant to reduction, persuasive force by the use of traction is implemented to assist relignment of fracture.
12Complications Shock Fat Embolism Syndrome Compartment Syndrome Delayed Union/NonunionAvascular NecrosisInfectionIt’s important that you understand each of these complications and nursing roles related to each.
14Nursing Process: Planning Nursing DiagnosisRisk for peripheral neurovascular dysfunction related to nerve compressionAcute pain, evidenced by pain descriptors, guarding, crying, related to edema, movement of bone fragments, and muscle spasms.Risk for infection related to disruption of skin integrity and presence of environmental pathogens secondary to open fracture.Further examplesRisk for impaired skin integrity related to immobility and presence of cast.Ineffective therapeutic regimen management related to lack of knowledge regarding muscle atrophy, exercise program, and cast care as evidenced by questioning of longp0term effect of casting and cast care.
15Nursing Process: Interventions Expected Outcome: normal neurovascular examinationNursing StrategiesAssess for S&S peripheral neurovascular dysfunctionUnrelieved pain or pain on passive movementParesthesias, cool, pallor, diminished pulsesElevate extremity above level of heart to reduce edema by promoting venous returnFurther nursing strategiesApply ice compresses as ordered to reduce edema and provide comfortNotify physician immediately is client complains of increasing pain that is unrelieved by meds because this may indicate neurovascular impairment.Teach client the signs of peripheral neurovascular dysfunction to enable participation in care.For each of the other nursing diagnoses ( on previous slide), consider appropriate nursing interventions.
16The Patient with a Hip Fracture Surgical repair is preferred method of treatment.Intra capsular Fx (head and neck of femur): endoprothesisExtracapsulr Fx (trochanteric): nails, plates, intramedullary devices.Nursing Management for both is the same.
17Nursing Interventions Relieving PainPromoting Hip Function & StabilityPromoting Wound HealingPromoting Normal Urinary Elimination PatternsPromoting Skin IntegrityPromoting Effective Coping MechanismsPromoting Patient Orientation & Participation in Decision MakingMonitoring & Preventing Potential Complications
18Joint Replacement Arthroplasty: replacement of all parts of the joint Contributing factors to joint replacement:PainOsteoarthritisRheumatoid arthritisTraumaCongenital deformity
19Joint Replacement Cont’ Joints frequently replaced:HipKneeFingerJoints sometimes replaced:ShoulderElbowWristAnkle
20Special considerations with Hip Fractures/Repair/Replacement Do NOTForce flexion >90Force adductionForce internal rotationCross legsPut footwear on without assistive device before 8 weeksSit on chair without arms to aid in raising to standDOUse elevated toilet seatPlace chair inside shower or tubUse pillow between legs when on sideKeep hip in neutral positionNotify surgeon if severe pain, deformity or loss of functionIt is critical that you know these Do’s and Don’ts and that you could implement them into a plan for patient teaching regarding recovery from hip surgery.
21Continued Strategies for Hip Repair/Replacements Provide abduction pillow to prevent adductionMonitor and manage complicationsNeurovascularDVTPulmonarySkinBladder controlDelayed complications: infection, nonunion, avascular necrosis, fixation device problems.Monitor drainage from site (hemovacs)ml of drainage is common in first day
22Cast Application Analgesic: admin ordered analgesic Skin preparation: clean, drySupport body part during applicationMonitor smoothness of cast materialPosition limp on pillow to dry, elevated above heart.Position client comfortably - q2hrPrepare for discharge
235 P Assessment Pain Pallor Pulselessness Paresthesia Paralysis Following cast application, monitoring for immediate complications includes assessing the 5 Ps
24Unexpected Outcomes of Casting MalunionOsteomyelitisPressure ulcerMuscle weaknessCold extremitySkin irritationUnable to perform cast care
25Post Removal Observe underlying skin: colour, temp, integrity Assess client’s verbal and nonverbal responsesExplain exercise plan and demonstrate exercisesSkin careClient’s are often disappointed with the appearance of a limb following cast removal – muscle atrophy, skin condition, and even hair growth may impact their response.
26Traction Maintain established line of pull Prevent friction of skin Maintain counteractionContinuous (usually)Maintain correct body alignmentWhen casting or open reduction alone are not sufficient for realigning a fracture, traction may be implemented.
28Skin Traction Non-invasive Assess traction set-up Assess mobility restrictionsAssess PainAssess NV statusUnderstanding Intermittent releasePatients in traction will experience an extreme limitation in movement and mobility. Nursing measures must focus on this reality.
29Skeletal TractionTraction is external and internal (via pins, wires, nails)Similar care principles as skin traction.ContinuousPin CareInspect pins every 8 hours at minimum
30While this may be a drawing of skin or skeletal fracture, the point of including it is to illustrate the forces involved in traction.Free hanging weights are often used to create the force needed for traction. Part of assessing the traction set-up is ensuring that weights are indeed hanging freely and not subject to interference by activity of patient or others within the room (you don’t want visitors going by and pulling on the weights or swinging them around.--- ouch!!!)
31Principles of Traction Weights or traction never removed unless orderedPatient must be in proper alignmentRopes unobstructedWeights hang freeKnots or other devices not hung-up on pulleys or bedframe
32Amputation Levels: determined by Circulation and function at most distal end that will healComplications: hemorrhage, infection, skin breakdown, joint contracture and phantom painRehabilitation: multidisciplinaryNursing Managementrelieving painminimizing altered sensory perceptionpromoting wound healingenhancing body imageself-care
33Amputation Stump Dressing Promote healingResidual limb shaping for prosthesis fittingControl edemaGentle handlingAseptic techniqueClosed rigid or soft dressing