Transcript Nursing Care of the Adult System with Musculoskeletal Stressors

Nursing Care of the Adult
System with Musculoskeletal
Stressors
Zelne Zamora, DNP, RN
Human Skeleton
Bone is a Living Tissue
Musculoskeletal System Facts
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Activity = stress→ maintenance
of bone strength
↓ mobility → measurable losses
in strength and muscle tone
within 48 hours
Long bones and multiple fractures
take longer to heal
Effective healing of fractures
depends on blood supply,
immobilization and alignment
Musculoskeletal System Facts
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Major body systems are
impacted by immobility
 Lungs
 Renal
 Cardiovascular
 Skin
Types of Injuries Related to
Musculoskeletal System:
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Fractures
Damage to a
muscle,ligament, tendon or
joint
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Sprains
Soft Tissue Trauma
Soft tissue trauma
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Treatment first aid for
soft tissue injuries
R – rest
I – ice for 48-72 hours
C – compression
E – Elevation above
level of the heart
Fracture: Disrupts Bone Continuity
CAUSES
Blunt force trauma
Pressure
Accidents that cause
above
Repetitive stress
EPIDEMIOLOGY
Very young
Very old are most
susceptible
Types of Fractures
Fig. 63-6
Types of Fractures
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Avulsion – ligament or tendon attached to bone pulls away
Comminuted – many small fragments (> 2 pieces)
Displaced – displacement of fracture fragments, can be
axially displaced, angulated or rotated
Greenstick – incomplete fracture in which the bone bends
Impacted – one broken end driven and wedged into the
other – commonly seen with comminuted fxs
Interarticular – related to joints
Longitudinal – lengthwise along bone
Oblique – across the shaft of the bone, combo of bending
and twisting
Pathologic – related to disease making bones brittle
Spiral – fracture line spirals around the shaft of the bone
Stress – bone subjected to repeated stress, AKA fatigue fx
Incomplete Fracture
Simple (closed) Fracture
WARNING!
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Next slides with graphic photos
Compound (open) Fracture
What Type of Fracture?
What Type of Fracture?
What Type of Fractures?
What Type of Fracture?
What Type of Fracture?
Signs and Symptoms of Fractures
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Pain, especially upon movement
Loss of function
Deformity - rotation
Crepitus
Swelling
Ecchymosis (may develop later)
Diagnostic Tests
X-rays
 MRI
 CT scan
 Bone Scan
 Arthroscopy
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LABS
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Serum Calcium (9-11 mg/dl)
Phosphorus (2.5-4.5 mg/dl)
Alkaline phosphatase (4.313 U/dl)
Calcitonin
Vitamin D
Myoglobin (negative in both urine and
serum)
How Fractures Heal
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Hematoma
Granulation
Callus formation
Consolidation
Remodeling
WARNING!
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Next slides with graphic photos
Factors Impairing Bone Healing
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Inadequate reduction
Increased edema
Bone loss due to
damage
Movement
Infection
Factors Impairing Bone Healing
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Bone necrosis
Anemia
Endocrine imbalances
Poor nutrition
Treatments for Fractures
Closed reduction
 Open reduction
 Open reduction
internal fixation
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Pins, plates, screws,
nails, grafts,
implants
Treatments for Fractures
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Open reduction external fixation
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Casts, splints, braces, traction
Compound fractures may involve cleaning,
debriding and infection prevention
Traction
Casts – Extremities
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Re-alignment
Maintaining alignment
Uniform pressure on encased soft tissue
Casts
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Plaster
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Softer
Heat given off during application
Hardens over time – easily
“dented”
Skin irritation/breakdown
Usually applied first, then
changed to fiberglass
Assess CMS – circulation,
motion, sensation
Casts
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Non-plaster or fiberglass
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Lighter weight
Stronger – dry thoroughly
Durable
Water resistant
Casts
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Cast construction and
molding may allow
movement of a joint
while immobilizing a
fracture
Short vs long
Extremity: arm or leg
Walking cast
Casts
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Cast construction and
molding may allow
movement of a joint
while immobilizing a
fracture
Body cast
Spica cast
Cast Care
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Elevate, elevate,
elevate!
Neurovascular checks
(CMS)
Care of skin
Pain management
Cast Care
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Be alert to pressure
area formation
Good Hygiene
Good nutrition
Circle drainage marks
on cast note date/time
Turning
Care of External Fixators
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Wash hands. Gloves
must be used. Prepare
a clean work surface.
Use sterile Q-tips
cleaning from the pin
working outwards.
Agency/unit protocols
may vary.
Report tenderness,
redness, swelling,pus,
necrosis, foul odor,
fever, pin looseness.
S/S of neurovascular impairment
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Pallor
Cyanosis
Prolonged capillary
refill
Edema
Increased pain
S/S of neurovascular impairment
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Cool/cold tissue
Diminished or absent
pulses
Changes in sensation
Nerve
impairment
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Peroneal nerve
Tibial
Radial
Ulnar
Median
Fat Embolism Syndrome (FES)
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Pathophysiology
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Fat particles enter circulation via fracture site
Increase clotting and viscosity
Fat Embolism Syndrome (FES)
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Clinical presentation
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Hypoxia /
hypoventilation
ALOC – restlessness,
anxiety
Petechaie
Tachycardia/ chest
pain
Temp elevated
Retinopathy
Decreased urine
output
Fat Embolism Syndrome (FES)
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Medical Treatment
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Early immobilization of fx
Adequate oxygenation
Adequate hydration
Nursing interventions
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Awareness & vigilance – 1224hrs
Accurate I&O
Compartment Syndrome
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Increased tissue
pressure in small space
Compromises
circulation
Bivalve cast (cast saw)
If severe, fasciotomy
Compartment Syndrome
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Commonly caused by: Poor cast care - CMS
Compartment Syndrome
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http://www.youtube.com/watch?v=k1QnE
cTP-cY
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Warning: Graphic slide
All rights and images to “Rizzoli & Isles” are courtesy of TNT broadcasting.
Fasciotomy
Fasciotomy
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Surgical procedure to
release constricting
muscle fascia to relieve
muscle tissue pressure
(Smeltzer et al, 2008)
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WARNING: Graphic
picture coming in next
slide
Cast syndrome
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Superior mesenteric artery syndrome:
compression due to confinement in body cast
Decreased intestinal motility
Ileus can occur
Can be psychological: claustrophobic-like
reaction to cast
Cast syndrome
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Nursing: insert NG tube
to decompress stomach
IV fluid till GI motility
restored
Med for nausea /
vomiting
Worst case: bowel
gangrene
Disuse Syndrome
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Muscle atrophy from disuse
Prevention: isometric exercises, tense/ relax
muscles in cast, ankle exercises, finger
exercises, etc
Traction
Uses
To reduce a fracture or dislocation
 Immobilize and maintain alignment
 Prevent or reduce muscle spasm
 Correct or prevent deformity
 Provide rest and comfort post-op
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Types of Traction
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Skin (good for up to
7lbs. of weight).
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Attaches to skin only
Skeletal (pulling force
directly to bones, can
go up to 30 lbs of
weight)
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Use of pins and screws
Traction Must
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Establish a line of pull
Have equal counterforce
Be free of friction
Be applied with body in
correct alignment
Buck’s Traction
Uses an external pulling
force
 Leg must be fully in boot,
heel touching
 CMS remains priority in
care
 DOES NOT use countertraction
 Skin breakdown with boot
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Skeletal Traction
Uses an external
pulling force
 Steinman pins or
external fixator
 Priority: CMS and pin
care
 Uses traction and
counter-traction
 Infection can lead to
osteomyelitis
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Nursing care of client in traction
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No interference with lines of
pull
Patient is in good alignment
Pin assessment, skin
assessment, neurovascular
checks
Nursing care of client in traction
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Check that correct
weights are being used
Weights are to be off
the floor
Position and attachment
of weights is safe
Check counter-traction
Nerves
Complications of Immobility
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Gastrointestinal
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Genitourinary
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Constipation
Cystitis, retention, calculi
Respiratory
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Pneumonia
Complications of Immobility
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Neurovascular
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Skin
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Thrombophlebitis, compartment
syndrome
Breakdown
Psychosocial
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Boredom, sensory deprivation, altered
sense of time
Amputations
Reasons for amputation
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Trauma
Tumor
Infection
Advanced PVD
Compartment
syndrome
complications
WARNING: graphic
picture coming
Catagories of Lower limb
amputation
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Foot – toe, midtarsal, Boyd, Symes
BKA – transtibial
AKA – transfemoral
Hip Disarticulation
Pre-Op Care
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Stabilization of diabetes
Well nourished and hydrated
PT and OT consultations
Emotional Support
Teaching
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Pain management, phantom
limb
Prosthetic preparation
Post-op Care
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VS and respiratory
status
Wound dressing and
drainage
Be vigilant of
hemorrhage
Accurate I&O
Pain Management
Stump positioning and
conditioning
Phantom Limb Pain
Crutch Walking
Points to remember
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Never rest armpit on
the top of the crutch.
There should be 2
fingers width between
armpit and top of
crutch.
Points to remember
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Be sure to ask if
patient must navigate
stairs
Wear tie shoes with
low heels
Rubber tips clean and
in good condition
Crutch Gaits: points of contact
2 point
 3 point
 4 point
 Swing to
 Swing through
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Crutch Gaits: points of contact
Skills – wound vacs
(Vacuum assisted closure)
Negative pressure wound
therapy – open wounds
 Use of Macro- and microstrain
 Removes infectious materials
 Promotes perfusion
 Protected healing environment
 Reduce edema
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Wound vac
Parts:
 Machine
 Sponge
 Elastic cover
 Suction end
 Use of sterile
technique
 Cut sponge to fit
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Wound vac - Nursing
Maintain suction
 If small leak, can
cover with more
tegaderm
 Pamphlet for quick
reference
 Educate patient on
wound vac –
discharge home with
vac
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