Muskuloskeletal PDF

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How to treat skeletal injuries, prepare for surgeries, traction devices, osteoporosis..etc ...

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Musculoskeletal Structures of the musculoskeletal system includes: bones, joints, and skeletal muscles; mobility can be impaired by disease, surgery, trauma. If the nerves are damaged, sensory perception and comfort are affected. ★ Gerontologic considerations: functional problems, risk for falls, decreased bone density, decreased muscle mass and strength, and decreased flexibility. - Unable to perform ADLs safely, slower movements (don’t rush them, be patient) and bony prominences, risk for developing arthritis (cartilage degeneration; provide moist heat; shower or warm moist compress) - Kyphotic posture: widened gait, shift in center of gravity - Reinforce need to exercise: weight bearing especially ★ Kyphosis: hunched back, risk for falls ★ Scoliosis: S shape of the spine, can be noticed upon physical assessment. Assessment: ★ Subjective data: important health info, past health history, medications, surgery or other treatments. - Family history of any type of musculoskeletal disorders: gout, allergies, not enough calcium. Steroids can decrease bone density and increase risk for osteoporosis. - Figure out their day to day routine; workplace, activities (excessive typing or sitting?) Do they live a sedentary or active lifestyle. - Practice proper body mechanics to maintain safety. ★ Assess by inspection; palpate to find any bony prominences or deformities. - Normal spinal curvatures, no muscle atrophy or asymmetry, no joint swelling, deformity, or crepitation (could indicate fractures), no tenderness on palpation of spine , joints, or muscles. FULL range of motion of all joints, muscle strength should be 5/5. NORMALS. ★ DX studies: xray, CT, MRI, Arthrocentesis. Biopsy possibly ★ Lab studies: - Calcium: 9.5-10 - phosphorus: 3.0-4.5 - alkaline phosphatase: 30-120 - LDH: 100-190 -AST: 0-35 -ALD: 3.0-8.2 ★ Arthroscopy: view the joints; dx tool or surgical procedure. - Knee and shoulder are most commonly evaluated - Synovial biopsy and surgery to repair traumatic injury can be done. - MUST have mobility in joint. - Light general anesthesia used. - Immediately after; assess neuro every hour, document findings. Monitor distal pulses, warmth, color, cap refill, pain, movement, and sensation of affected extremity. - ROM should be encouraged and taught before procedure. - Acetaminophen post op, ice for 24hrs and elevated for 12-24hrs. - If surgery is done and opioid analgesic combo is normally given. - Monitor for swelling, increased joint pain, thrombophlebitis, infection - Monitor for heavy bleeding. Osteoporosis: chronic progressive metabolic bone disease marked by low bone mass,

deterioration of bone tissue, and increased bone fragility eventually. ★ Possible causes: diabetes, hyperthyroidism, hyperparathyroidism, suchings, cirrhosis, AIDS ★ Caused when there is a greater bone reabsorption than bone building occurring. ★ Increases risk for fractures. ★ More common in women due to lower calcium intake, less bone mass, bone reabsorption begins earlier and becomes more rapid at menopause, pregnancy and breastfeeding, and longevity: women live longer than men. ★ Risk Factors: >65, female, low BMI, White or Asain, smoking, fracture history, sedentary lifestyle, estrogen deficiency, excessive alcohol, diet low in vitamin D or calcium, low testosterone in men ★ PREVENT: reg weight bearing: walking is VERY good, improve diet/ supplements: fluoride, calcium, and vitamin D. Limit carbonated beverages. ★ Clinical Manifestations: most commonly in spine, hips and wrists, back pain (sharp or acute) , spontaneous fractures, gradual loss of height, kyphosis or “dowager’s hump” ★ Focus on: proper nutrition, calcium supplements, exercise, prevention of fractures, drug therapy. - Diet: low fat dairy, fruits and vegetables, and protein sources, increased fiber and moderation in alcohol and caffeine CALCIUM AND VITAMIN D!! ★ Bisphosphonates: - Alendronate: take drug on empty stomach in the AM with glass of water, remain upright for 30 min after, dental exam before, report chest discomfort and d/c med. - Poor renal function, hypocalcemia, or GERD should not take. ★ Estrogen therapy: raloxifene; prevention and treatment of osteoporosis. INcreases bone mineral density and reduces fractures. NOT for his of thromboembolism. ★ MRI can view bone quality Osteomyelitis: severe infection of the bone, bone marrow, and surrounding soft tissue ★ Most common organism is staphylococcus aureus; but can be cause by variety ★ Leads to ischemia and vascular compromise, infection spreads through bone leading to necrosis. ★ Assess pain, movement, sensation, warmth, temp, distal pulses, and cap refill ★ Exogenous or hematogenous - Exo: infectious organisms from outside body through open fractures - Hematogenous: organisms carried by bloodstream from other areas ★ Infection of less than a month in duration ★ Local manifestations: bone pain worsens with activity; unrelieved by rest, swelling, tenderness, warmth, restricted movement. ★ Fever normally greater than 101; ulcerations may be present on hands or feet, ★ Elevated WBC, ESR norm in beginning but rises as disease progresses. ★ Systemic: fever, night sweats, chills, restlessness, nausea, malaise, drainage (late) ★ Septicemia, septic arthritis, pathologic fractures, amyloidosis ★ DX: bone or soft tissue biopsy, blood/ wound cultures, WBC, ESR will find any inflammation in body, C reactive protein, X-rays/MRI/CT scans, bone scans. ★ Cultures or bone biopsy, surgical debridement and decompression, aggressive, prolonged IV antibiotic therapy. - IV antibiotics via CVAD, may be started in hospital, continued at home or skilled

nursing facility. IV antibiotics for 4-6 weeks or longer, variety of antibiotics depending on organism; to be effective. - Contact precautions needed. PO antibiotics after IV maybe, DON’T stop taking antibiotics because you feel better. ★ Casts or braces, neg pressure wound therapy, hyperbaric oxygen therapy, removal of prosthetic devices, muscle flaps, skin grafts, bone grafts, amputation. Fractures: disruption or break in continuity of structure of bone, majority of fractures are from traumatic injury, or due to disease process (cancer or osteoporosis) ★ Elderly are at great risk for falls and fractures (hips commonly) ★ Health impact of regular physical activity: assists with weight management, maintain and improve bone mass, helps prevent high BP, increases lean muscle and decreases body fat, increases strength, flexibility, and endurance, reduce symptoms of anxiety and depression, reduces risk of heart disease, diabetes, and enhances sense of well being and may reduce risk of depression ★ Assess skin color, temp, sensation, movement, pulses, cap refill, and pain. ★ OPEN vs. CLOSED fractures. - May need sterile gauze over open fracture - Localized pain, decreased function, inability to bear weight or use, guard against movement, may or may not have deformity. IMMOBILIZE if suspect fractures. ★ Fracture healing: factors that influence healing: - Displacement and site of fracture, bloody supply to area, immobilization, internal fixation device, infection or poor nutrition, age, smoking. ★ Patients with fractured ribs have severe pain when they take deep breaths, monitor resp status! ★ Complications of fractures: infection, fat embolism, compartment syndrome, and VTE ★ Infection: high incidence in open fractures and soft tissue injuries, devitalized and contaminated tissue an ideal medium for pathogens, PREVENTION is key, can lead to chronic osteomyelitis. ★ Fat embolism: presence of systemic fat globues from fracture to tissues and organs after skeletal injury - Contributory factor deaths with fractures, most common with long bone, ribs, tibia, and pelvis fractures. Fractured Hips or pelvis. - Low arterial oxygen level, dyspnea, and tachypnea are the earliest signs and symptoms. Altered mental status is the earliest sign, increased resp, pulse, and temp, chest pain SOB, crackles, decreased SaO2. Petechia, - TX: bedrest, gentle handling, O2, hydration (IV), steroids,fracture immobilization ★ Compartment Syndrome: swelling increase pressure within confined space, compromises neurovascular function of tissue, involves the leg but can occur in any muscle group; - Lower leg and forearm are common sites. - Excruciating pain, hurting more than it should be; pain meds not working. - Call HCP immediately so limb can be save, no circulation is going to affected limb; if not treated, cyanosis, tingling, numbness, paresis and necrosis occur. - S/S: pain, pressure, paralysis, paresthesia, pallor, pulselessness (may be too late at this point) -

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DO NOT elevated above heart, no ice, fasciotomy (surgical decompression) commonly done. Opens up space to relieve pressure. AT huge risk for infection. ★ VTE: high susceptibility aggravated by inactivity of muscles, prophylactic anticoagulant drugs, anti embolism stockings, sequential compression devices, ROM exercises - PREVENT main goal, inactivity is often cause; - Lovenox Management of Fractures: ★ Assess ABC, remove jewelry on affected extremity, apply direct pressure if there is bleeding, keep patient warm and in supine position, check neurovascular status of area distal to fracture, immobilize extremity by splinting, recheck circulation after splinting, cover any open areas with a dressing. - In ER setting: management begins with reduction and immobilization of fracture - Elevate fractured extremity higher than heart and apply ice for first 24-48hrs as needed to reduce edema. ★ Manual traction, closed reduction, skeletal traction, open reduction. ★ Buck’s Traction: good for hip patients, pulling force to reduce/align extremity. - 5-10lbs weight, velcro boot, belt, or halter. - Purpose is to decrease muscle spasms and promote comfort - Skin traction, weights pulling in one direction while body is counter weight - Consider: prevent infection, constipation, skin breakdown, DVT, and PE - Weights should NEVER touch the floor; should hang FREELY at all times. ★ Byrant’s Traction: for hips mainly, look out for complications, assess them every hour for 24hrs and then every 4. ★ Skeletal traction: long term pull to maintain alignment - Pin or wire inserted into bone, weights 15-30lbs, risk for infection and complications of immobility. - PIN SITE care extremely IMportant. Fracture Immobilization: ★ Cast: temporary, allows patients to perform many normal activities of daily living, perform normal activities and involves joints. ROM important. - Cast care: frequent neurovascular assessments, ice for first 24hrs, elevated above heart for first 48, exercise joints above and below, use hair dryer on cool setting for itching, check with HCP about getting cast wet. - Finger should be able to fit in between skin and cast at the top or bottom. - Dry thoroughly after getting it wet, report increasing pain, ice, and analgesics, - Report swelling with pain and discoloration or movement. Report burning or tingling under cast - Report sores or foul odor under cast. - DO NOT: elevated with compartment syndrome, get plaster cast wet, insert objects in cast, bear weight for 48 hours, cover cast with plastic for prolonged period of time. - Care of extremity after removal of cast: 1045 ★ External fixation: metal pins and rods to apply traction, compresses fracture fragments, immobilizes and holds fracture fragments in place - Immobile area, do ROM above and below affected site, hand hygiene and sterile

technique when cleaning the pins. Prevent complications. Clear drainage or minimum serous drainage is okay, but not yellow purulent drainage. - Assess for loosening and infection. ★ Internal fixation: pins and rods or plates could be in place. Still at risk for infection and osteomyelitis; just not as big of a risk. ★ Drug therapy: central and peripheral muscle relaxants - Carisoprodol, cyclobenzaprine, methocarbamol - Tetanus and diphtheria toxoid, bone penetration antibiotics. - PCA pump (morphine, fentanyl, or hydromorphone) to increase comfort. NEVER give meperidine can cause seizures Nursing assessment: - Paresthesia, absent or increased sensation, restricted or lost function, deformities, shortening, rotation, or crepitation, muscle weakness, imaging findings. - Peripheral vascular: color and temp, cap refill, pulses, edema Overall goal: healing with no complications, satisfactory pain relief, maximal rehabilitation HIP fracture: osteoporosis is the biggest risk factor. partial just the ball, total is the hip joint and the ball. ★ hip/knee arthroplasty: hip precautions - Keep heels off bed at ALL times. - Meperidine should NOT be given because of the toxic metabolites that can cause seizures and other adverse events in older adults. - Skin (buck’s) traction before surgery to decrease pain associated with muscle spasms - Regular pillows or abduction devices to prevent subluxation or hip dislocation - Ambulation can begin day after surgery, Inspect bony prominences every 8-12hrs, reposition every 1-2hrs. - PCA pump, Lovenox, antibiotics, incision care, prevent hazards of immobility. - NO pillows under the knee for knee surgeries, no bending further than 90 degrees of joints. - Watch out for shortening limb or external rotation of the leg -

Amputation: ★ Traumatic or elective ★ Phantom limb sensation can occur: real pain to the patient, that nerve is still there; - Give them pain meds opioids, mirror therapy may be beneficial: looking at affected leg in mirror. IV infusions of calcitonin may be beneficial. ★ Elevate if not contraindicated; 24-48hrs after surgery, keep them flat mostly. - ROM, check dressing. Keep patient prone for some time (20-30 min) so prosthesis can fit properly. - Prevent flexion contractures. Trapeze and firm mattress. - For wrapping to be effective, reapply bandages every 4-6 hours or more often if they become loose. Figure 8 wrapping decreased restriction of blood flow, distatl to proximal direction, anchor bandage to highest joint. - Wrapping promotes shaping of stump, assess neurovascular system! Sprains and strains:

★ Pain,edema, decreased function, contusion ★ RICE: rest, ice for first 24-48hrs and heat after, compression, and elevation ★ NSAIDS: ibuprofen, aspirin, IMMOBILIZE (assume fractured until after xray) ★ Assess neurovascular status in area distal to injury Carpal Tunnel Syndrome: ★ Most common compression neuropathy in upper extremity ★ Tinel’s sign: lightly tapping nerve and tingles occur, or BP cuff applied and inflated ★ Phalen’s sign: flexing wrist 90 degrees and getting paresthesias. ★ Prevent; splinting (or hand brace), apply ice, and NSAIDS could be beneficial (after meals) Osteoarthritis: ★ Slowly progressive noninflammatory disorder of the diarthrodial joints ★ Cartilage worn down and bones rubbing together (crepitus), medication and rest is number one treatment for them ★ Heat or Cold therapy can be used. ★ Risk factors: obesity, athletes, diabetes, blood disorders, trauma, heavy manual occupations. ★ Older than 60 typically, female, may be unilateral/ single joint; affects weight bearing joints and hands, spine. NSAIDS, Acetaminophen or analgesics for pain. ★ CHRONIC joint pain and stiffness. Gout: joint immobilization, local application of heat and cold ★ Joint aspiration: increase in uric acid, lots of pain ★ Avoidance of food and fluids with high purine content; organ meats, shellfish, oily fish with bones. Avoid ASPIRIN and DIURETICS and STRESS. Drink plenty of fluids to prevent renal stones. ★ Alluproprinal; maintenance medication to decrease uric acid buildup - Monitor BUN/CR. Frequent CBC checks, avoid alcohol and caffeine, N/V/D and anemia can occur. ★ IV Colchicine; acute symptoms. Take with food; may cause nausea, vomiting, diarrhea. Low back pain: leading cause of job related disability ★ Major contributor to missed worked days; NURSES at huge risk. ★ Being obese, sedentary, poor posture, smoking, lack of muscles. - Pregnancy, stress, prior compre fractures, congenital spinal problems, fam history ★ DX: acute pain, impaired physical mobility, ineffective coping, ineffective health management ★ Prevention: safe manual handling, assess need for assistance with household chores, regular exercise (swimming/walking), no high heeled shoes, good posture, avoid prolonged sitting or standing, footstool to lessen back strain, calcium intake and vitamin D, NO smoking!! ★ Treat as outpatient if not severe; - NSAIDS (acetaminophen wont help), muscle relaxants, massage, back manipulation, acupuncture, cold and hot compresses ★ Severe pain: corticosteroids and opioids ★ Brief period of rest at home, avoid prolonged bed rest, avoid activities that increase pain, lifting, bending, twisting, prolonged sitting. ★ Weight reduction, sufficient rest periods, local heat and cold applications, physical

therapy, exercise and activity throughout the day, complementary and alternative therapies. ★ Sleep in side lying position, with knees and hips bent - Back with lift under knees and legs or back with 10-in high pillow, prevent lower back from straining forward, maintain appropriated body weight. ★ Laminectomy: removal of disc pieces through part of vertebrae ★ Discectomy: removal of disc where pain is located ★ Inspect the dressing for blood or any type of drainage. ★ CFS leakage or nerve damage may occur place pt flat if it occurs and report immediately; drain should have no more than 250mL in 8hrs during first 24hrs. monitor for bleeding, log rolling every 3 hours from side to back and vice versa. (turn while back is kept as straight as possible; turning sheet can be used for obese patients) ★ Limit daily stair climbing, restrict or limit driving, do not lift objects heavier than 510lbs, restrict pushing and pulling (push rather than pull), avoiding bending and twisting at waist, take daily walk. (FOR THE FIRST 4-6 WEEKS). - Maintain good posture, dont sit or stand for too long. Total Hip Arthroplasty: ★ Keep patients heels off bed to prevent injury, abduction pillow or splint ot prevent adduction between legs. ★ Be alert to decreasing mental status or WBC elevation. ★ Turn cough, deep breathe and use incentive spirometer every 2 hours. ★ Dont bend more than 90 degrees. Dont cross legs, report pain asap, call 911 for chest pains and shortness of breath ★ CHECK AND DOCUMENT color, temp, distal pulses, cap refill, movement, and sensation ★ Teach patients about ROM exercises....