Care of Clients with Problems Care of Clients with Problems Related to the Musculoskeletal Related to the Musculoskeletal

SystemSystem

Earl Francis R. Sumile, RNEarl Francis R. Sumile, RNInstructor, College of NursingInstructor, College of Nursing

University of Santo TomasUniversity of Santo Tomas

Diagnostic ProceduresDiagnostic Procedures

1.1. Radiologic studiesRadiologic studiesa.a. X-raysX-raysb.b. Computed tomographyComputed tomography or CT scan or CT scan

– Non- invasive procedure where a body part Non- invasive procedure where a body part can be acanned from different angles with can be acanned from different angles with an x-raybeam and a computer calculates an x-raybeam and a computer calculates varrying tissue densities and records a varrying tissue densities and records a cross section image on paper done to cross section image on paper done to determine extent of fracture in difficult to determine extent of fracture in difficult to define areasdefine areas

Diagnostic ProceduresDiagnostic Procedures

c.c. MyelographyMyelography• Injection of radioopaque dye into Injection of radioopaque dye into

subarachnoid space at posterior spine to subarachnoid space at posterior spine to determine level of disc herniation or site of determine level of disc herniation or site of tumortumor

Diagnostic ProceduresDiagnostic Procedures

2.2. ArthrographyArthrography• Radioopaque or air injected into joint cavity- outines Radioopaque or air injected into joint cavity- outines

soft tissue structure and contour of jointsoft tissue structure and contour of joint

3.3. Bone scanningBone scanning• Parenteral injection of bone seeking radioactive Parenteral injection of bone seeking radioactive

isotopeisotope

4.4. ElectromyographyElectromyography• Graphic presentation of the electrical potential of Graphic presentation of the electrical potential of

musclesmuscles

Diagnostic ProceduresDiagnostic Procedures

5.5. Magnetic Resonance ImagingMagnetic Resonance Imaging• Noninvasive scanning technique that uses Noninvasive scanning technique that uses

magnetism and radiofrequency waves to magnetism and radiofrequency waves to produce cross-sectional images of body produce cross-sectional images of body tissues on computer screentissues on computer screen

6.6. ArthroscopyArthroscopy• Endoscopic direct visualization of joint, Endoscopic direct visualization of joint,

especially kneeespecially knee

Diagnostic ProceduresDiagnostic Procedures

7.7. ArthrocentesisArthrocentesis• Needle aspiration of synovial fluidNeedle aspiration of synovial fluid

8.8. Bone Biopsy or Muscle biopsyBone Biopsy or Muscle biopsy

9.9. LaboratoryLaboratorya.a. Uric acidUric acid

b.b. Antinuclear antibody (ANA) for systemic Lupus Antinuclear antibody (ANA) for systemic Lupus ErythematosusErythematosus

c.c. Complement fixation (CF) for Rheumatoid ArthritisComplement fixation (CF) for Rheumatoid Arthritis

d.d. Calcium, Alkaline Phosphate, PhosphorusCalcium, Alkaline Phosphate, Phosphorus

Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic Modalities Modalities

1.1. ReductionReduction• Realigning an extremity into anatomical Realigning an extremity into anatomical

positionposition

a.a. Open- use of surgical methodsOpen- use of surgical methods

b.b. Closed- use of non-surgical methods; Closed- use of non-surgical methods; manipulationmanipulation

Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic ModalitiesModalities

2.2. ImmobilizationImmobilization ManualManual Skin- adhesive- plaster or adhesive is Skin- adhesive- plaster or adhesive is

applied longitudinally on the lower applied longitudinally on the lower extremeties and an elastic bamndage extremeties and an elastic bamndage applied in an spiral motionapplied in an spiral motion

Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic ModalitiesModalities

2.2. Bryant’s traction- indicated for children Bryant’s traction- indicated for children aged 0-3 year’s not more than 40 lbs.aged 0-3 year’s not more than 40 lbs.1.1.Traction is always applied on both endsTraction is always applied on both ends

Nursing ResponsibilityNursing Responsibility– Nurse should be able to pass hand between Nurse should be able to pass hand between

the patient’s buttocks and mattressthe patient’s buttocks and mattress

Bryant tractionBryant traction

Buttocks sightly elevetated and clear of bed

Knee slightly flexed

Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic ModalitiesModalities

Buck’s Extension TractionBuck’s Extension TractionIndicated for older patients to those weighing Indicated for older patients to those weighing

over 40 lbs.over 40 lbs.

Nursing ResponsibilityNursing ResponsibilityOnly the affected extremity is placed on Only the affected extremity is placed on

tractiontraction

Buck’s Extension TractionBuck’s Extension Traction

Musculo-Skeletal Therapeutic Musculo-Skeletal Therapeutic ModalitiesModalities

Dunlop TractionDunlop TractionUsed in affectations of the upper extremitiesUsed in affectations of the upper extremities

Dunlop TractionDunlop Traction

Nursing Care of Clients with Nursing Care of Clients with Adhesive TractionAdhesive Traction

1.1. Unwrap and wrap and elastic bandage at Unwrap and wrap and elastic bandage at least once a shiftleast once a shift

2.2. Check skin integrity for allergic reactions Check skin integrity for allergic reactions to plasterto plaster

3.3. Note circulation, sensation and mobility Note circulation, sensation and mobility of the affected extremitiesof the affected extremities

Skin- non adhesiveSkin- non adhesive

Uses canvass or cloth that is applied on the Uses canvass or cloth that is applied on the patient’s skinpatient’s skinPelvic girdle tractionPelvic girdle traction• Applied like a girdle and connected to two ropes with Applied like a girdle and connected to two ropes with

weights that hangs at the foot part of the bedweights that hangs at the foot part of the bed• Indicated for low back painIndicated for low back pain

Head Halter TractionHead Halter Traction• Applied on chin and occipital region connected to a Applied on chin and occipital region connected to a

hanger with weights that hangs at the head part of the hanger with weights that hangs at the head part of the bedbed

• Usually indicated for cervical spine affectationsUsually indicated for cervical spine affectations

Skin- non adhesive tractionSkin- non adhesive traction

Cotrel TractionCotrel Traction• Combination of the head halter and pelvic Combination of the head halter and pelvic

traction used in scoliosistraction used in scoliosis

Russell TractionRussell Traction• Permits patient to move freely in bed and Permits patient to move freely in bed and

permits flexion of the knee and hip jointpermits flexion of the knee and hip joint• Buck’s extension and the knee is suspended Buck’s extension and the knee is suspended

in a sling to which a rope is attachedin a sling to which a rope is attached

Russell TractionRussell Traction

Nursing Care of Clients with non-Nursing Care of Clients with non-adhesive tractionadhesive traction

Rest period are providedRest period are provided

Skeletal TractionSkeletal Traction

Applied into a boneApplied into a bone

Crutchfield Skeletal TractionCrutchfield Skeletal Traction• Applied into the parietal; bonesApplied into the parietal; bones

Indicated for cervical spine affectationsIndicated for cervical spine affectations

Crutchfield TongCrutchfield Tong

Skeletal TractionSkeletal Traction

Balanced Skeletal TractionBalanced Skeletal Traction• Applied alone or with skeletal traction to Applied alone or with skeletal traction to

promote patient mobilitypromote patient mobility

Balanced Skeletal TractionBalanced Skeletal Traction

Principles of CarePrinciples of Care

1.1. The patient should always be on either The patient should always be on either supine or dorsal recumbent positionsupine or dorsal recumbent position

2.2. The should always be an counteraction The should always be an counteraction (patient’s weight)(patient’s weight)

3.3. The line of deformity should be in line The line of deformity should be in line with the tractionwith the traction

4.4. Traction should be continuousTraction should be continuous5.5. There should be no friction within the line There should be no friction within the line

of tractionof traction

b. Cast- Comparison of Cast Materialsb. Cast- Comparison of Cast MaterialsPlaster Plaster Synthetic Synthetic

Material Material Plastc of Paris, comprised Plastc of Paris, comprised of powdered calcium of powdered calcium sulfate crystals sulfate crystals impregnated into the impregnated into the bandages bandages

Polyester and cotton, Polyester and cotton, fiberglass or plastic. fiberglass or plastic. Polyester and cotton is Polyester and cotton is impregnated with water- impregnated with water- activated polyurethane activated polyurethane resin resin

Drying time Drying time 24-48 hours 24-48 hours 7-15 mins of setting7-15 mins of setting

15-30 mins for weight 15-30 mins for weight bearing bearing

Advantages Advantages Less costly Less costly

More effective for More effective for immobilizing severely immobilizing severely displaced bonesdisplaced bones

Smooth surfaceSmooth surface

Does not require Does not require expensive equipment for expensive equipment for application application

Less likely to indent into Less likely to indent into skinskin

Lighter in weightLighter in weight

Less restrictiveLess restrictive

Does not crumbleDoes not crumble

NonabsorbentNonabsorbent

Can be immersed in water Can be immersed in water

c. Bracesc. Braces

• Knight-taylorsKnight-taylors• For thoraco-lumbar affectationsFor thoraco-lumbar affectations

• MilwaukeeMilwaukee• For scoliosisFor scoliosis

Nursing CareNursing Care• Use cotton clothing as barrierUse cotton clothing as barrier

d. Fixatorsd. Fixators

• RAEFRAEF• Roger Anderson External FixatorRoger Anderson External Fixator

• Ilizarov deviceIlizarov device• Indicated for comminuted fracturesIndicated for comminuted fractures

3. Rehabilitation3. Rehabilitation

• Active or dynamic program aimed at Active or dynamic program aimed at enabling an ill or disabled enabling an ill or disabled to achieve the to achieve the highesthighest levellevel of physical, mental, social, of physical, mental, social, and economic self-sufficiency of which he and economic self-sufficiency of which he is capableis capable

Members of the Rehabilitation teamMembers of the Rehabilitation team

a.a. PatientPatient

• Key member of health teamKey member of health team

b.b. Rehabilitation nurseRehabilitation nurse

• Develops plan of patient careDevelops plan of patient care

c.c. PhysicianPhysician

• Makes medical diagnosis; directs teamMakes medical diagnosis; directs team

d.d. PhysiatristPhysiatrist

• Physician specialist in physical medicinePhysician specialist in physical medicine

e.e. Physical TherapistPhysical Therapist

• Teaches or supervises patient in prescribed exercise Teaches or supervises patient in prescribed exercise programprogram

Members of the Rehabilitation teamMembers of the Rehabilitation team

f.f. PsychologistPsychologist• Helps patient or family explore feelingsHelps patient or family explore feelings

g.g. Occupational TherapistOccupational Therapist• Helps develop skills for home and work situationsHelps develop skills for home and work situations

h.h. Social WorkerSocial Worker• Assists patient and family adjust socio-economicallyAssists patient and family adjust socio-economically

i.i. Vocational CounselorVocational Counselor• Tests patient’s interest and aptitudesTests patient’s interest and aptitudes

j.j. Rehabilitation EngineerRehabilitation Engineer• Uses technology in designing or constructing Uses technology in designing or constructing

devices to help the handicappeddevices to help the handicapped

Transfer and Assistive DevicesTransfer and Assistive Devices

1.1. transferring a client from bed to stretchertransferring a client from bed to stretcher• stretcher must be perpendicular to bedstretcher must be perpendicular to bed

2.2. transferring a client from bed to wheelchairtransferring a client from bed to wheelchair• the wheelchair must be parallel to the head of the the wheelchair must be parallel to the head of the

bedbed

3.3. CanesCanes• Height of cane is from floor to waist levelHeight of cane is from floor to waist level• Cane is held by opposite the affected extremityCane is held by opposite the affected extremity

Transfer and Assistive DevicesTransfer and Assistive Devices

4.4. CrutchesCrutches• Height of crutch is from floor to axilla minus Height of crutch is from floor to axilla minus

2 inches2 inches• Patient’s weight is borne by the palm, of the Patient’s weight is borne by the palm, of the

hand and not on the axillahand and not on the axilla• When going upstairs, unaffected leg firstWhen going upstairs, unaffected leg first• When going upstairs, affected leg firstWhen going upstairs, affected leg first

Crutch-walking techniquesCrutch-walking techniques

• Two point gaitTwo point gait (two alternate gait) (two alternate gait)• Three point gaitThree point gait• Four point gaitFour point gait• Swinging crutch gaitsSwinging crutch gaits

• Both legs are lifted off the ground simultaneously and Both legs are lifted off the ground simultaneously and swung forward while patient pushes up on crutchesswung forward while patient pushes up on crutches

• Swing-to gaitSwing-to gait• Lift and swing body up to crutchesLift and swing body up to crutches

• Swing-through gaitSwing-through gait• Lift swing body beyond crutchesLift swing body beyond crutches

ExercisesExercises

a.a. IsometricIsometric• Alternate contraction and relaxation of the Alternate contraction and relaxation of the

muscle without moving the jointmuscle without moving the joint

a.a. Done on the affected extremityDone on the affected extremity

b.b. IsotonicIsotonic• Range of motion exercisesRange of motion exercises• Done on the unaffected extremityDone on the unaffected extremity

Heat or Cold Application in TraumaHeat or Cold Application in Trauma

Cold ApplicationCold Application• first 24 hoursfirst 24 hours• To decrease To decrease

hemorrhagehemorrhage• To relieve painTo relieve pain• To reduce To reduce

inflammationinflammation

Heat ApplicationHeat Application– After 24 hoursAfter 24 hours– To relieve pain from To relieve pain from

muscle spasmsmuscle spasms– To reduce swelling To reduce swelling

by increasing by increasing circulationcirculation

– To promote healing To promote healing by increasing by increasing oxygenationoxygenation

4. Orthopedic Operative 4. Orthopedic Operative ProceduresProcedures

a.a. ArthrotomyArthrotomy

– Surgical opening into a jointSurgical opening into a joint

b.b. ArthrodesisArthrodesis

– Fixation of a jointFixation of a joint

c.c. Spinal fusionSpinal fusion

– Surgical removal of 1 or more Surgical removal of 1 or more vertebra and fusing them togethervertebra and fusing them together

4. Orthopedic Operative 4. Orthopedic Operative ProceduresProcedures

d.d. Hip replacementHip replacement– Placement of prosthesis on the hip Placement of prosthesis on the hip

jointjoint– IndicationIndication

Hip fractureHip fractureInability to move leg voluntarilyInability to move leg voluntarilyShortening and external rotation of Shortening and external rotation of the legthe leg

Nursing Management on Hip Nursing Management on Hip ReplacementReplacement

Avoid positioning on the operative siteAvoid positioning on the operative site

Maintain abduction of hipMaintain abduction of hip

Pillows between legsPillows between legs

Provide chair with firm, non-reclining Provide chair with firm, non-reclining seat and armsseat and arms

Nursing Management on Hip Nursing Management on Hip ReplacementReplacement

Avoid hip flexion beyond 60 degrees Avoid hip flexion beyond 60 degrees for 10 daysfor 10 daysAvoid hip flexion beyond 90 degrees Avoid hip flexion beyond 90 degrees from day 10 to 2 monthsfrom day 10 to 2 monthsAvoid adduction of the affected leg Avoid adduction of the affected leg beyond midline for 2 monthsbeyond midline for 2 monthsPartial weight bearing status for 2 Partial weight bearing status for 2 monthsmonths

TraumaTrauma

ContusionContusion– Injury to the soft tissue produced by Injury to the soft tissue produced by

blunt forceblunt force

SprainSprain– Injury to the ligamentous structures Injury to the ligamentous structures

caused by wrenching or twistingcaused by wrenching or twisting

– Forcible hyperextension of a joint with Forcible hyperextension of a joint with tissue damage like whiplash injurytissue damage like whiplash injury

TraumaTrauma

StrainStrain– Tearing of musculotendenous unit caused Tearing of musculotendenous unit caused

excessive stretchingexcessive stretching

DislocationDislocation– Joint articulating surfaces are partially Joint articulating surfaces are partially

separatedseparated– No longer in anatomical contactNo longer in anatomical contact

FracturesFractures– Break on continuity of boneBreak on continuity of bone

Nursing AssessmentNursing Assessment

1.1. PainPain– Increasing until immobilizedIncreasing until immobilized

2.2. Loss of functionLoss of function

3.3. Localized swelling or discolorationLocalized swelling or discoloration

4.4. DeformityDeformity

5.5. CrepitusCrepitus– Grating soundGrating sound

General Classifications of General Classifications of FracturesFractures1.1. Simple or closedSimple or closed

– Skin is intact over fracture siteSkin is intact over fracture site

2.2. Compound or openCompound or open– With an external wound in contact with the With an external wound in contact with the

underlying fractureunderlying fracture

3.3. CompleteComplete– Entire cross section is displacedEntire cross section is displaced

4.4. IncompleteIncomplete– Portion of cross section undisplacedPortion of cross section undisplaced

General Classifications of General Classifications of FracturesFractures1.1. GreenstickGreenstick

– One side broken and other bentOne side broken and other bent

2.2. TransverseTransverse– Straight across the boneStraight across the bone

3.3. ObliqueOblique– Angle or slanting across the boneAngle or slanting across the bone

4.4. SpiralSpiral– Twisting or coils around shaftTwisting or coils around shaft

5.5. ComminutedComminuted– Splintered into several fragmentsSplintered into several fragments

General Classifications of General Classifications of FracturesFractures

DepressedDepressed– Fragments are drived-in; facial or skullFragments are drived-in; facial or skull

CompressionCompression– Fractured bone compressed by another bone; Fractured bone compressed by another bone;

vertebravertebraImpactedImpacted– Fractured bones are pushed into each other Fractured bones are pushed into each other

(telescoped)(telescoped)DisplacedDisplaced– Fragments are separated from fracture lineFragments are separated from fracture line

LinearLinear– Fracture parallel with long axisFracture parallel with long axis

COMPARING ARTHRITISCOMPARING ARTHRITIS

RheumatoidRheumatoid OsteoarthritisOsteoarthritis GoutyGouty

EtiologyEtiology AutoimmuneAutoimmune

+ Rh factor+ Rh factor

DegenerativeDegenerative

senescencesenescence

Metabolic or Metabolic or familial purine familial purine metabolismmetabolism

IncidenceIncidence 35-45 women35-45 women Men or more in Men or more in womenwomen

Men over 40Men over 40

Signs and Signs and symptomssymptoms

Subcutaneaous Subcutaneaous nodulesnodules

Morning stiffnessMorning stiffness

Swan neck deformitySwan neck deformity

Heberdens noduleHeberdens nodule TophiTophi

Areas Areas affectedaffected

Joints of handsJoints of hands Weight bearing jointWeight bearing joint Great toeGreat toe

ManagementManagement Aspirin, NSAIDsAspirin, NSAIDs

Paraffin bathParaffin bath

SymptomaticSymptomatic ColchicineColchicine

Avoid purine Avoid purine dietdiet

AllopuyrinolAllopuyrinol