Musculoskeletal Care Modalities

1. Musculoskeletal Care Modalities

2. Managing care of the patient in Cast: • A rigid, external immobilizing device • Is used to: • Immobilize a reduced Fracture ( allow the mobilization of the pt) • Correct a deformity • Apply uniform pressure to underlying soft tissue • Support and stabilize weakened Joint

3. Types of Casts: • Short arm cast 2.Long arm cast • Short leg cast 3.Long leg cast • Walking cast ( long or short) reinforced for strength • Body cast: encircle the trunk • Shoulder spica cast: a body jacket that enclosed the trunk and the shoulder and elbow • Hip spica cast: enclose the trunk and lower extremity ( double hip spica cast ( includes both legs

4. Casting Materials: • Plaster: Rolls of plaster bandage, need 24 to 72 hrs to dry completely • Nonplaster: Fiberglass cast ( lighter in wt, stronger, water resistant), has pores so diminish skin problems

9. Long-Arm and Short-Leg Cast and Common Pressure Areas

10. Teaching Needs of the Patient With a Cast • Prior to cast application • Explain condition necessitating the cast • Explain purpose and goals of the cast • Describe expectations during the casting process: eg, the heat from hardening plaster • Cast care: keep dry; do not cover with plastic • Positioning: elevation of extremity; use of slings • Hygiene • Activity and mobility

11. Cont… • Explain exercises • Do not scratch or stick anything under the cast • Cushion rough edges • Report the following signs and symptoms: persistent pain or swelling; changes in sensation, movement, skin color, or temperature; and signs of infection or pressure areas • Required follow-up care • Cast removal

12. Nursing Process—Assessment of the Patient With a Cast • Prior to casting • Perform general health assessment • Evaluate emotional status • Determine presenting signs and symptoms and condition of the area to be casted • Knowledge • Monitor neurovascular status and the potential for complications

13. Nursing Process—Diagnosis of the Patient With a Cast • Deficient knowledge • Acute pain • Impaired physical mobility • Self-care deficit • Impaired skin integrity • Risk for peripheral neurovascular dysfunction

14. Collaborative Problems/Potential Complications • Compartment syndrome • Pressure ulcer • Disuse syndrome • Delayed union or nonunion of fracture(s)

15. Interventions • Relieve pain • Elevate to reduce edema • Apply ice or cold intermittently • Implement position changes • Administer analgesics • Unrelieved pain may indicate compartment syndrome; discomfort due to pressure may require change of cast • Muscle setting exercises: see Chart 67-3 • Patient teaching: see Chart 67-4

16. Interventions (cont.) • Heal skin wounds and maintain skin integrity • Treat wounds to skin before the cast is applied • Observe for signs and symptoms of pressure or infection • Pad cast and cast edges • Patient may require tetanus booster • Maintain adequate neurovascular status • Assess circulation, sensation, and movement • Five “P’s” • Notify physician at once of signs of compromise • Elevate extremity no higher than the heart • Encourage movement of fingers or toes every hour

17. Managing patient with an External fixator: • Are used to manage open fractures with soft tissue damage. They provide stable support for severe comminuted (crushed or splintered) fractures while permitting active treatment of damage soft tissue. • Nursing intervention: • Prepare the patient psychologically • Cover sharp points on the fixator or pins to prevent injuries • Elevate the extremity to reduce swelling • Assess neuromuscular status every 2 hrs • Assess pin site for sign of infection and loosening of the pin • Pin care • Encourage isometric and active exercise within the limit of tissue damage. Later the nurse help the patient to mobilize within the prescribed weight bearing limit • Teaching patient self care

18. External Fixation Devices (cont.)

20. Managing the patient in Traction: • Is used as short-term intervention until other modalities, such as external or internal fixation are possible. • Traction: is the application of a pulling force to a part of the body • Is used to minimize muscle spasm, to reduce fractures, align and immobilize fractures, to reduce deformity. • The effect of traction is evaluated by radioactive studies.

21. Traction (cont.) • All traction needs to be applied in two directions. The lines of pull are “vectors of force.” The result of the pulling force is between the two lines of the vectors of force.

22. Managing the patient in Traction (cont…): • Principle of effective traction: • Countertraction must be maintained for effective traction • Must be continuous to be effective • Never interrupted • Weight are not removed • The patient must be in in good body alignment in the center of the bed • Ropes must be unobstructed • Weight must hang freely

23. Types of tractions: I. Skin traction: is used to control muscle spasm and to immobilize an area before surgery. No more than 2-3.5 kg of traction should be used, pelvic traction 4.5 to 9 kg depending on the patient weight • Complications: • Skin breakdown, nerve pressure (drop foot), and circulatory impairment ( DVT) • Nursing interventions: • Ensuring effective traction • Monitor and managing potential complications

24. Skin Traction

25. Types of tractions (cont…): II. Skeletal traction: applied directly to the bone by using metal pin or wires. Most frequently used to treat fracture of long bones and the cervical spine. Is a surgical procedure. Skeletal traction uses 7-12 kg, as the muscle relax the traction weight is reduced to prevent fracture dislocation and to promote healing • After removing the traction cast or splint are then used to support the healing bone.

26. Skeletal Traction

27. Nursing Interventions: • Maintaining effective traction: the nurse should not remove wt from skeletal traction unless life-threatening situation occurs • Maintaining positioning: such as the foot to prevent footdrop (planter flexion), inward and outward rotation. • Preventing skin breakdown • Monitoring neuromuscular status • Providing pin site care • Promoting exercise • Assess sensation and movement • Assess pulses, color capillary refill, and temperature of fingers or toes • Assess for indicators of DVT • Assess for indicators of infection

28. Joint Replacement: • Total Hip Replacement: Is the replacement of a severely damaged hip with an artificial joint • Indication: arrithritis, femoral neck fracture, failure of previous reconstructive surgeries, and problems resulting from congenital hip diseases.

31. Cont… • Nursing interventions: 1.Prevent dislocation: • positioning the leg in abduction, • don’t turn the patient in the affected side, • never flex the hip more than 90 degree ( • don’t elevate the head of the bed more than 60 degree • protective positioning include maintaining abduction, avoiding internal and external rotation, hyperextension, and a cute flexion

32. Cont……. 2. Monitoring wound drainage 3. Preventing DVT 4. Prevent infection 5. Teach patient self care 6. Continuing care

33. Total knee replacement: Indication:sever pain and functioning disabilities related to joint surfaces destroyed by arrithritis, bleeding into the joint • Nursing interventions: • Maintain the compressed bandage over the knee • Ice may be applied to decrease the swelling and bleeding • Encourage active flexion of the foot every hour • Prevent complications • Monitor drainage bag • Place the patient leg in continuous Passive motion device ( promote circulation and movement of the knee joint) • Weight bearing limits are prescribed. Patient can get out of the bed the evening of the surgery or the day after surgery

35. CPM Device

36. (chap 68) Management of patient with musculoskeletal disorders

37. Acute low Back pain: • Causes: • A cut lumbosacral strain, • unstable lumbosacral ligaments and weak muscles, • osteoarithritis of the spine, • spinal stenosis, intervertebral disk problems, • and unequal leg length. • Other causes include kidney diorders, pelvic problems, retroperitoneal tumors, abdominal aneurysims, obesity and stress. • L4-L5 and L5-S1 has the greatest degenrative changes

38. Clinical manifestations: • A cute or chronic back pain lasting more than 3 months without improvement) • Fatique • Pain radiating down the leg ( radiculopathy; Sciatica) • Patient’s gait, spinal mobility, reflexes, leg length, leg motor strength and sensory perception may altered

39. Cont… • Assessment and diagnostic findings: • Focused history and physical examination ( reflexes, sensory impairment, straight leg raising, muscle strength • X-ray of the spine, CT scan, MRI • Bone scan and blood study • Myelogram and dicogram • Electromyogram and nerve conduction studies • Medical management: Analgesia, rest, stress reduction and relaxation • Review the Nursing process

40. Positioning to Promote Lumbar Flexion

41. Proper and Improper Lifting Techniques

42. Proper and Improper Standing Postures

43. Carpal Tunnel Syndrome • Median Neuropathy at the Wrist is a medical condition in which the median nerve is compressed at the wrist • Irritation of the flexor tendon and median nerve Manifestations • Numbness and tingling • Thumb • Index finger • Lateral ventral surface of the middle finger

44. Tinel’s Sign—Assessment of Carpal Tunnel Syndrome

45. Dupuytren’s Contracture

46. Carpal Tunnel Syndrome Risk Factors • Computer use • Jackhammer operation • Mechanical work • Gymnastics • Radial bone fracture history • Rheumatoid arthritis

47. possible treatments: • treating any possible underlying disease or condition, immobilizing braces, physiotherapy, massage therapy, medication • Ultimately, carpal tunnel release surgery may be required in which outcomes are generally good

48. Metabolic bone disorders: I.Osteoporosis: • Is characterized by a reduction in the total bone mass and a changes in bone structure which increases the tendency for fracture. • The rate of bone resorption is greater than the rate of bone formation, resulting in a reduced total bone mass. • The bones become porous, brittle, and fragile • Result in compression fractures of the thoracic and lumber spine, fractures of the neck, intertrochanteic region of the femur, and colle’s fracture of the wrist • Pathophysiology: • Loss of bone mass over time due to Aged-related loss: Decreased calcitonin, decreased estrogen ( which prevent bone breakdown), parathyroid hormone increases with age result in increase bone Resorption

49. Pathophysiology of Osteoporosis

50. Risk factors: see chart 68-7 • Assessment and diagnostic findings: • Routine X-ray, and bone sonometer • Lab. Studies: Serum Ca, Serum Ph, urine calcium excretion, ESR • Medical Management: • Adequate balanced diet rich in calcium and Vit D • Regular weight bearing exercise promotes bone formation • Pharmacological therapy: Hormonal replacement therapy ( look for side effect of estrogen and progesterone replacement therapy which result in cancers… thus frequent breast examination is recommended ) • Alendronate alternative to Hormonal replacement therapy: inhibiting osteoclast function and dedcreases bon loss • Calcitonin: suppress bone loss