Musculoskeletal Disorders

Prepared by: John Gil B. Ricafort, RN

Rheumatoid Arthritis (RA) - chronic systemic disease characterized by inflammatory changes in the joints and related structures - common in women than in men - may occur at any age but the peak is usually between 35-50 years old - IDIOPATHIC cause, said to be an autoimmune problem

- associated with viral and bacterial infections, lifestyle and hormonal factors Clinical Manifestations Fatigue Anorexia Malaise Painful joints, warm, swollen, limited in motion, stiff in morning and period after inactivity

Muscle weakness Diagnostic Tests Xray CBC; anemia is common ESR elevated Rheumatoid factor (POSITIVE)

Treatment Pharmacologic Agents Salicylates NSAIDs Corticosteroids Methotrexate Surgery

Nursing Interventions 1. Administer analgesics as prescribed 2. Supply zipper-pull, easy-toopen beverage carton, lightweight cups, and unpackaged silverware to make it easy for the patient to perform daily activities 3. Provide emotional support 4. Prepare for surgery

Key Nursing Diagnoses 1. Ineffective role performance related to crippling effects of rheumatoid arthritis 2. Impaired physical mobility related to pain and joint deformities. 3. Acute pain related to joint inflammation

Osteoarthritis - the most common form of arthritis - a chronic deterioration and a nonsystemic disorder of the joint cartilage and formation of a reactive new bone at the margin subchondral areas of the joints. - IDIOPATHIC cause - associated with aging, obesity and trauma

- common sites are weightbearing joints and terminal interphalangeal joints of fingers Clinical Manifestations Pain and stiffness of joints Heberdens nodes Bouchards nodes Decreased ROM

Diagnostic Tests X-ray Elevated ESR Treatment: SAME with RA

Nursing Interventions 1. Administer analgesics/ antiinflammatory 2. Provide emotional support 3. Encourage patient to perform as much self-care as his immobility and pain allow. 4. Promote rest periods and comfort

Gout - a disorder in the purine metabolism; causes high levels of uric acid in the blood and the precipitation of urate crystals in the joints and in the kidneys. - more common in men than in women - familial tendency

Clinical Manifestations Joint pain, redness, heat, swelling; commonly affected sites are great toe, ankle Headache Malaise Anorexia Diagnostic Tests X-Ray Serum Uric Acid Evaluation

Management Drug therapy Colchicine NSAIDs Uricosuric Agent Analgesics Diet: Low purine Joint rest and protection

Nursing Interventions 1. Assess joints for pain, motion, appearance 2. Provide bed rest and joint immobilization 3. Administer antigout medications as ordered. 4. Administer analgesics as ordered. 5. Increase OFI to 2000-3000ml per day

Fractures - a break in the continuity of the bone usually caused by trauma Types 1. Open or Compound 2. Closed or Simple 3. Transverse 4. Oblique 5. Spiral 6. Greenstick

Clinical Manifestations Pain, aggravated by motion Loss of motion Edema on the site Hematoma/ discoloration Assymetry Diagnostic Tests X-Ray

Management Traction Reduction Application of a Casts

Nursing Interventions 1. Provide emergency care for fractures. 2. Perform a neurovascular check on affected extremity 3. Observe for signs and symptoms of Compartment Syndrome. 4. Observe for signs and symptoms of Fat embolism

5. Encourage diet high in protein and vitamins to promote healing. 6. Encourage fluid to prevent constipation, renal calculi and UTI. 7. Provide care for client in traction, with a casts or with open reduction.

TRACTIONS - used to treat fractures, dislocations, correct or prevent deformities, improve or correct contractures or decrease muscle spasms by exerting a pulling force on a part of the body

Basis for Traction Usage: 1. 2. 3. 4. 5. Patients condition Age Weight Skin condition Duration of traction to be applied 6. Purpose of traction

Types of Traction

1. Skin Traction - 5 to 8 lbs (2.5 to 3.5 kg)

2. Skeletal Traction - 25 to 40 lbs (11.5 to 18 kg)

SKIN TRACTION Types: 1. Bucks Traction - exerts straight pull on affected extremity - generally used to temporarily immobilize the leg in a client with a fractured hip - shock blocks at the foot of the bed to produce countertraction and prevent the client from sliding down in bed

2. Russell Traction - knee is suspended in a sling attached to a rope and pulley on the Balkan Frame - generally used to stabilize fractures of the femoral shaft while client is awaiting for surgery.

3. Cervical Traction - cervical head halter attached to weights hang over head of bed - used for soft tissue damage or degenerative disc disease of cervical spine and to maintain alignment - elevate the head of the bed to produce countertraction

4. Pelvic Traction - pelvic girdle with extension straps attached to ropes and weights - used for low back pain to reduce muscle spasms and maintain alignment - client in SEMI-FOWLERS with KNEE BENT

SKELETAL TRACTION - traction is applied directly to the bones using pins, wires, or tongs (Crutchfield Tongs) that are surgically inserted. - used for fractured femur, tibia, humerus and cervical spine.

Complications of Traction 1. Pressure sores 2. Muscle atrophy 3. Weakness 4. Contractures 5. GI disturbances 6. Respiratory problems 7. Circulatory problems 8. Osteomyelitis

Key Nursing Diagnoses 1. Constipation related to immobility 2. Impaired physical mobility related to restrictions associated with traction 3. Impaired tissue integrity related to immobility

Nursing Intervention The nurses main responsibility includes patient teaching, maintaining traction apparatus, assessing for complications and caring for pins in insertion sites. Nursing Care: 1. Check traction apparatus frequently to ensure that: a. Ropes are aligned and weights are hanging freely

b. Bed in proper position c. Line of traction is within the long axis of the bone 2. Maintain client in proper alignment a. Align in center of bed b. DO NOT rest affected limb against foot of bed 3. Perform neurovascular checks to affected extremity.

4. Observe for and prevent footdrop a. Provide footplate b. Encourage plantarflexion and dorsiflexion 5. Observe for and prevent deep venous thrombosis 6. Observe for and prevent skin irritation and breakdown Russell Traction: popliteal area Thomas Splint: popliteal area

Cervical: pad chin area and protect ears 7. Provide pin care 8. Assist with ADL; provide overhead trapeze to facilitate moving, using bedpan 9. Prevent complications of immobility 10. Encourage active ROM exercises to unaffected extremity

11. Check carefully for orders about turning Bucks Traction: client may turn to unaffected side (place pillows between legs before turning) Russell Traction: client may turn slightly from side to side without turning body below the waist

CASTS - used to immobilize a body part Casting Materials: 1. Plaster of Paris - takes 24 72 hours to dry - precautions must be taken until cast is dry to prevent dents - signs of a dry casts: SHINY WHITE, HARD, RESISTANT

- must be kept dry since water can ruin a plaster cast 2. Synthetic Casts (Fiberglass) - strong, lightweight; sets in about 20 minutes - can be dried using cast dryer or hair blowdryer on cool setting - water-resistant; however it must be dried thoroughly to prevent skin problem under the cast

Cast Drying ( Plaster Cast) 1. Use palms of hands, NOT FINGERTIP, to support cast when moving or lifting client 2. Support cast on rubber or plastic protected pillows with cloth pillowcase along length of cast until dry 3. Turn client every 2 hours to reduce pressure and promote drying

4. DO NOT cover the cast until it is dry (may use fan to facilitate drying) 5. DO NOT use heat lamp or hair dryer on plaster cast

Nursing Care for Clients with Cast: 1. Perform neurovascular checks to area distal to cast:

a. Report absent or diminished pulse, cyanosis or blanching, coldness, lack of sensation or inability to move fingers or toes, and excessive swelling b. Report complaints of burning, tingling or numbness 2. Note any odor from the cast that may indicate infection 3. Note any bleeding on cast in a surgical patient

4. Check for hot spots that may indicate inflammation under cast. 5. Instruct the patient to wiggle toes or fingers 6. Elevate the affected extremity above the heart 7. DO NOT scratch or insert foreign objects under cast 8. Avoid eating crackers while on casts

ASSISTIVE DEVICES for WALKING: 1. Cane Nursing Care: Teach client to hold cane in hand opposite affected extremity and to advance cane at the same time the affected leg is moved forward

2. Walker Nursing Care: Teach client to hold upper bars of walker at each side, then to move the walker forward and step into it. 3. Crutches - when the client assumes erect position the top of crutch must be 2 INCHES below the axilla, and the tip of each crutch is 6 INCHES in front and sides of the feet

- clients elbow should be slightly flexed when head is on hand grip - weight should NOT be borne by the axilla. CRUTCH GAITS: a. FOUR-POINT GAIT - used when weight bearing is allowed on both extremities

a. b. c. d.

Advance the right crutch Step forward with left foot Advance left crutch Step forward with right foot

b. TWO-POINT GAIT - typical walking pattern - an acceleration of Four-point gait

a. Step forward moving both right crutch and left leg simultaneously b. Step forward moving both left crutch and right leg simultaneously.

c. THREE-POINT GAIT - used when weight bearing is permitted on one extremity only

a. Advance both crutches and affected extremity several inches, maintaining good balance b. Advance the unaffected leg to the crutches, supporting the weight of the body on the hands.

d. SWING-TO GAIT - used for clients with paralysis of both lower extremities who are unable to lift feet from floor a. Both crutches are placed forward b. Client swings forward to the crutches