CONCEPT: BASIC CARE AND
COMFORT
PREPARED BY:
AARATI SHARMA
Masters Nursing & counseling Psychology
Registered Nurse Nepal and USA
MUSCULOSKELETAL INJURIES:
• _____ Any break in the continuity of the bone occurring in the shaft
or diaphysis (complete, incomplete, or bending, open or closed).
Treatment includes realignment of bone fragments, maintenance of
realignment of bone fragments, maintenance of realignment by
immobilization, and restoration of function. (FR)
• ___ Injury to the muscle tissue or tendon in the form of incomplete
tears. Results from overstretching, overuse, or excess stress, causing
bleeding into the muscle, pain, swelling, and muscle spasm.
Treatment includes ice packs for the first 24 hours followed by moist
or dry heat, sling or crutches, and muscle relaxants. (ST)
• ___ Injury involving the ligamentous structures surrounding a joint;
tear or stretching of the joint. Immobilization is crucial after swelling
has subsided. Treatment includes immobilization, cast application
after swelling decreases, cold or heat, and correct positioning. (SP)
INITIAL NURSING MANAGEMENT
FRACTURE:– break in the continuity of the bone
Compound fracture: bone exposed to air because of break in the skin
Complete fracture: bone is separated completely into two parts
Simple fracture: skin remains intact
Signs and Symptoms
P : Pain
A : Abnormal motion
S : Soft tissue edema
O : Obvious deformity
D : Discoloration
PRIORITY ASSESSMENT
Neurovascular Compromise: 5Ps
1. Paresthesis : Numbness & Tingling sensation
2. Pain : Increasing Pain/ Pain unrelieved by analgesic
3. Pallor-Polar : Blanching on skin – Cold to touch
4. Pulselessness
5. Paralysis : on longer movement
COMPLICATIONS OF FRACTURE
1. COMPARTMENT SYNDROME
Build up pressure in a compartment that can't expand
-Asess for NeuroVascular Compromise :
- Early Sx:5P'S and late Sx: 2'C – Cool to touch & Cyanosis
- Notify the HCP
2. DISUSE SYNDROME : when affected parts aren't used for long time
- Deterioration of affected extremity
Contractures : Permanent shortening of a muscle or joints
Muscle Atrophy : a decrease in the mass of the muscle when not in use
Intervention: ROM (moving without pain)
3. FAT EMBOLISM
Release of fat globule after 48-72hrs after injury of the long bones
S/Sx: HYPOXIA/ DYSPNEA
: NEUROLOGICAL ABNORMALITIES
: PETECHIAL RASH: chest& neck
NOTIFY HCP IMMEDIATELY
4. Constipation
Due to immobility : Increase high fluid and high fibre diet
: Exercise
5. Crepitus: AIR inside the subcutaneous tissue
IMMOBILIZATION – prevention of movement
1. CAST –Rigid external device
• TYPES OF CAST
Criteria
Plaster of paris (gypsum) Fiberglass (type of
plastic)
Drying time
36-48hrs
20-30 mins
Weight
Heavy
light
Cost
Affordable
Costly
Characteristics of a Dry Cast
• hard, white,
• shiny, with resonant sound,
• and cold to touch
Casts
Do’s
1. Let it dry Plaster of Paris – 24-48 hrs
Fiberglass- 20-30 min
2. May hastens drying using the cool setting of hair dryer, electric
fan(OK)
3. Use palm of hands to prevent indentation
4. Rubber, plastic surfaces
5. Neurovascular check
6. Maintain cleanliness and skin care
Don’ts
1. Use of warm water- contribute hotspot prone for infection
2. Don’t cover until dry – moistens- weak cast
3. Finger- prone to indentation leads to uneven cast, prone to
compartment syn.
4. Avoid cloth surfaces
Care for client with Cast
C- clean using mild soap & water, OK wiping
A- Assess for temp. sensation of extremity, apply ice, assess capillary
refill
S- sling provided, skin care
T- turn pt every 2hrs
E- Elevate & exercise
D- Do not put anything inside the cast “use cool setting of hair dryer
2. TRACTION:
T –o exert a pulling force
R –educe nerve compression
A –llows alignment
C –ontrols contractures / deformity
T –o decrease muscle spasms
I –njured part is maintained in position
O –bserve if weights hang freely
N –o obstruction on pulled
Important Principles of Maintaining Traction
1. Maintain established line of pull.
2. Prevent friction.
3. Maintain countertraction.
4. Maintain continuous traction unless ordered otherwise.
5. Maintain correct body alignment
SKIN TRACTION
SKELETAL TRACTION
Description
Applied to the skin
Applied to the bone
Maxm WT.
4.5- 8lbs
25-45lbs
(Note: 1 kg=2.2 pounds)
Duration
Short; Intermittents
Long; Continous
PRIORITY
Skin care every shift
WOF: Infection & Irritation
PIN SITE care every
shift
WOF: Bleeding,
Infection & Loose pins
TYPES OF SKIN TRACTION
1. Bryant's Traction:
• For children with congenital hip dysplasia.
• Buttocks shouldn’t touch the bed.
• Run your hand over bed to check it.
2. BUCK'S TRACTION
Indication:Hip fracture and knee injuries
Note: Maintain straight alignment on bed
• Priority: Prevent Foot Drop
Use foot board/foot plate
3. RUSSEL'S TRACTION:
INDICATION: Hip fracture and knee injuries
Note: Should be slightly bend
Priority: Prevent Foot Drop
Use foot board/ Foot plate
TYPES OF SKELETAL TRACTION
1. CRUTCHFIELD TONG:
Indication: For Facture of Cervical Spine
It relieves pain and end muscle spasms.
2. HALO TRACTION:
•For keeping the
head and neck still​
3. 90-90 degree Traction:
• For femur
fracture
• Wt. Hang freely
• No obstruction
4. Balanced Skeletal Traction:
• For femur fracture
• Overhead Trapezes (Provide Independence/ Movement)
Assistive Devices
• Assess client’s use of assistive devices; evaluate correct use; assist
client to ambulate with an assistive device.
ASSISTIVE DEVICES
CRUTCHES
CANE
WALKER
Allowance from axilla to axillary
bar: 2 inches or 3 fingers
Position of the nurse during:
- Ambulation: Bad side
- Transferring: Good side
C - Cane
O - Opposite
A - Affected
L – Leg
Elbow angle: 30 degrees angle
Pressure is put on: Hand bar/
Palm of the hand
Complication:
* Brachial Palsy/Crutch Palsy
Elbow Angle: 30degree elbow
flexion
Handle should be level with: Greater
Trochanter
Elbow Angle: 30 degree flexion
Distance:
• 6’’ to the side
• 6” to the front
“TRIPOD position”
Distance: 6-10” on side of foot
Movement: CANE + Affected side
followed by Unaffected Leg
Distance: Lift or roll 6” rule
Movement:
WALKER + Affected side followed
by UNAFFECTED side
Hoyer lift: Used for patients who cannot help themselves and/or are
too heavy for safe lifting by others
• Lock bed, raise the bed to promote use of good body mechanics by
the nurse
CRUTCHES
A. How do you measure the length of crutch?
2-3 finger widths below the anterior axillary fold to a point lateral to and slightly
in front of the foot.
B. How to measure the hand grip?
When the handgrips are properly placed, the angle of elbow flexion is about 30
degrees
C. How to teach crutch gaits. There are four.
Two Point
You move a crutch and the opposite foot together followed by the other foot and crutch
Two together at every time
Three Point
You move two crutches and bad leg together
Three things move together at every time
3 together then 1
Four Point
You move everything separately
You have two legs and two crutches
You move ANY crutch, but once you move that, your sequence is LOCKED IN
You then move the opposite foot followed by the other crutch followed by the other foot
Very slow but very stable
Swing Through
Non weight bearing (amputations)
You plant the crutches then you swing through
You never put the leg down
CRUTCH GAITS
TYPE
DESCRIPTION
WEIGHT BEARING
2 Point
▪ Advance Right Crutch with Left Leg Together
▪ Advance Left Crutch with Right Leg Together
Wt. bearing on both legs
4 Point
▪ Right Crutch
▪ Left Leg
▪ Left Crutch
▪ Right Leg
Arthritis & assistance with walking
Wt. bearing on both legs
3 Point
▪ Advance Both Crutches and Bad Leg Forward
▪ Advance Good Leg while keeping body weight on
crutches
BROKEN leg, Sprain @ Strain
Wt. bearing on Unaffected Legs
Swing – To
▪ Advance Both crutches
▪ Advance Both Legs TO THE LEVEL of the Crutches
BILATERAL Paralysis
Non- wt bearing
When both leg can’t bear wt
Swing - Through
▪ Advance Both crutches
▪ Advance Both Legs BEYOND THE LEVEL of the
Crutches
Non- wt bearing
D. When do client use these?
“Even for even, odd for odd” Therefore, ask yourself HOW MANY LEGS
ARE AFFECTED?
1. Use the even numbered gaits (two and four) when the weakness is
evenly distributed (when you have even number of legs messed up).
• Use two point for mild problem (mild bilateral weaknesses).
• Use four point for severe problem (severe bilateral weaknesses).
2. Use the odd numbered gait (three point) when one leg is odd.
3. If they can’t bear weight / amputation for instance, use swing
through.
Examples:
1.Early stages of rheumatoid arthritis. Two point (systemic disease
therefore two.)
2.LAK (Left above Knee) amputation. Swing through.
3. First day post op right knee replacement, partial weight bearing
allowed. Three point.
4. Advanced stages of amyotrophic lateral sclerosis. Four point.
5. Left hip replacement, second day post op, NWB. Swing through.
6. Bilateral total knee replacement, first day post op, WB allowed. Four
point.
7. Bilateral total knee replacement, three weeks post op. Two point.
(WB- weight bearing; NWB- Non-weight bearing)
E) Going up and down stairs
CRUTCHES
•“Up with the good, down with the bad”
• Upstairs: lead with good foot then crutches go second.
• Downstairs: lead with the bad foot then crutches go second.
• Crutches always move with bad leg.
F. Miscellaneous
CANES
• Always hold on opposite side of bad leg/GOOD leg side, but advance
it with the bad leg
WALKER
• Pick them up, set it down, walk to it
• If client need to tie their belongings to it, tie to side not at the front
else tip the walker over
• Boards (NCLEX EXAM) does not like wheels on walkers or tennis balls
on walkers
MUSCULOSKELETAL DISORDERS
1. Osteoporosis
➢ age-related metabolic disease
➢ bone demineralization results in the loss of bone mass
➢ yields – BRITTLE bones which breaks easily
Risk factors
0 – Old age
S – Steriods, Smoking
T – Trauma
E – Endocrine problem eg hyperparathyroidism
O – Oophorectomy-removal of the ovaries, menopause
P- Pregnancy, poor posture
O- Over intake of caffeine and alcohol
R- Race eg. Asians
R- Renal failure because kidney synthesize Vit D
O- Obvious family history
S- Small thin frame
I- Inadequate intake of Vitamin D and Calcium
S- Sedentary lifestyle
S/Sx :
B – Bone Pain
R – Reduced height
E – Easily fractured
A – Always falling
K – Kyphosis
EXERCISE : Weight Bearing Exercise- working against gravity
Ex: Brisk walking, Jogging, Dancing, Water/Aquatic aerobics
DRUG THERAPY
• Calcium supplements 1500 mg/day
• Vitamin D supplements 400-600 IU/day
Biphosphonates
• Alendronate (Fosamax)
• IBANDRONATE (BONIVA) – morning before breakfast with full glass of water
• Risedronate (Actonel)
• Calcitonin (Calcimar, Miacalcin) -brings the Calcium back to the bones
• Raloxifene (Evista) - estrogen receptor modulator
Side Effect: Bloating, weight gain, breast tenderness, DVT risk
Diet
High Calcium Diet
Decrease calcium absorption
• chocolate
•Okra
•Sweet potato
•Spinach
•Coffee
•Caffeinated drinks
Q. Patient diagnosed with osteoporosis is taking Biphosphonates. What
would you include in the health teaching about this medication?
Select all that apply:
1.Take it with water only
2.Take it daily before bed time
3.Take medication on a full stomach
4. Take medication upon arising
5. Remain upright for 30min after taking the medication
6. May take with other medication
7. No food or drinks for 30min after taking the medication
ANS: 1457
MUSCULOSKELETAL SURGERIES
Sign & Symptoms: Hip dislocation
S – Shortening
E – External Rotation
A - Adduction
Prevent Dislocation
Position: ABDUCTION (away) & Extension
• Keep the knees apart at all times.
• Put a pillow under the knees while sleeping.
• Never cross the legs when seated.
• Avoid bending forward when seated in a chair.
• DO NOT sit on soft chairs, rocking chairs, sofas, or stools.
• Use a raised toilet seat at or above knee height.
• Put abduction pillow in between the legs when turning or getting out of bed.
• Scoot to the edge of the bed or chair before standing.
• DO NOT bend over, raise your legs, or cross your legs when you get dressed.
• DO NOT bend or squat to wash your legs and feet. Use long-handled equipment to reach them.
• DO NOT sit in the bottom of a regular bathtub; use a tub seat or bench
Abductor Pillow
TROCHANTER ROLL
Amputation
Amputation is the surgical removal of a diseases part or organ.
Causes:
• Bone cancer
• Osteomyelitis
• Peripheral Vascular Disease
• Diabetes Mellitus (DM)
Complications of Amputation
1. Bleeding
Bedside: TORNIQUET
2. Contractures – permanent shortening of the muscles and joint
How to prevent:
A. First 24-48 hours – Elevate the stump
B. B. After 24-48 hours – Do not elevate unless indicated by HCP
3. Phantom pain – is the pain felt where the limb has been amputated
4. Phantom sensation – sensation of itching or “tingly”, where the
missing part used to be
Stump care : Torniquet @bedside to prevent bleeding
• Cleanse with mild soap and water
• NO lotions, creams, oils – may cause skin breakdown which may lead to
infection
• Elastic bandage
• Residual sock – change daily
“Toughen” Residual Limb:
1. Massage once completely healed
2. Soft pillow – Firm pillow – Hard surface (back of the chair)
Purpose: To apply direct pressure to the end of the stump in preparation
for prosthesis
Nursing Diagnosis: Body Image Disturbance
THANK YOU