Assessment of Musculoskeletal Function
Chapter 66
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Data r/t functional ability: ADLs; ability to perform various activities; note any problems r/t
mobility
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Health hx: family history, general health, nutrition, occupation, learning needs,
socioeconomic factors, and medications (OTC, herbal)
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Physical assessment: posture, gait, bone integrity, joint function, muscle strength, skin,
neurovascular status
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Body & bone alignment, deformities, symmetric parts, crepitus, ROM
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Musculoskeletal System Assessment
Assess pain and altered sensations.
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Have pt describe and locate pain
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Dull, deep ache, “boring,” soreness
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Aching, muscle cramps
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Fracture pain: sharp, piercing –relieved by immobilization
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Radiating pain: Shooting, throbbing
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Paresthesias: burning, tingling, numbness
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Musculoskeletal System Assessment
Assess pain and altered sensations
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Peripheral nerve functions - Test & evaluate sensation of nerves
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Evaluate motion
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Peroneal nerve, tibial nerve, radial nerve, ulnar nerve, median nerve
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Normal Spine and 3 Abnormalities
Musculoskeletal System Assessment:
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Check for Contractures
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Effusion
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Dislocation of joints – Luxation
Partial dislocation - Subluxation
BS p 2346
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Evaluate Muscle strength
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Muscle clonus – twitching, seizures
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Detecting Fluid in the Knee - crepitus
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Assess for other musculoskeletal disorders: Rheumatoid Arthritis which may develop Hand
deformity - Ulnar Deviation & “Swan-Neck”
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Review Diagnostic Evaluation, X-rays, Computed tomography, MRIs, Arthrography, Bone
densitometry and Bone scans, Arthroscopy
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Arthrocentesis and Electromyography
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Biopsy reports and Laboratory studies
When reviewing radiographic tests, check for Loss of joint space, look for Osteophytes at the bone
margins. Check for Normal cartilage (may be seen with bone deformities or bone disease),
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Scans may Identify acute & chronic tears of the joint capsules or support ligaments of the
knee, shoulder, ankle, hip or wrist.
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Radiopaque contrast is injected into the joint cavity to outline the bone, bone cavity and Soft
tissue of joint structure is outlined. The joint undergoes ROM under series of Contrast agent
leaks out of the joint when a tears is present
Musculoskeletal Care Modalities
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Chapter 67
Cast - A rigid, external immobilizing device
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Uses: to Immobilize a reduced fracture; to correct deformity; it aaplies uniform
pressure to the soft tissues; and Provides support to stabilize a joint
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Permits patient mobilization while restricting movement of a body part.
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Types of Casts
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- Short-Leg cast with common pressure areas
- Extends from below the knee to the base of the toes
- Foot if flexed at a right angle in a neutral position.
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Short-Arm cast –Long-leg cast - Extends from the elbow to the palmar crease;
secured around the base of thumb – thumb spica or gauntlet cast
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Long-leg cast – extends from the upper, middle third thigh to the base of the toes.;
knee is slightly flexed
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Walking cast – a short or long-leg cast reinforced for strength.
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Body cast – Encircles the truck
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Shoulder spica cast – a body jacket that encloses the trunk, shoulder and elbow.
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Hip spica cast – encloses the trunk and lower extremity. A double hip spica includes
both legs
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Cast Materials
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Nonplaster (fiberglass) – water activated polyurethane; porous, lighter yet stronger, its Rigid, durable & water resistant. Dries fast; less skin problems
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Plaster – crytallizing reaction which gives off heat; Slow drying; 24-72 hrs.
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Patient Teaching – teach them about Cast Care
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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
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Cast care: keep dry; do not cover with plastic
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Positioning: elevation of extremity; use of slings
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Hygiene
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Activity and mobility; Explain exercises
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Do not scratch or stick anything under the cast
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Cushion rough edges
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Report persistent pain, swelling, changes in sensation; movement; skin color;
temperature; signs of infection; pressure areas
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Follow-up care Required
Cast removal
Nursing Process: Assessment of Patient with a Cast
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Prior to casting
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Perform general health assessment
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Evaluate emotional status
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Determine the condition signs & sx. of the area to be casted
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Assess the pt’s. knowledge
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Monitor neurovascular status for potential complications
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Nursing Process: Caring for the Patient with a Cast
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List the Nursing Diagnosis for the patient with a cast
Nursing Process: Diagnosis of Patient with a Cast
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Impaired physical mobility
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Self-care deficit – inability to perform ADLs
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Acute pain – unrelieved pain must be reported immediately to avoid poss. Paralysis
necrosis
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Impaired skin integrity
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Risk for peripheral neurovascular dysfunction
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Knowledge deficit
Collaborative Problems/Potential Complications
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Compartment syndrome -
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Pressure ulcer
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Disuse syndrome -
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Delayed union or nonunion of fracture(s)
Nursing Process: Planning the Care of the Patient With a Cast
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Increase knowledge of treatment regimen
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Pain relief
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Improved physical mobility
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Achieve maximum level of self-care,
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Healing (of trauma-associated lacerations, abrasions)
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Maintain adequate neurovascular function
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Absence of complications
Interventions –
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Relieve pain:
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Elevate to reduce edema
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Apply ice or cold intermittently
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Implement position changes
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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 for home care: see Chart 67-4
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Interventions
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Heal skin wounds and maintain skin integrity
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Treat skin wounds before applying cast
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Observe for S/SX of pressure or infection
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Pad cast and cast edges
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Patient may require tetanus booster
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Maintain adequate neurovascular status
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Assess circulation, sensation, and movement
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Notify physician at once of signs of compromise
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Elevate extremity no higher than the heart
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Encourage movement of fingers/toes every hour
External Fixation Devices
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Used to manage open fractures
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Supports complicated or comminuted fractures
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Reassure patient concerned by appearance of device
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Minimal discomfort; early mobility may be anticipated
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Elevate to reduce edema
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Monitor for S/SX of complications, including infection
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Provide pin care
External Fixation Devices
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Traction - Applies pulling force to a part of the body
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Purposes:
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Reduction & alignment; immobilize fractures
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Reduce deformity and muscle spasms
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Increase space between opposing forces
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Used as a short-term intervention until other modalities are possible
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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.
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Principles of Effective Traction - Whenever traction is applied, a counterforce must
be applied. Frequently the patient’s body weight and positioning in bed supply the
counterforce
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Traction must be continuous to reduce and immobilize fractures
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Skeletal traction is never interrupted. Any factor that reduces pull must be
eliminated
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Weights are not removed unless intermittent traction is prescribed
Ropes must be unobstructed and weights must hang freely
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Knots or the footplate must not touch the foot of the bed
Types of Traction
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Skin traction:
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Buck’s extension traction
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Cervical head halter
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Pelvic traction
Skeletal traction: Balanced Skeletal Traction With
Thomas Leg Splint
The amount of weight applied during skin traction must not exceed the tolerance of the skin. No
more than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used on an extremity.
Preventing Complications: Nursing Care for the Patient in Traction
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Properly apply and maintain traction
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Monitor for complications of skin breakdown, nerve pressure, and circulatory impairment
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Inspect skin at least 3 times a day
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Assess sensation, movement, pain, tenderness
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Assess pulses, color capillary refill, and temperature of fingers or toes
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Assess for indicators of DVT and infection
Preventative Interventions
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Promptly report alteration in sensation or circulation
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Provide back care and skin care I Pin care
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Regularly shift position, active foot & leg exercises every hour
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Use special mattresses or pressure-reduction devices
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Elastic hose, pneumatic/ TED compression hose, or anticoagulant therapy may be
prescribed
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Use of the Trapeze
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Exercises to maintain muscle tone and strength
Nursing Process: Assessment of the Patient in Traction
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Assess neurovascular status
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Assess mobility-related complications: pneumonia, atelectasis, constipation, nutritional
problems, urinary stasis, and UTI
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Assess for pain and discomfort; plus assess emotional and behavioral responses
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Assess coping ability & pt. knowledge
Nursing Process: Diagnosis of the Patient in Traction
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Deficient knowledge; Anxiety; Acute pain; Self-care deficit and Impaired physical
mobility
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Collaborative Problems/Potential Complications; Pressure ulcer; Atelectasis; Pneumonia
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Constipation; Anorexia; Urinary stasis and infection; DVT
Interventions:
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Prevent skin breakdown, nerve pressure, and circulatory impairment
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Measures to reduce anxiety
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Encourage patient participation in decision making and in care; reinforce
information
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Encourage frequent visits to reduce isolation
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Provide diversional activities
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Use assistive devices
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Physical Therapy consultation
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Prevent atelectasis and pneumonia - Auscultate lungs every 4 to 8 hours
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Encourage coughing & deep breathing exercises
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High-fiber diet and encourage fluids; Identify and include food preferences and
Joint Replacements
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Done to treat severe joint pain, disability, repair of joint fractures or joint necrosis
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Common joint replacements include the hip, knee, and fingers
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Joints including the shoulder, elbow, wrist, and ankle may also be replaced
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Patient Care After Hip or Knee Replacement Surgery
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Prevent infection - Infection may occur in the immediate postoperative period (within 3
months), as a delayed infection (4 to 24 months), or due to spread from another site (more
than 2 years)
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Prevention of DVT
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Patient teaching and rehabilitation
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Hip Prosthesis; Position the leg in abduction to prevent dislocation of the prosthesis - Do
not flex hip more than 90° . Also Avoid internal rotation. Provide protective positioning.
Hip precautions: see Chart 67-8
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Prevent Hip Dislocation after total Hip Replacement by using an Abduction Pillow. Avoiding
Hip Dislocation
Knee Prostheses: Encourage active flexion exercises. May Use continuous passive motion
(CPM) device if indicated
Nursing Process: Pre-op Care of Patient Undergoing Orthopedic Surgery
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Routine pre-op assessment, VS, Pain, LOC
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Hydration status & Medication history
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Possible infection
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Ask about colds, dental problems, UTIs, other infections within 2 weeks
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Neurovascular status, tissue perfusion
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Support and coping
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S/SX of bleeding: wound drainage
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Mobility restrictions
Nursing Diagnosis of Patient Undergoing Orthopedic Surgery
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Acute pain; Risk for peripheral neurovascular dysfunction; Impaired physical mobility;
Risk for situational low self-esteem and/or disturbed body image; Risk for ineffective
therapeutic regimen management
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Postoperative Collaborative Problems/Potential Complications includes:
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Hypovolemic shock; Atelectasis; Pneumonia; Urinary retention; Infection
Thromboembolism: DVT or PE; Constipation or fecal impaction
Nursing Process: Planning the Care of the Patient Undergoing Orthopedic Surgery
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Major pre and post-op goals: relief of pain, adequate neurovascular function, health
promotion, improved mobility, and positive self-esteem
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Postoperative goals include the absence of complications
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Relief of Pain - Administration of medications
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Patient-controlled analgesia (PCA); Medicate before planned activity & ambulation
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Use alternative methods of pain relief by repositioning, distraction, guided imagery,
etc.
Specific individualized strategies to aid in healing and reducing pain
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Use ice or cold. Elevation of affected extremity, Immobilization