Care of client
with musculoskeletal injury or
disorder
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What can go wrong
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Fractures
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Hip
Mandible
Degenerative joint disease
Osteoporosis
Herniated disc
Amputation
CONCEPTS: FRACTURES
Reduction/Realignment
Immobilization
Nursing care
Prevention and early detection:
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complication
Realignment=Reduction
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Correct bone alignment goal: restore
injured part to normal or near-normal
function
Closed vs. open reduction
Open reduction = surgery
Immobilization:
to maintain alignment
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Cast
Traction
External fixation
Internal fixation
CASTS
Casts
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External, circumferential
Thermochemical reaction = warmth
Nursing care:
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No weight bearing 24-72 hours
“flat hands”
Elevate
Neuro-vascular checks
CASTS
Cast: Client/Family Teaching
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Keep dry
No foreign objects in cast
No weight bearing until MD order (at
least 48 hour)
Elevate above heart (48 hours)
Signs of problems to report
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Pain, tingling, burning
Sores, odor
External fixation
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Metal pins inserted into bone
Pins attach to external rods
Nursing care:
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Assess for s/s infection
Teach pin care: ½ H2O2+ ½ H2o
Open reduction: assess incision
Elevate
Neurovascular checks
EXTERNAL FIXATION
Internal Fixation
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Pins, plates, screws surgically inserted
Nursing care:
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Assess incision site
MD orders: activity, weight bearing, ROM,
Assess s/s infection; temp. q 2-4 hours
Neurovascular checks:
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5 “P’s”
INTERNAL FIXATION
Traction
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Pulling forces: traction +
countertraction
Purpose(s):
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Prevent or reduce muscle spasm
Immobilization
Reduce a fracture
Treat certain joint conditions
Types of Traction
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Skin
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Buck’s
Russell’s
Bryant’s (“babies cry with Bry”)
Skeletal
Balanced suspension
(Lewis, 1660-1661)
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Nursing
Concerns/Interventions
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Assess neurovascular status
Assess skin (bony prominences, under
elastic wraps, etc.)
Assess pin sites (skeletal tx)
Maintain correct body alignment
Weights hang freely
Hazards of immobility
TRACTION
SKIN TRACTION
BUCK’S TRACTION
SKELETAL TRACTION
Nursing Diagnoses
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Neurovascular dysfunction, risk for
Acute pain, R/T edema, muscle spasms,
movement of bones
Infection, risk for
Impaired skin integrity, risk for
Impaired physical mobility
Complications of Fractures
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Compartment syndrome
Fat embolism
Venous thrombosis
Infection
COMPARTMENT SYNDROME
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FACIOTOMY –
wound is left open
If no improvement,
amputation
Hip Fracture
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In 1999 (USA) hip fractures resulted in
approximately 338,000 hospital
admissions
Up to 25% of community-dwelling older
adults who sustain hip fractures remain
institutionalized for at least a year
Hip Fractures
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One-third of older women who fracture
their hip will die within a year because
of lengthy convalescence that makes
them susceptible to complications, like
lung and bladder infections.
The Lancet 1999;353:878-82
Fracture of hip
Types of hip fractures (Lewis pg. 1675):
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Intracapsular
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Capital
Subcapital
Transcervical
Extracapsular
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Intertrochanteric
Subtrochanteric
ORIF
vs
“Total Hip”
Open reduction/internal fixation:
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pins, screws, plate(s)
Total hip:
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endoprosthesis – replace
femoral head
Internal fixation =
immobilization
Nursing Care
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Risk for peripheral neurovascular dysfunction
Pain
Impaired mobility:
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Prevent thrombus
Safety
Constipation
Risk for impaired skin integrity:
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Immobility
Incision
Femoral head prosthesis
(total hip)
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Prevent dislocation:
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Do not flex > 90 degrees
No internal rotation (toes to ceiling)
Maintain abduction
Do not position on operative side
Patient teaching:
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Precautions for 6-8 weeks
Notify dentist: prophylactic antibiotics
Lewis: pg. 1678
Fracture of mandible
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Trauma vs. Therapeutic
Immobilization: wiring, screws, plate(s)
Nursing care:
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Airway (Cutter with client)
Oral hygiene
Nutrition
Communication
What can go wrong
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Fractures
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Hip
Mandible
Degenerative joint disease
Osteoporosis
Herniated disc
Amputation
Degenerative Joint Disease:
Osteoarthritis
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Not normal part of aging process
Cartilage destruction:
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Trauma
Repetitive physical activities
Inflammation
Certain drugs (corticosteroids)
Genetics
Assessment
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Location, nature, duration of pain
Joint swelling/crepitus
Joint enlargement
Deformities
Ability to perform ADL’s
Risk factors
Weight (history of obesity)
Nursing Interventions
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Pain management
Rest with acute pain; exercise to
maintain mobility
Splint or brace
Moist heat
Alternative therapies
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TENS, acupuncture, therapeutic touch
Surgical management: total joint
arthroplasty (replacement)
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Elbow, shoulder, hip, knee, ankle, etc.
Pre-operative teaching:
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“What to expect” (CPM, abduction pillow,
drains, compression dressing, etc.)
Postoperative exercises: quad sets, glute
sets, leg raises, abduction exercises
Pain management:
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PCA
Use of pain scale
Total Joint Arthroplasty
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Post-operative care:
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5 P’s
Observe for bleeding
Pain management
Knee: CPM
Check incision for s/s infection
Total Joint Arthroplasty
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Postoperative Care
Prevent:
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Dislocation
Skin breakdown
Venous thrombosis (DVT)
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TED/Sequential compression
Anticoagulants
Exercises: plantar flexion, dorsiflexion, circle feet,
glute & quad sets
Osteoporosis
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Primary – often women postmenopause
Secondary – corticosteroids, immobility,
hyperparathyroidism
Bone demineralization = decreased bone
density
Fractures:
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Wrist
Hip
Vertebral column
Silent disease
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Dowager’s hump (kyphosis)
Pain
Compression fractures
Spontaneous fractures
X-ray can not detect until > 25%
calcium in bone is lost
Diagnosis: bone density ultrasound
Interventions
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Hormone replacement
Calcium & vitamin D
Calcitonin, Fosamax, Actonel, Evista
Avoid alcohol and smoking
Daily weight bearing, sustained exercise
(walking, bike)
Safety in home (throw rugs, pets, etc.)
What can go wrong
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Fractures
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Hip
Mandible
Degenerative joint disease
Osteoporosis
Herniated disc
Amputation
Location of PPT on Web is
below
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http://www.scribd.com/doc/9378673/m
usculoskeletal-disorders-care-of-clientwith-fall-2005