MANAGEMENT OF MUSCULOSKELETAL CONDITIONS.

Presenter: Mrs.Qolisese

INTRODUCTION MS also known as the locomotors system is an organ system that enables movement using the muscular and skeletal system. It provides : form,support,stability&move ment to the body.

Cont..
Problems occur to most body systems
as a result of an inactive lifestyle and the MS is affected by prolonged immobility. Nurses need to encourage client movement as much as possible-early ambulation after illness or surgery. They therefore need to be equipped with the knowledge and skills to carry quality nursing care.

OBJECTIVES
At the end of this session the student should be able to: Assess clients with orthopaedic problems Identify the different types of fractures. Discuss the nursing management of fracture patients. Describe the pre and post operative management of orthopedic patients. Design nursing care plan Prepare discharge plan for orthopedic clients.

Lecture Content
1. ASSESSMENT OF CLIENTS WITH ORTHOPAEDIC DISORDERS 1.1 Subjective data 1.2 Objective data 2. TYPES OF FRACTURES 2.1 Open 2.2 Closed 2.3 Incomplete 2.4 Varieties of Fractures

MANAGEMENT OF FRACTURES
3.1 3.2 3.3 3.4 3.5 Principles of treatment Basic Treatment techniques Operative procedure Nursing Care Plan Discharge Plan

LECTURE
Definition of Fractures: Break in the continuity of the bone. ASSESSMENT OF PATIENTS WITH MUSCULO SKELETAL DISORDERS. JOINTS: Pain Stiffness Swelling, heat Limitation of movement

Cont...
MUSCLES: Pain (cramps) Weakness

BONES:
Pain Deformity Trauma (fractures, sprains, dislocations)

Cont...
Functional Assessments (ADL) Self deficit in:

bathing toileting dressing grooming eating communicating mobility aids

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SELF

CARE BEHAVIOURS Heavy lifting Repetitive motion to joints Nature of exercise programs Weight gain (recent)
OBJECTIVE

DATA EQUIPMENT NEEDED - Tape Measure - Skin Marking Pen - Goniometer to measure joint angles

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METHODS

OF ASSESSMENT Inspection and palpation of joints Observation of Range of Movement Age

INSPECTION Compare corresponding paired joints Inspect for symmetry of structure note the size

and contour. Inspect the skin and the color note if there is any swelling, mass or deformity.

cont..
PALPATION Palpate each joint including its skin for

temperature. RANGE OF MOVEMENT Ask for active range of movement Familiarize yourself with the type of each joint and its normal range of motion so you can recognize limitations. MUSCLE TESTING Test the strength of the prime mover muscles groups for each joint.

cont...
CERVICAL

SPINE Inspect the alignment of head and neck Spine straight and the head erect SHOULDER Inspect and compare both shoulders posteriorly and interiorly. Check the size and contour of the joint. Test ROM (Range of movement)

cont..
ELBOW Inspect size and contour in both flexed and

extended position Look for any deformity Test range of movement WRIST AND HAND Inspect the hands and wrists on the dorsal and palmar sides noting position, contour and shape.

TYPES OF FRACTURE
Closed fractures no communication

Incomplete fractures whole thickness of the

bone is not broken, but it is bent. Open fractures break in the bone communicates with a wound in the skin.

Varieties of Fractures
Transverse Longitudinal Oblique and spiral Comminuted Compression Pathological fracture

Principles of treatment
PURPOSE

to establish the length, shape and alignment of the fractured bones or joints and restore anatomic function.

Cont...
PRINCIPLES

patients extremity/fracture site must be handled gently. provide initial medical treatment. equipment and personnel must be readily available to treat impending/existing shock and also to control hemorrhage. maintain aseptic technique. positioning must allow adequate circulatory and respiratory function with adequate exposure . patient must be comfortable.

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PRIMARY GOAL 1.UPPER EXTREMITY - to preserve mobility. - to restore range of movement (ROM). 2. LOWER EXTREMITY - to restore alignment and length. - to provide stability of the extremity for weight bearing.

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OPEN

FRACTURES Involves soft tissue Several associated conditions may arise such as: secondary hemorrhage. infection. severe damage to soft tissue. damage to blood vessels/nerves. ischaemic paralysis.

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BASIC

TREATMENT TECHNIQUES

Closed Reduction manipulating fragments into position without incising the skin. Treatment of choice to decrease the opportunity for infection. Improve results (including bone union of the fracture)

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EXTERNAL FIXATION: - Provides rigid fixation and reduction with the ability to manage severe soft tissue wounds. INDICATIONS FOR EXTERNAL FIXATOR: - Severe open fractures - Highly comminuted closed fractures. - arthrodesis - infected joints - infected non union - fracture stabilization to protect arterial or nerve

Cont...
- anastomosis - major alignment and length deficits - congenital contractures COMPONENTS OF EXTERNAL FIXATOR - bone anchoring devices (e.g. threaded pins, Kichner wires). - longitudinal supporting devices e.g. threaded or smooth rods.

INTERNAL FIXATION
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To correct long bones fractures Application of compression plates and screws and insertion of pins, intramedullary rods, nails or wiring.

EXTERNAL FIXATORS
1. MANIPULATION 2. SKIN/SKELETAL TRACTION

Cont...
3. THOMAS SPLINT BALANCED SUSPENSION

4.

CASTS

Cont..

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The use of POP calcined Gypsum plaster to immobilize body parts Procedure is carried out by the doctors/physiotherapists POP hardens after it has been soaked and applied X-ray of the fracture is used to guide POP application

Care of the Cast

Expose to air for circulation & avoid sweating Wet cast takes 24-48 hrs to dry completely Review patients clinical record Knowledge of the purpose Elevate extremity & support entire length of injured body part Look out for sharp cast areas & pressure to tissue

Cont

Perform frequent neurovascular assessment Palpate the cast for hot spots may indicate the presence of underlying infection Report any damage promptly

Client and family teaching

Do not place any object in the cast Keep cast dry if made of POP Use blow drier to dry cast made of fiber glass Assess the injured extremity for: Coolness

Changes in color
Increased in pain Increased in swelling Loss of sensation

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5. TYPES OF SCREWS, PLATES & RODS

MANAGEMENT OF PATIENTS WITH FRACTURES

OPEN REDUCTION AND INTERNAL FIXATION(ORIF) Method of providing exposure of the fracture site and using pins, wire, screws, a plate and screw combination, rods or nails to correct the fracture. Also used when close methods such as skeletal traction fails to reduce the fractures.

PRE-OPERATIVE PREPARATION

Assess the clients nutritional status. Ask the client if he/she had been treated with corticosteroid could contribute to current orthopedic condition. Assess the clients general condition from head to toe ensure that the patient is not suffering from any acute infections. Prepare the client for postoperative routine deep breathing and coughing exercises.

Cont..
explain the procedure clearly to the client to allay anxiety. Allow the patient to practice on how to use the bed pan/urinal. Explain to the patient to expect casts and external fixiator post operatively.

POSTOPERATIVE MANAGEMENT
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Position in bed. Maintain a patent airway Close monitoring of vital signs Administer warm humidified oxygen (3-5 litres) for adult. Pain management Encourage deep breathing and coughing exercises Keep the fractured limb in line with his/her body.

Cont
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close monitoring of the wound drain Keep an accurate record of the intake and output Patients personal hygiene. Encourage the patient to exercise his/her limbs to avoid complications (in bed) Administer medications as prescribed Provide high protein diet. Encourage the patient to drink a lot of fluids.

Care of the traction

Skeletal traction: Never remove the weight Maintain the line of pull Center the client on the bed Ensure the the weight hangs freely Not touching the floor Ensure that nothing is lying on or obstructing the ropes. Knots at the end of the rope should not touch the pulleys

Cont

Frequent skin assessment to include pin care policy Report signs of infection Assess the need for analgesics Neurovascular assessment Assess for common complications of immobility including: Formation of renal calculi DVT Paralytic ileus-Loss of appetite Pneumonia-client and family knowledge

Skin traction

Frequently assess skin for evidence of pressure, shearing or pending breakdown Protect pressure sites with padding Protect dressing as indicated

COMPLICATIONS
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compartment syndrome Shock Atelectasis/pneumonia Osteomylitis Wound infections Deep venous thrombosis Fat embolism Thrombo embolism

NURSING MANAGEMENT
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Assessment Nursing Diagnosis Objectives Nursing Interventions Evaluation

PATIENT EDUCATION/DISCHARGE PLAN

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Teach the client activities that minimizes development of complication Educate the client to be compliant to medication Encourage the client to eat a lot of healthy food Teach the patient some signs and symptoms of orthopaedic complications. Advise the patient to report to the nearest hospital should he experience symptoms Continue with the exercise he was taught Follow up

NURSING CARE PLAN

*Must be prepared
NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION EVALUATION

Risk for peripheral Has normal neurovascular neurovascular dysfunction's examination e.g. compartment syndrome

Assess for signs

and symptoms of peripheral neurovascular dysfunction such as pain, discoloration etc. Elevate extremity above heart to reduce edema Apply ice compression

Patients is free from peripheral neurovascular dysfunction

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Anxiety
Anxiety Patients will verbalize concerns Explain the procedure to the client Encourage verbalization of feelings. Encourage patient and family participation Patient relax and able to verbalize feelings/conc erns.

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Pain management
Pain due to Relieve pain injury
Position the

Pain relieved

injured limb in align with body Avoid unnecessary movement of the limb Administer prescribed medication

Cont..
Infection
Risk of infection related to disrupt skin integrity No wound infection Assess pin No evidence site and of wound aseptic infection dressing technique Send wound swabs for culture and sensitivity Vital signs Pressure

OTHER COMMON TYPES OF FRACTURES

COLLES FRACTURE Fracture distal radium common with adults. FRACTURE OF THE HUMERUS involves the shaft of the humerus. FRACTURE PELVIS can be life threatening depends on the mechanism of injury. FRACTURE OF THE TIBIA vulnerable to injury because it lacks anterior muscle covering.

AMPUTATION
NURSING MANAGEMENT: - Assessment most important part to assess is the vascular and neurological status. - Nursing Diagnosis - disturbed body image related to amputation and impaired mobility - impaired skin integrity - Objectives - Nursing Intervention - Evaluation

TYPES OF JOINT SURGERY

1. 2.

3.

Synovectomy removal of sinovial fluids Osteotomy removing or adding a wedge or slice of bone to change alignment and shift weighting bearing, thereby correcting deformity and relieving pain. Debridement removal of degenerative debris such as loose bodies, osteophytes, joint debris and degenerated menisci.

ARTHROPLASTY
Reconstruction or replacement of a joint

Hip arthroplasty (tha)

- relief of pain - improve function Knee Arthroplasty (TKA) - unremitting pain and stability as a result of severe destructive deterioration of the knee joint.

Cont
Finger Joint Arthroplastry

device used to help restore function in fingers. Elbow and Shoulder Arthroplastry COMPLICATIONS - infection - deep venous thrombosis

Cont..
NURSING MANAGEMENT

Assess Nursing Diagnosis Objectives Nursing Intervention Evaluation

 PATIENT TEACHING/DISCHARGE PLAN

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Assess home environment for safety reason Social support must also be assessed Rehabilitation services elderly Educate the patient and relatives on how to look after the patient at home. Teach the patient/relative on when and how often to take medications.

Cont
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Continue with his/her exercises Encourage the patient to eat nutritious/high protein food To drink a lot of water. Teach the client some signs and symptoms of complications. Advise him/her to report to the nearest health centre/hospital if developing signs and symptoms. Follow up clinic

 OTHER COMMON CONDITIONS

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Osteomylitis severe infection of the above. Multiple myeloma malignant neoplasms of plasma cells Osteogenic sarcoma neoplasm of the bone Osteoclastoma destructive tumor that arises in the calcellous ends of long bones in young adults.

NURSING CARE OF CLIENTS WITH MS TRAUMA

SOFT TISSUE TRAUMA Sprain. Soft tissue trauma is treated with measures that decrease swelling and alleviates pain. Severe sprains may require surgery A splint to rest the injured area Apply ice for the 1st 24-48hrs then apply heat

CONT
Elevate the injured extremity to or above the heart to increase venous return and decrease swelling Ankle sprains-use air cast Knee injury knee immobilizer A sling for an upper extremity Physiotherapy -rehabilitation

Cont
The pain that result from soft tissue trauma is due primarily to the injury to the muscles or ligaments and secondarily to bleeding and edema at the injury site Teach the client the ACRONYM RICE R-Rest I-Ice C-Compression E-Evaluation/Elevation

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Rest-allows the injured muscle or ligaments to heal Ice-cold causes vasoconstriction and decreases the pooling of blood in the injured area Ice also numbs the tenderness Compression-ice bandage compression dressing can decrease the formation of edema /decrease pain

Cont..
Elevation/evaluation-elevating the extremity promotes venous return, decreases edemadecreases pain. Continuous evaluation of the effectiveness of the procedure

Dislocation and Subluxation

Nursing diagnosis and intervention focuses on: Relieving pain Correcting the dislocation Preventing complication e.g. neurovascular compromise

Neurovascular Assessment
Monitor neurovascular by assessing: Pain increased Pulses decreased or absent Pallor skin Paralysis inability to move a body part/extremity Paresthesia numbness/tingling/pins/needles

Reference List
Brown, D., and Edwards, H., (2005) Pages 1636 1708) Lewiss Medical Surgical Nursing Assessment and Management of Clinical Problems Elsevier Marrickville Australia Jarvis, C., (1996) Pocket Companion for Physical Examination and Health Assessment WB Saunders USA.

Reference List
Nettina, S., (1996) The Lippincott Manual of
Nursing Practice Lippincott Raven East Washington Square Philadelphia.

Rothrock, J.C., (2007) Alexanders Care of the

Patient in Surgery Mosby Elsevier San Antonio Texas.