Care of Clients with Problems

Related to the Musculoskeletal

System

Irene M. Magbanua, RN
Review Specialist
St Paul University Manila
Review of the Anatomy and
Physiology
Assessment :
 Diagnostic Procedures
1. Radiologic studies
b. X-rays
c. Computed tomography or CT scan
– Non- invasive procedure where a body part
can be scanned from different angles with
an x-ray beam and a computer calculates
varying tissue densities and records a cross
section image on paper done to determine
extent of fracture in difficult to define areas
 Diagnostic Procedures
c. Myelography
• Injection of radio opaque dye into
subarachnoid space at posterior spine to
determine level of disc herniation or site of
tumor
 Diagnostic Procedures
2. Arthrography
• Radioopaque or air injected into joint cavity- outlines
soft tissue structure and contour of joint
2. Bone scanning
• Parenteral injection of bone seeking radioactive
isotope
2. Electromyography
• Graphic presentation of the electrical potential of
muscles
 Diagnostic Procedures
5. Magnetic Resonance Imaging
• Noninvasive scanning technique that uses
magnetism and radio frequency waves to
produce cross-sectional images of body
tissues on computer screen
5. Arthroscopy
• Endoscopic direct visualization of joint,
especially knee
 Diagnostic Procedures
7. Arthrocentesis
• Needle aspiration of synovial fluid
7. Bone Biopsy or Muscle biopsy
8. Laboratory
a. Uric acid
b. Antinuclear antibody (ANA) for systemic Lupus
Erythematosus
c. Complement fixation (CF) for Rheumatoid Arthritis
d. Calcium, Alkaline Phosphate, Phosphorus
 Musculo-Skeletal Therapeutic
Modalities
1. Reduction
• Realigning an extremity into anatomical
position

a. Open- use of surgical methods

b. Closed- use of non-surgical methods;
manipulation
 Musculo-Skeletal Therapeutic
Modalities
2. Immobilization
 Manual
 Skin- adhesive- plaster or adhesive is
applied longitudinally on the lower
extremities and an elastic bandage applied
in an spiral motion
 Musculo-Skeletal Therapeutic
Modalities
2. Bryant’s traction- indicated for children aged
0-3 year’s not more than 40 lbs.
1.Traction is always applied on both ends

Nursing Responsibility
– Nurse should be able to pass hand between the
patient’s buttocks and mattress
Bryant traction

Knee slightly flexed

Buttocks slightly
elevatated and
clear of bed
 Musculo-Skeletal Therapeutic
Modalities
Buck’s Extension Traction
Indicated for older patients to those
weighing over 40 lbs.

Nursing Responsibility
Only the affected extremity is placed
on traction
Buck’s Extension Traction
 Musculo-Skeletal Therapeutic
Modalities
Dunlop Traction
Used in affectations of the upper
extremities
Dunlop Traction
 Nursing Care of Clients with
Adhesive Traction
1. Unwrap and wrap and elastic bandage at
least once a shift
2. Check skin integrity for allergic reactions
to plaster
3. Note circulation, sensation and mobility
of the affected extremities
Skin- non adhesive
 Uses canvass or cloth that is applied on the
patient’s skin
Pelvic girdle traction
• Applied like a girdle and connected to two ropes with
weights that hangs at the foot part of the bed
• Indicated for low back pain
Head Halter Traction
• Applied on chin and occipital region connected to a
hanger with weights that hangs at the head part of the
bed
• Usually indicated for cervical spine affectations
 Skin- non adhesive traction
Cotrel Traction
• Combination of the head halter and pelvic
traction used in scoliosis
Russell Traction
• Permits patient to move freely in bed and
permits flexion of the knee and hip joint
• Buck’s extension and the knee is suspended
in a sling to which a rope is attached
Russell Traction
Nursing Care of Clients with non-
adhesive traction
Rest period are provided
Skeletal Traction
 Applied into a bone
Crutchfield Skeletal Traction
• Applied into the parietal; bones
Indicated for cervical spine affectations
Crutchfield Tong
Skeletal Traction
Balanced Skeletal Traction
• Applied alone or with skeletal traction to
promote patient mobility
Balanced Skeletal Traction
Principles of Care
1. The patient should always be on either
supine or dorsal recumbent position
2. There should always be an counteraction
(patient’s weight)
3. The line of deformity should be in line
with the traction
4. Traction should be continuous
5. There should be no friction within the line
of traction
 b. Cast- Comparison of Cast Materials
Plaster
Material Plastic of Paris, comprised
of powdered calcium
sulfate crystals
impregnated into the
bandages
Synthetic
Polyester and cotton,
fiberglass or plastic.
Polyester and cotton is
impregnated with water-
activated polyurethane
resin

Drying time 24-48 hours 7-15 mins of setting

15-30 mins for weight
bearing
Advantages Less costly Less likely to indent into
More effective for skin
immobilizing severely Lighter in weight
displaced bones Less restrictive
Smooth surface Does not crumble
Does not require expensive Nonabsorbent
equipment for application Can be immersed in water
c. Braces
• Knight-taylors
• For thoraco-lumbar affectations
• Milwaukee
• For scoliosis

Nursing Care
• Use cotton clothing as barrier
d. Fixators
• RAEF
• Roger Anderson External Fixator
• Ilizarov device
• Indicated for comminuted fractures
3. Rehabilitation
• Active or dynamic program aimed at
enabling an ill or disabled to achieve the
highest level of physical, mental, social,
and economic self-sufficiency of which he
is capable
Members of the Rehabilitation team
a. Patient
• Key member of health team
a. Rehabilitation nurse
• Develops plan of patient care
a. Physician
• Makes medical diagnosis; directs team
a. Physiatrist
• Physician specialist in physical medicine
a. Physical Therapist
• Teaches or supervises patient in prescribed exercise
program
Members of the Rehabilitation team
f. Psychologist
• Helps patient or family explore feelings
g. Occupational Therapist
• Helps develop skills for home and work situations
g. Social Worker
• Assists patient and family adjust socio-economically
g. Vocational Counselor
• Tests patient’s interest and aptitudes
g. Rehabilitation Engineer
• Uses technology in designing or constructing
devices to help the handicapped
Transfer and Assistive Devices
1. transferring a client from bed to stretcher
• stretcher must be perpendicular to bed
1. transferring a client from bed to wheelchair
• the wheelchair must be parallel to the head of the
bed
1. Canes
• Height of cane is from floor to waist level
• Cane is held by opposite the affected extremity
Transfer and Assistive Devices
4. Crutches
• Height of crutch is from floor to axilla minus
2 inches
• Patient’s weight is borne by the palm, of the
hand and not on the axilla
• When going upstairs, unaffected leg first
• When going upstairs, affected leg first
Crutch-walking techniques
• Two point gait (two alternate gait)
• Three point gait
• Four point gait
• Swinging crutch gaits
• Both legs are lifted off the ground simultaneously and
swung forward while patient pushes up on crutches
• Swing-to gait
• Lift and swing body up to crutches
• Swing-through gait
• Lift swing body beyond crutches
Exercises
a. Isometric
• Alternate contraction and relaxation of the
muscle without moving the joint
a. Done on the affected extremity
b. Isotonic
• Range of motion exercises
• Done on the unaffected extremity
Heat or Cold Application in Trauma
Cold Application Heat Application
• first 24 hours – After 24 hours
• To decrease – To relieve pain from
muscle spasms
hemorrhage
– To reduce swelling by
• To relieve pain increasing circulation
• To reduce – To promote healing by
inflammation increasing
oxygenation
 4. Orthopedic Operative
Procedures
a. Arthrotomy
– Surgical opening into a joint
a. Arthrodesis
– Fixation of a joint
a. Spinal fusion
– Surgical removal of 1 or more
vertebra and fusing them together
 4. Orthopedic Operative
Procedures
d. Hip replacement
– Placement of prosthesis on the hip
joint
– Indication
Hip fracture
Inability to move leg voluntarily
Shortening and external rotation of
the leg
Nursing Management on Hip
Replacement
Avoid positioning on the operative site
Maintain abduction of hip
Pillows between legs
Provide chair with firm, non-reclining
seat and arms
Nursing Management on Hip
Replacement
Avoid hip flexion beyond 60 degrees
for 10 days
Avoid hip flexion beyond 90 degrees
from day 10 to 2 months
Avoid adduction of the affected leg
beyond midline for 2 months
Partial weight bearing status for 2
months
Trauma
Contusion
– Injury to the soft tissue produced by
blunt force
Sprain
– Injury to the ligamentous structures
caused by wrenching or twisting
– Forcible hyperextension of a joint with
tissue damage like whiplash injury
Trauma
Strain
– Tearing of musculotendenous unit caused
excessive stretching
Dislocation
– Joint articulating surfaces are partially
separated
– No longer in anatomical contact
Fractures
– Break on continuity of bone
Nursing Assessment
1. Pain
– Increasing until immobilized
1. Loss of function
2. Localized swelling or discoloration
3. Deformity
4. Crepitus
– Grating sound
General Classifications of
Fractures
1. Simple or closed
– Skin is intact over fracture site
1. Compound or open
– With an external wound in contact with the
underlying fracture
1. Complete
– Entire cross section is displaced
1. Incomplete
– Portion of cross section undisplaced
General Classifications of
Fractures
1. Greenstick
– One side broken and other bent
1. Transverse
– Straight across the bone
1. Oblique
– Angle or slanting across the bone
1. Spiral
– Twisting or coils around shaft
1. Comminuted
– Splintered into several fragments
General Classifications of
Fractures
Depressed
– Fragments are drived-in; facial or skull
Compression
– Fractured bone compressed by another bone;
vertebra
Impacted
– Fractured bones are pushed into each other
(telescoped)
Displaced
– Fragments are separated from fracture line
Linear
– Fracture parallel with long axis
 COMPARING ARTHRITIS
Rheumatoid Osteoarthritis Gouty
Etiology Autoimmune Degenerative Metabolic or
+ Rh factor senescence familial, purine
metabolism

Incidence 35-45 women Men or more in Men over 40

women

Signs and Subcutaneaous nodules Heberden’s nodule Tophi

symptoms Morning stiffness Bouchard’s nodule
Swan neck deformity

Areas affected Joints of hands Weight bearing joint Great toe

(hips, wrist, spine)
Management Aspirin, NSAIDs Symptomatic Colchicine
Paraffin bath Avoid purine diet
Allopurinol