NUR 170 Ch 27 Musculoskeletal Care

Guidelines for assisting patients using a Cane

-Ensuring that the patient holds the cane on the unaffected side. • Reminding the patient to remain erect, rather than leaning over the cane. • Ensuring that the patient moves the unaffected leg and the cane forward together, then moves the affected leg forward.

Caring for a patient with a amputation

-It is important that the limb stump heal well and be shaped correctly to fit into a prosthesis, or artificial limb, such as an arm or a leg. -Initially, observe the sutures or staples in the stump to en-sure that all edges of the wound are approximated and grow-ing together well. If the incision does not heal well, it maybreak open or the skin may break down with the pressure ofa prosthesis. -If left to heal on its own, the stump will have a squared-off shape. However, in order to fit into the socket of a prosthetic limb, the stump must have a smooth, rounded shape. That is the reason for wrapping the stump with an elastic bandage in the postoperative healing phase, so it will heal in the correct shape to fit into the prosthesis. -The patient with an amputation is dealing with a disturbed body image and all the possible life changes that accompany it. It is important for you to be accepting of the patient and not communicate rejection of the altered body imagine, even nonverbally. You need to listen when the patient wants to talk about his or her feelings and lifestyle changes as a result of the amputation.

Alignment of the CPM Machine

-Line up the machine so that the break in the platform is centered beneath the patient's knee. Ensure that the CPM machine is positioned so the supported leg is maintained in correct body alignment with the hips and the rest of the body. -Place the machine so that the patient's leg rests comfortably on the platform, set the dial to the degrees of flexion & speed ordered by the physician and turn on machine. Remain with the patient 10 to 20 repetitions to make sure the patient tolerates it.

Physicians orders for the CPM Machine

-Physician will order length of time machine is to be on during a 24hr period an when to increase or decrease flexion degrees to improve joint function.

Traction

-Skin traction: involves use of ropes, pulleys, and weights to align bone ends after a fracture; weights are attached to a frame held in place with elastic bandages or other wrap on the skin; may be used to prevent severe muscle spasm due to displaced bones until surgerycan be performed. -Skeletal traction: uses wires, rods, or tongs that penetrate the skin and subcutaneous tissue and are inserted into the bone; these then attach to a frame with weights or only to a frame to hold the bone in place or move the bone with the weights.

Caring for a Patient in a Fiberglass Cast

-Teach the patient to avoid putting anything between the castand the skin beneath it, especially for the purpose ofscratching. Skin sheds outer epidermal cells, but when thecast is in place, the cells that have been shed tend to pile uprather than flake off, causing intense itching at times. If the patient uses an implement such as an ink pen or straight-ened coat hanger to scratch beneath the cast, it can abradethe skin. The warm, dark, moist area beneath the cast is aperfect medium for bacterial growth, leading to severe in-fection. One alternative is to use a portable hair dryer toblow cool air down the cast to relieve the itching. • Observe for any drainage staining the cast or any malodorous discharge, which would indicate infection beneath thecast. Report such observations to the physician. • Assess circulation to the casted limb. If swelling occurs, thecast may cause restricted circulation, which can lead to tis-sue necrosis or nerve damage. To assess circulation, perform neurovascular checks every 2 hours for the first 24 hoursafter the cast is applied or surgery is performed. The neurovascular checks then may be decreased to every 4 hoursor according to facility policy. -Place tape "petals" over the edges of the cast if they begin to crack or crumble over time. To reinforce the edges of the cast with tape, also called "petaling" a cast, cut 3- to 4-inchstrips of tape. On one end of each strip, cut the tape in a point. Place the square end of the tape against the cast between the patient's skin and the cast. Fold the pointed edge of the tape over to the outside of the cast. This technique also can be used to cover rough edges of the cast that may irritate the skin and cause breakdown. • Casts of all materials are being used less frequently now, with removable walking boots and splints favored more by physicians and patients alike. These types of immobilizers can be removed at night and therefore do not cause pressure on the injured limb. They also allow better for swelling and often are more comfortable for patients.

Walker Styles

-The most common style is a metalframe with four legs and one open side so that the patientmoves behind the walker and steps into the frame. -Other styles include the type with two legs and two wheels. The wheels are located on the front of the walker , allowing thepatient to push the walker rather than having to pick up the whole frame to advance it forward. -A walker style popular for home use has four wheels with hand brakes and a seat where the person can sit to rest when the brakes are secured.

Crutch Walking Gaits

-Two-Point Gait: For patients who are able to bear partial weight on the affected limb; patient moves one foot and the opposite crutch forward at the same time, then moves remaining foot and crutch forward. -Three-Point Gait: For patients who are unable to bear weight on the affected limb; patient moves both crutches and the affected foot forward at the same time without touching down or placing weight on it,then brings the unaffected foot forward. -Four-Point Gait: For patients able to bear weight on the affected limb; patient moves the first crutch forward, then the opposite foot forward; patient then moves remaining crutch forward, then remaining affected foot forward. -Swing-to Gait: For patients able to bear weight on the affected limb; patient stands on both feet and moves both crutches forward at the same time; patient then swings both feet forward to the level ofthe crutches. -Swing-through Gait: This is the same as the swing-to gait except that the patient swings both feet forward beyond the level of the crutches.

Sprain

-an injury to a joint that results in damage to muscles and ligaments. -Severe sprains may cause ligaments to be completely torn. -Mild sprains often cause only minor muscle and ligament damage. -The ankle is the joint that is most often sprained, but a sprain can occur in other joints as well. The sprained joint must be supported and rested in order to heal.

Cane

-is used when a patient can bear weight on the affected leg but needs extra support while ambulating. -A cane is the correct height when the top of it is even with the patient's hip joint as the tip is positioned 4 inches (10 cm) away from the side of the foot. -A single-pronged cane has one tip and may have a varietyof handles. -A multipronged cane generally has three or four tips. A three-pronged tip may be called a tripodcane, and a four-pronged tip may be called a quad cane. In many situations, the multipronged cane is preferred because there is less chance that the cane could slide or slip as thepatient leans on it.

Caring for a Patient in Skin Traction

-the limb is wrapped with an elastic bandage or fitted with a Velcro wrap to which a frame is attached. One or more ropes are attached to the frame; on the other end of each rope, a weight is attached. An overhead frame is affixed to the bed, with a trapeze bar,or triangular piece, attached for the patient to use as a handgrip when moving in bed.

Walker

-used by patients who can bear full weight on both legs but need assistance to maintain balance. -A walker that is the correct fit will come up to the patient's hip joint. When the patient grips the handles, his or her elbows should be bent at a 30 degree angle

magnetic resonance imaging (MRI)

-would be contraindicated because of metal implants, pacemakers, or claustrophobia. -MRI is used when pathological fractures occur because these fractures usually are associated with bone tumors. -MRIs also used to examine congenital problems of the spine. -MRIs are generally ordered to view soft tissue conditions such as injuries to joints, and ligament, tendon, or muscle tears. -Bone scans are ordered when there is suspected widespread diseaseof the bones, as in a metabolic condition or cancer.

Performing Neuromuscular Checks

Assessment Step 1. Determine the area of the limb distal to the surgicalsite or cast that is to be evaluated. Planning Steps 1. Obtain a neurovascular check flow sheet. 2.Determine when the last neurovascular check wasdone. Perform checks every 2 hours for the first 24 hours after surgery or application of a cast unless otherwise ordered. Implementation Steps 1.Follow the Initial Implementation Steps located onthe inside front cover. 2.Ask the patient if he or she is experiencing numbness, burning, or tingling in the affected limb. Test sensation of the affected and unaffected limbs by touching each with a paper clip and asking the patient to tell you when he or she feels the sensation of the paper clip touching the limb. A decreased sensation in the affected limb may indicate impairment of sensory nerve function. 3. Assess for edema at the surgical site and distal to thesite or cast. Compare the size of the distal aspect ofthe extremity to the unaffected extremity. Edema in-dicates impairment of circulation and should bemonitored closely to determine if it increases. 4. Touch the patient's skin distal to the surgical site orcast with the back of your hand. Assess for warmthand compare to the warmth of the same area on theunaffected limb. Cooler temperature of the affected limb may indicate impairment of circulation. 5. Assess the color of the skin and nailbeds in the distal portion of the affected limb. These should be the same as in the unaffected limb; nailbeds should be pink. Pallor or cyanosis indicates impairment of circulation. 6. Test capillary refill in the nailbeds of the fingers or toes distal to the surgical site or cast. Compare it to that in the unaffected limb. Slower refill time in the affected limb or refill longer than 5 seconds indicates that circulation is impaired. 7. Ask the patient to move the fingers or toes of the affected extremity. Movement should be free of discomfort if motor nerves are unimpaired. 8. Palpate distal pulses if possible and compare with the pulses on the unaffected limb. Each should be present and equal if no circulatory impairment is present. 9. Ask the patient to describe his or her pain in the affected limb, including the type of pain and its intensity. Ask him or her to rate it on a scale of 0 to 10.Pain should gradually decrease in intensity as healing occurs. A sudden increase in pain could indicate infection or compression. 10. Follow the Ending Implementation Steps located onthe inside back cover. Evaluation Steps 1. Determine deviations from normal during neurovas-cular checks and report them to the health-careprovider. 2. Evaluate the patient's pain level and report com-plaints of increasing pain, which

Applying Elastic Bandages

Assessment Steps 1. Check the physician's order for placement and pur-pose of the elastic bandage. 2. Assess the patient's limb or stump for skin break-down or wounds. 3. Assess for edema in the limb or stump. Planning Steps 1. Obtain the correct width of elastic bandage. Usewider widths to cover larger areas, such as forstump wrapping. 2. Obtain metal closures, safety pins, or tape to holdwrap in place. Implementation Steps 1. Follow the Initial Implementation Steps located onthe inside front cover.For Figure-of-Eight Wrap on the Ankle 2. Wrap two turns around the instep of the foot to secure the end of the wrap. 3. Bring the bandage around the inner ankle and behind the lower leg. 4.Bring the bandage around the outer ankle, across the top of the foot, and back to the instep. 5. Bring the bandage under the foot, then across thetop of the foot to the inner ankle. 6. Bring the bandage around the inner ankle and behind the lower leg. 7. Repeat the above steps until bandaging is complete.Each additional wrap should be approximately 1/4to 1/2inch (0.51 to 1.3 cm) more proximal than the previ-ous wrap, making an evenly distributed crisscross pat-tern across the dorsal surface of the foot and ankle. 8. Secure the bandage end with tape, safety pins, ormetal clasps. 9. Follow the Ending Implementation Steps located onthe inside back cover. For Spiral Turn on the Forearm or Leg 2. Start at the narrower area of the lower leg or wristarea of the forearm. 3. Wrap two turns to anchor the wrap. 4. Wrap the bandage around the arm or leg, progress-ing up the limb with each turn at a 30-degree angle,overlapping the elastic bandage with each turn. 5. Repeat the above steps until bandaging is complete. 6. Secure the bandage end with tape, safety pins, ormetal clasps. 7. Follow the Ending Implementation Steps located onthe inside back cover. To Wrap a Below-the-Knee Amputation 2. Wrap the elastic bandage two times above the knee joint. 3. Fold the bandage at an angle on itself and hold inplace with your thumb. 4.Bring the bandage down the front of the stump, overthe end of the stump, and up the back of the stump,holding it in place. 5. Fold the bandage back on itself and keep holdingboth turns in place while you wrap the back length ofthe stump, the end of the stump, and up the frontlength of the stump. 6. Repeat Steps 4 and 5 two more times, covering thestump entirely. Most stumps will require two elastic bandages in order to have adequate length to complete the recurrent turn wrap. 7. Anchor these folded layers of bandage by wrappingthe bandage around the circumference of the leg,catching all the folds of the bandage. 8. Wrap the remaining bandage in a figure-of-eightstyle from the stump to below the knee joint, cover-ing the sides of the stump. 9. Secure the bandage end with tape, safety pins, ormetal clasps. 10. Follow the Ending Implementation Steps located onthe inside back cover. Evaluation Steps 1. Make certain the wrap is not too tight by ensuring that you can slip two fingers underneath the band-age at its proximal end. Ask the patient if it is painfulor causing numbness or tingling in the limb. If so, re-move and rewrap more loosely. 2.For all wraps except on a stump: Assess fingers andtoes for edema, warmth, capillary refill, sensation,movement, and color. If circulation is impaired, re-move and rewrap more loosely. 3. Determine if wrap is too loose such that it sags orcomes loose as the patient moves. If so, remove andrewrap more tightly.

Splint

Firm plastic molded form used to keep a joint or joints from flexing; may be applied to alimb and wrapped in place with gauze or an elastic bandage; sometimes "air splints" areused when transporting injured patients; can be slipped beneath the injured limb, wrapped around it, then inflated to immobilize the joint.

CPM Machine side effects

First 24 hours patient may experience much discomfort when the machine first begins to flex the knee. The more the patient tenses the affected leg muscles, the more pain experienced. Teach patient to use breathing relaxation techniques and use proper pain management.

Fracture Types and healing

Fracturesare breaks in the bone. -Hairline Fracture: a narrow crack. -Comminuted Fracture: a bone that is broken into many small pieces. -To promote healing of a fracture, the broken ends of the bones must be supported in close proximity to one anotherfor 4 to 8 weeks or longer to allow the bone to grow together. -This may require the insertion of pins, wires, or screws tohold the bone pieces together. Generally, a cast or immobi-lizer is placed on a limb to accomplish this. If the fracturedbones are in the trunk of the body, support may be provided in other ways, such as wires inserted into the bones to hold them together.

Cast

Hard plaster or fiberglass encasement for a limb; used to immobilize joints, usually to stabilize fractures until they heal; sometimes used to immobilize severely sprained joints until healing can occur; often used after musculoskeletal surgeries to stabilize the joint and surgical sites.

Caring for a Patient in Skeletal Traction

It is the nurse's responsibility to prevent such infections by performing pin-site care as ordered. Generally, orders for this care include cleansing the skin insertion sites using sterile gauze saturated with normal saline or hydrogen peroxide. In addition, you need to assess the pin sites for signs of infection.Small amounts of serous or serosanguineous drainage at the insertion site is a normal finding. Immediately report to the physician any purulent drainage because this is indicative ofinfection. Also report increasing redness of the skin around the insertion site. Most physicians do not order ointment at pin sites because the moisture can promote bacterial growth. Tongs are used on the skull to provide cervical traction after surgery or fracture to the cervical vertebrae. The tong insertion sites are located on either side of the skull. The hair in the area usually has been shaved to decrease the chances of infection. Again, you will clean the insertion sites according to orders and make the same assessments as for pin sites. • Ensure that the weights hang freely and do not rest on the floor. • Ensure that the ropes pull in a straight line without crossing one another. • Assess for skin breakdown beneath the external traction devices. • When turning a patient in traction, have another person lift up on the weights, causing slack in the ropes while the patientis turned. After the patient is supported and aligned, the second person then gently and slowly releases the weights to hang freely. • Ensure that the patient's body is in proper alignment so that the traction pulls correctly.

Continuous Passive Motion Machine (CPM)

Nurses concerns after a total knee replacement. Very soon after surgery (24hrs), flexion of the new knee joint begins. This machine is designed to gently flex the patient's knee according to the number of degrees flexion on the setting and then gently extend the knee. The leg is supported on a platform that gently bends and straightens the knee as it moves.

Treatment for a Sprain (RICE)

REST, ICE, COMPRESSION, ELEVATE

Placement of CPM Machine

Sits on the patient's bed and is connected to power source. The platform where the patient's leg rests is lined with sheepskin to prevent skin break down.

Immobilizer

Soft fabric with firm internal stays; opens and closes with Velcro fasteners; used to protect an injured limb and to keep its joints from flexing; often a "boot" for foot and ankle injuries.

Caring for a Patient with Total Hip Replacement

To prevent dislocation of a new total hip replacement, the patient and nursing staff must be careful to avoid hip flexion be-yond 90 degrees. The following guidelines will help you keep the patient's hip prosthesis in place: •Keep the abductor pillow in place while the patient is in bed. •Avoid turning the patient on the operative side, according tophysician's orders. •Assist the patient out of bed carefully to prevent flexion of thehip more than 90˚. •Ensure that the patient calls for help if any items are dropped and that the patient does not lean forward, which would flexthe hip beyond 90˚. •Assist the patient to get up from the chair or bedside commode without leaning forward.

Abductor Pillow

Wedge shaped foam pillow, often with Velcro straps straps, placed between the legs of patients who have had total hip replacement surgery; keeps hips abducted while patient is in bed; straps keep the pillow in place and prevent shifting.

Amputation Reasoning

When a limb is so damaged by trauma that it cannot besaved, it will be amputated, or surgically removed. Other reasons for amputation include severely decreased blood flow to the limb and gangrene(death of tissue) in a limb.

Caring for a Patient with Total Knee Replacement

When a patient has had a total knee replacement, it is importantthat the CPM therapy be performed correctly to prevent limited range of motion in the prosthetic knee joint. These guidelines will be useful when caring for a patient with a total knee replacement: •Ensure that the patient's pain is managed so that he or she can tolerate passive exercise. •Set the degrees of flexion on the CPM machine according tothe physician's orders. •Follow orders exactly regarding the length of time the CPM machine is to be in use and advancing the degrees of flexion. •Assist the patient in and out of bed using a walker or other assistive device. •Follow the physician's orders regarding the amount of weightbearing allowed on the operative knee.

Elastic bandages

Woven bandage containing elastic to stretch as it is wrapped around an injured area; elastic helps compress the area to decrease edema.

Physical therapists

are members of the health-careteam who are responsible for assessing deficiencies in musculoskeletal function and developing a plan ofcare. It is very important to follow the orders of thephysician and recommendations of the physical therapist regarding patient activity and mobility.

Crutches

are used when a patient is unable to bear full weight on a lower limb. The patient may be restricted to no weight bearing or partial weight bearing. Crutches fit correctly when there are three finger breadths of space between the axillary pad and the patient's axilla, as the patientis standing with the crutch tips 4 to 6 inches to the side of the heel.

Spica Cast

encases the hips and one or both legs. There is an open area for the perineum, and an abductor bar keeps the legs and hips a specific distance apart. These casts are often used to correct hip dysplasia in young children. It is very important that you move the patient in a spica cast carefully, and do not use the abductor bar to lift the patient. It is not designed for that purpose, and doing so can damage the spica cast.

Joint Replacement

joint replacement is a surgery to remove damaged articular bone surfaces and replace them with metal and plasticsurfaces. -It is performed when a joint has severe degenerative changes, usually due to advanced osteoarthritis, which causes degeneration and inflammation of joints over time. -The most commonly replaced joints are the knees and the hips. Because these joints bear the body's weight, they maybe come stressed over time. -If the joint has been injured in the past, osteoarthritis is more likely to develop in later life.

Ilizarov frame

named for the Russian doctor who developed it. Thisframe is composed of metal rings on the outside of the limb,with rods and wires that attach to those rings. The rods andwires also penetrate the skin and insert into the bone. Thisfixator is used to stabilize small bone pieces, such as in acomminuted fracture, keeping the fragments aligned whilebone growth occurs. I

X-Rays (diagnostic test)

ordered for suspected fractures or significant trauma.

Computed Tomography (CT)

scans are most helpful to further identify fractures that may be difficult to see on x-rays, as well to view congenital abnormalities of the musculoskeletal system.

Crutches Guidelines for assisting patients

• Ensuring that the patient is bearing weight on the hands and wrists, not on the axillary pads. Safety: Bearing weight onthe axilla can cause compression of nerves and can lead to nerve damage affecting the arm and hand. • Instructing the patient that, when he or she is walking upstairs on crutches, the patient should place the unaffected leg on the step, then move up the crutches and the affected leg. • Instructing the patient that, when he or she is walking down-stairs on crutches, the patient should place the crutches and affected leg on the downward step, then bring down the unaffected leg. • Assisting the patient, if needed, to use the appropriate crutch-walking gait. • Reminding the patient to keep the affected foot slightly forward, rather than bending the knee and holding the foot behind the crutches. Safety: If the knee is flexed and the foot is held behind the crutches, it can affect the patient's balance, causing him or her to fall backward.

Guidlines for assisting Patients with walkers

• Ensuring that the patient stands between the back legs of the walker. Safety: Standing too far behind the walker canaffect balance and lead to falls. •If the walker is the type that the patient must pick up and move forward, ensuring that the patient sets the walker down and steps forward into it, rather than simply carrying it. • If the walker is the rolling style with hand brakes, ensuring that the brakes are set (handles pulled downward) before the patient attempts to sit on the walker seat. • If one leg is weak, instructing the patient to move the affected leg forward with the walker, then move the unaffected leg forward.

Caring for a patient in a Plaster Cast

• Support the limb on pillows in such a way that air circulatesall around the cast for even drying. • Avoid touching the wet or damp cast with your fingers because they can leave dents in the cast that will remain after it dries, causing pressure points on the skin beneath the cast. • If it is necessary to touch the cast, use only the palms of your hands.