Saunders Musculoskeletal Problems RN Nclex 60

Page 1 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 1 preview image

C H A P T E R 60Musculoskeletal Problemshttp://evolve.elsevier.com/Silvestri/comprehensiveRN/P r i o r i t y C o n c e p t s ___________________________________Functional Ability; MobilityI. Anatomy and PhysiologyA. Skeleton1. Axial portiona. Craniumb. Vertebraec. Ribs2. Appendicular portiona. Limbsb. Shouldersc. HipsB. Tvpes of bones: Long, short, flat irregular1. Spongy bonea. Spongy7bone is located in the ends oflong bones and the center of flat andirregular bones.b. Spongy7bone can withstand forcesapplied in manv directions.2. Dense (compact) bonea. Dense bone covers spongy7bone.b. Forms a cylinder around a centralmarrow cavityc. Better able to withstand longitudinalforces than horizontal forces3. Characteristics of bonesa. Support and protect structures of thebody7b. Provide attachments for muscles,tendons, and ligamentsc. Contain tissue in the central cavities,which aids in the formation of bloodcellsd. Assist in regulating calcium andphosphate concentrations4. Bone growth

Page 2 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 2 preview image

a. The length of bone growth results fromossification of the epiphyseal cartilageat the ends of bones; bone growthstops between the ages of IS and 25years.b. The width of bone growth results fromthe activity of osteoblasts; it occursthroughout life but slows down withaging.occurs, bone resorptionaccelerates. decreasing bone mass andpredisposing the client to injury.C. Types of joints (Table 60-1)1. Characteristics of jointsa. Allow movement between bonesb. Formed where 2 bones joinc. Surfaces are covered with cartilage.d. Enclosed in a capsule (synovial joints)e. Contain a cavitv filled with synovialfluid (svnovial joints)f. Ligaments hold the bone and joint in thecorrect position.g. Articulation is the meeting point of 2 ormore bones.2. Svnovial fluida. Found in the svnovial joint capsuleb. Formed by the synovial membrane,which lines the joint capsulec. Lubricates the cartilaged. Provides a cushion against shocksD. Muscles1. Characteristics of musclesa. Made up of bundles of muscle fibersb. Provide the force to move bonesc. Assist in maintaining postured. Assist with heat production2. Process of contraction and relaxationa. Muscle contraction and relaxationrequire large amounts of adenosinetriphosphate.b. Contraction also requires calcium,which functions as a catalvst.c. Acetylcholine released by the motor endplate of the motor neuron initiates anaction potential.d. Acetylcholine is then destroyed by

Page 3 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 3 preview image

acetylcholinesterase.e. Calcium is required for muscle fibercontraction and acts as a catalyst forthe enzyme needed for the sliding-together action of actin and myosin.f. Following contraction, adenosinetriphosphate transports calcium out toallow actin and myosin to separate andallow the muscle to relax.3. Skeletal musclesa. Skeletal muscles are attached to 2 bonesby cartilaginous tendons calledenthuses(the connective tissue betweentendon or ligament and bone).b. The point of origin is the point ofattachment that does not move.c. The point of insertion is the point ofattachment that moves when themuscle contracts.d. Skeletal muscles act in groups.e. Prime movers contract to producemovement.f. Antagonists relax.g. Synergists contract to stabilize bodymovement.h. Nerves activate and control themuscles.E. Bone healing1. Description: Bone union or healing is the process thatoccurs after the integrity of a bone is interrupted.2. Stages (Fig. 60-1)II. Risk Factors Associated with Musculoskeletal Problems: See Box 60-1 formore informationin. Diagnostic TestsA. Radiography and magnetic resonance imaging (MRI) (refer toChapter 58 for information on MRI)1. Description: Radiography and MRI are commonlyused procedures to diagnose problems of themusculoskeletal system.2. Interventionsa. Handle injured areas carefully andsupport extremities above and belowthe joint.b. Administer analgesics as prescribedbefore the procedure, particularly if

Page 4 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 4 preview image

the client is in pain.c. Remove any radiopaque and metallicobjects, such as jewelry.d. Ask the client if she is pregnant; MRImay be contraindicated in pregnancy.e. Shield the client's testes, ovaries, orpregnant abdomen.f. The client must lie still during aprocedure.g. Inform the client that exposure toradiation from radiography is minimaland not dangerous.h. The health care provider wears a leadapron if staving in the room with theclient having radiography.i. Complete the screening process peragency policy.B. Arthrocentesis1. Description: Arthrocentesis is used to diagnose jointinflammation and infection.a. Arthrocentesis involves aspiratingsvnovial fluid, blood, or pus via aneedle inserted into a joint cavity.b. Medication, such as corticosteroids,may be instilled into the joint ifnecessarv to alleviate inflammation.2. Interventionsa. Ensure that informed consent has beenobtained.b. Apply an elastic compression bandagepostprocedure as prescribed.c. Use ice to decrease pain and swelling.d. Pain may worsen after aspirating fluidfrom the joint; analgesics may beprescribed.e. Pain can continue for up to 2 davs afteradministration of corticosteroids into ajoint.f. Instruct the client to rest the joint for 8to 24 hours postprocedure.g. Instruct the client to notify the primaryhealth care provider (PHCP) if a feveror swelling of the joint occurs.C. Arthroscopy1. Description: Used to diagnose and treat acute andchronic problems of the joint.a. Arthroscopy provides an endoscopic

Page 5 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 5 preview image

examination of various joints.b. Articular cartilage abnormalities can beassessed, loose bodies removed., andthe cartilage trimmed.c. A biopsy may be performed during theprocedure.2. Interventionsa. Instruct the client to fast for 8 to 12hours before the procedure.b. Ensure that informed consent wasobtained.c. Administer pain medication asprescribed postprocedure.d. Assess the neurovascular statusof the affected extremity.e. An elastic compression bandage shouldbe worn postprocedure for 2 to 4 daysas prescribed.f. Instruct the client that walking withweight-bearing usually is permittedafter sensation returns but to limitactivity for 1 to 4 da vs as prescribedfollowing the procedure.g. Instruct the client to elevate theextremity as often as possible for 24hours following the procedure and toplace ice on the site to minimizeswelling for 12 to 24 hourspostprocedure.Ah. Advise the client to notify theFHCP if fever or increased knee painoccurs or if edema continues for morethan 3 da vs postprocedure.D. Bone mineral density measurements1. Dual-energy x-ray absorptiometrya. Dual-energy x-ray absorptiometrymeasures the bone mass of the spine.,wrist and hip bones, and total body.b. Radiation exposure is minimal.c. It is used to diagnose metabolic bonedisease and to monitor changes inbone density with treatment.d. Inform the client that the procedure ispainless.

Page 6 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 6 preview image

e. All metallic objects are removedbefore the test.2. Quantitative ultrasounda. Quantitative ultrasound evaluatesstrength density, and elasticity ofvarious bones, using ultrasound ratherthan radiation.b. Inform the client that the procedure ispainless.E. Bone scan1. Description: A bone scan is used to identify, evaluate,and stage bone cancer before and after treatment; it isalso used to detect fractures.a. Radioisotope is injected intravenouslyand will collect in areas that indicateabnormal bone metabolism and somefractures, if they exist.b. The isotope is excreted in the urine andfeces within 48 hours and is notharmful to others.2. Interventionsa. Food and fluids may be withheld beforethe procedure.b. Ensure that informed consent has beenobtained.c. Remove all jewelry and metal objects.▲d. Following the injection of theradioisotope, the client must drink32 oz of water (if not contraindicated)to promote renal filtering of the excessisotope.e. From 1 to 3 hours after the injection,have the client void to clear excessisotope from the bladder before thescanning procedure is completed.f. Inform the client of the need to liesupine during the procedure and thatthe procedure is not painful.g. Monitor the injection site for rednessand swelling.h. Encourage oral fluid intake followingthe procedure.

Page 7 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 7 preview image

bone scan, because only a minimal amount ofradioactivity exists in the radioisotope used for theprocedure.F. Bone or muscle biopsy1. Description: Biopsy may be done during surgery orthrough aspiration or punch or needle biopsy.2. Interventionsa. Ensure that informed consent wasobtained.▲b. Monitor for bleeding, swelling.hematoma, or severe pain.c. Elevate the site for 24 hours followingthe procedure to reduce edema.d. Apply ice packs as prescribed followingthe procedure to prevent thedevelopment of a hematoma and todecrease site discomfort.e. Monitor for signs of infection followingthe procedure.f. Inform the client that mild to moderatediscomfort is normal following theprocedure.G. Electromyography (EMG)1. Description: EMG is used to evaluate muscleweakness.a. Electromyography measures electricalpotential associated with skeletalmuscle contractions.b. Needles are inserted into the muscle,and recordings of muscular electricalactivity are traced on recording paperthrough an oscilloscope.2. Interventionsa. Ensure that informed consent wasobtained.b. Instruct the client that the needleinsertion is uncomfortable.c. Instruct the client not to take anystimulants or sedatives for 24 hoursbefore the procedure.d. Inform the client that slight bruisingmav occur at the needle insertion sites.e. Mild analgesics can be used for thepain.IV. InjuriesA. Strains

Page 8 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 8 preview image

1. Strains are an excessive stretching of a muscle ortendon.2. Management involves cold and heat applications,exercise with activity limitations, antiinflammatorymedications, and muscle relaxants.3. Surgical repair may be required for a severe strain(ruptured muscle or tendon).B.Sprains1. Sprains are an excessive stretching of a Egament,usually caused by a twisting motion, such as in a fallor stepping onto an uneven surface.2. Sprains are characterized bv pain and swelling.3. Management involves rest ice, a compressionbandage, and elevation (RICE) to reduce swelling, aswell as joint support. RICE is considered a first-aidtreatment rather than a cure for soft tissue injuries.4. Casting mav be required for moderate sprains to allowthe tear to heal.5. Surgery mav be necessary for severe Egament damage.C. Rotator cuff injuries1. The musculotendinous or rotator cuff of the shouldercan sustain a tear, usually as a result of trauma.2. Injury is characterized bv shoulder pain and theinability to maintain abduction of the arm at theshoulder (drop arm test).3. Management involves nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy,sling support, and ice-heat applications.4. Surgery mav be required if medical management isunsuccessful or a complete tear is present.V. FracturesA. Description: A break in the continuity’ of the bone caused bvtrauma, twisting as a result of muscle spasm or indirect loss ofleverage., or bone decalcification and disease that result inosteopenia.B. Types of fractures (Box 60-2)C. Assessment of a fracture of an extremity1. Pain or tenderness over the involved area2. Decrease or loss of muscular strength or function3. Obvious deformity of the affected area4. Crepitation, erythema, edema, or bruising5. Muscle spasm and neurovascular impairmentAD.Initial care of a fracture of an extremity

Page 9 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 9 preview image

1. Immobilize the affected extremity with a cast or splint.2. Assess the neurovascular status of the extremity.3. Interventions for a fracture:Reduction, fixation,traction, castac o mPo u n <(open) fracture exists, splint the extremity andcover the wound with a sterile dressing.E. Reduction restores the bone to proper alignment.1. Closed reduction is a nonsurgical interventionperformed by manual manipulation.a. Closed reduction may be performedunder local or general anesthesia.b. A cast may be applied followingreduction.2. Open reduction involves a surgical intervention; thefracture mav be treated withinternal fixationdevices.F.Fixation1. Internal fixation follows an open reduction (Fig. 60-2).a. Internal fixation involves theapplication of screws, plates, pins,wires, or intramedullary rods to holdthe fragments in alignment.b. Internal fixation mav involve theremoval of damaged bone andreplacement with a prosthesis.c. Internal fixation provides immediatebone stabilization.2.External fixation isthe use of an external frame tostabilize a fracture by attaching skeletal pins throughbone fragments to a rigid external support (Fig. 60-3).a. External fixation provides morefreedom of movement than withtraction.b. Monitor pin stability and provide pincare to decrease infection risks.c. Risk of infection exists with bothfixation methods.d. External fixation is commonlv usedwhen massive tissue trauma is present.G. Traction (Fig. 60-4)1. Descriptiona. Traction is the exertion of a pullingforce applied in 2 directions to reduceand immobilize a fracture.b. It provides proper bone alignment and

Page 10 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 10 preview image

reduces muscle spasms.j2. Interventionsa. Maintain proper body alignment.b. Ensure that the weights hang freely anddo not touch the floor.c. Do not remove or lift the weightswithout a PHCP's prescription.d. Ensure that pullevs are not obstructedand that ropes in the pullevs movefreely.e. Place knots in the ropes to preventslipping.f. Check the ropes for fraying.H.Skeletal traction1. Descriptiona. Traction is applied mechanically to thebone with pins, wires, or tongs.b. Tvpical weight for skeletal traction is 25to 40 lb (11 to 18 kg).J2. Interventionsa. Monitor color, motion, and sensation ofthe affected extremity.b. Monitor the insertion sites for redness,swelling,, drainage, or increased pain.c. Provide insertion site care as prescribed.3. Cervical tongs and a halo fixation device: See Chapter58 regarding care of the client with these types ofdevices.I.Skin traction1. Description: Skin traction is applied by using elasticbandages or adhesive, foam boot, or sling.2. Cervical skin traction relieves muscle spasms andcompression in the upper extremities and neck (see Fig.60-4).a. Cervical skin traction uses a head halterand chin pad to attach the traction.b. Use powder to protect the ears fromfriction rub.c. Position the client with the headof the bed elevated 30 to 40 degrees, andattach the weights to a pullev systemover the head of the bed.3. Buck's (extension) skin traction is used to alleviatemuscle spasms and immobilize a lower limb by

Page 11 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 11 preview image

maintaining a straight pull on the limb with the use ofweights (see Fig. 60-4).a. A boot appliance is applied to attach tothe traction.b. The weights are attached to apulley; allow the weights to hang freelyover the edge of bed.c. Not more than 8 to 10 lb (3.5 to 4.5 kg) ofweight should be appEed as prescribed.d. Elevate the foot of the bed to provide thetraction.4. Russell's skin (sling) traction: See Fig. 60-4 and Chapter39 regarding this type of traction.5. Pelvic skin traction is used to relieve low back, hip, orleg pain or to reduce muscle spasm (see Fig. 60-4).a. Apply the traction belt snuglyover the pelvis and iliac crest and attachto the weights.b. Use measures as prescribed to preventthe client from sEpping down in bed.J. Balanced suspension traction (see Fig. 60-4)1. Descriptiona. Balanced suspension traction is usedwith skin or skeletal traction.b. Used to approximate fractures of thefemurftibia, or fibulac. Balanced suspension traction isproduced by a counterforce other thanthe client.2. Interventionsa. Position die client in a low-Fowler'sposition on either the side or die back.b. Maintain a 20-degree angle from thethigh to the bed.c. Protect the skin from breakdown.d. Provide pin care if pins are used withskeletal traction.e. Clean the pin sites with sterile normalsaline and hvdrogen peroxide orpovidone-iodine as prescribed or peragency polio7.K. Casts1. Description: Plaster, fiberglass, or air casts are used toimmobilize bones and joints into correct alignment

Page 12 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 12 preview image

after a fracture or injury.2. Interventionsa. Keep the cast and extremity elevated.b. Allow a wet plaster cast 24 to 72 hoursto div (synthetic casts dry in 20minutes).c. Handle a wet plaster cast with thepalms of the hands (not fingertips)until drv.d. Turn the extremity every 1 to 2 hours,unless contraindicated, to allow aircirculation and promote diving of thecast.e. A hair drver can be used on a coolsetting to drv a plaster cast (heatcannot be used on a plaster cast,because the cast heats up and bumsthe skin).f. Monitor closely for circulatoryimpairment; prepare for bivalving orcutting the cast if circulatoryimpairment occurs.g. Petal the cast or apply moleskin to theedges to protect the client's skin;maintain smooth edges around tire castto prevent crumbling of the castmaterial.h. Monitor for signs of infection such asincreased temperature, hot spots onthe cast,, foul odor, or changes in pain.i. If an open draining area exists on theaffected extremity, the PHCP willmake a cutout portion of the castknown as awindow,for assessment andwound care purposes.j. Instruct the client not to stick objectsinside the cast.k. Teach tire client to keep the cast deanand drv.l. Instruct the client in isometric exercisesto prevent muscle atrophy.

Page 13 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 13 preview image

VI. Complications of Fractures (Box 60-3)A.Fat embolism(see Priority Nursing Actions)Priority N u r s i n g A c t i o n sFatEmbolism in a ClientFollowving a Fracture1. Nctifr die primary health care provider |PHCP}.2. Administer owgen.3. Administer intravenous (TV)fluids as prescribed.4 Monitor vital signs and respirator/ status.5. Prepare for intubation and mechanical ventilation if necessary as indicated bvarterial blood gas values.6. Follow up on results of diagnostic tests such as chest x-ray or computedtomography (CT) scan.7. Document the event, actions taken, and die client's response.ReferenceIgnatavidus, Workman, Rebar (201S), p. 1034.B.Pulmonary embolism1. Description: Pulmonary embolism is caused bv themovement of foreign particles (blood, clot, fat., or air)into the pulmonary circulation.2. Assessmenta. Restlessness and apprehensionb. Sudden onset of dyspnea and chestpainc. Cough, hemoptvsis, hypoxemia, orcrackles3. Interventionsa. Notify the PHCF immediately if signsof emboli are present.b. Administer oxvgen and otherprescriptions; intravenous (IV)anticoagulant therapy may beprescribed.C.Compartment syndrome1. Descriptiona. Tough fascia surrounds muscle groups,forming compartments from whicharteries, veins, and nerves enter andexit at opposite ends.b. Compartment syndrome occurs whenpressure increases within 1 or morecompartments, leading to decreasedblood flow, tissue ischemia, and

Page 14 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 14 preview image

neurovascular impairment.c. Neurovascular damage may beirreversible if not treated within 4 to 6hours after die onset of compartmentsyndrome.2. Assessmenta. Unrelieved or increased pain in thelimbb. Tissue that is distal to the involved areabecomes pale, dusky, or edematous.c. Fain with passive movementd. Loss of sensation (paresthesia)e. Pulselessness (a late sign)3. Interventionsa. Notify the PHCP immediately andprepare to assist the PHCP.b. Continue to elevate the affectedextremity.c. If severe, assist the PHCF withfasciotomv to relieve pressure andrestore tissue perfusion.d. Loosen tight dressings or bivalverestrictive cast as prescribed.D. Infection and osteomyelitis1. Description: Infection and osteomyelitis (inflammatoryresponse in bone tissue) can be caused by theintroduction of organisms into bones leading tolocalized bone infection.2. Assessmenta. Tachycardia and fever (usually above101° F [38.3° C]).b. Erythema and pain in the areasurrounding the infectionc. Leukocytosis and elevated erythrocytesedimentation rate (ESR)d. Confirmed bv radiographic assessment,such as plain radiographs, MRI, orbone scan3. Interventionsa. Notify the PHCP.b. Prepare to initiate aggressive, long-termIV antibiotic therapy. A central venousaccess line wTill likely be required.c. Surgery is performed for resistantosteomyelitis with sequestrectomyand/or bone grafts.d. For unrelenting infection andosteomyelitis, hyperbaric oxygen

Page 15 of 15

Saunders Musculoskeletal Problems RN Nclex 60 - Page 15 preview image

therapv is used (if available) topromote healing.E. Avascular necrosis1. Description: Avascular necrosis occurs when a fractureinterrupts the blood supply to a section of bone,leading to bone death.2. Assessmenta. Painb. Decreased sensationc. Confirmed bv radiographic assessment,such as plain radiographs, MRI, orbone scan3. Interventionsa. Notify the PHCP if pain or numbnessoccurs.b. Prepare the client for removal ofnecrotic tissue, because it serves as afocus for infection.VII. Crutch WalkingA. Description1. An accurate measurement of the client for crutches isimportant, because an incorrect measurement coulddamage the brachial plexus.2. The distance between the axillae and the arm pieces onthe crutches should be 2 to 3 fingerwidths in the axillaspace.3. The elbows should be slightly flexed, 20 to 30 degrees,when the client is walking.4. When ambulating with the client, stand on the affectedside.5. Instruct the client never to rest the axillae on theaxillary bars.6. Instruct the cEent to look up and outward whenambulating and to place the crutches 6 to 10 inches(25.5 cm) diagonally in front of the foot.7. Instruct the cEent to stop ambulation if numbness ortingling in the hands or arms occurs.B. Crutch gaits (Table 60-2)C. Assisting the client with crutches to sit and stand1. Place the unaffected leg against the front of the chair.2. Move the crutches to the affected side, and grasp thearm of the chair with the hand on the unaffected side.3. Flex the knee of the unaffected leg to lower self intothe chair while placing the affected leg straight out infront.

Preview Mode

This document has 49 pages. Sign in to access the full document!

Report

Learning Tools

Writing Tools

Browse Resources

Saunders Musculoskeletal Problems RN Nclex 60 - Page 1

Study Now!

Document Details

Related Documents

NSG 3160 NCLEX Review Chapter 15

NSG 3160 NCLEX Review Chapter 14

NSG 3160 NCLEX Review Chapter 24

Lippincott Style NCLEX Questions

NCLEX PN Test Practice Questions

Lecture Notes NCLEX

NCLEX Study Guide

Comprehensive NCLEX Review

NCLEX Style Questions Nutrition

Key Concepts for NCLEX

Company

Explore

Study Tools