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Saunders Musculoskeletal Problems RN Nclex 60

Comprehensive musculoskeletal review: anatomy, bone types, structure, and functions. Key for understanding mobility and functional ability—great for NCLEX prep and nursing fundamentals.

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    C H A P T E R 60 Musculoskeletal Problems http://evolve.elsevier.com/Silvestri/comprehensiveRN/ P r i o r i t y C o n c e p t s ___________________________________ Functional Ability; Mobility I. Anatomy and Physiology A. Skeleton 1. Axial portion a. Cranium b. Vertebrae c. Ribs 2. Appendicular portion a. Limbs b. Shoulders c. Hips B. Tvpes of bones: Long, short, flat irregular 1. Spongy bone a. Spongy 7 bone is located in the ends of long bones and the center of flat and irregular bones. b. Spongy 7 bone can withstand forces applied in manv directions. 2. Dense (compact) bone a. Dense bone covers spongy 7 bone. b. Forms a cylinder around a central marrow cavity c. Better able to withstand longitudinal forces than horizontal forces 3. Characteristics of bones a. Support and protect structures of the body 7 b. Provide attachments for muscles, tendons, and ligaments c. Contain tissue in the central cavities, which aids in the formation of blood cells d. Assist in regulating calcium and phosphate concentrations 4. Bone growth

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    a. The length of bone growth results from ossification of the epiphyseal cartilage at the ends of bones; bone growth stops between the ages of IS and 25 years. b. The width of bone growth results from the activity of osteoblasts; it occurs throughout life but slows down with aging. occurs, bone resorption accelerates. decreasing bone mass and predisposing the client to injury. C. Types of joints (Table 60-1) 1. Characteristics of joints a. Allow movement between bones b. Formed where 2 bones join c. Surfaces are covered with cartilage. d. Enclosed in a capsule (synovial joints) e. Contain a cavitv filled with synovial fluid (svnovial joints) f. Ligaments hold the bone and joint in the correct position. g. Articulation is the meeting point of 2 or more bones. 2. Svnovial fluid a. Found in the svnovial joint capsule b. Formed by the synovial membrane, which lines the joint capsule c. Lubricates the cartilage d. Provides a cushion against shocks D. Muscles 1. Characteristics of muscles a. Made up of bundles of muscle fibers b. Provide the force to move bones c. Assist in maintaining posture d. Assist with heat production 2. Process of contraction and relaxation a. Muscle contraction and relaxation require large amounts of adenosine triphosphate. b. Contraction also requires calcium, which functions as a catalvst. c. Acetylcholine released by the motor end plate of the motor neuron initiates an action potential. d. Acetylcholine is then destroyed by

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    acetylcholinesterase. e. Calcium is required for muscle fiber contraction and acts as a catalyst for the enzyme needed for the sliding- together action of actin and myosin. f. Following contraction, adenosine triphosphate transports calcium out to allow actin and myosin to separate and allow the muscle to relax. 3. Skeletal muscles a. Skeletal muscles are attached to 2 bones by cartilaginous tendons called enthuses (the connective tissue between tendon or ligament and bone). b. The point of origin is the point of attachment that does not move. c. The point of insertion is the point of attachment that moves when the muscle contracts. d. Skeletal muscles act in groups. e. Prime movers contract to produce movement. f. Antagonists relax. g. Synergists contract to stabilize body movement. h. Nerves activate and control the muscles. E. Bone healing 1. Description: Bone union or healing is the process that occurs after the integrity of a bone is interrupted. 2. Stages (Fig. 60-1) II. Risk Factors Associated with Musculoskeletal Problems: See Box 60-1 for more information in. Diagnostic Tests A. Radiography and magnetic resonance imaging (MRI) (refer to Chapter 58 for information on MRI) 1. Description: Radiography and MRI are commonly used procedures to diagnose problems of the musculoskeletal system. 2. Interventions a. Handle injured areas carefully and support extremities above and below the joint. b. Administer analgesics as prescribed before the procedure, particularly if

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    the client is in pain. c. Remove any radiopaque and metallic objects, such as jewelry. d. Ask the client if she is pregnant; MRI may be contraindicated in pregnancy. e. Shield the client's testes, ovaries, or pregnant abdomen. f. The client must lie still during a procedure. g. Inform the client that exposure to radiation from radiography is minimal and not dangerous. h. The health care provider wears a lead apron if staving in the room with the client having radiography. i. Complete the screening process per agency policy. B. Arthrocentesis 1. Description: Arthrocentesis is used to diagnose joint inflammation and infection. a. Arthrocentesis involves aspirating svnovial fluid, blood, or pus via a needle inserted into a joint cavity. b. Medication, such as corticosteroids, may be instilled into the joint if necessarv to alleviate inflammation. 2. Interventions a. Ensure that informed consent has been obtained. b. Apply an elastic compression bandage postprocedure as prescribed. c. Use ice to decrease pain and swelling. d. Pain may worsen after aspirating fluid from the joint; analgesics may be prescribed. e. Pain can continue for up to 2 davs after administration of corticosteroids into a joint. f. Instruct the client to rest the joint for 8 to 24 hours postprocedure. g. Instruct the client to notify the primary health care provider (PHCP) if a fever or swelling of the joint occurs. C. Arthroscopy 1. Description: Used to diagnose and treat acute and chronic problems of the joint. a. Arthroscopy provides an endoscopic

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    examination of various joints. b. Articular cartilage abnormalities can be assessed, loose bodies removed., and the cartilage trimmed. c. A biopsy may be performed during the procedure. 2. Interventions a. Instruct the client to fast for 8 to 12 hours before the procedure. b. Ensure that informed consent was obtained. c. Administer pain medication as prescribed postprocedure. d. Assess the neurovascular status of the affected extremity. e. An elastic compression bandage should be worn postprocedure for 2 to 4 days as prescribed. f. Instruct the client that walking with weight-bearing usually is permitted after sensation returns but to limit activity for 1 to 4 da vs as prescribed following the procedure. g. Instruct the client to elevate the extremity as often as possible for 24 hours following the procedure and to place ice on the site to minimize swelling for 12 to 24 hours postprocedure. A h. Advise the client to notify the FHCP if fever or increased knee pain occurs or if edema continues for more than 3 da vs postprocedure. D. Bone mineral density measurements 1. Dual-energy x-ray absorptiometry a. Dual-energy x-ray absorptiometry measures 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 bone disease and to monitor changes in bone density with treatment. d. Inform the client that the procedure is painless.

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    e. All metallic objects are removed before the test. 2. Quantitative ultrasound a. Quantitative ultrasound evaluates strength density, and elasticity of various bones, using ultrasound rather than radiation. b. Inform the client that the procedure is painless. E. Bone scan 1. Description: A bone scan is used to identify, evaluate, and stage bone cancer before and after treatment; it is also used to detect fractures. a. Radioisotope is injected intravenously and will collect in areas that indicate abnormal bone metabolism and some fractures, if they exist. b. The isotope is excreted in the urine and feces within 48 hours and is not harmful to others. 2. Interventions a. Food and fluids may be withheld before the procedure. b. Ensure that informed consent has been obtained. c. Remove all jewelry and metal objects. ▲ d. Following the injection of the radioisotope, the client must drink 32 oz of water (if not contraindicated) to promote renal filtering of the excess isotope. e. From 1 to 3 hours after the injection, have the client void to clear excess isotope from the bladder before the scanning procedure is completed. f. Inform the client of the need to lie supine during the procedure and that the procedure is not painful. g. Monitor the injection site for redness and swelling. h. Encourage oral fluid intake following the procedure.

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    bone scan, because only a minimal amount of radioactivity exists in the radioisotope used for the procedure. F. Bone or muscle biopsy 1. Description: Biopsy may be done during surgery or through aspiration or punch or needle biopsy. 2. Interventions a. Ensure that informed consent was obtained. ▲ b. Monitor for bleeding, swelling. hematoma, or severe pain. c. Elevate the site for 24 hours following the procedure to reduce edema. d. Apply ice packs as prescribed following the procedure to prevent the development of a hematoma and to decrease site discomfort. e. Monitor for signs of infection following the procedure. f. Inform the client that mild to moderate discomfort is normal following the procedure. G. Electromyography (EMG) 1. Description: EMG is used to evaluate muscle weakness. a. Electromyography measures electrical potential associated with skeletal muscle contractions. b. Needles are inserted into the muscle, and recordings of muscular electrical activity are traced on recording paper through an oscilloscope. 2. Interventions a. Ensure that informed consent was obtained. b. Instruct the client that the needle insertion is uncomfortable. c. Instruct the client not to take any stimulants or sedatives for 24 hours before the procedure. d. Inform the client that slight bruising mav occur at the needle insertion sites. e. Mild analgesics can be used for the pain. IV. Injuries A. Strains

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    1. Strains are an excessive stretching of a muscle or tendon. 2. Management involves cold and heat applications, exercise with activity limitations, antiinflammatory medications, and muscle relaxants. 3. Surgical repair may be required for a severe strain (ruptured muscle or tendon). B. Sprains 1. Sprains are an excessive stretching of a Egament, usually caused by a twisting motion, such as in a fall or stepping onto an uneven surface. 2. Sprains are characterized bv pain and swelling. 3. Management involves rest ice, a compression bandage, and elevation (RICE) to reduce swelling, as well as joint support. RICE is considered a first-aid treatment rather than a cure for soft tissue injuries. 4. Casting mav be required for moderate sprains to allow the tear to heal. 5. Surgery mav be necessary for severe Egament damage. C. Rotator cuff injuries 1. The musculotendinous or rotator cuff of the shoulder can sustain a tear, usually as a result of trauma. 2. Injury is characterized bv shoulder pain and the inability to maintain abduction of the arm at the shoulder (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 is unsuccessful or a complete tear is present. V. Fractures A. Description: A break in the continuity’ of the bone caused bv trauma, twisting as a result of muscle spasm or indirect loss of leverage., or bone decalcification and disease that result in osteopenia. B. Types of fractures (Box 60-2) C. Assessment of a fracture of an extremity 1. Pain or tenderness over the involved area 2. Decrease or loss of muscular strength or function 3. Obvious deformity of the affected area 4. Crepitation, erythema, edema, or bruising 5. Muscle spasm and neurovascular impairment A D. Initial care of a fracture of an extremity

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    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, cast a c o m P o u n < (open) fracture exists, splint the extremity and cover the wound with a sterile dressing. E. Reduction restores the bone to proper alignment. 1. Closed reduction is a nonsurgical intervention performed by manual manipulation. a. Closed reduction may be performed under local or general anesthesia. b. A cast may be applied following reduction. 2. Open reduction involves a surgical intervention; the fracture mav be treated with internal fixation devices. F. Fixation 1. Internal fixation follows an open reduction (Fig. 60-2). a. Internal fixation involves the application of screws, plates, pins, wires, or intramedullary rods to hold the fragments in alignment. b. Internal fixation mav involve the removal of damaged bone and replacement with a prosthesis. c. Internal fixation provides immediate bone stabilization. 2. External fixation is the use of an external frame to stabilize a fracture by attaching skeletal pins through bone fragments to a rigid external support (Fig. 60-3). a. External fixation provides more freedom of movement than with traction. b. Monitor pin stability and provide pin care to decrease infection risks. c. Risk of infection exists with both fixation methods. d. External fixation is commonlv used when massive tissue trauma is present. G. Traction (Fig. 60-4) 1. Description a. Traction is the exertion of a pulling force applied in 2 directions to reduce and immobilize a fracture. b. It provides proper bone alignment and

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    reduces muscle spasms. j 2. Interventions a. Maintain proper body alignment. b. Ensure that the weights hang freely and do not touch the floor. c. Do not remove or lift the weights without a PHCP's prescription. d. Ensure that pullevs are not obstructed and that ropes in the pullevs move freely. e. Place knots in the ropes to prevent slipping. f. Check the ropes for fraying. H. Skeletal traction 1. Description a. Traction is applied mechanically to the bone with pins, wires, or tongs. b. Tvpical weight for skeletal traction is 25 to 40 lb (11 to 18 kg). J 2. Interventions a. Monitor color, motion, and sensation of the 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 Chapter 58 regarding care of the client with these types of devices. I. Skin traction 1. Description: Skin traction is applied by using elastic bandages or adhesive, foam boot, or sling. 2. Cervical skin traction relieves muscle spasms and compression in the upper extremities and neck (see Fig. 60-4). a. Cervical skin traction uses a head halter and chin pad to attach the traction. b. Use powder to protect the ears from friction rub. c. Position the client with the head of the bed elevated 30 to 40 degrees, and attach the weights to a pullev system over the head of the bed. 3. Buck's (extension) skin traction is used to alleviate muscle spasms and immobilize a lower limb by

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    maintaining a straight pull on the limb with the use of weights (see Fig. 60-4). a. A boot appliance is applied to attach to the traction. b. The weights are attached to a pulley; allow the weights to hang freely over the edge of bed. c. Not more than 8 to 10 lb (3.5 to 4.5 kg) of weight should be appEed as prescribed. d. Elevate the foot of the bed to provide the traction. 4. Russell's skin (sling) traction: See Fig. 60-4 and Chapter 39 regarding this type of traction. 5. Pelvic skin traction is used to relieve low back, hip, or leg pain or to reduce muscle spasm (see Fig. 60-4). a. Apply the traction belt snugly over the pelvis and iliac crest and attach to the weights. b. Use measures as prescribed to prevent the client from sEpping down in bed. J. Balanced suspension traction (see Fig. 60-4) 1. Description a. Balanced suspension traction is used with skin or skeletal traction. b. Used to approximate fractures of the femur f tibia, or fibula c. Balanced suspension traction is produced by a counterforce other than the client. 2. Interventions a. Position die client in a low-Fowler's position on either the side or die back. b. Maintain a 20- degree angle from the thigh to the bed. c. Protect the skin from breakdown. d. Provide pin care if pins are used with skeletal traction. e. Clean the pin sites with sterile normal saline and hvdrogen peroxide or povidone-iodine as prescribed or per agency polio 7 . K. Casts 1. Description: Plaster, fiberglass, or air casts are used to immobilize bones and joints into correct alignment

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    after a fracture or injury. 2. Interventions a. Keep the cast and extremity elevated. b. Allow a wet plaster cast 24 to 72 hours to div (synthetic casts dry in 20 minutes). c. Handle a wet plaster cast with the palms of the hands (not fingertips) until drv. d. Turn the extremity every 1 to 2 hours, unless contraindicated, to allow air circulation and promote diving of the cast. e. A hair drver can be used on a cool setting to drv a plaster cast (heat cannot be used on a plaster cast, because the cast heats up and bums the skin). f. Monitor closely for circulatory impairment; prepare for bivalving or cutting the cast if circulatory impairment occurs. g. Petal the cast or apply moleskin to the edges to protect the client's skin; maintain smooth edges around tire cast to prevent crumbling of the cast material. h. Monitor for signs of infection such as increased temperature, hot spots on the cast,, foul odor, or changes in pain. i. If an open draining area exists on the affected extremity, the PHCP will make a cutout portion of the cast known as a window, for assessment and wound care purposes. j. Instruct the client not to stick objects inside the cast. k. Teach tire client to keep the cast dean and drv. l. Instruct the client in isometric exercises to prevent muscle atrophy.

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    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 s Fat Embolism in a Client Follow ving a Fracture 1. 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 bv arterial blood gas values. 6. Follow up on results of diagnostic tests such as chest x-ray or computed tomography (CT) scan. 7. Document the event, actions taken, and die client's response. Reference Ignatavidus, Workman, Rebar (201S), p. 1034. B. Pulmonary embolism 1. Description: Pulmonary embolism is caused bv the movement of foreign particles (blood, clot, fat., or air) into the pulmonary circulation. 2. Assessment a. Restlessness and apprehension b. Sudden onset of dyspnea and chest pain c. Cough, hemoptvsis, hypoxemia, or crackles 3. Interventions a. Notify the PHCF immediately if signs of emboli are present. b. Administer oxvgen and other prescriptions; intravenous (IV) anticoagulant therapy may be prescribed. C. Compartment syndrome 1. Description a. Tough fascia surrounds muscle groups, forming compartments from which arteries, veins, and nerves enter and exit at opposite ends. b. Compartment syndrome occurs when pressure increases within 1 or more compartments, leading to decreased blood flow, tissue ischemia, and

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    neurovascular impairment. c. Neurovascular damage may be irreversible if not treated within 4 to 6 hours after die onset of compartment syndrome. 2. Assessment a. Unrelieved or increased pain in the limb b. Tissue that is distal to the involved area becomes pale, dusky, or edematous. c. Fain with passive movement d. Loss of sensation (paresthesia) e. Pulselessness (a late sign) 3. Interventions a. Notify the PHCP immediately and prepare to assist the PHCP. b. Continue to elevate the affected extremity. c. If severe, assist the PHCF with fasciotomv to relieve pressure and restore tissue perfusion. d. Loosen tight dressings or bivalve restrictive cast as prescribed. D. Infection and osteomyelitis 1. Description: Infection and osteomyelitis (inflammatory response in bone tissue) can be caused by the introduction of organisms into bones leading to localized bone infection. 2. Assessment a. Tachycardia and fever (usually above 101° F [38.3° C]). b. Erythema and pain in the area surrounding the infection c. Leukocytosis and elevated erythrocyte sedimentation rate (ESR) d. Confirmed bv radiographic assessment, such as plain radiographs, MRI, or bone scan 3. Interventions a. Notify the PHCP. b. Prepare to initiate aggressive, long-term IV antibiotic therapy. A central venous access line w T ill likely be required. c. Surgery is performed for resistant osteomyelitis with sequestrectomy and/or bone grafts. d. For unrelenting infection and osteomyelitis, hyperbaric oxygen

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    therapv is used (if available) to promote healing. E. Avascular necrosis 1. Description: Avascular necrosis occurs when a fracture interrupts the blood supply to a section of bone, leading to bone death. 2. Assessment a. Pain b. Decreased sensation c. Confirmed bv radiographic assessment, such as plain radiographs, MRI, or bone scan 3. Interventions a. Notify the PHCP if pain or numbness occurs. b. Prepare the client for removal of necrotic tissue, because it serves as a focus for infection. VII. Crutch Walking A. Description 1. An accurate measurement of the client for crutches is important, because an incorrect measurement could damage the brachial plexus. 2. The distance between the axillae and the arm pieces on the crutches should be 2 to 3 fingerwidths in the axilla space. 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 affected side. 5. Instruct the client never to rest the axillae on the axillary bars. 6. Instruct the cEent to look up and outward when ambulating 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 or tingling in the hands or arms occurs. B. Crutch gaits (Table 60-2) C. Assisting the client with crutches to sit and stand 1. Place the unaffected leg against the front of the chair. 2. Move the crutches to the affected side, and grasp the arm of the chair with the hand on the unaffected side. 3. Flex the knee of the unaffected leg to lower self into the chair while placing the affected leg straight out in front.

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