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Nursing Care of the Adult WithMusculoskeletal Alterations

Lorraine C. Haertel, PhD, RN, CS, ARNPAssistant Professor of Clinical Nursing

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IntroductionBone FractureBone Healing

Bone Union Complications

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Pathophysiology

Classification of fractures– Extent of break

• Complete – across entire bone• Incomplete – through part of the bone

– Extent of soft tissue damage• Open – soft tissue injury• Closed – no visible soft tissue injury

– Cause• Pathologic/spontaneous – occurs with minimal trauma due to

weakened bone• Fatigue/stress – i.e., sports injury• Compression – i.e., vertebrae fx due to osteoporosis

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Common Types of Fractures

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Stages of Bone Healing

Hematoma formation– Occurs 24-72 hours after fx– Inflamed & painful

Hematoma to Granulation Tissue Callus formation

– Beginning of nonbony union Osteoblastic Proliferation

– Callus transformed into bone Bone Remodeling

– Bone is reorganized into former structural arrangement Bone Healing Completed

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Stages of Bone Healing

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Complications of Bone Healing– Nonunion

• Failure of healing at fx site– Delayed union

• Bony union does not occur in usual amt of time– Malunion

• Bone union results in deformity Some Causes of Nonunion and Delayed Union

– **Poor blood supply or loss of blood supply– Insufficient nutrients– Insufficient immobilization– Metabolic disorders

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Complications of Fractures

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Complications of Fractures

Hemorrhage ShockFat EmbolismTetanusAcute Compartment Syndrome (ACS)Avascular NecrosisInfectionDVT

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Hemorrhage/Shock– Fxs of long bones & pelvis prone to excessive

bleeding

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Fat Embolism– High risk - multiple fxs or fx of long bones– Older pt with a hip fx has highest risk– Pulmonary perfusion problems, defective gas exchange– Usually occurs within 48 hours– S&S

• Confusion – an early manifestation due to low arterial oxygen levels in brain

• Restlessness, dyspnea, tachycardia, tachypnea, fever, petechiae, drowsy

– Treatment• Oxygen – administer first, then notify MD• Restore fluid/blood volume to prevent shock

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Fat Embolism - Petechiae

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Tetanus– Occurs in open fx & puncture wounds– Administer tetanus toxoid if not previously

given

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Compartments

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Pathophysiology of ACS

Acute Compartment Syndrome (ACS)– Increased pressure in compartment(s)– Massive compromise of circulation– Pressure is internal or external– Plasma proteins leak edema– Blood flow decreases– Ischemia – Tissue pales, weak pulses, area tense, pain, cyanosis,

tingling, numbness, paresis, more severe pain. • Notify MD immediately with sx of ACS

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Nursing and Medical Care of ACS

– Emergency situation – irreversible damage within hours– Compartment pressures can be monitored– Bivalve cast– Fasciotomy to relieve pressure & restore circulation

• Incision through skin & SQ tissue into fascia– Wound care, debride, skin graft– Complications

• Infection• Motor weakness• Contracture• Myoglobinuric renal failure (rhabdomyolysis)

– Hyperkalemia, cardiac dysrhythmias• Amputation in extreme cases

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Two Months Post-Fasciotomy

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Completely Healed

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Avascular Necrosis– Death of bone as result of loss of blood supply

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Infection (Bone infection/osteomyelitis)– Most common with an open fx

• Skin integrity is lost & organisms gain access easily• Example – pt with open fx of tibia• Broad spectrum intravenous antibiotics, contact isolation, sterile technique for dressing changes

– Acute Osteomyelitis• Temp > 101 degrees• Redness, heat, swelling, pain/tenderness WBC, ESR, inc C-Reactive Protein

– Chronic Osteomyelitis• Skin ulceration with sinus tract formation• Drainage• Pain

– Treatment• IV antibiotics• Sterile dressing changes, packing the wound• Pain medication• Standard or contact isolation• Hyperbaric Oxygen Therapy (HBO)• Bone Grafts

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Osteomyelitis

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Osteomyelitis – Bone X-Ray

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DVT• Often develops in immobile pts

– Lovenox– ASA– Early ambulation– TEDS, SCD, Foot pumps

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Nursing Process

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Assessment of Bone Fracture

Assess preceding events– Head injury, spinal cord injury– Remember ABCs when prioritizing

History– Medication history

• Glucocorticoids osteoporosis– Medical history

• Will offer info that may impede healing– For example, hx of PVD arterial circulation to bone bone receives

less oxygen & nutrients • Bone cancer risk for fx

– Diet history• Protein, vitamin C, B complex vitamins• Dietary referral as needed

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Physical Assessment MS Assessment

– Bone alignment/deformity– Altered length of extremity– Bone shape– Pain

• Muscle spasm– ROM

• Decreased or loss of function– Crepitus/creptitation

• Grating sound when affected part is moved• Created by bone fragments at fx site

– Skin integrity• Intact, ecchymosis, SQ emphysema

– Swelling

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Neurovascular Assessment

– Skin color– Skin temperature– Movement– Sensation– Pulses– Capillary refill– Pain

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Neurovascular Assessment

Please PulsesRemember, Refill (Capillary)Check Color (Skin)The Temperature (Skin)Motor Movement

– &Sensation SensationPronto Pain

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Neurovascular Assessment

The 5 Ps (Really 6 Ps)– Pain– Pulse– Paresthesia– Pallor– Paralysis – A 6th P is Pressure when assessing for S&S of ACS

CMS– Circulation

• Color, temp, edema, capillary refill– Motion

• Flexion, extension– Sensation

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Psychosocial assessmentLabs/Diagnostics

– H&H– ESR

• An increase during fx healing suggests bone infection.• Notify physician

– Serum Ca & PO4

– X-rays– CT scan– Bone scan

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Nursing Diagnoses

Risk for impaired tissue perfusionPainImpaired physical mobilityRisk for infectionActivity intoleranceRisk for impaired skin integrity

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Goals

Pain Immobility Perfusion & oxygenation Infection Nutrition Bowel/bladder elimination Bone function Understanding Rehabilitation Minimize anxiety Self-care

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InterventionsFx Emergency Care in the Community

Fx Emergency Care in Community– First assess for resp distress, bleeding, head injury– Assess fx

• Control bleeding, VS, supine– Neurovascular Monitoring

• Compare to unaffected side– Temperature, color, sensation, movement, capillary refill,

pulses, pain

– Immobilize extremity• Recheck circulation

– Dressing

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InterventionsED and Hospital Care

In Emergency Department– Reduction – realign bone ends using traction or surgery

• Closed method• Open method

– Immobilization • Bandages, casts, traction, internal/external fixation

In Hospital– NV assessments every 1 hour for first 24 hours– Neurovascular (NV) monitoring q 4 hours once stable

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Nonsurgical Management of Fractures

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Nonsurgical Management of Fxs

Closed reduction– Bandages, splints, cast or traction– Be aware of excessive external pressure ACS

Cast– Cast care

• Wet casts– Use palms of hands– Use cloth covered pillow

• Dry Cast– Assess cast not too tight as it is drying– Assess drainage and cast integrity

– Cast complications• Infection• Circulation impairment and peripheral nerve damage• Prolonged immobility complications

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Traction

Traction– Purposes

• Reduce fx aka realign bones• Dec pain and muscle spasms• Prevent/correct deformities• Promote healing

– Manual Traction– Skin Traction

• Traction wt limited to 5-10 pounds• Risk of skin irritation & pressure problems

– Skeletal Traction• Pins, wires, tongs, screws are surgically inserted into bone to aid in

bone alignment• Traction wt up to 45 pounds

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Types of Traction

Buck’s Traction– Simplest of LE tractions– Fx of hip or femur preop, prevent hip contractures, hip

dislocation

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Nursing Responsibilities in Traction Care

– Maintain straight alignment of ropes and pulleys– Maintain continuous pull– Assure wts hang free

• Don’t remove wts• Don’t lift wts• Don’t place wts on floor

– Inspect for skin breakdown at least every 8 hours– Encourage movement of unaffected areas– Assess every pt complaint immediately and thoroughly

• For example, c/o pain may not be fracture pain but ACS pain

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Nursing Responsibilities in Traction Care (Continued)

– Assess skeletal pin site for inflammation, infection, drainage, color, odor, excessive redness• Notify MD if pin site is red, swollen,

crusty with dried blood. Indicates inflammation & possible infection. Can lead to osteomyelitis. Treat immediately.

– Pin care for skeletal tx per hospital policy/ MD order

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Nursing Responsibilities in Traction Care (Continued)

– Active, passive ROM– Incentive Spirometry (IS)

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Nursing Responsibilities in Traction Care (Continued)

– Skin assessment– Pin assessment/Pin Care– Pharmacologic Management

• Muscle relaxants– methocarbamol (Robaxin)– cyclobenzapine HCl (Flexeril)– carisoprodol (Soma)

• Analgesics– Nutritional considerations

• Protein, vitamins, calcium, increased fiber, 2-3L fluid intake, diversional activity

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Surgical Management of Fractures

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Surgical Management of Fx

Surgical Management– Pre-op care– Operative procedures

• ORIF – open reduction with internal fixation• External fixation

– Post -op• Pain relief medications• Anti-inflammatory meds• Muscle relaxants

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External Fixation – Tibial Fracture

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Location of Hip Fractures

Read Articles

in Class Folder

(Transcervical)

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Clinical Manifestations

External rotationMuscle spasmShortening of

affected extremitySevere painTenderness in

general area Read Articles in Class Folder

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Surgical Repair

Possible Buck’s tractionOpen reduction internal fixation (ORIF)Hemiarthroplasty

– Generally replacement of the femerol head onlyTotal Hip Arthroplasty (THA)Total Hip Repair (THR)

– Cemented– Uncemented

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ORIF - Hip

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Pre-Operative Nursing Care

Analgesics & muscle relaxantsPositioningTractionTeaching

– Exercise unaffected leg and both arms– Overhead trapeze– Use opposite side rail to change positions– How to get OOB and chair transfers– Wt bearing status after surgery

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Post-Operative Nursing Care

Expected postop care initially Risk for NV impairment Assess for other complications

– Dislocation, excessive drainage, tromboembolism, infection Elevate leg when in chair Abductor pillow

– Prevent moving operative leg toward and beyond body’s midline Sandbags Overbead trapeze Walker Meds for comfort PT for ambulation DC criteria

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Post-Op Hip Precautions

No > 90 degree flexionNo adductionNo internal rotation; do the following activities

– Use long shoehorn, stocking helper– Chairs with arms– Elevated toilet seat– Shower chair– Abduction pillow– Hip in straight position– Dental work; antibiotics before dental work is done

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Dislocation S&S

PainLimb shorteningExternal rotation

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Nursing Diagnoses

Risk for peripheral NV dysfunctionPainRisk for infectionImpaired physical mobilityRisk for impaired skin integrity

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Virtual THA

http://www.edheads.org/activities/hip

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AmputationSoft Tissue Injuries

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Amputation

Amputation– UE – most from trauma– LE – PVD secondary to DM, atherosclerosis

• Also, infection (osteomyelitis, gangrene), trauma, cancer, etc.

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Nursing Interventions - • Stump Care

– Assess tissue perfusion– Prevent infection

• Positioning• Turning• Exercises • Ambulation • Psychological support• Discharge teaching

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AKA vs. BKA

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Complications of Amputations

– Hemorrhage– Infection– Contractures– Phantom limb sensation / Phantom limb pain

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DC and Community Care

– Use of prosthesis– Amputee WC– Refer to

• Social services• Occupational rehab• Home health agency• Pt/Family support groups• National Amputation Foundation (New York)• American Amputee Foundation (Little Rock, AR)

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Amputee Wheelchair

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Sports Related Soft Tissue Injuries

– Contusion – a soft tissue injury• S&S - Ecchymosis, hematoma• Tx - Cold for 24 hrs, moist heat, elastic bandage

– Strains – a muscle pull, and;– Sprains – a torn ligament

• S&S - Pain, swelling• Tx - Rest, elevation, ice, heat, elastic bandage, use

– Joint Dislocations – bone surfaces lose contact• S&S - Pain, deformity• Tx - Immobilize, reduction, bandages, splints

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Review Questions

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Review Questions

List the signs and symptoms of bone fractures. What lab values do you expect to be altered in a patient

with a fractured bone? What complications may occur after a bone fracture? What risk factors place a patient at risk for a hip fracture? What are the different types of fractures that can occur to

the hip? List the signs and symptoms of a hip fracture. Describe the various types of surgical techniques for a hip

fracture. List factors that may impede the healing of a fractured

femur.

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Describe the post operative nursing care of a patient after hip surgery.

What complications can occur in a patient after hip surgery? What nursing interventions are appropriate to prevent or treat these complications?

What are the benefits of administering pain medication to the patient who had hip replacement surgery?

What discharge teaching instructions would you give to a patient after hip surgery?

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Discuss the nursing care of the patient who had an AKA and a BKA.

Explain the different types of tractions discussed in class. What are the nursing responsibilities in caring for a

patient who is in traction? What are the complications a patient may experience who

had a cast applied? Identify common nursing diagnoses for patients who had

a bone fracture, are in traction, have a cast, have an amputation.