When performing a musculoskeletal

assessment on a client who complains of

muscle weakness with cramping, the
nurse should be sure to assess for
a. overuse through strenuous exercise.
b. ingestion of a potassium-wasting diuretic.
c. inadequate nutrition related to dieting.
d. a sedentary lifestyle

 When performing a musculoskeletal

assessment on a client who complains of
muscle weakness with cramping, the
nurse should be sure to assess for
a. overuse through strenuous exercise.
b. ingestion of a potassium-wasting diuretic.
c. inadequate nutrition related to dieting.
d. a sedentary lifestyle

 The nurse is taking a medical history from

a client whose chief complaint is low back
pain. The nurse would recognize the
occupation that puts the client at risk for
low back pain is
a. truck driver.
b. computer operator.
c. elementary school teacher.
d. dentist.

 The nurse is taking a medical history from

a client whose chief complaint is low back
pain. The nurse would recognize the
occupation that puts the client at risk for
low back pain is
a. truck driver.
b. computer operator.
c. elementary school teacher.
d. dentist.

 The school nurse assesses a 13-year-old

client and finds lateral thoracic spine
curvature with a raised shoulder and hip.
The nurse records these findings as
a.lordosis.
b.scoliosis.
c.kyphosis.
d.genu varum.

 The school nurse assesses a 13-year-old

client and finds lateral thoracic spine
curvature with a raised shoulder and hip.
The nurse records these findings as
a.lordosis.
b.scoliosis.
c.kyphosis.
d.genu varum.

 To evaluate a clients swollen right knee

further, the nurse should first
a. put the knee through range of motion.
b. test muscle strength.
c. compare the right knee to the left knee.
d. palpate for crepitus.

 To evaluate a clients swollen right knee

further, the nurse should first
a. put the knee through range of motion.
b. test muscle strength.
c. compare the right knee to the left knee.
d. palpate for crepitus.

 A client with a new cast for his fractured

ulna tells the nurse that he cannot feel his
fingers. The nurse should initially
a. notify the physician immediately.
b. remove the padding around the fingers
to increase space.
c. reassure the client that this is normal.
d. check for capillary refill in the clients
fingers.

 A client with a new cast for his fractured

ulna tells the nurse that he cannot feel his
fingers. The nurse should initially
a. notify the physician immediately.
b. remove the padding around the fingers
to increase space.
c. reassure the client that this is normal.
d. check for capillary refill in the clients
fingers.

MUSCULOSKELETAL PROBLEMS
I. INFECTIONS
A. OSTEOMYELITIS
ETIOLOGY:

Open fractures, Infected tissue,

Distant infection hematogenous
ORGANISMS: Staph, Strep, Pneumococcus, E. Coli
COMMON IN GROWING BONES
PATHOLOGY:
Inflammation Exudation in bone spaces Pressure build-up in
the bone Pressure on BV dead bone tissue - Sequestrum
Form. of new bone Involucrum traps org. & sequestra
Chronic infection
S & S: pain, tenderness, heat, swelling, restricted movement

COMPLICATION:
Fracture
Amputation

Restricted bone growth

Osteomyelitis

0STEOMELITIS Disease Progression

Gangrene with Bone Exposed

09/11/16

UST College of Nursing

15

MGT:
1. Antimicrobials
4 to 8 wks parenteral
4 to 8 wks oral antibiotics. (e.g.
Oxacillin)
2. Analgesics
3. Debridment; I & D; C&S
4. Warm compress
5. Surgery: Sequestrectomy
Saucerization
Antibiotic beads

Antibiotic beads
Bioabsorbable materials
may be used such as
calcium sulfate beads to fill
the void as well as provide
high concentrations of
antibiotic locally, with little
to no systemic effects.

Tuberculous
Spondyloarthrophathy

Pott's disease

I. INFECTIONS (Cont.)
B. POTTS DISEASE
ORGANISM:
TB Bacilli
PRIMARY FOCUS:
Lungs
PATHOLOGY:
Infection Bone destruction Collapse of vertebra
Gibbus formation Spinal cord compression
S & S:
MGT:
Anti-Kochs medications, Spinal brace
SURG:
Spinal fusion
*Bone infections are difficult to treat because they are relatively
inaccessible to protective macrophages and antibodies

SIGNS AND SYMPTOMS

Signs and symptoms

back pain
fever
night sweating
anorexia
weight loss
Spinal mass, sometimes associated with
numbness, tingling, or muscle weakness of the
legs

ARTHRITIS
A. RHEUMATOID

TRIGGERS IMMUNE SYSTEM TO

ATTACK JOINTS & ORGANS

PATHOLOGY:

Synovitis Destruction of articular cartilage

Joint degeneration, Bones rub together
Formation of fibrous tissue
Fibrous ossification

Ankylosis

SYMPTOMS:

Joint stiffness, pain & swelling

Low grade fever
Loss of appetitie
Skin lumps on elbows & hands
Loss of energy
Dry mouth & eyes

HAND DEFORMITIES:
SWAN - NECK: Hyperextension of prox.
interphalangeal joint
BOUTONNIERE DEF.: Flexion of proximal
interphalangeal joint
ULNAR DRIFT

1. Morning stiffness > 1 hour

2. Arthritis of three or more joints
3. Arthritis of hand joints and wrists
4. Symmetrical arthritis
5. Subcutaneous nodules
6. A positive serum rheumatoid factor
(RF)
7. Typical radiological changes
(erosions and/or periarticular
osteopenia)
Note: Four or more of the above
criteria are needed for the diagnosis of
RA.
* Criteria 1-4 must be present for at
least six weeks or more.
Presence
ofrheumatoid
criteria
is not
conclusive
Criteria*for
the diagnosis of
arthritis
(American
College of Rheumatology,
evidence for the 1987
diagnosis
revision). of RA.
(Kumar & Clark,
Pagano,is
1996;
Smyth
& Jansen, 1997)
* Absence
of 1998;
criteria
not
conclusively

MUSCULOSKELETAL PROBLEMS
RHEUMATOID ARTHRITIS
STAGES:
1. SYNOVITIS:

proliferative inflam. in joint capsule

tissue thickening with edema and congestion

2. PANNUS:

inflam. granulation tissue involv. articular

surface to joint interior
joint degeneration
joint invaded with tough fibrous tissue

3. FIBROUS ANKYLOSIS

with subluxation and distortion of affected joint

limited joint mobility

4. BONY ANKYLOSIS

fibrous tissue calcifies

Management

Bed rest during acute pain

passive ROM exercises
splint painful joints
heat and cold applications
well-balanced diet
physical therapy

 Surgery
osteotomy, synovectomy or arthroplasty

pharmacotherapy
Aspirin
NSAIDS
indomethacin (Indocin)
phenylbutazone (Butazolidin)
Ibuprofen (Motrin)

 Naproxen (Naprosyn)
Sulindac (Clinoril)

Gold compounds (chrysotherapy)

sodium thiomalate (Myochrisine)
aurothioglucose (Solganal)
auranofin (Ridaura)

Corticosteroids
intra-articular injections

Drug therapy
First-line Drugs
Acetylsalicylate
(Aspirin),
Corticosteroids

"Second-line or
"Slow-acting Drugs
- Disease-modifying
Anti-rheumatic
Drugs (DMARDs)

MUSCULOSKELETAL PROBLEMS
II. ARTHRITIS
B. OSTEOARTHRITIS
PATHOLOGY:
Degeneration of articular cartilage Cartilage erosion
Boney outgrowths SPURS (Osteophytes) Hypertrophy
Heberdens nodes, Bouchards nodes
Heberdens N. boney outgrowths over distal
interphalangeal joints
Bouchards N. boney knowbs over prox.
Interphalangeal joints
Knee involvement: Varus, Valgus, Limited ROM,
Crepitus

Pathologic Changes Seen With

Osteoarthritis

Normal

Degenerated

DIFFERENCE BETWEEN RA & OA

RA
Pain
Joint
Symptoms
ESR
Weight
Age

stiffening upon waking

ankylosis
systemic
increased
underweight
young

OA
aching ff. exercise
motion limitation
local
normal
overweight
4th decade

 Management
relieve strain & further trauma to joints
local moist heat
cold packs
cane or walker if indicated
proper body mechanics
avoid excessive weight bearing and
standing
physical therapy
relief of pain (NSAIDS)
joint replacement as needed

JOINT SURGERY
Arthrodesis
- fusion of joint into functional position
Synovectomy
- removal of synovial membrane with an arthroscope
Arthroplasty
- total joint replacement with metal, plastic, or porous
coated prosthesis

NURSING CARE
Arthrodesis
- Cast care
Total Knee Replacement
- Use Continuous passive motion (CPM)
- Use knee immobilizer when OOB
- use for 8 out of 24 hrs.

Anti-Arthritis Medications

DRUGS
ASA
NSAIDs
Steroids
Antimalarials
Gold

SE
Tinnitus; bleeding
GI; Bleeding
GI; Cushings
GI; Hematologic
Rashes, hematologic; GI. GU
Oral safer than injectable
Takes weeks - months to work

Cytoxan
Methotrexate

GI; Cystitis
Immunosuppression

Osteoarthritis/ Gouty Arthritis

 As a beneficial exercise program, the

nurse teaching a group of clients with
osteoarthritis would suggest
a. minimal exercise several times daily,
followed by rest periods.
b. regular daily, low-impact exercise
program.
c. daily vigorous aerobic exercise
followed by a warm shower or bath.
d. strength-building exercises with
weights or resistance.

 As a beneficial exercise program, the

nurse teaching a group of clients with
osteoarthritis would suggest
a. minimal exercise several times daily,
followed by rest periods.
b. regular daily, low-impact exercise
program.
c. daily vigorous aerobic exercise
followed by a warm shower or bath.
d. strength-building exercises with
weights or resistance.

II. ARTHRITIS
C. GOUTY ARTHRITIS
PATHOLOGY:

Formation of tophi urate crystals

in synovium & soft tissues
>>inflammation>>release of
lysosomes by neutrophiles
>>tissue damage

COMPLICATION: Deformities; kidney damage

S & S:

*Extreme pain,
Swelling,
Erythema of involved joints,
*First metarsophalangeal joint of great
toe first area involved

Gout

Comparison of Gouty/Normal
Joint

Nursing and Medical Management

restrict eating foods
high in purines
Limit alcohol intake,
beer and wine
Management of pain:
bedrest, immobilize,
local heat application

LOW PURINE DIET

AVOID HIGH PURINE FOODS:
MEATS
FOWL
FISH & SHELL FISH
LENTILS, DRIED PEAS & BEANS
NUTS
OATS

MEDICATIONS
For acute attacks
Colchicine: decrease uric acid crystal deposit
Butazolidin,
Indomethacin
Preventive:
Probenecid (Benemid): enhance uric acid
excretion.
* Warn against use of ASA
ASA+Benemid= urate retention
* Report symptoms of: drowsiness,
dizziness, nausea & vomiting,
urinary frequency, dermatitis.
Allopurinol (Zyloprim): dec uric acid formation
* Long Term * Give with meals
* Force fluids

SYSTEMIC LUPUS ERYTHEMATOSUS

Collagen disorder;
Autoimmune
Manifestations:
- butterfly rash
- Raynauds phenomenon
- Photosensitivity
- Hair loss
- Joint pain

Complications:
Renal Damage
Cardiac Damage

Management:
- Salicylates
- NSAIDs
- Steroids
- Gold
- Methotrexate
- Cytoxan
** NO CURE

 The nurse assesses that the individual

most susceptible to osteoporosis is the
a. muscular 50-year-old man with
diabetes.
b. obese 50-year-old woman who is
allergic to milk.
c. thin 70-year-old man with gout.
d. slender 75-year-old woman.

 The nurse assesses that the individual

most susceptible to osteoporosis is the
a. muscular 50-year-old man with
diabetes.
b. obese 50-year-old woman who is
allergic to milk.
c. thin 70-year-old man with gout.
d. slender 75-year-old woman.

OSTEOPOROSIS
INCIDENCE:
Middle life & >
PATHOLOGY:Bone resorption faster than bone formation;
Decrease bone mass
ETIOLOGIC FACTORS:
Calcium deficiency
Lack of regular exercise
Dec. sex hormones Dec. bone Ca storage
MGT:
Ca supplements (CaCO3 best form)
PREC!: *Ca supplements can impair iron absorption
*Some foods (red meats, colas, bran, bread,
whole grain cereals) inhibit Ca absorption
*Take Ca 2h a.c. / p.c. Drink plenty of fluids
Reduction of alcohol & tobacco
Exercise - moderate
*Mechanical stress stimulate bone formation

Osteoporosis
- Height loss and discovery of
unsuspected fractures on X-ray --1 st
diagnostic clues
Vertebral collapse

kyphosis

Osteoporotic Changes
Height
59
53
5
49
46
43

MEDICATIONS
Hormone replacement:
Estrogen and Progesterone - slow bone loss
*Monitor for: breast tenderness, regular
mammograms and serum calcium
level
Analgesics and local heat - relieve pain
Supportive devices: braces
Vit D replacement- Calcitriol, calciferol
SE: dry mouth, metallic taste
Calcitonin- (Calcimar)- reduce bone resorption
and slow the decline in bone mass
SE: Chest pain, SOB

Biphosphonates- Etidronate (Didronel)

- increase bone density and restore lost
bone - inhibit resorption of bone
* monitor for nephrotoxicity aand
seizures
Fluoride- Alendronate (Fosamax)
- stimulate bone formation
*strict dosage precautions
*causes GI distress, esophageal erosion
*administer on empty stomach
*do not eat or drink for 30 mins
*take with water 6 8oz. not juice and
*remain upright for 30 mins after taking
drug
Monitor: hypercalcemia and tetany
serum electrolytes
Increase fluid intake and calcium rich foods

Pagets Disease:
Etiology and Risk factors

Cause is unknown
Family history
Older than 50 years of age
Slightly greater in men
than in women
Most commonly affects the
skull, femur, tibia, pelvic
bones and vertebrae

 Primary proliferation of
osteoclasts that
produces bone
resorption
compensatory
increase in osteoblastic
activity that replaces the
bone
Bone develops classic
mosaic pattern
(disorganized)
Pathologic fractures
occur

Management:
Non pharmacologic
therapy:
Physical therapy

Pharmacological
therapy

Calcitonin
Bisphosphonates
Plicamycin
Analgesics

Surgery:
Reduction of
Fractures
Arthroplasty

Proper Diet
Safety of
Environment

 The client with osteomalacia is depressed and

anxious about the outcome of the illness. The
most beneficial nursing response would be
a.Osteomalacia is a serious illness, but some
adjustments in lifestyle can offer a normal life
expectancy.
b.Treatment with NSAIDs and high-dose
calcium supplements will correct the disorder
in about a year.
c.Vitamin D will stimulate healing, and afterward
a low maintenance dose with adequate
calcium and protein will improve the condition.
d.Cortisone and active weight-bearing exercises
will reduce the symptoms and ultimately
resolve this condition.

 The client with osteomalacia is depressed and

anxious about the outcome of the illness. The
most beneficial nursing response would be
a.Osteomalacia is a serious illness, but some
adjustments in lifestyle can offer a normal life
expectancy.
b.Treatment with NSAIDs and high-dose
calcium supplements will correct the disorder
in about a year.
c.Vitamin D will stimulate healing, and afterward
a low maintenance dose with adequate
calcium and protein will improve the condition.
d.Cortisone and active weight-bearing exercises
will reduce the symptoms and ultimately
resolve this condition.

TRAUMATIC CONDITIONS
A. StrainStrain stretching injury to a muscle due to
mechanical overloading, forcible stretching or
unusual muscle contractions
- pull/twist >> trauma >> inflammation,
pain, loss of mobility
Ecchymosis will result as blood vessels
rupture
B. SprainSprain tear in the ligament surrounding a
joint due to overuse, misuse or
excessive twisting

Knee Injury

Menu

TRAUMA TO LIGAMENTS AND TENDONS

(KNEE AND ACHILLES TENDON)
S & S: Pain, Swelling, Joint instability, Loss of
function
MGT: R
Rest of the injured part
I
Ice for at least 48 to 72 hours
C
Compression with elastic
bandages, splints, or casts
E
Elevation of the extremity slightly
above level of heart

C. Dislocations
- displacement of bone from its correct position within a
joint
- Subluxation - partial dislocation
- Causes: congenital; disease or injury
- Manifestations: popping sound or giving out
sensation, pain in affected area, limited joint
movement, deformity
- Common sites: hip, knee, shoulder
- Interventions:
- Assess infants for congenital hip dislocation
- Immobilize the joint
Traumatic Hip Dislocation: danger of avascular
necrosis of the femoral head

E. Fractures
break in the continuity of the bone
Due to:
to stress, trauma, overuse, repeated wear
Pathophysiologic Changes:
Changes
Muscle spasms
pain, swelling, tenderness
temporary splinting of the fractured area
Deformity, shortening of the extremity, crepitus

Spiral Fx: Due to twisting.

Check for child abuse

Compound Fx:
Check for tetanus

CLINICAL MANIFESTATIONS

1. PAIN
2. MUSCLE SPASM
3. LOSS OF FUNCTION
4. DEFORMITY
5. SHORTENING
6. SWELLING AND DISCOLORATION
7. CREPITUS/CREPITATIONS

Stages of Bone Healing

*Hematoma formation
*Cellular Proliferation
*Callous formation
*Ossification
*Consolidation and Remodeling

MUSCULOSKELETAL PROBLEMS
TRAUMATIC CONDITIONS
E. FRACTURES (Cont)
Types: Simple / Compound; Incomplete / Complete
Complications:
1. Immediate: Hemorrhage & Shock
Fat Embolism (Sx: petechia,dyspnea)
Pul. Embolism
Infection & Osteomyelitis
Compartment Syndrome
Avascular Necrosis
DIC

Compartment Syndrome
Abnormal increase in pressure within a confined
space
impaired circulation
Causes: restrictive dressings, tight cast and severe
swelling, hemorrhage
Tissue damage in 30 mins
permanent damage in 4hrs
6 Ps- Pain, Pallor, Paresthesia, Pulselessness
Paralysis, Poikilothermia
Pain: more severe when elevated due to decreased
circulation & with passive motion

Permanent neuromuscular damage in 4-6 hrs

Treatment: **Notify MD STAT
Fasciotomy
Positioning affected extremity lower than the
heart
Removal of dressings/casts >> BI-VALVE CAST

Fat Embolism
An embolism originating in the bone
marrow
Occurs: first 72hrs after a fracture
long bone fractures

SX: Restlessness, changes in LOC,

tachycardia, tachypnea, dyspnea,fever
petechial rash over upper chest and
neck
O2 and treat symptoms as needed
CALL MD STAT!

Nursing Interventions:

Immediate Immobilization
Minimal Fracture manipulation
Adequate support of fractured
bones during positioning and turning
Support respiratory function
(initially administer oxygen then
position in Fowlers position)

 A client with a left lower leg fracture in a

cast for 3 days complains to the nurse that
the pain medication does not relieve the
pain under the cast, especially when the
leg is elevated. The most appropriate
action by the nurse would be to
1.elevate the cast on pillows.
2.administer analgesics.
3.notify the physician.
4.distract the client with conversation.

 A client with a left lower leg fracture in a cast for

3 days complains to the nurse that the pain
medication does not relieve the pain under the
cast, especially when the leg is elevated. The
most appropriate action by the nurse would be to
1. elevate the cast on pillows.
2.administer analgesics.
3.notify the physician.
4.distract the client with conversation.
Unrelieved pain is a manifestation of
compartment syndrome

MUSCULOSKELETAL PROBLEMS
TRAUMATIC CONDITIONS
E. FRACTURES: Complications (cont)
2. Delayed:

Delayed union, Malunion, Non-union

Principles in Fracture Management:

1. Reduction
Open: Use of surgery & IFD
Closed: Manipulation, meds: analgesics &
muscle relaxant
2. Immobilization
Devices:
a. EFD

Types of Internal Fixation Devices

09/11/16

UST College of Nursing

86

TRAUMATIC CONDITIONS
E. FRACTURES
Principles in Fracture Management:
2. Immobilization (cont.)
b. Traction
Principles
Types: Straight running
Balanced suspension
Application: Skin
Skeletal
Fitted Adjustable
Manual
Special Considerations

PURPOSES:

TRACTION

TO REDUCE, ALIGN AND IMMOBILIZE

FRACTURES
TO MINIMIZE MUSCLE SPASMS
TO REDUCE DEFORMITY
TO INCREASE SPACE BETWEEN
OPPOSING SURFACES

NURSING MANAGEMENT:

PRINCIPLES OF EFFECTIVE
TRACTION
Continuous to be effective
Never interrupted
Weights are NOT removed
Observe good body alignment
Ropes must be unobstructed
Weights must hang freely

NC: Russell Traction: NO side to side movement

TYPES OF TRACTION

1. SKIN TRACTION

a. BUCKS EXTENSION

TRACTION
Indication: femur/hip
involvement
- Simplest form of traction

b. RUSSELS TRACTION
Indication: Femur/ Hip joint
fracture

- incorporates the use of a KNEE

SLING
- Hip is flexed to 20 from the
mattress.

Bryants Traction

c. BRYANTS TRACTION
Indication: children with CONGENITAL
HIP DISLOCATION
-for children BELOW 2-3 years
-for children weighing LESS THAN 3040 lbs.
N/R: - Buttocks should not touch the
mattress.
- assess neurovascular status

 Intermittent
Continous:
Horizontal
Wts. hang from
head of bed

d. CERVICAL TRACTION
Indication: cervical spine fracture
- make use of a Cervical halter or
cervical sling.
-HOB is elevated to 30-40

e. PELVIC TRACTION
Indication: Pelvic bone fracture
- used for lumbar fracture
- make use of a pelvic halter.
- Supine position

Pelvic traction

Halo pelvic traction

Balanced Suspension
Traction
- Make use of Thomas Splint with
Pearson Attachment.
-Hips are flexed 30 from the
mattress.

NC: * No side to side motion

Change of linen: head to foot

Care of pin site:

-Clean with
antiseptic
-Apply antibiotic
-NO betadine >>
rust pins
-NO peroxide >>
-Aerobic infection

2. IMMOBILIZATION (Cont.)
c. Cast: Plaster of Paris / Fiberglass

DRY CAST VS. WET CAST

DRY

WET

Appearance

White & Shiny

Grey

Percussion

Resonant

Dull

Odor

Odorless

Musty

Texture

Firm, hard &

rough

Damp to
touch

Shoulder-spica

Hip-spica

 In caring for a client with a wet plaster cast, the

nurse would
1. make certain to handle the casted limb with
open palms.
2. firmly grip the anterior surface of the cast to
prevent jarring the limb.
3. gently prop the casted limb on a hard surface
until completely dry.
4. cover the casted limb with a light blanket to
speed drying time.

 In caring for a client with a wet plaster cast, the

nurse would
1. make certain to handle the casted limb with
open palms.
2. firmly grip the anterior surface of the cast to
prevent jarring the limb.
3. gently prop the casted limb on a hard surface
until completely dry.
4. cover the casted limb with a light blanket to
speed drying time.

Cast Care
- Plaster of paris or fiberglass

Keep cast and extremity elevated

Allow a wet cast to dry 24- 48 hours
Monitor for circulatory impairment
INSTRUCT not to insert anything inside
the cast
Keep cast clean and dry
Isometric exercises to prevent muscle
atrophy

TRAUMATIC CONDITIONS
E. FRACTURES
Principles in Fracture Management: (Cont.)
2. Immobilization (cont.)
Devices (cont.) :
d. Splints
e. Braces
Types: Cervical
Thoracic: Taylor
Lumbar: Jewette, Chair-back
Scoliosis: Milwaukee
Leg

BODY BRACE

LEG BRACE

 3. Rehabilitation
- Ambulatory Aids: Walkers, Canes Crutch-walking
*Gaits: 2-point; 3-point; 4-point
- Diet
- PT

 The principal concept that a nurse would include

in a teaching plan regarding partial weightbearing is that the client should
1.prevent the affected foot from touching the
floor, bearing weight only on the
unaffected
limb.
2.rest the affected foot on the floor and place
weight on it 30% to 50% of the time.
3.use a walker or crutches and bear 30% to 50%
of weight on the affected limb.
4.bear as much weight as can be tolerated 30%
to 50% of the time.

 The principal concept that a nurse would include

in a teaching plan regarding partial weightbearing is that the client should
1.prevent the affected foot from touching the
floor, bearing weight only on the
unaffected
limb.
2.rest the affected foot on the floor and place
weight on it 30% to 50% of the time.
3.use a walker or crutches and bear 30% to 50%
of weight on the affected limb.
4.bear as much weight as can be tolerated 30%
to 50% of the time.

 Cane held on
non-affected side
Cane walks
together with weak
leg

WALKER

-The MOST stable among the assistive

devices

SEQUENCE:
a. Advance walker within arms length
(Approx 10-12 inches in front of the
patient.)
b. Walk inside the walker.

Measurement:
2 below axilla
6 front of foot
2 to the side of foot
elbow flexion (20 30 degrees)
Exercises to prepare for CW:
- hand muscle ex
- arm muscle ex
Gaits
Stair climbing:
UP: good leg >> crutches with bad
leg
Down: bad leg with crutches
>>good leg

CRUTCHES
IMPORTANT MUSCLES USED
a. Shoulder Depressor/ lassitimus
dorsi
- needed first to advance the body
forward.
- needed to lift the pelvis off the
ground.

b. elbow extensors/ triceps

- needed to prevent buckling of
the elbow joint.

c. finger flexors
-needed to grasp the hand grip.

 Crutch gait walking

- 4 point- most stable- partial weight
bearing
- 3 point- allows affected leg to be
partially or completely free of weight
bearing
- 2 point- faster version of 4 point gait

CRUTCH WALKING:
Nursing Considerations:
- stand on the affected side when
ambulating with client
- When ambulating: Instruct to
- look up and outward when
- place crutches 6-10 inches
diagonally in front of the foot.

HIP FRACTURES

Common among elderly women

Affected leg is adducted, externally rotated
and the limb is shortened
complaints of pain in the GROIN or in the
medial side of the bone.
Unable to move affected leg
Same signs & symptoms with fracture

Hip Fractures
Total or partial hip replacement
Traction can be used pre-operatively
Post-op care:
- maintain leg and hip in proper alignment
- maintain legs in abduction
- avoid bending
- use trochanter roll to prevent external
rotation
- make sure hip flexion does not exceed 90
degrees
- Avoid low chairs

Intertrochanteric Hip fractures

09/11/16

UST College of Nursing

134

 The nurse ensures postoperative

positioning for a client who has a total hip
arthroplasty is
a. high-Fowlers position with leg internally
rotated.
b. semi-Fowlers position with leg
externally rotated.
c. supine position with small pillow and
knees flexed.
d. side-lying position on unaffected side
with operated side extended.

 The nurse ensures postoperative

positioning for a client who has a total hip
arthroplasty is
a. high-Fowlers position with leg internally
rotated.
b. semi-Fowlers position with leg
externally rotated.
c. supine position with small pillow and
knees flexed.
d. side-lying position on unaffected side
with operated side extended.

 A client enters the emergency department with an

injured right knee after falling at home. When the
client proudly reports that he immediately put a hot
compress on the injury, the nurses best response is
a.That was quick thinking for you to apply the
compress, because the heat will reduce swelling.
b.The immediate application of heat will reduce the
pain and swelling of your injury.
c.Let me exchange the hot compress for a cold one.
Heat may cause more bleeding and discomfort.
d.I know that the heat makes your knee feel better,
but neither hot nor cold applications affect the
injury.

 A client enters the emergency department with an injured

right knee after falling at home. When the client proudly
reports that he immediately put a hot compress on the
injury, the nurses best response is
a.That was quick thinking for you to apply the compress,
because the heat will reduce swelling.
b.The immediate application of heat will reduce the pain
and swelling of your injury.
c.Let me exchange the hot compress for a cold one.
Heat may cause more bleeding and discomfort.
d.I know that the heat makes your knee feel better, but
neither hot nor cold applications affect the injury.

NURSING CARE
Intracapsular Fx, ORIF w/ Prosthetic Implant
- Hip flexion limited to 90 degree flexion for 2-3 mons.
- No adduction beyond the midline for 2-3 mons.
- No extreme int. or ext. rotation for 2-3 mons.
- Turn to back or unaffected side holding affected leg in
abduction 30 degrees
- Sitting: Day 1-10: hip flexion up to 60 degrees
Day 10-2 mons.: hip flexion 90 degrees
- Partial weight-bearing for 2 mons.
- Diet: hi-fiber, lo-Ca, increased fluids
- Use TEDS
- HT: avoid: sitting in low chairs, lifting, leg crossing,
jogging, jumping
Use ambulatory aids as needed

Total Hip Replacement

- Keep hips in abduction & extension
- When sitting: hip limited to 90 degree
flexion
- Use firm chair
- Turning: Use abductor pillow

LOW BACK PAIN

CONTRIBUTORY FACTORS:
1. Spondylolisthesis forward slip of affected vertebral body
2. Spondylosis defect in the 6th lumbar vertebra
3. Ankylosing Spondylitis progressive fusion of vertebra
4. Scoliosis
5. Kyphosis
6. Lordosis (sway back)
7. HNP

Scoliosis

- lateral curvature of the thoracic, lumbar or

thoracolumbar spine.
- Rotation of the vertebral column causes rib
cage deformity
Types:
- Functional- poor posture or discrepancy in leg
lengths
- Structural- deformity of the vertebral bodies
congenital, neuromuscular, idiopathic
(infantile, juvenile and adolescent)
- Different stresses on the vertebral bodies
causes imbalance of osteoblastic activity
- Curve progresses rapidly during adolescent
growth spurt

Signs:
Uneven hemlines, one hip higher than the other, unequal
shoulder heights and iliac crests, asymmetric thoracic
cage
Diagnosis:
Spinal X-rays (cobbs method) , Adams forward bending
test, scoliometer
Complications:
Pulmonary insufficiency, back pain, HNP, sciatica,
degenerative arthritis of the spine
Treatment:
- will depend on the degree of curvature
- 10-20 deg : exercises- pelvic tilt- strengthen torso
muscles
- 20-40 deg: exercises + braces- worn until the bone
growth complete
- 40 deg above: spinal surgery- instrumentation with
fusion

 Nursing considerations:
- Suggest loose, fitting clothes, wear
undergarments when wearing the brace
- Wear the brace for 23 hours a day
- Advise to increase activities gradually
After corrective surgery:
- check neurovascular status q2-4hrs
- logroll
- monitor I&O, bleeding
- encourage DBCE
- medicate for pain
- do ROM
- Offer emotional support for altered body image

 A client reports that when he bent over to

pick up a heavy piece of equipment from
the floor, he felt pain in his back that
radiated down his left leg. The nurse
assesses that this clients injury is
probably
a. a dislocated hip.
b. a herniated disc.
c. spondylitis.
d. degenerative joint disease.

 A client reports that when he bent over to

pick up a heavy piece of equipment from
the floor, he felt pain in his back that
radiated down his left leg. The nurse
assesses that this clients injury is
probably
a. a dislocated hip.
b. a herniated disc.
c. spondylitis.
d. degenerative joint disease.

SPINAL CORD INJURY

Emergency Care
Immobilize Head and Spine
Transport client in position which he is found

Hospital Care
Airway
Immobilize (Halter traction, Crutchfield tongs, Stryker
frame)
Steroids
Bladder & Bowel Care
Skin Care
NG Tube
Prevent deformities

 If patient has a severe cervical injury

should be placed in skeletal traction
various types of tongs may be used:
Crutchfield, Barton, Gardner-Wells

HERNIATED NUCLEUS POLPUSUS

- common site: lumbar
- Causes: trauma/strain
joint degeneration IV disc
- SX: Cervical: Shoulder & arm pain
Lumbar: Low back & leg pain

Syptoms:
- severe low back pain >> buttocks, legs, feet
(unilateral) >> sciatic pain
intensified by: valsalva, coughing,
sneezing, bending
- motor & sensory loss >>weakness & atrophy
of leg muscles
Dx: (+) straight leg test
(+) Lasegues sign (pain when thigh & knee
are flexed at 90 degrees)
X-ray
MRI
Myelography

Treatment:
Conservative:
- bedrest w/ pelvic traction
(increase fluids, antiembolic stockings,
use fracture bedpan)
- Head & neck in neutral position
- Log roll
- Heat application
- Exercise program
- Corticosteroids: epidural & oral
- NSAIDS
- PT
- muscle relaxants

Surgery: Laminectomy & Spinal fusion

*Flat supine 1st 8hrs >> turn to
sides
*check dsg for CSF leaks
*check VS & neurovascular
status of legs
*check bowel & bladder
Chymopapain Injection: for lumbar herniation
*enforce bedrest after treatment
H.T.
- use firm mattress
- wear brace
- good body mechanics

SPINAL CORD INJURY

TYPES:
1. Transient Concussion
full recovery
2. Contusion
3. Laceration
4. Cord Compression
5. Complete Cord Transection
PATHOLOGY:
Primary reaction: *Injury
bleeding extradural,
subdural, subarachnoid
*nerve fiber swells
disintegration
Secondary reaction: Ischemia, Hypoxia, Edema
destruction of myelin & axon
cord degeneration
- maybe reversible 4-6 hrs. after injury
- Mgt: Dexamethasone
Mannitol decrease edema
Dextran inc. capillary flow

SPINAL CORD INJURY

PATHOLOGY (cont.):
Emergency Care:
1. Immobilize with spinal board, H & N in
neutral position
2. Cervical collar
3. Avoid any twisting movement
Suspect victims of accidents (motor, sports, diving,
falls) as having SCI until such injury is ruled out
Manifestations:
1. Pain: back or neck
2. Fear: back or neck is broken
3. Total sensory & motor paralysis below
neurological level
4. Loss of bowel & bladder control
5. Loss of sweating & vasomotor tone
6. Loss of respiratory function

SPINAL CORD INJURY

Manifestations (cont.):
Spinal Shock: sudden depression of reflex
activity of SC (areflexia) below level of injury;
muscles innervated below cord are completely
paralyzed, flaccid, (-) reflexes
Damage at Cervical: most critical
quadriplegia, (-) movements chest & trunk
respiratory difficulty
Damage at Thoracic:
chest, trunk, bowel, bladder and LE
muscle losses (paraplegia)
Damage at Lumbar & Sacral:
paralysis of LE

- May last for 7 days to 3 months

- Indications that SC is resolving:
*return of reflexes,
*devt of hyperreflexia rather
than flaccidity
*return of reflex emptying of
the bladder
*babinski reflex

Wedge fracture

Flexion teardrop fracture

Common mechanism of
shearing of the spine

shear

Unilateral facet dislocation

resulting from combined
flexion and rotation

Bilateral facet dislocation

Common mechanism of
flexion-rotation
Flexion-distraction
injury of the lumbar
spine

Common mechanism of
extension injury

Hyperextension injury

Hyperextension sprain

Common mechanism of
injury of burst fracture
Burst fracture

SPINAL SURGERY
CERVICAL:
HOB elevated 30-45 degrees
Trach care and suctioning PRN
Check screws of brace for loosening
OOB with brace as soon as tolerated
Use cervical brace
Keep head in neutral position
Avoid: prone position, propping up on pillows,
sitting or
standing for more than 30 mins.

SPINAL SURGERY
THORACIC:
HOB elevated 30 degrees
BR for 1 wk.
Chest tube care if present
Avoid: twisting & bending motions, vigorous pushing or
pulling with arms
Use brace before getting OOB
LUMBAR:
Use frim mattress
When in bed: flat head pillow, slight knee flex
Log roll in turning
Discourage sitting except for BM
Mobility: Use braces for 4 mons.
OOB: Laminectomy: 1 day p.o.
Spinal Fusion: 3-5 days p.o.
When lying on side, avoid extreme knee flexion

Osteosarcoma
- bone tumors; primary or secondary
- 10-25 years of age - most common
- Sx: Palpable mass or hard lump, pain, pathologic
fractures, decreased sensation, numbness and limited
movement
- Tumor erodes bone cortex elevating the periosteum
- Inc. serum alkaline phosphatase - bone lysis
- Interventions:
Radiation
Chemotherapy
Surgical removal of tumor

Bone Tumors

Hughes, 1983.

Amputation
Surgical removal of a part of a limb
Post-op care:
- monitor VS
- evaluate for phantom limb sensation and pain;
provide reassurance
- 1st 24hrs,elevate stump >> flat on bed to
prevent flexion hip contractures
- after 48hrs - prone position several times a
day
- maintain application of ace wrap to promote
stump shrinkage

A Common method of wrapping an amputation stump.

Top, above-knee amputation. Bottom, Wrapping for
below-knee amputation.

Bunions and Their Surgical

Correction

 Carpal Tunnel Syndrome

median nerve at the wrist compressed by
a thickened flexor tendon sheath, skeletal
encroachment, edema, or a soft tissue
mass
reduces the amount of space inside the wrist
and crushes the central nerve

commonly caused by repetitive hand

activities
associated with
Arthritis
Hypothyroidism
Pregnancy

Carpal Tunnel Syndrome

Clinical Manifestations
- Pain
Night pain
Radiating or referred pain into the arm
and shoulder
Numbness
Paresthesia
Weakness along the median nerve
(thumb and first two fingers)

Identifying Carpal Tunnel

Syndrome
Tinnels Sign
elicited in patients by percussing
lightly over the median nerve,
located on the inner aspect of the
wrist
positive if pt. reports tingling,
numbness, and pain

Treatment
Resting with splints to prevent
hyperextension and prolonged flexion of the
wrist
Avoidance of repetitive flexion of the wrist
use of ergonomic changes at work to reduce wrist
strain

NSAIDS
Carpal canal cortisone injections
Non-traditional alternatives
Yoga postures
Relaxation
Acupuncture

Surgical Management
Endoscopic laser surgical release of
the transverse carpal ligament
Wear hand splint after surgery
Limit hand use during healing
Assistance with personal care and ADLs
**Full recovery of motor and sensory
function after nerve release surgery may
take several weeks or months

Scoliosis
- lateral curvature of the thoracic, lumbar or
thoracolumbar spine. Rotation of the vertebral
column causes rib cage deformity
Types:
- Functional- poor posture or discrepancy in leg
lengths
- Structural- deformity of the vertebral bodies
congenital, neuromuscular, idiopathic (infantile,
juvenile and adolescent)
- Different stresses on the vertebral bodies causes
imbalance of osteoblastic activity; curve progresses
rapidly during adolescent growth spurt

Scoliosis
Signs:
Uneven hemlines, one
hip higher than the
other, unequal
shoulder heights and
iliac crests, asymmetric
thoracic cage
Diagnosis:
Spinal X-rays (cobbs
method) , Adams
forward bending test,
scoliometer

Complications:
Pulmonary insufficiency,
back pain, HNP, sciatica,
degenerative arthritis of
the spine
Treatment:
- 10-20 deg- exercisespelvic tilt- strengthen torso
muscles
- 20-40- exercises + bracesworn until the bone growth
complete
- 40 above- spinal surgeryinstrumentation with
fusion

Scoliosis
Nursing considerations:
- Suggest loose, fitting clothes, wear
undergarments when wearing the brace
- Wear the brace for 23 hours a day
- Advise to increase activities gradually
After corrective surgery:
- check neurovascular status q2-4hrs, logroll
- monitor I&O, bleeding
- encourage DBCE, medicate for pain, do ROM
- Offer emotional support for altered body image

Treatment: Surgical

Posterior fusion and Harrington Rod

instrumentation
Wisconsin wire technique and Luque wiring

Zielke System

Hip/thigh shortening

CLICKING SOUND ORTOLANIS SIGN