Clients with Alterations in Muscoloskeletal Function

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Ankylosis: abnormal joint rigidity
arthroplasty: surgical reconstruction of a diseased or damaged joint
Articulation: junction of two or more bones
contusion: injury to soft tissues caused by a blunt force
crepitus: a grating sound produced by bone fragments rubbing together
dislocation: bones of the joint are displaced from their normal position
fracture: a break in the continuity of the bone
isometric contraction: the length of muscle remains constant but the force generated by the muscle increases
Isotonic contraction: shortening of the muscle with no increase in tension within the muscle
kyphosis: excessive convex curvature of the thoracic spine
lumbar lordosis: abnormally increased concavity of the lumbar spine
scoliosis: deviation of the spine to the left or right
sequestrum: area of necrosed bone tissue
sprain: injury to the ligaments surrounding a joint caused by a wrenching or twisting motion
strain: injury to the muscle caused by excessive use, stress, or stretching
How are fractures classified?: by the type and extent of the break
What are signs & symptoms of fractures?: swelling, deformity, loss of function, shortening, & ecchymosis
Greenstick fracture: most commin in children because their bones are soft & do not always break clean. Similar to breaking a live stick.

Complication: injury to growth plate
Often result of trauma
Complete break: across the entire bone
can be displaced or non-displaced
Comminuted: or fragmented, may be open or closed
open: break in the skin, adds possible complication of infection
closed: may be non-surgically fixed
Incomplete: a break that does not divide into two peices

spiral
greenstick
Causes of fracture: trauma
osteoporosis
tumors
How long does it take for bones to heal in healthy adults?: 6 weeks
How long does it take for bones to heal in older adults adults?: may take 3-6 months
Healing of fractures is affected by: nutrition, hormones (post-menopause), and concurrent diseases such as PVD, diabetes, etc
Complications of fractures are: compartment syndrome
shock
fat embolus
DVT
infection
Compartment Syndrome: Can occur in the lower arm or the leg
It is a medical emergency.
It's caused by increased pressure in the compartement and if not treated will lead to necrosis of the tissue.
Causes of compartment syndrome: crushing injuries - where there is fluid shift causing the tissues in the compartment to fill with fluid resulting in pressure on the vessels and nerves

Casts - the injured area is not permitted to swell due to the constriction of the cast. The fluid goes to the path of least resistance: the compartment
symptoms of compartment syndrome: *pain is not relieved by pain meds
*painful response to passive dorsiflexion of toes or fingers
*changes in CMS (color, motion, sensitivity)
*renal failue due to release of protein from damaged muscle causing vasoconstriction in the kidneys
treatment of compartment syndrome: fasciotomy followed by grafting

*this complication is highly preventable. CMS checks q2 hours & elevate arm or extremity 2 inches above the heart
fasciotomy: a slice made through the skin and through the muscle to relieve the pressure and it will heal as an open wound-leaving scarring and the need for skin grafts
Volkmann's Contracture: usually upper extremities
Fat embolism: *Life threatening
*Cause - fat gobules released from the bone into the blood stream. Occurs mostly in long bones and mulitple fractures. The fat migrates to the small vessels that nourish the major organs- mainly the lungs
*Usually occurs within the first 48 hours
Symptoms of fat embolism: SOB, elevated V.S., low grade temp, petechiae (on neck, chest, & upper arms)
treatment of fat embolism: Oxygen, elevate HOB, move to a specialty unit
DVT in regard to fracture: this is not due to the fracture but due to any lower extremity trauma/surgery or prolonged bed rest. It ocurs 2-3 days after surgery.
Symptoms of DVT: positive Homan's, tenderness, warmth, and swelling
Prevention of DVT: Ted hose, Seq teds, ankle pumps, prophylactic heparin.

*Remove TEDs for 10 min q shift to check skin, check for c/o burning on the heel, apply lotion - prevention of pressure ulcers
traction: created by forward pull with weights distal to fx
counter traction: client's body weight
created with backward pull proximal to fx
Uses of fraction: *to provide alignment
*rest
*relief of muscle spasm
Can be continuous as with a fx or intermitten as with muscle spasms or strain
Running traction: weights pull one way while body provides counter-traction.
When position of bed is changed the pull changes (raise HOB, turn, slide down in bed).
Balanced traction: allows for movement without altering pulling force
Dunlop: skin and skeletal used for humerus or shoulder
Bryant: used with children
Bucks: skin for fx femurs pre-op. Can turn 90º onto affected side. (shortened and externally rotated) decrease muscle spasms and maintain bone alignment.
Russell's: used with Bucks. Gives leg support and adds comfort and mobility
90/90: femur fx
Thomas Pearson: used with post-op total hip replacement (THR) and with skeletal traction. Both for mobility and comfort.
Cervical traction: can be skin or skeletal-head halter, crutchfield tongs. Bed must be kept flat.
Russell's skin: not seen much any more
Balanced sling traction: skin
Thomas leg spling with person attachment: also called T-P splint
Used with skeletal traction for fx femurs.
May be used to rest injured leg
Over-the-face: also called 90/90
for fx humerus
Side arm traction: fx upper arm
may see this without actual counter pull at the shoulder.
It may just be used to maximally elevate an injured hand.
Be alert for pressure points, pin sites, properly wrapped Buck's and alignment.
Nursing care: turning q2h (with Buck's you can turn either way 90º, skeletal traction and T-P splints turn 45º)
Post op you can turn 90º to unaffected side, CMS checks q2h, check for skin breakdown of skin, check that ropes are in the pulleys and weights hang freely, ankle pumps, C&DB 10xs q 1h while awake, encouraged use of trapeze to keep elbows from rubbing on the bed.
External fixator: used when break is severe and/or tissue and muscle is lost
When open reduction/internal fixation is done it allows for: earlier rehabilitation
thumb spica: Used for thumb/hand & wrist fx
i.e. reconstruction arthroplasty
Long Arm Cast LAC: used for fx at distal humerus, radius and ulna
1 2/3 hip spica: used for fx at L femur ad for pelvis, hip fx
short leg cast SLC: used for ankle, foot or toes, fx
long leg cast LLC: tip-fib or ankle fx
body cast: used for fx thoracic spine; post op fusion, scoliosis
shoulder spica: unstable shoulder or humerus fx, dislocation of shoulder
walking cast: used for SLC & LLC
What is a green cast?: a wet cast, gray in color with a musky smell
Cast care for green cast: keep uncovered, handle with palms of hands, turn q2h to allow drying
May petal edges to have cast split
Nursing care for green cast: includes cast care, checking for tightness, CMS checks
Amputations: surgical or traumatic removal of a body part
Causes of amuputations: PVD (artherosclerosis, IDDM), trauma (crusing injuries), & traumatic amputation
below the kneee amputation BKA: tries to preserve the knee joint to allow for easier useof a prosthesis
above the knee amputation AKA: when tissue just below the knee is not viable
The higher the amputation the more energy needed for ambulation
Complications of amputations: infection, phantom pain (severe burning, crushing or cramping), flexion contractures.

Flexion contractures must be avoided or sitting and the use of a prosthesis will be difficult if not impossible
Nursing care of amputations: *Maintain self-esteem
*Put in prone position for 30 min q 3-4 h to prevent hip flexion contracture
*keep knee joint flat on bed
*pain control
*ace wrap to hold dressing and shape stump-distal to proximal
Ace wrapping amputations: amputations are covered with a cast or stump shrinker if the client is to be fitted with a prosthesis now (5-6 weeks). The cast helps the stump maintain a uniform shape. The cast will be changed q 1- days as the swelling decreases.
Hip fractures: Occcurs mostly in the elderly due to falls. The fracture is usually at the proximal femur in or near the greater trochanger
hip fractures sub-trochanteric: most distal
Usually repaired with plates and screws and sometimes with rods
hip fracture interochanteric: area distal to the femoral head
Repaired with screws and pins
hip fracture femoral head or neck: screws or endoprosthesis (Austin Moore) or total hip
Have to remove the joint and stretch muscles and tendons
Symptoms of hip fractures: shortened, externally rotated, adduction
Nursing care for hip fractures: maintain Buck's traction, turning CMS checks, Post-op care same as all surgical clients. Use pillows for comfort unless has Austin Moore or THR
Total joints: mostly older people due to osteoarthritis. Can be due to trauma, fractured hip, avascular necrosis
Total knee: Post op: bulky dressing groin to toes, hemovac, consta-vac, may have a Zimmer Splint to prevent knee flexion, turn q2h, IS, pillows for position of comfort (POC) but keep knee extended, Continuous Passive Motion (CPM) 8-20 h/d, increase to 90º, weight bearing as tolerated (WBAT)to no weight bearing (NWB) depending on cemented or non-cemented, ankle pumps, Seq Teds, OOB day one
Total hip: Cemented vs non-cemented
Post-op: knees kept 6 inces apart with pillows or abductor pillows, bed to chair day 1, Hi rise or total hip chair or pillows in low chairs, turn q 2h to unaffected side, hemovac, consta-vac, SEQ, IS, ankle exercises, may have Zimmer splint, check for DVT, CMS, WBAT to partial weight bearing (PWB) to NWB, (if non-cemented will be NWB for 6-8 weeks)OOB day one. Always check LS & BS. If no BS after having a general diet make NPO and tell doctor.
Why make client NPO if no BS?: paralytic ileus
Symptoms of paralytic ileus: no BS, no BM for 3 days, abdominal distension, & projectile vomiting
Diskectomy: removal of the nucleus polpulsus of a herniated disk.

Log roll, OOB day of surgery, home in 1-2 days, no drains, can sit but not bend
Laminectomy: removal of one or more laminae plus the herniation. Stay 2-3 days, log roll, may have a corset, spinal checks
laminectomy with fusion: uses an Illiac Bone Graft (IBG). Done in unstable spine. Uses bone from illiac crest. Will have 2 dressing and 2 drains.
nursing care for laminectomy with fusion: Keep flat, log roll, spinal checks, BS, LS, IS, SEQ, May have a Thoraco-lumbar-sacral-orthotic (TLSO), Lenght of stay 3-5 days, check for DVT, ankle pumps, anesthesia, PCA.

Nurse will probably have to straight cath q6h or insert a foley. No BM for 3 days=laxative
What are the beneifts of immediate postoperative prosthesis fitting: *May avoid hazards of immobility such as skin breakdown, UTIs, respiratory complications, etc
* Better emotional adjustment(substitute limb is already present)
*Shortens rehan time because rigid dressing (controlled tissue compression and protection from injury, edema, pain, phantom limb sensations, minimize contracture formation, etc.)
What are contraindications for immediate prosthesis fitting?: *Extremity infected prior to OR
*Peripheral vascular diseasewith poor perfusion to extremity
*Most AKA's (too debilitated from condition with created need for the AKS, e.g, gangrene, DM, osteomyelitis
*Unable to follow specific directions regarding weight bearing
What is the procedure for immediate postoperative fitting?: *Closed/flap surgical technique is used
*In OR, an occlusive dressing (e.g. Telfa) is placed over end of residual limb, followed by a sterile stocking, padding over pressure areas, and a rigid cast
*Use plaster of paris bandages for the cast, start at distal end and wrap using firm, even pressure
*The socket of distal end of cast is designed to connect to a pylon which then connects to a foot-ankle assembly
What is the progression with immediate postoperative prosthesis fitting?: *Partial weight bearing
During first week, can place no more than 20-25 lbs on prosthesis
May monitor using paired scalse or beeper placed between cast and prosthesis
*Early ambulation (immediate partial weight bearing)
Stand at bedside first day post-op (may even ambulate with walker 1-2 minutes)
Ambulation time each day (start with 3 minutes BID)
*Controlled progressive ambulation implemented in PT (parallel bars, crutches, cane, independent ambulation)
*Cast changes necessary as residual limb heals and shrinks (every 10-14 days)
*Full weight bearing starts after 2-3 weeks
*Permanent prosthesis as early as 5-6 weeks
Complications of immediate prosthesis fitting: abrasion or tissue damage of residual limb, wound dehiscence
Conventional delayed prosthesis fitting: Occlusive dressing applied and residual limb wrapped with elastic bandage; can also cast
Conventional delayed prosthesis fitting Soft dressing (with or without elastic bandange) - advantages & disadvantages: advantages - Allows for wound inspection and care

disadvantages - lack of controlled wound pressure (edema-pain),
likelihood of wound contamination,
probability of knee contractures
Conventional delayed prosthesis fitting, when are sutures removed: sutures removed in approximately 2-3 weeks, after which patient begins partial weight bearing using a temporary prosthesis
Residual limb excoriation: toughening residual limb helps prevent excoriation
- progressive pressure (soft pillow, firm pillow, hard surface)
- no more than 1-2 socks on residual limb
- massage after wound completely healed

Discontinue use of prosthesis if excoriation of residual limb is noted; contact physician
When does full weight bearing start with conventional delayed prosthesis fitting?: approximately 6 weeks
When is permanent prosthesis fitted for conventional delaysed prosthesis fitting?: permanent prosthesis at approximately 12 weeks
In order to be effective traction must always have: counter-traction to maintain positioning and/or alignement
Straight/running traction: *exerts pull in 1 plane
*counter-traction is provided by the patient's body weight (patient usually flat or trendelenburg)
*Can be skin or skeletal
*Examples include Buck's extension, pelvic, head halter (all forms of skin traction); Crutchfield tongs, Gardner-Wells tongs (both forms of skeletal traction)

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