Care of the Clients with

Musculoskeletal Disorders

▪ LABORATORY/ DIAGNOSTIC TESTS

√ Blood Tests
◊ESR ( elevated in SLE and arthritis)
◊ Rheumatoid factors ( + in rheumatoid arthritis)
◊ Lupus erythematosuscells(Le cells)
◊ Antinuclear antibodies (ANA) (+ in Rheumatoid arthritis)
◊ Anti- DNA (+ in SLE)
◊ C- reactive protein (+ in rheumatoid arthritis)
◊ Uric Acid (elevated in Gout)
◊Mineral s
○ Calcium
● Decreased levels in osteomalacia , osteoporosis.
● Increased levels in bone tumors, healing fractures, Paget’s disease
○ Alkaline Phosphatase
● Elevated level s in bone cancer, osteoporosis, osteomalacia, Paget’s
disease
○ Phosphorus
● Increased levels in healing fractures, bone tumors.

◊ Muscle Enzymes
○ Aldolase

● Elevated in muscle dystrophy, dermatomyositis

○ AST (aspartate amino transferease)

○ CK (creatinePhospokinase )
Elevated in traumatic injuries
○ LDH (lactic Dehyrogenase)
●Elevated in skeletal muscle necrosis, extensive cancer

√ X-Rays(Roentgenography)
Done primarily to detect bone fractures
√ Bone Scan
● Measures radioactivity in bone 2 hrs.after IV injections of a radio isotope; detects
bone tumors, osteomyelitis.
◊Nursing Care
○Patient must void immediately before procedure
○ Patient must remain still during scan
√ Arthroscopy
◊ Insertion of fiberopticcs scope into a joint to visualize it, performs biopsies or remove
loosesbodies .
◊ Performed in OR under sterile technique
◊ Nursing care
Pressure Dressing for 24 hrs.
Patient must limit activity for several days
√ Arthtrocentesis : removal of synovial fluid, blood pus from a joint.
√ Myelography
◊ Lumbar puncture is done to withdraw a small amount of CSF, which is replaced
with a radiopaque dye ; used to detect tumors or herniated intravertebral discs.
◊ Nursing Care Pretest
Consent form must be signed
Check for iodine allergy
Keep on NPO after liquid breakfast
◊ Nursing Care post test
● If dye has been completely removed (oil Dye), Keep patient flat for 12 hrs.
●If dye has not been completely removed (water based dye-Amipaque ), keep head of
bed elevated( 30_ 45) to prevent causing meningeal s irritations and seizures.
● If water based dyesused pit patient on seizure precautions and do not administer
any phenothiazine
√ Electromyography (EMG)
◊ Measures and records activity of contracting muscle in response to electrical
stimulation; helps differentiate muscle disease from motor neuron dysfunction.
◊ Explain procedure to patient and prepare him for discomfort of needle insertion.

COMMON MUCULO-SKELETAL INTERVENTIONs

√ RANGE OF MOTION EXERCISE
◊ Types
○ Active – done by the patient. Increase and maintains muscle tone and joint
mobility.
○ Passive- Done by the nurse without help from the patient, maintains joint mobility
only
○Active assistive – patient moves body part as far as possible and nurse completes
exercise or stronger arm and leg perform exercise to weaker arm leg.
○ Active resistive – contraction of muscle against an opposing force; increase muscle
power.
√ Isotonic Exercise
Involves change in both muscle length and tension
√Isometric Exercise
●Active exercise through contraction/ relaxation of muscle- no joint movement –length
of muscle does not change
● Patient increase tension in muscle does not change
● maintains muscle strength and seize

√ASSISTIVE DEVICE FOR WALKING

●Cane
○ Types- single, tripod cane, quadripod cane.
○ Patient must hold cane in hand opposite affected extremity. Advance cane as the
affected leg is moved forward

● Walker
○ Hip level
○ lift and walk
○ Positioned at the back when ongoing down the stirs
◊ Crutches
○ Assure proper length
● with patient standing: top of the crutch is 2 inches below the axilla and the tip of
each crutch is 6 inches in front and to the side of the feet ( 2 inches forward, then 4
inches to the side ).
● patient’s elbows should be slightly flexed when hand is on bar (30 degree).
●Weight must not be borne by axillae, but on palms of the hand to prevent crutch
palsy.
○ Crutch gaits.
● Four point gait. Advance right crutch followed by the left foot , then left crutch
followed by the right foot
● Two point gait. Advance right crutch and left foot together , then the left crutch and
the right foot together .
● three point gait . advance the both crutches and affected leg together , followed by
the unaffected leg. None or Little weight bearing is allowed .
● Swing to gait. Advance both crutches, swing the body so that the feet will be at the
level of crutches.
○ swing through gait. Advance both crutches , swing the body so that the feet will be
past the level of the crutches .
○ Going up and down the stairs
● Up with the good ( good leg first, then bad leg and crutches ).
● Down with the bad ( bad Leg and crutches first, then good leg).

√ CARE OF THE CLIENT WITH CAST

●Carry with palms of the hand. To prevent indentions and pressure.
Elevated wioth pillow support.To prevent edema.
Expose to dry .dry cast appears white, shiny, hard and resonant
►keep clean and dry
► Observe “hot spots” & musty odor. These are sign and symptoms of infection
► maintain skin integrity_”petalling”
► Do neurovascular check:
○ skin color
○ Skin temperature
○ sensation
○ Mobility
○ Pulse
► Windowing- to facilitate observation under cast
► Bivalving-If Cast is too tight/ Healing process has occurred. It is splitting of the
cast.

Care of Client With Traction

►Traction
○ The act of pulling associated with counterpull
► Purpose
○ reduce/ immobilize fractures
○ relieve muscle spasm
○Prevent / correct deformities
►Types
○ Skin Traction
● Bucks’s traction
○ exerts straight pull on affected extremity, temporary to immobilize the leg in patient
with a fractured hip
○ Shock blocks at the foot of the bed produce counter traction and prevent the patient
from sliding down in bed.
○ Has a horizontal weight
○ Turn towards unaffected side, with 2 pillows in between legs.
○ Check for pressure sore at the heel of the feet and signs and symptoms of
thrombophlebitis.

● Russell Traction
○Knee is suspended in a sling attached to a rope and pulley on a Balkan frame,
Creating horizontal traction.
○ Weights are attached to the foot of the bed creating horizontal traction.
○ Used to treat fracture of the femur
○ Allows patient to move about in the bed more freely and permits bending of the knee
joint.
○ Hip should be flexed at 20 degree ; foot of bed usually elevated by shock blocks to
provide countertraction .
○ Assess back of the knee for pressure sores.
○ Check for signs and symptoms of thrombophlebitis.

●Bryant Traction
○ Both legs raised at 90 degree angle to bed because the weight of the child is not adequate to
provide countertraction.
○ Used for children under 2 years and 30 pounds to treat fractures of the femur and hip
dislocation
○ Buttocks must be slightly off the mattress. To enhance efficacy of the weights that
hang over head of bed.
○ Knees slightly flexed . To prevent hyperextension deformity.

● Cervical Traction
○ Cervical head halter attached to weights that hang over head of bed.
○ Used for soft tissue damage ore degenerative disc disease of cervical spine to reduce muscle
spasm and maintain alignment.
○ Usually intermittent traction, elevated head of bed to provide countertraction.

●Pelvic Traction
○ Pelvic girdle with extension straps attached to ropes and weights used for low back to reduce
muscle spasm and maintain alignment.
○Usually intermittent, patient in semi-Fowler’s postion with knee gatched 20-30 degree angle,
secure pelvic girdle around iliac crests.
○ Encourage to use overhead trapeze.
● Skeletal Traction- traction applied directly to the bones using pins,wire , or tongs
(Crutchfield) that are surgically inserted, used for fractures femur , tibis , humerus , cervical
spine.

● Balanced suspension traction

○ produced by a counterforce other than the patients weight.
○ Extremity floats or balances in the traction apparatus.
○patient may change position without disturv\bing the line of traction.

● Thomas splint with Pearson attachment

○ Use with skeletal traction in fractures of the femur; hip should be flexed at 20 degree
○ Use footplate to prevent footdrop
○ Check pressure at the inguinal area (groin)

● PRINCIPLES IN THE CASE OF THE CLIENT WITH TRACTION

○ The line of pull should be in line with the deformity
○ There should be an adequate counteraction
○ Apply traction continuously
○ Allows the weight to hang freely
○ turn the client as indicated
○ Avoid friction
○ Pin site care for skeletal traction
○ Cleanse and apply antibiotic
○ Do neurovascular check
○ Prevent complications of immobility
● DISORDERS OF THE MUSCULOSKELETAL SYSTEM

Trauma
● Strain. Damage to tendon due to twisting motion
● Sprain. Damage to ligament due to twisting motion
● Subluxation. Complete disarticulation
● Fracture. Any impairment in the bone integrity

TYPES OF FRACTURE
● Cpmplete. The entire circumference of the bone is impaired .
● Incomplete . Only partial circumference of the bone is impaired
● Transverse. The line of break is across the bone.
● Oblique. The line of break goes diagonal along the bone.
● Spiral. The line of break goes around along the bone.
● Greenstick. One side of the bone is impaired , the other side is bent . It affects
cartilaginous bones: common in children.
● Comminuted. Bone ends are splintered into 2 or more small pieces.
● Impacted. One bone enters the intramedullary space of another bone end.
● Closed or simple – no break in skin.
● Open or Compound – break in skin with or without protrusion of bone .
● stress . this is due to other systematic diseases.
●Pathologic . This is due to other systematic diseases
● Traumatic. This is due to injury.

Assessment
● pain, aggravated by motion, tenderness
● Loss Of motion
●Edema
● Crepitus
● Ecchymosis
● Shortening of the limb
● Obvious deformity
● X-ray reveals fracture

Collaboration management
●Traction
●Reduction
►Closed reduction through manual manipulation followed by application of cast (with external
fixation) (CREF).
►Open reduction through surgery ( with Internal Fixation) (ORIF)
►Cast
► Monitor for disorientation and confusion in the elderly. This may result from stress of
fracture , unfamiliar surroundings, coexisting systematic disease, cerebral ischemia, etc.
► Prevent complications of immobility.
► Encourage use of trapeze to facilitate movement
►Analgesics

Care of Clients with open reduction

► Check dressings
► Empty Hemovac
►Assess LOC
►Turn q 2 hour
► turn to unoperative side only
► Plac e 2pillows between legs while turning & when lying on side
► Measures to prevent thrombus formation
● Elastic Hose
● Dorsiflexion of foot
● Anticoagulants such as aspirin
● encourage quadriceps setting and gluteal setting exercises
► Observe for adequate bowel and bladder function.
► Assist patient in getting in and out of bed first and second post-op daqy.
► Avoid weight bearing until allowed
● provide care for the patient with a hip prosthesis if necessary (similar to care of patient with
total hip replacement)

COMPLICATIONS OF FRACTURES
● Hypovolemic shock. This is due to massive bleeding .
●Fat embolism. This usually follows fracture of the long bones , e.g lower extremeties
or multiple fractures.
● Compartment Syndrome. This results from fractures of arms or legs where closed
compartment are present.
● a Compartments contains blood vessels, nerves, muscle which are enclosed by
fascia.

Fractures
Tight dressings
Tight Cast

Edema of contents of the compartment

↑pressure within closed compartment

5 P’s
Pain
Pallor
Pulselessness
Paresteshia
Paralysis

Contractures Function
e.g Volkmann’s contracture disability

○Collaborative Management of Compartment Syndrome

► Extremity elevated above the level of the heart
► Notify Physician
► remove tight dressing or cast
► Surgery: Fasciotomy with delayed primary closure of wound, 3-5 days after to allow
edema of compartment to subside
► Avascular Necrosis. Decreased bone tissue perfusion leads to bone tissue death.
Neck of the femur is commonly affected.
► delayed Union or Nonunion or Malunion. May result from infection, poor
circulation, ineffective immobilization, inadequate reducation or poor health condition.

○ TOTAL HIP REPLACEMEnt

► Replacement of both acetabulum and head of femur with prostheses
► Indications
► rheumatoid arthritis or osteoarthritis causing severe disability and intolerance
pain.
► Fractured hip with nonunion
○ Nursing Intervention
○ Provide routine post op care
○In addition to routine post op care.
► In addition to routine post op care
● Maintain abduction of affected limb at all times with abductor splint or 2 pillows
between legs.
► Prevent external rotation by placing trochanter rolls along hip
► Prevent hip flexion
► Head of bed flat if ordered
► Raised head of bed 20 -30 for meals if ordered; use abductor splint or two pillows
between knees while turning and lying on side.
► Get patient out of bed 2-4 days post op
► Avoid adduction and hip –flexion- do not use low chair
► Teach client
● Prevention of adduction of affected limb and hip flexion
● Do not cross legs.
● Used raised toilet seat
● Do not bend down to put on shoes or socks
● Do not sit in low chairs.
● Assess signs of wound infection.
● Exercise program as ordered.
●Partial weight bearing only until full weight bearing allowed; used three point crutch
gait.

■ RHEUMATOID ARTHRITIS

Chronic Systemic disease characterized by inflammatory changes in joints and related

structures.

Occurs in women more than men(3:1); peak incidence between 20 and 40 years of age.

Cause unknown

May be autoimmune process/may be genetic.

Predisposing factors include fatigue, cold emotional stress, infection

Joint distribution is symmetric- most commonly involves wrists, elbow, shoulder,

knees, hips, ankles and jaw.
If unarrested, affected joints progress through four stages of deterioration: synovitis,
pannus formation, fibrous ankylosis and bony ankylosis.

Assessment

Fatigue, anorexia, malaise, weight loss, slight temperature elevation.

Painful, warm,swollen joints with limited motion, stiff in morning and after periods of
inactivity.

Crippling deformity in long standing disease.

Muscle weakness secondary to inactivity

History of remissions and exacerbations.

Some patients have other manifestations: subcutaneous nodules, eye, vascular, lung
or cardiac problems.

► Sjoren’s Syndrome
● Excessive dryness of the eyes, mouth and vagina.