MUSCULOSKELETAL

SYSTEM
DISORDERS
PYRAMID POINTS
 Assessment findings in a fracture
 Initial care of a fracture
 Various types of traction
 Nursing care of the client in traction
 Client education for the use of a halo device
 Client education related to crutch walking
 Client education related to the use of a cane
or walker
PYRAMID POINTS
 Assessment findings and interventions for
complications of a fracture
 Care of the client following hip pinning and
hip prosthesis
 Care of the client following total knee
replacement
 Treatment measures for the client with a
herniated intervertebral disc
 Care of the client following disc surgery
PYRAMID POINTS
 Interventions following amputation
 Treatment modalities for the client with
rheumatoid arthritis
 Client education related to osteoporosis
 Client education related to gout
INJURIES
 STRAINS
 An excessive stretching of a muscle or tendon
 Management involves cold and heat
applications, exercise with activity limitations,
antiinflammatory medications, and muscle
relaxants
 Surgical repair may be required for a severe
strain (ruptured muscle or tendon)
INJURIES
 SPRAINS
 An excessive stretching of a ligament usually
caused by a twisting motion
 Characterized by pain and swelling
 Management involves rest, ice, and a
compression bandage to reduce swelling and
provide joint support
 Casting may be required for moderate sprains
to allow the tear to heal
 Surgery may be necessary for severe
ligament damage
 INJURIES

 ROTATOR CUFF INJURIES

 Musculotendinous or rotator cuff of the shoulder
sustains a tear usually as a result of trauma
 Characterized by shoulder pain and the inability to
maintain abduction of the arm at the shoulder (drop
arm test)
 Management involves nonsteroidal antiinflammatory
drugs (NSAIDs), physical therapy, sling support, and
ice/heat applications
 Surgery may be required if medical management is
unsuccessful or for those who have a complete tear
FRACTURES
 DESCRIPTION
 A break in the continuity of the bone caused
by trauma, twisting as a result of muscle
spasm or indirect loss of leverage, or bone
decalcification and disease that result in
osteopenia
TYPES OF FRACTURES
 CLOSED OR SIMPLE
 Skin over the fractured area remains intact
 GREENSTICK
 One side of the bone is broken and the other is
bent; most commonly seen in children
 TRANSVERSE
 The bone is fractured straight across
 OBLIQUE
 The break extends in an oblique direction
 TYPES OF FRACTURES

 SPIRAL
 The break partially encircles bone
 COMMINUTED
 The bone is splintered or crushed, with three or more
fragments
 COMPLETE
 The bone is completely separated by a break into
two parts
 INCOMPLETE
 A partial break in the bone
TYPES OF FRACTURES
 OPEN-COMPOUND
 The bone is exposed to air through a break in
the skin, and soft tissue injury and infection
are common
 IMPACTED
 A part of the fractured bone is driven into
another bone
 DEPRESSED
 Bone fragments are driven inward
TYPES OF FRACTURES
 COMPRESSION
 A fractured bone compressed by other bone
 PATHOLOGICAL
 A fracture due to weakening of the bone
structure by pathological processes, such as
neoplasia or osteomalacia; also called
spontaneous fracture
TYPES OF FRACTURES

From Ignativicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia:

W.B. Saunders.
FRACTURE OF AN
EXTREMITY
 ASSESSMENT
 Pain or tenderness over the involved area
 Loss of function
 Obvious deformity
 Crepitation
 Erythema, edema, ecchymosis
 Muscle spasm and impaired sensation
FRACTURE OF AN
EXTREMITY
 INITIAL CARE
 Immobilize affected extremity
 If a compound fracture exists, splint the
extremity and cover the wound with a sterile
dressing
INTERVENTIONS FOR A
FRACTURE
 Reduction
 Fixation
 Traction
 Casts
REDUCTION
 DESCRIPTION
 Restoring the bone to proper alignment
REDUCTION
 CLOSED REDUCTION
 Performed by manual manipulation
 May be performed under local or general
anesthesia
 A cast may be applied following reduction
CLOSED REDUCTION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders.
REDUCTION
 OPEN REDUCTION
 Involves a surgical intervention
 May be treated with internal fixation devices
 The client may be placed in traction or a cast
following the procedure
FIXATION
 INTERNAL FIXATION
 Follows open reduction
 Involves the application of screws, plates,
pins, or nails to hold the fragments in
alignment
 May involve the removal of damaged bone
and replacement with a prosthesis
 Provides immediate bone strength
 Risk of infection is associated with the
procedure
INTERNAL FIXATION

From Browner BB et al (1992) Skeletal trauma. Philadelphia: W.B. Saunders.

FIXATION
 EXTERNAL FIXATION
 An external frame is utilized with multiple pins
applied through the bone
 Provides more freedom of movement than
with traction
EXTERNAL FIXATION

From Ignatavicius, D., Workman, M. (2002). Medical-surgical nursing, ed 3, Philadelphia: W.B.

Saunders. Courtesy of Smith and Nephew, Inc., Orthopedics Division, Memphis, TN.
TRACTION
 DESCRIPTION
 The exertion of a pulling force applied in two
directions to reduce and immobilize a fracture
 Provides proper bone alignment and reduces
muscle spasms
TRACTION
 IMPLEMENTATION
 Maintain proper body alignment
 Ensure that the weights hang freely and do not
touch the floor
 Do not remove or lift the weights without a
physician’s order
 Ensure that pulleys are not obstructed and
that ropes in the pulleys move freely
 Place knots in the ropes to prevent slipping
 Check the ropes for fraying
SKELETAL TRACTION
 DESCRIPTION
 Mechanically applied to the bone using pins,
wires, or tongs
 IMPLEMENTATION
 Monitor color, motion, and sensation (CMS) of
the affected extremity
 Monitor the insertion sites for redness,
swelling, or drainage
 Provide insertion site care as prescribed
SKELETAL TRACTION

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders.
CERVICAL TONGS AND
HALO FIXATION DEVICE
 Head and Spinal Cord Injuries
SKIN TRACTION
 DESCRIPTION
 Traction applied by the use of elastic
bandages or adhesive
SKIN TRACTION: SIDE ARM

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders.
TYPES OF SKIN TRACTION
 Cervical traction
 Buck’s traction
 Bryant’s traction
 Pelvic traction
 Russell’s traction
CERVICAL SKIN TRACTION
 Relieves muscle spasms and compression in
the upper extremities and neck
 Uses a head halter and a chin pad to attach
the traction
 Use powder to protect the ears from friction
rub
 Position the client with the head of the bed
elevated 30 to 40 degrees and attach the
weights to a pulley system over the head of the
bed
CERVICAL SKIN TRACTION

From James, S. Ashwill, R., & Droske, S. (2002). Nursing care of children, ed 2,
Philadelphia: W.B. Saunders.
HEAD HALTER TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BUCK’S SKIN TRACTION
 Used to alleviate muscle spasms; immobilizes a
lower limb by maintaining a straight pull on the
limb with the use of weights
 A boot appliance is applied to attach to the
traction
 Weight is attached to a pulley; allow the weights
to hang freely over the edge of bed
 Not more than 5 pounds of weight should be
applied
 Elevate the foot of the bed to provide the traction
BUCK’S SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BRYANT’S AND RUSSELL’S
SKIN TRACTION
 Refer to the module entitled Pediatric
Nursing, Musculoskeletal Disorders for
information related to these types of traction
PELVIC SKIN TRACTION
 Used to relieve low back, hip, or leg pain and
to reduce muscle spasm
 Apply the traction snugly over the pelvis and
iliac crest and attach to the weights
 Use measures as prescribed to prevent the
client from slipping down in bed
PELVIC SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BALANCED SUSPENSION
 DESCRIPTION
 Used with skin or skeletal traction
 Used to approximate fractures of the femur,
tibia, or fibula
 Produced by a counterforce other than client
BALANCED SUSPENSION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BALANCED SUSPENSION
 IMPLEMENTATION
 Position the client in low Fowler’s, either on
the side or back
 Maintain a 20-degree angle from the thigh to
the bed
 Protect the skin from breakdown
 Provide pin care if pins are used with the
skeletal traction
 Clean the pin sites with sterile normal saline
and hydrogen peroxide or Betadine as
prescribed or per agency procedure
DUNLOP’S SKIN TRACTION
 DESCRIPTION
 Horizontal traction to align fractures of the
humerus; vertical traction maintains the
forearm in proper alignment
 IMPLEMENTATION
 Nursing care is similar to Buck’s traction
DUNLOP’S SKIN TRACTION

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
CASTS
 DESCRIPTION
 Made of plaster or fiberglass to provide
immobilization of bone and joints after a
fracture or injury
CASTS

From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing:

Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.
CASTS
 IMPLEMENTATION
 Keep the cast and extremity elevated
 Allow a wet cast 24 to 48 hours to dry
(synthetic casts dry in 20 minutes)
 Handle a wet cast with the palms of the hand
until dry
 Turn the extremity unless contraindicated, so
that all sides of the wet cast will dry
 Heat can be used to dry the cast
CASTS
 IMPLEMENTATION
 The cast will change from a dull to a shiny
substance when dry
 Examine the skin and cast for pressure areas
 Monitor the extremity for circulatory impairment
such as pain, swelling, discoloration, tingling,
numbness, coolness, or diminished pulse
 Notify the physician immediately if circulatory
compromise occurs
 Prepare for bivalving or cutting the cast if
circulatory impairment occurs
CASTS
 IMPLEMENTATION
 Petal the cast; maintain smooth edges around
the cast to prevent crumbling of the cast
material
 Monitor the client’s temperature
 Monitor for the presence of a foul odor, which
may indicate infection
 Monitor drainage and circle the area of
drainage on the cast
 Monitor for warmth on the cast
CASTS
 IMPLEMENTATION
 Monitor for wet spots, which may indicate a need
for drying, or the presence of drainage under the
cast
 If an open draining area exists on the affected
extremity, a cut-out portion of the cast or a window
will be made by the physician
 Instruct the client not to stick objects inside the
cast
 Teach the client to keep the cast clean and dry
 Instruct the client on isometric exercises to prevent
muscle atrophy
COMPLICATIONS OF
FRACTURES
 Fat embolism
 Compartment syndrome
 Infection and osteomyelitis
 Avascular necrosis
 Pulmonary emboli
FAT EMBOLISM
 DESCRIPTION
 An embolism originating in the bone marrow
that occurs after a fracture
 Clients with long bone fractures are at the
greatest risk for the development of fat
embolism
 Usually occurs within 48 hours following the
injury
FAT EMBOLISM
 ASSESSMENT
 Restlessness
 Mental status changes
 Tachycardia, tachypnea, and hypotension
 Dyspnea
 Petechial rash over the upper chest and neck
 IMPLEMENTATION
 Notify the physician immediately
 Treat symptoms as prescribed to prevent
respiratory failure and death
COMPARTMENT SYNDROME
 DESCRIPTION
 Increased pressure within one or more
compartments causing massive compromise
of circulation to an area
 Leads to decreased perfusion and tissue
anoxia
 Within 4 to 6 hours after the onset of
compartment syndrome, neuromuscular
damage is irreversible
ANTERIOR COMPARTMENT
SYNDROME

From Black JM, Hawks JH, Keene AM (2001): Medical-surgical nursing: clinical
management for positive outcomes 6th ed., Philadelphia, W.B. Saunders.
COMPARTMENT SYNDROME
 ASSESSMENT
 Increased pain and swelling
 Pain with passive motion
 Inability to move joints
 Loss of sensation (paresthesia)
 Pulselessness
 IMPLEMENTATION
 Notify the physician immediately
INFECTION AND
OSTEOMYELITIS
 DESCRIPTION
 Can be caused by the interruption of the
integrity of the skin
 The infection invades bone tissue
INFECTION AND
OSTEOMYELITIS
 ASSESSMENT
 Fever
 Pain
 Erythema in the area surrounding the fracture
 Tachycardia
 Elevated white blood cell (WBC) count
 IMPLEMENTATION
 Notify the physician
 Prepare to initiate aggressive IV antibiotic
therapy
AVASCULAR NECROSIS
 DESCRIPTION
 An interruption in the blood supply to the bony
tissue, which results in the death of the bone
 ASSESSMENT
 Pain
 Decreased sensation
 IMPLEMENTATION
 Notify the physician if pain or decreased
sensation occurs
 Prepare the client for removal of necrotic tissue
because it serves as a focus for infection
PULMONARY EMBOLISM
 DESCRIPTION
 Caused by immobility precipitated by a
fracture
PULMONARY EMBOLISM
 ASSESSMENT
 Restlessness and apprehension
 Dyspnea
 Diaphoresis
 Arterial blood gas changes
 IMPLEMENTATION
 Notify the physician if signs of emboli are
present
 Prepare to administer anticoagulant therapy
CRUTCH WALKING
 DESCRIPTION
 An accurate measurement of the client for
crutches is important because an incorrect
measurement could damage the brachial
plexus
 The distance between the axilla and the arm
pieces on the crutches should be two
fingerwidths in the axilla space
 The elbows should be slightly flexed 20 to 30
degrees when walking
BRACHIAL PLEXUS

From Crossman AR, Neary D (1995). Neuroanatomy: an illustrated color text. Edinburgh:
Churchill Livingstone.
CRUTCH WALKING
 DESCRIPTION
 When ambulating with the client, stand on the
affected side
 Instruct the client never to rest the axilla on the
axillary bars
 Instruct the client to look up and outward when
ambulating
 Instruct the client to stop ambulation if
numbness or tingling in the hands or arms
occurs
CRUTCH WALKING

From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2,
St. Louis, 2000, Mosby.
CRUTCH GAITS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
CANES
 DESCRIPTION
 Made of a lightweight material with a rubber tip
at the bottom
SINGLE- AND QUAD-FOOT
CANES

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
CANES
 IMPLEMENTATION
 Stand at the affected side of the client when
ambulating
 The handle should be at the level of the
client’s greater trochanter
 The client’s elbow should be flexed at a 25- to
30-degree angle
CANES
 CLIENT EDUCATION
 Hold the cane close to the body
 Hold the cane in the hand on the unaffected
side so that the cane and weaker leg can work
together with each step
 Move the cane at the same time as the
affected leg
 Inspect the rubber tips regularly for worn
places
HEMICANES OR QUAD-FOOT
CANES
 Used for clients who have the use of only one
upper extremity
 Hemicanes provide more security than a quad-
foot cane; however, both types provide more
security than a single-tipped cane
 Position the cane at the client’s unaffected side
with the straight nonangled side adjacent to the
body
 Position the cane 6 inches from client’s side with
the handgrips level with the greater trochanter
WALKERS
 Stand adjacent to the client on the affected
side
 Instruct the client to put all four points of the
walker flat on the floor before putting weight
on the hand pieces
 Instruct the client to move the walker forward
and to walk into it
TYPES OF HIP FRACTURES
 Intracapsular
 Extracapsular
INTRACAPSULAR HIP
FRACTURE
 Bone is broken inside the joint
 Skin traction is applied preoperatively to
immobilize and prevent pain
 Treatment includes a total hip replacement or
internal fixation with replacement of the
femoral head with a prosthesis
 Avoid hip flexion to prevent displacement
EXTRACAPSULAR HIP
FRACTURE
 Fracture can occur at the greater trochanter
or can be an intertrochanteric fracture
 Trochanteric fracture is outside the joint
 Preoperative treatment includes balanced
suspension traction
 Avoid hip flexion to prevent displacement
 Surgical treatment includes internal fixation
with nail plate, screws, or wires
INTERNAL FIXATION

From Black JM, Matassarin-Jacobs E (1997): Medical-surgical nursing: clinical

management for continuity of care 5th ed., Philadelphia, W.B. Saunders.
HIP REPLACEMENTS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St.
Louis: Mosby. Courtesy of Zimmer, Inc., Warsaw, IN.
TOTAL HIP REPLACEMENT

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
HIP FRACTURE
 POSTOPERATIVE
 Maintain leg and hip in proper alignment
 Prevent flexion or external or internal rotation
 Turn the client from back to unaffected side
 Do not position to the affected side unless
prescribed by the physician
 Maintain leg abduction to prevent internal or
external rotation
HIP FRACTURE
 POSTOPERATIVE
 Use a trochanter roll to prevent external
rotation
 Ensure that the hip flexion angle does not
exceed 60 to 80 degrees
 Elevate the head of the bed 30 to 45 degrees
for meals only
 Ambulate as prescribed by the physician
 Avoid weight bearing on the affected leg as
prescribed; instruct the client in the use of a
walker to avoid weight bearing
HIP FRACTURE
 POSTOPERATIVE
 Keep the operative leg extended, supported,
and elevated when getting client out of bed
 Avoid hip flexion greater than 90 degrees and
avoid low chairs when out of bed
 Monitor the wound for infection or hemorrhage
 Monitor circulation and sensation of the
affected side
HIP FRACTURE
 POSTOPERATIVE
 Maintain the Hemovac or Jackson-Pratt drain
if in place; maintain compression to facilitate
drainage and monitor and record output of
drainage
 Drainage should continuously decrease in
amount, and by 48 hours postoperatively,
drainage should be approximately 30 ml in an
8-hour period
HIP FRACTURE
 POSTOPERATIVE
 Maintain the use of antiembolism stockings
and encourage the client to flex and extend
the feet and ankles
 Instruct the client to avoid crossing the legs
and bending over
 Physical therapy will begin postoperatively as
prescribed by the physician
TOTAL KNEE REPLACEMENT
 DESCRIPTION
 Implantation of a device to substitute for the
femoral condyles and the tibial joint surfaces
KNEE PROSTHESIS

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
TOTAL KNEE REPLACEMENT
 POSTOPERATIVE
 Monitor the incision for drainage and infection
 Maintain the Hemovac or Jackson-Pratt drain
if in place
 Begin continuous passive motion (CPM) 24 to
48 hours as prescribed to exercise the knee
and provide moderate flexion and extension
 Administer analgesics before CPM to
decrease pain
CONTINUOUS PASSIVE
MOTION

From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills,
St. Louis, 1996, Mosby.
TOTAL KNEE REPLACEMENT
 POSTOPERATIVE
 The leg should not be dangled to prevent
dislocation
 Prepare the client for out-of-bed activities as
prescribed
 Avoid weight bearing and instruct the client in
crutch walking
HERNIATION:
INTERVERTEBRAL DISC
 DESCRIPTION
 Nucleus of the disc protrudes into the annulus
causing nerve compression
 TYPES
 Cervical
 Lumbar
DISC HERNIATION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders.
CERVICAL DISC
 DECRIPTION
 Occurs at C5 to C6 and C6 to C7 interspaces
 Causes pain and stiffness in the neck, top of
the shoulders, scapula, upper extremities, and
head
 Produces paresthesia and numbness of the
upper extremities
CERVICAL DISC
 IMPLEMENTATION
 Provide bed rest to relieve pressure and
reduce inflammation and edema
 Provide immobilization as prescribed via
cervical collar, traction, or brace
 Apply hot, moist compresses as prescribed to
increase the blood flow and relax spasms
 Instruct the client to avoid flexing, extending,
or rotating the neck
 Instruct the client to avoid long periods of
sitting
CERVICAL DISC

 IMPLEMENTATION
 Instruct the client that while sleeping, to avoid
the prone position and keep the head, spine, and
hip in alignment
 Instruct the client in the use of analgesics,
sedatives, antiinflammatory agents, and
corticosteroids as prescribed
 Prepare the client for a corticosteroid injection
into the epidural space if prescribed
 Assist the client with the application of a cervical
collar or cervical traction as prescribed
CERVICAL COLLAR
 Used for cervical disc herniation
 Holds the head in a neutral or slightly flexed
position
 The client may have to wear a cervical collar
24 hours a day
 Inspect the skin under the collar for irritation
 When the pain subsides, the client is taught
cervical isometric exercises to strengthen the
muscles
CERVICAL COLLAR

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders. Courtesy of Zimmer, Inc., Dover, OH.
LUMBAR DISC
 DESCRIPTION
 Most often occurs at L4 to L5 or L5 to S1
interspaces
 Postural deformity occurs
 Produces muscle weakness, sensory loss, and
alteration of the tendon reflexes
 The client experiences low back pain and muscle
spasms with radiation of the pain into one hip and
down the leg (sciatica)
 Pain is aggravated by bending, lifting, straining,
sneezing, and coughing, and is relieved by bed
rest
LUMBAR DISC
 IMPLEMENTATION
 Provide bed rest as prescribed
 Apply moist heat and massage as prescribed
 Instruct the client to sleep on the side with the
knees and hips in a position of flexion and with
a pillow between the legs
 Apply pelvic traction as prescribed to relieve
muscle spasms
LUMBAR DISC
 IMPLEMENTATION
 Begin ambulation gradually as the
inflammation and edema subsides
 Instruct the client in the use of muscle
relaxants, antiinflammatory medications, and
corticosteroids as prescribed
 Instruct the client in the use of a corset or
brace as prescribed
 Instruct the client regarding correct posture
while sitting, standing, walking, and working
LUMBAR DISC
 IMPLEMENTATION
 Instruct the client to lift objects by bending the
knees and keeping the back straight, avoiding
lifting anything above the elbows
 Instruct the client regarding a weight-control
program as prescribed
 Instruct the client in an exercise program as
prescribed to strengthen abdominal and back
muscles
DORSOLUMBAR ORTHOSIS

From Mosby’s medical, nursing, and allied health dictionary, ed 6, (2002). St. Louis:
Mosby. Courtesy of Truform Orthotics and Prosthetics, Cincinnati, OH.
LOW BACK CARE

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
TYPES OF DISC SURGERY
 CHEMOLYSIS
 Injections to dissolve affected disc
 DISCECTOMY
 Removal of herniated disc tissue and related
matter
 DISCECTOMY WITH FUSION
 Fusion of vertebrae with bone graft
 LAMINOTOMY
 Division of the lamina of a vertebrae
 LAMINECTOMY
 Removal of the lamina
DISC SURGERY
 PREOPERATIVE
 Reassure the client that surgery will not
weaken the back
 Instruct the client regarding coughing and
deep-breathing exercises
 Instruct the client about logrolling and range-
of-motion exercises
DISC SURGERY: CERVICAL
DISC
 POSTOPERATIVE
 Monitor for respiratory difficulty
 Encourage coughing and deep breathing
 Monitor for hoarseness and inability to cough
effectively because this may indicate laryngeal
nerve damage
 Use throat sprays or lozenges for sore throat
and do not use those that may numb the
throat to avoid choking
DISC SURGERY: CERVICAL
DISC
 POSTOPERATIVE
 Monitor the wound for drainage
 Provide a soft diet if the client complains of
dysphagia
 Monitor for sudden return of radicular pain,
which may indicate that the cervical spine has
become unstable
DISC SURGERY: LUMBAR
DISC
 POSTOPERATIVE
 Monitor for wound hemorrhage
 Monitor sensation and motor ability of the
lower extremities as well as color,
temperature, and sensation of toes
 Monitor for urinary retention, paralytic ileus,
and constipation
 Initiate measures to prevent constipation such
as a high-fiber diet, increased fluids, and stool
softeners as prescribed
DISC SURGERY: LUMBAR
DISC
 POSTOPERATIVE
 When turning and repositioning the client,
place the bed in a flat position and a pillow
between the legs; turn the client as a unit
(logroll) without twisting the client’s back
 When positioning the client, a pillow is placed
under the head with the knees slightly flexed
 Avoid extreme knee flexion when the client is
lying on the side
DISC SURGERY: LUMBAR
DISC
 POSTOPERATIVE
 To assist the client out of bed, raise the head
of the bed while the client lies on the side; the
client's head and shoulders are supported by
the first nurse, the client pushes self to a
sitting position, and the second nurse eases
the legs over the side of the bed
 Instruct the client to avoid sitting because it
places a strain on the surgical site
DISC SURGERY: LUMBAR
DISC
 POSTOPERATIVE
 Administer narcotics and sedatives as
prescribed to relieve pain and anxiety
 Encourage early ambulation
 Assist the client with the use of a back brace
or corset if prescribed
AMPUTATION OF A LOWER
EXTREMITY
 DESCRIPTION
 The surgical removal of a lower limb or part of
the limb
LEVELS OF LOWER
EXTREMITY AMPUTATION

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4,

Philadelphia: W.B. Saunders.
AMPUTATION FLAPS

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
AMPUTATION OF A LOWER
EXTREMITY
 POSTOPERATIVE
 Monitor vital signs
 Monitor for infection and hemorrhage
 Mark bleeding and drainage on the dressing if
it occurs
 Keep a tourniquet at the bedside
 Monitor for pulmonary emboli
AMPUTATION OF A LOWER
EXTREMITY
 POSTOPERATIVE
 Observe for and prevent contractures
 Monitor for signs of necrosis and neuroma
 Evaluate for phantom limb sensation and pain;
explain sensation and pain to the client, and
medicate the client as prescribed
 Check the physician’s orders regarding
positioning
AMPUTATION OF A LOWER
EXTREMITY
 POSTOPERATIVE
 If prescribed, during the first 24 hours, elevate
the foot of the bed to reduce edema, then keep
the bed flat to prevent hip flexion contractures
 Do not elevate the stump itself because
elevation can cause flexion contracture of the
hip joint
 After 24 and 48 hours postoperatively, position
the client prone if prescribed to stretch the
muscles and prevent flexion contractures of hip
AMPUTATION OF A LOWER
EXTREMITY
 POSTOPERATIVE
 In the prone position, place a pillow under the
abdomen and stump and keep the legs close
together to prevent abduction
 Maintain application of an Ace wrap or elastic
stump shrinker as prescribed to provide stump
shrinkage
 Remove and rewrap the Ace bandage or
elastic stump shrinker three to four times daily
as prescribed
AMPUTATION OF A LOWER
EXTREMITY
 POSTOPERATIVE
 Wash the stump with mild soap or water and
apply lanolin to the skin if prescribed
 Massage the skin toward the suture line to
increase circulation
 Prepare for a cast application if prescribed to
prepare the stump for prosthesis
 Encourage the client to look at the stump
 Encourage verbalization regarding loss of the
body part and assist the client to identify
coping mechanisms to deal with the loss
STUMP WRAPPING

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
BELOW-THE-KNEE
AMPUTATION
 POSTOPERATIVE
 Prevent edema
 Do not allow the stump to hang over the edge
of the bed
 Do not allow the client to sit for long periods of
time to prevent contractures
ABOVE-THE-KNEE
AMPUTATION
 POSTOPERATIVE
 Prevent internal or external rotation of the limb
 Place a sandbag or rolled towel along the
outside of the thigh to prevent rotation
AMPUTATION OF A LOWER
EXTREMITY
 REHABILITATION
 Instruct the client in crutch walking
 Prepare the stump for prosthesis
 Prepare the client for the fitting of the stump
for prosthesis
 Instruct the client in exercises to maintain
range of motion
 Provide psychosocial support to the client
RHEUMATOID ARTHRITIS
(RA)
 DESCRIPTION
 Chronic systemic inflammatory disease; the
etiology may be related to a combination of
environmental and genetic factors
 Leads to destruction of connective tissue and
synovial membrane within the joints
 Weakens and leads to dislocation of the joint
and permanent deformity
 Formation of pannus occurs at the junction of
synovial tissue and articular cartilage projecting
into the joint cavity and causing necrosis
RHEUMATOID ARTHRITIS
(RA)
 DESCRIPTION
 Exacerbations are increased by physical or
emotional stress
 Risk factors include exposure to infectious
agents; fatigue and stress can exacerbate the
condition
 Vasculitis can cause malfunction and eventual
failure of an organ or system
RHEUMATOID ARTHRITIS
(RA)
 ASSESSMENT
 Inflammation, tenderness, and stiffness of the
joints
 Moderate to severe pain and morning stiffness
lasting longer than 30 minutes
 Joint deformities, muscle atrophy, and
decreased range of motion
 Spongy, soft feeling in the joints
RHEUMATOID ARTHRITIS
(RA)
 ASSESSMENT
 Low-grade temperature, fatigue, and
weakness
 Anorexia, weight loss, and anemia
 Elevated sedimentation rate and positive
rheumatoid factor
 X-ray showing joint deterioration
 Synovial tissue biopsy presents inflammation
RHEUMATOID ARTHRITIS
EARLY, MODERATE, AND
ADVANCED STAGE

From Monahan FD, Neighbers M: Medical-surgical nursing: foundations

for clinical practice, ed. 2, Philadelphia, 1998, W.B. Saunders.
RHEUMATOID ARTHRITIS
MUSCLE ATROPHY

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.
RHEUMATOID NODULE

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.
BOUTONNIERE DEFORMITY

From Zitelli BJ, Davis HW: Atlas of Pediatric Physical Diagnosis, ed. 3, St. Louis, 1997, Mosby.
SWAN NECK DEFORMITY

From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts

and clinical practice, ed. 6, St. Louis, 1999, Mosby.
RHEUMATOID (RA) FACTOR
 DESCRIPTION
 A blood test used to diagnose rheumatoid
arthritis
 VALUES
 Nonreactive: 0 to 39 IU/ml
 Weakly reactive: 40 to 79 IU/ml
 Reactive: greater than 80 IU/ml
RHEUMATOID ARTHRITIS
(RA)
 PAIN
 Salicylates (acetylsalicylic acid [aspirin])
 Monitor for side effects including tinnitus,
gastrointestinal (GI) upset, or prolonged
bleeding time
 Administer with meals or a snack
 Monitor for abnormal bleeding or bruising
RHEUMATOID ARTHRITIS
(RA)
 NONSTEROIDAL ANTIINFLAMMATORY
DRUGS (NSAIDs)
 May be prescribed in combination with
salicylates if pain and inflammation has not
decreased within 6 to 12 weeks following
salicylate therapy
 Monitor for side effects such as GI upset, CNS
manifestations, skin rash, hypertension, fluid
retention, and changes in renal function
RHEUMATOID ARTHRITIS
(RA)
 CORTICOSTEROIDS
 Administer as prescribed during exacerbations
or when commonly used agents are ineffective
 ANTINEOPLASTIC MEDICATIONS
 Administer as prescribed in clients with life-
threatening RA
 GOLD SALTS
 Administer as prescribed in combination with
salicylates and NSAIDs to induce remission
and decrease pain and inflammation
RHEUMATOID ARTHRITIS
(RA)
 PHYSICAL MOBILITY
 Preserve joint function
 Provide ROM exercises to maintain joint
motion and muscle strengthening
 Balance rest and activity
 Splints during acute inflammation to prevent
deformity
 Prevent flexion contractures
RHEUMATOID ARTHRITIS
(RA)
 PHYSICAL MOBILITY
 Apply heat or cold therapy as prescribed to
joints
 Apply paraffin baths and massage as
prescribed
 Encourage consistency with exercise program
 Instruct the client to stop exercise if pain
increases
 Exercise only to the point of pain
 Avoid weight bearing on inflamed joints
RHEUMATOID ARTHRITIS
(RA)
 SELF-CARE
 Assess the need for assistive devices such as
higher toilet seats, chairs, and wheelchairs to
facilitate mobility
 Collaborate with occupational therapy to
obtain assistive adaptive devices
 Instruct the client in alternative strategies for
providing activities of daily living
RHEUMATOID ARTHRITIS
(RA)
 FATIGUE
 Identify factors that may contribute to fatigue
 Monitor for signs of anemia
 Administer iron, folic acid, and vitamin
supplements as prescribed
 Monitor for drug-related blood loss by testing
the stool for occult blood
 Instruct the client in measures to conserve
energy such as pacing activities and obtaining
assistance when possible
RHEUMATOID ARTHRITIS
(RA)
 BODY IMAGE DISTURBANCE
 Assess the client’s reaction to the body
change
 Encourage the client to verbalize feelings
 Assist the client with self-care activities and
grooming
 Encourage the client to wear street clothes
RHEUMATOID ARTHRITIS
(RA)
SURGICAL INTERVENTIONS
 SYNOVECTOMY
 Removal of the synovia to help maintain joint
function
 ARTHRODESIS
 Bony fusion of a joint to regain some mobility
 JOINT REPLACEMENT (ARTHROPLASTY)
 Replacement of diseased joints with artificial
joints
 Performed to restore motion to a joint and
function to the muscles, ligaments, and other
soft tissue structures that control a joint
OSTEOARTHRITIS
 DESCRIPTION
 Also known as degenerative joint disease
(DJD)
 Cause is unknown but may be caused by
trauma, fractures, infections, or obesity
 Progressive degeneration of the joints caused
by wear and tear
OSTEOARTHRITIS
 DESCRIPTION
 Causes the formation of bony build-up and the
loss of articular cartilage in peripheral and
axial joints
 Affects the weight-bearing joints and joints that
receive the greatest stress such as the knees,
toes, and lower spine
JOINT CHANGES IN
OSTEOARTHRITIS

From Ignatavicius DD, Workman ML, Mishler MA, Medical-surgical nursing

across the healthcare continuum, ed. 3, Philadelphia, 1999, W.B.Saunders.
OSTEOARTHRITIS
 ASSESSMENT
 Joint pain that early in the disease process
diminishes after rest and intensifies after
activity
 As the disease progresses, pain occurs with
slight motion or even at rest
 Symptoms are aggravated by temperature
change and humidity
 Crepitus
OSTEOARTHRITIS
 ASSESSMENT
 Joint enlargement
 Presence of Heberden’s nodes or Bouchard’s
nodes
 Limited ROM
 Difficulty getting up after prolonged sitting
 Skeletal muscle atrophy
 Inability to perform activities of daily living
 Compression of the spine as manifested by
radiating pain, stiffness, and muscle spasms in
one or both extremities
SEVERE OSTEOARTHRITIS

From Kamal A, Brockelhurst J: Color atlas of geriatric medicine, ed. 2, St. Louis, 1991, Mosby.
HEBERDEN’S NODES

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.
BOUCHARD’S NODES

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.
OSTEOARTHRITIS
 PAIN
 Administer NSAIDs, salicylates, and muscle
relaxants as prescribed
 Prepare the client for corticosteroid injections
into joints as prescribed
 Place affected joint in a functional position
 Immobilize the affected joint with a splint or
brace
 Avoid large pillows under the head or knees
 Provide a bed or foot cradle
OSTEOARTHRITIS
 PAIN
 Position the client prone twice a day
 Instruct the client on the importance of moist
heat, hot packs or compresses, and paraffin
dips as prescribed
 Apply cold applications as prescribed when
the joint is acutely inflamed
 Encourage adequate rest recommending 10
hours of sleep at night and a 1- to 2-hour nap
in the afternoon
OSTEOARTHRITIS
 NUTRITION
 Encourage a well-balanced diet
 Encourage weight loss if necessary
OSTEOARTHRITIS
 PHYSICAL MOBILITY
 Reinforce the exercise program and the
importance of participating in the program
 Instruct the client that exercises should be
active rather than passive and to exercise only
to the point of pain
 Instruct the client to stop exercise if pain is
increased with exercising
 Instruct the client to decrease the number of
repetitions in an exercise when the
inflammation is severe
OSTEOARTHRITIS
SURGICAL INTERVENTIONS
 OSTEOTOMY
 The bone is cut to correct joint deformity and
promote realignment
 TOTAL JOINT REPLACEMENT (TJR)
 Performed when all measures of pain relief
have failed
 Hips and knees are most commonly replaced
 Contraindicated in the presence of infection,
advanced osteoporosis, and severe
inflammation
RHEUMATOID ARTHRITIS AND
OSTEOARTHRITIS
CLIENT EDUCATION
 Assist the client to identify and correct hazards
in the home
 Instruct the client in the correct use of assistive
adaptive devices
 Instruct in energy conservation measures
 Review prescribed exercise program
 Instruct the client to sit in a chair with a high,
straight back
RHEUMATOID ARTHRITIS AND
OSTEOARTHRITIS
CLIENT EDUCATION
 Instruct the client to use a small pillow, only
when lying down
 Instruct the client in measures to protect the
joints
 Instruct the client regarding the prescribed
medications
 Stress the importance of follow-up visits with
the health care provider
OSTEOPOROSIS
 DESCRIPTION
 An age-related metabolic disease
 Bone demineralization results in the loss of
bone mass, leading to fragile and porous
bones and subsequent fractures
 Greater bone resorption than bone formation
occurs
 Occurs most commonly in the wrist, hip, and
vertebral column
 Can occur postmenopausal or as a result of a
metabolic disorder or calcium deficiency
OSTEOPOROTIC CHANGES

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
OSTEOPOROSIS
 ASSESSMENT
 Back pain after lifting, bending, or stooping
 Back pain that increases with palpation
 Pelvic or hip pain, especially with weight
bearing
 Problems with balance
 Decline in height from vertebrae compression
OSTEOPOROSIS
 ASSESSMENT
 Kyphosis of the dorsal spine
 Constipation, abdominal distention, and
respiratory impairment as a result of
movement restriction and spinal deformity
 Pathological fractures
 Appearance of thin, porous bone on x-ray
DOWAGER’S HUMP

From Seidel HM et al: Mosby’s guide to physical examination, ed. 4, St. Louis, 1999, Mosby.
SEVERE OSTEOPOROSIS

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.
OSTEOPOROSIS
 IMPLEMENTATION
 Assess risk for injury
 Provide a safe and hazard-free environment
and assist the client to identify hazards in the
home environment
 Use side rails to prevent falls
 Move the client gently when turning and
repositioning
OSTEOPOROSIS
 IMPLEMENTATION
 Encourage ambulation; assist with ambulation if
the client is unsteady
 Instruct in the use of assistive devices such as a
cane or walker
 Provide ROM exercises
 Instruct in the use of good body mechanics and
exercises to strengthen abdominal and back
muscles in order to improve posture and provide
support for the spine
 Instruct the client to avoid activities that can
cause vertebral compression
OSTEOPOROSIS
 IMPLEMENTATION
 Apply a back brace as prescribed during an
acute phase to immobilize the spine and
provide spinal column support
 Encourage the use of a firm mattress
 Provide a diet high in protein, calcium, vitamin
C and D, and iron
 Encourage adequate fluid intake to prevent
renal calculi
 Instruct the client to avoid alcohol and coffee
MILWAUKEE BRACE

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
OSTEOPOROSIS
 IMPLEMENTATION
 Administer estrogen or androgens to decrease
the rate of bone resorption as prescribed
 Administer calcium, vitamin D, and
phosphorus as prescribed for bone
metabolism
 Administer calcitonin as prescribed to inhibit
bone loss
 Administer analgesics, muscle relaxants, and
antiinflammatory medications as prescribed
GOUT
 DESCRIPTION
 A systemic disease in which urate crystals
deposit in joints and other body tissues
 Leads to abnormal amounts of uric acid in the
body
 Primary gout results from a disorder of purine
metabolism
 Secondary gout involves excessive uric acid in
the blood that is caused by another disease
GOUTY JOINT

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations

for clinical practice, ed 2, Philadelphia: W.B. Saunders.
PHASES OF GOUT
 ASYMPTOMATIC
 No symptoms
 Serum uric acid is elevated
 ACUTE
 Excruciating pain and inflammation of one or
more small joints, especially the great toe
PHASES OF GOUT
 INTERMITTENT
 Asymptomatic period between acute attacks
 CHRONIC
 Results from repeated episodes of acute gout
 Results in deposits of urate crystals under the
skin and within the major organs, especially
the renal system
GOUT
 ASSESSMENT
 Excruciating pain in the involved joints
 Swelling and inflammation of the joints
 Tophi (hard, fairly large, and irregularly shaped
deposits in the skin) that may break open and
discharge a yellow, gritty substance
 Low-grade fever
 Malaise and headache
 Pruritus
 Presence of renal stones
 Elevated uric acid levels
GOUT

From Clinical Slide Collection of the Rheumatic Diseases, © 1991,1995,1997.

Used with permission of the American College of Rheumatology.
GOUT
 IMPLEMENTATION
 Provide a low-purine diet as prescribed
 Instruct the client to avoid foods such as organ
meats, wines, and aged cheese
 Encourage a high fluid intake of 2000 ml to
prevent stone formation
 Encourage weight-reduction diet if required
 Instruct the client to avoid alcohol and
starvation diets because they may precipitate
a gout attack
GOUT
 IMPLEMENTATION
 Increase urinary pH (above 6) by eating
alkaline-ash foods such as citrus fruits and
juices, milk, and other dairy products
 Provide bed rest during the acute attacks
 Monitor joint ROM ability and appearance of
joints
 Position the joint in a mild flexion position
during acute attack
GOUT
 IMPLEMENTATION
 Elevate the affected extremity
 Protect the affected joint from excessive
movement or direct contact with sheets or
blankets
 Provide heat or cold for local treatments to
affected joint as prescribed
 Administer NSAIDs and antigout medications
as prescribed