Assessment of Musculoskeletal Function

Chapter 66

Data r/t functional ability: ADLs; ability to perform various activities; note any problems r/t
mobility

Health hx: family history, general health, nutrition, occupation, learning needs,
socioeconomic factors, and medications (OTC, herbal)

Physical assessment: posture, gait, bone integrity, joint function, muscle strength, skin,
neurovascular status

Body & bone alignment, deformities, symmetric parts, crepitus, ROM

Musculoskeletal System Assessment

Assess pain and altered sensations.

Have pt describe and locate pain

Dull, deep ache, boring, soreness

Aching, muscle cramps

Fracture pain: sharp, piercing relieved by immobilization

Radiating pain: Shooting, throbbing

Paresthesias: burning, tingling, numbness

Musculoskeletal System Assessment

Assess pain and altered sensations

Peripheral nerve functions - Test & evaluate sensation of nerves

Evaluate motion

Peroneal nerve, tibial nerve, radial nerve, ulnar nerve, median nerve

Normal Spine and 3 Abnormalities

Musculoskeletal System Assessment:

Check for Contractures

Effusion

Dislocation of joints Luxation

Partial dislocation - Subluxation

BS p 2346

Evaluate Muscle strength

Muscle clonus twitching, seizures

Detecting Fluid in the Knee - crepitus

Assess for other musculoskeletal disorders: Rheumatoid Arthritis which may develop Hand
deformity - Ulnar Deviation & Swan-Neck

Review Diagnostic Evaluation, X-rays, Computed tomography, MRIs, Arthrography, Bone

densitometry and Bone scans, Arthroscopy

Arthrocentesis and Electromyography

Biopsy reports and Laboratory studies

When reviewing radiographic tests, check for Loss of joint space, look for Osteophytes at the bone
margins. Check for Normal cartilage (may be seen with bone deformities or bone disease),

Scans may Identify acute & chronic tears of the joint capsules or support ligaments of the
knee, shoulder, ankle, hip or wrist.

Radiopaque contrast is injected into the joint cavity to outline the bone, bone cavity and Soft
tissue of joint structure is outlined. The joint undergoes ROM under series of Contrast agent
leaks out of the joint when a tears is present

Musculoskeletal Care Modalities

Chapter 67

Cast - A rigid, external immobilizing device

Uses: to Immobilize a reduced fracture; to correct deformity; it aaplies uniform

pressure to the soft tissues; and Provides support to stabilize a joint

Permits patient mobilization while restricting movement of a body part.

Types of Casts

- Short-Leg cast with common pressure areas

- Extends from below the knee to the base of the toes
- Foot if flexed at a right angle in a neutral position.

Short-Arm cast Long-leg cast - Extends from the elbow to the palmar crease;
secured around the base of thumb thumb spica or gauntlet cast

Long-leg cast extends from the upper, middle third thigh to the base of the toes.;
knee is slightly flexed

Walking cast a short or long-leg cast reinforced for strength.

Body cast Encircles the truck

Shoulder spica cast a body jacket that encloses the trunk, shoulder and elbow.

Hip spica cast encloses the trunk and lower extremity. A double hip spica includes
both legs

Cast Materials

Nonplaster (fiberglass) water activated polyurethane; porous, lighter yet stronger, its Rigid, durable & water resistant. Dries fast; less skin problems

Plaster crytallizing reaction which gives off heat; Slow drying; 24-72 hrs.

Patient Teaching teach them about Cast Care

Prior to cast application - Explain condition necessitating the cast; Explain purpose
and goals of the cast; Describe expectations during the casting process: eg, the heat
from hardening plaster

Cast care: keep dry; do not cover with plastic

Positioning: elevation of extremity; use of slings

Hygiene

Activity and mobility; Explain exercises

Do not scratch or stick anything under the cast

Cushion rough edges

Report persistent pain, swelling, changes in sensation; movement; skin color;

temperature; signs of infection; pressure areas

Follow-up care Required

Cast removal

Nursing Process: Assessment of Patient with a Cast

Prior to casting

Perform general health assessment

Evaluate emotional status

Determine the condition signs & sx. of the area to be casted

Assess the pts. knowledge

Monitor neurovascular status for potential complications

Nursing Process: Caring for the Patient with a Cast

List the Nursing Diagnosis for the patient with a cast

Nursing Process: Diagnosis of Patient with a Cast

Impaired physical mobility

Self-care deficit inability to perform ADLs

Acute pain unrelieved pain must be reported immediately to avoid poss. Paralysis
necrosis

Impaired skin integrity

Risk for peripheral neurovascular dysfunction

Knowledge deficit

Collaborative Problems/Potential Complications

Compartment syndrome -

Pressure ulcer

Disuse syndrome -

Delayed union or nonunion of fracture(s)

Nursing Process: Planning the Care of the Patient With a Cast

Increase knowledge of treatment regimen

Pain relief

Improved physical mobility

Achieve maximum level of self-care,

Healing (of trauma-associated lacerations, abrasions)

Maintain adequate neurovascular function

Absence of complications

Interventions

Relieve pain:

Elevate to reduce edema

Apply ice or cold intermittently

Implement position changes

Administer analgesics

Unrelieved pain may indicate compartment syndrome; discomfort due to pressure

may require change of cast

Muscle setting exercises: see Chart 67-3

Patient teaching for home care: see Chart 67-4

Interventions

Heal skin wounds and maintain skin integrity

Treat skin wounds before applying cast

Observe for S/SX of pressure or infection

Pad cast and cast edges

Patient may require tetanus booster

Maintain adequate neurovascular status

Assess circulation, sensation, and movement

Notify physician at once of signs of compromise

Elevate extremity no higher than the heart

Encourage movement of fingers/toes every hour

External Fixation Devices

Used to manage open fractures

Supports complicated or comminuted fractures

Reassure patient concerned by appearance of device

Minimal discomfort; early mobility may be anticipated

Elevate to reduce edema

Monitor for S/SX of complications, including infection

Provide pin care

External Fixation Devices

Traction - Applies pulling force to a part of the body

Purposes:

Reduction & alignment; immobilize fractures

Reduce deformity and muscle spasms

Increase space between opposing forces

Used as a short-term intervention until other modalities are possible

Traction needs to be applied in two directions. The lines of pull are vectors of force. The
result of the pulling force is between the two lines of the vectors of force.

Principles of Effective Traction - Whenever traction is applied, a counterforce must

be applied. Frequently the patients body weight and positioning in bed supply the
counterforce

Traction must be continuous to reduce and immobilize fractures

Skeletal traction is never interrupted. Any factor that reduces pull must be
eliminated

Weights are not removed unless intermittent traction is prescribed

Ropes must be unobstructed and weights must hang freely

Knots or the footplate must not touch the foot of the bed

Types of Traction

Skin traction:

Bucks extension traction

Cervical head halter

Pelvic traction

Skeletal traction: Balanced Skeletal Traction With

Thomas Leg Splint

The amount of weight applied during skin traction must not exceed the tolerance of the skin. No
more than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used on an extremity.
Preventing Complications: Nursing Care for the Patient in Traction

Properly apply and maintain traction

Monitor for complications of skin breakdown, nerve pressure, and circulatory impairment

Inspect skin at least 3 times a day

Assess sensation, movement, pain, tenderness

Assess pulses, color capillary refill, and temperature of fingers or toes

Assess for indicators of DVT and infection

Preventative Interventions

Promptly report alteration in sensation or circulation

Provide back care and skin care I Pin care

Regularly shift position, active foot & leg exercises every hour

Use special mattresses or pressure-reduction devices

Elastic hose, pneumatic/ TED compression hose, or anticoagulant therapy may be

prescribed

Use of the Trapeze

Exercises to maintain muscle tone and strength

Nursing Process: Assessment of the Patient in Traction

Assess neurovascular status

Assess mobility-related complications: pneumonia, atelectasis, constipation, nutritional

problems, urinary stasis, and UTI

Assess for pain and discomfort; plus assess emotional and behavioral responses

Assess coping ability & pt. knowledge

Nursing Process: Diagnosis of the Patient in Traction

Deficient knowledge; Anxiety; Acute pain; Self-care deficit and Impaired physical
mobility

Collaborative Problems/Potential Complications; Pressure ulcer; Atelectasis; Pneumonia

Constipation; Anorexia; Urinary stasis and infection; DVT

Interventions:

Prevent skin breakdown, nerve pressure, and circulatory impairment

Measures to reduce anxiety

Encourage patient participation in decision making and in care; reinforce

information

Encourage frequent visits to reduce isolation

Provide diversional activities

Use assistive devices

Physical Therapy consultation

Prevent atelectasis and pneumonia - Auscultate lungs every 4 to 8 hours

Encourage coughing & deep breathing exercises

High-fiber diet and encourage fluids; Identify and include food preferences and

Joint Replacements

Done to treat severe joint pain, disability, repair of joint fractures or joint necrosis

Common joint replacements include the hip, knee, and fingers

Joints including the shoulder, elbow, wrist, and ankle may also be replaced

Patient Care After Hip or Knee Replacement Surgery

Prevent infection - Infection may occur in the immediate postoperative period (within 3
months), as a delayed infection (4 to 24 months), or due to spread from another site (more
than 2 years)

Prevention of DVT

Patient teaching and rehabilitation

Hip Prosthesis; Position the leg in abduction to prevent dislocation of the prosthesis - Do
not flex hip more than 90 . Also Avoid internal rotation. Provide protective positioning.
Hip precautions: see Chart 67-8

Prevent Hip Dislocation after total Hip Replacement by using an Abduction Pillow. Avoiding
Hip Dislocation

Knee Prostheses: Encourage active flexion exercises. May Use continuous passive motion
(CPM) device if indicated
Nursing Process: Pre-op Care of Patient Undergoing Orthopedic Surgery

Routine pre-op assessment, VS, Pain, LOC

Hydration status & Medication history

Possible infection

Ask about colds, dental problems, UTIs, other infections within 2 weeks

Neurovascular status, tissue perfusion

Support and coping

S/SX of bleeding: wound drainage

Mobility restrictions

Nursing Diagnosis of Patient Undergoing Orthopedic Surgery

Acute pain; Risk for peripheral neurovascular dysfunction; Impaired physical mobility;
Risk for situational low self-esteem and/or disturbed body image; Risk for ineffective
therapeutic regimen management

Postoperative Collaborative Problems/Potential Complications includes:

Hypovolemic shock; Atelectasis; Pneumonia; Urinary retention; Infection

Thromboembolism: DVT or PE; Constipation or fecal impaction

Nursing Process: Planning the Care of the Patient Undergoing Orthopedic Surgery

Major pre and post-op goals: relief of pain, adequate neurovascular function, health
promotion, improved mobility, and positive self-esteem

Postoperative goals include the absence of complications

Relief of Pain - Administration of medications

Patient-controlled analgesia (PCA); Medicate before planned activity & ambulation

Use alternative methods of pain relief by repositioning, distraction, guided imagery,

etc.

Specific individualized strategies to aid in healing and reducing pain

Use ice or cold. Elevation of affected extremity, Immobilization