UP COLLEGE OF NURSING

MEDICAL-SURGICAL NURSING
Musculoskeletal Problems and Fractures
I.

MUSCULOSKELETAL PROBLEMS

RHEUMATOID ARTHRITIS

With bone erosion

Chronic systemic disease with recurrent

inflammation of the linings of the joints/ membrane

SYSTEMIC

A. PREDISPOSING FACTORS
Most common in women3% occurrence
20-50 years old onset
B. PARTS INVOLVED
Any finger joints
Cervical spine
Heart involvement
Pericarditis
Myocarditis
Lungs
Can lead to pneumonia
Pleural effusion
C. MANIFESTATIONS
Knobby appearance of joints
Bilateral involvement
Swelling
Warm to touch
Subcutaneous nodules & redness
Tenderness
Bony prominences remission & exacerbation
PAIN USUALLY WORSENS IN AM

Decreased symptoms with moderate activity

Low grade temperature
General body malaise, fatigue
Stiffness

D. NURSING MANAGEMENT
1. Enforce CBR with joints extended
2. Provide emotional support
3. Heat/warm application
Warm bath
Paraffin bathSOAK LOWER

EXTREMITIES

4-5X

4. Institute daily exercise programs

5. Administer medications as ordered
Aspirin
NSAIDs
Phenylbutazone (Butazoladin)
SE: GI irritation, peripheral neuropathy
Gold Salt Treatmentgiven for 2-4 weeks
Steroids to reduce edema/swelling
6. Maintain proper body alignment
7. Balance, rest and exercise

8. Well balanced/ nutritious diet

OSTEOARTHRITIS
Degeneration of articular cartilage in the joints
caused by wear and tear of joint surfaces

LOCALIZED
DISTAL PHALANGEAL JOINT INVOLVEMENT

Weight bearing joints affected: hips, knees, spine

A. PREDISPOSING FACTORS
Middle older age onset
Women 20% occurrence
B. MANIFESTATIONS
GRAFTING DURING MOVEMENT/CREPITUS
Pain
and
stiffness
that
worsens
after
activity/exercise
HEBERDENS NODES on distal phalangeal joints
C. NURSING MANAGEMENT

Normal amount of rest

Rest affected joint only

Avoid over activity

Provide emotional support

Heat application:
Hot packs
Warm soaks
Paraffin bath

ROM exercises

Administer medicationsSAME with RA

GOUTY ARTHRITIS

Metabolic disorder characterized by increased level

of uric acid in the blood: inflammatory type of
arthritis caused by deposits of urate crystals in and
around the joints (TOPHI)
A.

MANIFESTATIONS
Severe pain usually on great toes
Mono/Polyarthritis
Tophi (large accumulation of urates in the joints)
Joints are red, warm, painful and swollen
Joint damage and deformity
Presence of hyperuricemia

B. NURSING MANAGAMENT
1. Give medications as ordered:

Indomethacin

Probenecid/ Benemid

Allopurinol/Zylopurininhibits synthesis
of uric acid; for GOUT

Colchecinepromotes excretion of uric

acid; for ACUTE GOUT
2. Bed rest during acute attack
3. Keep covers away from affected joint
4. Force fluids
5. Application of heat or cold
6. Limit intake of purine, purine-rich food

 organs meat
legumes
anchovies
nuts
7. Limit alcohol intake
II. FRACTURE
Loss/ break in the continuity of the long bone
Pain, tenderness, swelling, loss of function, deformity,
crepitus (grating sound), discoloration, bleeding from an
open wound with protrusion of bone ends
A. MANAGEMENT: 3 PRINCIPLES OF FRACTURE
TRACTION

Reduction or realignment of bone fragments

o Closed Manipulation a cast or sling is
used
o Internal Fixation surgery; open
reduction; various types of holding devices
are used
o External fixation pins are inserted into
the bone above and below the fracture and
held in place by a clamping device
o Traction applying force in two direction
to reduce and regain normal length and
alignment
Maintenance of Realignment of immobilization
Restoration of Function

B. GENERAL CLASSIFICATIONS
1. Complete involves the entire cross section of the
bone
2. Incomplete only a portion of the cross section of
the bone
3. Open wound of fracture extends through the skin
and mucous membrane (compound)
4. Closed does not communicate with outside
(simple)
C. SPECIFIC TYPES
1. Greenstick one side of the bone is broken, other
side is bent
2. Transverse straight across the bone
3. Compression fractured bone has been
compressed by another bone; seen in vertebral
fracture
4. Impacted one bone fragment is driven firmly into
the other by force, producing the fracture
5. Pathologic occurs through an area of diseased
bonebone cysts, bony metastasis
6. Comminuted bone splintered into fractures
7. Depressed fragments is in drivesskull and
facial bone
D. LOCATION OF FRACTURE
1. Hip Fracture
a.
FRACTURE OF THE
(extracapsular)

NECK OF THE FEMUR

b.
THORACENTRIC
REGION
OF
FEMUR
(intracapsular)
c. Subthoracentric fracture
Treatment
Skin traction for immobilization
Trochanter roll
Open reduction and internal fixation (ORIF)
Pre-operative care

Immobilization

Anti-coagulant therapy HEPARIN

Assess for complications:

Skin breakdown
Presence of thromboembolism
Respiratory congestion
Senile Dementia
Post-operative care

Turn to sides and positioning

Exercise and monitor for signs of complications:

Thromboembolism
Pneumonia
Fat embolism
Measure for crutches in walking shoes
Avoid leaning on crutches
2. Pelvic Fracture
Specific Nursing Management
Check for bladder and bowel injuries
Check for bleeding
Enforce bed rest, immobilize affected extremities
Provide pelvic sling to immobilize affected
extremities
D. NURSING MANAGEMENT
1. Always maintain patent airway
2. Proper body alignment
3. Prevent shock by:
a. immobilization of affected part
b. Providing a splint
4. Monitor for presence of complications
a. Fat embolismmost feared complication
(Pulmonarysudden sharp chest pain, and
sudden DOB; Cerebralheadache, dizziness)
b. Hemorrhage
c. Compartment syndromecompression of
the artery and nerves of affected
extremities *Check NVS
5. For immobilization and relief of pain, the area on
the side of the fractured clavicle is stabilized by
pinning the sleeves to the shirt or by using a
triangular sling or a figure 8 bandage
6. Observe, record and report the following:
a. Pain (alert) behavioral symptom in the
infant and young children
i. Determine exact area of pain
ii. Assess any increase in pain or
lack of relief from analgesics
b. Pulse

i. Check brachial, radial, ulnar,

digital pulses if upper extremity
is involved
ii. Check
femoral,
popliteal,
posterior tibial, dorsalis pedis
pulses if lower extremities are
involved
c. Paresthesia
i. Check for diminished sensation,
numbness and lack of sensation
ii. Check nerve functioning of the
hand by pricking the web space
between the thumb and index
finger, the distal pad of the small
finger and the distal surfaces of
the index finger
iii. Check nerve functioning of the
foot by pricking the web space
between the first and second toes
d. Paralysis
i. Assess hand function by making
the child to hyperextend his
thumb or wrists to oppose his
thumb and little finger and to
abduct all his fingers
ii. Assess motor function of the foot
by asking the child to dorsiflex
and plantar-flex his ankles and to
flex and extend his toes
e. Pallor
i. Note color of extremities distal to
the fractured site
ii. Assess capillary return of the nail
beds following blanching
iii. Assess temperature of affected
extremity
TYPES OF FRACTURE

Closed

Transverse

Closed
Compression

Oblique

Open

Greenstick

Spiral

Comminuted

II. TRACTION
Force applied in 2 directions through a system of ropes,
pulleys and weights
A. PURPOSES
Regain normal length and alignment

Reduce and immobilize

Lessen or eliminate muscle spasm
Prevent fracture deformity

B. TYPES
1. Skin Traction applied using adhesive or mole skin
strips fastened with elastic bandage
Accomplished by a weight that pulls on the tape,
sponge ribbon/plastic material attached to the skin
traction on the skin transmits traction to the
neuromusculoskeletal structures
Shave part of skin
Inspect for irritation and pressure on p. nerves
a. Bucks extension when partial or temporal
immobilization desired
b. Pelvic
2.

Skeletal applied to bones using wires, pins, tongs

placed through bones most effective means of traction
Femur
Humerus
Tibia
Watch out for S/Sx of infection around the pin tract
a. Thomas splint with Pearson attachment
b. Crutchfield tongs

3.

Cervical to reduce fracture, obtain spine

immobilization to prevent cord damage/compression
Cervical vertebrae use of crutchfield tongs
inserted in the skull

C. NURSING MANAGEMENT
a. SKIN
1. Detection of pressure points
2. Provide daily re-wrapping
3. Maintain proper positioning
4. Maintain weight freely and dont manipulate
5. Monitor for presence of vaso-occlusive
process/vascular occlusion
b. SKELETAL
1. Inspection of dressing
2. Traction apparatus (alignment)
3. Prevent complicationbed rest
c. MUSCLES
1. Strengthening exercises for upper and lower
extremities
2. Preparation of patient for crutch walking to
strengthen upper body
3. Place pressure on the palm not on the axilla
because it may cause brachial paralysis
OTHERS:
d. VASCULAR
Balance Suspension Traction
1. Check
Producedforby6 aPscounterforce
than patients body weight;
(includingother
polar/coldness)
traction on extremities constant despite movement
o
Russells deg traction fracture of femoral shaft

GENERAL MANAGEMENT:
1.
Ropes and pulleys in straight alignment
2.
Pull should be in line with long axis of bone
3.
Weights should hang free, ropes unobstructed
4.
Weight applied must not exceed tolerance of skin/bone
5.
Check and monitor: Infection: odorosteomyelitis
6.
Active motion of unaffected joints encouraged
7.
Skin should be examined for evidence of friction, pressure over the
bony prominences
8.
Investigate patients complaint

b.
c.
d.
2.
III. CASTS
To immobilize while the fracture heals, hold bone
fragments in reduction
Apply uniform compression of soft tissue
Permit any weight bearing activities
A. COMPLICATIONS TO MONITOR
1. Infectioncheck for foul smelling odor of cast
2. Compartment syndrome following tight casting
3. Complications of immobility
4. Vascular occlusion/ Constriction of circulation
vascular insufficiency due to unrelieved swelling
gangrenous necrosis
SSx unrelieved pain, bleeding, tingling,
numbness, swelling, no pulse, inability to
move finger/toes, temperature changes of skin
NSG bivalve the cast splint
Spread cast sufficiently to relieve
constriction
5. Pressure of cast on tissues, bony parts
a. Causes necrosis and bed ulcers, nerve
palsies
b. SSX unrelieved pain
c. Pressure sites: heel malleoli, sacrum,
fibula, cut at the pain joint, elevate each
flap of plate
B. NURSING MANAGEMENT
1. Handle wet cast with palm of hand not fingers
2. Casts should be allowed to be air dried
3. Elevate 1-2 pillows during drying to promote
venous return
4. Adhesive tape petals attached to reduce irritation
at cast edge
C. TYPE OF CASTS
1. Forearm below elbow to proximal palmar crease
2. Gauntlet below elbow to proximal palmar crease
including thumb
3. Long Arm Cast upper level of axilla to proximal
palmar crease; elbow immobilized at Right angle
4. Boot or short leg below knee, base of toes
5. Long leg junction of the upper and middle third
of thighs to the base of toes, foot is at R angle in a
neutral position
6. Spica body cast trunk and lower extremity
D. CARE OF CAST
While cast dries
1. Extremity
a. Explain feeling of heat under the plaster

Leave area enclosed in cast uncovered until dry

to make it musty
Elevate on pillow when cooled and hardened
Avoid weight bearing on cast 48 hours

Spica
a.

Bed board under the mattress to prevent sag of

bed secondary to pressure of cast
b. Support the curves of the cast with small
plastic covered flexible pillow-prevents
cracking
c. No pillow under head and shoulder adds
pressure on chest
After cast dries
1. Keep level by elevating lumbar/sacral area with
small pillow when head of bed is elevated/on bed
pan
2. Protect toes from pressure of bedding
3. Encourage to maintain physiologic position by
a. Using overhead trapeze
b. Place good foot on bed and pushing down
while lifting himself up on the trapeze
4. Avoid twisting motions
5. Avoid position that put pressure and groin, back,
chest and abdomen
6. Inspect irritations
7. Massage accessible skin
8. Turn patient as a unit
9. Watch out for (nausea) of cast syndrome (acute
obstruction of duodenum after spica is applied)
a. Position of prone to relieve pressure
b. If necessary remove cast
c. NGT suction
d. Maintain Normal electrolyte balance
Removing a cast
1. Use electric cast cutter or shears
2. After cast is removed, support part with pillow
3. Gently move extremity
4. Wash skin with mild soap oil
5. Muscle strengthening exercise
6. Treat edema of foot following removal of deg cast
7. Instruct the patient
a. Wear shoes
b. Elevate foot when sitting
c. Wrap leg with an elastic compression bandage
or use elastic stockings
OBSERVATION OF PATIENT IN CAST
1. Listen to patients complaints
2. Ask patient to localize exact site of pain
3. Watch out for signs of pressure and constriction of
circulation. Notify physician if present
4. Loosen/ Bivalve the cast
IV. AMPUTATION
Below the knee
A. SURGICAL MANAGEMENT
1.
Closed

2.
3.

Open
Immediate
post
surgical
prosthesis
provide/improve
position
sense
(PREVENT
THROMBOEMBOLISM
AMBULATION)

THROUGH

EARLY

B. NURSING MANAGEMENT
Pre-operative care
Psychological adjustment
Physical preparation:
Assess for circulation
Assess for infection
Assess for nutritional status

Assess for physical conditioning

Post-operative care

Place in an extended position

Place in an elevated position

Watch out for complications:

Hemorrhage
Infection
Phantom
limbNURSING

PRIORITY:
ADMINISTER ANALGESICS AS ORDERED

Thromboembolism

V. REHABILITATION
A. MANAGEMENT
1. Watch out for problems as:
Flexion deformity
Non-shrinkage of stump
Abduction deformities of the hip
2. Institute exercises as:
SYSTEMIC
ERYTHEMATOSUS
LUPUS
Stretching
of flexor muscles
Chronic
inflammatory
ROM exercise disease that involves the vascular and
connective
tissue of multiple organs (RENAL, CV, skin)
3. Stump
conditioning
Promote shrinkage of stump
A. PREDSIPOSING
FACTORS
Promote stump
toughening
Genetic
AUTOIMMUNEINCREASE SERUM ANA CONFIRMS SLE
Viruses
B. MANIFESTATIONS
Insidious onset
Characterized by remission & exacerbation
Butterfly rash on face erythematous
Polyarthralgia/ joint pains
Normocytic/Nomochromic anemiadecreased RBC (n: 4-6 per
cubic meter)
Fever
Malaise
Weight loss
Reynauds phenomenon
C. NURSING INTERVENTIONS
Supportive, depends on affected organs
Health Teaching on:
Adequate rest and exercise/CBR
Regular nutritious meals ff .up treatment regimen
infection
OCPs
IUDexacerbation
Administer medications
Salicylates/Aspirin (PASA)
NSAIDs
Indomethacin/ Indocin

IMPORTANT POINTS TO TAKE NOTE:

Nephritis occurs on early stage of the disease
Manifestations:
Microscopic hematuria
Proteinuria
Red cell casts
Treatment
Symptomatic
Salicylates, steroids
Diagnostics
Variable