Musculoskeletal Care Modalities

Ns. A Fauji, M. Kep., Sp. KMB

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Managing care of the patient in Cast:

A rigid, external immobilizing device

Is used to:

1. Immobilize a reduced Fracture ( allow the mobilization of the pt)mobilization of the pt)

2. Correct a deformity

3. Apply uniform pressure to underlying soft tissue

4. Support and stabilize weakened Joint

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Types of Casts:

1. Short arm cast 2.Long arm cast

2. Short leg cast 3.Long leg cast

3. Walking cast ( long or short) reinforced for strength

4. Body cast: encircle the trunk4. Body cast: encircle the trunk

5. Shoulder spica cast: a body jacket that enclosed the trunk and the shoulder and elbow

6. Hip spica cast: enclose the trunk and lower extremity ( double hip spica cast ( includes both legs

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Casting Materials:

Plaster: Rolls of plaster bandage, need 24 to 72 hrs to dry completely

Nonplaster: Fiberglass cast ( lighter in wt, Nonplaster: Fiberglass cast ( lighter in wt, stronger, water resistant), has pores so diminish skin problems

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Long-Arm and Short-Leg Cast and Common Pressure Areas

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Teaching Needs of the Patient With a Cast

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 Cast care: keep dry; do not cover with plastic Positioning: elevation of extremity; use of slings Hygiene Activity and mobility

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Cont

Explain exercises

Do not scratch or stick anything under the cast

Cushion rough edges

Report the following signs and symptoms: persistent pain or Report the following signs and symptoms: persistent pain or swelling; changes in sensation, movement, skin color, or temperature; and signs of infection or pressure areas

Required follow-up care

Cast removal

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Nursing ProcessAssessment of the Patient With a Cast

Prior to casting

Perform general health assessment

Evaluate emotional status

Determine presenting signs and symptoms and condition of the area to be castedof the area to be casted

Knowledge

Monitor neurovascular status and the potential for complications

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Nursing ProcessDiagnosis of the Patient With a Cast

Deficient knowledge

Acute pain

Impaired physical mobility

Self-care deficit

Impaired skin integrity

Risk for peripheral neurovascular dysfunction

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Collaborative Problems/Potential Complications

Compartment syndrome

Pressure ulcer

Disuse syndrome

Delayed union or nonunion of fracture(s)

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Interventions

Relieve pain

Elevate to reduce edema

Apply ice or cold intermittently

Implement position changes

Administer analgesics 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: see Chart 67-4

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Interventions (cont.)

Heal skin wounds and maintain skin integrity

Treat wounds to skin before the cast is applied

Observe for signs and symptoms of pressure or infection

Pad cast and cast edges

Patient may require tetanus booster

Maintain adequate neurovascular status Maintain adequate neurovascular status

Assess circulation, sensation, and movement

Five Ps

Notify physician at once of signs of compromise

Elevate extremity no higher than the heart

Encourage movement of fingers or toes every hour

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Managing patient with an External fixator:

Are used to manage open fractures with soft tissue damage. They provide stable support for severe comminuted (crushed or splintered) fractures while permitting active treatment of damage soft tissue.

Nursing intervention: Prepare the patient psychologically Cover sharp points on the fixator or pins to prevent injuries Elevate the extremity to reduce swelling Elevate the extremity to reduce swelling Assess neuromuscular status every 2 hrs Assess pin site for sign of infection and loosening of the pin Pin care Encourage isometric and active exercise within the limit of tissue damage.

Later the nurse help the patient to mobilize within the prescribed weight bearing limit

Teaching patient self care

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External Fixation Devices (cont.)

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Managing the patient in Traction:

Is used as short-term intervention until other modalities, such as external or internal fixation are possible.

Traction: is the application of a pulling force to a part of Traction: is the application of a pulling force to a part of the body

Is used to minimize muscle spasm, to reduce fractures, align and immobilize fractures, to reduce deformity.

The effect of traction is evaluated by radioactive studies.

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Traction (cont.)

All 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.

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Managing the patient in Traction (cont):

Principle of effective traction:

1. Countertraction must be maintained for effective traction

2. Must be continuous to be effective

3. Never interrupted

4. Weight are not removed4. Weight are not removed

5. The patient must be in in good body alignment in the center of the bed

6. Ropes must be unobstructed

7. Weight must hang freely

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Types of tractions:

I. Skin traction: is used to control muscle spasm and to immobilize an area before surgery. No more than 2-3.5 kg of traction should be used, pelvic traction 4.5 to 9 kg depending on the patient weight

Complications: Complications: Skin breakdown, nerve pressure (drop foot), and circulatory

impairment ( DVT)

Nursing interventions:1. Ensuring effective traction

2. Monitor and managing potential complications

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Skin Traction

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Types of tractions (cont):

II. Skeletal traction: applied directly to the bone by using metal pin or wires. Most frequently used to treat fracture of long bones and the cervical spine. Is a surgical procedure. Skeletal traction uses 7-12 kg, as the muscle relax the traction weight is reduced to prevent fracture relax the traction weight is reduced to prevent fracture dislocation and to promote healing

After removing the traction cast or splint are then used to support the healing bone.

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Skeletal Traction

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Nursing Interventions:

1. Maintaining effective traction: the nurse should not remove wt from skeletal traction unless life-threatening situation occurs

2. Maintaining positioning: such as the foot to prevent footdrop (planter flexion), inward and outward rotation.

3. Preventing skin breakdown4. Monitoring neuromuscular status4. Monitoring neuromuscular status5. Providing pin site care6. Promoting exercise Assess sensation and movement Assess pulses, color capillary refill, and temperature of fingers or toes Assess for indicators of DVT Assess for indicators of infection

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Joint Replacement:

Total Hip Replacement: Is the replacement of a severely damaged hip with an artificial joint

Indication: arrithritis, femoral neck fracture, failure of previous reconstructive surgeries, and problems resulting from congenital hip diseases.

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Cont

Nursing interventions:

1.Prevent dislocation:

A. positioning the leg in abduction,

B. dont turn the patient in the affected side,

C. never flex the hip more than 90 degree ( C. never flex the hip more than 90 degree (

D. dont elevate the head of the bed more than 60 degree

E. protective positioning include maintaining abduction, avoiding internal and external rotation, hyperextension, and a cute flexion

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Cont.

2. Monitoring wound drainage

3. Preventing DVT

4. Prevent infection4. Prevent infection

5. Teach patient self care

6. Continuing care

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Total knee replacement:

Indication: sever pain and functioning disabilities related to joint surfaces destroyed by arrithritis, bleeding into the joint

Nursing interventions:1. Maintain the compressed bandage over the knee2. Ice may be applied to decrease the swelling and bleeding3. Encourage active flexion of the foot every hour3. Encourage active flexion of the foot every hour4. Prevent complications5. Monitor drainage bag6. Place the patient leg in continuous Passive motion device ( promote

circulation and movement of the knee joint)7. Weight bearing limits are prescribed. Patient can get out of the bed the

evening of the surgery or the day after surgery

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CPM Device

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Crutches

If your injury or surgery requires you to get around without putting any weight on your leg or foot, you may have to use crutches.

Proper Positioning When standing up straight, the top of your crutches should

be about 1-2 inches below your armpits.be about 1-2 inches below your armpits. The handgrips of the crutches should be even with the top

of your hip line. Your elbows should be slightly bent when you hold the

handgrips. To avoid damage to the nerves and blood vessels in your

armpit, your weight should rest on your hands, not on the underarm supports.

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Type

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