Learning Objectives
1. In relationship to a client with a musculoskeletal disorder, discuss the diagnostic benefits of the following tests: laboratory tests including ESR, CBC, RF, uric acid, CK, calcium, and phosphorus levels; x-ray; arthrogram; myelogram; CT scan; MRI; bone scan; ultrasound; arthrocentesis; arthroscopy; bone biopsy; and EMG.
2. Describe the components of data collection for a client with a musculoskeletal disorder.
3. Identify the major components of nursing care necessary to protect the client from the hazards of immobilization.
4. Discuss the important areas of nursing care for the client who has had an amputation and now has a new limb prosthesis.
5. Explain the aspects of nursing care needed for a client who has been surgically treated for IVD or HNP.
6. State the nursing considerations for clients with TMJ, muscular dystrophy, and osteoporosis.
7. Differentiate among the following conditions: inflammatory disorders (RA, OA, ankylosing spondylitis, bursitis, and tenosynovitis); repetitive strain injuries (carpal tunnel syndrome and lateral epicondylitis); and systemic disorders with musculoskeletal manifestations (gout, SLE, scleroderma, and rickets or osteomalacia), stating the nursing considerations for each disorder.
8. Compare and contrast the following: strain, sprain, and fracture. Identify the four categories and five types of common fractures.
9. Describe the nursing implications for the care of a client in a cast.
10. Differentiate between skin traction and skeletal traction, including indications and nursing considerations for each type of traction.
11. Discuss the nursing measures for care of clients with the following treatments: external fixation, ORIF, and arthroplasty.
12. Identify the complications of fractures or bone surgery.
13. Explain the difference between primary and metastatic bone tumors.
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IMPORTANT TERMINOLOGY |
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acrosclerosis |
fracture |
replantation |
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amputation |
gangrene |
rickets |
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ankylosis |
gout |
sclerodactyly |
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arthritis |
halo device |
scleroderma |
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arthrocentesis |
kyphosis |
scoliosis |
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arthrogram |
laminectomy |
sequestration |
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arthroplasty |
lordosis |
skeletal traction |
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arthroscopy |
myelogram |
skin traction |
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bursitis |
neurovascular checks |
spinal stenosis |
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cast |
orthopedics |
sprain |
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dislocation |
osteomalacia |
strain |
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electromyogram |
osteomyelitis |
synovectomy |
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fasciotomy |
prosthesis |
tenosynovitis |
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Acronyms |
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AEA |
HNP |
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AKA |
IVD |
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BEA |
OA |
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BKA |
ORIF |
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CK |
RA |
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CMS |
RF |
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CPM |
SLE |
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DJD |
THA |
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ECG |
TMJ |
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EEG |
TLSO |
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ESR |
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The medical specialty that examines and treats diseases and injuries of the musculoskeletal system is called orthopedics (orth/o = straight). Surgeons who specialize in this area of medicine are orthopedists. Orthopedic nursing involves preventing further complications for clients with musculoskeletal conditions.
DIAGNOSTIC TESTS
Nursing care for clients with musculoskeletal disorders is likely to involve preparation for physical examinations, radiographic tests, and other diagnostic procedures. Be sure to explain the actual procedures to reduce tension or anxiety that clients may experience. Teach post-procedure activities that ease discomfort and promote wellness. Carry out physical preparation and document all aspects of care.
Laboratory Tests
Several laboratory tests are available to monitor the condition of bones and muscles. Complete blood cell count (CBC), uric acid levels, and blood levels of calcium and phosphorus help indicate the overall condition of the musculoskeletal system. Erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), and creatine kinase (CK) tests may show inflammation related to an infection or inflammatory condition.
Radiography (X-ray)
Radiography is the most common method of assessing the general state of bones. An x-ray study visualizes bones and other internal structures noninvasively so that the healthcare provider can diagnose abnormalities and monitor the effectiveness of treatments. Some types of radiographic examinations require the use of dye to visualize cavities within bony parts. Before giving a radiopaque dye, ask the client if he or she has any sensitivities to foods, especially any shellfish or medications containing iodine, as well as any sensitivities to latex or medications. Before a female client undergoes any x-ray procedure, determine if she is pregnant. Special precautions must be taken to protect the reproductive organs of all clients from potentially harmful radioactivity.
Key Concept Rather than asking your client, "Are you allergic to anything," ask your client, “What sensitivities do you have to food, iodine, latex, medications, or other substances”? If your client has sensitivities, your next question should be, "What happens when you are exposed to this substance?”
Arthrogram
An arthrogram is an x-ray study of a joint (e.g., knee or shoulder). A radiopaque or radiolucent substance is injected, and then a sequence of x-rays films is taken to determine the joint’s condition.
Myelogram
The myelogram (myel/o = spinal cord; bone marrow) is an x-ray examination of the spinal cord and vertebral canal after injection of a contrast medium or air into the spinal subarachnoid space. This diagnostic procedure is particularly valuable for evaluating spinal cord abnormalities caused by tumors, herniated intervertebral disks, or other lesions.
Computed Tomography
Computed tomography (CT) scanning provides a threedimensional radiographic view of a body part. CT scanning is painless and can be performed with or without the use of contrast agents. The amount of radiation the client receives is the same as what he or she would receive during a conventional chest x-ray. The scanner takes a series of crosssectional pictures of the body part in minute slices across the coronal plane (vertically, from front to back). A CT scan is useful in diagnosing bone, ligament, and tendon injuries, soft tissue disorders, and tumors.
Other Diagnostic Tests
Magnetic Resonance Imaging
In magnetic resonance imaging (MRI), a powerful magnetic field enables a scanning machine to produce detailed images of internal organs without the use of potentially dangerous ionizing radiation or x-rays. The use of a magnetic field and radio frequencies produces measurable signals, which a computer translates into three-dimensional visual images. MRI is safer and less expensive than invasive procedures such as biopsy, surgery, or the use of radioactive isotopes or dyes. For these reasons, many examiners prefer to use MRI whenever possible. MRI units are expensive, however, and not all institutions have MRI capabilities. Portable MRI units are often available for rural facilities.
Nursing Alert Clients who have metallic implants, such as orthopedic screws, may not be eligible for MRI scanning. Severe damage and death can result if metallic implants are exposed to the intense magnetic fields of an MRI.
Bone Scan
A bone scan is used to detect primary bone tumors, metastatic bone disease, osteomyelitis, osteoporosis, inflammation, bone or joint infections, and stress fractures. It requires the intravenous (IV) injection of a radioisotope, such as technetium 99m, which then enhances the visualization of abnormal tissue areas. The client must lie quietly during the entire scan. After the test, instruct the client to drink extra fluids, to increase excretion of the isotope.
Ultrasound
Ultrasound technology, which uses sound waves and their echoes to display images, helps to evaluate soft tissue masses, osteomyelitis, infection, congenital and acquired pediatric disorders, bone mineral density, sports injuries, and fracture healing. This method is noninvasive, inexpensive, readily available, and safe because it does not involve ionizing radiation.
Arthrocentesis
An arthrocentesis is aspiration of synovial fluid, blood, or pus from a joint cavity. By examining these fluids, a healthcare provider can diagnose infections, inflammatory conditions, and bleeding. After the test, a compression dressing is applied and the joint is rested for 1 day.
Arthroscopy
Arthroscopy is a minimally invasive procedure used in viewing joints for diagnostic and treatment purposes. It uses a special endoscope, called an arthroscope, which has a lens and a light source at its end that transmits a picture to a video monitor in the operating room (OR). Because the flexible scope can bend inside the joint, the surgeon views and operates on the joint’s interior, using only a very tiny incision referred to as a “stab wound.” The procedure is known as a closed procedure because the joint does not need to be laid open.
The procedure is performed in the OR or same-day surgery facility, often under local anesthesia. Surgeons use arthroscopy to diagnose and treat joint disorders. For example, foreign or loose objects (e.g., a piece of cartilage, a bone spur) can be removed. A rough and worn joint can be made smoother and more comfortable. Tissue samples can be obtained via biopsy, and a torn meniscus or ligament can be diagnosed and possibly repaired. Arthroscopic surgery is much safer, more comfortable, and more cost effective than open surgery, and for these reasons it is used whenever possible.
Following the procedure, elevate the client’s joint and apply ice to control edema and pain. Teach the client how to monitor the site for evidence of infection.
Biopsy
A biopsy of bone, tissue, or muscle may be performed using local anesthesia to diagnose tumors, infections, muscle inflammation or atrophy, and various other problems. After the procedure, monitor the biopsy site for bleeding, swelling, infection, or hematoma.
Electromyogram
The electromyogram (EMG) is a test of electrical conductivity, similar to the electrocardiogram (ECG) or the electroencephalogram (EEG). The provider places fine needles into the client’s muscles (my lo = muscle), and measures the electrical impulses within the muscles, both at rest and during activity. The provider can then determine whether or not the client’s muscles respond appropriately to stimuli.
Nursing Alert Do not confuse the term myogram with the term myelogram. The combining form my/o refers to muscle, whereas the combining form mye/lo refers to the spinal column.
COMMON MEDICAL TREATMENTS
Joint, bone, and muscle disorders often cause pain and limit movement. Common treatments for these disorders include application of heat or cold through hot baths or soaks, hot or cold compresses or packs, or paraffin baths. Heat causes vasodilation, thereby drawing oxygen, leukocytes, and nutrients to an injured or diseased area to promote healing and prevent infection.
Physical therapy is another common medical treatment for joint, bone, and muscle disorders. The simplest therapies for joints are passive range of motion (PROM) and active range of motion (AROM) exercises. Massage, if joints are not damaged or inflamed, often helps to soothe aching joints.
Muscle, bone, or joint fractures or diseases accompanied by damage to surrounding soft tissues are treated by external immobilization devices to alleviate pain and discomfort, prevent further injury, and promote healing. External immobilization is achieved through the use of braces, corsets, splints, casts, and traction.
COMMON SURGICAL TREATMENTS
Common surgical treatments for muscle, bone, and joint disorders are performed to remove or repair damaged or diseased parts. Disorders that may require surgery include fractures, ligament ruptures, arthritic joints, or accidental limb amputation.
Surgery is necessary if a fractured joint or bone cannot heal with external immobilization alone. A bone fracture that results in multiple fragments usually cannot be realigned without surgically opening the body part and reattaching the fragments using surgical hardware such as pins, screws, or plates. Joint replacement surgery, or arthroplasty, is a common treatment for the client with either arthritis or severe fractures that may not heal. Various surgical procedures are performed to immobilize or repair the spinal column if trauma or disruption of the spinal space and cord occurs. Amputation is the surgical choice if a limb is damaged by injury or disease beyond repair.
NURSING PROCESS
DATA COLLECTION
Carefully observe and document the status of a client with a musculoskeletal disorder. Establish a baseline for future comparison. Report any changes from the baseline findings.
Observe for any skeletal deformity. Observe posture, coordination, and body build, noting any asymmetry or deformity. Palpate soft tissues, joints, and muscles. Measure muscle mass. Palpate the skin temperature for warmth and document any swelling, crepitation, tenderness, skin discoloration, or other abnormality.
To determine the client’s musculoskeletal function, perform range-of-motion exercises (ROM). Check for bilateral muscle strength, as well as for balance and gait. A healthcare provider may refer the client to a specialist if limited mobility is suspected. Also evaluate the client’s ability to use mobility aids, such as a wheelchair, walker, cane, or crutches safely .
Observe the client’s emotional response to the disorder or disease. Does he or she need assistance to meet daily needs? Does the disorder affect social activities or self-esteem? Is the client anxious or fearful of the outcome?
Immobilization Devices
The nurse must carefully monitor clients who have immobilization devices in place because it is extremely important to prevent and promptly treat any complications (see In Practice: Data Gathering in Nursing 77-1). Areas of concern include pressure, infection of the wound or bone, and hemorrhage.
IN PRACTICE :DATA GATHERING IN NURSING 77-1
KEY FINDINGS WITH AN IMMOBILIZATION DEVICE IN PLACE
Complications of Pressure
• Edema: Swelling under the device, at the edges of the device, or of the entire extremity
• Skin color: Blanched, mottled, or cyanotic; inspect the client’s fingers and toes frequently and separately for signs of circulatory impairment
• Numbness, tingling, or the inability to move: inability to move the fingers or toes and to identify specifically which digit is touched; inability to flex the foot (dorsiflexion and plantar flexion) if the ankle and foot are not casted
• Cool temperature of digits: Sensation of being colder on affected side if pressure exists
• Severe pain: Most likely caused by swelling if medication fails to relieve severe pain
• Lack of distal pulse: Indicative of inadequate blood flow
• Slow capillary refill: Lack of color return in 2 to 4 seconds after nail bed is compressed
Wound Infection
• Elevated temperature, pulse, and respirations; the client may develop hypotension if infection is developing
• Odor of decaying tissue
• Elevated leukocyte count
• Drainage of blood or serous fluid from the fracture area (may be seen at pin insertion sites or in cast window, or may soak through cast)
• Redness and swelling in surrounding tissues
• Pain
• Swelling
Infection of the Bone (Osteomyelitis)
• Fever
• Pain
• Redness and heat
• Elevated leukocyte count
• Nausea, with or without vomiting
• Headache
• Swelling and pressure
Hemorrhage
• Diminished color, motion, and sensitivity of distal limb
• Tachycardia
• Hypotension
• Rapid respirations
• Anxiety panic, or confusion
• Diaphoresis
• Oliguria (decreased urine output) or anuria (no urine output)
A primary concern while observing such clients is to watch for signs of pressure. Undue pressure of any kind can cause serious neurovascular compromise or damage to nerves and blood vessels. Pressure, and its accompanying lack of blood or nerve supply, can cause tissue necrosis (death) and other complications.
Nursing Alert Follow Standard Precautions when providing care for clients with compound fractures, wound infections, or the possibility of hemorrhage.
