PLANNING AND IMPLEMENTATION
When planning care, include clients and their families. For clients undergoing surgical procedures (e.g., lumbar decompression, joint replacement, insertion of a fixation device or prosthesis), provide preoperative and postoperative care.
Clients with musculoskeletal disorders may also require assistance with mobility, pain control, cast care, nutritional needs, and emotional problems. They need to understand their disorder, prognosis, and treatment. Develop nursing care plans that meet the client’s individual needs.
Preventing Disorders of Immobility
Prolonged bed rest is dangerous for clients with musculoskeletal disorders because of the increased risk for complications such as skin breakdown, contractures, constipation, and thromboembolism (also referred to as deep vein thrombosis). Provide teaching to prevent such complications. Work closely with physical therapists to help clients regain mobility.
Providing Comfortable Positioning and Proper Alignment
Some clients must remain in bed. Maintaining proper body alignment is essential. Turn clients frequently to prevent skin breakdown. Pillows, sandbags, splints, and trochanter rolls help prevent footdrop and contractures. PROM and AROM exercises promote and maintain joint mobility and muscle strength. Encourage clients to move independently as much as possible.
Providing Skin Care
Maintain skin integrity and protect against irritation. When bathing clients, minimize the use of soap. Use lotion for cleansing and for soothing dry skin. Reduce friction and shear forces through proper positioning. Keep sheets smooth and clear of crumbs after meals. If necessary, use special beds, air mattresses, foam pads, and flotation pads to help reduce pressure; however, their use is not a substitute for frequent skin care. Nursing observations with documentation of the client’s circulation, motion, and sensation (CMS) distal to the injury are important aspects of monitoring musculoskeletal problems. CMS checks are also known as neurovascular checks because they monitor the function and status of nerves and blood vessels, as well as the movement of muscles that could be damaged. Preventative skin care is important because many musculoskeletal problems involve difficulty with movement and prolonged immobility. If a client has an incision or pins in place, give special care to these skin breaks. Use the protocol prescribed by the healthcare facility. Use Standard Precautions and wear sterile gloves, if necessary, for pin site care.
Providing Adequate Nutrition
To promote healing, the client with a musculoskeletal disorder should receive a high-protein diet. Increased fiber and fluids help to maintain normal elimination. Record intake and output. Observe for signs of urinary infection or constipation. Give IV fluids, as ordered. Many clients receive nutritional supplements, such as Ensure.
Providing Activity and Exercise
Determine how much activity clients are allowed. Too little or too much exercise can be harmful. Place a trapeze on the bed frame of clients who are confined to bed so they can help lift their bodies for nursing care. Clients can also use a trapeze for exercise. Encourage clients to exercise unaffected body parts as much as possible.
Remind clients in casts or splints to flex and extend unaffected joints and muscles frequently. Usually, casted extremities are most comfortable when they are elevated. Remind clients to wiggle the fingers or toes of the affected extremities. Instruct clients to do isometric (muscle-setting) exercises of immobilized parts as often as possible. A continuous passive motion (CPM) machine is sometimes used to exercise extremities. Assist clients to be out of bed as much as possible. Help them use crutches, walkers, or other assistive devices.
Periodically evaluate outcomes of care with clients, families, and members of the healthcare team. Have short-term goals been met? Are long-term goals still realistic? In planning for further nursing care, such as the need for follow-up care at home or continued physical therapy, consider prognosis, the presence of any complications, and responses to care.
NCLEX Alert Nursing interventions for conditions such as hemorrhage, infection, and pain are very common clinical situations. Be sure that you are aware of these interventions and can decide which intervention has priority (e.g., generally hemorrhage before infection because excessive bleeding can be life-threatening), but read the situation carefully.
COMMON MUSCULOSKELETAL DISORDERS
Amputation is the absence or removal of all or part of a limb or body organ. An amputation may be congenital, or it may result from an injury or surgery. Reasons for surgical amputation include malignancy, trauma, gangrene, infections, and neurovascular compromise related to diabetes mellitus or cardiovascular disease.
A surgical amputation is the treatment of choice only when other means cannot control or arrest a disease process. In such cases, amputation is often a life-saving measure. In malignant disease, surgery may offer improved comfort, increased function, and greater potential longevity. Amputation does not always cure malignancies.
Level of Amputation
The disease process for which the procedure is necessary determines the level of amputation. Amputation of any extremity is performed at the most distal point possible. When a surgeon is able to preserve joints and maximize limb length, prosthetic fitting is easier and clients retain more functional ability.
Amputations are classified according to the affected limb and the level of the amputation. An amputation of the hand is called a below-the-elbow amputation (BEA); an amputation of the forearm and any part of the upper arm is called an above-the-elbow amputation (AEA). Amputation of the leg may be below-the-knee amputation (BKA) or above-the-knee amputation (AKA). Sometimes, only a finger or toe is amputated. An example of this description is “amputation of first finger, right hand, below second knuckle.”
Phantom Limb Pain
Phantom limb pain, a frequent after effect of amputation, refers to the sensation of pain, pressure, or itching that occurs in the area of the amputation, and the feeling that the absent body part is still present. If possible, discuss this concept with the client before surgery because he or she may be too embarrassed to mention phantom pain when it occurs. Encourage clients who seem to be disturbed and uneasy following amputation to discuss their feelings. If phantom pain or discomfort is causing the distress, explain that the sensation is common and results from damage to the nerves in the stump. Reassure clients that phantom pain generally disappears in time. For pain relief, tell clients to “move” the missing limb. By activating the damaged nerves leading to the amputated limb, clients usually feel great relief. Other interventions include use of analgesics, transcutaneous electrical nerve stimulation (TENS), ultrasound, and visual imaging. Persistent pain can interfere with prosthesis fitting.
A prosthesis is an artificial device that replaces part or all of a missing extremity. Over the years, the design of prostheses has improved, and they have become more lightweight and reliable. The use of computer technology has resulted in better-fitting prosthetic devices that are more functional and natural looking.
Clients are fitted with prostheses as soon as possible after surgery; sometimes surgeons attach temporary prostheses while clients are still anesthetized. Leg prostheses are most successful. Skirts and trousers can conceal leg prostheses, which can be equipped with shoes that match. Therapists and specially trained nurses assist the person in learning to walk with the new prostheses.
Typically, arm prostheses are more complicated because the hand is an exquisite motor and sensory organ. Functional artificial hands usually do not look real. Above-the-elbow amputees can use either functional or cosmetic prostheses. A practical prosthetic hand is fashioned with a mechanical hook, consisting of metal prongs placed opposite each other to replace the fingers and thumb. The opposition placement is necessary to allow the amputee to hold articles in a normal manner. Clients can activate their prostheses by body movements or an external electrical power source.
After amputation surgery, a rigid or compression dressing is applied to the stump to protect the limb, permit healing, control edema, and minimize pain and trauma. Two sets of compression bandages are needed so that bandages can be changed at least twice per day, or more often if a client perspires freely. Teach clients and their family members how to apply bandages. Correct stump wrapping reduces edema and is important to later use of a prosthesis. Wrap the stump so that it forms a cone shape. Obtain instructions for the recommended wrapping of each client’s stump.
Preventing Complications. Potential complications following amputation include hemorrhage, infection, failure of the stump incisions to heal, and deformity of proximal structures. Use the following nursing actions to prevent complications:
• Keep a tourniquet within reach at all times to be applied if severe, life-threatening bleeding occurs.
• Observe the dressing for bleeding.
• Change the dressing using aseptic technique.
• If the surgeon has inserted drains, monitor and document the amount, color, consistency, and odor of drainage.
• Avoid dislodging drains when turning the client.
• When changing dressings, check the incision closely for signs of healing. Report any signs of dark-red to black tissue, opened areas along the incision line, unusual drainage, or lack of healing. Dark-red or black tissue is a sign of gangrene, which is necrosis of tissue caused by insufficient or lack of blood supply.
• Encourage the client who has had a leg amputated to lie in a prone position, rather than on the back. To prevent hip contractures, do not place pillows under the stump when the client is on the back. Reduce stump edema by elevating the foot of the bed.
• If ordered, apply skin traction to the stump as soon as the client returns from surgery. A cast of lightweight material is sometimes applied to the stump to maintain its shape.
• If no cast is in place, cleanse, dry, and carefully inspect the stump according to the institution’s protocols. Report any redness or irritation because any irritation or skin breakdown will interfere with the use of a prosthesis and may lead to infection.
Client Teaching. Teach and encourage prosthesis self-care as soon as possible. Show clients how to wash, rinse, and dry the stump. Teach clients how to inspect the stump for signs of complications and how to use prostheses. Teach clients who are wearing limb socks to avoid skin problems by keeping the socks free of wrinkles. Instruct clients how to maintain the actual prostheses.
Providing Emotional Support. Clients who have amputations naturally react with grief because of their limb loss and change in body image. They may exhibit irritability, anger, depression, and other emotions. Allow time for clients to express such feelings. Listen to their concerns and provide support. Refer clients to support or recreation groups. Help family members adjust to the change and provide support for them as well through listening, understanding, and encouragement.
Assisting With Exercise. When clients undergo foot or leg amputations, they are prepared for walking by increasing the strength of upper extremities. Exercises to increase arm strength for crutch walking may start preoperatively. Encourage ROM exercises. Physical therapists may show clients how to maintain muscle tone. Direct your efforts to help clients prevent contractures. Usually, by the first or second postoperative day, most clients can sit up at the edge of the bed and soon progress to a wheelchair. Periodic bed rest is advisable because prolonged sitting may cause contractures and edema. Crutch walking should begin as soon as possible. Amputation changes a person’s sense of balance; thus, clients who have experienced amputation require close supervision as they resume movement and ambulation.
Replantation of Severed Limbs
Replantation is the reattachment of a completely severed body part. With the advent of microvascular surgery, some clients who suffer traumatic amputations may have their limbs successfully replanted, although this procedure is sometimes impossible. Factors affecting the success of this type of surgery include the availability of a specialist and equipment for the procedure, the client’s general condition, and the condition of the severed extremity. Usually, reattachment of lower extremities is less successful than reattachments of upper extremities because of the large and complex sciatic nerve system that innervates the legs.
Postoperative management includes anticoagulation therapy, a caffeine-free diet to prevent vasospasm, wound care, administration of antibiotics, and continuous inspection of the replanted part. Perform frequent neurovascular checks of the replanted limb. Monitor for complications, such as bleeding, arterial or venous compromise, infection, or decreased ROM.
Chronic Back Pain
Back pain, particularly lower-back pain, is a malady that affects nearly 80% of all individuals. It has many causes, but perhaps the most common contributing factor is that the human body stands and walks upright, with most of its weight centering on the lumbar region of the pelvis. The stresses of upright mobility may cause lumbosacral ligament strain and aching muscles. As the body grows older, the combination of prolonged muscular and ligament strain, pressure on the lumbosacral vertebrae, and the aging process itself results in problems such as osteoarthritis, spinal stenosis (narrowing of the intervertebral space), and intervertebral disk problems. All of these conditions cause pain because of pressure on the nerves or inflammation of the lower back muscles.
Back pain may be caused by abnormal or exaggerated curvatures of the vertebral column. Lordosis (“swayback”) is an abnormal curvature of lumbar vertebrae. Kyphosis (“humpback” or “hunchback”) is an abnormal curvature of the thoracic spine. Scoliosis is a lateral (side-to-side) angulation of the spinal column. Abnormal spinal column curvatures may be caused by poor posture, congenital disease, malignancy, compression fractures, osteoarthritis, rheumatoid arthritis, rickets, or aging. Treatment for these conditions will include combinations of therapies, including exercise and electrical muscle stimulation. In more severe cases, braces, casts, or traction may be used. Scoliosis is more common in adolescence and may require insertion of spine-strengthening braces (Milwaukee brace) and support rods (Harrington rod).
NCLEX Alert Clinical situations on an NCLEX may contain terminology that will affect the correct response. Be sure that you are aware of the nursing interventions, side effects, client teaching, and other issues associated with the terminology
Intervertebral Disk Disease
Intervertebral disk disease (IVD) results when a small pad or disk of cartilage (the nucleus pulposus) located between two vertebrae presses against the spinal nerves that radiate out from the spinal cord. Typically, disk problems occur in the cervical or lumbar areas. Also known as a herniated nucleus pulposus (HNP), the phenomenon is often referred to as a “herniated disk” or “slipped disk.” Another term for IVD is sciatica, because the sciatic nerve is commonly a site of damage and resulting pain.
Signs and symptoms of IVD include back, shoulder, or neck pain; and paresthesia (numbness), muscle spasm, depressed deep-tendon reflexes, and neurologic dysfunction. Risk factors include advancing age, smoking, degenerative joint disease, and progressive bone disorders, such as osteoporosis. Persons whose occupations require exposure to vibrating equipment, repetitive work movements, or frequent bending, twisting, heavy lifting, pushing, or pulling are at risk for IVD.
Diagnostic Tests. Diagnosis can be made with a CT scan or MRI, performed in conjunction with the presentation of a positive history and physical examination. The CT scan and MRI can identify spinal stenosis. CT scanning can be combined with myelography using a water-soluble dye to outline nerve root filling. This procedure is particularly useful for clients who have had prior surgery. Diskography (x-ray studies) can evaluate the disk’s internal structure.
Medical and Surgical Treatment. Clients are rarely immobilized. Instead, physical therapists recommend a treatment plan that includes regular walking or aquatic exercise. Lumbosacral corsets or braces may be used to improve muscular support of the lower back; however, they do not significantly decrease long-term pain. Clients wear them only for a short time because prolonged use weakens the supporting abdominal muscles. Antispasmodic and analgesic medications may be helpful. The therapist may also prescribe ultrasound, intermittent traction, or TENS therapies.
If such methods are unsuccessful in relieving symptoms, clients may choose surgery. Spinal disorders caused by pressure on a spinal nerve can often be treated surgically by removing the causes of pressure, if possible.
In an operation called a lumbar decompression, the surgeon removes a portion of the vertebra to expose the spinal cord and takes out the bone fragment, herniated disk, tumor, or clot pressing on neural elements. A laminectomy is a type of lumbar decompression that exposes the spinal canal and allows for relief of compression of the spinal cord and spinal nerve roots. A diskectomy removes the herniated disk, which can relieve pressure on the nerves. This procedure can usually be performed on an outpatient basis using an endoscope, resulting in only a very small incision.
Microdiskectomy may also be used to remove a herniation. The surgeon makes a small incision and uses a microscope to help visualize the disk. Because microdiskectomy is quicker and less traumatic than more invasive surgeries, the client experiences a shorter hospital stay and recovers more rapidly. Sometimes, the weakened vertebra can be strengthened by the attachment of a steel rod or by grafting a piece of bone from the tibia or iliac crest, or from donated bone, onto several vertebrae or between a vertebra and the sacrum in a process is called spinal fusion. When the graft heals, the spine in that area will be stiff.
Another surgical procedure is the interbody fusion. In this procedure, bone grafts or substitutes are placed between the vertebrae after the disk space is cleaned out. The bone graft is supplemented with a metal fusion cage or other instrument. The surgeon determines the specific type of fusion to be done after careful testing to determine the cause of spinal instability.
Nursing Considerations. For the client undergoing surgery, provide routine postoperative care and assist with pain management. Give meticulous wound care to prevent contamination because infection could lead to meningitis. Watch closely for signs of bleeding and other drainage, leakage of cerebrospinal fluid, or shock caused by trauma. Evaluate the client’s neurologic function at frequent intervals. Carefully follow the healthcare provider’s orders for the client regarding turning, positioning, and getting out of bed.
When a lumbar decompression has been performed, carefully observe the client’s sensation and mobility in the legs. Observe for further complications, such as spinal nerve damage or spinal cord damage, which may have occurred during surgery. Immediately report any complaints of tingling, numbness, or difficulty in moving the legs.
Be alert for the edema that may be an inflammatory response to the trauma of surgery. Edema around the tissues of the surgical site may cause pressure on the spinal cord and may also lead to fluid collection in the legs. In Practice: Data Gathering in Nursing 77-2 provides information on factors to consider following lumbar decompression.
IN PRACTICE: DATA GATHERING IN NURSING 77-2
POSTLUMBAR DECOMPRESSION CONCERNS
• Nerve damage: Change in sensation or mobility of legs; tingling, numbness of legs, urinary retention
• Edema: Collection of fluid in legs; severe pain, which could indicate edema within spinal column
• Change in level of consciousness: Possibly indicative of encephalitis or meningitis
• Muscle spasms: Leg pain; possibly prevented by exercises
• Thrombophlebitis: Leg pain; can be prevented by surgical stockings, exercises, and ambulation
• Additional injury: Prevented by avoiding heavy lifting for a period
• Infection: Fever, wound drainage, erythema
Following cervical decompression, also observe for nerve damage suggested by the following:
• Difficulty or change in sensation of arms
• Difficulty in moving arms
• Difficulty in breathing
In addition, if a cervical laminectomy or decompression was performed, monitor the client’s upper extremities for evidence of nerve damage or impaired respiratory function.
Although adequate rest is required, encourage clients to move to prevent respiratory complications. Assist the client in participating with the turning procedures prescribed by the healthcare provider. For example, the client can hold the body straight and keep the arms crossed over the chest while being rolled as a single entity (logroll turn). Use a turning sheet if necessary.
Manage postoperative pain. Pain medication is often given via a patient-controlled analgesia (PCA) pump or epidural catheter. Offer analgesics before moving, turning, or ambulating the client. Encourage the use of pain medications so that the client is reasonably comfortable both at rest and with activity.
Key Concept Pain is often viewed as the fifth vital sign, after temperature and blood pressure. Clients with acute or chronic pain need consistent, reliable pain relief
The client is usually allowed out of bed on the day of surgery. Assist the client to his or her side, then gradually and smoothly move the legs over the side of the bed as the client pushes up with the arms to a sitting position. Finally, help the client rise to a standing position, while maintaining spinal support and alignment at all times.
Most clients wear a thoracic-lumbar-sacral orthosis (TLSO) brace or a corset to support the back and to maintain the effects of surgery. Before applying a brace, put a thin cotton shirt on the client to protect the skin. Be sure to smooth all wrinkles to avoid unnecessary pressure against the skin. Follow the institution’s policy and manufacturer’s instructions for applying the device. When placing a bedpan, never lift the client, but rather roll the client onto the pan. Always use a fracture bedpan. Rationale: It is smaller and the client does not arch the back when using it. Teach the client never to reach or stretch for articles.
During the first few postoperative days, the client may develop muscle spasms, especially in the legs. The physician may order exercises to relieve these spasms. Teach the client isometric exercises for the quadriceps because he or she can perform these exercises without moving in bed. Apply antiembolism stockings and pneumatic compression devices. These items help prevent thrombus formation related to immobility.
After lumbar decompression surgery, the client is gradually allowed to do light work, but must always avoid heavy lifting. Instruct the client to take caution when lifting anything for at least 1 year after surgery. Reinforce proper body mechanics and appropriate lifting techniques. Emphasize that disregarding precautions—even once during convalescence—may result in injury.
If a spinal fusion has been performed, the client may encounter more limitations. He or she usually must wear a brace or corset whenever leaving bed. Occasionally, the physician orders the client to wear the brace at all times. Sometimes, the physician applies a body cast. Tell the client to avoid prolonged sitting because it places extra strain on the back. The client is never moved unless the healthcare provider has ordered it and healthcare personnel have learned the correct procedure. The client who is paralyzed also needs care appropriate to the degree of paralysis.
After a cervical diskectomy, the client usually wears a cervical collar to limit neck extension, rotation, and flexion. Teach the client to keep his or her neck in a neutral and aligned position. Instruct the client to wear the collar as directed by the physician. Show the client how to open the cervical collar and wash and dry the neck. Assist the client with sitting by supporting the client’s neck and shoulders.
Temporomandibular Joint Disorders
Temporomandibular joint (TMJ) disorders are painful, aching disorders involving the facial bones and muscles around the joint between the mandible and the temporal bones. TMJ may affect one side or both sides of the face. Chewing may make the condition worse. The joints may have limited movement, and the client may note clicking sounds during chewing. In more severe cases, tinnitus and deafness may be present. Stress, malocclusion (malposition-ing) of the upper and lower jaw, poorly fitting dentures, rheumatoid arthritis, and neoplasms are the most common causes of TMJ. Successful treatment involves identifying the cause, physical therapy, anti-inflammatory agents, and braces or surgery, if indicated.