musculoskeletal nursing

1. ★ RICE

  • Rest
  • Ice pack apply
  • Compression bandage
  • Elevation

2. ★ cast

  • Plaster, fiberglass (synthetic), or air casts are used to immobilize bones and joints into correct alignment after a fracture or injury.
  • Allow a wet plaster cast 24 to 72 hours to dry. (Synthetic cast dries in 20 minutes.) Handle a wet plaster with the palms of the hands until dry. A hairdryer can be used on a cool setting to dry a plaster cast, but heat cannot be used on a plaster cast because the cast heats up and burns the skin. Ensure that no roughcasting material remains in contact with the skin. Petal the cast edges with waterproof adhesive tape or apply moleskin to the edges to protect the client’s skin. If a hip spica cast is placed, the cast edges around the perineum and buttocks may need to be taped with waterproof tape. Maintain smooth edges around the cast to prevent crumbling of the cast material. Instruct the client not to stick objects inside the cast. Monitor for signs of infection such as increased temperature, hot spots on the cast, foul odor, or changes in pain. Teach the client to keep the cast clean and dry. Keep the cast and extremity elevated. Turn the extremity every 1 to 2 hours to allow air circulation and promote drying of the cast. Monitor a casted extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. Notify the HCP immediately if a circulatory compromise occurs. Prepare for bivalving or cutting the cast if circulatory impairment occurs. Instruct the client in isometric exercises to prevent muscle atrophy.

3. splint

  • If a compound (open) fracture exist, splint the extremity and cover the wound with a sterile dressing.

4. ★ brace

  • Braces are not curative but may slow the progression of the curvature to allow skeletal growth and maturity.
  • Braces usually are prescribed to be worn 16 to 23 hours a day. Advise the child to wear soft non-irritating clothing under the brace. Inspect the skin for signs of redness or breakdown. Keep the skin clean and dry, and avoid lotions and powders because of these cakes and lead to skin breakdown. Instruct in prescribed exercises. Exercises help maintain and strengthen spinal and abdominal muscles during treatment. Encourage verbalization about body image and other psychosocial issues.

5. reduction

  • Reduction restores the bone to proper alignment
1) closed reduction
    • Closed reduction is a non-surgical intervention performed by manual manipulation.
    • A cast may be applied following reduction.
2) open reduction
    • Open reduction involves surgical intervention. The fracture may be treated with internal fixation devices, such as rods, wires, or pins.

6. fixation

1) internal fixation
    • Internal fixation involves the application of screws, plates, pins, or intramedullary rods to hold the fragments in alignment. Internal fixation may involve the removal of damaged bone and replacement with a prosthesis.
    • ORIF (Open Reduction with Internal Fixation)
    • ex) halo fixation
2) external fixation
    • External fixation is the use of an external frame to stabilize a fracture by attaching skeletal pins through bone fragments to a rigid external support. External fixation provides more freedom of movement than traction. External fixation is commonly used when massive tissue trauma is present.
    • Monitor pin stability and provide pin care to decrease infection risks. The risk of infection is commonly used when massive tissue trauma is present.

7. ★ traction

  • Traction is the exertion of a pulling force applied in two directions to reduce and immobilize a fracture. Traction provides proper bone alignment and reduces muscle spasms.
1) skeletal traction
    • Traction is applied mechanically to the bone with pins, wires, or tongs. The typical weight for skeletal traction is 25 to 40 lb.
    • Monitor the insertion sites for redness, swelling, increased pain, or drainage. Provide insertion site care as prescribed. Clean the pin sites with sterile NS and hydrogen peroxide or povidone-iodine (Betadine) as prescribed.
    • ex) cervical tongs, Gardner wells tongs
2) skin traction
    • Skin traction is applied by using elastic bandages or adhesive, foam boot, or sling.
    • Protect the skin from breakdown.
    • ex) cervical skin traction (head halter traction), Buck’s extension skin traction, Bryant’s traction Russell’s sling skin traction, pelvic traction
    •  Cf.) Buck’s extension skin traction: affected leg에만 적용
    • Bryant’s traction :  both leg 에 적용, 엉덩이는 1inch정도 뜨게. 오로지 소아에게만 적용 (2세 이하)
3) balanced suspension traction with Pearson attachment
    • Balanced suspension traction is used with skin or skeletal traction
    • Maintain proper body alignment. Maintain the correct amount of weight as prescribed. Ensure that the weights hang freely and do not touch the floor. Do not remove or lift the weights without an HCP’s prescription. Ensure that pulleys are not obstructed and that ropes in the pulleys move freely. Place knots in the ropes to prevent slipping. Check the ropes for fraying. Monitor color, motion, and sensation of the affected extremity.

8. ★ crutch

  • an assistive device
  • Safety is the priority concern when the client uses an assistive device. When ambulating with the client, stand on the affected side.
  • Be sure that the client demonstrates the correct use of the device. Accurate measurement of the client for crutches is important because an incorrect measurement could damage the brachial plexus. The distance between the axillae and the arm pieces on the crutches should be two to three finger-widths in the axilla space. The elbows should be slightly flexed, 20 to 30 degrees when the client is walking. Instruct the client to look up and outward when ambulating and to place the crutches 6 to 10 inches diagonally in front of the foot and 6 to 10 inches inside of the foot. Instruct the client never to rest the axillae on the axillary bars. Instruct the client to stop ambulation if numbness or tingling in the hands or arms occurs.
  • crutch gait
① two-point gait • Used with partial weight-bearing limitations and with bilateral lower extremity prostheses.

• The crutch on the affected side and the unaffected foot are advanced at the same time.

② three-point gait • Used for partial weight-bearing or no weight-bearing on the affected leg. Requires that the client have strength and balance.

• Both crutches and the foot of the affected extremity are advanced together, followed by the foot of the unaffected extremity.

③ four-point gait • Used if weight-bearing is allowed and one foot can be placed in front of the other.

• The right crutch is advanced, then the left foot, then the left crutch, and then the right foot.

④ swing-to gait • Used when there is adequate muscle power and balance in the arms and legs.

• Both crutches are advanced together, then both legs are lifted and placed down on a spot behind the crutches. The feet and crutches form a tripod.

⑤ swing-through gait • Used when there is adequate muscle power and balance in the arms and legs.

• Both crutches are advanced together. Then both legs are lifted through and beyond the crutches and placed down again at a point in front of the crutches.

⑥ going up the stairs • The client moves the unaffected leg up first. The client moves the affected leg and the crutches up.
⑦ going down the stairs • The client moved the crutches and the affected leg down. The client moves the unaffected leg down.
⑧ sit and stand • Place the unaffected leg against the front of the chair. Move the crutches to the affected side, and grasp the arm of the chair with the hand on the unaffected side. Flex the knee of the unaffected leg to the lower self into the chair while placing the affected leg straight out in front. Reverse the steps to move from a sitting to a standing position.

9. cane

  • an assistive device
  • Safety is the priority concern when the client uses an assistive device. When ambulating with the client, stand on the affected side. Use of a gait or transfer belt may be necessary.
  • Be sure that the client demonstrates the correct use of the device. The handle should be at the level of the client’s greater trochanter. The client’s elbow should be flexed at a 15 to 30 degrees angle. Instruct the client to hold the cane 4 to 6 inches to the side of the foot. Instruct the client to inspect the rubber tips regularly for worn places.
  • Instruct the client to hold the cane in the hand on the unaffected side so that the cane and weaker leg can work together with each step. Instruct the client to move the cane at the same time as the affected leg.

10. walkers

  • an assistive device
  • Safety is the priority concern when the client uses an assistive device. Stand adjacent to the client on the affected side.
  • Instruct the client to put all four points of the walker flat on the floor before putting weight on the handpieces. Instruct the client to move the walker forward, followed by the affected or weaker foot and then the unaffected foot.

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