Nursing Care of Patients with Musculoskeletal Disorders (I)
Yun-Hsiang Lee PhD, RN. School of Nursing
National Taiwan University
Content
• Basic concepts of musculoskeletal system
• Assessment
• Disorders & Management● Fracture ● Amputation● Arthritis
• Nursing Care
Musculoskeletal System
• The muscular and skeletal systems provide support to the body and allow for movement.
• The bones of the skeleton protect the body’s internal organs and support the weight of the body.
• Musculoskeletal disorders
Injury: Fracture, AmputationDisease: ArthritisHips & Knees ReplacementMalnutrition
1.緻密骨2.海綿骨–紅骨髓:具造血功能,形成血球。–黃骨髓:含脂肪細胞。3.骨骼血液供應
骨骼功能支持運動保護儲存:鈣、磷及脂肪。製造血球:
Prevalence of work related musculoskeletal disorders (WMSDs)
N=232
Hossain, et al. (2018). Prevalence of work related musculoskeletal disorders (WMSDs) and ergonomic risk assessment among readymade garment workers of Bangladesh: A cross sectional study. PLoS One, 13(7), e0200122.
Assessment
Clinical skills• Taking history
– The current symptomsPainStiffnessJoint swelling…
– The evolution of the problem (Acute or Chronic)
– The involvement of other systems– The impact of the disease on the
person’s life
• Physical Examination• X-ray, Sona, CT, MRI, Blood
test (Alk-P, CRP..)– Alk-P: 鹼性磷酸酶 (alkaline
phosphatase)-關節腔鏡檢查(arthroscopy)
關節半月板切除術(診斷+ 治療)-關節穿刺術(arthrocentesis)
Disorders & Management-Fracture-
Description
A disruption or break in the continuity of the structure of bone
Traumatic injuries account for the majority of fractures
髋骨骨折好發?肱骨易傷的神經?
Life or Limb Threatening Emergencies• Major pelvic fracture
– Exsanguinations (失血狀況致命)• Compartment syndrome
– Ischaemia, myoglobinuria, renal failure
• Open fracture – Osteomyelitis (骨髓炎)
• Limb injury with vascular injury– Amputation
• Fat Embolism Syndrome
Disorders & Management-Fracture-
Six PsPain.Paralysis.Paresthesia (感覺
異常)Pulselessness. Poikilothermic (溫度改變).Pallor
尿中肌紅蛋白
Life or Limb Threatening Emergencies• Fat Embolism Syndrome (happen < 48 hours)
Disorders & Management-Fracture-
譫妄與昏迷
低血氧、喘
瘀斑
Clinical Manifestations
• Immediate localized pain
• Function decreasing
• Inability to bear weight or use affected part
• May or may not see obvious bone deformity
Fracture Complications
Disorders & Management-Fracture-
Early Local damageSoft TissuesNervesVesselsInfection
Early generalBleedingFat embolismInfection-Tetanus (破傷風), gangrene
Late LocalAvascular necrosis (骨壞死)OsteomyelitisCRPS-complex regional pain
CRPS: Complex Regional Pain Syndrome
• Diagnosis– History
– Examination
– Ix -Xrays, CT
– Re-examination of p’t prn if in doubt
– Recognised specific injury
– Ask for advice
Disorders & Management-Fracture-
• Treatment– Reduction (復位)restore bones and joints to normal anatomical position
(1) Traction (牽引)(2) Closed Reduction
(3) Open Reduction
– Retention (保留)Maintain reduced position-until bone union or healing of soft tissues
– Rehabilitation
• Traction: Application of pulling force to attain realignment– Prevent or reduce
pain – Prevent muscle
spasm– Immobilize a joint or
part of the body– Reduce a fracture or
dislocation– Treat a pathologic
condition
Disorders & Management-Fracture-
• Skin traction
• 使用膠帶、海棉橡皮或塑膠物貼附於皮膚上,再施以拉力。
1. <2.3~4.5 kg(5~10 lb)牽引力量2. Short time 2~3天
3. 如果需長期或較重的牽引,則應使用骨骼牽引或考量手術。
• Type of Skin traction
- Buck's Traction (布克氏牽引) : It is used preoperatively for patient with a hip fraction to reduce muscle spasms.
Disorders & Management-Fracture-
• 適用於髖部骨折之暫時固定、下背痛及股骨骨折
• 不適用於糖尿病性壞疽、鬱積性皮膚炎、動脈硬化、嚴重的靜脈曲張的病人。
• Type of Skin traction
- Pelvic Traction
Disorders & Management-Fracture-
45º
間歇
- Cervical Traction
• Type of Skin traction
- Russell's Traction
(路斯爾氏牽引)
-股骨幹骨折,
-兩側Traction治療下背痛
Disorders & Management-Fracture-
Disorders & Management-Fracture-
• Skeletal traction
• 金屬針及線穿透皮膚、皮下組織及骨頭。
• 牽引繩索應保持離開床鋪和鋪蓋的位置,並應在滑輪輪溝內。
• 所有牽引重力均需懸空,繩索、砂袋不能碰到床或地面。
• 牽引力可達12~15 kg
(25~30 lb)。
• Type of Skeletal traction
- Balanced Skeletal Traction
(平衡骨骼牽引)
- For patient with
femur, hip or lower leg
fracture
Disorders & Management-Fracture-
• Type of Skeletal traction - Overhead Arm Traction
(高位手臂牽引)
-肱骨骨折
-上臂臂或肘部外傷或骨折,造成腔室症候群,壓迫臂動脈,使得肌肉纖維因缺血而壞死所引起手緊繃僵硬。
-減少弗克曼氏(Volkmann’s)攣縮
Disorders & Management-Fracture-
• Closed reduction
Nonsurgical, manual realignment
• Open reduction
Correction of bone alignment through a surgical incision
Nursing Care-Fracture-
6PCTMS
• Casts
– Temporary circumferential immobilization device
– Common following closed reduction
Disorders & Management-Fracture-
合併症:
急性十二指腸阻塞
• Internal fixation
– Pins, plates, intramedullary rods, and screws
– Surgically inserted at the time of realignment
Disorders & Management-Fracture-
• External fixation
– Metallic device composed of pins that are inserted into the bone and attached to external rods
Disorders & Management-Fracture-
Pin Care
Nursing Assessment • Brief history of the accident
• Mechanism of injury
• Special emphasis focused on the region distal to the site of injury
• Neurovascular assessment– Color and temperature
• cyanotic and cool/cold: arterial insufficiency
• Blue and warm: venous insufficiency
– Capillary refill (want < 3 sec)
– Peripheral pulses (↓ indicates vascular insufficiency)
– Edema, Sensation, Motor function, Pain
Nursing Care-Fracture-
Nursing Diagnosis• Risk for peripheral neurovascular dysfunction
• Acute pain
• Risk for infection
• Risk for impaired skin integrity
• Impaired physical mobility
• Ineffective therapeutic regimen management
Nursing Care-Fracture-
• 踝幫浦運動(ankle pumping)• 臀肌收縮• 股四頭等長收縮• 主動或被動ROM• 直舉腿運動• 負重運動
Nursing ImplementationGeneral post-op care
• Assess dressings/casts for bleeding/drainage
• Prevent complications of immobility
• Measures to prevent constipation
• Frequent position changes/ ambulate as permitted
• ROM exercised of unaffected joints
• Deep breathing
• Isometric exercise 等長運動
• Prevent infection (antibiotics)
• Nutrition support
Nursing Care-Fracture-
Nursing ImplementationPost-op care for Total Hip Replacement
-Do Not Flex hip greater than 90 degrees.
-Use elevated toilet seat
-Place hip in adduction (外展)
-Prevent external rotation (勿外旋)
-Do Not Cross legs
Nursing Care-Fracture-
<90度
Nursing ImplementationPost-op care for
Total Knee Replacement
• Physical Therapy
• Gradually return to normal activities– Walking, climbing stairs
– No running, playing tennis
– Stationary Bicycle – regain strength in knee and leg muscles
– Swimming
-CPM also called continuous passive motion, is a device that is used to gently flex and extend the knee joint.
Nursing Care-Fracture-
Control weight