ORTHOPEDIC NURSING

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 Review of Anatomy and
Physiology
• The musculo-skeletal system consists of
the muscles, tendons, bones and cartilage
together with the joints
• The primary function of which is to
produce skeletal movements

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 Muscles
Three types of muscles exist in the body
• 1. Skeletal Muscles
• Voluntary and striated
• 2. Cardiac muscles
• Involuntary and striated
• 3. Smooth/Visceral muscles
• Involuntary and NON-striated

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 TENDONS
• Bands of fibrous connective tissue that tie
bones to muscles

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 LIGAMENTS
• Strong, dense and flexible bands of fibrous
tissue connecting bones to another bone

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 BONES
• Variously classified according to
shape, location and size
• Functions
1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition

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 JOINTS
• The part of the Skeleton where two or
more bones are connected

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 CARTILAGES
• A dense connective tissue that consists of
fibers embedded in a strong gel-like
substance

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 BURSAE
• Sac containing fluid that are located
around the joints to prevent friction

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 ASSESMENT OF THE
MUSCULO-SKELETAL
SYSTEM
• The nurse usually
evaluates this small part of
the over-all assessment
and concentrates on the
patient’s posture, body
symmetry, gait and muscle
and joint function

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 ASSESMENT OF THE
MUSCULO-SKELETAL
SYSTEM
• 1. HISTORY
• 2. Physical Examination
• Perform a head to toe assessment
• Nurses need to inspect and palpate
• The special procedure is the
assessment of joint and muscle
movement
• Usually, a tape measure and a
protractor are the only instruments

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 ASSESSMENT OF THE
MUSCULO-SKELETAL
SYSTEM
• Gait
• Posture
• Muscular palpation
• Joint palpation
• Range of motion
• Muscle strength

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 ASSESMENT OF THE
MUSCULO-SKELETAL
SYSTEM
LABORATORY PROCEDURES
• 1. BONE MARROW ASPIRATION
• Usually involves aspiration of the
marrow to diagnose diseases like
leukemia, aplastic anemia
• Usual site is the sternum and iliac
crest
• Pre-test: Consent
• Intratest: Needle puncture may be
painful
• Post-test: maintain pressure dressing
and watch out for bleeding
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 ASSESMENT OF THE
MUSCULO-SKELETAL
SYSTEM
LABORATORY PROCEDURES
• 2. Arthroscopy
• A direct visualization of the joint cavity
• Pre-test: consent, explanation of procedure,
NPO
• Intra-test: Sedative, Anesthesia, incision will
be made
• Post-test: maintain dressing, ambulation as
soon as awake, mild soreness of joint for 2
days, joint rest for a few days, ice application
to relieve discomfort

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 ASSESMENT OF THE
MUSCULO-SKELETAL
SYSTEM
LABORATORY PROCEDURES
3. BONE SCAN
• Imaging study with the use of a contrast
radioactive material
• Pre-test: Painless procedure, IV
radioisotope is used, no special
preparation, pregnancy is contraindicated
• Intra-test: IV injection, Waiting period of 2
hours before X-ray, Fluids allowed,
Supine position for scanning
• Post-test: Increase fluid intake to flush
out radioactive material

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 ASSESMENT OF THE
MUSCULO-SKELETAL
SYSTEM
LABORATORY PROCEDURES
4. DXA- Dual-energy XRAY
absorptiometry
• Assesses bone density to diagnose
osteoporosis
• Uses LOW dose radiation to
measure bone density
• Painless procedure, non-invasive,
no special preparation
• Advise to remove jewelry
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 Common
musculoskeletal
problems
The Nursing Management

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 Nursing Management of common
musculo-skeletal problems
PAIN
• These can be related to joint
inflammation, traction, surgical
intervention
• 1. Assess patient’s perception of pain
• 2. Instruct patient alternative pain
management like meditation, heat
and cold application, TENS and
guided imagery

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 Nursing Management
PAIN
• 3. Administer analgesics as prescribed
• Usually NSAIDS
• Meperidine can be given for severe
pain
• 4. Assess the effectiveness of pain
measures

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 Nursing Management
IMPAIRED PHYSICAL MOBILITY
• 1. Instruct patient to perform range of
motion exercises, either passive or
active
• 2. Provide support in ambulation with
assistive devices
• 3. Turn and change position every 2
hours
• 4. Encourage mobility for a short period
and provide positive reinforcements for
small accomplishments

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 Nursing Management
SELF-CARE DEFICITS
• 1. Assess functional levels of the patient
• 2. Provide support for feeding problems
• Place patient in Fowler’s position
• Provide assistive device and supervise mealtime
• Offer finger foods that can be handled by patient
• Keep suction equipment ready

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 Nursing Management
SELF-CARE DEFICITS
• 3. Assist patient with difficulty bathing and
hygiene
• Assist with bath only when patient has
difficulty
• Provide ample time for patient to finish
activity

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 Musculoskeletal Modalities

• Traction
• Cast

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 Nursing Management
Traction
• A method of fracture immobilization by
applying equipments to align bone
fragments
• Used for immobilization, bone alignment
and relief of muscle spasm

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 Traction
• Skin traction- Buck, Bryant

• Skeletal traction

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 Traction
• Balanced Suspension traction

• Running/Straight traction

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 Traction
• Pulling force exerted on bones to
reduce or immobilize fractures, reduce
muscle spasm, correct or prevent
deformities

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 Traction
• TO decrease muscle spasms
• TO reduce, align and immobilize
fractures
• To correct deformities

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 Nursing Management
Traction: General principles
• 1. ALWAYS ensure that the
weights hang freely and do not
touch the floor
• 2. NEVER remove the weights
• 3. Maintain proper body alignment
• 4. Ensure that the pulleys and ropes
are properly functioning and
fastened by tying square knot
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 Nursing Management
Traction: General principles
• 5. Observe and prevent foot drop
• Provide foot plate
• 6. Observe for DVT, skin irritation and
breakdown
• 7. Provide pin care for clients in skeletal
traction- use of hydrogen peroxide

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 Nursing Management
Traction: General principles
8. Promote skin integrity
• Use special mattress if possible
• Provide frequent skin care
• Assess pin entrance and cleanse the pin with
hydrogen peroxide solution
• Turn and reposition within the limits of traction
• Use the trapeze

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 Nursing Management
CAST
• Immobilizing tool made of plaster of Paris
or fiberglass
• Provides immobilization of the fracture

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 Nursing Management
CAST: types
1. Long arm
2. Short arm
3. Short leg
4. Long leg
5. Spica
6. Body cast

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 Casting Materials
• Plaster of Paris
• Drying takes 1-3 days
• If dry, it is SHINY, WHITE, hard and
resistant
• Fiberglass
• Lightweight and dries in 20-30 minutes
• Water resistant

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 Cast application
1. TO immobilize a body part in a specific position
2. TO exert uniform compression to the tissue
3. TO provide early mobilization of UNAFFECTED
body part
4. TO correct deformities
5. TO stabilize and support unstable joints

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 Nursing Management
CAST: General Nursing Care
• 1. Allow the cast to air dry (usually 24-72 hours)
• 2. Handle a wet cast with the PALMS not the
fingertips

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 Nursing Management
CAST: General Nursing Care
• 3. Keep the casted extremity ELEVATED using a
pillow
• 4. Turn the extremity for equal drying. DO NOT
USE DRYER for plaster cast
• Encourage mobility and range of motion
exercises

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 Nursing Management

CAST: General Nursing Care

• 5. Petal the edges of the cast to
prevent crumbling of the edges
• 6. Examine the skin for
pressure areas and Regularly
check the pulses and skin

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 Nursing Management

CAST: General Nursing Care

• 7. Instruct the patient not to
place sticks or small objects
inside the cast
• 8. Monitor for the following: pain,
swelling, discoloration,
coolness, tingling or lack of
sensation and diminished pulses
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 Nursing Management
CAST: General Nursing Care
• Hot spots occurring along the cast
may indicate infection under the cast

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 Common
Musculoskeletal
conditions
Nursing management

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 METABOLIC BONE
DISORDERS
Osteoporosis
• A disease of the bone characterized by a
decrease in the bone mass and density
with a change in bone structure

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 METABOLIC BONE
DISORDERS
Osteoporosis: Pathophysiology
• Normal homeostatic bone turnover is
altered rate of bone RESORPTION is
greater than bone FORMATION
reduction in total bone mass reduction in
bone mineral density prone to
FRACTURE

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 METABOLIC BONE
DISORDERS
Osteoporosis: TYPES
• 1. Primary Osteoporosis- advanced age, post-
menopausal
• 2. Secondary osteoporosis- Steroid overuse, Renal
failure

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 METABOLIC BONE
DISORDERS
RISK factors for the development of
Osteoporosis
• 1. Sedentary lifestyle
• 2. Age
• 3. Diet- caffeine, alcohol, low Ca and
Vit D
• 4. Post-menopausal
• 5. Genetics- caucasian and asian
• 6. Immobility
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 METABOLIC DISORDER
ASSESSMENT FINDINGS
• 1. Low stature
• 2. Fracture
• Femur
• 3. Bone pain

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 METABOLIC DISORDER
LABORATORY FINDINGS
• 1. DEXA-scan
• Provides information about bone
mineral density
• T-score is at least 2.5 SD below the
young adult mean value
• 2. X-ray studies

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 METABOLIC DISORDER
Medical management of Osteoporosis
• 1. Diet therapy with calcium and
Vitamin D
• 2. Hormone replacement therapy
• 3. Biphosphonates- Alendronate,
risedronate produce increased bone
mass by inhibiting the OSTEOCLAST
• 4. Moderate weight bearing exercises
• 5. Management of fractures

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 METABOLIC DISORDER
Osteoporosis Nursing Interventions
1. Promote understanding of
osteoporosis and the treatment
regimen
• Provide adequate dietary supplement
of calcium and vitamin D
• Instruct to employ a regular program
of moderate exercises and physical
activity
• Manage the constipating side-effect of
calcium supplements
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 METABOLIC DISORDER
Osteoporosis Nursing Interventions
• Take calcium supplements with meals
• Take alendronate with an EMPTY stomach
with water
• Instruct on intake of Hormonal
replacement

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 METABOLIC DISORDER
Osteoporosis Nursing Interventions
2. Relieve the pain
• Instruct the patient to rest on a firm
mattress
• Suggest that knee flexion will cause
relaxation of back muscles
• Heat application may provide comfort
• Encourage good posture and body
mechanics
12/07/21• Instruct to avoidRON
twisting
R.N.,M.D. and heavy lifting 54
 METABOLIC DISORDER
Osteoporosis Nursing Interventions
• 3. Improve bowel elimination
• Constipation is a problem of calcium
supplements and immobility
• Advise intake of HIGH fiber diet and
increased fluids

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 METABOLIC DISORDER
Osteoporosis Nursing Interventions
• 4. Prevent injury
• Instruct to use isometric exercise to
strengthen the trunk muscles
• AVOID sudden jarring, bending and
strenuous lifting
• Provide a safe environment

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 Juvenile rheumatoid Arthritis
• Definition:
• AUTO-IMMUNE inflammatory joint
disorder of UNKNOWN cause
• SYSTEMIC chronic disorder of
connective tissue

• Diagnosed BEFORE age 16 years old

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 Juvenile rheumatoid Arthritis
• PATHOPHYSIOLOGY : unknown

• Affected by stress, climate and genetics

• Common in girls 2-5 and 9-12 y.o.

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Juvenile rheumatoid Arthritis
Systemic JRA Pauci-articular Polyarticular

FEVER MILD joint pain Morning joint

and swelling stiffness and
fever
Salmon-pink IRIDOCYCLITIS Weight
rash Bearing joints
Five or more Less than 4 Five or more
joints joints joints
Anorexia, Very Good Poor prognosis
anemia, fatigue prognosis
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 JRA
• Symptoms may decrease as child enters
adulthood
• With periods of remissions and
exacerbations

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 JRA
Medical Management
1. ASPIRIN and NSAIDs- mainstay
treatment
2. Slow-acting anti-rheumatic drugs
3. Corticosteroids

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 JRA
Nursing Management
1. Encourage normal performance of daily
activities
2. Assist child in ROM exercises
3. Administer medications
4. Encourage social and emotional
development

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 JRA
Nursing Management
During acute attack:
• SPLINT the joints
• NEUTRAL positioning
• Warm or cold packs

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS
• The most common form of degenerative
joint disorder

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS
• Chronic, NON-systemic disorder of joints

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Pathophysiology
• Injury, genetic, Previous joint damage, Obesity,
Advanced age  Stimulate the chondrocytes to
release chemicals chemicals will cause
cartilage degeneration, reactive inflammation of
the synovial lining and bone stiffening

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Risk factors
• 1. Increased age
• 2. Obesity
• 3. Repetitive use of joints with previous
joint damage
• 4. Anatomical deformity
• 5. genetic susceptibility

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
• 1. Joint pain
• 2. Joint stiffness
• 3. Functional joint impairment limitation
• The joint involvement is ASYMMETRICAL
• This is not systemic, there is no FEVER, no
severe swelling
• Atrophy of unused muscles
• Usual joint are the WEIGHT bearing joints
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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
1. Joint pain
• Caused by
• Inflamed cartilage and synovium
• Stretching of the joint capsule
• Irritation of nerve endings

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
2. Stiffness
 commonly occurs in the morning after
awakening
 Lasts only for less than 30 minutes
 DECREASES with movement, but worsens after
increased weight bearing activitry
 Crepitation may be elicited

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Diagnostic findings
1. X-ray
• Narrowing of joint space
• Loss of cartilage
• Osteophytes
2. Blood tests will show no evidence of
systemic inflammation and are not useful

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Medical management
• 1. Weight reduction
• 2. Use of splinting devices to support joints
• 3. Occupational and physical therapy
• 4. Pharmacologic management
• Use of PARACETAMOL, NSAIDS
• Use of Glucosamine and chondroitin
• Topical analgesics
• Intra-articular steroids to decrease inflam
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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing Interventions
1. Provide relief of PAIN
• Administer prescribed analgesics
• Application of heat modalities. ICE PACKS may
be used in the early acute stage!!!
• Plan daily activities when pain is less severe
• Pain meds before exercising

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing Interventions
2. Advise patient to reduce weight
• Aerobic exercise
• Walking
3. Administer prescribed medications
• NSAIDS

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 DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing Interventions
4. Position the client to prevent flexion
deformity
• Use of foot board, splints, wedges and
pillows

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 Rheumatoid arthritis
• A type of chronic systemic inflammatory
arthritis and connective tissue disorder
affecting more women (ages 35-45) than
men

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 Rheumatoid arthritis
FACTORS:
Genetic
Auto-immune connective tissue disorders
Fatigue, emotional stress, cold, infection

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 Rheumatoid arthritis
Pathophysiology
• Immune reaction in the synovium  attracts
neutrophils  releases enzymes  breakdown of
collagen  irritates the synovial liningcausing
synovial inflammation edema and pannus
formation and joint erosions and swelling

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 Rheumatoid arthritis
ASSESSMENT FINDINGS
• 1. PAIN
• 2. Joint swelling and stiffness-
SYMMETRICAL, Bilateral
• 3. Warmth, erythema and lack of
function
• 4. Fever, weight loss, anemia, fatigue
• 5. Palpation of join reveals spongy tissue
• 6. Hesitancy inRON
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joint movement
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 Rheumatoid arthritis
ASSESSMENT FINDINGS
• Joint involvement is SYMMETRICAL and
BILATERAL
• Characteristically beginning in the hands, wrist and
feet
• Joint STIFFNESS occurs early morning, lasts MORE
than 30 minutes, not relieved by movement,
diminishes as the day progresses

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 Rheumatoid arthritis
ASSESSMENT FINDINGS
• Joints are swollen and warm
• Painful when moved
• Deformities are common in the hands and feet
causing misalignment
• Rheumatoid nodules may be found in the
subcutaneous tissues

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 Rheumatoid arthritis
Diagnostic test
• 1. X-ray
• Shows bony erosion
• 2. Blood studies reveal (+) rheumatoid factor,
elevated ESR and CRP and ANTI-nuclear antibody
• 3. Arthrocentesis shows synovial fluid that is cloudy,
milky or dark yellow containing numerous WBC and
inflammatory proteins

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 Rheumatoid arthritis
MEDICAL MANAGEMENT
• 1. Therapeutic dose of NSAIDS and Aspirin to
reduce inflammation
• 2. Chemotherapy with methotrexate, antimalarials,
gold therapy and steroid
• 3. For advanced cases- arthroplasty, synovectomy
• 4. Nutritional therapy

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 Rheumatoid arthritis
MEDICAL MANAGEMENT
GOLD THERAPY:
• IM or Oral preparation
• Takes several months (3-6) before effects can be
seen
• Can damage the kidney and causes bone marrow
depression
• May NOT work for all individuals

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 Rheumatoid arthritis
Nursing MANAGEMENT
1. Relieve pain and discomfort
• USE splints to immobilize the affected
extremity during acute stage of the
disease and inflammation to REDUCE
DEFORMITY
• Administer prescribed medications
• Suggest application of COLD packs during
the acute phase of pain, then HEAT
application as the inflammation subsides
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 Rheumatoid arthritis
Nursing MANAGEMENT
2. Decrease patient fatigue
• Schedule activity when
pain is less severe
• Provide adequate periods
of rests
3. Promote restorative sleep
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 Rheumatoid arthritis
Nursing Management
4. Increase patient mobility
• Advise proper posture and body
mechanics
• Support joint in functional
position
• Advise ACTIVE ROME
• Avoid direct pressure over the
joint
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 Rheumatoid arthritis
Nursing Management
5. Provide Diet therapy
• Patients experience anorexia,
nausea and weight loss
• Regular diet with caloric
restrictions because steroids
may increase appetite
• Supplements of vitamins, iron
and PROTEIN
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 Rheumatoid arthritis
6. Increase Mobility and prevent
deformity:
• Lie FLAT on a firm mattress
• Lie PRONE several times to
prevent HIP FLEXION contracture
• Use one pillow under the head
because of risk of dorsal kyphosis
• NO Pillow under the joints
because this promotes flexion
contractures

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 Rheumatoid arthritis
• Capsaicin
• Unknown mechanism, probably
Inhibits substance “P”
• Reduces pain
• Applied over the affected area
• Do NOT bandage the area
• Side effect: burning sensation
• Wash hands after application

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Hot versus Cold
HOT Cold

Use to RELIEVE joint Use to control

stiffness, pain and inflammation and pain
muscle spasm
After acute attack ACUTE ATTACK

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OA versus RA
RA OA
Onset is early Onset is late
Chronic systemic Degenerative disease
disease
Involves the synovium Involves the cartilages
Involved joints are Involved joints are
symmetrical- fingers, unilateral- weight
cervical spine bearing knee, hips
spine
Malaise, fever, anemia No other S/SX
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OA versus RA
RA OA
Joint tenderness, Crepitus, stiffness in
swelling, warmth and the morning decreases
redness after activity
Subcutaneous nodules
Stiffness that dimishes
Rest the joint, cold and Rest the joints, Avoid
heat modalities, ASA, overactivity, Weight
NSAIDS, DMARDS reduction, cold and
warm modalities, ASA
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 Gouty arthritis
• A systemic disease caused by deposition of uric
acid crystals in the joint and body tissues
• CAUSES:
• 1. Primary gout- disorder of Purine metabolism
• 2. Secondary gout- excessive uric acid in the
blood like leukemia

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 Gouty arthritis
• ASSESSMENT FINDINGS
• 1. Severe pain in the involved joints, initially the big
toe
• 2. Swelling and inflammation of the joint
• 3. TOPHI- yellowish-whitish, irregular deposits in
the skin that break open and reveal a gritty
appearance
• 4. PODAGRA-big toe

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 Gouty arthritis
ASSESSMENT FINDINGS
• 5. Fever, malaise
• 6. Body weakness and headache
• 7. Renal stones

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 Gouty arthritis
DIAGNOSTIC TEST
• Elevated levels of uric acid in the blood
• Uric acid stones in the kidney
• (+) urate crystals in the synovial fluid

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 Gouty arthritis
• Medical management
• 1. Allupurinol- take it WITH FOOD
• Rash signifies allergic
reaction
• 2. Colchicine
• For acute attack
• 3. Probenecid
• For uric acid excretion
in the kidney

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 Gouty arthritis
Nursing Intervention
1. Provide a diet with LOW purine
• Avoid Organ meats, aged and processed foods
• STRICT dietary restriction is NOT necessary
2. Encourage an increased fluid intake (2-
3L/day) to prevent stone formation
3. Instruct the patient to avoid alcohol
4. Provide alkaline ash diet to increase urinary
pH
5. Provide bed rest during
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early attack of gout 101
RON R.N.,M.D.
 Gouty arthritis
Nursing Intervention
6. Position the affected extremity in mild
flexion
7. Administer anti-gout medication and
analgesics

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 Fracture
• A break in the continuity of the bone and is
defined according to its type and extent

12/07/21 RON R.N.,M.D. 103

 Fracture
• Severe mechanical Stress to bone 
bone fracture
• Direct Blows
• Crushing forces
• Sudden twisting motion
• Extreme muscle contraction

12/07/21 RON R.N.,M.D. 104

 Fracture
TYPES OF FRACTURE
• 1. Complete fracture
• Involves a break across the entire
cross-section
• 2. Incomplete fracture
• The break occurs through only a part of
the cross-section

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12/07/21 RON R.N.,M.D. 106
 Fracture
TYPES OF FRACTURE
• 1. Closed fracture
• The fracture that does not cause a
break in the skin
• 2. Open fracture
• The fracture that involves a break in the
skin

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12/07/21 RON R.N.,M.D. 108
 Fracture
TYPES OF FRACTURE
• 1. Comminuted fracture
• A fracture that involves production of
several bone fragments
• 2. Simple fracture
• A fracture that involves break of bone
into two parts or one

12/07/21 RON R.N.,M.D. 109

 Fracture
ASSESSMENT FINDINGS
• 1. Pain or tenderness over the
involved area
• 2. Loss of function
• 3. Deformity
• 4. Shortening
• 5. Crepitus
• 6. Swelling and discoloration

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 Fracture
ASSESSMENT FINDINGS
1. Pain
• Continuous and increases in severity
• Muscles spasm accompanies the fracture
is a reaction of the body to immobilize the
fractured bone

12/07/21 RON R.N.,M.D. 111

 Fracture
ASSESSMENT FINDINGS
2. Loss of function
• Abnormal movement and pain can result
to this manifestation

12/07/21 RON R.N.,M.D. 112

 Fracture
ASSESSMENT FINDINGS
3. Deformity
• Displacement, angulations or rotation of
the fragments Causes deformity

12/07/21 RON R.N.,M.D. 113

 Fracture
ASSESSMENT FINDINGS
4. Crepitus
• A grating sensation produced when the
bone fragments rub each other

12/07/21 RON R.N.,M.D. 114

 Fracture
• DIAGNOSTIC TEST
• X-ray

12/07/21 RON R.N.,M.D. 115

 Fracture
EMERGENCY MANAGEMENT OF FRACTURE
• 1. Immobilize any suspected fracture
• 2. Support the extremity above and below
when moving the affected part from a vehicle
• 3. Suggested temporary splints- hard board,
stick, rolled sheets
• 4. Apply sling if forearm fracture is suspected
or the suspected fractured arm maybe
bandaged to the chest
12/07/21 RON R.N.,M.D. 116
 Fracture
EMERGENCY MANAGEMENT OF
FRACTURE
• 5. Open fracture is managed by covering a
clean/sterile gauze to prevent
contamination
• 6. DO NOT attempt to reduce the facture

12/07/21 RON R.N.,M.D. 117

 Fracture
MEDICAL MANAGEMENT
• 1. Reduction of fracture either open or
closed, Immobilization and Restoration of
function
• 2. Antibiotics, Muscle relaxants such as
METHOCARBAMOL and Pain
medications

12/07/21 RON R.N.,M.D. 118

 Fracture
General Nursing MANAGEMENT
For CLOSED FRACTURE
• 1. Assist in reduction and immobilization
• 2. Administer pain medication and muscle
relaxants
• 3. teach patient to care for the cast
• 4. Teach patient about potential complication
of fracture and to report infection, poor
alignment and continuous pain
12/07/21 RON R.N.,M.D. 119
 Fracture
General Nursing MANAGEMENT
For OPEN FRACTURE
• 1. Prevent wound and bone infection
• Administer prescribed antibiotics
• Administer tetanus prophylaxis
• Assist in serial wound debridement
• 2. Elevate the extremity to prevent edema formation
• 3. Administer care of traction and cast

12/07/21 RON R.N.,M.D. 120

 Fracture
• FRACTURE COMPLICATIONS
• Early
• 1. Shock
• 2. Fat embolism
• 3. Compartment syndrome
• 4. Infection
• 5. DVT

12/07/21 RON R.N.,M.D. 121

 Fracture
• FRACTURE COMPLICATIONS
• Late
• 1. Delayed union
• 2. Avascular necrosis
• 3. Delayed reaction to fixation devices
• 4. Complex regional syndrome

12/07/21 RON R.N.,M.D. 122

 Fracture
• FRACTURE COMPLICATIONS: Fat Embolism
• Occurs usually in fractures of the long bones
• Fat globules may move into the blood stream because
the marrow pressure is greater than capillary pressure
• Fat globules occlude the small blood vessels of the
lungs, brain kidneys and other organs

12/07/21 RON R.N.,M.D. 123

 Fracture
• FRACTURE COMPLICATIONS: Fat Embolism
• Onset is rapid, within 24-72 hours
• ASSESSMENT FINDINGS
• 1. Sudden dyspnea and respiratory distress
• 2. tachycardia
• 3. Chest pain
• 4. Crackles, wheezes and cough
• 5. Petechial rashes over the chest, axilla and hard palate

12/07/21 RON R.N.,M.D. 124

 Fracture
• FRACTURE COMPLICATIONS: Fat Embolism
• Nursing Management
• 1. Support the respiratory function
• Respiratory failure is the most common cause of
death
• Administer O2 in high concentration
• Prepare for possible intubation and ventilator support

12/07/21 RON R.N.,M.D. 125

 Fracture
• FRACTURE COMPLICATIONS: Fat Embolism
• Nursing Management
• 2. Administer drugs
• Corticosteroids
• Dopamine
• Morphine

12/07/21 RON R.N.,M.D. 126

 Fracture
• FRACTURE COMPLICATIONS: Fat Embolism
• Nursing Management
• 3. Institute preventive measures
• Immediate immobilization of fracture
• Minimal fracture manipulation
• Adequate support for fractured bone during
turning and positioning
• Maintain adequate hydration and electrolyte
balance

12/07/21 RON R.N.,M.D. 127

 Fracture
• Early complication: Compartment syndrome
• A complication that develops when tissue perfusion in
the muscles is less than required for tissue viability

12/07/21 RON R.N.,M.D. 128

 Fracture

12/07/21 RON R.N.,M.D. 129

 Fracture
• Early complication: Compartment syndrome
• ASSESSMENT FINDINGS
1. Pain- Deep, throbbing and UNRELIEVED pain by opiods
• Pain is due to reduction in the size of the muscle
compartment by tight cast
• Pain is due to increased mass in the compartment by edema,
swelling or hemorrhage

12/07/21 RON R.N.,M.D. 130

 Fracture
• Early complication: Compartment syndrome
• ASSESSMENT FINDINGS
• 2. Paresthesia- burning or tingling sensation
• 3. Numbness
• 4. Motor weakness
• 5. Pulselessness, impaired capillary refill time and
cyanotic skin

12/07/21 RON R.N.,M.D. 131

 Fracture
• Early complication: Compartment syndrome
• Medical and Nursing management
• 1. Assess frequently the neurovascular status of the
casted extremity
• 2. Elevate the extremity above the level of the
heart
• 3. Assist in cast removal and FASCIOTOMY

12/07/21 RON R.N.,M.D. 132

 Strains

• Excessive stretching of a muscle or

tendon
• Nursing management
• 1. Immobilize affected part
• 2. Apply cold packs initially, then heat
packs
• 3. Limit joint activity
• 4. Administer NSAIDs and muscle
12/07/21
relaxants RON R.N.,M.D. 133
 Sprains

• Excessive stretching of the LIGAMENTS

• Nursing management
• 1. Immobilize extremity and advise rest
• 2. Apply cold packs initially then heat packs
• 3. Compression bandage may be applied to
relieve edema
• 4. Assist in cast application
• 5. Administer NSAIDS
12/07/21 RON R.N.,M.D. 134
 Herniated disk
• Occurs when all or part of the nucleus
pulposus forces through the weakened
or torn outer ring (annulus pulposus

12/07/21 RON R.N.,M.D. 135

 Herniated disk
• Impingement on the spinal nerves will
result to BACK PAIN

12/07/21 RON R.N.,M.D. 136

 Herniated disk
• Causes
1. Trauma
2. Strain
3. Joint degeneration

12/07/21 RON R.N.,M.D. 137

 Herniated disk
ASSESSMENT findings
1. Severe lower BACK PAIN that may
radiate to the buttocks or legs and
feet
2. Motor and sensory loss in the area
supplied by the compressed nerves

12/07/21 RON R.N.,M.D. 138

 Herniated disk
DIAGNOSIS of Herniated disk
1. Straight leg raising test
• (+) leg pain
2. LeSegue’s test
• 90 degrees knee and thigh  (-) DTR
3. XR
4. CT
5. MRI

12/07/21 RON R.N.,M.D. 139

 Herniated disk
Nursing Implementation
1. Provide complete BED rest for several days
2. Advise heat application over the area to lessen
pain and muscle spasm

12/07/21 RON R.N.,M.D. 140

 Herniated disk
Nursing Implementation
3. Provide exercise on bed
4. Assist in pelvic traction application
5. Provide the drugs as ordered
Aspirin
Diazepam
Muscle relaxant

12/07/21 RON R.N.,M.D. 141

 Herniated disk
Nursing Implementation
6. Provide care for laminectomy

12/07/21 RON R.N.,M.D. 142

 Laminectomy
• Removal of the spinal lamina to
stabilize the vertebral joint and
Removal of the protruding disk

• Usually accompanied by insertion of

metal plates

12/07/21 RON R.N.,M.D. 143

 Laminectomy
• Pre-operatively
• Routine pre-operative care
• Remind the patient that he should lie
non his BACK after the operation
• Monitor for worsening of symptoms
• Use anti-embolic stocking
• Encourage ROME
• Coordinate with the PT

12/07/21 RON R.N.,M.D. 144

 Laminectomy
• Pre-operatively
• Fluids to prevent renal stones
• Incentive spirometry
• Maintain on BED rest

12/07/21 RON R.N.,M.D. 145

 Laminectomy
• POST-operatively
• Maintain BED rest
• VERY IMPORTANT : LOG ROLLING TECHNIQUE
to turn
• Never lie on PRONE
• HEMOVAC drainage system= check tubing for
kinks, record amount, report colorless moisture
in dressing
• Provide straight BACKED chair for LIMITED
sitting ONLY

12/07/21 RON R.N.,M.D. 146

 Laminectomy
• HOME CARE
• AVOID sitting for a prolonged period of time
• AVOID twisting, bending at the waist
• Sleep on BACK
• Proper weight to PREVENT lordosis

12/07/21 RON R.N.,M.D. 147

 Amputation
Nursing Interventions
Post-operative care: after amputation
• Elevate stump for the FIRST 24
HOURS to minimize edema and
promote venous return
• Place patient on PRONE position
after 24 hours

12/07/21 RON R.N.,M.D. 148

 Amputation
Nursing Interventions
Post-operative care: after amputation
• Assess skin for bleeding and
hematoma
• Wrap the extremity with elastic
bandage

12/07/21 RON R.N.,M.D. 149

12/07/21 RON R.N.,M.D. 150