MUSCULO-SKELETAL NURSING

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

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

TENDONS
Bands of fibrous connective tissue that tie bones to muscles

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

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

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

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

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

ASSESMENT OF THE MUSCULOSKELETAL 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

ASSESMENT OF THE MUSCULOSKELETAL 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

ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM

Gait Posture Muscular palpation Joint palpation Range of motion Muscle strength

ASSESMENT OF THE MUSCULOSKELETAL 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

ASSESMENT OF THE MUSCULOSKELETAL 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

ASSESMENT OF THE MUSCULOSKELETAL 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 Xray, Fluids allowed, Supine position for scanning Post-test: Increase fluid intake to flush out radioactive material

ASSESMENT OF THE MUSCULOSKELETAL 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

Common musculoskeletal problems

The Nursing Management

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

Nursing Management
PAIN 3. Administer analgesics as prescribed
Usually NSAIDS Meperidine can be given for severe pain

4. Assess the effectiveness of pain measures

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

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

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

Musculoskeletal Modalities

Traction Cast

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

Traction
Skin traction- Buck, Bryant Skeletal traction-cervical,tibia, overhead arm traction

Traction
Balanced Suspension traction Running/Straight traction

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

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

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

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

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

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

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

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

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

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

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

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

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

Nursing Management
CAST: General Nursing Care Hot spots occurring along the cast may indicate infection under the cast

Common Musculoskeletal conditions

Nursing management

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

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

METABOLIC BONE DISORDERS

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

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

METABOLIC DISORDER
ASSESSMENT FINDINGS 1. Low stature 2. Fracture
Femur

3. Bone pain

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

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

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

METABOLIC DISORDER
Osteoporosis Nursing Interventions Take calcium supplements with meals Take alendronate with an EMPTY stomach with water Instruct on intake of Hormonal replacement

METABOLIC DISORDER
Osteoporosis Nursing Interventions 2. Relieve the pain Instruct the patient to rest on a firm mattress Suggest that knee flex ion will cause relaxation of back muscles Heat application may provide comfort Encourage good posture and body mechanics Instruct to avoid twisting and heavy lifting

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

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

Juvenile rheumatoid Arthritis

Definition:
AUTO-IMMUNE inflammatory joint disorder of UNKNOWN cause SYSTEMIC chronic disorder of connective tissue Diagnosed BEFORE age 16 years old

Juvenile rheumatoid Arthritis

PATHOPHYSIOLOGY : unknown Affected by stress, climate and genetics Common in girls 2-5 and 9-12 y.o.

Juvenile rheumatoid Arthritis

Systemic JRA Pauci-articular
FEVER MILD joint pain and swelling

Polyarticular
Morning joint stiffness and fever

Salmon-pink rash Five or more joints

Weight IRIDOCYCLITIS Bearing joints Less than 4 joints Five or more joints Poor prognosis

Anorexia, Very Good anemia, fatigue prognosis

JRA
Symptoms may decrease as child enters adulthood With periods of remissions and exacerbations

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

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

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

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS The most common form of degenerative joint disorder

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS Chronic, NON-systemic disorder of joints

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

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

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

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS: Assessment findings 1. Joint pain Caused by
Inflamed cartilage and synovium Stretching of the joint capsule Irritation of nerve endings

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

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

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

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

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS: Nursing Interventions 2. Advise patient to reduce weight
Aerobic exercise Walking

3. Administer prescribed medications

NSAIDS

DEGENERATIVE JOINT DISEASE

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

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

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

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

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 in joint movement

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

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

Rheumatoid arthritis
Diagnostic test 1. X-ray
Shows bony erosion

2. Blood studies reveal (+) rheumatoid factor, elevated ESR and CRP and ANTInuclear antibody 3. Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing numerous WBC and inflammatory proteins

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

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

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

Rheumatoid arthritis
Nursing MANAGEMENT 2. Decrease patient fatigue Schedule activity when pain is less severe Provide adequate periods of rests 3. Promote restorative sleep

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

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

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

Rheumatoid arthritis
Capsaicin
Unknown mechanism Reduces pain Applied over the affected area Do NOT bandage the area Side effect: burning sensation Wash hands after application

Hot versus Cold

HOT Use to RELIEVE joint stiffness, pain and muscle spasm After acute attack Cold Use to control inflammation and pain ACUTE ATTACK

OA versus RA
RA Onset is early Chronic systemic disease Involves the synovium Involved joints are symmetrical- fingers, cervical spine Malaise, fever, anemia OA Onset is late Degenerative disease Involves the cartilages Involved joints are unilateral- weight bearing knee, hips spine No other S/SX systemic

OA versus RA
RA OA Joint tenderness, swelling, warmth and Crepitus, stiffness in redness the morning decreases Subcutaneous nodules after activity Stiffness that dimishes Rest the joints, Avoid Rest the joint, cold and overactivity, Weight heat modalities, ASA, reduction, cold and NSAIDS, DMARDS warm modalities, ASA

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

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

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

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

Gouty arthritis
Medical management 1. Allopurinol- take it WITH FOOD
Rash signifies allergic reaction

2. Colchicine
For acute attack

3. Probenecid
For uric acid excretion

in the kidney

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 early attack of gout

Gouty arthritis
Nursing Intervention 6. Position the affected extremity in mild flexion 7. Administer anti-gout medication and analgesics

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

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

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 crosssection

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

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

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

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

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

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

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

Fracture
DIAGNOSTIC TEST X-ray

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 relaxants

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

Herniated disk
Occurs when all or part of the nucleus pulposus forces through the weakened or torn outer ring (annulus pulposus

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

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

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

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

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

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

Herniated disk
Nursing Implementation 6. Provide care for laminectomy

Laminectomy
Removal of the spinal lamina to stabilize the vertebral joint and Removal of the protruding disk Usually accompanied by insertion of metal plates

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

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

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

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

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

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