Musculoskeletal and Sensory Review

Musculoskeletal System

• Strains and Sprains
  • Symptoms: Pain, limited function, and loss of support.
  • Diagnosis: History and physical examination; X-ray, ultrasound, or MRI may be used based on severity.
  • Treatment (RICE):
    • Rest
    • Ice
    • Compression
    • Elevation
  • Third-degree strains may require surgical repair for torn tendons or muscles. Third-degree sprains may need arthroscopic surgery.

Fractures

• Types of Fractures

  • Closed (intact skin)
  • Open (bone visible)
  • No need to memorize subcategories (complete, compression, etc.)
  • Focus on patient care related to fractures.

• Complications of Fractures

  • Compartment Syndrome:
    • Swelling inside the cast causes pressure on blood vessels, leading to compression.
    • Can result in permanent loss of affected limb if not treated quickly.
  • Neurovascular Compromise:
    • Sharp fragments from the fracture can damage blood vessels and nerves surrounding the body.
  • Venous Thromboembolism (VTE):
    • Develops in large vessels of extremities due to immobility, traumatic injuries, chronic diseases, surgeries, obesity, smoking, and oral contraceptives.
    • Patients with fractures/surgery are at higher risk.
  • Fat Embolism:
    • Rare, but can occur after orthopedic surgery, especially in long bone fractures.
    • Fat globules are released from yellow bone marrow into the vasculature.
    • Obstruction of pulmonary vascular bed by fat globules.
    • Can impair organs, leading to hypoxia.
    • Usually happens within 48 hours of injury.
    • Symptoms: Hypoxia, headache, lethargy, agitation, confusion, decreased LOC, seizures, vision changes; tachypnea, tachycardia, fever, chest pain, dyspnea, crackles; petechiae (measles-like rash) on neck, upper arms, and chest (specific to fat embolism).

• Treatment of Fat Embolism

  • Oxygen.
  • IV fluids.
  • Steroids (e.g., prednisone).
  • Bed rest and gentle handling.

Traction

• Purpose: Application of pulling force to realign fractured bones.

• Types:

  • Skin Traction:
    • Uses hook and loop fastener like a Velcro boot.
  • Skeletal Traction:
    • Uses pins to attach to weights that keep the fracture aligned.
    • Key considerations: Body alignment, weights hanging freely, no manipulation of settings.

• Nursing Considerations for Traction

  • Skeletal traction: Maintain body alignment, ensure weights hang freely, monitor skin integrity and pin sites for infection (redness, swelling, discharge), clean pin sites per orders.
  • Skin traction: Good skin care, avoid removing or manipulating weights without an order.
  • Inspect skin every 8 hours for irritation or inflammation.
  • Assess neurovascular status (pulses, skin temperature, circulation) of the affected body part.
  • Monitor circulation hourly for the first 24 hours and every 4 hours after.
  • Report severe pain, diminished pulse, pale skin, or poor ROM.

Osteoporosis

• Disease of the old population, more common in menopausal women.

• Bone mineral density (BMD) decreases with osteoporosis.

• Primary: Due to age and loss of estrogen (women) or decreased testosterone (men).

• Secondary: Due to medical conditions, cancer, hormones, or certain medications.

• Euro-American postmenopausal women have a 50% chance of fragile fracture.

• Patient Teaching

  • Calcium supplements with Vitamin D.
  • Avoid excessive alcohol and caffeine.
  • Stop smoking.
  • If lactose intolerant, consume soy, rice, tofu with calcium and Vitamin D.
  • Include fruits, vegetables, low-fat dairy, and protein.
  • Increase fiber in diet.
  • Consume Vitamin D-fortified products (eggs, swordfish, salmon, chicken liver, enriched cereals, orange juice, milk, bread products).

• Lifestyle Changes

  • Daily walking for 30 minutes, 3-5 times a week.
  • Abdominal muscle tightening, deep breathing, pectoral stretching.
  • Muscle tightening, resistive and range of motion exercises for mobility.

Osteomyelitis

• Infection of the bones, most commonly caused by staphylococcus aureus.

• Causes and Risk Factors

  • Exogenous (outside body): Open fracture, surgery.
  • Endogenous (inside body): Organisms already in the bloodstream (e.g., sepsis).
  • Contagious: Bone infection from skin infection.
  • Poor dental hygiene leading to osteomyelitis in facial bones.
  • Foot ulcers in diabetic patients.
  • Pressure ulcers.
  • Post-hip surgery.
  • UTI spreading to lower vertebrae.
  • Long-term IV drug use.
  • Chronic open wounds.
  • Periodontal infections, diabetes, HIV, bone surgery.

• Types

  • Acute: Fever (above 101°F), swelling, erythema, heat, tenderness, constant localized bone pain that worsens with movement.
  • Chronic: Sinus tract formation, pain in local area, drainage from affected area.

• Diagnostics

  • Elevated WBCs and ESR.
  • Positive blood culture.
  • MRI or radionuclide scans to assess infection and perfusion.

Gout

• Systemic disease with urate crystals depositing in joints, causing inflammation.
• Uric acid levels are high.
• Allopurinol is commonly given as medication.
• Great toe commonly affected.

Osteoarthritis

• Disease of the cartilage. Cartilage thins, leading to bone rubbing against bone.
• Symptoms: Joint pain, loss of function, especially in weight-bearing joints.
• Fingers may develop Heberden's nodules.

Arthroplasty

• Surgical procedure to restore joint function; can be total joint arthroplasty (TJA).

• Patients with osteoarthritis (OA) and rheumatoid arthritis (RA) can have this surgery.

• Hip and knee joints are commonly replaced.

• Contraindications:

  • Infection.
  • Advanced osteoporosis.
  • Uncontrolled diabetes or hypertension.

• Complications

  • Venous Thromboembolism (VTE): High risk post-op; give heparin subq or enoxaparin, ambulate early, use SCDs.

Rheumatoid Arthritis

• Autoimmune, chronic inflammation of joints, tissues, and organs.

• Systemic illness.
  Complications:

• Vasculitis: Inflammation of blood vessels.

• Kaplan syndrome: Nodes in the lungs

• Felty syndrome: Hepatomegaly, splenomegaly, and leukopenia.

• Sjogren's syndrome: Dry eyes, dry mouth, dry vagina.

• Respiratory complications: Pleurisy, pneumonitis, diffuse interstitial fibrosis, pulmonary hypertension, nodes in the lungs.

• Cardiac complications: Pericarditis, myocarditis.
  feet.

• Symptoms:

  • Dry eyes, dry mouth, burning, itches.
  • Paresthesias in hands and feet.
  • Cardiac and respiratory complications.

• Hand Deformities:

  • Boutonniere deformity
  • Swan neck deformity.

• Early vs. Late Disease:

  • Joint inflammation in early stages, deformities (swan neck, ulnar deviation) in late stages.
  • Moderate to severe pain and morning stiffness.
  • Systemic effects: Fatigue, paresthesia, weakness, anorexia in early stages; osteoporosis, severe fatigue, anemia, weight loss, subcutaneous nodules, peripheral neuropathy, low-grade fever in late stages.
  • Late-stage vasculitis, pericarditis, fibrotic lung disease, Sjogren's syndrome, kidney disease, Felty syndrome.

Sensory System: Hearing

• Hearing loss is the interruption of the ability to receive auditory signals.

• Types

  • Conductive: Can regain hearing through hearing aids. Temporary; the tympanic membrane cannot vibrate; sounds do not reach the middle or inner ear.
  • Sensorineural: May benefit from cochlear implants. Damage to the cochlea or acoustic nerve.
  • Mixed: Both conductive and sensorineural components are affected; dysfunction of air and bone conduction.

• Symptoms

  • Turning of the head, straining to hear, asking questions to be repeated, not acknowledging questions, ignoring phone/doorbells, responding incorrectly, increasing volume, withdrawing from social activities, speaking loudly.

• Management

  • Removal of cerumen (ear wax).
  • Hearing aids or cochlear implants.
  • Surgery.
  • Lip reading.
  • Hearing and speech therapist.
  • Sign language.

• Nursing Care

  • Establish effective communication methods.
  • Ensure patient and family understand the use of hearing aids.
  • Refer to hearing-impaired agencies.

• Hearing Aid Care

  • Keep hearing aid dry.
  • Clean ear mold with mild soap and water; use a soft toothbrush.
  • Do not use alcohol to clean.
  • Turn off when not in use to save battery.
  • Check and replace the battery frequently.
  • Store in a safe place.
  • Avoid dropping or exposing to extreme temperatures.
  • Avoid hairspray, cosmetics, oils.
  • Adjust volume to the lowest setting to prevent feedback.
  • If not working, try changing the battery, check connections, clean the sound hole, adjust the volume.

Cataracts

• Clouding of the lens.

• Blurred vision, diplopia, reduced visual acuity.

• Pupil looks white and cloudy. Gradual loss of vision.

• Post-Surgery Complications:

  • Sharp sudden pain in eye.
  • Bleeding or increased discharge.
  • Bruising of the eye.
  • Green or yellow thick drainage.
  • Eyelid swelling or inability to open the eye.
  • Reappearance of bloodshot sclera.
  • Decreased vision.
  • Flashes of light or floating shapes.

• Patient Teaching:

  • Take eye drops as prescribed.
  • Use Tylenol for mild pain.
  • Wear glasses.
  • Best vision in 4-6 weeks.

Glaucoma

• Blocked drainage canal, increased intraocular pressure (IOP).
  avoid this.

• Timolol:

  • It's a beta-blocker that can cause bronchospasm; caution in patients with respiratory issues (asthma, COPD).

• Post-Op Care:

  • Wear patch and metal shield, especially at night.
  • Avoid lying on the operative side; lie on the unaffected side.
  • Teach signs and symptoms of infection or increased IOP.
  • Wait 10-15 minutes between eye medications.
  • Wash hands with soap and water.
  • Punctal occlusion to prevent systemic absorption.

Macular Degeneration

• Decline in central vision, blurring, distortion, and color perception changes.