Comprehensive Nursing Notes for Mobility Problems

Learning Outcomes

• Utilize the nursing process to administer care for clients with mobility issues, including:

  • Fractures

  • Surgical correction of herniated disks (lumbar/cervical)

  • Hip fractures (total hip replacement/open reduction/internal fixation)

  • Total knee replacement

  • Spinal cord injury (SCI)

• Understand complications associated with fractures and provide nursing interventions to prevent these complications.

• Explain nursing responsibilities regarding traction and casts.

• Conduct neurovascular assessments to monitor blood flow and nerve function.

• Collaborate with healthcare professionals for rehabilitation and home care needs, ensuring comprehensive patient support.

Structures and Functions of the Musculoskeletal System

• Composition:

  • Voluntary muscle: enabled movement under conscious control.

  • Bone: provides structure, support, and houses bone marrow for blood cell production.

  • Cartilage: reduces friction between bones and joints, maintains their shape, and acts as a cushion.

  • Ligaments: strong connective tissue that connects bone to bone, providing joint stability.

  • Tendons: fibrous connective tissue that attaches muscle to bone, enabling movement.

  • Fascia: connective tissue that separates structures and allows movement (surrounding muscles, bones, and blood vessels).

  • Bursae: small fluid-filled sacs that reduce friction between tendons, muscles, and bones at joints.

  • Connective tissue: provides support and flexibility throughout the body.

• Purposes:

  • Protects body organs from injury.

  • Provides support and stability to maintain posture.

  • Stores minerals (like calcium and phosphorus) crucial for various bodily functions.

  • Allows for coordinated movement necessary for daily activities.

  • Blood cell production (hematopoiesis) occurs in the bone marrow of bones.

Bone Types

The human skeleton contains 206 bones, classified into:

• Long bones: provide support, enable movement, and are crucial for blood cell production (e.g., femur, humerus).

• Short bones: cube-shaped and composed of spongy bone, providing stability (e.g., carpals in the wrist).

• Flat bones: protect internal organs and serve as attachment points for muscles (e.g., skull, ribs).

• Irregular bones: support and protect various body parts (e.g., vertebrae, pelvis).

• Sesamoid bones: small, round bones embedded in tendons, aiding in joint function (e.g., patella).

Assessment of the Musculoskeletal System

Objective Data

• Physical Examination:

  • Muscle strength testing (scale of 0-5) to evaluate functional ability:

  • 0/5: No contraction detected.

  • 1/5: Flicker or trace contraction observed.

  • 2/5: Active movement with gravity eliminated.

  • 3/5: Active movement against gravity.

  • 4/5: Active movement against gravity with some resistance.

  • 5/5: Active movement against full resistance (considered normal strength).

• Other Measures:

  • Measure limb length and circumferential muscle mass to assess for asymmetry.

  • Assess for use of assistive devices, posture, and gait to identify mobility issues.

  • Inspect for scoliosis and perform straight-leg raises to gauge flexibility and strength.

Diagnostic Studies of the Musculoskeletal System

• Common Diagnostic Studies Include:

  • Standard X-ray: the first-line imaging for fractures and bone abnormalities.

  • Bone scan: useful for detecting bone cancer that will light up like a hot spot on the scan.

  • CT scan: provides detailed cross-sectional images of bone and soft tissue.

  • Diskogram: evaluates pain originating from intervertebral discs.

  • DEXA (Dual energy X-ray absorptiometry): measures bone density to assess for osteopenia or osteoporosis.

  • EMG (Electromyogram): evaluates the health of muscles and the nerve cells that control them.

  • MRI (Magnetic Resonance Imaging): provides detailed views of soft tissues, including ligaments and discs.

  • Myelogram: uses contrast to look for issues in the spinal column, such as herniated discs.

  • SSEP: sensory-evoked potentials assess the functional integrity of pathways from the spinal cord to the brain.

  • Thermography: captures heat patterns in tissues, often used for muscular issues.

  • QUS (Quantitative Ultrasound): assesses bone density without ionizing radiation.

• Interventional Studies:

  • Arthrocentesis: procedure to aspirate fluid from a joint for analysis.

  • Arthroscopy: minimally invasive procedure using a camera to visualize internal joint structures.

Intervertebral Disc Disease

• Degenerative Disc Disease (DDD):

  • Characterized by loss of fluid in intervertebral discs leading to reduced elasticity and flexibility, resulting in potential pain and limited mobility.

• Herniated Disc:

  • Occurs when disc material protrudes and compresses spinal nerves, often due to degeneration or trauma.

• Surgical Interventions:

  • Spinal fusion (ankylosis) using bone graft from the patient’s fibula or iliac crest or donor tissue (allograft), which stabilizes the spine post-surgery.

  • May involve metal fixation to enhance stability of the spine post-operation.

Nursing Management: Vertebral Disc Surgery

• Postoperative Care:

  • Maintain proper spinal alignment until healing is confirmed through X-ray or patient's functional recovery.

  • Use of pillows under thighs when supine and between legs when side-lying to minimize pressure on the surgical site.

  • Log roll the patient to reposition safely without twisting the spine.

  • Monitor pain levels regularly and implement pain management strategies per physician’s orders.

  • Avoid bending, twisting, or lifting weights over 10lbs to facilitate recovery.

• Neurovascular Assessment:

  • Continuous assessment for signs of spinal cord edema, particularly after cervical surgery where loss of function may be imminent.

• Assessment of Donor Site:

  • Regularly check the bone graft site for signs of complications like infection or graft failure.

• Peripheral Neurological Status:

  • Assess movement and sensation in extremities as well as vital signs every 2-4 hours for the first 48 hours post-op.

  • Compare with pre-op neurological status to detect any deterioration or recovery.

  • Assess circulation through capillary refill time and pulses.

Spinal Cord Injuries (SCI)

• Caused by trauma or damage leading to temporary or permanent changes in function.

• Incidence:

  • Approximately 17,000 new cases annually in the U.S.; currently 282,000 individuals live with SCI, highlighting the need for proper management and rehabilitation.

  • High mortality risk within the first year is prevalent due to complications.

  • Approximately 30% rehospitalization rate due to secondary complications like infections or falls.

• Types of Injuries:

  • Variance in function depending on injury level (e.g., C4 injury results in tetraplegia; T6 injury results in paraplegia).

  • Can be caused by blunt or penetrating trauma and damage that progresses after the initial injury (e.g., inflammation or swelling).

  • Conditions like spinal shock could occur immediately after injury leading to temporary loss of function.

  • Vasogenic shock may occur with injuries at T6 or higher, affecting vital signs and circulation.

  • Compression fractures may lead to chronic pain and complications if not treated promptly.

Common Fracture Types

• Types of Fractures:

  • Closed (simple): does not break through the skin.

  • Open (compound): breaks through the skin, classified into:

    • Grade I (clean wound, minimal contamination).

    • Grade II (larger wound, more soft tissue damage).

    • Grade III (contaminated with significant soft tissue injury).

  • Transverse

  • Spiral

  • Greenstick - incomplete fracture

  • Comminuted

  • Oblique

  • Pathologic

  • Stress

Colles’ Fracture

• Characteristics:

  • Most common in older adults due to osteoporosis, often resulting from falls.

  • Presentation includes dorsal displacement of the distal fragment (known as silver-fork deformity).

• Assessment:

  • Movement

  • Capillary refill

  • Pulses

  • Color

  • Temperature

• Management:

  • Closed reduction followed by casting or splinting; neurovascular assessment should be done to check for complications.

  • Reduce edema (ice and splinting)

  • Move fingers and shoulder to reduce edema, increase venous return, and prevent stiffness and contracture

Nursing Process: The 6 P's for Neurovascular Assessment

• Key Indicators:

  • Pain: assess and manage to facilitate comfort.

  • Pressure: monitor for swelling or compartment syndrome.

  • Pallor: check for color changes indicating compromised circulation.

  • Pulselessness: assess for weak or absent pulses.

  • Paresthesia: monitor for sensations of numbness or tingling.

  • Paralysis: assess for loss of movement indicating neurological compromise.

Complications of Fractures

• Early Complications:

  • Shock: a life-threatening condition due to blood loss or other factors.

  • Fat embolism: fat droplets may enter the bloodstream, causing blockages.

  • Compartment syndrome: pressure within muscles builds to dangerous levels.

  • Venous thromboembolism (VTE), pulmonary embolism (PE): blood clots forming due to immobilization or injury.

• Delayed Complications:

  • Avascular necrosis: death of bone tissue due to insufficient blood supply.

  • Complex regional pain syndrome (CRPS): chronic pain condition that can occur after injury.

  • Nonunion or malunion: improperly healed fractures leading to further complications.

Emergency Management of Fractures

• Initial Actions:

  • Immobilization of the affected body part to prevent further injury.

  • Ensure splinting above and below the fracture site for stabilization.

  • Cover open fractures with sterile dressings to prevent infection.

Medical Management of Fractures

• Fracture Reduction:

  • Aim to restore anatomic alignment through either closed (manipulation without surgery) or open (surgical intervention) methods.

  • Use of fixation devices (like pins, plates, or screws) as needed to maintain alignment during healing.

  • External fixation requires pin care and constant infection monitoring

Caring for Patients with Casts or Traction

• Assessment:

  • Regularly check neurovascular status to monitor for circulation and nerve function.

  • Monitor for signs of complications: pressure ulcers, deep vein thrombosis (DVT), and skin integrity issues.

• Patient Education:

  • Instruct patients on care techniques and warning signs to report, including increased pain, swelling, or skin changes.

Traction Management

• Used to align fractures and reduce muscle spasms effectively.

• Key Principles:

  • Continuous force must be applied to maintain alignment and promote healing.

  • Monitor for complications such as skin breakdown, nerve damage, or blood flow issues.

Rehabilitation Considerations

• Pelvic Fractures:

  • Management varies by type of fracture; may involve bed rest and active symptom management.

• Hip Fractures:

  • Likely to require surgical fixation, with care approaches similar to other orthopedic surgeries for optimal recovery.

Nursing Priorities Post-Operative Care for Hip Replacement

• Prevent dislocation and enhance mobility through proper positioning and support devices.

• Regularly assess for complications and manage pain effectively, involving patient education regarding activity limitations.

• Schedule rehabilitation therapies, including physical therapy (PT) and occupational therapy (OT), for comprehensive recovery support.

Knee Replacement Needs

• Postoperative assessment includes monitoring for complications and the strategic use of continuous passive motion (CPM) devices to enhance recovery.

• Education:

  • Discuss the importance of activity restrictions and signs of potential complications such as swelling or infection post-surgery.

Osteomyelitis Management

• Treatment includes IV antibiotics and thorough wound assessments to prevent complications, including chronic infections.

• Patient education focuses on understanding signs of infection, proper hygiene practices, and the importance of follow-up appointments.

Amputation Care

• Focus on stump care routines, managing phantom limb sensations, and promoting mobility through the utilization of prosthetics.

• Regular monitoring for skin integrity and circulation to prevent complications is critical in post-amputation care.