Nursing of Adult Patients with Medical & Surgical Conditions Musculoskeletal Disorders.
Nursing Care of Patients with Musculoskeletal Disorders (I)
Transcript of Nursing Care of Patients with Musculoskeletal Disorders (I)
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