Nursing Care of the Patient with Musculoskeletal & Connective Tissue Disorders Chapter 46

Bone & Soft Tissue Disorders
Strain, Sprain, Dislocation

Bursitis: Inflammation of the fluid filled sac(bursa)
RX: Joint rest, elevation & application of the heat, analgesics

Rotator Cuff Injury: made up of four muscles that help move & stabilize the shoulder joint.

Carpal Tunnel Syndrome
Median Nerve Compression in wrist’s carpal tunnel.
Common in people who perform repetitive motions of hand & wrists. Ex) typing on a computer

Carpal Tunnel Syndrome Treatment:
Relieve inflammation & rest wrist
Splint, Anti-inflammatory
Surgery and teach prevention

Break in Bone from trauma or pathological(from disease)

Open or Compound: break skin or soft tissue—infection risk
Closed: does not break skin

Avulsion Fracture:
fragment of bone tears away from the main mass of bone due to physical trauma.

Comminuted Fracture:
bone is broken into several pieces & fragments(protrudes through the skin=Osteoporosis

Impacted Fracture:
one end of the bone is driven into the end of another bone(painful)

Green Stick Fracture:
Only one side of the bone is broken while the opposite side is bent-incomplete(children)

Intraarticular Fracture:
Break crosses into the surface of a joint(cartilage damage)

Displaced Fracture:
Snaps into two and moves so that the two ends are lined up straight.

Pathological Fracture:
Disease that weakens the bones, and stress fracture.

Spiral Fracture/Torsion fracture:
Caused by twisting force on the bone.

Longitudinal Fracture:
Line of force runs roughly from lateral to medial.

Oblique Fracture:
Diagonal to the bone’s axis.

Stress fracture:
Common overuse injury(athletes), fall or car crash.

Transverse Fracture:
Break is across the bone.

**Fracture Signs & Symptoms
Pain, Decreased ROM
Limb Rotation
Deformity, Shortening of Limb
Swelling & Bruising


Diagnostic Tests
X-Ray, CT Scan

Emergency Treatment
**Splint it as it lies
Seek Medical attention

Fracture Management
**Realignment of Bone Ends

Closed reduction:
Manuel Realignment

Closed Reduction Tractions:
Efforts to realign broken bones

Temporary measures when operative fixation is not available for a period of time.

Applied through the skin(Skin Traction)

Through pins inserted into bones(Skeletal Traction)

Traction Goals (Closed Reduction)
**Regain normal length and alignment of involved bone.
Lessen or eliminate muscle spasm.
Relieve pressure on nerves, especially spinal.
Prevent or reduce skeletal deformities or muscle contractures.

Skin Traction:
Body alignment in the middle of the bed.
Ropes & weights must be unobstructed.
Knots in the rope or footplate must not touch the pulley or foot of bed.

Skeletal Traction:
High risk for pressure & breakdown.
Perform pin site care.

**Traction setup: weights on the traction setup must be hanging freely.

Types of Traction:
**Buck’s Traction: Fractures, Femur, Tibia or Fibula.
Thomas Ring: Fractures of Tibia or Fibula.
Russell’s: Femur Fracture.
Balanced Suspension & Skeletal Traction
Halo-Femoral: For spinal injuries uses pins & wires.

Fracture Management:
Internal Fixation: If fracture could not be reduced by closed method.

Open Reduction with Internal Fixation: Surgically repairing a fractured bone, involves either plates & screws or an intramedullar rod to stabilize the bone.

External Fixation: Pins are inserted through skin into the bone and held in place by an external frame.

Complications of Fractures:
Nonunion, Neurovascular Compromise
Hemorrhage, Infection
Thromboembolitic Complications
Acute Compartment Syndrome

***Fat Embolism Syndrome:
Signs & Symptoms: Respiratory distress, confusion & restlessness

Compartment Syndrome:
Compression of nerves, blood vessels and muscle in closed space(compartment) within the body.

Leads to tissue death from lack of O2.

Blood vessels being compressed by the raised pressure within the compartment.

Acute, Subacute, and Chronic compartment syndrome.

Compartment Syndrome (5 P’s)
1. Pain out of proportion to what is expected.
2. Paresthesia
3. Pallor
4. Paralysis
5. Pulsenessness/unequal pulses
Tense swollen shiny skin, bruising of the skin.

Nursing Diagnosis:
Acute Pain **
Risk for Ineffective Tissue Perfusion
Risk for Ineffective Skin Integrity

Cast Care:
Always keep the cast clean.
Pain Control
Neurovascular Checks
Skin Care: never scratch under a cast.

Infection of the bone…**Prevention Is Key!!!

S & S Fever, Redness, Heat, Pain, Swelling & Pain.

RX: Long term Antibiotic Therapy, incision & drainage, Amputation

Osteomyelitis Nursing Care:
Medication Teaching, Hand Hygiene, Sterile Dressing Changes

Low Bone Mass as Bone loses Density.
Prone to Fractures, spine, wrist & hip most common.
All bones affected.

Osteoporosis Fracture Effects:
Hip/Vertebral Fractures:
Reduced quality of life
Increased disability
Risk of Death(During year after Fracture)

Lab Test
CK-MM(CK3): Skeletal muscle creatine kinase released in to the bloodstream due to tissue damage(crushing injury)

Decreased Serum Calcium: 8.5-10.5(normal)
Uric Acid: male-4.4-7.6
female: 2.3-6.6

Osteoporosis Prevention:
Build Bone through age 30
-Obtain Adequate Calcium and Vitamin D
-Major dietary source of calcium: milk, yogurt and a variety of cheeses.
-Fortified with calcium and Vitamin D: Orange, juice, milk
-Regular Exercises(Especially Childhood)-promotes bone
formation & improve strength
-Avoid Alcohol & Smoking

Osteoporosis Risk Factors:
Aging, Female
Fracture History
Family History
Petite Body Build
Postmenopausal Women
Low Testosterone & Estrogen, Low Calcium Intake
Low Vitamin D, Excessive Caffeine, Protein & Sodium
*Sedentary Lifestyle, Excessive Alcohol & Smoking

Osteoporosis Signs & Symptoms:
Dowager’s Hump: An abnormal outward curvature of the vertebrae of upper back.

Kyphosis: Vertebrae leads to forward bending of the spine & creates a hump at the upper back.
height decreases, Back Pain & Fracture

Osteoporosis Diagnostic Tests
Duel-energy X-Ray Absorptiometry
Serum Calcium, Vitamin D Decreased
Serum Phosphorus Increased
Serum Alkaline Phosphates Increased

Osteoporosis Interventions:
Reduce Risk Factors, Calcium Supplements, Vitamin D Supplements & Medication.

Antiresorptive Medications:
alendronate(Fosamax)-administer with full glass water on arising in AM. Do not lie down for 30 min after medication.
Calcitonin(Fortical, Miacalcin)

Selective Estrogen Receptor Modulator
raloxifene(Evista): side effects: Hot Flashes
Anabolic(Bone Forming)

Osteoporosis Nursing Care
**Pain Relief, Symptom Management
Education: Diet-Increase Calcium, Vitamin D, Exercise, Medication & Fall Prevention..very important.

Paget’s Disease
Increased Bone loss
Disorganized Bone Deposits
No obvious Symptoms Usually
X-Ray, Bone Scan
Relieve Pain, Teach, Promote Life quality

Bone Cancer
Primary Malignant Tumors

Most common
50% Occur in Distal Femur in Young Men
Metastasizes to Lung within 2 years

Ewing’s Sarcoma
Most malignant
Tumor:long bones of the arms & legs
Pelvis, Chest & Skull

Cancer of Cartilaginous Cells
Better Prognosis

Bone Biopsy Nursing Care:
**Elevate the biopsy site for 24 hours to reduce Edema.
**Do not place in a dependent position.
Monitor VS 4th hourly.
Monitor site for edema, bleeding & hematoma.
Administer oral analgesic for pain.

Primary Bone Cancer
Therapeutic Interventions
Surgery, Chemotherapy, Radiation.
Nursing Care: Postoperative Care, Supportive

Metastatic Bone Disease
Bone-seeking Cancers
Prostate, Breast, Lung & Thyroid
Pathological Fractures
Severe Pain
Therapeutic Interventions: Radiation
Nursing Care: Supportive care as with other cancers.

Systemic Connective Tissue Disorder
Uric Acid Buildup
Urate Crystals deposited in joints/connective tissue
Severe Inflammation….Very Painful

Gout: Causes & Types
Primary: Inherited Problem with Purine Metabolism.
Secondary: Another health problem.

Gout Signs & Symptoms:
Acute: Swollen, Red, Hot, Painful inflamed joints, Great toe.

Chronic Gout: Urate deposits under skin, Renal Stones.

Gout–Diagnostic Tests:
Serum Uric Acid
Joint Fluid-Uric Acid Crystals

Gout Therapeutic Interventions:
allopurinol(Zyloprim)- Maintain fluid intake 2000ml/3000ml/day
Give with food
Therapeutic effect occurs after a week or longer.
Avoid foods with high in Purine.

Gout: Nursing Care
Diet: Avoid foods high in Purine.(sardines, scallops, yeast, organ meat, legumes, spinach, gravies)

Avoid Asprin, Diuretics, Alcohol

Increase Fluids, Bed rest in acute stage.

Systemic Lupus Erthematosus
Autoimmune Disease
Genetic Link
Abnormal Antibodies
Affects Connective Tissue

Systemic Lupus Signs & Symptoms:
Butterfly Rash, Photosensitive, Fever
Fatigue, Malaise
Arthralgia(joint pain), Myalgia(muscle pain)
Weight loss
Mucosal Ulcers, Alopecia, Skin Lesions

Systemic Lupus Diagnostic Tests:
Erythrocyte Sedimentation Rate(ESR)
Immunological Tests: Antinuclear Antibody Titers & Antibodies Against SR Proteins

Systemic Lupus Therapeutic Interventions:
Immunomodulating Drugs
Topical Cortisone & Chloroquine(Aralen)

Systemic Lupus Patient Education:
Skin Care, Avoid prolonged exposure to sun, Exercise, Immunizations
Stress Reduction & Community Support Groups

Inflammation develops into Fibrosis and Sclerosis of Tissues.
Autoimmune Response
Progresses very rapidly
Poor Prognosis

Scleroderma S & S:
Arthritis, Fatigue
Sclerderma: Pitting edema, tightening, hardening, thickening of skin tissue
Loss of ROM & Contractures

Sclerderma Interventions:
Steroids, Immunosuppresants, Antacids, Histamine Blockers & Rehabilitation Therapy

Sclerderma Nursing Care:
Pain Control, Bed Cradle, Sock/Glove
Skin Protective-Mild Soaps & Lotions

Osteogenesis Imperfecta:
Congenital Abnormality Characterized by Skeletal Bone Fragility.
Brittle bone disease, Pathological Fractures
Collagen Synthesized Abnormally

Osteogenesis Imperfecta S & S:
Fragile Bones, Potential Hearing Loss
Scoliosis: Curvature of the Spine.
Britlle or Discolored Teeth
Smooth, Thin Skin

Osteogenesis Imperfecta Diagnosis:
History of Fracture
Physical & Skin Biopsy

Osteogenesis Imperfecta Nursing Care:
Careful Handling, Teaching
Support Groups-Osteogenesis Imperfecta Foundation

Diffuse inflammation of skeletal muscle
Woman greater than Men

Treatment: Prednisone

Muscular Dystrophy
Loss of Muscle Tissue
Progressive Muscle Weakness, Genetic

Muscular Dystropy Nursing Diagnosis:
Impaired Physical Mobility
Ineffective Breathing Pattern
Self Care Deficit
Deficient Knowledge

Degenerative Joint Disease(DJD)
Cartilage wears down over time
Degeneration of articular Cartilage
Most commonly affects joints in: Hands, Hips, Knees, Neck, Lower Back

Osteoarthritis Causes:
Risk Factors: Aging, Obesity, Excessive Wear & Tear on Synovial Joints

Osteoarthritis S & S:
Joint Pain: Intensifies after Physical Activity
Heberden’s & Bouchard’s Nodes- Bony nodes on joints of fingers.

Osteoarthritis Diagnostic Tests:
X-ray, CT Scan, MRI, Synovial Fluid Analysis

Osteoarthritis Interventions:
No cure, Medication: NSAIDs, Rest & Exercise, Weight Control

Rheumatoid Arthritis:
Chronic, Progressive, Systemic Inflammatory Disease
Destroys Synovial Joints and other Connective Tissue
Includes Major Organs

Rheumatoid Arthritis S & S:
Early Symptoms;
Bilateral, Symmetrical Joint Inflammation
Reddened, Warm, Swollen, Stiff & Painful
Stiffness at Resting
Activity Decreases Pain & Stiffness
Low Grade Fever, Weakness, Fatigue
Joint Deformity

Rheumatoid Arthritis Diagnosis:
Rheumatoid Factor (RF)
Red Blood Cell (RBC)
Erythrocyte Sedimentation Rate (ESR)
Antinuclear Antibody (ANA)
C-reactive Protein (CRP)
****Sometime RF may be negative but they still have Arthritis.

Rheumatoid Arthritis Interventions:
leflunomide (Arava)
etanercept (Enbrel)

Patient Education: Disease Process, Medication Management
Rest & Exercise, Vocational Counselor, Community Resources

Total Hip Replacement:
Acetabular Cup Inserted into Pelvic Acetabulum
Femoral Component Inserted Into Femur

Total Hip Replacement
Post Operative Care to Prevent Complications:
***Prevent Adduction or Hyperflexion
***Do not flex hip more than 90 degrees

Skin Breakdown, Prevent Pressure Ulcers
Bleeding: Monitor incision/drainage from drain
Neurovascular Compromise: Neurovascular Checks
Pain, Pulses, Paraesthesia, Paralysis & Pallor

Total Hip Replacement
Grade the pain on pain scale
Look for signs of capillary refill

Check coloring in fingers & toes, they should be pink.
White coloring means inadequate arterial blood perfusion.
Bluish means inadequate venous blood return.

Total Hip Replacement:
Ambulation, Physical Therapy, Use Walker/Crutches
**Post op: The nurse needs to get physical therapy to get patient up after hip replacemet for the first time.

Total Hip Replacement:
Thromboembolitic Complication
Compression Device, Leg Exercises & enoxaparin (Lovenox)

Self Care: Assistive dressing devices, Raised toilet seat, Rehabilitation

Total Knee Replacement:
Prophylactic Antibiotic
**Report s/s of infection, any changes in the shape of the knee

Metal Implant: anticoagulant bleeding (needs to be notified by caregiver)
Continuous Passive Motion Machine (CPM)

Levels of Amputation:
Below the Knee(BKA)
Above the Knee(AKA)
Below the Elbow(BEA)
Above the Elbow(AEA)

Amputation Nursing Care:Postoperative
Complication: Hemorrhage, limb edema
Wound Infection
**Use a mirror to visualize all area of residual limb.
No oils, creams, lotions or alchohol rub
Use clean woolen sock
Pain Control: Phantom Pain
Mobility & Ambulation

Phantom Pain:
Perceptions that an individual experience relating to a limb or an organ that is not physically part of the body.

Medications to reduce the pain: antidepressants/anti-platelets
Light massage, electrical stimulation, and hot & cold therapy

Nursing Care:Prosthesis, Lifestyle Adaptation

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