NCLEX: Musculoskeletal disorders

Musculoskeletal disorders: Surgery

Focus Topic: Musculoskeletal disorders

For some patients with musculoskeletal disorders, surgery can offer a bright alternative to a life of chronic pain and disability. Surgical procedures include amputation, joint replacement, laminectomy and spinal fusion, and open reduction and internal fixation.

Amputation
Perhaps more than any other surgery, amputation can dramatically change a patient’s life. Your role includes providing support and detailed instruction in postoperative care.

Patient preparation
Prepare the patient for amputation by taking these steps:
• Before surgery, reinforce the surgeon’s explanation of the procedure and contact the surgeon if the patient requires additional information.
• Support the patient as he confronts all of the issues surrounding loss of a limb.

Monitoring and aftercare
After the procedure, take these steps:
• Be prepared to care for the cast or elastic wrap that the surgeon applies around the stump. This helps control swelling, minimize pain, and mold the stump so that it fits comfortably into a prosthesis.
• As appropriate, instruct the patient to report drainage through the cast, warmth, tenderness, or a foul smell.
• Warn the patient that the cast may slip off as swelling subsides. If so, he should immediately wrap the stump or slip on a custom-fitted elastic stump shrinker.

Home care instructions
Before discharge, give the patient these instructions:
• Emphasize that proper home care of the stump can speed healing. Tell the patient to inspect the stump carefully each day, using a mirror. He should call the practitioner if the incision is open, red or swollen, warm, painful to touch, or seeping drainage. Teach him to clean the stump daily with mild soap and water; then rinse and dry it thoroughly.
• Instruct the patient to rub the stump with alcohol daily to toughen the skin. Because alcohol may cause irritation in some patients, warn him to watch for and report this. Teach him not to apply powder or lotion because this may soften or irritate the skin.
• Teach him to massage the stump toward the suture line to mobilize the scar and prevent its adherence to bone.

• Advise him to avoid exposing the skin around the stump to excessive perspiration, which can be irritating. He may need to change his elastic bandages or stump socks during the day to avoid this.
• As stump muscles adjust to amputation, tell the patient he may have twitching, spasms, or phantom limb pain. Heat (for example, a hot bath, heating pad, or warm compress), massage, or gentle pressure can decrease these symptoms. If the stump is sensitive to touch, tell the patient to rub it with a dry washcloth for 4 minutes three times per day.
• Stress the importance of performing prescribed exercises to help minimize complications, maintain muscle strength and tone, prevent contractures, and promote independence.
• Stress the importance of positioning to prevent contractures.
• To prepare the stump for a prosthesis, teach progressive resistance maneuvers. First, the patient should push his stump gently against a soft pillow. Have him progress to pushing it against a firm pillow, a padded chair, and finally, a hard chair.

Joint replacement
Total or partial replacement of a joint with a synthetic prosthesis restores mobility and stability, relieves pain, and increases the patient’s sense of independence and self-worth.

Musculoskeletal disorders: A pretty hip joint

Focus Topic: Musculoskeletal disorders

Recent improvements in surgical techniques and prosthetic devices have made joint replacement a common treatment of severe chronic arthritis, degenerative joint disorders, and extensive joint trauma. Many joints can be replaced with prostheses, with hip and knee replacements being the most common.

Musculoskeletal disorders

Patient preparation
Before the procedure, take these steps:
• Tell the patient that because of the complexity of joint replacement, he’ll start having extensive tests and studies long before the day of surgery.
• Discuss postoperative recovery with the patient and his family. Explain that his activity will be limited after surgery and that he’ll soon begin an exercise program to maintain joint mobility.
• As appropriate, show him ROM exercises. If he’s having a total knee replacement, demonstrate the continuous passive motion (CPM) device he’ll use during recovery.
• Point out that surgery may not relieve his pain immediately. Reassure him that pain will diminish dramatically after edema subsides and that analgesics will be available as needed.

Monitoring and aftercare
After surgery, help the patient follow activity limitations. When he’s in bed, turn him regularly for the prescribed period while maintaining the affected joint in proper alignment. If traction is used, periodically check the weights and other equipment. Assess the patient’s level of pain and provide analgesics, as ordered. If you’re administering opioid analgesics, be alert for signs of toxicity or over-sedation.

Musculoskeletal disorders: Dangerous globules

Focus Topic: Musculoskeletal disorders

During recovery, take these steps:
• Monitor for complications of joint replacement, particularly hypovolemic shock from blood loss during surgery. Also watch for signs of fat embolism. This potentially fatal complication is caused by release of fat molecules in response to increased intermedullary canal pressure from the prosthesis. The fat globules then combine with platelets to form emboli, which may occlude vessels that supply the brain, lungs, kidneys, or other organs. Symptoms typically occur within 24 to 72 hours but may occur up to a week after injury.
• Inspect the incision frequently for signs of infection. Change the dressing as necessary, maintaining strict sterile technique. Periodically assess neurovascular and motor status distal to the joint replacement site.

• Immediately report abnormalities or complications, such as a dislocated total hip replacement. Signs and symptoms of this are sudden, severe pain, shortening, or internal or external rotation of the involved leg.
• Reposition the patient often to enhance comfort and prevent pressure ulcers.
• Encourage coughing and deep breathing to prevent pulmonary complications.
• Stress adequate fluid intake to avert urinary stasis and constipation.
• Have the patient begin exercising the affected joint, as ordered, perhaps even on the day of surgery. The practitioner may prescribe CPM (using a machine or a system of suspended ropes and pulleys) or a series of active or passive ROM exercises.
• Before the patient with a knee or hip replacement is discharged, make sure that he has a walker and knows how to use it.

Home care instructions
Before discharge, assess whether the patient needs home health care and take these steps:
• Reinforce the practitioner’s and physical therapist’s instructions for an exercise regimen. Remind the patient to closely adhere to the prescribed schedule and not to rush rehabilitation, no matter how good he feels.
• Review prescribed activity limitations.
• Instruct the patient on the importance of taking anti-inflammatory medication for pain relief and to speed the healing process.
• If the patient has undergone hip replacement, instruct him to keep his hips abducted and not to cross his legs when sitting. This helps reduce the risk of dislocating the prosthesis. Also tell him to avoid flexing his hips more than 90 degrees when rising from a bed or chair. Encourage him to sit in chairs with high arms and a firm seat and to sleep only on a firm mattress.
• Caution the patient to promptly report signs of infection, such as persistent fever and increased pain, tenderness, and stiffness in the joint and surrounding area. Remind him that infection may still develop several months after joint replacement.
• Tell the patient to report a sudden increase of pain, which may indicate dislodgment of the prosthesis.

Laminectomy and spinal fusion
In laminectomy, the surgeon removes one or more of the bony laminae
that cover the vertebrae. This procedure has two main uses:

  • To relieve pressure on the spinal cord or spinal nerve roots resulting from a herniated disk (most common)
  • To treat compression fracture or dislocation of vertebrae or a spinal cord tumor.

Musculoskeletal disorders: Nothin’ confusin’ about fusion

Focus Topic: Musculoskeletal disorders

After removing the lamina, the surgeon may stabilize the spine by performing spinal fusion using bone chip grafts between vertebral spaces.
Spinal fusion may also be done without a laminectomy in patients whose vertebrae are seriously weakened by trauma or disease. Usually, spinal fusion is done only when more conservative treatments — such as prolonged bed rest, traction, physical therapy, or a back brace — prove ineffective.

Musculoskeletal disorders

Patient preparation
Before laminectomy and spinal fusion, take these steps:
• Discuss postoperative recovery and rehabilitation. Point out that surgery won’t relieve back pain immediately and that pain may even worsen after the operation. Explain that relief will come only after chronic nerve irritation and swelling subside, which may take several weeks. Reassure him that analgesics and muscle relaxants will be available during recovery.
• Tell the patient that he’ll return from surgery with a dressing over the incision and that his activity will be limited postoperatively for a period of time.
• Explain that he’ll be turned often to prevent pressure ulcers and pulmonary complications. Show him the logrolling method of turning, and explain that he’ll use this method later to get in and out of bed by himself.
• Just before surgery, perform a baseline assessment of motor function and sensation in the patient’s lower trunk, legs, and feet. Carefully document the results for comparison with postoperative findings.

Monitoring and aftercare
After the procedure, take these steps:
• Position the patient as ordered by the practitioner for the prescribed period of time.
• When he can assume a side-lying position, make sure he keeps his spine straight with his knees flexed.
• Inspect the dressing frequently for bleeding or cerebrospinal fluid (CSF) leakage, and report either immediately. The practitioner will probably perform the initial dressing change, and you may be asked to perform subsequent changes.
• Assess motor and neurologic function in the patient’s trunk and lower extremities, and compare the results with baseline findings. Also evaluate circulation in the patient’s legs and feet and report any abnormalities. Give analgesics and muscle relaxants as ordered.
• Every 2 to 4 hours, assess urine output and auscultate for the return of bowel sounds. If the patient doesn’t void within 8 to 12 hours after surgery, notify the practitioner and prepare to insert a urinary catheter to relieve retention. If the patient can void normally, assist him in getting on and off a bedpan while maintaining proper alignment.

Home care instructions
Before discharge, take these steps:
• Teach the patient and his caregiver proper incision care measures. Tell them to check the incision site often for signs of infection — such as increased pain and tenderness, redness, swelling, and changes in the amount and character of drainage — and to report any signs immediately.
• Make sure the patient understands the importance of resuming activity gradually after surgery. As ordered, instruct him to start with short walks and to slowly progress to longer distances.
• Review with the patient any prescribed exercises, such as pelvic tilts, leg raises, and toe pointing. Advise him to rest frequently and avoid overexertion.

Musculoskeletal disorders: Get up, stand up

Focus Topic: Musculoskeletal disorders

• Review any prescribed activity restrictions. Usually, the practitioner will prohibit sitting for prolonged periods, lifting heavy objects, bending over, and climbing long flights of stairs. He may also impose other restrictions, depending on the patient’s condition.
• Teach the patient proper body mechanics to lessen strain and pressure on his spine.
• Instruct the patient to sleep only on a firm mattress. If necessary, advise him to purchase a new one or to insert a bed board between his mattress and box spring.

Open reduction and internal fixation
During open reduction, the surgeon restores the normal position and alignment of fracture fragments or dislocated joints. He then inserts internal fixation devices — such as pins, screws, wires, nails, rods, or plates — to maintain alignment until healing can occur.

Patient preparation
Before the procedure, take these steps:
• Because this procedure requires general or regional anesthesia, instruct the patient not to eat after midnight the night before.
• Tell the patient that he’ll likely receive a sedative and antibiotics before going to the operating room.

Monitoring and aftercare
After the procedure, take these steps:
• Describe to the patient the bulk dressing and surgical drain that he’ll have in place for several days postoperatively.

• Tell him that he may need a cast or splint for support when the drain is removed and swelling subsides.

Home care instructions
Before discharge, assess whether the patient needs home health care and give the patient these instructions:
• Teach him how to care for the device, if appropriate. Tell him to check his skin regularly under and around the device, if possible, for irritation and breakdown. Also instruct him to watch for signs of incisional infection (redness, swelling, drain age, and foul odor from the site).
• Advise him to follow the practitioner’s orders about exercising and placing weight on the affected joint.

Musculoskeletal disorders

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