NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: MUSCULOSKELETAL SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

IMMOBILITY: Impaired physical mobility or limitation of physical movement may be accompanied by a number of complications that can involve any or all of the major systems of the body. Regardless of the cause of immobilization, there are a number of conditions that arise primarily as a complication of immobility. These are discussed.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Types of immobility:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Physical—physical restriction due to limitation in movement or physiological processes (e.g., breathing).
  • Intellectual—lack of action due to lack of knowledge (e.g., mental retardation, brain damage).
  • Emotional—immobilized when highly stressed (e.g., after loss of loved person or diagnosis of terminal illness).
  • Social—decreased social interaction due to separation from family when hospitalized or when alone, as in old age.

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain, trauma, injury.
  • Loss of body function or body part.
  • Chronic disease.
  • Emotional, mental illness; neglect.
  • Malnutrition.
  • Bedrest, traction, surgery, medications.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data: psychological/social effects of immobility:

a. Decreased motivation to learn; decreased retention.

b. Decreased problem-solving abilities.

c. Diminished drives; decreased hunger.

d. Changes in body image, self-concept.

e. Exaggerated emotional reactions, inappropriate to situation or person; aggression, apathy, withdrawal.

f. Deterioration of time perception.

g. Fear, anxiety, feelings of worthlessness related to change in role activities (e.g., when no longer employed).

  • Objective data: physical effects of immobility:

a. Cardiovascular.

(1) Orthostatic hypotension.
(2) Increased cardiac load.
(3) Thrombus formation.

b. Gastrointestinal.

(1) Anorexia.
(2) Diarrhea.
(3) Constipation.

c. Metabolic.

(1) Tissue atrophy and protein catabolism.
(2) BMR reduced.
(3) Fluid/electrolyte imbalances.

d. Musculoskeletal.

(1) Demineralization (osteoporosis).
(2) Contractures and atrophy.
(3) Skin breakdown.

e. Respiratory.

(1) Decreased respiratory movement.
(2) Accumulation of secretions in respiratory tract.
(3) O2/CO2 level imbalance.

f. Urinary.

(1) Calculi.
(2) Bladder distention, stasis.
(3) Infection.
(4) Frequency.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Impaired physical mobility related to specific client condition.
  • Impaired skin integrity related to physical immobilization.
  • Urinary retention related to incomplete emptying of bladder.
  • Constipation related to inactivity.
  • Risk for disuse syndrome related to lack of range of motion.
  • Bathing/hygiene self-care deficit related to musculoskeletal impairment.
  • Sensory/perceptual alteration related to complications of immobility.
  • Body image disturbance related to physical limitations.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prevent physical, psychological hazards.

a. Apply nursing measures to promote venous flow, muscle strength, endurance, joint mobility, skin integrity.

b. Assess and counteract psychological impact of immobility (e.g., feelings of helplessness, hopelessness, powerlessness).

c. Help maintain accurate sensory processing to prevent and lessen sensory disturbances.

d. Help adapt to altered body image due to increased dependency, sensory deprivation, and changes in status and power that accompany immobility.

e. Offer counseling when sexual expression is impaired.

  • Goal: health teaching: how to prevent physical problems related to immobility (e.g., anticonstipation diet, range of motion, skin care); teach activities while immobile that encourage independence and provide sensory stimulation.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Minimal contractures, skin breakdown, muscle atrophy, or loss of strength.
  • Interest in self and environment; positive self-image.
  • Returns to optimal level of physical activity.

FRACTURES: disruptions in the continuity of bone as the result of trauma or various disease processes, such as Cushing’s syndrome or osteoporosis, that weaken the bone structure.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

  • Open or compound—fractured bone extends through skin and mucous membranes; increased potential for infection.
  • Closed or simple—fractured bone does not protrude through skin.
  • Complete—fracture extends through entire bone, disrupting the periosteum on both sides of the bone, producing two or more fragments.
  • Incomplete—fracture extends only partway through bone; bone continuity is not totally interrupted.
  • Greenstick or willow-hickory stick—fracture of one side of bone; other side merely bends; usually seen only in children.
  • Impacted or telescoped—fracture in which bone fragments are forcibly driven into other or adjacent bone structures.
  • Comminuted—fracture having more than one fracture line and with bone fragment broken into several pieces.
  • Depressed—fracture in which bone or bone fragments are driven inward, as in skull or facial fractures.

B. Methods used to reduce/immobilize fractures: reduction or setting of the bone—restores bone alignment as nearly as possible.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Closed reduction—manual traction or manipulation. Usually done under anesthesia to reduce pain and muscle spasm. Maintenance of reduction and immobilization is accomplished by casting (fiberglass or plaster of Paris).
  • Open reduction—operative procedure utilized to achieve bone alignment; pins, wires, nails, or rods may be used to secure bone fragments in position; prosthetic implants may also be used.
  • Traction reduction—force is applied in two directions: to obtain alignment, and to reduce or eliminate muscle spasm. Used for fractures of long bones. May be:

a. Continuous—used with fractures or dislocations of bones or joints.

b. Intermittent—used to reduce flexion contractures or lessen pain and muscle spasm.

c. Applied as follows:

(1) Skin—traction applied to skin by using a commercial foam-rubber Buck’s traction splint or by using adhesive, plastic, or a moleskin strip bound to the extremity by elastic bandage; exerts indirect traction on bone or muscles (e.g., Bryant’s, Buck’s extension, head, pelvic, Russell’s).
(2) Skeletal—direct traction applied to bone using pins (Steinmann), wires (Kirchner). Pin is inserted through the bone in or close to the involved area and usually protrudes through skin on both sides of the extremity. Skeletal traction for fractured vertebrae accomplished with tongs (e.g., Crutchfield tongs, Gardner-Wells tongs).

d. Specific types of traction:

(1) Cervical—direct traction applied to cervical vertebrae using a head halter or Crutchfield, Gardner-Wells, or Vinke tongs that are inserted into the skull.Traction is increased with weights until vertebrae move into position and alignment is regained. After reduction is obtained, weights are decreased to the amount needed to maintain reduction. Weight amount is prescribed by physician.
(2) Balanced suspension—countertraction produced by a force other than client’s body weight; extremity is suspended in a traction apparatus that maintains the line of traction despite changes in the client’s position (e.g., Russell’s leg traction, Thomas’ splint with Pearson’s attachment)
(3) Running—traction that exerts a pull in one plane; countertraction is supplied by the weight of the client’s body or can be increased through use of weights and pulleys in the opposite direction (e.g., Buck’s extension, Russell’s traction). (4) Halo—an apparatus that employs both a plastic and metal frame; molded frame extends from axilla to iliac crest and houses a metal frame. The struts of the frame extend to skull and attach to round metal (halo) device. The halo is attached to skull by four pins—two located anterolaterally and two located posterolaterally. They are inserted into external cortex of the cranium. Used to immobilize the cervical spine following spinal fusion, give some correction to scoliosis before spinal fusion, and immobilize nondisplaced fracture of spine.

  • Immobilization—maintains reduction and promotes healing of bone fragments.
    Achieved by:

a. External fixation:

(1) Casts—types:

(a) Spica—applied to immobilize hip or shoulder joints.
(b) Body cast—applied to trunk.
(c) Arm or leg cast—joints above and below site included in cast.

(2) Splints, continuous traction.

(3) External fixation devices (Charnley)—multiple pins/rods through limb above and below fracture site, attached to external metal supports. Client able to become ambulatory.

b. Internal fixation—pins, wires, nails, rods.

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Pain, tenderness.

b. Tingling, numbness.

c. Nausea.

d. History of traumatic event.

e. Muscle spasm.

  • Objective data:

a. Function: abnormal or lost.

b. Deformities.

c. Ecchymosis, increased heat over injured part.

d. Localized edema.

e. Crepitation (grating sensations heard or felt as bone fragments rub against each other).

f. Signs of shock.

g. Indicators of anxiety.

h. X-ray: fracture—positive interruption of bone; dislocation—abnormal position of bone.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain related to interruption in bone.
  • Impaired physical mobility related to fracture treatment modality.
  • Risk for injury related to complications of fractures.
  • Knowledge deficit (learning need) regarding cast care, crutch walking, traction.
  • Constipation related to immobilization.
  • Risk for impaired skin integrity related to immobility or friction from materials used to immobilize the fracture during healing.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: promote healing and prevent complications of fractures.

a. Diet: high protein, iron, vitamins to improve tissue repair; moderate carbohydrates to prevent weight gain; no increase in calcium to prevent kidney stones (decalcification and demineralization occur when client is immobilized).

(1) Encourage increased fluid intake, to prevent kidney stones.

(2) Prevent or correct constipation through increasing bulk foods, fruits, and fruit juices, or using prescribed stool softeners, laxatives, or cathartics as necessary.

b. Provide activities to reduce perceptual deprivation—reading, handcrafts, music, special interests/hobbies that can be done while maintaining correct position for healing.

  • Goal: prevent injury or trauma in relation to:

a. Fracture care:

(1) Maintain affected part in optimum alignment.

(2) Maintain skin integrity; check all bony prominences for evidence of pressure q4h and prn, depending on amount of pressure.

(3) Monitor: circulation in, sensation of, and motion of (CSM) affected part q15 min for first 4 hours; q1h until 24 hours; q4h and prn, depending on amount of edema.

(4) Maintain mobility in unaffected limb and unaffected joints of affected limb by active and passive ROM; prevent footdrop by using ankle-top sneakers.

b. Skin traction:

(1) Maintain correct alignment:

(a) If tape or moleskin is used, shave extremity and apply benzoin to improve adherence of strip and reduce itching.

(b) Check apparatus for slippage, bunching; replace prn.

(2) Prevent tissue injury:

(a) Check all bony prominences for evidence of pressure: q15 min for first 4 hours; q1h until 24 hours, q4h and prn, depending on amount of edema.

(b) Nonadhesive (e.g., Bryant’s) traction may be removed q8h to check skin.

c. Skeletal traction:

(1) Maintain affected part in optimum alignment:

(a) Ropes on pulleys.

(b) Weights hang free.

(c) Elevate head of bed as prescribed.

(d) Check knots routinely.

(2) Maintain skin integrity:

(a) Frequent skin care.

(b) Keep bed linens free of crumbs and wrinkles.

(3) Prevent infection: special skin care to pin insertion sites three times daily. Keep area around pins clean and dry. Use prescribed solution for cleansing.

(4) Monitor circulation in, sensation of, and motion of affected part.

(5) Maintain mobility in unaffected limb and unaffected joints; prevent footdrop of affected limb.

d. Running traction:

(1) Keep well centered in bed.
(2) Elevate head of bed only to point of countertraction.
(3) No turning from side to side—will cause rubbing of bony fragments.
(4) Check distal circulation frequently.
(5) Frequent back care to prevent skin breakdown.
(6) Fracture bedpan for toileting.
(7) Avoid excessive padding of splints in groin area to prevent tissue trauma.

e. Balanced suspension traction:

(1) Maintain alignment and countertraction:

(a) Ropes on pulleys.
(b) Weights hang free.
(c) Elevate head of bed as prescribed.
(d) Check knots routinely.

(2) May move client, but turn only slightly (no more than 30 degrees to unaffected side).
(3) Heel of affected leg must remain free of the bed.
(4) 20-degree angle between thigh and bed.
(5) Check for pressure from sling to popliteal area.
(6) Provide foot support to prevent footdrop.
(7) Maintain abduction of extremity.
(8) Check for signs of infection at pin insertion sites; cleanse three times daily as ordered.
(9) If tape or moleskin is used, shave extremity and apply benzoin to improve adherence of strip and reduce itching.

f. Cervical traction :

(1) May be placed on specialized bed (e.g., Stryker frame).

(2) Position: maintain body alignment.

(3) Keep tongs free from bed, and keep weights hanging freely to allow traction to function properly.

g. Halo traction:

(1) Several times a day, check screws to the head and screws that hold the upper portion of the frame, to determine correct position.
(2) Pin sites cleansed three times daily with bacteriostatic solution to prevent infection.
(3) Monitor for signs of infection.
(4) Position as any other client in body cast, except no pressure to rest on halo—pillows may be placed under abdomen and chest when client is prone.
(5) Institute ROM exercises to prevent contractures.
(6) Turn frequently to prevent development of pressure areas.
(7) Allow client to verbalize about having screws placed in skull.
(8) Postapplication nursing care same as pin insertion for other traction.

h. External fixation devices:

(1) Pin care same as for skeletal traction.
(2) Teach clothing adjustment.
(3) Teach to adjust for size of apparatus.

i. Internal fixation devices:

(1) Monitor for signs of infection/allergic reaction to materials used for maintenance of reduction (drainage, pain, increased temperature).
(2) Position as ordered to prevent dislocation.

j. Casts:

(1) Support drying cast on firm pillow; avoid finger imprints on cast.
(2) Elevate limb to reduce edema.
(3) Prevent complications of fractures as listed.
(4) Closely monitor circulation (blanching, swelling, decreased temperature); sensation (absence of feeling; pain or burning); and motion (inability to move digits of affected limb).
(5) Be prepared to notify physician or cut cast if circulatory impairment occurs.
(6) Protect skin integrity: avoid pressure of edges of cast; petal prn.
(7) Monitor for signs of infection if skin integrity impaired.

  • Goal: provide care related to ambulation with crutches.

a. Teach appropriate gait (Teaching Crutch Walking).

b. Measure crutches correctly (Measuring Crutches Correctly).

(1) Subtract 16 inches from total height; top of crutch should be 2 inches below the axilla.
(2) Complete extension of the elbows should be possible without pressure of axilla bar into the axilla.                                                                                                                                       (3) Handgrip should be adjusted so that complete wrist extension is possible.
(4) Instruct in correct body alignment:

(a) Head erect.
(b) Back straight.
(c) Chest forward.
(d) Feet 6 to 8 inches apart, wide base for support.

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

  • Goal: provide safety measures related to possible complications following fracture.
  • Goal: health teaching.

a. Explain and show apparatus before application, if possible.

b. Pin care at least once daily to prevent granulation and cellulitis.

c. Correct position for rest/sleep and prevention of injury with halo traction—no pressure on halo.

d. Purpose of cast: to immobilize, to support body tissues, to prevent or correct deformities.

e. Teach signs and symptoms of complications to report related to cast care (i.e., numbness, odor, crack/break in cast; extremity cold, bluish).

f. Isometric exercises for use with affected joint.

g. Safety measures with crutches:

(1) Weight-bearing on hands, not axilla.
(2) Position crutches 4 inches to side and 4 inches to front.
(3) Use short strides, looking ahead, not at feet.
(4) Prevent injury: if client begins to fall, throw crutches to side to prevent falling on them; body should be relaxed.
(5) Check for environmental hazards: rugs, water spills.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • No injury or complications related to apparatus or immobilization (e.g., infection, tissue injury, altered circulation/sensation, dislocation).
  • Bone remains in correct alignment and begins to heal.
  • Demonstrates elevated limb position to relieve edema with casted extremity.
  • Lists complications related to circulation or neurological impairment and infection.
  • Begins to use affected part.
  • Demonstrates correct technique for ambulation with crutches—no pressure on axilla, uses strength of arms and wrists.
  • No falls while using crutches.
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COMPARTMENT SYNDROME: an accumulation of fluid in the muscle compartment, resulting in an increase in pressure that reduces blood flow to the tissues. Can lead to neuromuscular deficit, amputation, and death.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: inability of the fascia surrounding the muscle group to expand to accommodate the increased volume of fluid → compartment pressure increases → venous flow impaired → arterial flow continues, increasing capillary pressure→ fluid pushed into the extravascular space →intracompartment pressure further increased →
prolonged or severe ischemia → muscle and nerve cells destroyed, contracture, loss of function, necrotic tissue, infection, release of potassium, hydrogen, and myoglobin into bloodstream.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Fractures.
  • Burns.
  • Crushing injuries.
  • Restrictive bandages.
  • Cast.
  • Prolonged lithotomy positioning.
  • Ischemic injury (arterial or venous injury).

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Severe, unrelenting pain, unrelieved by narcotics and associated with passive stretching of muscle.

b. Paresthesias.

  • Objective data:

a. Edema; tense skin over limb.

b. Paralysis.

c. Decreased or absent peripheral pulses.

d. Poor capillary refill.

e. Limb temperature change (colder).

f. Ankle-arm pressure index (API) decreased; 0.4 indicates ischemia.

g. Urine output—decreased (developing acute tubular necrosis); reddish-brown color.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain related to tissue swelling and ischemia.
  • Risk for injury related to neuromuscular deficits.
  • Impaired physical mobility related to contracture and loss of function.
  • Risk for infection related to tissue necrosis.
  • Altered urinary elimination related to acute tubular necrosis from myoglobin accumulation.
  • Body image disturbance related to limb disfigurement.

E. Nursing care plan/implementation:

  • Goal: recognize early indications of ischemia.

a. Assess neurovascular status frequently (q1h): skin temperature, capillary refill, peripheral pulses, mobility, and sensation.

b. Listen to client complaints; report suspected complications.

c. Report non-relief of pain with narcotics.

d. Recognize unrelenting pain with passive muscle stretching.

  • Goal: prevent complications.

a. Elevate injured extremity initially; if ischemia suspected, keep extremity at heart level to prevent compensatory increase in blood flow.

b. Avoid tight bandages, splints, or casts.

c. Monitor intravenous infusion for signs of infiltration.

d. Prepare client for fasciotomy (incision of skin and fascia to release tight compartment).

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Relief from pain; normal perfusion restored.
  • Neurovascular status within normal limits.
  • Retains function of limb; no contractures or infection.
  • Compartment pressure returns to normal (<20 mm Hg).
  • No systemic complications (e.g., normal cardiac and renal function, acid-base balance within normal limits).
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FURTHER READING/STUDY:

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