NCLEX: Caring for the Client with Disorders of the Musculoskeletal System

Terms you’ll need to understand:
Bone density
Clostridium
Crepitation
Demineralize
Dowager’s hump
Fasciotomy
Isometric exercises
Paresis
Pathological fractures
Purine
Tens unit

Nursing skills you’ll need to master:
Stump wrapping
Caring for a client in traction
Caring for a client with a cast
Measuring and teaching crutch walking
Measuring and teaching the use of canes
Measuring and teaching the use of walkers

Fractures
A fracture is defined as simply a break in the continuity of the bone. Four major categories of bone fractures are classified according to the amount of tissue damage: simple or closed, compound, comminuted, and green stick.
The first category is a simple or closed fracture. The second type is a compound fracture. With a compound fracture, the skin surface is broken.
There is more danger of infection and osteomyelitis with compound fractures.

The third type of fracture is the comminuted, which causes damage to soft tissue nerves and blood vessels. The last major category is the green stick. This category occurs more often in children.
A fifth type of fracture is the pathological fracture. These fractures occur without major injury or trauma. The bones on these clients have been weakened by diseases such as osteoporosis, osteogenesis imperfecta, or metastatic cancer.
The nurse candidate must be aware of the need for early intervention in the care of clients with fractures. Symptoms indicating a fracture include
- Coolness and blanching distal to the break
- Crepitation
- Disalignment
- Shortness of the affected limb
- Swelling

Treating Fractures
Treatment of fractures focuses on measures to limit movement, control pain, decrease edema, prevent complications, and promote healing. The following highlights the care you must know about for taking the exam:
Treatment of a fracture includes
- Splinting the affected area
- Elevating the affected extremity
- Removing any jewelry from the extremity
- Administering medication, such as
- Antibiotics for open fractures that are susceptible to gas-growing clostridium
- Antithrombotics
- Heparin
- Lovenox
- Narcotics and muscle relaxers for pain
- Using traction

Traction
It is important to explore a little more on the traction treatment. Traction utilizes a pulling force to maintain proper alignment of the bone so healing can occur. It can also reduce the fracture and decrease muscle spasms, which decreases pain. The following information outlines the types of traction and your role in the care of traction necessary for effectively taking the exam:
- Manual traction—Maintained by the caregiver’s hand
- Skin traction—Maintained by using straps or wraps applied to the skin

Example of Buck’s traction.


Example of 90-90 traction.


Example of balance suspension with Thomas ring splint and Pearson attachment.


Example of the Crutchfield tong traction.


Here are some points to remember in maintaining traction:
- Weights must hang free.
- Linens should not lie on ropes.
- Ropes should remain within the pulley.
- Assess circulation, pulses, and movement of extremity.
- Maintain proper body alignment.

Casts
Related to traction is the use of casts for fracture healing. Casts are rigid devices used to keep a specific body part immobile. This allows the bone fragments to stay in place and heal. The following accentuates what you need to know about the management of the client with a cast:
- Allow the cast to dry from the inside out.
- Handle a wet cast with the palms of your hands.
- Place the extremity on a plastic-lined pillow.
- Note any drainage on the cast by circling it and noting the time of observation.
- Petal rough edges of the cast.
- Instruct the client not to scratch or place objects beneath the cast, such as hangers or toys.
- Assess circulation, pulses, and movement of extremity.

Compartment Syndrome
A complication that can occur after a fracture is compartment syndrome. This is a serious condition resulting from pressure within different compartments (these separate the blood vessels, muscles, and nerves) that cause decreased circulation to the area—usually the leg and forearm. This disorder can lead to irreversible motor weakness, infection, and amputation of the limb.
A major element in compartment syndrome is prevention. The nurse candidate must be able to recognize the clinical manifestations of compartment syndrome, which include the following:
- Cyanosis
- Numbness
- Pain (especially pain that is unrelieved by medication)
- Pallor
- Paresis/paralysis
- Swelling
 

- Tingling: An easy way to remember the symptoms that should put you on alert for compartment syndrome is to remember the four Ps:
- Pain
- Pallor
- Pulselessness
- Paresthesia

Treating Compartment Syndrome
Treatment of compartment syndrome requires a means to relieve the pressure. Two types of treatments can be used to accomplish this goal: bivalve treatment and fasciotomy. Bivalve treatment means cutting the cast on each side and is done if the cast is too tight, causing pressure and restricting blood flow. If symptoms persist, the client might require the second type of treatment—a surgical procedure called a fasciotomy. This is done by the surgeon making an incision through the skin and subcutaneous tissue into the fascia to relieve the pressure and improve circulation.

Osteomyelitis
Another complication that can occur with fractures is osteomyelitis.
Osteomyelitis occurs when an infection has invaded the bone area. Clients at risk for osteomyelitis include the malnourished, the elderly, the overweight, and people who have a chronic illness (such as cardiovascular disease). The symptoms that can occur with osteomyelitis are
- Fever
- Malaise
- Swelling in the infected area
- Tenderness in the infected area
- Purulent drainage in the infected area
- Pain in the infected area

Treating Osteomyelitis
The treatment of osteomyelitis can involve several modalities. One course of treatment includes medications, which can include the use of antibiotics (the specific antibiotics used depend on the wound and blood culture results) and pain medication. Surgical debridement of the wound might also speed the elimination of infection in the bone. The following contains nursing interventions you need to know for the exam:
- Immobilize the body part.
- Administer pain medication.
- Perform neurovascular assessment.
- Perform sterile dressing changes.
- Teach the client how to use IV access devices for at-home antibiotic administration.
- Provide a diet high in protein and vitamin C.

Osteoporosis
Osteoporosis is a disease whereby bone demineralizes, resulting in bone density reduction. The wrist, hip, and vertebral column are most often affected.
The density of bones decreases rapidly in postmenopausal women due to decreases in estrogen. It has been determined that almost one-half of women over age 65 have osteoporosis. The following highlights the risk factors associated with osteoporosis:
- Age (there’s a greater incidence over age 60)
- Low body weight
- Race (it occurs more in Asian and Caucasian women)
- Sedentary lifestyle
- Low dietary calcium intake
- Smoking
- Alcohol consumption
- Decreased estrogen levels

Clinical manifestations of osteoporosis include
- Back pain
- Constipation
- Decrease in height
- Dowager’s hump
- Fractures

Treatment of Osteoporosis
Treatment of osteoporosis involves direct involvement of the client.
Exercises to increase the muscles are recommended, including walking, swimming, and water aerobics. The client should also be taught to eat foods high in calcium, vitamin D, fiber, and protein. Foods high in calcium include molasses, apricots, breads, cereal, milk, dairy products (especially yogurt), beans, carrots, asparagus, and collard greens. They should also be taught to avoid alcohol and caffeine.
Excess caffeine can cause calcium to be excreted in the urine.

Another important aspect to teach clients with osteoporosis involves safety measures—for example, avoiding the use of throw rugs and teaching the clients to avoid falls.
Medications have been developed that are efficient in combating and preventing the disease, and some general medications are given for pain relief:
- Biphosphonates (examples are Fosamax and Didronel)
- Calcitonin
- Calcium supplements
- Estrogen for post-menopausal women
- Muscle relaxers
- NSAIDs
- Selective estrogen receptor modules, or SERMs (for example, Evista)

Gout
Gout is the formation of uric acid deposits in the joints, particularly the joint of the big toe. It is an arthritic condition resulting from the body’s inability to metabolize purine foods. The buildup of uric acid, the end product of purines, causes inflammation in the joints involved. Symptoms of gout include painful joints and tophi (growths of urate crystals) that occur most often on the outer ear of the client with gout.

Treatment of the Client with Gout
The treatment regimen used for clients with gout follows two distinct paths: diet and drugs. Diet is the path directed toward decreasing purine in the diet.
The following indicates foods that are low in purine and that should be increased in the diet:
- Cheese
- Eggs
- Fats
- Gelatin
- Milk
- Most vegetables
- Nuts
- Sugar

The client should avoid high-purine foods such as these:
- Dried beans
- Fish
- Liver
- Lobster
- Oatmeal
- Oysters
- Peas
- Poultry
- Spinach

The second path of treatment for clients with gout is drugs, which are the primary element in the care of this client. Colchicine is prescribed for the acute episode of gout. Allopurinol (Zyloprim) is used in chronic gout to both reduce the production of uric acid and promote the excretion of it.

Rheumatoid Arthritis
Rheumatoid arthritis is a connective tissue disorder believed to be due to a C reactive protein immune response. It is destructive to the joints and can cause deformities. The usual onset of the disease is between 35 and 45 years of age, and it affects women three times more often than men. The person with RA exhibits many symptoms. The following highlights the most common symptoms you need to be familiar with for the exam:
- Subcutaneous nodules (usually on the ulnar surface of the arm)
- Warmth, tenderness, and swelling in the affected joints

Diagnosis is made by the history of the clinical course of the disease, as well as elevations in the following laboratory tests:
- Protein
- Rheumatoid factor
- Sedimentation rate

Treatment of Rheumatoid Arthritis
The treatment plan for RA involves the use of a combination of drugs, exercise, and pain relief measures such as heat and ice. If the interventions are not effective in providing mobility and pain relief, surgery might be required to replace the joint. The following highlights medications, comfort measures, and joint mobility interventions you need to know when testing on the topic of rheumatoid arthritis:
- Medications, including
- Antiarthritics (for example, etanercept [Enbrel] and Infliximab [Remicade])
- Antibiotic therapy (for example, Minocycline)
- Cytotoxic agents (for example, Methotrexate)
- Disease modifying antirheumatic medications, or DMARDs (for example, hydroxycholorquine [Plaquenil])
- Gold salts
- NSAIDs
- Salycilates
- Steroids
- Application of heat and ice to the affected joints
- A regular exercise program to maintain joint mobility. Isometric exercis- es of the gluteal, quadriceps, and abdominal muscles while sitting helps to maintain muscle strength and trunk stability

Musculoskeletal Surgical Procedures
A client who has a dysfunction of the musculoskeletal system might have to undergo a surgical procedure. Surgery might be performed to relieve pain, provide stability, and improve function of the joint. The discussion that follows focuses on the care necessary for clients who have had a break in a hip, have had a joint disability or damage, or require an amputation because of disease or trauma.

Fractured Hip and Hip Replacement
Fracture of the hip is most common in white, elderly females. A fractured hip can contribute to death in the elderly due to it predisposing them to infection and respiratory complications. The most definitive symptoms associated with a fractured hip are disalignment and shortening of the affected leg.
The client also cannot move the leg without pain and complains of pain in the hip and groin on the affected side. Diagnosis is made by a hip x-ray that confirms the break.

Treatment of a Fractured Hip
The treatment option for a hip fracture is to repair it by the use of internal fixation devices or prosthetic joint placement. The preoperative care of a hip fracture includes the use of Buck’s traction to immobilize the hip, resulting in a reduction of muscle spasms and pain. Medications are also administered to relieve pain, relax the muscle, and prevent complications.
After the surgery, the nurse candidate needs to become familiar with assessments and specific nursing measures. The following highlights the care required after hip surgery:
- Assess for bleeding and shock.
- Ambulate early, with no weight bearing on the affected leg.
- Have the client sit in a recliner and not in straight chairs. The affected leg should be bent no more than 45°.
- When in bed, the client should be turned to the unaffected side.
- Monitor output from any existing drains.
- Collaborate with physical therapy on mobility treatments and exercises.

Total Knee Replacement
Total knee replacements are performed for clients who have severe joint pain that makes them immobile. It is also considered when people have arthritic destruction of the articular cartilages or deformity of the knee, and in clients who are not able to walk or have limited motion due to knee instability. The goal of the surgery is twofold:
- Restore full flexion and extension.
- Provide adequate strength and stability of the knee for most functional activities.
Post-operative efforts for the client after total knee replacement are directed toward preventing complications and restoring mobility. The candidate should consider the nursing care requirements for this client when studying for the exam. Along with the usual medication administration (pain medication, antithrombotics, and antibiotics), these clients need specific limb care and physical therapy. The following includes the specific care of the postoperative knee replacement, use of the CPM machine, and physical therapy regimen that are important to know for the exam:
- Keep the knee in extension to prevent contractures.
- Maintain the patella in alignment with the toes.
- Use two persons for transfer until the client regains muscle strength.
- Support the affected leg during a transfer.
- Follow a set protocol for movement, ambulation, and weight bearing.

Clients are usually placed on a device called a continuous passive motion (CPM) machine in the recovery room. This device is applied early to increase circulation and range of motion of the knee joint. Flexion of the knee is an important aspect of care because, if it is not achieved, another surgery might be required. You need to know the usual guidelines for the use of the machine. The major information for use of the machine follows:
CPM control machines are usually placed at the foot of the bed, beyond the reach of the client.
- On day 1, the client should be on the CPM with a setting of 0°–45°.
- The CPM machine should be on for 2 hours and off for 1 hour.

Following 2 hours on the CPM machine, the leg should remain in extension for 1 hour; then resume use of the CPM machine.

Physical Therapy for Total Knee Replacement
Physical therapy is invaluable in supervising the exercises for strength and range of motion. The nurse needs to be aware of the usual regimen followed.
The client exercise program to be followed after a total knee replacement is
- Begins therapy with prescribed exercises on the second day post-op.
- Ankle pumps are used to promote circulation and decrease edema.
- Quad sets, glut sets, straight leg raises are performed to improve neuro- muscular control.
Clients with total knee replacements are usually discharged within 3–4 days with a plan for continued exercises. An initial appointment is needed with the physical therapy department within 48–72 hours of discharge.

Amputations
Amputations occur when a part of the body is removed, usually an extremity. Causes of amputations include trauma, infection and possible sepsis, peripheral vascular disease, and accidents. Amputations are done to relieve pain or improve the quality of life. They can also be required to save the patient’s life.

Interventions Post Amputation Surgery
The candidate needs to be aware of the nursing care required for amputation clients. Specific problems that might occur with the client after an amputation include pain, hemorrhage, and infection. You need to be aware of the therapeutic measures to use with phantom limb pain that commonly occurs in amputation. Some ways to deal with phantom limb pain is to treat it as any other pain. If the pain is real, it is nontherapeutic to remind the client of the missing limb. A TENS unit might be used to relieve the pain.
Other nursing measures you need to focus attention on are assessments.

Hemorrhage and infection are possible complications, so you would monitor for these. It is also important that mobility be restored; this can be fostered by collaboration with physical therapy and encouraging the use of a prosthetic limb. Additional nursing measures that focus on exercise and prevention of complications are
- Exercises (a trapeze bar is used to move in bed).
- A firm mattress is needed to make movement easier.

Prevent contractures by using the following nursing interventions:
- Placing the client in a prone position every 3–4 hours
- Using a sandbag to the knee
- Ensuring that the residual limb stays flat on the bed
The residual limb might be elevated for the first 24 hours after surgery to reduce swelling and pain.

The nurse candidate must also be aware of the psychological aspects of the loss of a limb. A disturbance in body image occurs with an amputation. The client might therefore go through the grief process.

Assistive Devices for Ambulation
Clients with musculoskeletal disorders often need devices to assist them with mobility. The following discusses how to measure and fit for three of these devices: crutches, canes, and walkers. This information will assist you in answering questions on the exam that refer to these topics.

Crutches
Crutches are prescribed for clients who need partial weight bearing or nonweight bearing assistance. A person who is to use crutches needs to have good balance, good upper body strength, and an adequate cardiovascular system. The procedure used to fit the client for crutches follows: With the crutch tip extended 6 inches diagonally in front of the foot, 2–3 finger widths should be allowed between the axilla and the top of the crutch to prevent nerve damage.
Five types of crutch-walking gaits exist, with the use depending on the amount of weight bearing allowed:
- Two-point gait—This permits limited weight bearing bilaterally. The right leg and left crutch move simultaneously; the left leg and right crutch move simultaneously.
- Three-point gait—Non-weight bearing or partial weight bearing is allowed on the affected leg. Both crutches and the affected leg move in unison. Body weight is supported on the unaffected leg.
- Four-point gait—This permits weight bearing on both legs. The crutches and feet move alternately. The left crutch and right foot move, and then the right crutch and left foot.
- Swing through—No weight bearing is permitted on the affected legs.

Both crutches move forward and both legs swing through between the crutches. The weight is borne by the crutches.
- Stairs—This is for climbing stairs. The client leads with the unaffected leg, and the crutches and affected leg move together. For descending stairs, the client leads with the crutches and affected leg.
Go up the stairs with the good leg first, and go down the stairs with the bad leg first.

Canes
Canes are the least stable of ambulation devices and should not be used for weight bearing or partial weight bearing activities. The cane does give a client greater balance and support and is recommended when this is needed.
There are basically three types of canes: the four-foot adjustable (quad or hemi), the adjustable, and the offset adjustable. Here’s how you adjust the cane for proper fit:
- To determine the proper length of the cane, the client should be stand- ing or lying supine.
- The client’s arm should lie straight along the side with the cane hand- grip level with the greater trochanter.
- The cane should be placed parallel to the femur and tibia with the tip of the cane on the floor or at the bottom of the shoe heel.

Walkers
Indications for walker use include the need for balance, stability, and decreased weight bearing. Walkers provide anterior and lateral stability with a wide base of support. Proper walker adjustment allows for 20°–30° elbow flexion. The three types of walkers are the standard, the folding, and the rolling walker. The following highlights the instructions that the exam taker should be aware of for the use of a walker.
The instructions for using walkers for partial or non-weight bearing are as follows:

1. Advance the walker an arm’s length.

2. Place all four legs on the floor.

3. Advance the affected leg.

4. Push the body weight through the arms.

5. Advance the unaffected leg.

The instructions for using walkers for balance and stability are as follows:

1. Advance the walker an arm’s length.

2. Set all four legs on the floor.

3. Take two complete steps into the walker.
For safety reasons, a gait belt is necessary when initiating cane and walker use.

Diagnostic Tests for Review
The diagnostic exams that are used for the musculoskeletal system are associated with the body part involved. Fractures are easily diagnosed by an x-ray of the area. As with all diseases or disorders, the usual exams are the CBC, urinalysis, and chest x-ray. Direct visualization is obtained by the use of scopic devices—for example, arthroscopes are typically used with knees. For clients with bone weaknesses, density testing is done to measure the degree of the problem. While reviewing the diagnostic exams that follow, you should be alert for the abnormalities that correlate with specific musculoskeletal diseases, such as the elevation levels of rheumatoid factor in rheumatoid arthritis:
- Arthrography
- Arthroscopy
- Bone biopsy
- Bone density testing
- Bone scan
- CT scan
- Electromyography
- Laboratory tests, including rheumatoid factor, antinuclear antibody titer, and erythrocyte sedimentation rate (ESR)
- MRI
- Muscle biopsy

Pharmacology for Review
Medications are invaluable as a method of treatment for musculoskeletal disorders. These medications are important in preventing some of the common complications that can occur with immobility. Commonly used medications include antithrombotics and antimicrobials. The uric acid inhibitors function well in curing the disease of gouty arthritis, and the newer DMARD classification has helped with osteoporosis. You need to focus on the drug classifications in this list and think about which drug would be used in which musculoskeletal disease:
- Analgesics
- Antiarthritics
- Anticoagulants
- Antimicrobial agents
- Antithrombotics
- Biphosphonates
- Cytotoxics
- DMARDs
- Muscle relaxants
- NSAIDs
- Salycilates
- SERMs
- Steroids
- Uric acid inhibitors
- Vitamins