Baloloy Rogelyn C.
Module No.6 Musculoskeletal Care Modalities
Learning Objectives
After successful completion of the module, the learner should be able to:
1. Differentiate the different musculoskeletal care modalities
2. Explain the purpose of the modalities
3. Identify the different types of cast
4. Utilize the nursing process in the care of client with musculoskeletal
care modalities
ENGAGEMENT
1. What comes to mind when you see a person with cast, traction or
external fixators?
EXPLORATION
I. Musculoskkeletal Care Modalities
A. Cast - A rigid, external immobilizing device
1. Uses
a. Immobilize a reduced fracture
b. Correct a deformity
c. Apply uniform pressure to soft tissues
d. Support and stabilize weakened joints
2. Materials:
a. Non-plaster (fiberglass)
b. Plaster of Paris
3. Types of cast
a. Short arm cast
b. Long arm cast
c. Short leg cast
d. Long leg cast
e. Walking cast ( long or short) reinforced for strength
f. Body cast: encircle the trunk
g. Shoulder spica cast: a body jacket that enclosed the trunk
and the shoulder and elbow
h. Hip spica cast: enclose the trunk and lower extremity
( double hip spica cast ( includes both legs)
4. Nursing intervention
a. Prior to cast application–Explanation of condition
necessitating the cast
Purpose and goals of the cast
Expectations during the casting process-for example
heat from hardening plaster
b. Cast care
keep dry, do not cover with plastic
Positioning: elevation of extremity, use of slings
Hygiene
Activity and mobility
Exercises
Do not scratch or stick anything under cast
Cushion rough edges
Signs and symptoms to report: persistent pain or
swelling, changes in sensation, movement, skin color
or temperature, signs of infection or pressure areas
Required follow-up care
Cast removal
B. Splint and Braces
1. Contoured splints of plaster or pliable thermoplastic materials
may be used for conditions that do not require rigid
immobilization, for those in which swelling may be
anticipated, and for those that require special skin care
2. Braces (i.e., orthoses) are used to provide support, control
movement, and prevent additional injury.
a. They are custom fitted to various parts of the body.
C. Nursing process: The care of client with brace, splint or
cast(Assessment)
1. Prior to application
a. General health assessment
b. Emotional status
c. Presenting signs and symptoms and condition of the area
2. Knowledge
3. Monitoring of neurovascular status and for potential
complications
D. Common nursing diagnoses
1. Deficient knowledge
2. Acute pain
3. Impaired physical mobility
4. Self-care deficit
5. Impaired skin integrity
6. Risk for peripheral neurovascular dysfunction
E. Planning
1. Major goals include knowledge of the treatment regimen,
relief of pain, improved physical mobility, achievement of
maximum level of self-care, healing of any trauma-associated
lacerations and abrasions, maintenance of adequate
neurovascular function, and absence of complications.
F. Nursing Interventions
1. Relieving pain
a. Elevation to reduce edema
b. Intermittent application of ice or cold
c. Positioning changes–Administration of analgesics
NURSING ALERT! Unrelieved pain may indicate compartment syndrome;
discomfort due to pressure may require change of cast
2. Healing skin wounds and maintaining skin integrity
a. Treat wounds to skin before the brace, splint, or cast is
applied
b. Observe for signs and symptoms of pressure or infection
Note: Patient may require tetanus booster
Maintaining adequate neurovascular status
Assess circulation, sensation, and
movement
Five “P’s”
Notify physician of signs of compromise at
once
Elevate extremity no higher than the heart
Encourage movement of fingers or toes
every hour
II. External Fixation Devices
A. purposes
1. Used to manage open fractures with soft tissue damage
2. Provide support for complicated or comminuted fractures
3. Patient requires reassurance due to appearance of device
4. Discomfort is usually minimal and early mobility may be
anticipated with these devices.
5. Elevate to reduce edema
6. Monitor for signs and symptoms of complications including
infection
7. Pin care
8. Patient teaching
III. Traction
A. The application of pulling force to a part of the body
1. Purposes
a. Reduce muscle spasms
b. Reduce, align, and immobilize fractures
c. Reduce deformity
d. Increase space between opposing forces
2. Used as a short-term intervention until other modalities are
possible
3. Principles of effective traction
a. Whenever traction of applied a counterforce must be
applied. Frequently the patient’s body weight and
positioning in bed supply the counterforce
b. Traction must be continuous to reduce and immobilize
fractures
c. Skeletal traction is never interrupted
d. Weights are not removed unless intermittent traction is
prescribed
e. Any factor that reduces pull must be eliminated
f. Ropes must be unobstructed and weights must hang freely
g. Knots or the footplate must not touch the foot of the bed
4. Types of traction
a. Skin traction
Buck’s extension traction
Cervical head halter
Pelvic traction
Skin traction is used to control muscle spasm
and to immobilize an area before surgery
No more than 2-3.5 kg of traction should be
used, pelvic traction 4.5 to 9 kg depending on
the patient weight
Complications
Skin breakdown, nerve pressure (drop
foot), and circulatory impairment ( DVT)
Nursing interventions
Ensuring effective traction
Monitor and managing potential
complications
b. Skeletal traction
Applied directly to the bone by using metal pin or
wires. Most frequently used to treat fracture of long
bones and the cervical spine
Is a surgical procedure
Skeletal traction uses 7-12 kg, as the muscle relax
the traction weight is reduced to prevent fracture
dislocation and to promote healing
After removing the traction cast or splint are then
used to support the healing bone.
5. Preventive nursing care needs of the patient with traction
a. Proper application and maintenance of traction
b. Monitor for complications of skin breakdown, nerve
pressure, and circulatory impairment
Inspect skin at least three times a day
Palpate traction tapes to assess for tenderness
Assess sensation and movement
Assess pulses color capillary refill, and temperature
of fingers or toes
Assess for indicators of DVT
Assess for indicators of infection
c. Promptly report any alteration in sensation or circulation
d. Frequent back care and skin care
e. Regular shifting of position
f. Special mattresses or other pressure reduction devices
g. Perform active foot exercises and leg exercises every hour
h. Elastic hose, pneumatic compression hose, or
anticoagulant therapy may be prescribed
i. Trapeze to help with movement for patients in skeletal
traction
j. Pin care
k. Exercises to maintain muscle tone and strength
6. Nursing Process: Care of client with traction
a. Assessment
Assessment of neurovascular status and for
complications
Assessment for mobility-related complications of
pneumonia, atelectasis, constipation, nutritional
problems, urinary stasis, or UTI
Pain and discomfort
Emotional and behavioral responses
Coping
Thought processes
Knowledge
b. Nursing diagnoses
Deficient knowledge
Anxiety
Acute pain
Self-care deficit
Impaired physical mobility
c. Planning
Major goals include understanding of the treatment
regimen, reduced anxiety, maximum comfort,
maximum level of self-care within the therapeutic
limits of the traction, and absence of complications.
d. Interventions
Interventions to prevent skin breakdown, nerve
pressure, and circulatory impairment
Measures to reduce anxiety
Providing and reinforcing information
Encourage patient participation in decision-
making and in care
Frequent visits (family and of caregivers/nurse)
to reduce isolation
Diversional activities
Use of assistive devices
Consultation with/referral for physical therapy
Prevention of atelectasis and pneumonia
Auscultate lungs every 4–8 hours
Coughing and deep breathing exercises
High-fiber diet
Encourage fluids
Identify and include food preferences, encourage
proper diet
IV. Joint replacement
A. Purpose
1. Used to treat severe joint pain and disability and for repair
and management of joint fractures or joint necrosis
2. Frequently replaced joints include the hip, knee, and fingers
3. Joints including the shoulder, elbow, wrist, and ankle may also
be replaced.
B. Needs of patient with joint replacement
1. Mobility and ambulation
a. Patients usually begin ambulation within a day after
surgery using walker or crutches
b. Weight-bearing as prescribed by the physician
2. Drain use postoperatively
a. Assess for bleeding and fluid accumulation
3. Prevention of infection
a. Infection may occur in the immediate postoperative period
(within 3 months), as a delayed infection (4–24 months), or
due to spread from another site (more than 2 years)
4. Prevention of DVT
5. Patient teaching and rehabilitation
C. Hip Prosthesis
1. Positioning of the leg in abduction to prevent dislocation of
the prostheses
2. Do not flex hip more than 90°
3. Avoid internal rotation
4. Protective positioning include maintaining abduction, avoiding
internal and external rotation, hyperextension, and a cute
flexion
5. Use of abduction pillow
EXECUTION
A 19 year old engineering student was seen at the Emergency Department
with right hand pain following an accident while “sea-biscuiting” (in which a
person holds onto an inflatable ring which is towed behind a motor boat).
Spiral fractures of his 2nd, 3rd and 4th metacarpal bones were identified on
x-ray and the patient was placed in a plaster cast and referred for hand
therapy.
Task 1. Formulate a nursing care based from the situation
Task 2. Make at least 4 NCP
EVALUATION
1. A client has bilateral knee pain from osteoarthritis. In addition to taking
the prescribed NSAID, the nurse should instruct the client to
a. Rest the knees as much as possible to decrease inflammation
b. Start a regular exercise program
c. Keep legs elevated when sitting
d. Avoid foods high in citrus acid
2. During the first 24 hours after an above-the-knee amputation for
vascular disease, nursing priority for stump care would be:
a. Initiating fitting for prosthesis
b. Elevating to reduce edema.
c. Inspecting for redness and pressure points.
d. Cleansing with soap and water.
3. The client is being evaluated for osteoporosis. Which diagnostic test is
the most accurate when diagnosing osteoporosis?
a. Serum alkaline phosphatase.
b. Serum bone Gla-protein test.
c. Dual-energy x-ray absorptiometry (DEXA).
d. X-ray of the femur.
4. A complication of Buck’s extension traction would be noted by a nurse
if:
a. Redness and purulent drainage appeared at the pin site.
b. Skin over the fracture site was flushed.
c. Toes of affected leg became dusky in color.
d. Dorsiflexion developed in the affected foot.
5. The nurse is teaching a client with metastatic bone disease about
measures to prevent hypercalcemia. It would be important for the
nurse to emphasize?
a. Early recognition of tetany
b. The importance of walking
c. The need to have at least 5 servings of dairy products daily
d. The need to restrict fluid intake to less than one liter per day
6. A client fractured his femur yesterday. Monitoring for which potential
complication must be included by the nurse in the client’s plan of care?
a. Fat emboli syndrome
b. Crush injury
c. Disturbed body image
d. Chronic pain
7. The nurse, assisting in applying a cast to a client with a broken arm,
knows that?
a. The wet cast should be handled with the palms of hands
b. The cast material should be dipped several times into the warm
water
c. The casted extremity should be placed on a cloth-covered surface
d. The cast should be covered until it dries
8. The nurse prepares a client for a bone scan. What priority assessment
should the nurse perform for this client?
a. History of claustrophobia
b. Presence of intravenous (IV) access
c. Current vital signs
d. Presence of metallic implants such as a pacemaker or aneurysm
clips
9. Upon a client’s admission for extracapsular fracture of the left femur,
how should a nurse expect the extremity to appear?
a. Internally rotated.
b. To have footdrop.
c. Shorter than the other leg.
d. Blanched over the fracture site.
10. The nurse assesses which of the following clinical manifestations
in a client with osteomyelitis? Select all that apply:
a. Restlessness
b. Fever
c. Petechial
d. Night sweats
e. Cool extremities
f. Nausea
