7.4 Musculoskeletal, Neurological & Integumentary Care and Wound Healing

Musculoskeletal, Neurological & Integumentary Care and Wound Healing

Clinical Core: Trauma, vascular compromise, and neurological deterioration demand rapid clinical assessment and decisive action. Nurses must safeguard tissue perfusion in acute compartment syndrome, maintain spinal and orthopedic stability, execute hyper-acute stroke interventions, preserve cerebral perfusion under rising intracranial pressure, and maintain skin integrity through stage-specific wound management.

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Musculoskeletal Care: Fractures, Compartment Syndrome & Traction

Fracture Classification and Cast Care

Fractures are categorized as closed (simple), where skin remains intact, or open (compound), where bone fragments breach the dermal barrier. Open fractures carry a high risk of osteomyelitis, requiring immediate coverage with sterile saline-soaked dressings, IV broad-spectrum antibiotics, tetanus toxoid prophylaxis, and emergent surgical debridement.

• Cast Care Principles:
  • Plaster of Paris: Takes 24 to 72 hours to dry completely. During drying, handle the cast exclusively with the flat palms of the hands rather than fingertips to avoid creating localized indentations that cause underlying dermal necrosis.
  • Fiberglass: Lightweight, water-resistant, and achieves full structural rigidity within 20 to 30 minutes.
  • Bedside Elevation: Elevate the casted extremity on pillows above the level of the heart for the first 24 to 48 hours to minimize dependent edema and enhance venous return.
  • Client Education: Instruct clients to perform frequent neurovascular checks (capillary refill, color, warmth, movement, sensation); report focal "hot spots" or foul odors beneath the cast (indicating infection/ulceration); and NEVER insert objects (coat hangers, rulers, knitting needles) inside the cast to scratch itching skin (risk of skin puncture and infection). Itching is alleviated by blowing cool air down the cast with a hair dryer.

Acute Compartment Syndrome: The 6 Ps and Surgical Decompression

Acute compartment syndrome is an orthopedic emergency resulting from elevated interstitial pressure within a closed, non-elastic myofascial compartment, compromising microvascular capillary perfusion and causing tissue ischemia, nerve injury, and muscle necrosis.

• Etiology: External compression (constrictive casts, tight dressings, pneumatic anti-shock garments) or internal expansion (bleeding, crush injury, severe fractures [tibial shaft and forearm], major soft-tissue trauma).
• The Classic 6 Ps of Neurovascular Assessment:
  1. Pain: Severe, persistent, deep aching pain that is out of proportion to the apparent injury, refractory to escalating opioid analgesics, and markedly aggravated by passive stretching of the muscles within the affected compartment. This is the earliest, most sensitive, and most reliable clinical indicator.
  2. Pressure: Palpable tenseness, firmness, and wood-like tightness of the swollen muscle compartment.
  3. Paresthesia: Numbness, tingling, burning, or loss of sensation along the sensory distribution of the traversing peripheral nerve. Indicates early nerve ischemia.
  4. Pallor: Pale, mottled, or cyanotic skin with sluggish capillary refill ($>3\text{ seconds}$) and cool extremity temperature.
  5. Paralysis: Inability to actively move digits or contract compartment muscles. A late sign of extensive neuromuscular death.
  6. Pulselessness: Diminished or completely absent distal arterial pulses. A very late, ominous sign indicating complete arterial collapse and irreversible gangrene.
• Immediate Emergency Nursing Interventions:
  • DO NOT elevate the extremity above the level of the heart. Elevating the limb decreases mean arterial perfusion pressure into the already compromised compartment, worsening ischemic tissue necrosis. Maintain the extremity at neutral heart level.
  • DO NOT apply ice or cold therapy. Hypothermia induces peripheral vasoconstriction, further reducing microvascular blood flow.
  • Immediately bivalve the cast or cut constrictive circumferential bandages down to the skin to relieve external compression.
  • Notify the orthopedic surgeon immediately.
  • Prepare the client for emergent surgical fasciotomy; surgical release of the inelastic fascia within 4 to 6 hours of onset is imperative to restore perfusion and prevent permanent Volkmann's ischemic contracture, rhabdomyolysis, and limb loss.

Traction Principles: Skin Versus Skeletal Traction

Traction applies a continuous pulling force to realign fractured bone fragments, immobilize the extremity, and relieve painful muscle spasms:

• Skin Traction (e.g., Buck's Extension): Non-invasive traction applied via foam boots, straps, or tape to the skin, utilizing lightweight pulling forces (5 to 8 lbs [2.3 to 3.6 kg]). Frequently applied as a temporary measure for fractured hips or femoral necks prior to surgical fixation. The nurse inspects skin under straps every 8 hours for pressure breakdown.
• Skeletal Traction: Invasive traction applied directly to the skeleton using surgically inserted pins, wires (Kirschner wire, Steinmann pin), or tongs, utilizing heavier loads (15 to 30 lbs [6.8 to 13.6 kg]) for complex femoral, tibial, or cervical spine fractures.
• Core Traction Rules:
  • Weights must hang freely suspended off the floor at all times. Weights must never rest on the floor, bed frame, or chairs.
  • Ropes must remain centered and unobstructed within the pulley grooves; knots must not contact pulleys.
  • Lines of pull must remain parallel to the long axis of the fractured bone; maintain correct countertraction by keeping the foot of the bed flat or elevated as ordered.
  • NEVER remove or lift traction weights without a direct prescriber order, except in life-threatening resuscitation events.
  • Pin Site Care: Clean pin sites daily using sterile 0.9% normal saline or chlorhexidine swabs. Use a separate sterile swab for each pin site to prevent cross-contamination. Monitor for erythema, purulent drainage, pin loosening, or focal bone tenderness (osteomyelitis).

Total Hip Arthroplasty (THA) Precautions: Posterior Approach

Following a total hip replacement with a posterior surgical approach, the prosthetic femoral head is prone to posterior dislocation from the acetabular cup. Nurses must enforce three non-negotiable hip precautions for 6 to 12 weeks postoperatively:

1. Do NOT flex the hip beyond 90 degrees: Prohibit bending forward at the waist past 90 degrees; use elevated toilet seats, long-handled shoehorns, and reacher devices; do not sit in low, soft armchairs.
2. Do NOT adduct the affected leg past midline: Prohibit crossing the legs at the knees or ankles. Maintain an abduction pillow (wedge) securely fastened between the client's legs while in bed and during repositioning.
3. Do NOT internally rotate the affected hip: Keep the toes and knee pointed straight forward or slightly externally rotated. When turning the client, turn exclusively toward the unaffected side, keeping the abduction wedge firmly in place between the thighs.

• Signs of Prosthetic Dislocation: Sudden, severe pain in the hip, an audible "pop", shortening of the affected leg, and abnormal internal or external rotation of the extremity. If observed, keep the client flat in bed and notify the orthopedic surgeon immediately.

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Neurological Nursing Care: Stroke, Seizures & Increased ICP

Acute Cerebrovascular Accident (Stroke) and rtPA Administration

Strokes are divided into ischemic (85%; thrombotic or embolic occlusion) and hemorrhagic (15%; intracerebral hemorrhage or ruptured saccular aneurysm, presenting with a catastrophic "worst headache of life").

• Acute Assessment & Rapid Triage:
  • Apply the FAST assessment: Face drooping, Arm weakness, Speech difficulty, Time to initiate emergency response.
  • An emergent non-contrast head CT scan should start within 20 minutes of hospital arrival, and be read within 45 minutes, to exclude intracranial haemorrhage before thrombolysis is considered.
• Intravenous Recombinant Tissue Plasminogen Activator (rtPA / Alteplase): Administered to dissolve intravascular thrombi and restore cerebral penumbral perfusion in acute ischemic stroke.
  • Therapeutic Window: Must be administered within 3 to 4.5 hours of the client's last known normal (LKN) symptom-free baseline.
  • Major Absolute Contraindications: Active internal hemorrhage; evidence of intracranial hemorrhage on CT; intracranial or intraspinal surgery or serious head trauma within the past 3 months; persistent, uncontrolled hypertension (systolic BP $>185\text{ mmHg}$ or diastolic BP $>110\text{ mmHg}$ refractory to IV labetalol or nicardipine); platelet count $<100,000/\mu\text{L}$; current use of anticoagulants with an elevated INR $>1.7$.
  • Post-Stroke Nursing Care: The client must remain strictly NPO until a formal bedside dysphagia screening is successfully completed by a speech-language pathologist or trained nurse to prevent fatal aspiration pneumonia. Position upright at 90 degrees for meals; use chin-tuck posture for swallowing. For unilateral spatial neglect (common in right-hemisphere strokes), approach the client initially from the unaffected side, but teach conscious visual scanning toward the affected, neglected field.

Seizure Precautions, Active Management & Status Epilepticus

• Seizure Precautions at Bedside: Ensure full padding on all four bed side rails; maintain functional oral suction apparatus and supplemental oxygen delivery systems at the head of the bed; set the bed in its lowest position; ensure emergency IV access.
• Nursing Actions During an Active Generalized Tonic-Clonic Seizure:
  1. Maintain airway patency; position the client onto their side (lateral recovery position) to facilitate oral drainage and prevent aspiration.
  2. Protect the client's head from trauma using a pillow or soft folded blanket.
  3. Loosen constrictive clothing around the neck.
  4. DO NOT restrain the client's limbs.
  5. NEVER force any object, bite block, or oral airway into the client's mouth (risks dental fracture, jaw trauma, and airway occlusion).
  6. Observe and document the precise onset, sequence of motor movements, pupillary changes, incontinence, and exact duration of the ictal and post-ictal phases.
• Status Epilepticus: Continuous seizure activity lasting $>5\text{ minutes}$, or two or more distinct seizures without full recovery of consciousness between episodes. A life-threatening medical emergency causing severe hypoxia, hyperpyrexia, and neuronal death.
  • Emergency Pharmacotherapy: Establish airway and high-flow oxygen; administer first-line rapid-acting IV benzodiazepines (Lorazepam 4 mg IV at 2 mg/min, or Diazepam); immediately follow with second-line long-acting anticonvulsant infusions (IV fosphenytoin, levetiracetam, or valproate) to prevent recurrent seizure discharge.

Traumatic Brain Injury & Increased Intracranial Pressure (ICP)

The skull is a rigid, non-compliant container. Under the Monro-Kellie Hypothesis, the total intracranial volume is constant, composed of brain tissue (80%), blood (10%), and cerebrospinal fluid (CSF, 10%). An expansion in any one compartment requires reciprocal displacement of another, or intracranial pressure rises.

• Normal ICP: $5\text{ to } 15\text{ mmHg}$; sustained pressures $>20\text{ mmHg}$ demand urgent clinical intervention.
• Glasgow Coma Scale (GCS): Evaluates three neurological parameters: Eye Opening (1 to 4), Verbal Response (1 to 5), and Motor Response (1 to 6). Total score ranges from 3 (deep coma/death) to 15 (fully awake, alert, oriented). A score of $\le 8$ indicates severe coma, mandating endotracheal intubation ("GCS 8, intubate").
• Clinical Manifestations of Rising ICP:
  • Earliest, Most Sensitive Indicator: Altered level of consciousness (LOC), manifested as restlessness, irritability, confusion, agitation, lethargy, or subtle personality changes.
  • Early Signs: Constant, dull headache (worse in the morning and aggravated by coughing or straining); nausea and projectile vomiting without preceding nausea; sluggish pupillary light response.
  • Late Sign — Pupillary Changes: A unilateral, sluggish, or fixed, dilated pupil ("blown pupil") indicates impending tentorial uncal herniation compressing cranial nerve III (oculomotor nerve).
  • Late Sign — Cushing's Triad: A classic, life-threatening triad indicating brainstem compression and imminent herniation:
    1. Profound Bradycardia (marked drop in heart rate).
    2. Severe Systolic Hypertension with a Widening Pulse Pressure (e.g., blood pressure rises from 120/80 to 190/60 mmHg).
    3. Irregular, Slow Respirations (e.g., Cheyne-Stokes breathing).
• Nursing Interventions to Control ICP:
  • Elevate the head of the bed 30 degrees; maintain head and neck in a neutral, midline position (prevents jugular vein compression and facilitates cerebral venous drainage).
  • Avoid extreme hip flexion or knee bending (which increases intra-abdominal and intrathoracic pressure, hindering venous return).
  • Maintain $PaCO_2$ strictly between $35\text{ to } 40\text{ mmHg}$; avoid hypercapnia ($CO_2$ is a potent cerebral vasodilator that surges cerebral blood flow and spikes ICP).
  • Avoid clustering nursing activities; space out bathing, turning, and suctioning to prevent cumulative ICP spikes. Limit endotracheal suctioning passes to $<10\text{ seconds}$ with pre-oxygenation.
  • Administer osmotic diuretics: IV Mannitol (20% solution) draws water from the parenchymal brain tissue into the vascular space for renal excretion; monitor serum osmolality and electrolytes. Alternatively, infuse 3% Hypertonic Saline.

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Integumentary Care: Pressure Injury Staging, Prevention & Wound Healing

Pressure Injury Staging (National Pressure Injury Advisory Panel [NPIAP])

Pressure injuries are localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from intense or prolonged pressure in combination with shear.

Evidence-Based Prevention and Risk Assessment

• The Braden Scale: Assesses risk across six physiological subscales: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear. Scores range from 6 to 23; a score $\le 18$ indicates high risk for pressure injury development, requiring immediate preventive interventions.
• Preventive Nursing Protocols: Reposition bedbound clients at least every 2 hours and chair-bound clients every 1 hour; utilize a 30-degree lateral tilted position to avoid direct, focal pressure over the greater trochanters; float heels completely off the mattress using pillows or dedicated heel suspension boots; avoid massaging reddened bony prominences (causes capillary breakdown); apply moisture-barrier creams for urinary/fecal incontinence; and optimize nutrition with high protein ($1.25\text{ to } 1.5\text{ g/kg/day}$) and adequate calories.

Phases of Wound Healing and Clinical Dressing Selection

• Phases of Wound Healing:
  1. Hemostasis (Immediate): Platelet aggregation, vasoconstriction followed by vasodilation, fibrin clot formation.
  2. Inflammatory Phase (Days 1 to 4): Neutrophils and macrophages phagocytose necrotic debris and bacteria; release growth factors; cardinal signs of erythema, heat, edema, and localized pain.
  3. Proliferative Phase (Days 4 to 21): Fibroblast proliferation, collagen deposition, angiogenesis, formation of beefy red granulation tissue, wound contraction, and epithelialization.
  4. Maturation / Remodeling Phase (21 days to 2 years): Collagen cross-linking and reorganization; tensile scar strength increases to approximately 80% of original tissue strength.
• Dressing Selection Guidelines:
  • Hydrocolloids (e.g., DuoDERM): Occlusive or semi-occlusive wafers; absorb light-to-moderate exudate; promote autolytic debridement; maintain moist wound environment; ideal for non-infected Stage 2 and shallow Stage 3 pressure injuries.
  • Hydrogels: Glycerin- or water-based gels; donate moisture to dry, desiccated wound beds; soothe pain; facilitate autolysis of dry slough.
  • Alginates and Hydrofibers: Derived from brown seaweed; highly absorbent (absorbing up to 20 times their dry weight in fluid); interact with exudate to form a soft hydrophilic gel; ideal for moderate to heavily draining wounds and packing deep tunneling cavities.
  • Transparent Films (e.g., Tegaderm): Semipermeable to oxygen and moisture vapor but impermeable to liquid and bacteria; non-absorptive; ideal for protecting intact skin (Stage 1 injuries) and securing intravenous catheters.
  • Foam Dressings: Highly absorbent polyurethane foam; cushions bony prominences; manages moderate-to-heavy drainage while keeping the wound bed moist.