Musculoskeletal System Trauma

1. MUSCULOSKELETAL TRAUMA
JOFRED M. MARTINEZ, RN, MAN
University of San Agustin Review Center
Iloilo City, Philippines

2. Contusions, Strains and Sprains
CONTUSION STRAIN SPRAIN
Pathophysiology bleeding into
soft tissue
stretching injury to a
muscle or a muscle
tendon unit
stretch and/or tear of
one or more ligaments
surrounding a joint
Etiology blunt force mechanical
overloading
forces going in opposite
directions
Manifestations swelling and
discoloration of
the skin
pain, limited motion,
muscle spasms,
swelling, and possible
muscle weakness
loss of function, feeling
of pop or tear,
discoloration, pain, and
rapid swelling

3. Contusions, Strains and Sprains

4. Contusions, Strains and Sprains

5. Contusions, Strains and Sprains

6. Grades of Sprain Severity
Grade Description Manifestation
1
Mild
Overstretching or
minimal tear of ligaments
with no joint instability
 Mild pain, swelling, tenderness
 Little or no bruising
 Minimal or no loss of joint function or ability
to bear weight
2
Moderate
Partial tear of the
ligament
 Moderate pain, bruising, and swelling
 Mild to moderate joint instability, functional
disability
 Weight bearing difficult
3
Severe
Complete tear or rupture
of the ligament
 Severe pain, swelling, and bruising
 Significant functional loss and joint instability
 Inability to bear weight

7. Grades of Sprain Severity

8. Contusions, Strains and Sprains
MANAGEMENT
Emergencycare rest, ice, compression, and elevation for the first 24 to
48 hours
Diagnosis x-ray, magnetic resonance imaging (MRI)
Medications nonsteroidal anti-inflammatory drugs (NSAIDs)
Treatment immobilized with a cast or splint
surgery to repair the torn ligaments, muscle, or tendons
physical therapy for rehabilitation

9. RICE Therapy
Action Interventions
Rest  Decrease regular activities of daily living and exercise as
needed.
 Limit weight bearing on the injured extremity for 48 hours.
 If you use a cane or crutch to avoid weight bearing, use it on
the uninjured side so you can lean away from and relieve
weight on the injured leg.
Ice  To avoid cold injury or frostbite, apply an ice pack to the
injured area for no more than 20 minutes at a time, four to
eight times a day.
 An ice bag, cold pack, plastic bag filled with crushed ice and
wrapped in a towel, or a bag of frozen peas may be used.

10. RICE Therapy
Action Interventions
Compression  Loosen the compression bandage if you experience
numbness, tingling, or swelling distal to the injury, or if the
distal extremity becomes cool or cyanotic (bluish-grey).
Elevation  Keep the injured extremity elevated on a pillow above heart
level to help reduce swelling and pain.

11. Nursing Care for Contusions, Sprains and Strains
Acute Pain
• Teach the patient to use RICE (rest, ice, compression, elevation)
therapy to care for the injury.
Impaired Physical Mobility
• Teach the correct use of crutches, walkers, canes, or slings if
prescribed.
• Encourage follow-up care.

12. Rotator Cuff Injuries, Knee Injuries and Joint Dislocation
ROTATOR CUFF
INJURIES
KNEE
INJURIES
JOINT
DISLOCATION
Pathophysiology tendinitis, bursitis,
and partial and
complete muscle
tears
ligament tears,
meniscal injury,
and patellar
dislocation
bones are displaced
out of their normal position
and joint articulation is lost
Etiology repetitive use injury
or degenerative
changes
sports activities contact sports, disease of
the joint, including
infection, rheumatoid
arthritis, paralysis, and
neuromuscular diseases

13. Rotator Cuff Injuries

14. Knee Injuries

15. Joint Dislocation

16. Joint Trauma
ROTATOR CUFF
INJURIES
KNEE
INJURIES
JOINT
DISLOCATION
Manifestations shoulder pain,
limited ROM
immediate pain, a
tearing or popping
sensation, swelling
pain, deformity, and
limited motion of the
affected joint
Diagnosis history and physical assessment
x-ray and MRI
Treatment RICE
NSAIDs
physical therapy
surgery
RICE
NSAIDs
physical therapy
surgery
RICE, NSAIDs
close reduction
manual traction
surgery

17. Joint Trauma

18. Joint Trauma

19. Nursing Care for Joint Trauma
History Taking
 circumstances of injury if known;
 pain, including location, character, timing, and activities or
movements that aggravate or relieve it
 history of prior musculoskeletal injuries;
 chronic illnesses;
 medications.

20. Nursing Care for Joint Trauma
Physical Assessment
 Compare the position, color, size, and temperature of the
affected joint to the corresponding unaffected joint.
 Palpate for tenderness, crepitus, temperature, and swelling.
 Instruct the patient or assist to move the joint through its normal
range of motion, stopping and noting where pain is experienced.
 When a joint dislocation is suspected, assess color, temperature,
pulses, movement, and sensation of the limb distal to the
affected joint.

21. Nursing Diagnosis and Interventions
Risk for Injury
• Monitor neurovascular status by assessing the 5 “P’s”: pain,
pulses, pallor, paralysis, and paresthesia.
• Maintain immobilization as ordered after reduction.
Acute Pain
• Encourage use of an appropriate splint or joint immobilizer.
• Teach safe application of ice or heat to the affected joint as
indicated.
• Instruct about using NSAIDs as ordered.

22. Nursing Diagnosis and Interventions
Preventing Dislocations
• Keep the knees apart at all times.
• Put a pillow between the legs when sleeping.
• Never cross the legs when seated.
• Avoid bending forward when seated in a chair.
• Avoid bending forward to pick objects on the floor.
• Use a high-seated chair and a raised toilet seat.
• Do not flex the hip to put on clothing.

23. Nursing Diagnosis and Interventions

24. Nursing Diagnosis and Interventions
Acute Pain
• Teach use of assistive devices such as a sling, crutches, or cane to
reduce stress on the affected joint or minimize weight bearing.
Impaired Physical Mobility
• Refer to physical therapy for appropriate exercises.
• Suggest occupational therapy.

25. Repetitive Use Injuries
CARPAL TUNNEL
SYNDROME
BURSITIS EPICONDYLITIS
Pathophysiology compression
of the median
nerve
inflammation of a
bursa
inflammation of the
tendon to
microvascular trauma
Etiology using computers
post menopausal
women
constant friction
between the bursa
and the
musculoskeletal
tissue
tears, bleeding, and
edema and
calcification of the
tendon

26. Repetitive Use Injuries
CARPAL TUNNEL
SYNDROME
BURSITIS EPICONDYLITIS
Manifestations pain, numbness
and tingling of the
thumb, index
finger, and lateral
ventral surface of
the middle finger
hot, red, edematous,
tender, and extension
and flexion of the
joint near the bursa
produce pain
point tenderness,
pain radiating down
the dorsal surface of
the forearm

27. Carpal Tunnel Syndrome

28. Bursitis

29. Epicondylitis

30. Repetitive Use Injuries
CARPAL TUNNEL
SYNDROME
BURSITIS EPICONDYLITIS
Diagnosis history and physical
examination
Phalen’s test
ultrasound
magnetic resonance
imaging (MRI)
electromyography (EMG)
nerve conduction studies
history and physical examination
ultrasound
magnetic resonance imaging (MRI)

31. Phalen’s Test

32. Tinel’s Sign

33. Repetitive Use Injuries
CARPAL TUNNEL
SYNDROME
BURSITIS EPICONDYLITIS
Emergency
Management RICE in the first 24 to 48 hours
Medications NSAIDs
narcotics
corticosteroids
NSAIDs
narcotics
NSAIDs
narcotics
corticosteroids
Treatment Surgery

34. Carpal Tunnel Syndrome

35. Nursing Interventions for Repetitive Use Injuries
Acute Pain
• Ask the patient to rate the pain on a scale of 0 to 10 before and
after any intervention.
• Encourage the use of immobilizers.
• Teach the patient to apply ice and/or heat as prescribed.
• Encourage use of NSAIDs as prescribed.
• Explain why treatment should not be abruptly discontinued.

36. Nursing Interventions for Repetitive Use Injuries
Impaired Physical Mobility
• Suggest interventions to alleviate pain (such as using an
immobilizer and taking pain medications).
• Refer to a physical therapist for exercises.
• Suggest consultation with an occupational therapist.

37. Objective Health Assessment

38. Muscle Grading Scale
Scale Assessment Description
0 (No visible) contraction; paralysis
1 Can feel contraction of muscle but there is no movement
of limb
2 Passive ROM
3 Full ROM against gravity
4 Full ROM against some resistance
5 Full ROM against full resistance

39. Traumatic Injuries of Bones

40. Traumatic Injuries of Bones
Etiology
• direct blow
• crushing force (compression)
• sudden twisting motion (torsion)
• severe muscle contraction
• stress or pathologic fracture

41. Fracture Classification
• open (compound) fracture
• closed (simple) fracture

42. Fracture Classification
• oblique fractures
• spiral fractures
• comminuted fractures

43. Fracture Classification
• avulsed fracture
• impacted fracture
• fissure fracture
• greenstick fracture

44. Fracture Classification
• stable fracture
• unstable fracture

45. Traumatic Injuries of Bones
Manifestations
• Deformity
• Swelling
• Pain/tenderness
• Numbness
• Guarding
• Crepitus
• Hypovolemic shock
• Muscle spasms
• Ecchymosis

46. Fracture Healing
Bone Injury

47. Fracture Healing
Fibrocartilaginous Callus Formation

48. Fracture Healing
Bony Callus Formation

49. Fracture Healing
Bone Remodelling

50. Fracture Complications
COMPARTMENT SYNDROME
Pathophysiology • pressure within this confined space constricts and entraps
the structures within it
Manifestations • pain
• normal or decreased peripheral pulse
• cyanosis
• tingling, loss of sensation (paresthesias)
• weakness (paresis)
• severe pain

51. Fracture Complications
COMPARTMENT SYNDROME

52. Fracture Complications
COMPARTMENT SYNDROME
Treatment • restrictive dressings are removed
• bivalving
• fasciotomy
Complication • Volkmann’s contracture

53. Fasciotomy

54. Fracture Complications
FAT EMBOLISM
Pathophysiology • fat globules lodge in the pulmonary vascular bed or
peripheral circulation
Etiology • long bone fractures and other major trauma
• hip replacement surgery
Manifestations • neurologic dysfunction
• pulmonary insufficiency
• petechial rash on the chest, axilla, and upper arms

55. Fracture Complications
FAT EMBOLISM
Treatment • early stabilization of long bone fractures
• intubation and mechanical ventilation
• fluid balance is closely monitored
• corticosteroids

56. Fracture Complications
DEEP VEIN THROMBOSIS
Pathophysiology • blood clot forms along the intimal lining of a large vein,
accompanied by inflammation of the vein wall
Etiology • venous stasis, or decreased blood flow
• injury to blood vessel walls
• altered blood coagulation
Manifestations • swelling, pain, tenderness, or cramping of the affected
extremity

57. Fracture Complications
DEEP VEIN THROMBOSIS
Diagnosis • doppler ultrasonography
• magnetic resonance imaging
• venogram
Treatment • early immobilization of the fracture
• early ambulation of the patient
• prophylactic anticoagulation
• antiembolism stockings and compression boots

58. Fracture Complications
INFECTION
Pathophysiology • Pseudomonas, Staphylococcus, or Clostridium organisms may
invade the wound or bone
Complication • osteomyelitis

59. Fracture Complications
DELAYED UNION AND NONUNION
Pathophysiology • prolonged healing of bones beyond the usual time period
• delayed union may lead to nonunion
Etiology • Injury-related: the type and location of facture and
accompanying soft tissue injury
• System related: age, general health, immune status, chronic
diseases, and smoking
Diagnosis • serial x-ray studies

60. Fracture Complications
DELAYED UNION AND NONUNION
Treatment • internal fixation and bone grafting
• bone debridement
• electrical or ultrasonic stimulation of the fracture site
• growth hormone or parathyroid hormone stimulation

61. Fracture Complications
COMPLEX REGIONAL PAIN SYNDROME
Pathophysiology • pain receptors become sensitized to catecholamines,
neurotransmitters associated with sympathetic nervous
system activity
Etiology • female
• older age
Diagnosis • history and physical examination
• x-ray

62. Fracture Complications
COMPLEX REGIONAL PAIN SYNDROME
Manifestations • severe, diffuse, and burning pain
• affected extremity is inflamed and edematous, later
becoming cool and pale
• muscle wasting, skin and nail changes, and bone
abnormalities
Treatment • sympathetic nervous system blocking agent

63. Management for Fractures
Emergency Care
• Immobilizing the fracture
• Maintaining tissue perfusion
• Preventing infection
Diagnosis
• X-rays and bone scans
• Blood chemistry studies, complete blood count (CBC), and
coagulation studies

64. Management for Fractures

65. Management for Fractures
Medications
• Antibiotics may be administered prophylactically
• Anticoagulants
• Stool softeners
• Antiulcer medications or antacids

66. Management for Fractures
Traction
• Manual traction

67. Management for Fractures
Traction
• Skin traction

68. Nursing Interventions for Patients in Skin Traction
• Frequently assess skin, bony prominences, and pressure points
for evidence of pressure, shearing, or pending breakdown.
• Protect pressure sites with padding and protective dressings as
indicated.
• Remove weights only if intermittent traction has been ordered to
alleviate muscle spasm.

69. Management for Fractures
Traction
• Balanced
suspension
traction

70. Management for Fractures
Traction
• Skeletal traction

71. Skeletal Traction
Traction
• Balanced
suspension
traction

72. Skeletal Traction
Traction
• Buck’s
extension
traction

73. Skeletal Traction
Traction
• Head halter

74. Skeletal Traction
Traction
• Pelvic girdle

75. Skeletal Traction
Traction
• Buck’s
extension
traction

76. Skeletal Traction
Traction
• Bryant’s
traction

77. Skeletal Traction
Traction
• Dunlop’s
traction

78. Skeletal Traction
Traction
• Russel’s traction

79. Skeletal Traction
Traction
• Halo pelvic
traction

80. Nursing Interventions for Patients in Skeletal Traction
• Never remove the weights.
• Frequently assess pin insertion sites and provide pin site care per
policy.
• Report signs of infection at the pin sites, such as redness,
drainage, and increased tenderness.

81. Nursing Interventions for Patients in Traction
Maintain the pulling force and direction of the traction:
• The patient’s weight provides counter traction.
• Center the patient on the bed; maintain body alignment with the
direction of pull.
• Ensure that weights hang freely and do not touch the floor.
• Ensure that nothing is lying on or obstructing the ropes.
• Do not allow the knots at the end of the rope to come into
contact with the pulley.

82. Nursing Interventions for Patients in Traction
• Perform neurovascular assessments frequently.
• Assess for common complications of immobility, including
pressure ulcer formation, renal calculi, deep venous thrombosis,
pneumonia, paralytic ileus, and loss of appetite.
• If a problem is detected, assist in repositioning. Stabilize the
fracture site during repositioning.
• Teach the patient and family about the type and purpose of the
traction.

83. Nursing Interventions for Patients in Traction
T - Temperature (Extremity, Infection)
R - Ropes hang freely
A - Alignment
C - Circulation Check (5 P's)
T - Type & Location of fracture
I - Increase fluid intake
O - Overhead trapeze
N - No weights on bed or floor

84. Management for Fractures
Casts

85. Management for Fractures
Casts
• Short arm
• Long arm

86. Management for Fractures
Casts
• Short leg
• Long leg

87. Management for Fractures
Casts
• Walking cast

88. Management for Fractures
Casts
• Hip spica cast

89. Management for Fractures
Casts
• Short leg hip
spica cast

90. Fracture Complications
Pressure areas in casts

91. Nursing Interventions for Patients in Casts
• Perform frequent neurovascular
assessments.
• Palpate the cast for “hot spots” that may
indicate the presence of underlying
infection.
• Promptly report increased or severe pain;
changes in neurovascular status; or a hot
spot or drainage on the cast.

92. Health Education for the Patient and Family
• Do not use a blow dryer to speed drying; do not cover the cast
while it is drying.
• A sensation of warmth during drying is normal.
• Do not put anything into the cast.
• Keep the cast clean and dry; use plastic wrap as needed to
protect it.
• If the cast is made of fiberglass, dry it with a blow dryer on the
cool setting if it becomes wet.

93. Health Education for the Patient and Family
• Notify your doctor immediately if you develop increased pain,
coolness, changes in color, increased swelling, and/or loss of
sensation.
• A sling may be used to distribute the weight of the cast evenly
around the neck.
• If crutches are used, arrange for physical therapist to teach
correct crutch walking.
• When the cast is removed, an oscillating cast saw will be used.

94. Management for Fractures
Surgery
• open reduction and
internal fixation (ORIF)

95. Management for Fractures

96. Management for Fractures
Surgery
• surgical fixation

97. Management for Fractures
Electrical Bone Stimulation

98. Nursing Care for Fractures
History Taking
• age
• history of traumatic event
• history of prior musculoskeletal injuries
• chronic illnesses
• medications (ask the older adult specifically
about anticoagulants and calcium
supplements).

99. Nursing Care for Fractures
Physical Assessment
• Pain with movement, pulses, edema, skin color and
temperature, deformity, range of motion, touch.
• The 5 P’s of neurovascular assessment.

100. Nursing Diagnosis and Interventions
Acute Pain
• Monitor vital signs.
• Ask the patient to rate the pain on a scale of 0 to 10 before and
after any intervention.
• Move the patient gently and slowly.
• Elevate the injured extremity above the level of the heart.
• Encourage distraction or other adjunctive methods of pain relief,
such as deep breathing and relaxation.

101. Nursing Diagnosis and Interventions
Acute Pain
• Administer NSAIDs and pain medications as prescribed. For
home care, explain the importance of taking pain medications
before the pain is severe.

102. Nursing Diagnosis and Interventions
Risk for Peripheral Neurovascular Dysfunction
• Support the injured extremity above and below the fracture site
when moving the patient.
• Assess the 5 P’s every 1 to 2 hours. Report abnormal findings
immediately.
• Assess nail beds for capillary refill. If nails are too thick or
discolored, assess the skin around the nail.
• Monitor the extremity for edema and swelling.
• Assess for deep, throbbing, unrelenting pain.

103. Nursing Diagnosis and Interventions
Risk for Peripheral Neurovascular Dysfunction
• Assess the ability to differentiate between sharp and dull touch
and the presence of paresthesias and paralysis every 1 to 2
hours.
• Monitor the tightness of the cast. If the cast is tight, be prepared
to assist the physician with bivalving.
• If compartment syndrome is suspected, assist the physician in
measuring compartment pressure. Normal compartment
pressure is 10 to 20 mmHg.

104. Nursing Diagnosis and Interventions
Bivalving

105. Nursing Diagnosis and Interventions
Risk for Peripheral Neurovascular Dysfunction
• Unless contraindicated, elevate the injured extremity above the
level of the heart.
• Administer anticoagulant per physician’s order.

106. Nursing Diagnosis and Interventions
Risk for Infection
• For patients with skeletal pins, follow established guidelines for
skeletal pin site care.
• Monitor vital signs and lab reports of WBCs.
• Use sterile technique for dressing changes.
• Assess the wound for size, color, and the presence of any
drainage.
• Administer antibiotics per physician’s orders.

107. Nursing Diagnosis and Interventions
Impaired Physical Mobility
• Teach or assist patient with ROM exercises of the unaffected
limbs.
• Teach isometric exercises, and encourage the patient to perform
them every 4 hours.
• Encourage ambulation when able; provide assistance as
necessary.
• Turn the patient on bed rest every 2 hours. If the patient is in
traction, teach the patient to shift his or her weight every hour.

108. Amputation

109. Amputation
Causes of Amputation
• Peripheral vascular disease (PVD)
• Peripheral neuropathy
• Untreated infection
• Motor vehicle crashes or accidents
involving machinery at work
• Combat-related trauma
• Frostbite, burns, or electrocution

110. Common Sites of Amputation

111. Amputation Complications
INFECTION
Pathophysiology • traumatic amputation has a greater risk of infection
Etiology • older patients, has diabetes mellitus, or suffers peripheral
neurovascular compromise
Manifestations • local manifestations include drainage, odor, redness, and
increased discomfort at the suture line.
• systemic manifestations include fever, an increased heart
rate, a decrease in blood pressure, chills, and positive
wound or blood cultures.

112. Amputation Complications
DELAYED HEALING
Pathophysiology • if infection is present or if the circulation remains
compromised, delayed healing
Etiology • older patients, electrolyte imbalances, diet that
lacks the proper nutrients, smoking, deep vein
thrombosis and decreased cardiac output

113. Amputation Complications
CHRONIC STUMP PAIN
Pathophysiology • neuroma formation
Manifestations • severe burning pain
Treatment • medications
• nerve blocks
• transcutaneous electrical nerve stimulation (TENS)
• surgical stump reconstruction

114. Amputation Complications
PHANTOM LIMB PAIN
Pathophysiology • pain in the amputated limb prior to its removal
Manifestations • tingling, numbness, cramping, or itching in the
phantom foot or hand
Treatment • pain management
• TENS
• surgery

115. Amputation Complications
CONTRACTURES
Pathophysiology • abnormal flexion and fixation of a joint caused by
muscle atrophy and shortening
Treatment • active or passive ROM exercises every 2 to 4 hours
• postural exercises

116. Management for Amputation
Diagnosis
• Preoperative - Doppler flowmetry,
segmental blood pressure determination,
transcutaneous partial pressure oxygen
readings, and angiography
• Postoperative - CBC, WBC, blood
chemistries, and a vascular Doppler
ultrasonography.

117. Management for Amputation
Medications
• analgesics
• antibiotics
• steroids
• H2 antagonists

118. Management for Amputation
Emergency Care
• Administer CPR as necessary, and control bleeding with direct
pressure.
• Keep the person in a supine position with the legs elevated.
• Apply firm pressure to the bleeding area, using a towel or article
of clothing.
• Wrap the amputated part in a clean cloth. If possible, soak the
cloth in saline.

119. Management for Amputation

120. Management for Amputation
Emergency Care
• Put the amputated part in a plastic bag and put the bag on ice.
• Send the amputated part to the emergency department with the
injured person, and be sure the emergency personnel know
what it is.

121. Management for Amputation
Assessment
• Health history: Mechanism of injury, current and past health
problems, pain, occupation, ADLs, changes in sensation in the
feet, cultural and/or religious guidelines for handling the
amputated part.
• Physical examination: Bilateral neurovascular status of the
extremities, bilateral capillary refill time, skin over the lower
extremities (discoloration, edema, ulcerations, hair, gangrene).

122. Nursing Diagnosis and Interventions
Acute Pain
• Ask the patient to rate the pain on a scale of 0 to 10 before and
after any intervention.
• Splint and support the injured area.
• Unless contraindicated, elevate the stump on a pillow for the first
24 hours after surgery.
• Move and turn the patient gently and slowly.
• Administer pain medications as prescribed. A PCA pump may be
ordered by the physician.

123. Nursing Diagnosis and Interventions
Acute Pain
• Encourage deep breathing and relaxation exercises.
• Reposition patient every 2 hours; turn from side to side and onto
abdomen.

124. Nursing Diagnosis and Interventions
Risk for Infection
• Assess the wound for redness, drainage, temperature, edema,
and suture line approximation.
• Take the patient’s temperature every 4 hours.
• Monitor WBC count.
• Use aseptic technique to change the wound dressing.
• Administer antibiotics as ordered.
• Teach the patient stump-wrapping techniques.

125. Nursing Diagnosis and Interventions
Risk for Impaired Skin Integrity
• Wash the stump with soap and warm water and dry thoroughly.
• Inspect the stump for redness, irritation, or abrasions.
• Massage the end of the stump, beginning 3 weeks after surgery.
• Expose any open areas of skin on the remaining part of the limb
for 1 hour four times a day.
• Change stump socks and elastic wraps each day. Wash these in
mild soap and water, and allow to completely dry before using.

126. Nursing Diagnosis and Interventions
Risk for Complicated Grieving
• Encourage verbalization of feelings, using open-ended questions.
• Actively listen and maintain eye contact.
• Reflect on the patient’s feelings.
• Allow the patient to have unlimited visiting hours, if possible.
• If desired by the patient, provide spiritual support by
encouraging activities such as visits from a spiritual leader,
prayer, and meditation.

127. Nursing Diagnosis and Interventions
Disturbed Body Image
• Encourage verbalization of feelings.
• Allow the patient to wear clothing from home.
• Encourage the patient to look at the stump.
• Encourage the patient to care for the stump.
• Offer to have a fellow amputee visit the patient.
• Encourage active participation in rehabilitation.

128. Nursing Diagnosis and Interventions
Impaired Physical Mobility
• Perform ROM exercises on all joints.
• Maintain postoperative stump shrinkage devices. (elastic bandages,
shrinker socks, an elastic stockinette, or a rigid plaster cast).
• Turn and reposition the patient every 2 hours.
• Reinforce teaching by the physical therapist in crutch walking or the
use of assistive devices.
• Encourage active participation in physical therapy.

129. References
1. LeMone, P. et al. (2011). Medical-Surgical Nursing: Critical
Thinking in Client Care. 5th Edition. New Jersey: Pearson
Education, Inc.
2. Smeltzer, S. C. et al. (2010). Brunner & Suddarth’s Textbook of
Medical-Surgical Nursing. 12th Edition. Philadelphia: Lippincott
Williams and Wilkins.
3. Williams. L. S. & Hopper, P. D. (2011). Understanding Medical-
Surgical Nursing. 5th Edition. Philadelphia: F. A. Davis Company