Musculoskeletal/​Neurological/​Psychosocial Study Guide for the CCRN

General Information

This is another wide-ranging area and it is covered by 18% of the CCRN® test questions. You can see that the content ranges from the physical body to the brain’s functions to mental health concerns. Problems with any or all of these could be present in critical care patients, and you not only need to know how the systems work but also what to do if a patient has an emergency in any of these areas. Use this study guide to help you know what to study.

Musculoskeletal

The musculoskeletal system is the primary force behind movement, stability, support, and strength of the body. Numerous conditions may affect the musculoskeletal system as primary concerns or secondary injuries. Review the following conditions that involve the musculoskeletal system. Know the premises of the conditions, how to assess these in patient populations, and how to intervene when necessary.

Compartment Syndrome

Compartment syndrome is a condition that can occur following a fracture, a burn, a surgery, an edema, or other musculoskeletal injury. In this event, compression of the tissues surrounding the injury can cause tissue death. Compression can occur from external sources such as a bandage or cast. Compression can also occur internally from restriction of the skin or internal tissues, such as in the event of bleeding or swelling.

Symptoms of compartment syndrome include unrelenting pain, extremity or abdominal swelling, decreased or tingling sensation distal to the injury, pallor, decreased pulses, and distal coolness. If the patient has an injury, pain is often disproportionate to the injury itself in this condition. Patients may also complain of increased pressure around the area of injury. Nurses must be aware of the symptoms of compartment syndrome, as early diagnosis and pressure relief are key to preventing significant injury to underlying muscles, tissues, blood vessels, and nerves. Pressure may be relieved by removing the compressing external device or performing surgical intervention (e.g., fasciotomy) to relieve the pressure and swelling.

Fractures

Fractures can occur due to a variety of events. Femur fractures and pelvic fractures are two of the more common fractures that can cause significant concern in critical care patients.

Femur fractures generally occur due to serious trauma such as a motor vehicle accident or fall. Complications of a femur fracture can include internal bleeding, fat embolism, infection, and respiratory distress syndrome. This risk is heightened if the fracture is compound or displaced. Femur fractures are often treated with casting or immobilization devices. Severe fractures may need surgical fixation.

Pelvic fractures may also occur in the event of a motor vehicle accident or fall. Pelvic fractures place patients at high risk for pelvic instability; bladder, genital, or renal injuries; and mobility concerns. Hypotension and shock can occur in the event of severe bleeding. Patients with pelvic fractures will most likely struggle with pain related to the fracture. Mobility will be limited, and rehabilitation and physical therapy will likely be required. Surgical fixation may be required in the event of a severe, unstable fracture.

Functional Issues

Other than infectious causes, the musculoskeletal system may be affected by a series of functional issues that can cause or complicate critical illness.

Mobility

Immobile patients are at considerable risk for illness and injury. Some of the most common conditions that plague patients with decreased mobility include skin breakdown, pressure ulcers, decreased muscle mass, decreased coordination, increased risk for falls, deep vein thrombosis, constipation, and depression. Patients should also be monitored for neurologic and cardiovascular decline.

Patients in critical care units are at high risk for decreased mobility and complete immobility due to their primary conditions. In order to avoid severe complications, nurses should turn patients every two hours, practice passive and active range of motion, encourage patient participation in mobilizing when possible, and implementing protective measures to prevent skin breakdown. All patients should be working toward progressive mobility. Constantly assessing and reassessing a patient’s ability to move about is essential to improved recovery measures without secondary injury or illness.

Falls

Falls are the number one adverse event that occurs in the hospital. Many times, falls can be prevented. Patients who are confused and agitated have a high risk of falling. Other common patients at increased risk include those with abnormal gait, orthostatic hypotension, vision problems, history of falls, and patients post-anesthesia or receiving sedatives. Many patients are injured after a fall, complicating their hospital stay and possibly leading to increased morbidity and mortality related to the injury.

Preventing falls are critical to improving patient outcomes. Nurses should frequently survey their patients’ environments with the objective of removing or at least limiting obstacles. Implementation of bed alarms, gait belts, and progressive mobility goals should be tailored to all patients to reduce their risk of falling. Beds should be locked and in the lowest position and the call light within reach of the patient. Nurses should also anticipate patient needs, such as toileting and easy access to commonly used items. Many facilities have active care plans and standards that are used to identify patients at highest risk for falls and how to prevent these adverse events.

Gait Disorders

Gait disorders fall along the same line of falls and immobility. Patients with gait disorders have an array of involuntary, abnormal movements that impact how they maneuver. Most gait disorders are poorly understood as to why they occur or how they progress. The most common gait disorder is functional tremor. Elderly patients often develop gait disorders due to decreased mobility in joints or balance. Nurses may assess gait disorders, such as in patients with dragging gait, knee buckling, slow stepping, swaying movements, hesitant gait, and hyperkinetic gait.

Patients with gait disorders should have a complete neurologic workup to determine any underlying causes, especially if the gait change is new. Nurses should implement fall precautions to prevent injury. The need for assistive devices, such as canes, walkers, braces, and gait belts, should also be addressed to protect the patient from injury.

Osteomyelitis

Osteomyelitis is one of the most common and critical musculoskeletal infections. It can occur from a variety of injuries. Other common musculoskeletal infections include cellulitis and septic arthritis. If not treated, these infections can quickly become serious, life-threatening events.

Signs and Symptoms

Osteomyelitis is an infection in the bone that often develops in the site of a large wound or after introduction of bacteria to an open sore. Infections that are harbored in the bone can be very difficult to treat. It is more commonly seen in patients with chronic wounds or slow or nonhealing ulcerations. Symptoms of this condition include pain, swelling, and erythema around the site. Purulent drainage may also be present if located near an open wound. Depending on the severity of the infection, systemic symptoms such as fever and chills can occur.

Diagnosis

Common lab work obtained when there is concern for osteomyelitis includes complete blood count (CBC), erythrocyte sedimentation rate (ESR), blood cultures, and C-reactive protein (CRP). This helps to identify how involved the inflammation and infection are and to determine if the infection has spread to the bloodstream (bacteremia). Radiologic imaging may be obtained to secure a diagnosis as well. Osteomyelitis may be seen on CT, MRI, X-ray, and bone scans. In some cases, bone biopsies are indicated to identify the offending organism.

Treatment

Treatment of osteomyelitis (as well as cellulitis and septic arthritis) includes the initiation of antibiotic therapy. Identifying the organism(s) present may become critical to assess the functionality of specific antibiotics and help to determine the course for treatment. Antibiotics must be given intravenously to ensure adequate concentrations in the bone. Oral antibiotics are often not potent enough to treat this type of infection.

In some cases, surgical intervention may be necessary. Depending on the location and severity of the infection, surgical debridement and sterile irrigation may be performed to remove any debris and bacterial toxins from the bone itself. Rarely, limb amputation may be required if the infection has become unmanageable by traditional therapies.