Page 1 - Musculoskeletal/Neurological/Psychosocial Study Guide for the CCRN

General Information

This is another wide-ranging area and it is covered by 13% 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 clients, and you not only need to know how the systems work, but what to do if a client 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 client populations, and how to intervene when necessary.

Compartment Syndrome

Compartment syndrome is a condition that can occur following a fracture, burn, surgery, edema, or other musculoskeletal injury. In this event, compression of the tissues surrounding of 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. Clients 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 clients.

Femur fractures generally occur due to serious trauma such as a motor vehicle accident or fall. Complications of 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 immobility 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 clients at high risk for pelvic instability; bladder, genital, or renal injuries; and mobility concerns. Hypotension can occur in the event of severe bleeding. Clients 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 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 clients are at considerable risk for illness and injury. Some of the most common conditions that plague clients with decreased mobility include skin breakdown, pressure ulcers, decreased muscle mass, decreased coordination, increased risk for falls, deep vein thrombosis, constipation, and depression. Clients should also be monitored for neurologic and cardiovascular decline.

Clients 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 clients every 1-2 hours, practice passive and active range of motion, encourage client participation in mobilizing when possible, and implementing protective measures to prevent skin breakdown and ulcerations. All clients should be working toward progressive mobility. Constantly assessing and reassessing a client’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. Clients who are confused and agitated have great risk of falling. Other common clients at increased risk include those with abnormal gait, orthostatic hypotension, and those with a history of falling. Many clients are injured after a fall, complicating their hospital stay and possibly leading to increased morbidity and mortality related to the injury.

Preventing fall events is critical to improving client outcomes. Nurses should frequently survey their clients’ 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 clients to reduce their risk of falling. Nurses should also anticipate client needs such as toileting and easy access to commonly used items. The nurse should attempt to help clients prior to them trying to help themselves. Many facilities have active care plans and standards that are used to identify clients 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. Clients 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 clients often develop gait disorders due to decreased mobility in joints or balance. Nurses may assess gait disorders, such as in clients with dragging gait, knee buckling, slow stepping, swaying movements, hesitant gait, and hyperkinetic gait.

Clients 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 balancing devices such as canes, walkers, braces, and gait belts should be addressed as well to protect the client 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

In the critical care world, 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. Infection that harbors in the bone can be very difficult to treat. It is more commonly seen in clients with chronic wounds or slow or non-healing 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, 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 (sepsis). Radiologic imaging may be obtained as well to secure a diagnosis. 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 (cellulitis and septic arthritis as well) 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 access to 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.

Rhabdomyolysis

Rhabdomyolysis occurs when damaged skeletal muscles release toxins into the bloodstream. Skeletal muscle damage can occur due to trauma, infection, sepsis, immobilization, ischemia, myopathy, extreme physical activity, and medications including SSRIs, lithium, antihistamines, and statins. Alcohol and drug abuse, especially cocaine, and toxins from animal or mushroom poisoning can also cause this condition.

Early recognition of rhabdomyolysis is critical to preventing long-term complications and renal failure. It may become life threatening. Signs and symptoms of rhabdomyolysis include muscle pain, weakness, fever, tachycardia, electrolyte imbalance, lethargy, hypotension, and metabolic acidosis. Presence of myoglobin in the urine may cause the urine to turn dark reddish-brown.

Diagnosis of rhabdomyolysis can be confirmed with creatinine kinase (CK) levels above 1000 u/L, which is five times greater than the normal level. Other labs that may be drawn include metabolic panel, urinalysis, and arterial blood gases.

Treatment of rhabdomyolysis focuses on the clearing of toxins from the body and reduction of risk for renal failure. Clients will require increased fluid administration to help flush the toxins. If experiencing metabolic acidosis, bicarbonate may be given to help normalize blood gas levels. Electrolyte imbalances should be corrected and clients may be given mannitol or dopamine to increase renal perfusion to assist in filtration and function. If rhabdomyolysis progresses to renal failure, dialysis may be indicated.

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