NLE Musculoskeletal Nursing — Musculoskeletal Assessment and DiagnosticsDetailed Explanation

Functional Anatomy of the Musculoskeletal System

The musculoskeletal system is composed of bones, joints, muscles, tendons, ligaments, cartilage, and bursae. Understanding its structure is the foundation of all musculoskeletal assessment. Bone is NOT a dead structure — it is living, vascular tissue that constantly remodels. Two cell types regulate this remodeling: osteoblasts, which BUILD new bone (think 'B' for Build), and osteoclasts, which RESORB or break down old bone (think 'C' for Consume/Clear). This balance is regulated by parathyroid hormone (PTH), calcitonin, and vitamin D. Bone also serves as the primary storage site for calcium and phosphorus — minerals critical for muscle contraction, nerve conduction, and blood clotting. Joints are classified by the degree of movement they permit. Synarthrodial joints are immovable (e.g., sutures of the skull). Amphiarthrodial joints allow slight movement (e.g., intervertebral discs, pubic symphysis). Diarthrodial (synovial) joints are freely movable (e.g., knee, hip, shoulder, elbow) and are the most clinically significant because they are most commonly injured or affected by disease. Synovial joints are lined with articular cartilage and surrounded by a joint capsule with a synovial membrane that produces synovial fluid for lubrication. Supporting soft tissue structures include: Tendons — connect muscle to bone (mnemonic: T connects to Two different things: musTle and Bone). Ligaments — connect bone to bone (both start with 'L' for Ligament-to-bone-to-bone Link). Cartilage — cushions joint surfaces and absorbs shock. Bursae — small fluid-filled sacs that reduce friction between tendons and bony prominences (inflammation of a bursa = bursitis, common in the shoulder and knee).

Health History and Physical Assessment

A thorough musculoskeletal health history is the first step of the nursing process (Assessment phase). The nurse begins by identifying the chief complaint and using the PQRST framework to characterize any pain: Provocation/Palliation (what makes it worse or better?), Quality (sharp, dull, aching, burning?), Region/Radiation (where is it? Does it spread?), Severity (rate 0–10 on the numeric pain scale), and Timing (when does it occur? Is it constant or intermittent?). Beyond pain, ask about morning stiffness — a hallmark of rheumatoid arthritis (RA) that is worse in the morning and lasts more than 30 minutes — versus osteoarthritis (OA) stiffness, which occurs after inactivity and resolves within 30 minutes. Ask about swelling, deformity, weakness, limited range of motion, and any restrictions in activities of daily living (ADLs). A thorough injury history should include the mechanism of injury (MOI) — for example, a rotational force on the ankle suggests a ligament sprain, while a direct fall on an outstretched hand (FOOSH) commonly causes a Colles' fracture of the wrist. Also assess: occupational hazards (construction workers, farmers), recreational activities (basketball, boxing — common in Filipino males), nutritional intake (calcium, vitamin D, protein), medications (corticosteroids, anticoagulants), and fall history (very important for elderly Filipino patients). Physical assessment follows the sequence: Inspection → Palpation → Movement. ALWAYS compare the affected limb to the opposite unaffected limb. Inspection: Look for swelling, deformity, muscle atrophy (wasting), redness, abnormal posture, and skin changes. Palpation: Feel for tenderness, warmth, crepitus (a grating sensation when a joint or fracture site moves — indicates bone fragments rubbing), effusion (fluid in a joint), and masses. Muscle Strength Testing uses the standard 0–5 scale: 0 = no contraction (complete paralysis), 1 = visible contraction but no movement, 2 = movement with gravity eliminated, 3 = movement against gravity only, 4 = movement against some resistance, 5 = full strength against full resistance (normal). Range of Motion (ROM): Assess ACTIVELY first (patient moves the joint). If the patient cannot, then assess PASSIVELY (examiner moves the joint). NEVER force a joint against pain or resistance. A goniometer measures joint angles in degrees. Key ROM movements: Flexion/Extension (bending/straightening), Abduction/Adduction (away from/toward midline), Internal/External Rotation, Pronation/Supination (forearm). Gait Assessment: Observe the patient walking. The normal gait has two phases: Stance Phase (foot is on the ground, about 60% of the cycle) and Swing Phase (foot moves forward, about 40%). Common abnormal gaits include: Antalgic gait — shortened stance phase on the painful leg to limit weight-bearing (the patient 'limps' away from the pain); Shuffling gait — seen in Parkinson disease; Ataxic gait — wide-based, unsteady, seen in cerebellar or neurological conditions. Always assess fall risk during gait testing and guard the patient closely.

Neurovascular Assessment: The Critical Safety Skill

Neurovascular assessment is the single most important safety skill in orthopedic nursing. It must be performed regularly on any patient with a fracture, cast, splint, traction device, or after orthopedic surgery. The purpose is to detect early signs of impaired circulation and nerve function — most critically, compartment syndrome, a surgical emergency where increased pressure within a closed muscle compartment compromises blood flow and nerve conduction, potentially causing permanent paralysis and tissue death within hours. The neurovascular check is summarized using the 5 Ps (or 6 Ps): 1. PAIN — The EARLIEST and most important warning sign. Key characteristics: increasing in intensity, unrelenting (not relieved by usual analgesics or repositioning), and PAIN ON PASSIVE STRETCH — when you passively flex the patient's fingers or toes and they report severe pain in the forearm or leg respectively, this is a hallmark sign of compartment syndrome. Pain out of proportion to the injury is a critical alert. 2. PALLOR — Assess skin color. Look for pallor (pale), cyanosis (bluish), or duskiness of the skin distal to the injury or cast. Also assess capillary refill: press on the nail bed until it blanches, then release — normal refill is LESS THAN 3 SECONDS. Slow refill indicates poor perfusion. 3. PULSELESSNESS — Assess the distal pulse (radial pulse for upper extremity injuries; dorsalis pedis and posterior tibial pulses for lower extremity injuries). A diminished or absent pulse is a LATE and OMINOUS sign of vascular compromise. By the time the pulse disappears, significant damage may have already occurred. 4. PARESTHESIA — Ask the patient if they feel numbness, tingling, or 'pins and needles' (parang nilalaslas or manhid in Filipino patient communication). This indicates nerve compression or ischemia. 5. PARALYSIS — Inability to move the fingers (for upper extremity) or toes (for lower extremity). This is also a LATE sign. 6. POIKILOTHERMIA (or Perishing Cold) — The affected extremity feels cool or cold to touch compared to the opposite limb, indicating reduced arterial blood flow. Always compare bilaterally — compare the temperature, color, and sensation of the affected limb with the unaffected limb. CRITICAL NURSING ACTION: Any deterioration in neurovascular status — especially increasing pain or paresthesia — must be REPORTED IMMEDIATELY to the physician. Do not wait for the next scheduled assessment. Compartment syndrome requires FASCIOTOMY (surgical incision of the fascia) within hours to prevent permanent damage. Documentation should include: which extremity was assessed, time of assessment, findings for each P, and comparison to baseline.

Diagnostic Studies in Musculoskeletal Nursing

Understanding diagnostic studies is critical for the NLE because nurses prepare patients for these procedures and implement post-procedure care. Knowing what each test reveals and its specific nursing responsibilities is essential. IMAGING STUDIES: 1. Plain Radiography (X-ray) — The FIRST-LINE study for suspected fractures, dislocations, and bone alignment problems. X-rays show bony structures well but are POOR at visualizing soft tissue (ligaments, tendons, cartilage, muscles). Nursing responsibilities: No special preparation needed. Confirm the patient is NOT pregnant (radiation risk to fetus). Remove all metal objects (jewelry, piercings, bra with metal wire) that would obscure the image. Two views (AP and lateral) are typically taken. 2. Computed Tomography (CT) — Provides detailed cross-sectional images of complex fractures, spinal injuries, and bony tumors. Better detail than plain X-ray. If contrast dye is used: Assess for allergy to iodine, seafood (shellfish), or contrast media. Check renal function (creatinine, BUN) — contrast can cause nephrotoxicity. Ensure adequate hydration before and after. 3. Magnetic Resonance Imaging (MRI) — The BEST study for SOFT TISSUE visualization: ligament tears, tendon injuries, cartilage damage, herniated intervertebral discs, bone marrow tumors, and osteomyelitis (bone infection). It uses magnetic fields and radiofrequency waves — NO radiation. Nursing responsibilities (CRITICAL): Screen for and remove ALL metal. Contraindicated for patients with: certain cardiac pacemakers, cochlear implants, metal surgical clips (especially intracranial), metallic foreign bodies in the eyes. Warn the patient about the enclosed space (claustrophobia — common concern) and the loud banging noise. The procedure takes 30–90 minutes. 4. Bone Scan (Radionuclide Scintigraphy) — A radioactive tracer, technetium-99m (Tc-99m), is injected intravenously. It accumulates in areas of HIGH bone turnover. 'Hot spots' (areas of increased uptake) indicate: tumor (primary or metastatic), osteomyelitis (bone infection), or occult fracture (fracture not visible on plain X-ray). Nursing responsibilities: ENCOURAGE FLUIDS after injection to distribute the tracer and promote renal excretion. Expect a 2–3 HOUR DELAY between injection and actual scanning (tracer needs time to distribute). Reassure the patient that the radioactive dose is very small and safe. 5. DEXA Scan (Dual-Energy X-ray Absorptiometry) — Measures BONE MINERAL DENSITY (BMD). Results reported as a T-score: Normal ≥ -1.0; Osteopenia: -1.0 to -2.5; Osteoporosis ≤ -2.5. Used to screen for and diagnose osteoporosis. No special preparation needed; remove metal. INVASIVE PROCEDURES: 6. Arthroscopy — A fiberoptic scope inserted into a joint (most commonly the knee or shoulder) to visualize, diagnose, biopsy, or repair internal structures (e.g., ACL repair, meniscus repair). Performed under general or regional anesthesia. PRE-PROCEDURE: Verify informed consent (the physician obtains consent; the nurse witnesses and verifies). Keep the patient NPO per anesthesia protocol (typically 8 hours for solid food, 2 hours for clear liquids). POST-PROCEDURE: Assess neurovascular status of the affected extremity. Apply compression dressing and ICE to control swelling and pain. ELEVATE the extremity. Teach the patient to report: increasing pain, fever (sign of infection), excessive swelling, redness/drainage from the incision site. Limit strenuous activity as ordered (typically 2–6 weeks depending on procedure). 7. Arthrocentesis (Joint Aspiration) — Aspiration of synovial fluid from a joint using a needle. Fluid is analyzed for: uric acid crystals (gout — negatively birefringent needle-shaped crystals), bacteria and WBC count (septic arthritis — infection), and blood (hemarthrosis — bleeding into joint from trauma). Also performed therapeutically to relieve pain from joint effusion. LABORATORY TESTS: Serum Calcium — normal 8.5–10.5 mg/dL; elevated in hypercalcemia (bone metastasis, hyperparathyroidism), low in osteomalacia. Alkaline Phosphatase (ALP) — elevated with active bone formation, bone disease (Paget's disease), fracture healing, and bone tumors. ESR (Erythrocyte Sedimentation Rate) and CRP (C-Reactive Protein) — nonspecific markers of inflammation; elevated in RA, osteomyelitis, septic arthritis. Rheumatoid Factor (RF) and Anti-CCP antibodies — elevated in Rheumatoid Arthritis (anti-CCP is MORE specific for RA). Uric Acid — elevated in gout (hyperuricemia). Phosphorus — regulated with calcium; abnormal in metabolic bone diseases.

Principles of Cast Care

Casts are rigid immobilization devices used to: maintain fracture alignment during healing, protect injured bones and soft tissues, and provide stability after orthopedic surgery. Types of Casts: PLASTER casts — made of plaster of Paris (calcium sulfate). Heavier and takes 24–72 hours to fully dry/cure. During the drying period, the cast generates HEAT (an exothermic reaction — normal and expected; reassure the patient). Advantages: molds better to body contours, less expensive. Disadvantages: heavy, not water-resistant. FIBERGLASS casts — made of polyurethane resin. Lighter and dries in approximately 30 minutes. Water-resistant. More expensive. Most commonly used today in Philippine hospitals. Nursing Care of a New (Wet) Cast: 1. SUPPORT WITH PALMS — When handling a fresh wet plaster cast, always use the PALMS of the hands, not the fingertips. Fingertips create indentations (dents) in the wet cast that, when hardened, create pressure points on the underlying skin — leading to skin breakdown and pressure ulcers. 2. ALLOW TO AIR DRY — Do NOT cover the wet cast with blankets or plastic. Do not use a hair dryer or heating lamp (uneven drying causes the cast to become brittle and crack). Elevate the casted extremity and allow air to circulate. 3. ELEVATE — Elevate the casted extremity ABOVE HEART LEVEL for the first 24–48 hours to reduce swelling and prevent further neurovascular compromise. Use pillows. 4. APPLY ICE — Apply ice bags wrapped in cloth (never directly on cast) over the first 24–48 hours to reduce swelling and pain. 5. NEUROVASCULAR CHECKS — Perform frequent neurovascular assessments of the digits distal to the cast. 6. CAST MONITORING — After the cast dries, monitor for: Hot spots — a localized area of warmth on the cast surface that may indicate infection or pressure ulcer beneath. Foul odor — indicates tissue breakdown or infection under the cast. Drainage — if drainage appears on the cast surface, CIRCLE THE DRAINAGE OUTLINE with a pen and write the DATE and TIME. Monitor if drainage is spreading. Report significant increases. Pressure ulcer signs — the patient may report increasing pain at a specific spot under the cast. 7. NEVER INSERT OBJECTS — Teach the patient NEVER to insert anything (pencil, ruler, chopstick) into the cast to scratch itching skin. This breaks the skin integrity and introduces bacteria, risking infection. Instead, recommend gentle tapping on the outside of the cast, a hair dryer on cool setting, or anti-itch medications. 8. KEEP CAST CLEAN AND DRY — Protect the cast from moisture (especially plaster). Cover with a plastic bag when showering. 9. PATIENT EDUCATION — Teach to report: increasing pain, numbness or tingling (paresthesia), skin changes at cast edges (maceration, sores), swelling that does not resolve with elevation, cast cracking or breaking. Specific Cast Types: Short arm cast (SAC) — wrist/forearm fractures. Long arm cast (LAC) — elbow/forearm fractures. Short leg cast (SLC) — ankle fractures. Long leg cast (LLC) — tibia/fibula fractures. Spica cast — hip or shoulder involvement; requires special positioning and log-rolling technique.

Principles of Traction

Traction is the application of a sustained pulling force to a body part to: reduce (realign) a fracture, maintain fracture alignment, relieve muscle spasm and pain, prevent or correct deformities, and immobilize a joint after injury or surgery. Types of Traction: 1. SKIN TRACTION — The pulling force is applied THROUGH THE SKIN using adhesive strips, foam boots, or bandages attached to weights. Common example: BUCK'S TRACTION — a short-term skin traction applied to the lower leg using a foam boot or adhesive straps, with weights typically 2–3.5 kg (5–8 lbs). Used pre-operatively for hip fractures to reduce pain and muscle spasm while awaiting surgery. Also used for low back pain or hip pain management. Limitations: Maximum weight is limited (skin cannot tolerate heavy weights); short-term use only (skin breakdown risk). 2. SKELETAL TRACTION — The pulling force is applied DIRECTLY TO THE BONE through a surgically inserted metal pin, wire, or tong (e.g., Steinmann pin or Kirschner wire through the distal femur or tibia; skull tongs for cervical spine injuries). Allows heavier weights and longer-term use. Main complication: PIN-SITE INFECTION (osteomyelitis risk). Nursing Care for ALL Traction (Traction Principles): 1. MAINTAIN THE PULL — Weights must HANG FREELY at all times. Never allow weights to rest on the floor, on the bed frame, or on any surface. Never remove or lift weights without a physician's order (removing weights removes the therapeutic force). 2. MAINTAIN ALIGNMENT — The patient must be kept in proper anatomical alignment. The body acts as COUNTERTRACTION (the opposing force). Prevent the patient from sliding to the foot of the bed (use the overhead trapeze). Keep the traction ropes in line with the pull force (straight line from the body part to the pulley). 3. ENSURE ROPES ARE ON PULLEYS — Check that the ropes are properly seated on the pulleys and that knots are tight and not frayed. Knots must not touch the pulleys (would interfere with the pull). 4. PIN-SITE CARE (for skeletal traction) — Perform pin-site care using ASEPTIC TECHNIQUE per physician order and hospital protocol. Typically involves cleaning around each pin with normal saline or chlorhexidine, then applying a sterile dressing. Assess pin sites for signs of infection: redness, warmth, swelling, purulent drainage, and LOOSENING of the pin (pin loosening in infected bone is an ominous sign). 5. NEUROVASCULAR CHECKS — Assess the affected extremity for the 6 Ps at regular intervals. 6. SKIN CARE — For skin traction, assess skin under the boot/straps for pressure sores. For all traction, perform regular pressure injury prevention measures (pad bony prominences, reposition as able, use pressure-redistribution mattress). 7. COMPLICATIONS OF IMMOBILITY — Traction requires prolonged bed rest, which risks: Pressure ulcers (especially sacrum, heels, occipital area), Deep Vein Thrombosis (DVT) — prophylaxis with anticoagulants (heparin) and compression stockings, Constipation (encourage fluids, high-fiber diet, stool softeners), Pneumonia/Atelectasis (encourage deep breathing and coughing exercises, incentive spirometry), Urinary tract infection (adequate hydration, proper perineal hygiene), Muscle wasting and contractures (range of motion exercises for unaffected joints), Depression and sensory deprivation (therapeutic communication, diversional activities). Under RA 9173, the nurse's independent functions include all of these preventive and monitoring activities — proactive care of the immobilized patient is a core nursing responsibility.

Assistive Devices and Gait Training

After musculoskeletal injury or orthopedic surgery, patients frequently need assistive devices to ambulate safely while protecting the injured limb. Nurses reinforce physical therapy teachings and assess safe use during ambulation. The three main assistive devices are crutches, walkers, and canes. CRUTCHES: Proper Fitting: When the patient stands upright, the axillary pad should be 2–3 finger-widths (approximately 5 cm or 2 inches) BELOW the axilla. The handgrip should be at wrist level (when the arm is at the side with slight elbow flexion). WEIGHT MUST BE BORNE ON THE HANDS AND WRISTS — NEVER ON THE AXILLA. If the patient leans on the axillary bar, the radial nerve (specifically the posterior cord of the brachial plexus) can be compressed, causing 'crutch palsy' — weakness or paralysis of the wrist extensors (wrist drop). Crutch Gaits: THREE-POINT GAIT: Used when ONE leg cannot bear weight at all (non-weight-bearing status). Sequence: Both crutches and the affected leg advance forward together (as a tripod unit), then the STRONG (unaffected) leg swings through. This is the most common gait after lower extremity fractures, ankle sprains, or post-operative procedures. FOUR-POINT GAIT: Used when BOTH legs can bear some weight. Sequence: Right crutch → Left foot → Left crutch → Right foot (alternating pattern). Slowest but most stable gait. TWO-POINT GAIT: Faster version of the four-point gait. Sequence: Right crutch and left foot together → Left crutch and right foot together. Both gaits (4-point and 2-point) are for partial weight-bearing patients. STAIR CLIMBING with Crutches — The golden rule: 'UP WITH THE GOOD, DOWN WITH THE BAD': Going UP stairs: The STRONG (unaffected) leg leads first up to the step, then the crutches and affected leg follow. Memory aid: 'Good goes to heaven first (goes up first).' Going DOWN stairs: The CRUTCHES and the AFFECTED (weak) leg go down first, then the STRONG leg follows. Memory aid: 'Bad goes to the ground first (goes down first).' WALKER: Provides the greatest stability of all assistive devices. Best for elderly patients and those with balance problems. Technique: Lift and advance the walker forward, place all four legs on the ground, then step into the walker (do not step TOO FAR into it — center of gravity must stay within the walker frame). Rolling walkers require slightly different instruction. CANE: Held on the STRONG (unaffected) side — the OPPOSITE side from the injury or weak leg. Rationale: When the cane is on the strong side, it advances with the weak leg. As the weak leg steps forward, the cane provides lateral support and reduces the load on the weak side. The handle should be at hip level (greater trochanter height). Fitting is correct when the elbow is at about 15–30 degrees of flexion. Memory aid: 'Cane with the CANE-ot side' — hold it on the side that CAN support you (the strong side).

This scenario presents the classic signs of ACUTE COMPARTMENT SYNDROME: (1) Increasing, unrelenting pain out of proportion to the injury and unrelieved by narcotics, (2) Severe pain on PASSIVE STRETCH (dorsiflexion of the foot stretches the anterior tibial compartment muscles), (3) Pallor, (4) Capillary refill >3 seconds (impaired perfusion), (5) Paresthesia (tingling = early nerve ischemia). This is a surgical emergency requiring FASCIOTOMY within hours to prevent permanent muscle and nerve damage. The nurse must immediately notify the physician, document all assessment findings with the time, stay with the patient, prepare for potential emergent fasciotomy, and avoid elevating the limb above heart level (elevation reduces arterial inflow and worsens ischemia in compartment syndrome). Under RA 9173, this constitutes both the nurse's independent function (assessment and reporting) and collaborative function (physician notification and preparation for intervention). Memorize: In compartment syndrome, DO NOT elevate — this is the OPPOSITE of routine fracture care.

The radioactive tracer (Tc-99m) requires 2–3 hours to circulate throughout the bloodstream and accumulate in areas of high bone turnover (hot spots). If the scan is performed too soon, the tracer will not have had sufficient time to localize, resulting in a non-diagnostic study. During the waiting period, the nurse should: (1) Encourage oral hydration (fluids help distribute the tracer evenly and promote renal excretion after the scan, reducing radiation exposure time), (2) Reassure the patient that the dose of radioactivity is very small and safe, (3) Instruct the patient to void before the scan (a full bladder may obscure pelvic bone images and cause discomfort during the scan). This is a commonly tested NLE nursing intervention for bone scan procedures.

Wet plaster is pliable and moldable. Fingertips exert concentrated point pressure that creates indentations (dents) in the wet cast. As the plaster hardens over the next 24–72 hours, these dents become hard internal protrusions that press against the underlying skin. This leads to: (1) Localized pressure injury (pressure ulcer) beneath the cast, manifesting as a 'hot spot' on the cast surface, foul odor, and persistent pain at the site, (2) Potentially progressing to full-thickness skin breakdown, infection, and osteomyelitis. The CORRECT technique is to use the PALMS of both hands to support the entire cast surface, distributing pressure evenly and preventing indentations. This is a patient-safety-critical technique and is frequently tested in NLE practical application questions.

In Buck's traction (skin traction), the pulling force must be continuous and unobstructed. When the weight rests on the footboard: (1) The therapeutic pull is lost, (2) Muscle spasm returns (causing increased hip pain), (3) Fracture alignment may be disrupted. Nursing interventions: (1) Instruct the patient to use the overhead trapeze and assist with repositioning upward in bed (restoring countertraction with body weight), (2) Ensure the traction weight is hanging freely off the foot of the bed, (3) Verify the rope is properly seated on the pulley with no knots touching the pulley, (4) Reassess the patient's pain level and neurovascular status, (5) Document the situation and the actions taken. Note: Weights must NEVER be removed or added without a physician's order. If the patient needs to be moved off the bed (e.g., for transport or surgery), this requires a physician's order to briefly maintain manual traction or release traction.

ERROR 1 CORRECTION: Weight must be borne on the HANDGRIPS, not the axillary pads. The axillary pads rest lightly against the chest wall for stability only. Bearing weight on the axilla compresses the radial nerve (posterior cord of the brachial plexus), causing CRUTCH PALSY — manifested as wrist drop, weakness in wrist and finger extension, and decreased sensation over the dorsum of the hand and thumb. The space between the axillary pad and axilla should be 2–3 finger-widths (5 cm). ERROR 2 CORRECTION: The rule for stairs is 'UP WITH THE GOOD, DOWN WITH THE BAD.' Going DOWN stairs: The CRUTCHES and AFFECTED (right) leg go DOWN first to the lower step, then the STRONG (left) leg follows. The patient was doing the OPPOSITE (going down with the good leg first, which is actually the pattern for going UP stairs). Re-educate and have the patient perform another return demonstration before being cleared for independent ambulation.

Post-arthroscopy, the priority assessment is NEUROVASCULAR STATUS of the affected extremity — assess circulation (capillary refill, skin color, pulse), sensation (paresthesia), and movement of the toes. This is the highest-priority action because arthroscopy carries risk of neurovascular injury from positioning, tourniquet use, or swelling. FIRST INTERVENTIONS: (1) Complete neurovascular assessment (assess and document all 6 Ps), (2) Apply compression dressing (reduces bleeding and edema) and ICE (wrapped in cloth; apply over the dressing to reduce swelling and pain; do not apply ice directly to skin), (3) ELEVATE the right lower extremity above heart level (reduces swelling by promoting venous and lymphatic drainage). Additional nursing actions: Monitor for signs of infection at the port sites (redness, drainage, fever). Provide analgesics as ordered. Educate the patient to report: increasing pain, fever >38°C, excessive swelling, or wound drainage. Limit weight-bearing and strenuous activity as per orthopedic surgeon orders. This post-procedure care bundle is frequently tested in NLE situational questions.