NLE Musculoskeletal Nursing — Musculoskeletal Assessment and DiagnosticsRevision Notes

Exam Tips

• NLE frequently tests the osteoblast vs. osteoclast distinction in the context of fracture healing and osteoporosis drug mechanisms.
• Know the three joint classifications and one example of each — a common NLE fill-in-the-blank type question.
• PTH raises blood calcium (stimulates osteoclasts); Calcitonin lowers blood calcium (inhibits osteoclasts). These are common pharmacology linkages tested in the NLE.
• Alkaline phosphatase is elevated when osteoblastic (bone-building) activity is high — as in fracture healing, Paget's disease, and bone tumors. Connect this to lab diagnostics.

Key Points

• Bone is LIVING, vascular tissue — it continuously remodels through the balanced activity of osteoblasts (BUILD bone) and osteoclasts (RESORB bone). Memory tip: 'B for Build = oBLast; R for Resorb = oCLast'.
• Bone stores CALCIUM and PHOSPHORUS. These minerals are regulated by three hormones: Parathyroid hormone (PTH) — raises blood calcium by stimulating osteoclasts and kidney reabsorption; Calcitonin — lowers blood calcium by inhibiting osteoclasts; Vitamin D — increases calcium absorption from the gut.
• Bone also performs HEMATOPOIESIS — the production of blood cells in red bone marrow (found in flat bones and the ends of long bones). This is why bone marrow biopsy sites include the iliac crest and sternum.
• Supporting structures: Tendons (muscle to bone), Ligaments (bone to bone), Cartilage (cushions joint surfaces, avascular — heals slowly), Bursae (fluid-filled sacs that reduce friction at joints).
• The three joint classifications by movement are: Synarthrodial (immovable — e.g., skull sutures), Amphiarthrodial (slightly movable — e.g., intervertebral joints, pubic symphysis), Diarthrodial/Synovial (freely movable — e.g., knee, hip, shoulder, elbow). Synovial joints have articular cartilage and a synovial membrane secreting lubricating synovial fluid.

Definitions

Section Title

Functional Anatomy of the Musculoskeletal System

Common Mistakes

• Confusing osteoblasts (build) with osteoclasts (resorb) — a very common NLE trap. Remember: 'BLAST = BUILD; CLAST = CRUSH/RESORB'.
• Forgetting that cartilage is AVASCULAR — students sometimes say cartilage has poor blood supply, but it has NONE (avascular). This is why articular cartilage injuries heal poorly.
• Mixing up tendons and ligaments: Tendons = Muscle-to-Bone (T for 'Ties muscle to bone'); Ligaments = Bone-to-Bone (L for 'Links bone to bone').
• Forgetting hematopoiesis as a bone function — bone is more than just a structural scaffold. Red bone marrow produces RBCs, WBCs, and platelets.

Exam Tips

• When an NLE question describes a patient with morning stiffness lasting 2 hours, bilateral joint involvement, and positive rheumatoid factor — think RHEUMATOID ARTHRITIS.
• When a question describes an elderly patient with knee pain that worsens after climbing stairs and improves with rest — think OSTEOARTHRITIS.
• PQRST is not just for pain — use it as a framework for assessing any musculoskeletal symptom (swelling, stiffness, weakness).

Key Points

• Use the PQRST framework to fully characterize musculoskeletal pain: Provocation/Palliation (what makes it better or worse?), Quality (sharp, dull, aching, burning?), Region/Radiation (where exactly? does it radiate?), Severity (0–10 pain scale), Timing (constant vs. intermittent? onset? duration?).
• KEY CLINICAL DISTINCTION — Morning stiffness lasting MORE than 1 hour = hallmark of RHEUMATOID ARTHRITIS (an inflammatory condition). Stiffness that worsens AFTER activity or at end of day = hallmark of OSTEOARTHRITIS (a degenerative condition). This distinction frequently appears in NLE situational questions.
• Always ask about MECHANISM OF INJURY — was there a fall, a twisting force, a direct blow? In elderly Filipino patients, ask about fall history and home hazards (especially slippery floors, no grab bars in the CR/comfort room).
• Medications to specifically ask about: Corticosteroids (prolonged use causes osteoporosis and avascular necrosis), Anticoagulants/antiplatelet drugs (affect bleeding risk for procedures and surgery), Bisphosphonates (used for osteoporosis — ask about dental procedures, as rare side effect is osteonecrosis of jaw).
• Assess nutritional history: calcium intake (dairy, green leafy vegetables common in the Filipino diet such as malunggay/moringa, kangkong), vitamin D (sunlight exposure, fish such as galunggong/sardines), and alcohol/tobacco use (both decrease bone density).

Definitions

Section Title

Musculoskeletal Health History

Common Mistakes

• Using only a numeric pain scale without qualifying the character and timing of pain — the NLE expects holistic PQRST assessment.
• Forgetting to ask about corticosteroid use as a risk factor for osteoporosis — many Filipino patients with asthma, lupus, or nephrotic syndrome are on long-term steroids.
• Missing the morning stiffness distinction between RA (>1 hour) and OA (improves with movement) — this is a high-frequency NLE question.

Exam Tips

• NLE questions about muscle strength grading often ask: 'The nurse notes the patient can raise their arm to comb their hair but cannot hold the arm up when the nurse pushes down.' This describes Grade 4 (movement against some resistance).
• A patient who can only move their leg when it is supported on the bed (gravity eliminated) has muscle strength Grade 2.
• The goniometer question is straightforward: it measures joint angles. Link it to ROM documentation.
• Remember the two gait phases: Stance (weight-bearing) and Swing (non-weight-bearing). Antalgic gait = SHORT stance phase on the PAINFUL side.

Key Points

• Follow the systematic sequence: INSPECT → PALPATE → MOVE. Always compare the affected side with the UNAFFECTED (contralateral) side for symmetry and as a baseline.
• INSPECTION: Look for swelling (edema, effusion), deformity (angulation, shortening, rotation), muscle atrophy (wasting from disuse), redness (erythema — suggests inflammation or infection), abnormal posture, and skin integrity.
• PALPATION: Feel for tenderness (point vs. diffuse), warmth (increased heat = inflammation), crepitus (a grating or crackling sensation/sound with joint movement — suggests cartilage damage or fracture fragments), and masses. Always palpate gently and observe the patient's facial expression for pain.
• MUSCLE STRENGTH GRADING (0–5 scale) — must memorize: 0 = No contraction (complete paralysis); 1 = Trace contraction visible/palpable but no movement; 2 = Movement with gravity eliminated (can move if arm is supported); 3 = Movement AGAINST GRAVITY only (can raise limb); 4 = Movement against SOME resistance; 5 = FULL STRENGTH against full resistance (NORMAL). Grade 3 is the clinical milestone — the patient can move against gravity.
• RANGE OF MOTION (ROM): Assess ACTIVELY first (patient moves the joint independently). If limited, then assess PASSIVELY (examiner moves the joint gently). Document movements: Flexion/Extension, Abduction/Adduction, Internal/External Rotation, Pronation/Supination (forearm). A GONIOMETER is the instrument used to measure joint angles precisely in degrees.
• NEVER force a joint through resistance or pain — this can worsen injury. If a patient resists passive movement due to muscle spasm, stop and document.
• GAIT ASSESSMENT: Two phases — STANCE PHASE (foot in contact with ground, bears weight — 60% of gait cycle) and SWING PHASE (foot moving forward, not bearing weight — 40%). Observe symmetry, stride length, arm swing, trunk stability. KEY ABNORMAL GAITS: Antalgic gait = shortened stance phase on the PAINFUL side (patient rushes to get weight off the painful leg); Shuffling gait = Parkinson's disease; Wide-based ataxic gait = cerebellar disease. Always assess fall risk during gait assessment and GUARD the patient.

Definitions

Section Title

Physical Assessment: Inspection, Palpation, and Range of Motion

Common Mistakes

• Beginning ROM assessment with passive movement instead of active — always ask the patient to move the joint first to detect pain and patient-controlled limitations before the examiner applies any force.
• Confusing the muscle strength scale numbers — memorize that 3 = against gravity only (no resistance), 4 = against SOME resistance, 5 = against FULL resistance (NORMAL).
• Not comparing bilateral sides — asymmetry is often the most important finding in musculoskeletal assessment.
• Forgetting to guard the patient during gait assessment — a very common clinical error and potential legal liability under RA 9173's standard of care provisions.

Exam Tips

• NLE PATTERN: 'A patient with a forearm cast reports increasing pain that is NOT relieved by pain medication. What is the PRIORITY nursing action?' Answer: Perform a neurovascular assessment immediately (check the 6 Ps, especially passive stretch), then report to the physician. The pain 'not relieved by analgesia' is the classic compartment syndrome red flag.
• Memorize the order of the 6 Ps from earliest to latest: Pain (EARLIEST) → Paresthesia → Pallor → Poikilothermia → Pulselessness (LATE) → Paralysis (LATE).
• The mnemonic for the 6 Ps: 'Pretty Pigeons Prefer Perching Peacefully, Pal' — Pain, Paresthesia, Pallor, Poikilothermia, Pulselessness, Paralysis.
• Capillary refill: Normal is LESS THAN 3 seconds. Any answer choice that says '2 seconds is abnormal' is incorrect.
• Priority nursing diagnosis for impaired neurovascular status: 'Risk for Peripheral Neurovascular Dysfunction' (NANDA-I). This is higher priority than pain management when perfusion is at risk, per Maslow's hierarchy (physiological safety first).

Key Points

• Neurovascular assessment (NVA) is MANDATORY and FREQUENT for any patient with: a fracture, cast, splint, traction, or following orthopedic surgery. The frequency is typically every 15–30 minutes immediately post-injury/surgery, then every 1–2 hours, then every 4 hours as the patient stabilizes — follow physician orders and facility protocol.
• ALWAYS compare the affected extremity with the OPPOSITE (unaffected) extremity as your baseline. Document findings clearly.
• THE 5 Ps (or 6 Ps) OF NEUROVASCULAR ASSESSMENT — memorize in order of appearance (earliest to latest sign of compromise): 1. PAIN (EARLIEST SIGN), 2. PARESTHESIA (early), 3. PALLOR (early to middle), 4. POIKILOTHERMIA/coolness (middle), 5. PULSELESSNESS (LATE, OMINOUS), 6. PARALYSIS (LATE SIGN).
• THE MOST CRITICAL FINDING: PAIN OUT OF PROPORTION to the injury, AND/OR pain on PASSIVE STRETCH of the fingers or toes (i.e., the nurse gently extends the patient's toes/fingers and this causes SEVERE pain in the calf or forearm) = EARLIEST AND MOST RELIABLE SIGN of developing COMPARTMENT SYNDROME.
• CAPILLARY REFILL: Normal = UNDER 3 seconds (press the nail bed until it blanches, release, count how quickly the pink color returns). Greater than 3 seconds = impaired circulation.
• COMPARTMENT SYNDROME: A surgical emergency. Caused by increased pressure within a muscle compartment (from swelling inside a cast, tight dressings, or internal bleeding) that compromises blood flow to nerves and muscles. Classic presentation: the 6 Ps with PAIN being the EARLIEST and most prominent. Treatment: FASCIOTOMY (surgical incision to release the compartment pressure). If untreated within hours, permanent nerve and muscle damage (Volkmann's ischemic contracture in the forearm) can result.
• NURSING RESPONSE to deteriorating NVA: IMMEDIATELY notify the physician/surgeon. Do NOT wait. Loosen or bivalve the cast if ordered. ELEVATE is generally done for swelling prevention, BUT if arterial compromise is suspected, do NOT elevate above heart level (this would decrease arterial pressure to the limb further — elevation is appropriate for venous/swelling issues, not arterial occlusion).
• Assess also: WARMTH vs. coolness, skin COLOR (pink/pale/dusky/cyanotic), EDEMA (measure limb circumference if ordered), and ability to move digits.

Definitions

Section Title

Neurovascular Assessment: The Critical Safety Skill

Common Mistakes

• Waiting too long to report deteriorating neurovascular findings — compartment syndrome can cause irreversible damage within 4–6 hours. Immediate reporting is a legal and ethical obligation under RA 9173.
• Thinking pulselessness is the EARLIEST sign of compartment syndrome — it is actually a LATE and ominous sign. Pain on passive stretch is the EARLIEST.
• Forgetting to perform the passive stretch test — many students omit this critical component of the NVA.
• Elevating a limb with suspected ARTERIAL compromise — elevation reduces arterial inflow. Reserve elevation for VENOUS/SWELLING issues (e.g., post-cast application swelling). In arterial occlusion, keep limb at heart level.

Exam Tips

• KEY IMAGING MNEMONICS: X-ray = BONES (first-line, cheap, accessible in Philippine barangay health centers and district hospitals); CT = COMPLEX bony detail and trauma; MRI = SOFT TISSUE and MARROW (most expensive, not always available in rural Philippine hospitals); Bone scan = METABOLIC ACTIVITY and occult fractures.
• MRI METAL SCREENING question pattern: 'Before MRI, the nurse should FIRST...' — Answer: Screen for and remove all metal objects; confirm no implanted metal devices (pacemaker, cochlear implant).
• DEXA T-score memorization: Normal ≥ -1.0; Osteopenia = -1.0 to -2.5; Osteoporosis ≤ -2.5. Think: '-2.5 and BELOW = disease (Osteoporosis)'.
• Post-arthroscopy: 3 priority actions = Neurovascular check + Compression/Ice/Elevation + Teach fever/pain/swelling reporting. This is a classic NLE post-procedure nursing care question.
• Gout: Uric acid crystals are NEEDLE-SHAPED (monosodium urate). Pseudogout: RHOMBOID-shaped calcium pyrophosphate crystals. The shape difference is a NLE trivia favorite.

Key Points

• PLAIN X-RAY (Radiography): FIRST-LINE and most common imaging for fractures, dislocations, and bone alignment. Shows bony structures clearly but POOR visualization of soft tissue (cartilage, ligaments, tendons, muscles). No contrast needed. Nursing: confirm no pregnancy (especially important in Filipino female patients of childbearing age), remove metal objects/jewelry, and shield reproductive organs if possible.
• COMPUTED TOMOGRAPHY (CT SCAN): Excellent for COMPLEX fractures (especially spinal, pelvic, calcaneal), cross-sectional bony detail, and surgical planning. If CONTRAST is used: assess for allergy to iodine/shellfish/previous contrast reactions (may require pre-medication with steroids and antihistamines), check serum creatinine/BUN for renal function (contrast is nephrotoxic — hold metformin 48 hours before and after contrast CT if on it), ensure adequate hydration.
• MAGNETIC RESONANCE IMAGING (MRI): GOLD STANDARD for SOFT TISSUE visualization — ligament tears, tendon ruptures, meniscus injuries, herniated intervertebral discs, cartilage damage, osteomyelitis, bone marrow abnormalities, and soft tissue tumors. No ionizing radiation. Nursing pre-MRI SAFETY SCREENING (CRITICAL): Screen and REMOVE all metal objects — jewelry, hairpins, piercings, clothing with metallic fibers. ABSOLUTE CONTRAINDICATIONS: certain cardiac pacemakers, cochlear implants, certain intracranial aneurysm clips, and some orthopedic implants (check manufacturer). Warn patient about: enclosed space (claustrophobia — anxiolytic may be ordered), LOUD banging/knocking noise (ear protection provided), and the need to remain STILL for 30–60 minutes.
• BONE SCAN (Radionuclide Scintigraphy): Uses an intravenously injected radioactive tracer — TECHNETIUM-99m (Tc-99m) — which is taken up by areas of HIGH bone turnover (osteoblastic activity). HOT SPOTS (increased uptake) = bone metastases/cancer, osteomyelitis (bone infection), occult (hidden) fractures not seen on X-ray, Paget's disease. COLD SPOTS (decreased uptake) = avascular necrosis. NURSING: (1) Wait 2–3 HOURS after injection for the tracer to distribute before scanning; (2) ENCOURAGE FLUIDS to promote tracer distribution and renal EXCRETION after the scan; (3) Have patient VOID before scanning for pelvic/hip views; (4) Reassure patient that the radiation dose is SMALL (comparable to a CT scan) and the tracer clears from the body within 24 hours.
• DEXA SCAN (Dual-Energy X-ray Absorptiometry): Measures BONE MINERAL DENSITY (BMD) to diagnose OSTEOPOROSIS. Results reported as a T-SCORE: T-score of -1.0 or above = NORMAL; T-score of -1.0 to -2.5 = OSTEOPENIA (low bone mass); T-score of -2.5 or below = OSTEOPOROSIS. Quick, painless, low radiation. No special prep. Filipino women over 65 and postmenopausal women are priority screening candidates.
• ARTHROSCOPY: Fiberoptic scope inserted into a joint (most commonly KNEE or SHOULDER) through a small portal. Allows direct visualization, biopsy, and surgical repair (e.g., meniscus repair, ACL reconstruction) — minimally invasive. Done under anesthesia (general or regional). Pre-procedure: Informed consent (the nurse verifies it is signed per RA 9173 and hospital protocol), NPO as ordered. Post-procedure nursing care: Neurovascular checks distal to the site, compression dressing and ICE (to reduce swelling and pain), ELEVATE the extremity, monitor for bleeding/hematoma, teach patient to report FEVER or increasing PAIN/SWELLING (signs of infection — septic arthritis), limit strenuous activity per physician order.
• ARTHROCENTESIS (Joint Aspiration): A needle is inserted into the joint space to aspirate SYNOVIAL FLUID. Purposes: (1) Diagnostic — analyze fluid for infection (WBC count, culture), gout crystals (urate = needle-shaped, negatively birefringent; pseudogout = rhomboid-shaped), or hemarthrosis (blood from ligament/meniscus injury); (2) Therapeutic — relieve pressure and pain from effusion. Post-procedure: Apply pressure dressing, monitor for re-accumulation of fluid and signs of infection.
• KEY LABORATORY TESTS: Serum CALCIUM and PHOSPHORUS (bone mineral status); Alkaline PHOSPHATASE — elevated with bone healing, Paget's disease, bone tumors (osteoblastic activity marker); URIC ACID — elevated in GOUT (target: <6 mg/dL with urate-lowering therapy); ESR (Erythrocyte Sedimentation Rate) and CRP (C-Reactive Protein) — non-specific markers of INFLAMMATION and INFECTION (elevated in RA, osteomyelitis, septic arthritis); RHEUMATOID FACTOR (RF) and ANTI-CCP antibodies — for diagnosing RHEUMATOID ARTHRITIS (Anti-CCP is more specific and may be positive earlier).

Definitions

Section Title

Diagnostic Studies: Imaging and Laboratory Tests

Common Mistakes

• Saying MRI is contraindicated in ALL patients with any metal implant — modern orthopedic implants (titanium rods, some plates) are often MRI-compatible. The nurse must CHECK the specific implant manufacturer's documentation.
• Forgetting to check RENAL FUNCTION before contrast CT — iodine-based contrast is nephrotoxic. In the Philippine setting where CKD is prevalent, this is a critical safety step.
• Confusing X-ray (shows bone) with MRI (shows soft tissue) — a common NLE scenario: 'A patient with a knee injury has a normal X-ray. The next recommended study is...' Answer: MRI (to see ligaments, cartilage, menisci).
• Not encouraging fluids after a bone scan — this is a specific, testable nursing action. The tracer is excreted by the kidneys, and fluids help reduce radiation exposure to the bladder.
• Forgetting to have the patient VOID before a bone scan of the pelvis/hip — the bladder accumulates tracer and can obscure pelvic bone findings on the scan.

Exam Tips

• HIGH-FREQUENCY NLE QUESTION: 'A nurse is applying a wet plaster cast. How should the nurse support it?' Answer: With the PALMS of both hands, not the fingertips.
• SEQUENCE OF POST-CAST APPLICATION NURSING CARE: (1) Elevate above heart level, (2) Apply ice, (3) Perform neurovascular checks, (4) Do NOT cover cast while wet, (5) Teach patient danger signs.
• Connect cast complications to the neurovascular assessment — increasing pain in a casted extremity ALWAYS warrants an immediate neurovascular check and physician notification.
• Plaster cast drying time: 24–72 hours. Fiberglass: ~30 minutes. This fact appears in NLE timing/priority questions.

Key Points

• TYPES OF CASTS: PLASTER casts — heavier, chalky white, take 24–72 hours to fully dry/cure (exothermic — generates heat while drying, which is NORMAL and should be explained to the patient). FIBERGLASS casts — lighter, available in colors, dry within 30 minutes, water-resistant (but the padding underneath is NOT — if it gets wet, the skin under cast can macerate). Plaster is more moldable and cheaper; fiberglass is more durable and lighter for long-term use.
• HANDLING A WET PLASTER CAST: Support ONLY with the PALMS of your hands — NEVER the fingertips. Fingertip pressure creates dents (indentations) in the soft plaster that harden into internal pressure points, causing pressure ulcers and neurapraxia under the cast. This is a classic NLE nursing action question.
• DRYING A WET CAST: Allow to air dry — do NOT cover with blankets or use a hair dryer/heat lamp (these can cause uneven drying, burns, or cracking). Reposition the patient every 2 hours to allow even drying. Keep the cast EXPOSED (uncovered) for air circulation.
• ELEVATE the casted extremity ABOVE HEART LEVEL for the first 24–48 hours post-application to reduce dependent edema and swelling. Apply ICE BAGS (wrapped in a cloth) to each side of the cast for the first 24 hours.
• NEUROVASCULAR CHECKS: Perform regularly after cast application per protocol (as above). A cast that was applied when there was little swelling may become too tight as swelling develops. BIVALVING (cutting the cast in half lengthwise) or WINDOWING (cutting an opening) may be ordered to relieve pressure.
• SIGNS OF COMPLICATIONS TO REPORT: (1) INCREASING PAIN or pain NOT relieved by elevation and analgesia (compartment syndrome); (2) NUMBNESS or tingling (nerve compression); (3) PALLOR or cyanosis of fingers/toes (vascular compromise); (4) DRAINAGE on the cast — circle and DATE the drainage mark to monitor for spread; a foul odor suggests infection or tissue necrosis under the cast; (5) HOT SPOT felt through the cast — suggests localized infection; (6) CAST EDGES digging into skin (petaling with tape may be done by the nurse to protect skin).
• PATIENT TEACHING (critical for home cast care): NEVER insert objects into the cast to scratch — this breaks skin integrity and introduces bacteria, leading to infection and skin breakdown. Keep the cast CLEAN and DRY. Do not bear weight on a new cast until approved by the physician. Report increasing pain, swelling, numbness, color change, or foul smell immediately. In Philippine community settings, advise patients to go to the nearest RHU (Rural Health Unit) or hospital if any of these occur.
• CAST PETALING: The nurse tucks small strips of moleskin or adhesive tape (cut with petal-shaped curved edges) over the rough cast edges at the proximal and distal ends to protect the skin from abrasion.

Definitions

Section Title

Principles of Cast Care

Common Mistakes

• Using fingertips instead of palms to support a wet cast — a classic NLE trap. Always use the PALMS.
• Covering a wet plaster cast with blankets to 'keep the patient warm' — this traps moisture and heat, causes uneven drying, and can cause the cast to crack or burn the skin.
• Telling patients it is acceptable to insert a blunt object (like a ruler) to scratch inside the cast — this is NEVER acceptable and must be explicitly taught against.
• Not circling drainage on the cast — without marking the original border and time, you cannot assess whether drainage is increasing.

Exam Tips

• NLE PATTERN: 'The nurse assesses that the weights of a patient in traction are resting on the floor. What should the nurse do?' Answer: REPOSITION THE PATIENT in bed (move them toward the head of the bed) so the weights hang freely — do NOT remove the weights.
• Buck's traction = SKIN traction = light weights (up to 3.5 kg) = no pin-site care needed. Contrast with skeletal traction = heavier weights = pin-site care required.
• The five principles of traction nursing care are all NLE-testable: Weights hang freely, ropes in grooves, knots secure, countertraction maintained, patient aligned.
• DVT prevention in traction = ankle pumps + compression devices + anticoagulation as ordered. This is a Maslow physiological safety priority.

Key Points

• DEFINITION AND PURPOSE: Traction applies a PULLING FORCE to a body part. Purposes: (1) Reduce (align) fractures; (2) Immobilize fractures and maintain alignment; (3) Correct or prevent deformities; (4) Relieve muscle spasm and pain; (5) Maintain skeletal alignment pre-operatively.
• TYPES: SKIN TRACTION — pull is applied THROUGH THE SKIN using adhesive strips, foam boots, or bandages. Example: BUCK'S TRACTION (lower extremity, especially used for hip fracture patients before surgery and for hip muscle spasm). Weight limit: 2–3.5 kg (light weight). Short-term use only. Skin must be assessed for breakdown. SKELETAL TRACTION — pull applied DIRECTLY TO BONE through a surgically inserted metal PIN or WIRE through the bone. Examples: Steinmann pin through the distal femur; Crutchfield tongs through the skull for cervical spine traction. Allows HEAVIER weights for longer periods. Risk: PIN-SITE INFECTION.
• FIVE PRINCIPLES OF TRACTION NURSING CARE (All must be maintained): (1) WEIGHTS must HANG FREELY — never allow weights to rest on the floor, bed, or chair. Never remove or adjust weights without a PHYSICIAN'S ORDER. (2) ROPES must remain in the GROOVES of the PULLEYS — inspect regularly; a rope off a pulley means traction is lost. (3) KNOTS must be secure and should NOT be against the pulley. (4) COUNTERTRACTION must be maintained — usually provided by the patient's own body weight (head of bed elevated for lower extremity traction). (5) The patient must be in CORRECT ALIGNMENT — traction is only effective if the patient is in proper position and not sliding toward the foot of the bed.
• PIN-SITE CARE (Skeletal Traction): Use ASEPTIC TECHNIQUE. Clean pin sites as ordered (typically with normal saline or chlorhexidine per hospital protocol). Assess for signs of PIN-SITE INFECTION: redness, warmth, swelling, purulent drainage, loosening of the pin. A loose pin is both a sign of infection and a loss of traction effectiveness — report immediately.
• COMPLICATIONS OF IMMOBILITY in traction (Prevention is key): PRESSURE INJURIES (skin breakdown — use pressure-relieving devices, reposition within the constraints of traction), DEEP VEIN THROMBOSIS/DVT (encourage ankle pumps, foot circles, use anti-embolic stockings/compression devices as ordered, administer anticoagulants as ordered), CONSTIPATION (increase fluid and fiber intake, use stool softeners), HYPOSTATIC PNEUMONIA (encourage deep breathing and coughing every 2 hours, use incentive spirometer), URINARY TRACT INFECTION (maintain adequate hydration, proper perineal care), MUSCLE ATROPHY (encourage isometric exercises of uninvolved muscles).
• PERFORMING NEUROVASCULAR CHECKS is essential in traction patients — the traction weight and position can cause circulatory compromise.

Definitions

Section Title

Principles of Traction

Common Mistakes

• Removing traction weights to reposition or turn the patient WITHOUT a physician's order — this is a serious nursing error. Document the issue and contact the physician before removing weights.
• Allowing traction weights to rest on the floor when the patient is moved toward the head of bed — the nurse must reposition the patient, NOT remove or rest the weights.
• Forgetting immobility complications — traction patients are at very high risk for DVT, pneumonia, pressure ulcers, and constipation. Preventive nursing care must be planned and documented.
• Neglecting pin-site assessment in skeletal traction — pin-site infections can progress to osteomyelitis rapidly.

Exam Tips

• STAIR RULE MEMORY TIP: 'UP with the GOOD (strong), DOWN with the BAD (weak/crutches).' This is one of the most frequently tested ambulatory aid questions in the NLE.
• CANE RULE: Strong side. CRUTCH WEIGHT: On the HANDS. Two distinct rules — do not mix them up.
• Three-point gait = one non-weight-bearing leg. Both crutches + affected leg advance first. Strong leg swings through second.
• Walker = most stability; Cane = least stability. Match the device to the patient's balance and weight-bearing status.

Key Points

• CRUTCHES — CORRECT FIT: The axillary pad should be 2–3 finger-widths (approximately 5 cm) BELOW the axilla when the patient is standing. Elbow should be slightly flexed (20–30 degrees) when hands are on the hand grips. CRITICAL: WEIGHT IS BORNE ON THE HANDS (hand grips), NEVER on the AXILLA. Pressure on the axillary pad can compress the BRACHIAL PLEXUS (radial nerve), causing 'CRUTCH PALSY' — wrist drop and hand weakness.
• CRUTCH GAITS: THREE-POINT GAIT — used when ONE leg CANNOT bear ANY weight (e.g., post-fracture, non-weight-bearing order). Sequence: BOTH crutches + AFFECTED (weak) leg advance TOGETHER, then the STRONG leg swings through (or steps through). This is the most common crutch gait in the orthopedic setting. FOUR-POINT GAIT — used when BOTH legs can bear SOME weight; requires coordination; Sequence: right crutch → left foot → left crutch → right foot. MOST STABLE but slow. TWO-POINT GAIT — faster version of four-point; right crutch + left foot together → left crutch + right foot together. SWING-TO GAIT / SWING-THROUGH GAIT — for patients with bilateral lower extremity involvement (e.g., paraplegia).
• STAIR CLIMBING WITH CRUTCHES — THE GOLDEN RULE: 'UP WITH THE GOOD, DOWN WITH THE BAD.' Going UP stairs: STRONG (unaffected) leg leads FIRST, then crutches + weak leg follow. Going DOWN stairs: CRUTCHES + WEAK (affected) leg lead FIRST DOWN, then strong leg follows. Memory tip: 'Good goes to Heaven (UP); Bad goes Down (to Hell).' This is a HIGH-FREQUENCY NLE question.
• WALKER — provides the MOST STABILITY of all assistive devices. Technique: Lift and advance the walker (place all four legs down on the floor), then step INTO the walker (first the weaker leg, then the stronger). Do not slide the walker — always lift it. Appropriate for patients needing maximum support (elderly, bilateral weakness). A ROLLATOR (wheeled walker) requires less lifting but provides less stability — appropriate for patients with adequate balance.
• CANE — provides the LEAST support among assistive devices. Held on the STRONG (UNAFFECTED) SIDE. The cane and the WEAK leg advance TOGETHER, creating a broader base of support on the weak side. Moving the cane to the SAME SIDE as the weak leg is INCORRECT and increases fall risk. The handle of the cane should be at the level of the greater trochanter (wrist crease with arm hanging loosely).
• GENERAL FALL PREVENTION: Always assess environment — clear pathways, non-slip mats (important in Filipino homes where floors may be ceramic/polished tile), adequate lighting, wear proper footwear. In Philippine hospitals, use the Morse Fall Scale for risk assessment.

Definitions

Section Title

Assistive Devices and Gait Training

Common Mistakes

• Teaching patients to hold the cane on the SAME SIDE as the weak leg — this is INCORRECT. The cane goes on the STRONG SIDE.
• Incorrectly teaching stair climbing: many students reverse the rule. Memorize: UP → Strong leg first; DOWN → Crutches + weak leg first.
• Accepting a crutch fit where the axillary pad is touching the axilla — there must always be 2–3 finger-widths of space to prevent brachial plexus compression.
• Using a walker by sliding it instead of lifting it — this causes uneven surface navigation problems and falls.