N513 - Muskuloskeletal Problems

Created by susan1982 

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Exam 3

What is the difference between a sprain and a strain?

Sprain: structural injury to tendons or ligaments
Complication: avulsion fracture
Strain: excessive stretching of muscle

What acute interventions should be done for strains/sprains?

RICE
Rest
Ice
Compression
Elevate

Describe the 6 healing stages of a fracture

1. Hematoma formation
2. Granulation:Days 3-14
3. Callus: New, but unorganized bone matrix
4. Ossification: From week 3 to 6 months
Healing complete, but not totally stable
5. Consolidation: Healing confirmed by x-ray
6. Remodeling: Completion may take up to a year

hat 4 things could delay ossification?

Inadequate reduction and immobilization
Excessive movement
Infection
Poor nutrition
Systemic disease

What is closed reduction?

- Nonsurgical
- Traction and countertraction manually applied to bone fragments to restore position, length, and alignment

What is open reduction?

- Correction of bone alignment through surgical incision
- Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails

What are the disadvantages of open reduction?

Possibility of infections
Complications associated with anesthesia
Effects of premorbid medical conditions

What is traction?

Application of a pulling force to an injured or diseased part of body or extremity while counter traction pulls in opposite direction

Purpose of any traction
- Prevent or ↓ muscle spasm
- Immobilize joint or part of body
- Reduce a fracture or dislocation
- Treat a pathologic joint condition

What neurovascular assessment should be done for fractures?

Neurovascular assessment
Circulation: Color, warmth, capillary refill, pulses, edema
Motion
Sensation: Extreme pain, numbness/tingling

What post op care should be provided for fractures?

Immediate assessment of surgical site
CMS, ongoing assessment
Assessment of pin sites, as appropriate
Education on mobilization plan
General post-op considerations, especially with immobility
- Potential for renal calculi

What are the 'Do's" of cast care?

Apply ice directly over fracture site for first 24 hours
Check with health care provider before getting fiberglass wet
Dry cast after exposure to water
Elevate extremity above level of heart for first 48 hours
Move joints above and below cast regularly
Report signs of possible problems to health care provider
Keep appointment to have fracture and cast checked

What are the "Dont's" of cast care?

DON'T
Get plaster cast wet
Remove any padding
Insert any objects inside cast
Bear weight on new cast for 48 hours
Not all casts are weight-bearing
Cover cast with plastic for prolonged periods

What is compartment syndrome?

Elevated intracompartmental pressure within a confined myofascial compartment
Compromises neurovascular function of tissues within that space

What can cause compartment syndrome?

Restrictive casts, splints, dressings
Swelling, internal bleeding

what are the 6 P's of impending compartment syndrome?

Paresthesia: Numbness and tingling
Pain: Distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through compartment
Pressure: ↑ in compartment
Pallor: Coolness, and loss of normal color of extremity
Paralysis: Loss of function
Pulselessness: Diminished/absent peripheral pulses

What renal complication can compartment syndrome cause and how does it come about?

Myoglobin released from damaged muscle cells precipitates as a gel-like substance
Causes obstruction in renal tubules
May result in acute tubular necrosis
Common signs of myoglobinuria
Dark reddish brown urine
Clinical manifestations associated with acute renal failure

How do you treat compartment syndrome?

Do not elevate extremity above heart level
Elevation may raise venous pressure and slow arterial perfusion
Do not apply cold compresses
May result in vasoconstriction and exacerbate compartment syndrome
Pressure must be relieved
Remove or loosen bandage or bivalve cast
Reduction in traction weight may ↓ external circumferential pressures
Surgical decompression may be necessary

What can lead to venous thrombosis?

Incorrectly applied casts or traction
Local pressure on a vein
Immobility

How can you prevent venous thrombosis?

Wear compression gradient stockings
Move fingers or toes of affected extremity against resistance and perform ROM exercises
Prophylactic anticoagulant drugs

What is FES?

Fat globules from fracture are distributed into tissues and organs after a traumatic skeletal injury
Enter circulation and lodge in: Lungs. Brain, Heart
Kidneys, Skin
Contributory factor in many deaths associated with fractures
*Most common in fractures of long bones, ribs, tibia, and pelvis

What are the clinical mainfestations of FES?

Initial manifestations occur 24-48 hours after injury
Lung damage manifests as hemorrhagic interstitial pneumonitis
Signs and symptoms of acute respiratory distress syndrome (ARDS)
Chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, decreased partial pressure of arterial oxygen

How is FES treated?

Treatment is directed at prevention
Careful immobilization of a long bone fracture is probably the most important factor in prevention
Management is essentially symptom-related and supportive
Most survive

What are complications of hip fractures?

Common in elderly
Surgical repair most effective
Post-op: Ambulation on PO day 1 or 2
Prevent dislocation, Maintain abduction
Avoid hip flexion >90 degrees
Avoid external or internal rotation
Complications: avascular necrosis, degenerative arthritis
Affected leg may be shorter

What patient teaching should be done for hip fractures?

Position restrictions: AVOID
Extreme hip flexion >90 degrees
Adduction (crossing legs)
Internal rotation
Do's
Use elevated toilet seat
Maintain neutral hip position when sitting, standing, lying
Use pillow between knees in bed
Chairs with arms, other assistive devices for standing up
Antibiotic prophylaxis for dental procedures

What is osteomylitis?

Severe infection of bone, bone marrow, surrounding tissue
Staph aureus most common agent
Direct or indirect entry

What is the pathophys of osteomylitis?

1. Pressure from organism growth leads to ischemia
2. Cortical devascularization, necrosis
3. Sequestrum

How is osteomylitis treated?

Sequestrum poorly accessible by antibiotics or natural defenses
May need surgical debridement
Long-term antibiotics

What is Osteoporosis?

Chronic, progressive metabolic bone disease

Bone resorption exceeds bone deposition
Occurs most commonly in spine, hips, and wrist
Many drugs can interfere with bone metabolism
- Corticosteroids
- Antiseizure drugs

General risk factors for osteoporosis include?

Female gender, early menopause, oophorectomy
Increasing age
Family history
White or Asian ethnicity
Small stature
Excess alcohol intake
Cigarette smoking
Anorexia, insufficient calcium intake
Sedentary lifestyle
Low testosterone levels in men

Risk factors specific to women include?

Lower calcium intake than men
Less bone mass because of smaller frame
Bone resorption begins earlier and accelerates after menopause
Pregnancy and breastfeeding deplete woman's skeletal reserve of calcium
Longevity increases likelihood of osteoporosis; women live longer than men

diseases associated with osteoporosis include?

Intestinal malabsorption
Kidney disease
Rheumatoid arthritis
Hyperthyroidism
Chronic alcoholism, cirrhosis of the liver
Hypergonadism
Diabetes mellitus

While completing an admission history for a 73-year-old man with osteoarthritis admitted for knee arthroplasty, the nurse asks about the patient's perception of the reason for admission. The nurse expects the patient to relate which of the following responses to this question?

A) Recent knee trauma
B) Debilitating joint pain
C) Repeated knee infections
D) Onset of "frozen" knee joint

B) Debilitating joint pain

The nurse is caring for a patient with osteoarthritis who is about to undergo total left knee arthroplasty. The nurse assesses the patient carefully to be sure that there is no evidence of which of the following in the preoperative period?

A) Pain
B) Left knee stiffness
C) Left knee infection
D) knee instability

Left knee infection

The nurse formulates a nursing diagnosis of impaired physical mobility related to decreased muscle strength for a 78-year-old patient following left total knee replacement. Which of the following would be an appropriate nursing intervention for this patient?

A) Promote vitamin D and calcium intake in the diet.
B) Provide passive range of motion to all of the joints q4hr.
C) Encourage isometric quadriceps-setting exercises at least qid.
D) Keep the left leg in extension and abduction to prevent contractures.

C) Encourage isometric quadriceps-setting exercises at least qid.

The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects which of the following will be included in the care of the affected leg?

A) Progressive leg exercises to obtain 90-degree flexion
B) Early ambulation with full weight bearing on the left leg
C) Bed rest for 3 days with the left leg immobilized in extension
D) Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation

A) Progressive leg exercises to obtain 90-degree flexion

The nurse is caring for a 75-year-old woman who underwent left total knee arthroplasty and has a new physician order to be "up in chair today before noon." Which of the following actions would the nurse take to protect the knee joint while carrying out the order?

A) Administer a dose of prescribed analgesic before completing the order.
B) Ask the physical therapist for a walker to limit weight bearing while getting out of bed.
C) Keep the continuous passive motion machine in place while lifting the patient from bed to chair.
D) Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting

D) Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting

The nurse is completing discharge teaching with an 80-year-old male patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to do which of the following?

A) Avoid crossing his legs.
B) Use a toilet elevator on toilet seat.
C) Notify future caregivers about the prosthesis.
D) Maintain hip in adduction and internal rotation.

D) Maintain hip in adduction and internal rotation.

The nurse interprets that which of the following prescribed medications is being used to treat osteomyelitis for a 54-year-old patient admitted to the nursing unit?

A) Thiamine (vitamin B1)
B) Gentamicin (Garamycin)
C) Chlordiazepoxide (Librium)
D) Oxycodone with acetaminophen (Percocet)

B) Gentamicin (Garamycin)

During a public health screening day, which of the following assessment findings would alert the nurse to the presence of osteoporosis in a 61-year-old female?

A) The presence of bowed legs
B) A measurable loss of height
C) Poor appetite and aversion to dairy products
D) The development of unstable, wide-gait ambulation

B) A measurable loss of height

The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patien admitteto the hospital. In reviewing this disorder, the nurse explains which of the following to the patient?

A) With a family history of osteoporosis, there is no way to prevent or slow bone resorption.
B) Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.
C) Estrogen replacement therapy must be maintained to prevent rapid progression of the osteoporosis.
D) Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

D) Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been most successful when the patient selects which of the following highest-calcium meals?

A) Chicken stir-fry with 1 cup each onions and snap peas, and 1 cup of steamed rice
B) Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple
C) A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk
D) A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

C) A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk

The nurse is caring for a 49-year-old patient admitted to the nursing unit with osteomyelitis. Which of the following symptoms will the nurse most likely find on physical examination of the patient?

A) Nausea and vomiting
B) Localized pain and redness
C) Paresthesia in the affected extremity
D) Generalized bone pain throughout the leg

B) Localized pain and redness

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which of the following responses by the nurse is most appropriate?

A) "Oral antibiotics are often required for several months."
B) "Intravenous antibiotics are usually required for several weeks."
C) "Surgery is almost always necessary to remove the dead tissue that is likely to be present."
D) "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

B. "Intravenous antibiotics are usually required for several weeks."

A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which of the following interventions?

A) Ambulate the patient to the bathroom every 2 hours.
B) Ask the patient about preferred activities to relieve boredom.
C) Allow the patient to dangle legs at the bedside every 2 to 4 hours.
D) Perform frequent position changes and range-of-motion exercises.

D) Perform frequent position changes and range-of-motion exercises.

The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-year-old patient who has low back pain from herniated lumbar disk. Which of the following would be an appropriate nursing intervention to treat this problem?

A) Provide gentle range of motion to the lower extremities.
B) Elevate the head of the bed 20 degrees and flex the knees.
C) Place the bed in reverse Trendelenburg with the feet firmly against the footboard.
D) Place a small pillow under the patient's upper back to gently flex the lumbar spine.

B) Elevate the head of the bed 20 degrees and flex the knees.

The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of lumbar herniated disk and lower back pain from other causes, which of the following would be the best question for the nurse to ask the patient?

A) "Is the pain worse in the morning or in the evening?"
B) "Is the pain sharp or stabbing, or burning or aching?"
C) "Does the pain radiate down the buttock or into the leg?"
D) "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?"

C) "Does the pain radiate down the buttock or into the leg?"

The nurse is admitting a 45-year-old patient to the nursing unit with a history of herniated lumbar disk and low back pain. In completing a more thorough pain assessment, the nurse would ask the patient if which of the following items aggravates the pain?

A) Bending or lifting
B) Application of warm moist heat
C) Sleeping in a side lying position
D) Sitting in a fully extended recliner

A) Bending or lifting

The nurse has reviewed proper body mechanics with a 45-year-old patient with a history of low back pain caused by a herniated lumbar disk. Which of the following statements made by the patient indicates a need for further teaching?

A) "I should sleep on my side or back with my hips and knees bent."
B) "I should exercise at least 15 minutes every morning and evening."
C) "I should pick up items by leaning forward without bending my knees."
D) "I should try to keep one foot on a stool whenever I have to stand for a period of time.

C) "I should pick up items by leaning forward without bending my knees."

12. Which of the following nursing interventions is most appropriate when turning a patient following spinal surgery?

A) Placing a pillow between the patient's legs and turning the body as a unit.
B) Having the patient turn to the side by grasping the side rails to help turn over.
C) Elevating the head of bed 30 degrees and having the patient extend the legs while turning.
D) Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

A) Placing a pillow between the patient's legs and turning the body as a unit.

The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disk, and schizophrenia. The nurse determines that which of the following would be the best exercise to include in an individualized exercise plan for the patient?

A) Yoga
B) Walking
C) Calisthenics
D) Weight lifting

B) walking

The nurse is caring for a patient hospitalized with exacerbation of asthma and herniated lumbar disk. Which of the following breakfast choices would be most appropriate for the nurse to encourage the patient to check on the breakfast menu?

A) Bran muffin
B) Scrambled eggs
C) Puffed rice cereal
D) Buttered white toast

A) bran muffin

What are the clinical manifestations of intervertebral disk damage?

- lower back pain, radiates down leg
- straight leg raise test mey be positive
- depressed/absent reflexes
- paresthesia, muscle weakness
- bowel/bladder urgency

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