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Chapter 62 (evolve)
Terms in this set (17)
The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.
A 19-yr-old male patient has a plaster cast applied to the right arm for a Colles' fracture after a skateboarding accident. Which nursing action is most appropriate?
Elevate the right arm on two pillows for 24 hours.
Apply heating pad to reduce muscle spasms and pain.
Limit movement of the thumb and fingers on the right hand.
Place arm in a sling to prevent movement of the right shoulder.
Clinical manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.
The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse?
2 × 6 cm right calf abrasion with sanguineous drainage
Left leg externally rotated and shorter than the right leg
Stooped posture with a shuffling gait and slow movements
Mild pain and minimal swelling of the right ankle and foot
Notify the health care provider immediately of this change in patient's condition, which suggest development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.
A 28-yr-old woman with a fracture of the proximal left tibia in a long leg cast and complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority?
Notify the health care provider immediately.
Elevate the left leg above the level of the heart.
Administer prescribed morphine sulfate intravenously.
Apply ice packs to the left proximal tibia over the cast.
To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes three or four times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.
A 42-yr-old man underwent amputation below the knee on the left leg after a recent heavy farm machinery accident. Which intervention should the nurse include in the plan of care?
Sit in a chair for 1 to 2 hours three times each day.
Dangle the residual limb for 20 to 30 minutes every 6 hours.
Lie prone with hip extended for 30 minutes four times per day.
Elevate the residual limb on a pillow for 4 to 5 days after surgery.
Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.
A nurse performs discharge teaching for a 58-yr-old woman after a left hip arthroplasty using the posterior approach. Which statement by the patient indicates teaching is successful?
"Leg-raising exercises are necessary for several months."
"I should not try to drive a motor vehicle for 2 to 3 weeks."
"I will not have any restrictions now on hip and leg movements."
"Blood tests will be done weekly while taking enoxaparin (Lovenox)."
The most common reason for knee arthroplasty is debilitating joint pain despite exercise, weight management, and drug therapy. Recent knee trauma, repeated knee infections, and onset of frozen knee joint are not primary indicators for a knee arthroplasty.
The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission?
Recent knee trauma
Debilitating joint pain
Repeated knee infections
Onset of frozen knee joint
The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis.
The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery?
Left knee stiffness
Left knee infection
Left knee instability
Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.
The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate?
Promote vitamin C and calcium intake in the diet.
Provide passive range of motion to all of the joints q4hr.
Keep the left leg in extension and abduction to prevent contractures.
Encourage isometric quadriceps-setting exercises at least four times a day.
The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient's knee is unlikely to dislocate.
The nurse is caring for a 76-yr-old man who has undergone left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively?
Progressive leg exercises to obtain 90-degree flexion
Early ambulation with full weight bearing on the left leg
Bed rest for 3 days with the left leg immobilized in extension
Immobilization of the left knee in 30-degree flexion to prevent dislocation
The patient should not force hip into adduction or internal rotation because these movements could dislocate the hip prosthesis. Sitting with feet flat on the floor (avoiding crossing the legs), using an elevated toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.
The nurse is completing discharge teaching with an 80-yr-old male patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed?
Uses an elevated toilet seat
Sits with feet flat on the floor
Maintains hip in adduction and internal rotation
Verifies need to notify future caregivers about the prosthesis
Arteriography determines viable tissue for salvage based on blood flow observed in real time and is considered the gold standard for evaluating arterial perfusion. Only arteriography determines where tissue perfusion stops and amputation needs to occur. Bilateral peripheral pulse assessment and areas of black, indurated, cold, and pale skin indicate ischemia.
The patient has frostbite on the distal toes of both feet. The patient is scheduled for amputation of damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability?
Arteriogram showing blood vessels
Peripheral pulse palpation bilaterally
Patches of black, indurated, cold tissue
Bilateral pale, cool skin below the ankles
For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. A plaster cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.
This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request?
"No one is available to assist and accompany the patient."
"The cast is not dry yet, and it may be damaged while using crutches."
"Rest, ice, compression, and elevation are in process to decrease pain."
"Excess edema and complications are prevented when the leg is elevated for 24 hours."
The patient does not understand the severity of ACL reconstructive surgery if planning to resume playing soccer soon; safe return will not occur for 6 to 8 months. Initial range of motion, immobilization, and progressive weight bearing will be overseen by a physical therapist.
A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required?
"I probably won't be able to play soccer for 6 to 8 months."
"They will have me do range of motion with my knee soon after surgery."
"I can't wait to get this done now so I can play soccer for the next tournament."
"I will need to wear an immobilizer and progressively bear weight on my knee."
The LPN/LVN can monitor pain intensity and administer analgesics. Assessment of skin integrity and determining correct alignment to enhance traction are within the RN scope of practice. Removing weights from the traction should not be delegated or done. Removal of weights can cause muscle spasms and bone misalignment, and should not be delegated or done.
The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/LVN?
Assess skin integrity around the traction boot.
Determine correct body alignment to enhance traction.
Remove weights from traction when turning the patient.
Monitor pain intensity and administer prescribed analgesics.
Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone may not decrease phantom limb pain.
An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings?
Use mirror therapy.
Give opioid analgesics.
Rebandage the residual limb.
Show the patient the leg is gone.
The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.
The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus?
Administer enoxaparin (Lovenox).
Provide range-of-motion exercises.
Apply sequential compression boots.
Immobilize the fracture preoperatively.
Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated, but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.
When entering the grocery store, a patient trips on the curb and sprains the right ankle. Which initial care is appropriate (select all that apply.)?
Apply ice directly to the skin.
Apply heat to the ankle every 2 hours.
Administer antiinflammatory medication.
Compress ankle using an elastic bandage.
Rest and elevate the ankle above the heart.
Perform passive and active range of motion.
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