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Med Surg- MUSCULOSKELETAL
Terms in this set (62)
What is a cast?
-Rigid external device molded to the contour of the body.
-Immobilized a reduced fracture or correct a deformity.
-Restrict body part movement.
What are nursing interventions related to cast care?
a. hold cast with palms
b. turn cast to promote drying (do not cover)
a. elevate effected limb
b. turn pt often
c. protect other body parts
d. provide hygiene care
e. check cast for rough edges
f. cover cast with plastic when bathing pt or if incontinent
g. no showers or swimming
What do you want to manage when patients have a cast?
-promote healing of skin abrasion
-maintain adequate neurovascular function
What is compartment syndrome?
Increased tissue pressure within a limited space (cast, muscle compartment)
-pt complains of deep pain; does not improve with opioids
-passive stretching of muscle causes pain
-nerve ischemia + swelling continues
-hypesthesia= a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli
-paresthesia= an abnormal sensation, typically tingling or pricking
How do you manage compartment syndrome?
1. elevate extremity
2. cut cast
3. notify MD
post op care:
1. sterile dressing, limb splinted, ROM, elevate limb, debridement/ grafting may be needed
What is a pressure ulcer?
-pressure on soft tissue
-susceptible areas: heel, malleoli (ankle), dorsum of toes, patella (knee), lateral epicondyle (elbow), ulnar styloid process
-s/s pt report pain and tightness, drainage, warmth
What is disuse syndrome?
-physical state caused by bed rest, immobility, and/or lack of physical activity
-significant atrophy (muscle loss)
What is a fracture?
-a break in the continuity of the bone
a. direct blow
b. crushing forces
c. twisting motions
d. extreme muscle contractions
-soft tissue damage (muscle, joints, ligaments, tendons, nerves, blood vessels)
What is a complete fracture?
bone is broken all the way through
What is an incomplete or green stick fracture?
bone cracks and bends but does not completely break
What is a comminuted fracture?
a break or splinter of the bone into more than two fragments
What is a closed (simple) fracture?
a broken bone that does not penetrate the skin.
What is an open compound fracture?
a fracture in which there is an open wound or break in the skin near the site of the broken bone
What is an avulsion fracture?
an injury to the bone in a location where a tendon or ligament attaches to the bone
What are nursing managements related to fractures?
-decrease edema (inflammation)
-comfort measures/ pain management
-encourage activity within pt's ability
What are some early complications related to fractures?
-decreased blood volume, decreased cardiac output, decreased tissue perfusion
fat emboli syndrome
-major cause of death
-sources: long bone, pelvic, crushed injuries & multiple fractures
c. PERSONALITY CHANGES, RESTLESSNESS, IRRITABILITY, CONFUSION AFTER FRACTURE (ABG)
What are some delayed complications related to fractures?
a. non union- bone grafting to stimulate callus formation (autograft, allograft) immobilization, non-weight bearing
b. mal union- healing improperly, re-fractured surgically and reset
c. avascular necrosis- bone loses blood supply and dies
-pain, decreased ROM, changes in x-ray
d. deep vain thrombosis (DVT)
e. DIC (disseminated intravascular coagulopathy)
-a sign of an underlying condition= bleeding
g. reaction to internal fixation devices
-pain, decreased function
h. complex regional pain syndrome
-severe burning pain, local edema, hyperesthesia, stiffness, discoloration, vasomotor skin changes, trophic changes, muscle atrophy, osteoporosis
i. heterotropic ossification
-painful muscle, limited movement
What is osteomyelitis?
bone infection; chronic/ acute
What causes osteomyelitis?
-soft tissue infection (pressure ulcer, vascular ulcer, incision)
-direct bone contamination (surgery, open fracture, traumatic injury like a gunshot wound)
-hematogenous- pathogen came from within the body
(70-80% of the time, it is staphylococcus aureus)
STAGE 4 PRESSURE ULCERS ARE AT A VERY HIGH RISK OF DEVELOPING OSTEOMYELITIS
What are some risk factors for osteomyelitis?
-impaired immune system
-corticosteroid therapy and immunosuppressant agents
What are some s/s of osteomyelitis?
-severe pain in the affected area
-swelling and redness
-fever of 103-104
What are some nursing interventions for osteomyelitis?
-handle limb gently= it can be painful
-keep extremity in good alignment
-handle secretions carefully= can be infectious
-manage the pt's pain
What are some clinical manifestations of bone tumors?
-pain (mild to severe, occasional to constant)
-spinal cord compression
-paraesthesia, paraplegia, urinary retention
What are some nursing interventions related to bone fractures?
-pt education= to understand the disease process
-preventing pathological fracture
-handling, external support and weight bearing restrictions
-promoting coping skills
-promoting home and community-based care
-monitoring and managing the complications
What is an amputation?
surgical removal of a body part or limb
-what is left over from surgery is referred to as a "residual limb"
-functional usefulness for prosthesis use (preservation of joint necessary)
What are some causes of amputations?
-accident or trauma
-peripheral vascular disease
-diabetes, CHF, malignant tumors
-chronic bone infection
-infected burns or damaged bone
peripheral artery disease due to diabetes
What are some nursing interventions related to amputations?
-minimize altered sensory perception
-promote wound healing
-enhance body image
-help resolve grief
- achieve mobility
-help modify perceptions
-residual desensitization: massages
-beta blockers: to dull the burning sensation
-anti-seizure meds: for stabbing, cramping pain
What is some amputation post-op nursing care?
-check for bleeding. drainage
-elevate first 24hrs= after that NO PILLOWS
-prone 24-48 hrs post-op
-legs kept together to prevent abduction contractures
-wrapping with ace bandage to shape the limb
What is phantom pain?
pain experienced in the area of a body part that has been surgically or traumatically removed
-soon after surgery or can last up to 2-3 months
-s/s: pain, numbness, tingling, muscle cramp, feeling extremity present
What is plantar fasciitis?
Inflammation of the thick band of tissue that connect the heel bone to the toes and creates an arch.
-heel pain: anterior medial
How To Help:
-shoes with support
How do you manage a pt with total knee replacement?
-elevate, ice (to manage edema)
-quad sets, active ROM
-weight bearing status
What is osteoporosis?
A medical condition in which the bones become brittle and fragile from loss of tissue.
-Osteoporosis occurs when the creation of new bone doesn't keep up with the removal of old bone.
What are some clinical manifestations of osteoporosis?
-fragile bones, fracture prone
-kyphosis, loss in height
-fractures (hip, wrist)
-pathological fractures= at a diseased site
-chronic pain= from the vertebrae mostly
-impairment of balance and respiratory function
What are some risk factors related to osteoporosis?
-after menopause (45-55 yrs)
a. celiac disease
a. corticosteroids, anti-seizure meds
b. bone loss might not be recovered once medication is stopped
How do you prevent/ treat osteoporosis?
-weight bearing exercises
-reduction of caffeine, cigarettes, and alcohol
What are some nursing interventions related to osteoporosis?
-safety precautions, fall prevention
-handle pt gently
-improving bowl function
What is osteomalacia?
inadequate mineralization of the bone; bone weakening.
-pain, bowing of bones, pathological fractures, kyphosis
-risk for falls and fractures
-deficiency of activated vitamin D (calcitriol)
What causes osteomalacia?
-vitamin D deficiency
-malabsorption syndrome (celiac disease)
-small bowel resection
-chronic pancreatitis= malabsorption
-liver and kidney disease
-prolonged use of anti-seizure meds
-underlying causes, diet, sunlight exposure
What are the treatments/ teaching for pt's with osteomalacia?
-vitamin D supplement
-exposure to sunlight
What is traction?
pulling force to assist reducing fracture
-weight, ropes, pulleys, skin or bone
-counter traction needed
CONTINUOUS, NEVER INTERRUPTED, GOOD BODY ALIGNMENT, ROPES NOT OBSTRUCTED, WEIGHTS HANGING FREELY, AND KNOTS MUST NOT TOUCH PULLEY OR FOOT OF BED.
What are tractions used for?
-reduce pain and muscle spams
-increase space between the opposing forces
What are the different types of tractions?
1. skin traction- used to reduce muscle spasms & immobilize a body part before surgery
2. skeletal traction-applied to the bone, distal to the fracture by surgeon under aseptic technique
What are nursing interventions related to pt in traction?
-promote understanding of treatment
-achieve maximum self care
-attaining maximum mobility
-achieving maximum comfort
-never change setting except medical emergency
-never D/C without MD order
-look for signs of infection
-encourage ROM exercises
-avoid foot drop
-check with MD about turning and repositioning pt
What are possible complications that come with traction?
-atelectasis= complete or partial collapse of the entire lung or lobe of the lung.
-urinary stasis and infection
-venous stasis with DVT, PE
-foot drop (contracture)
What are the nursing interventions for orthopedic surgery?
-maintaining adequate neurovascular function
-helping the pt maintain self esteem
-monitoring and managing potential complications
-promoting home and community based care
What is the main priority with a patient after a total hip replacement?
-monitoring wound drainage
-promoting home and community based care
-continuation care in home and community
How do you prevent orthopedic post-op complications?
1. thrombus formation= use ACE hose, sequential compression devices
2. pneumonia due to immobility= Turn, Cough, Deep Breathe, incentive spirometer
3. UTI= push fluids
4. pressure ulcers= turn q. 2h
5. infection= aseptic technique, hand washing
What do you ask when assessing the pt for the first time?
"Interview" the pt
-ask about sensation
-current medications being used
What are characteristics of abnormal gait patterns?
-leg length discrepancy
antalgic= avoiding pain and weight bearing while walking
-ataxic= unsteady, uncoordinated
-shuffling gait- Parkinson's disease
-steppage gait- lower motor neuron disease
What is fasciculation?
involuntary twitching of muscle fiber groups
What is crepitus?
grating sound created by the rubbing of bone fragments
What is the clonus reflex?
rhythmic contraction of a muscle
What is ecchymosis?
a discoloration of the skin resulting from bleeding underneath, typically called a bruise.
What is the etiology (cause) of back pain?
1. mechanical= joint or muscle sprain
2. congenital= born with abnormality
3. degenerative= herniated disc
4. arthritis= aging disease process
5. bone disease= Ca of bone
6. weakness of muscles= inactivity/ immobility
7. obesity, stress, depression
What are nursing interventions for pts with back pain?
-semi-fowlers with knees flexed
-traction/ bed rest
-proper body mechanics
What does R.I.C.E. stand for?
What is a strain?
-microscopic incomplete tear, with bleeding
-etiology= overuse, over-stretching, excessive stress
-s/s= soreness, sudden pain with local tenderness with local use
What is a sprain?
Injury to ligaments surrounding joints
-blood vessels rupture
-etiology= twisting, poor joint stability
-s/s= edema, joint tenderness, painful ROM
What is gout?
-also known as "kings disease"
-purine metabolism; disease of the joints caused by deposit of uric acid crystals in the joints.
-foods rich in purines (steak, shell fish, caviar and organ meats)
What are risk factors for gout?
-cardiovascular disease (HTN)
-some chemotherapeutic agents
-chronic kidney disease
What are s/s of gout?
-sudden onset of severe pain the the distal joints, mainly the big toes
-toe becomes swollen, red hot, pt becomes febrile
-tophi= deposits of uric acid on ear cartilage (seen as bumps on lobes) in peripheral areas
What are nursing interventions associated with gout?
-rest to the inflamed joint
-if not contraindicated push fluids (help remove the uric acid)
-can produce kidney stones if stasis in kidneys
-recurrent in pt not compliant with diet
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