Exam 4: Chapter 40 - Musculoskeletal Care Modalities Flashcards
A cast is a
rigid external immobilizing device that is molded to the contours of the body.
Most common casting materials consist of
fiberglass or plaster of Paris, as these materials can be molded
Pressure areas in arm in cast?
Ulna Styloid, Radial Styloid, Olecranon, Lateral Epicondyle
avascular necrosis
death of tissue due to insufficient blood supply
Cast syndrome
psychological (claustrophobic reaction) or physiologic (superior mesenteric artery syndrome) responses to confinement in body cast
external fixator
external metal frame attached to bone fragments to stabilize them
heterotopic ossification
misplaced formation of bone
naurovascular status
neurologic (motor and sensory components) and circulatory functioning of a body part
osteolysis
lysis of bone from inflammatory reaction against polyethylene particulate debris
osteomyelitis
infection of the bone
msteotomy
surgical cutting of bone
paresthesia
an abnormal sensation of tingling or numbness or burning
the patient may require a tetanus booster if the wound is dirty and if the last known booster was given more than _____ years ago
Five
the main concern following the application of an immobilization device is assessment and prevention of neurovascular dysfunction or compromise of the affected extremity. Assessments are performed at least every _____ for the first 24 hours and every _____ to _____ hours thereafter to prevent neurovascular compromise related to edema and/or the device
Hour
1-4
the 6 “P’s” indicative of neurovascular compromise are:
Pain Poikilothermia Pallor Pulselessness Paresthesia Paralysis
to augment the flow of fluid, the nurse elevates the extremity so that it is above the level of the heart during the first _____ to _____ hours postapplication to enhance arterial perfusion and control edema and notifies the primary provider at once if signs of compromised neurovascular status are present
24-48
pain associated with the underlying condition (eg _____) is frequently controlled by immobilization
fracture
pain due to edema that is associated with trauma, surgery or bleeding into the tissues can frequently be controlled by _____ and if prescribed, intermitten application of ice or cold packs
elevation
pain associated with _____ _____ is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual doses of analgesic agents
compartment syndrome
severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending _____ _____. This may also occur from too tight elastic wraps used to hold splints in place
pressure ulcer
the nurse must never ignore complaints of pain from the patient in a cast because of the possibility of problems such as impaired tissue perfusion, compartment syndrome or pressure ulcer formation. A patients unrelieved pain and increasing analgesic requirements must be reported immediately to the _____ _____ to avoid necrosis, neuromuscular damage and possible paralysis
primary provider
while the cast is on the nurse observes the patient for systemic signs of _____, which include an unpleasant odor from the cast, splint or brace and purulent drainage staining the cast. If the infection progresses, a fever may develop. The nurse must notify the _____ _____ if any of these signs occur
Infection
Primary Provider
Every joint that is not immobilized should be exercised and moved through its range of motion to maintain function. The nurse encourages the patient to move all fingers or toes _____ when awake to stimulate circulation
Hourly
_____ _____ - the most serious complication of casting and splinting- occurs when increased pressure within a confined space (eg cast, muscle compartment) compromises blood flow and tissue perfusion. Ischemia and potentially irreversible damage to the soft tissues within that space can occur within a few hours if action is not taken. A tight or rigid cast/splint that constricts a swollen limb is associated with this complication.
compartment syndrome
diagnosis of _____ _____ is based on clinical suspicion, assessment of the 6 P’s (pain, poikilothermia, pallor, paresthesia, pulselessness, and paralysis) and intracompartmental pressure (ICP)
compartment syndrome
the earliest indicator of developing _____ _____ is pain that seems out of proportion to the underlying injury and pain on passive stretch of other muscles in the immobilized limb. The patient may complain that the cast, brace or splint is too tight. The primary provider must be notified immediately as a delay in diagnosis increases the risk of failed treatment, poor outcomes, additional operations and the possibility of amputation.
Compartment syndrome
pulselessness, paresthesia, and complete paralysis are found in the late stages of _____ _____
compartment syndrome
if compartment syndrome is due to a cast or tight splint may be loosened or removed and the cast cut to release constriction and allow for inspection of the skin. The nurse assists in maintaining limb alignment, and the extremity must then be elevated no higher than the _____ to maintain arterial perfusion. If pressure is not relieved and circulation is not restored an emergent surgical fasciotomy may be necessary to relieve the pressure within the muscle compartment
heart
casts or splints can put pressure on soft tissues, particularly if they are inappropriately applied, causing tissue anoxia and pressure ulcers. _____ extremity sites most at risk are the heel, malleoli, dorsum of the foot, head of the fibula, and anterior surface of the patella. The main pressure sites on the _____ extremity are located at the medial epicondyle of the humerus and the ulnar styloid.
lower
upper
if pressure necrosis occurs, the patient typically reports a very painful _____ _____ and tightness under the cast. The cast may feel warmer in the affected area, suggesting underlying tissue erythema. Drainage may stain the cast or splint and emit an unpleasant odor
hot spot
immobilization in a cast, splint or brace can cause muscle atrophy and loss of strength, and can place patients at risk for _____ _____, which is the deterioration of body systems as a result of prescribed or unavoidable musculoskeletal inactivity
disuse syndrome
to prevent disuse syndrome the nurse instructs the patient to tense or contract muscles (isometric muscle contraction) without moving the underlying bone. Isometric exercises should be preformed _____ while the patient is awake
hourly
quadriceps setting exercise
·position pt supine with leg extended
·instruct pt to push knee back onto the mattress by contracting the anterior thigh muscles
·encourage pt to hold the position for 5 to 10 secs
·let pt relax
·have pt repeat the exercise 10 times each hour when awake
gluteal setting exercise
·position pt supine with legs extended
·instruct pt to contract the muscles of the buttocks
·encourage the pt to hold the contraction for 5 to 10 secs
·let the pt relax
·have pt repeat exercise 10 times each hour awake
complications with a cast splint or brace to report to primary care provider:
uncontrolled swelling and pain cool pale fingers or toes paresthesia paralysis purulent drainage staining cast signs of systemic infection cast splint or brace breaks
to control _____ the immobilized arm is elevated above heart level with a pillow. When the pt is lying down the arm is elevated so that each joint is positioned higher than the preceeding proximal joint (elbow higher than shoulder hand higher than elbow)
swelling
Volkmann’s ischemic contracture
rare but potentially devastating ischemic necrosis of the forearm muscles
circulatory disturbances in the hand may become apparent with signs of cyanosis, swelling and an inability to move the fingers. A missed compartment syndrome in the arm can result in a _____ ischemic contracture which may lead to devastating impairement of motor function and sensibility. Contracture of the fingers and wrist occurs as the result of obstructed arterial blood flow to the forearm and hand. The pt is unable to extend the fingers, describes abnormal sensation (unrelenting pain, pain on passive stretch) and exhibits signs of diminished circulation to the hand
volkmanns
the pt leg must be supported on pillows to the level of the heart to control swelling. Cold therapy or ice packs should be applied as prescribed over the fracture site for _____ to _____ days. The pt is taught to elevate the immobilized leg when seated. The pt should also resume a recumbent position several times a day with the immobilized leg elevated to promote venous return and control swelling. Gentle toe and ankle exercises that allow for isometric contraction of muscles beneath the cast have also been shown to increase venous return and deminish edema
1-2
the nurse assesses circulation by observing the color, temp. and capillary refill of the exposed toes. Nerve function is assessed by observing the pt ability to move the toes and by asking about the sensations in the foot. Numbness, tingling, and burning may indicate _____ nerve injury resulting from pressure at the head of the _____
peroneal fibula
injury to the peroneal nerve as a result of pressure is a cause of _____ (the inability to maintain the foot in a normally flexed position) Consequently the pt drags the foot when ambulating
footdrop
when the pt exhibits an acute anxiety reaction characterized by behavioral changes and autonomic responses (increased respiratory rate, diaphoresis, dilated pupils, increased heart rate, elevated blood pressure)
cast syndrome
_____ _____ _____ syndrome is the physiologic manifestation associated with immobilization from a body cast. With decreased physical activity, gastrointestinal motility decreases and intestinal gases accumulate. The pt exhibits abdominal distention and discomfort, nausea and vomiting, leading to food aversion, poor intake, and weight loss. This may eventually lead to increased abdominal pressure and ileus
superior mesenteric artery
the nurse monitors the pt in a large body cast for potential physiologic cast syndrome, noting bowel sounds every _____ to _____ hours, and reports abdominal discomfort and distention, nausea, and vomiting to the primary provider
4-8
What are external fixators used for
used to manage fractures with soft tissue damage. Complicated fractures of the humerus, forearm, femur, tibia and pelvis are managed with external skeletal fixators. They are also used to correct defects, treat nonunion, and lengthen limbs
after the external fixator is applied, the extremity is elevated to the level of the heart to reduce swelling if appropriate. Any sharp points on the fixator or pins are covered with caps to prevent device induced injuries. The nurse must be alert for potential problems caused by pressure from the device on the skin, nerves or blood vessels and for the development of compartment syndrome. The nurse monitors the neurovascular status of the extremity every _____ to _____ hours and promptly reports changes to the primary provider. Because the pins are inserted externally particular attention is focised on the pin sites for signs of inflammation and infection. The end goal is to avoid ________
2-4
osteomyelitis
the nurse assesses each pin site at least every _____ to _____ hours for redness, swelling, pain around the pin sites, warmth, and purulent drainage, because these are the most common indicators of pin site infections. In the first 48 to 72 hours postinsertion, some serous drainage, skin warmth, and mild redness at the pin sites is expected; these are expected to subside after 72 hours
8-12
currently there is no consensus or researched based evidence to direct the best method for cleansing and dressing percutaneois pin sites to minimize infection rates and complications. In the absence of such research, aseptic technique during pin insertion is advised, along with general strategies such as cleansing each pin site seperately to avoid cross contamination with nonshedding material (gauze, cotton tipped swab) and using chlorhexidine 2mg/ml solution once _____
weekly
if signs of infection are present or if the pins or clamps seem loose, the nurse notifies the _____ _____
primary provider
the nurse never adjusts the clamps on the external fixator frame. It is the _____ _____ responsibility to do so
primary providers
What is Ilizarov Fixation?
a specialized type of external fixator consisting of numerous wires that penetrate the limb and are attached to a circular metal frame. This device is used to correct angulation and rotational defects, to treat nonunion (failure of bone fragments to heal) and to lengthen limbs. The device gently pulls apart the cortex of the bone and stimulates new growth through daily adjustment of the telescoping rods
Traction uses..
a pulling force to promote and maintain alignment to an injured part of the body.
The goals of traction include
decreasing muscle spasms and pain, realignment of bone fractures, and correcting or preventing deformities
At times traction needs to be applied in more than one direction to achieve the desired line of pull. When this is done, one of the lines of pull counteracts the other. These lines of pull are known as the _____ _____ _____.
vectors of force
complications of traction to report promptly to the primary provider
uncontrolled swelling and pain cool pale fingers or toes paresthesia paralysis purulent drainage signs of systemic infection loose fixator pins or clamps
when caring for the pt in traction the nurse should follow these additional principles:
·traction must be continuois to be effective in reducing and immobilizing fractures
·skeletal traction is never interrupted
·weights are not removed unless intermitten traction is prescribed
·any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated
·the pt must be in good body alignment in the center of the bed when traction is applied
·weights must hang freely and not rest on the bed or floor
·knots in the rope or the footplate must not touch the pulley or the foot of the bed
_____ traction may be prescribed for short term use to stabalize a fractured leg, control muscle spasms, and immobilize an area before surgery
Skin
