final exam Flashcards
How should you position a client with a hip replacement?
later
how do you assess a client with a hip replacement?
later
What nursing actions are needed for a patient with a hip replacement?
later
Abduction
later
Adduction
later
total joint replacement
abduction or adduction?
later
knee replacements
abduction or adduction?
later
knee replacements
later
What is CPM?
Discuss
later
What is the standard care for hip replacements?
later
what is the standard care for knee replacements?
later
Total joint replacement
activities of daily living defecit
later
total joint replacement
self-care deficit
later
total joint replacement
Assistive devices that can enable self care
later
Total joint replacement
community resources for the client and family
later
pre op and post op care
later
“impact choices” in article
later
the most common cause of painful or increased dysfunction of a joint is due to ___________.
______ loosening is the most common cause of failed joint replacement and can appear yrs after surgery by wear and tear on prosthetic device
loosening of the prosthetic
Aseptic
the number 1 reason for reoperation
hip dislocation
posterior hip dislocations are the most common and happen from flexion, adduction, and internal rotation of the hip joint
Anterior hip dislocations
not common
happen from extension and external rotation
to prevent hip dislocation, teach patient and family
the risk, proper positioning techniques, and use of adaptive equipment
confirmation of a dislocation is often a
x-ray
patients often complain of immediate pain and describe hearing a pop
infection in joint replacement occurs in less than 2% of cases, but it is the result of
presence of infections such as the skin or urinary tract, certain diseases such as diabetes and alcoholism, use of immunosuppressant drugs, obesity, and non-healing ulcers
infection of the joint capsule is usually confirmed by
a needle aspiration.
gram positive bacilli
the ultimate outcome for TJR and infection is
preserving the joint prosthetics
if the infection in a joint replacement cannot be treated,
remove the hardware, prolong antibiotic tx, and repeat the joint repalcement
to prevent infection in a joint replacement,
prophylactic antibiotics can be used before dental procedures and invasive tx
A major concern and potential life threatening complication of joint replacements is
DVTs!!! and pulmonary emboli
Virchow’s triad is a physiological bodily response to DVTs in joint replacements
when all are met, a blood clot can occur
The Virchow’s triad consists of:
- Alterations in normal blood flow
- Injuries to the vascular endothelium
- Alterations in the consistancy of blood (hypercoagulability)
patients with a joint replacement may meet all the triad criteria such as
local vessel wall damage, hypercoagulability, and venous stasis after surgery
to prevent DVTs in joint repalcements
use anticoagulants (coumadin), low-molecular weight heparin or unfractionated heparin post op (immediately post op and up to 14 days after surgery)
Preoperative assessment of joint replacement
focuses on obtaining history and physical:
past medical hx –general health, previous surgeries, hospitalizations, illnesses, immunizations, meds, allergies, hx of blood transfusions, fx status and ability to complete ADLs, transfers, and ambulation
personal hx – culture/religion, economic issues, home environment, occupation, tobacco, alcohol, drug use, diet, exercise regimen
pain – chronic vs acute, location, intensity, exacerbation, meds, home tx
musculoskeletal – inspect and palpate surgical extremity, posture, alignment, symmetry, muscle tone, ROM
vial signs – BP, temp, pulse, respiratory rate, pulse ox
Postop assessment of joint replacement
musculoskeletal – surgical area, incision line for intactness, redness, warmth, amt of drainage, amt of edema, sensation, pulses
pain – intensity, location, radiation, evaluation of previous interventions to treat pain
vitals – until stable
function – assess amt of help needed for bed mobility, transfers, ambulation, and ADLs
exercise for total joint replacement often begins in
the preoperative setting
total joint replacements: hips and knees
preoperative
complete review of medication regimen, signs and symptoms of infection, review a surgical procedure.
Physical therapy will to a musculoskeletal evaluation and instruct them to complete a preoperative home exercise program; proper transfers in and out of bed, chairs, and vehicles; instructions on use of assistive devices such as canes and walkers; and information regarding postoperative rehabilitation
prehabilitation exercise can have
long-term benefits
occupational therapist they provide information and instruction in the use of assistive devices
proper use of a long-and old sponge or stock Donner can allow the patient to safely complete activities without risk of injury
social workers help to coordinate evaluation of
home needs and initiating discharge planning
total joint replacement: hips and knees postoperative
therapeutic exercise begins shortly after surgery and continues until the patient has reached his or her maximal functional recovery
Focus of inpatient rehab postop is safe mobility. Most patients are transferred out of bed and stand on day one after surgery. Early movement with prophylactic measures is essential in diminishing the risk of postoperative DVT. Proper transfer techniques can reduce aggravation of symptoms and injury. Choice of prosthetic component may affect weight-bearing status. Some surgeons may restrict weight-bearing of patients with non-cemented THA components. Cemented components generally allow immediate full weightbearing or weight-bearing as tolerated.bone grafting or fracture during surgery may limit weight bearing
CPM machine for total knee replacement
used while in bed in an effort to improve range of motion. This is more challenging for hip replacement patients because hip precautions must be maintained at all times. For example, hip precautions for a posterolateral THA may include no hip flexion beyond 90°, no crossing of midline with the operated leg, and no rotation.
Rehabilitation continues upon discharge from the hospital
true. It continues to focus on addressing functional deficits the patient may have. For example, a patient with a total knee replacement will typically exhibit lower extremity edema, muscle weakness, especially in the quadriceps, range of motion limitations in the operated knee, and gait deficits requiring the use of assistive device
Gait training, progressive resistive exercise, balance training, patellar mobilization, soft tissue mobilization, electrical stimulation for quadriceps, strengthening and edema control, and range of motion and stretching exercises are typical interventions for this patient
Modalities, including ice and later moist heat, are commonly used to minimize edema and pain and to facilitate stretching and exercise.
Significant quadriceps weakness is found with
total knee replacement
a total hip replacement often has a significant weakness in the
hip abductor musculature. This leads to significant gait deviation, known as the Trendelenburg gait pattern. The patient with this deficit will latterly deviate his or her trunk to the weakened side in an effort to decrease pelvic drop due to the hip weakness. Patients should be encouraged to use appropriate assistive devices to avoid this deviation. As with the total knee replacement patient, range of motion exercises, progressive resistive exercise, soft tissue mobilization, and balance and gait training are standard interventions. A comprehensive home exercise program is essential
total hip replacement precautions
to not bend operated hip greater than 90°
do not cross legs or brain operated leg past the midline of the body
do not twist or turn operated leg inward
do not raise the operated leg up higher than the rest of the body ( such as a knee to chest position)
electrical stimulation may be used for facilitation of muscle strengthening, and ice and heat are commonly used as well. As with other joint replacements, and appropriate and comprehensive home exercise program is essential for achieving optimal functional outcomes
true of joint replacements
expected outcomes for joint replacement surgical patients
pain management with pain under control
adequate range of motion
return of functional mobility
increased quality of life
successful outcomes are measured in terms of return to maximal mobility and range motion, with a low incidence of complications
educating patients and families about the healing process after joint replacement is a key nursing interventions to promote recovery
nurses can actively prevent common complications and reinforced what patients are taught in physical therapy
nursing diagnoses of joint replacement
acute pain potential for infection impaired physical mobility potential for ineffective tissue perfusion constipation inffective breathing pattern
for acute pain of joint replacement
alleviate or produce pain to a level that’s acceptable to the patient by proper positioning, I stood extremity, guided imagery, music therapy, or distraction. Use of IV and PO medications, patient controlled analgesia as prescribed by physician, administer before any activity
potential for infection for joint replacement
outcome is to have no infection at the surgical site by hand washing, universal precautions, appropriate wound care techniques, assessment of wound color temperature and drainage, appropriate antibiotic use as prescribed, teaching patient and family of proper techniques of wound care and dressing changes
impaired physical mobility for joint replacement
outcome is to increase mobility and advancement to independence with or without a device by use of adaptive equipment necessary, active/active assisted/passive range of motion exercises, mobility as soon as possible, teaching patient and family of proper mobilization techniques
potential for ineffective tissue perfusion for joint replacement
outcome is to maintain adequate tissue perfusion to extremities and to be free of thrombosis by encouraging range of motion exercises, teach ankle pumps and circular motion of feet, TED hose as appropriate, sequential devices as appropriate, frequent assessment of extremities for pulses color temperature and sensation, administer anticoagulants as ordered, monitor lab values as ordered
constipation for joint replacement
outcome is maintenance of irregular bowel pattern as per patient by encouraging activity as soon as possible, encourage fluid intake, encourage proper diet, assessed bowel sounds and monitor for nausea and vomiting, administer laxatives and stool softener as ordered
ineffective breathing pattern for joint replacement
outcome is to maintain proper ventilation by oxygen support as needed, teaching coughing and deep breathing exercises, teaching use of incentive spirometry, teach proper positioning for effective breathing: sitting position, slightly forward, and shoulders relaxed. Assess lung sounds and pulse oximetry
exercises for patients after hip or knee surgery
ankle pumps: Bend ankles to move feet up and down, alternating feet. Repeat this exercise several times throughout the day
Quad sets!!!: slowly tighten muscles on thigh of straight leg while counting to 5; repeat with the other leg
Straight leg raise: Bend un-involved leg. Keep other leg straight as possible and tighten muscles on top of thign. Slowly lift straight leg 6 to 8 inches from bed and hold for 5 seconds; lower. Relax.
Short arc quad: place large can or rolled up towel under leg. Straighten knee and leg. Hold for 5 seconds and repeat with other leg
Heel slides: bend knee and pull heels towards buttocks. hold for 5 seconds. Return to starting point and repeat with other knee
In preparation for total knee surgery, a 200-lb client with osteoarthritis must lose weight. Which of the following exercises should the nurse recommend as best if the client has no contraindications?
- Weight lifting.
- Walking.
- Aquatic exercise.
- Tai chi exercise.
- When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client’s osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.
Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time?
- Teaching how to prevent hip flexion.
- Demonstrating coughing and deep-breathing techniques.
- Showing the client what an actual hip prosthesis looks like.
- Assessing the client’s fears about the procedure.
- Before implementing a teaching plan, the nurse should determine the client’s fears about the procedure. Only then can the client begin to hear what the nurse has to share about the individualized teaching plan designed to meet the client’s needs. In the preoperative period, the client needs to learn how to correctly prevent hip flexion and to demonstrate coughing and deep breathing. However, this teaching can be effective only after the client’s fears have been assessed and addressed. Although the client may appreciate seeing what a hip prosthesis looks like, so as to understand the new body part, this is not a necessity.
The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage? 1. Numbness.
- Bleeding.
- Dislocation.
- Pinkness.
- The nurse should suspect nerve damage if numbness is present. However, whether the damage is short-term and related to edema or long-term and related to permanent nerve damage would not be clear at this point. The nurse needs to continue to assess the client’s neurovascular status, including pain, pallor, pulselessness, paresthesia, and paralysis (the five P’s). Bleeding would suggest vascular damage or hemorrhage. Dislocation would suggest malalignment. Pink color would suggest adequate circulation to the area. Numbness would suggest neurologic damage.
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following?
- A developing infection.
- Bleeding in the operative site.
- Joint dislocation.
- Glue seepage into soft tissue.
- The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g., blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g., pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form before the wound is closed.
A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome?
- The client drinks 2,000 mL of fluid per day.
- The client understands how to manage the incision.
- The client’s bed linens are changed as needed.
- The client’s skin remains cool throughout hospitalization.
- An average adult requires approximately 1,100- 1,400 mL of fluids per day. In some instances, such as when a person has an increase in body temperature or has increased perspiration, additional water may be necessary. With an increase in body temperature, there is also an increase in insensible fluid loss. The increased loss of fluid causes an increased need for fluid replacement. If the loss is significant and/ or goes untreated, an individual’s intake will not be balanced with output. Managing the incision, changing the bed linens, or keeping the client’s skin cool are not outcomes indicative of resolution of a fluid volume deficit.
After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following?
- Elevate the sequential compression device (SCD) on two pillows.
- Change the settings on the SCD to make the client more comfortable.
- Stop the SCD to remove dressings and bathe the leg.
- Discontinue the SCD when the client is ambulatory.
- After knee arthroplasty, the knee will be extended and immobilized with a firm compression dressing and an adjustable soft extension splint in place. A sequential compression device (SCD) will be applied. The SCD can be discontinued when the client is ambulatory, but while the client is in bed the SCD needs to be maintained to prevent thromboembolism. The SCD should be positioned on the bed, but not on two pillows. Settings for the SCD are ordered by the orthopedic surgeon. Initial dressing changes are completed by the orthopedic surgeon and changed as needed per physician order.
The nurse is preparing the discharge of a client who has had a knee replacement with a metal joint. The nurse should instruct the client about which of the following? Select all that apply.
- Notify health care providers about the joint prior to invasive procedures.
- Avoid use of Magnetic Resonance Imaging (MRI) scans. 3. Notify airport security that the joint may set off alarms on metal detectors.
- Refrain from carrying items weighing more than 5 lb.
- Limit fluid intake to 1,000 mL/ day.
1, 2, 3.
The nurse should instruct the client to notify the dentist and other health care providers of the need to take prophylactic antibiotics if undergoing any procedure (e.g., tooth extraction) due to the potential of bacteremia. The nurse should also advise the client that the metal components of the joint may set off the metal-detector alarms in airports. The client should also avoid MRI studies because the implanted metal components will be pulled toward the large magnet core of the MRI. Any weight bearing that is permitted is prescribed by the orthopedic surgeon and is usually not limited to 5 lb. Post surgery, the client can resume a normal diet with regular fluid intake.
Following a total hip replacement, the nurse should position the client in which of the following ways?
- Place weights alongside of the affected extremity to keep the extremity from rotating.
- Elevate both feet on two pillows.
- Keep the lower extremities adducted by use of an immobilization binder around both legs.
- Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.
- After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck’s extension traction. The client must not abduct or flex the operated hip because this may produce dislocation.
Following a total hip replacement, the nurse should do which of the following? Select all that apply.
- With the aid of a coworker, turn the client from the supine to the prone position every 2 hours.
- Encourage the client to use the overhead trapeze to assist with position changes.
- For meals, elevate the head of the bed to 90 degrees. 4. Use a fracture bedpan when needed by the client.
- When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises.
2, 4, 5.
Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.
A client is to have a total hip replacement. The preoperative plan should include which of the following? Select all that apply.
- Administer antibiotics as prescribed to ensure therapeutic blood levels.
- Apply leg compression device.
- Request a trapeze be added to the bed.
- Teach isometric exercises of quadriceps and gluteal muscles.
- Demonstrate crutch walking with a 3-point gait.
- Place Buck’s traction on the bed.
1, 3, 4.
Administration of antibiotics as prescribed will aid in the acquisition of therapeutic blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will initially assist the client with walking by using a walker. The client will not use Buck’s traction. The client will require anti-embolism stockings and use of a leg compression device to minimize the risk of thrombus formation and potential emboli; the leg compression device is applied during surgery and maintained per physician order.
The nurse is teaching the client to administer enoxaparin (Lovenox) following a total hip arthroplasty? The nurse should instruct the client about which of the following? Select all that apply.
- Report promptly any difficulty breathing, rash, or itching. 2. Notify the health care provider of unusual bruising.
- Avoid all aspirin-containing medications.
- Wear or carry medical identification. 5. Expel the air bubble from the syringe before the injection. 6. Remove needle immediately after medication is injected.
1, 2, 3, 4.
Client/ family teaching should include advising the client to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to healthcare provider immediately. Instruct the client not to take aspirin or nonsteroidal anti-inflammatory drugs without consulting health care provider while on therapy. A low-molecular weight heparin is considered to be a high-risk medication and the client should wear or carry medical identification. The air bubble should not be expelled from the syringe because the bubble insures the client receives the full dose of the medication. The client should allow 5 seconds to pass before withdrawing the needle to prevent seepage of the medication out of the site.
A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying which of the following?
- “Don’t worry. Your new hip is very strong.”
- “Use of a cushioned toilet seat helps to prevent dislocation.”
- “Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them.”
- “Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation.”
- Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90-degree flexion of affected hip for at least 4 to 6 weeks after the procedure. Use of an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to “not worry” is not therapeutic. A cushioned toilet seat does not prevent hip dislocation.
The nurse is assessing a client who had a left hip replacement 36 hours ago. Which of the following indicates the prosthesis is dislocated? Select all that apply.
- The client reported a “popping” sensation in the hip.
- The left leg is shorter than the right leg.
- The client has sharp pain in the groin.
- The client cannot move his right leg.
- The client
1, 2, 3.
Dislocation of a hip prosthesis may occur with positioning that exceeds the limits of the prosthesis. The nurse must recognize dislocation of the prosthesis. Signs of prosthesis dislocation include: acute groin pain in the affected hip, shortening of the affected leg, restricted ability or inability to move the affected leg, and reported “popping” sensation in the hip. Toe wiggling is not a test for potential hip dislocation.
A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
- Stabilize the leg with Buck’s traction.
- Apply an ice pack to the affected hip.
- Position the client toward the opposite side of the hip.
- Notify the orthopedic surgeon.
- If a prosthesis becomes dislocated, the nurse should immediately notify the surgeon. This is done so the hip can be reduced and stabilized promptly to prevent nerve damage and to maintain circulation. After closed reduction, the hip may be stabilized with Buck’s traction or a brace to prevent recurrent dislocation. If ordered by the surgeon, an ice pack may be applied post reduction to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic surgeons may order the client be turned toward the side of the reduced hip but that is not the nurse’s first response.
The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first? 1. A 55-year-old client who is 6 feet tall and weighs 180 lb. 2. A 90-year-old who lives alone.
- A 74-year-old who has periodontal disease with periodontitis.
- A 75-year-old who has asthma and uses an inhaler.
- Infection is a serious complication of total hip replacement and may necessitate removal of the implant. Clients who are obese, poorly nourished, elderly, have poorly controlled diabetes, rheumatoid arthritis, or concurrent infections (e.g., dental, urinary tract) are at high risk for infection. Clients who are of normal weight and have well-controlled chronic diseases are not at risk for infection. Living alone is not a risk factor for infection.
The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit?
- The client can walk throughout the entire hospital with a walker.
- The client can walk the length of a hospital hallway with minimal pain.
- The client has increased independence in transfers from bed to chair.
- The client can raise the affected leg 6 inches with assistance.
- Expected outcomes at the time of discharge from the surgical unit after a hip replacement include the following: increased independence in transfers, participates in progressive ambulation without pain or assistance, and raises the affected leg without assistance. The client will not be able to walk throughout the hospital, walk for a distance without some postoperative pain, or raise the affected leg more than several inches. The client may be referred to a rehabilitation unit in order to achieve the additional independence, strength, and pain relief.
The nurse is assessing a client’s left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal findings? Select all that apply.
- Reduced edema of the left knee.
- Skin warm to touch.
- Capillary refill response.
- Moves toes.
- Pain absent.
- Pulse on left leg weaker than right leg.
1, 2, 3, 4.
Postoperatively, the knee in a total knee replacement is dressed with a compression bandage and ice may be applied to control edema and bleeding. Recurrent assessment by the nurse for neurovascular changes can prevent loss of limb. Normal neurovascular findings include: color normal, extremity warm, capillary refill less than 3 seconds, moderate edema, tissue not palpably tense, pain controllable, normal sensations, no paresthesia, normal motor abilities, no paresis or paralysis, and pulses strong and equal.
On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following?
- Encourage the client to apply full weight-bearing.
- Order a walker for the client.
- Place a straight-backed chair at the foot of the bed.
- Apply a knee immobilizer.
- The knee is usually protected with a knee immobilizer (splint, cast, or brace) and is elevated when the client sits in a chair. Pre- and post-surgery, the physician prescribes weight-bearing limits and use of assistive devices for progressive ambulation. Positioning a straight-backed chair at the foot of the bed is not an action conducive for getting the client out of bed on the evening of surgery for a total knee replacement.
When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which of the following information in the discharge plan? Select all that apply.
- Report signs of infection to health care provider.
- Keep the affected leg and foot on the floor when sitting in a chair.
- Remove anti-embolism stockings when sleeping.
- The physical therapist will encourage progressive ambulation with use of assistive devices.
- Change the dressing daily.
1, 4.
After a total knee replacement, efforts are directed at preventing complications, such as thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the affected leg must remain elevated when the client sits in a chair. After discharge, the client may undergo physical therapy on an outpatient basis per physician order. The client should leave the dressing in place until the follow-up visit with the surgeon.
Following a total joint replacement, which of the following complications has the greatest likelihood of occurring?
- Deep vein thrombosis (DVT).
- Polyuria.
- Intussception of the bowel.
- Wound evisceration.
- Deep vein thrombosis is a complication of total joint replacement and may occur during hospitalization or develop later when the client is home. Clients who are obese or have previous history of a DVT or PE are at high risk. Immobility produces venous stasis, increasing the client’s chance to develop a venous thromboembolism. Signs of a DVT include: unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the physician for definitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Intussusception of the bowel and wound evisceration tend to occur after abdominal surgeries.
Which of the following should the nurse identify as the least likely factor contributing to a client’s peripheral vascular disease?
- Uncontrolled diabetes mellitus for 15 years.
- A 20-pack-year history of cigarette smoking.
- Current age of 39 years.
- A serum cholesterol concentration of 275 mg/ dL.
- Typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease. Uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because of the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/ dL are considered a risk factor for peripheral vascular disease.
A client has severe arterial occlusive disease and gangrene of the left great toe. Which of the following findings is expected?
- Edema around the ankle.
- Loss of hair on the lower leg.
- Thin, soft toenails.
- Warmth in the foot.
- The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin, soft toenails (i.e., not thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present.
A client with absent peripheral pulses and pain at rest is scheduled for an arterial Doppler study of the affected extremity. When preparing the client for this test, the nurse should:
- Have the client sign a consent form for the procedure.
- Administer a pretest sedative as appropriate.
- Keep the client tobacco-free for 30 minutes before the test.
- Wrap the client’s affected foot with a blanket.
- The client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arteries. Because this test is noninvasive, the client does not need to sign a consent form. The client should receive an opioid analgesic, not a sedative, to control the pain as the blood pressure cuffs are inflated during the Doppler studies to determine the ankle-to-brachial pressure index. The client’s ankle should not be covered with a blanket because the weight of the blanket on the ischemic foot will cause pain. A bed cradle should be used to keep even the weight of a sheet off the affected foot.
The client with peripheral arterial disease says, “I’ve really tried to manage my condition well.” Which of the following should the nurse determine as appropriate for this client? 1. Resting with the legs elevated above the level of the heart.
- Walking slowly but steadily for 30 minutes twice a day.
- Minimizing activity as much and as often as possible.
- Wearing antiembolism stockings at all times when out of bed.
- Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause the disease to worsen.
Which of the following should the nurse include in the teaching plan for a client with arterial insufficiency to the feet that is being managed conservatively?
- Daily lubrication of the feet.
- Soaking the feet in warm water.
- Applying antiembolism stockings.
- Wearing firm, supportive leather shoes.
- Daily lubrication, inspection, cleaning, and patting dry of the feet should be performed to prevent cracking of the skin and possible infection. Soaking the feet in warm water should be avoided because soaking can lead to maceration and subsequent skin breakdown. Additionally, the client with arterial insufficiency typically experiences sensory changes, so the client may be unable to detect water that is too warm, thus placing the client at risk for burns. Antiembolism stockings, appropriate for clients with venous insufficiency, are inappropriate for clients with arterial insufficiency and could lead to a worsening of the condition. Footwear should be roomy, soft, and protective and allow air to circulate. Therefore, firm, supportive leather shoes would be inappropriate.
A client says, “I hate the idea of being an invalid after they cut off my leg.” Which of the following would be the nurse’s most therapeutic response?
- “At least you will still have one good leg to use.”
- “Tell me more about how you’re feeling.”
- “Let’s finish the preoperative teaching.”
- “You’re lucky to have a wife to care for you.”
2.
Encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope. The nurse should avoid value-laden responses, such as, “At least you will still have one good leg to use,” that may make the client feel guilty or hostile, thereby blocking further communication. Furthermore, stating that the client still has one good leg ignores his expressed concerns. The client has verbalized feelings of helplessness by using the term “invalid.” The nurse needs to focus on this concern and not try to complete the teaching first before discussing what is on the client’s mind. The client’s needs, not the nurse’s needs, must be met first. It is inappropriate for the nurse to assume to know the relationship between the client and his wife or the roles they now must assume as dependent client and caregiver. Additionally, the response about the client’s wife caring for him may reinforce the client’s feelings of helplessness as an invalid.
The client asks the nurse, “Why can’t the physician tell me exactly how much of my leg he’s going to take off? Don’t you think I should know that?” On which of the following should the nurse base the response?
- The need to remove as much of the leg as possible.
- The adequacy of the blood supply to the tissues.
- The ease with which a prosthesis can be fitted.
- The client’s ability to walk with a prosthesis.
- The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply the prosthesis will not function properly because tissue necrosis will occur. Although the client’s ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant.
A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should:
- Elevate the stump.
- Reinforce the dressing.
- Call the surgeon.
- Draw a mark around the site.
- The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of bleeding are identified, the surgeon should be notified. The stump is not elevated because adhesions may occur, interfering with the ability to fit a prosthesis. The dressing would be reinforced if the bleeding is determined to be of venous origin, characterized by slow oozing of darker blood that ceases with the application of a pressure dressing. Typically, operative dressings are not changed for 24 hours. Therefore, the dressing is reinforced to prevent organisms from penetrating through the blood-soaked areas of the initial postoperative dressing.
A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first?
- Tell the client it is impossible to feel the pain.
- Show the client that the toes are not there.
- Explain to the client that her pain is real.
- Give the client the prescribed opioid analgesic.
- The nurse’s first action should be to administer the prescribed opioid analgesic to the client, because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client’s apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.
The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches?
- Abdominal exercises.
- Isometric shoulder exercises.
- Quadriceps setting exercises.
- Triceps stretching exercises.
- Use of crutches requires significant strength from the triceps muscles. Therefore, efforts are focused on strengthening these muscles in anticipation of crutch walking. Bed and wheelchair push-ups are excellent exercises targeted at the triceps muscles. Abdominal exercises, range-of-motion and isometric exercises of the shoulders, and quadriceps and gluteal setting exercises are not helpful in preparing for crutch walking.
The nurse teaches a client about using the crutches, instructing the client to support her weight primarily on which of the following body areas?
- Axillae.
- Elbows.
- Upper arms.
- Hands.
- When using crutches, the client is taught to support her weight primarily on the hands. Supporting body weight on the axillae, elbows, or upper arms must be avoided to prevent nerve damage from excessive pressure.
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse’s first step in planning the dietary instructions?
- Determining the client’s knowledge level about cholesterol.
- Asking the client to name foods that are high in fat, cholesterol, and salt.
- Explaining the importance of complying with the diet.
- Assessing the client’s and family’s typical food preferences.
- Before beginning dietary instructions and interventions, the nurse must first assess the client’s and family’s food preferences, such as pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client’s current knowledge level and then building on this knowledge base.
Nurse Jessie is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?
a. arranging for the wheelchair
b. asking her family to visit
c. assisting her to sit out of bed in a chair qid
d. encouraging the use of an overhead trapeze
- Answer D. Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Using the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Sitting in a wheelchair would require too great hip flexion initially. Asking her family to visit would not facilitate the resumption of activities. Sitting in a chair would cause too much hip flexion. The client initially needs to be in a low Fowler’s position or taking a few steps (as ordered) with the aid of a walker.
- The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
a. exercise doing weight bearing activities
b. exercise to reduce weight
c. avoid exercise activities that increase the risk of fracture
d. exercise to strengthen muscles and thereby protect bones
- Answer A. Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.
- A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen. Which factor indicates further information is needed by the nurse?
a. The client’s dietary habits include foods high in bulk.
b. The client’s fluid intake is between 2500-3000 ml per day
c. The client engages in moderate exercise each day
d. The client’s bowel habits were not discussed.
- Answer D. Foods high in bulk are appropriate. Exercise should be a part of a bowel training regimen. To assess the client for a bowel training program the factors causing the bowel alteration should be assessed. A routine for bowel elimination should be based on the client’s previous bowel habits and alterations in bowel habits that have occurred because of illness or trauma. The client and the family should assist in the planning of the program which should include foods high in bulk, adequate exercise, and fluid intake of 2500-3000 ml.
A plaster cast can tolerate weight bearing once it is dry which varies from?
24-72 hrs
A client has a fiberglass -nonplaster- cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. The nurse replies that the client will be able to bear weight on the cast within
20-30 min
A nurse is giving the client with a left leg cast crutch walking instruction using the three-point gait. The client is allowed touch-down of the affected leg. The nurse tells the client to advance the:
crutches and the left leg, then advance the right leg
A client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the:
the client is taught to hold the can on the opposite side of weakness. Left hand and 6 inches lateral to the left foot
A nurse is caring for the client who has developed compartment syndrom from a severely fractured arm. The client asks the nurse how this can happen. The nurse response is based on what understanding
compartment syndrom is caused by bleeding and swelling within a compartment lined by fascia which does the expand.
A nurse is repostitioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse plans to use what
pillow to keep the right leg abducted druing turning
A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the contiuous passive motion (CPM) maching. The nurse’s response is based on the understanding that the device should be used
as much as the client can tolerate
A nurse has an order to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which of the following to protect the knee joint
apply a knee immobilizer before getting the client up and elevate the client’s surgical leg while sitting
A client has just undergon spinal fusion after suffering a heniated lumbar disk. THe nurse would avoid what in the room
an overhead trapeze because it use could promote twisting of the spine after surgery
A throarcolumbosacral orthosis (TLSO) is applied when
the device (back brace) is applied in the morning before getting out of bed. The back brace is fitted to the client. THe closures should be secure but not overly looses or tight. A layer of clothing is worn between the orthosis and the skin
A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. THe nurse would prepare to transfer the client from the stretcher to the bed by using what
a slider board and the assistance of four people
A nurse is caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to note in the client
uric acid level of 8mg/dl
gout is diagnosed by the prsence of persisitent hyperuricmia, with the uric acid level higher than 7mg/dl. Additionally uric acid in an aspirated sample of synovial fluid confirms the diagnosis
A patient with osteomalacia (softening of bone tissue characterized by inadequate mineralization of osteoid) is deficient in what vitamin
vitamin D
The stiffness and joint pain that occurs in osteoarthritis increase with what?
pain increases with activity and is relieved by rest
What is the earlies symptom of compartment syndrom
paresthesia (numbness and tingling in the fingers)
An older cient is brought to the ER department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture(hip fracture). The nurse would expect to note that following inspection of the client’s leg
shorteing of the affected leg, adduction, and external rotation. The client may also report slight groin pain or pain in the medial side of the knee
A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. The nurse should do what
pain with knee extension is a common compaint after knee replacement.The nurse should encourage client to keep the knee extended and administer analgesics PRN
A nurse is caring for a client who had above the knee amputation 2 days ago. THe residual limb was wrapped with an elastic compression bandage that has fallen off. THe nurse immediately does what
rewraps the residual limb with an elastic compression bandgae otherwise excessive edema will rapidly form
If a nurse supects a fat embolim the initial action of the nurse is what?
initial action is to place the client in a fowler’s position
A client has had sugery to repair a fractured left hip. The nurse plans to use which of the following important items when repositioning the client from side to side in the bed
following surgery to repair a fractrued hip, an abductor splint is used to maintain teh affected extremity in god alignment. An overhead tapeze and bed pillow are also use, but they are not PRIORITY item to be used
A nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency enemia. The nurse instructs the client to increase intake of what
meat, liver, other organ meats, blackstrap molasses and oysters
Following knee arthocopy the client is instructed to do what
avoid excessive use of the joint for several days, to elevate the knee while sitting, to avoid twisting the knee, and to return to the physcician for follow up in about 7 days. Ice is applied to the affected joint for pain and swelling. Administer analgesics as ordered
joint replacement nursing indications
Encourage fluid intake of 3L per day. Enourage client to perform self-care activities at maximal level.
Get client out of bed as soon as possible.
Keep client out of bed as much as possible.
Keep abductor pillow in place while client is in bed (hip replacement).
Use elevated toilet seat and chairs with high seats for those who have had hip or knee replacements (prevents dislocation).
Do not flex hip more than 90 degrees (hip replacement)
joint replacement: whats the normal amt of drainage fluid post op?
Orthopedic wounds have a tendency to ooze more than other wounds. A suction drainage device usually accompanies the client to the postoperative floor. Check drainage often. 200-400 ml in a 24 hr time frame is normal
joint replacement problems
A big problem after joint replacement is infection.
fractures of bone predispose the patient to what?
Fractures of bone predispose the client to anemia, especially if long bones are involved. Check H&H every 3-4 days to monitor erythropoiesis. Iron can be given PO with meals. (watch for constipation)
after hip replacement, instruct the client not to…
After hip replacement, instruct the client NOT to lift the leg upward from a lying position or to elevate the knee when sitting. This upward motion can pop the prosthesis out of the socket.
joint replacement hazards of immobility
Hazards of Immobility:
Immobile clients are prone to complications: skin integrity problems; formation of urinary calculi (client’s milk intake may be limited); and venous thrombosis (client may be on prophylactic anticoagulants).
osteoarthritis
Noninflammatory arthritis. OA is characterized by a degeneration of cartilage, a wear-and-tear process. It usually affects on or two joints. It occurs asymmetrically. Obesity and overuse are predisposing factors.
NURSING ASSESSMENT:Joint pain that increases with activity and improves with rest. Morning stiffness. Asymmetry of affected joints. Crepitus (grating sound in the joint). Limited movement. Visible joint abnormalities indicated on radiographs. Joint enlargement and bony nodules.
NURSING INTERVENTIONS:(same as RF)
Instruct in weight-reduction diet.
Remind client that excessive use of the involved joint aggravates pain and may accelerate degeneration.
Teach client to: Use correct posture and body mechanics.
Sleep with rolled terry cloth towel under cervical spine if neck pain is a problem.
Relieve pain in fingers and hands by wearing stretch gloves at night.
Keep joints in functional position.
Tylenol or NSAIDs
hip fracture complication
In clients with hip fractures, thromboembolism is the most common complication. Prevention includes passive ROM exercises, use of ted hose, elevation of the foot of the bed 25 degrees to increase venous return, and low-dose anticoagulation therapy (lovenox IM or xarelto PO). **hip fx compare effected to unaffected side- it will be shorter and externally rotated
amputation
DESCRIPTION: Surgical removal of a diseased part or organ.
Causes for amputation include the following:
Peripheral vascular disease, 80% (75% ar diabetics).
Trauma.
Congenital deformities.
Malignant tumors
Infection.
Amputation necessitates major lifestyle and body-image adjustments.
NURSING ASSESSMENT: Prior to amputation, symptoms of peripheral vascular disease include:
Cool extremity.
Absent peripheral pulses.
Hair loss on affected extremity.
Necrotic tissue or wounds: blue or blue-gray, turning black. Drainage possible with or without odor.
Leathery skin on affected extremity.
Decrease of pain sensation in affected extremity.
Inadequate circulation is determined by: Arteriogram and Doppler flow studies.
NURSING PLANS AND INTERVENTIONS:Provide wound care:
Mark dressing for bleeding, and check marking at least every 8 hours.
Measure suction drainage every shift.
Change dressing as needed (physician usually performs initial dressing change): large tourniqiet at bedside for frank hemorrhage
Maintain aseptic technique.
Observe wound color and warmth.
Observe for wound healing.
Monitor for signs of infection: fever, tachycardia, redness of incision area.
Maintain proper body alignment in and out of bed.
Position client to relieve edema and spasms at residual limb (stump) site.
Elevate stump for the first 24 hours postop
Do not continually elevate stump after 48 hrs postop. (can cause contracture).
Keep stump in extended position, and turn client to prone position three times a day to prevent hip flexion contracture.
Be aware that phantom pain is real; it will eventually diappear, and it responds to pain meds.
Handle affected ody part gently and with smooth movements.
Provide passive ROM until client is able to perform active ROM. Collaborate with rehab team members for mobility improvement.
Encourage independence in self-care, allowing sufficient time for client to complete care and to have input into care.
amputation
The residual limb or stump should be elevated on one pillow. If the residual limb is elevated too high, the elevation can cause a contracture.
Describe postop residual lib care after amputation for the first 48 hours?
Elevate stump for first 24 hours. Do not elevate stump after 48 hours. Keep stump in extended position, and turn client to prone position three times a day to prevent flexion contracture.
Describe nursing care for the client who is experiencing phantom pain after amputation.
Be aware that phantom pain is real and will eventually disappear. Administer pain meds; phantom pain responds to meds.
List three nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems.
Passive ROM exercises, elastic stockings, and elevation of foot of bed 25 degrees to increase venous return.
degenerative joint disease
loss of articular cartilage. Slow deterioration. Non-inflammatory. Mobile joints such as spine, knee, hip, and, foot, knees and hips are most predominant because of weight-bearing. Equal opportunity disease for men women and race.
Generative joint disease and joint versus normal joint
yellow, opaque, rough, areas of malacia, increased cartilage growth
Loose fissures and cartilage become loose and is first seen on x-ray
a normal joint is smooth white and translucent cartilage
risk factors of degenerative joint disease
aging, obesity, occupations, athletic overuse, gymnastics, metabolic disease such as diabetes and hemophilia, genetics.
Secondary degenerative joint disease can occur from a congenital anomaly, sepsis.
Signs and symptoms of degenerative joint disease
symptoms are initially in the joint. It is not a systemic problem. Signs and symptoms depend on the point or joint. Pain on weightbearing and motion and relieved by rest is initial symptom. As it progresses rest does not relieve the pain in the patient is often awakened at night, this is when surgery becomes an option.
Fatigue, fever
Will have stiffness after rest. If they sit for an hour or two and then get up you can see their symptoms in the way they get up. People with degenerative joint disease will usually use some assistance getting up and stand there for a minute or two and then go on. Weather can cause more pain in the joint as it is affected by a lowering of the barometric pressure and increased humidity. There may be crepitus and the joint when they move. There may be some malalignment so that the legs don’t look symmetrical.
Major point is that degenerative joint disease is not a system problem is a joint problem. Over time you will get some systemic response such as fatigue from pain and the body trying to protect itself from the pain and they will also get a fever if synovitis is going on.
Degenerative joint disease in the hips
men. Can be very disabling. It is a joint problem but is frequently seen in both hips because as you tried to splint the pain on one side, it changes your alignment and starts to break down on the other side. The patient will say that the pain is in the leg, inside of the leg, around the knee, in the client, and has general hip pain. With this kind of pain it becomes difficult to sit and stand. Important consideration of living for these patients: don’t have them sit in a chair where their needs are higher than their but because this is about alignment for them and they boost the ability to get up easily because it takes more momentum. There is a decreased range of motion in the hip, crepitus, flexion deformity.
Lifestyle considerations are to decreased walking. Older adults will have lots of other symptoms as well when they stopped walking
With hip involvement there is pain: weight bearing, sitting and rising become difficult.
Degenerative joint disease of the knees
more common in younger people. Dancers. Softening of posterior surface of knee or patella. Seen in older female clients because of degeneration of femoral and tibial condyles
degenerative joint disease lab and xray findings
there are no significant lab findings or x-ray changes. X-ray changes are seen in late stages when you get cracks and fragments. The ESR may be elevated if there is synovitis.
nursing management for degenerative joint disease is to conserve energy and conserve structural integrity. To conserve energy, the nurse can provide pain relief by
medications – effective if you add an anti-spasmodic, if there is synovitis he made need a mad that decreases inflammation. Aspirin and nonsteroidal’s are used as well as injections of cortisone or hyaluron. Aspirin is used in larger amounts than normal because he can decrease joint inflammation and decreased pain but you have to teach the patient that if they get ringing in their ears they need to decrease the dose immediately. side effects include GI irritation such as ulcers skew can prescribe an enteric coated med. With osteoarthritis, nonsteroidal’s are better. injection of cortisone can be very painful and the next day you may become stiff. It can only be done two times a year and the pain it may not be relieved for a long time. Injection of hyaluron prolongs the time they have to have a joint replacement because it cushions the joint. There’s low adverse side effects and reduce the need for pain medication. There is a series of 3 to 4 injections and it is a technique associated paint.
Decrease pain
relieve spasm
decrease secondary inflammation
rest – can decreased pain perception.
if it is acutely inflamed you can splint it but if you splinted for too long you lose mobility in the joint
Systemic – allow for naps periods: 1 to 2 rest periods per day but this is unrealistic with employment
Psychological rest will decrease pain because you are decreasing the stress in the environment
You can use TENS if the pain is vertebral as other pain relief measures.acupuncture, glucosamine sulfate with condroitin, hypnosis and music therapy can also work
to conserve structural integrity for degenerative joint disease
position the body for functional alignment, not for comfort so encourage patients not to put pillows under her knees and to bend the knees and encouraged them to walk
CPM machines can be used because keeping the knee in constant motion prevents it from becoming staff and it decreases start pain when the patient starts weight bearing. CPMs do not replace weight-bearing walking, range of motion, and activity. Research doesn’t support functional or quickness of recovery change.
heat – good for long-term pain
ice – better for acutely inflamed joints or immediately postop. Keep it on for maximum of 20 min. and leave it off for one hour.
Diet therapy – with obesity you want to decrease caloric intake. Standard postop diet should be high in proteins and high in calcium her bill and health
surgery – is done for functionality and to relieve pain. Major surgery
general preoperative ortho concerns
dehydration, medications, and insulin levels if the patient is a diabetic
Hydration – the patient in pain may self immobilize so they have problems with dehydration, so check blood in preop. They want to get up and go to the bathroom so they have dehydration issues. For hydration status check skin turgor, input and output, urine specific gravity, smell and look at urine, ask them if they’re thirsty. In dehydration, RBCs increase, H&H increases
With current medications anticoagulant ability as a concern because orthopedic surgery is bloody. Ask them if they have been taking long-term aspirin. Corticosteroids are a concern because they can delay healing. Look at their insulin
Possible infection – preop make sure you have no indwelling Foley for this patient because infection is a major postop concern. The majority of postop total joint replacement infection comes from intraoperative procedures itself such as the equipment or sterile field. Before surgery prevent infection with high-dose antibiotics. An infection in a joint replacement is more problematic or likely to occur because the peripheral vascular circulation in a joint is very minimal and antibiotic is hard to get into it and the immune system doesn’t respond well to it. Sepsis can occur and this will cause if removal of the joint. You can only do one revision and then they end up with a frozen joint. You can use a clean operating room and only have nurses work in that operating room
stop smoking preoperatively. If not teach them about incentive spirometers
Exercise such as quad setting and gluteal setting, isometric contractions for both sides because a complication of the replacements are DVT’s especially in the operative leg because it is very swollen
cleaning regimen a day or two p preop must be done
hip replacement
assess cardiovascular for DVT’s. The patient with varicose veins are more likely to get DVT’s
respiratory
renal
hepatic
infection. You can look at the mouth preoperatively for infection indicated by gum disease, dental caries. Urine cultures can be done preop to rule out a UTI 2 to 3 days preop. Most infection however is intraoperative
hip replacements
preoperative preparation includes home of environment evaluation and norms established for postoperative period. Stairclimbing is avoided for three months postop. May have to sleep on first floor. Assess their pedal pulses and document prior to surgery because if they are absent postop it is a major concern. If they were absent preop and also postop this is not abnormal.
Hip replacements
preop teaching can be done on positioning, isometric foot and ankle exercises and calf exercises, upper extremity strengthening exercises for a Walker, gait training for a Walker and assistive devices such as Fox polls were grabbers so they don’t have to bend over.
C & DB and IS
hip replacement postop
you want a firm mattress, pillows for the abduction splint so that they don’t had adduct. You have to keep the legs apart and put a wedge or a pillow between the legs otherwise you can pop the full moral head out of the socket. Raise the head of the bed is more than 45°. You don’t want to sit them all the way up because the full moral head will pop out to to the bending action. Have them lying or walking. If they sit in a chair postoperatively or on a commode have them recline and put a pillow behind their back study don’t set up but are more at an angle, so bad posture is good for them. When you’re turning them, turn them on the unaffected side. We don’t want like dropping.
Exercise
ambulation – when getting them out of bed by them on their unaffected side, elevate the head of the bed and give it in bed to the unaffected side and then they stand. Have bank get out more frequently because it increases movement and is good for aeration. They may experience orthostatic hypotension so be careful getting them up
hip replacement postop
teach them the importance of abduction do not sleep on the operated side keep affected leg elevated when seated do not cross the legs no stooping
dislocation of prosthetic
worst-case scenario. Immediately stop activity and call the physician
signs and symptoms include shortening of extremity which is often the right is shorter than the left and there may be a lump on the right side. They suddenly scream in pain and states they can move the extremity they don’t want to go to therapy and pain meds are asked for more frequently. Immediately stop activity and call the physician. They may have a malalignment such as the turned leg, abnormal rotation
treating increased pain with joint replacement
treat their pain. Narcotics are well used because surgery is very invasive. It is more effective with anti-spasmodic because of stretching done during surgery. Pre-Medicaid for physical therapy this is a principle of rehab. Pre-Medicaid about 30 min. prior to therapy
total joint replacement postop
they may have a trained for the first 24 hours with 200 to 500 mL of bloody drainage in the hemovak, then 10 mL after the first day. It is a vascular supply so there is a lot of initial drainage. 47 days postop you will see a swollen extremity that is darker on one side and if you have a blowout it’s terrifying because the patient has had a decrease in drainage and the train is out but there is some drainage in the knee that’s been holding so when the patient then signees and blood squirts out everywhere it’s scary. A blowout is not an acute hemorrhage just get some 4 x 4’s and tell them that this is not uncommon that this is a blood pocket and it will allow you to live a little better now that it is out. Apply pressure. Can happen and hips and knees. Can continue to ooze for a little bit then stops. warmth decreases
total joint replacement postop
THROMBOEMBOLISM
you want to assess every day, use anti-embolic stockings, do ankle exercises. Early ambulation and anti-coagulation is extremely important. 20% of patients with a total joint replacement will have a pulmonary embolism! This is a major concern postop
iNFECTION
this population is at an increased risk
remove their wound suction and indwelling catheter as soon as possible. Assess her temperature routinely postop. they will have a temperature elevation postop. You are looking for a temperature that is higher than this temperature to assess for infection or if it is elevated a week later
With hip replacements the pain postop decreases
knee replacement postop
same concerns as total joint replacement postop. They will have the suction drainage up to the first day with 200 mL in the first eight hours.
Use a CPM machine to keep the joy moving. You will see 10° of extension and 50° of flexion the first day and then 90° of flexion by discharge
General postop ortho includes bleeding, pain, impaired mobility, and tissue perfusion. With tissue perfusion and he becomes extremely swollen. You may have a hotter need temperature in the affected knee postop and you become concerned about infection or a clot.
amputation is
the partial or complete surgical removal of the limb as the result of an injury, intolerable pain, gangrene, vascular obstruction, uncontrollable infection, or congenital anomalies
rehab goals for amputation
provide the client with the knowledge and skills needed for physical, emotional, and social adjustment.
Major causes of amputations
Medical (most common reason for amputation) : diabetes, peripheral vascular disease, cancer, gangrene, infection. It is usually the lower extremity for medical reasons and accounts for most amputations.
Trauma such as accidents that involve a crushing injury, Burns, frostbite. It is often the upper extremity
Congenital anomalies can be upper or lower extremities or birth defects. Least cause of amputations
the increase in the number of people living with amputation is thought to be related to the
aging population and the increase in dysvascular conditions such as diabetes
African Americans with diabetes have a
higher chance of getting amputation compared to Caucasians with diabetes.
Traumatic amputations occur most commonly in
among adolescents and adults younger than age 45 years
the surgeon determines the level of amputation depending on the reason for the amputation such as gangrene, cancer, infection
circulation in the witness evaluated for ample blood flow to support a wound or incision healing. As much of the length of the limb as possible is saved to increase the clients ability to use the prosthetic. It is easier for the client to use a prosthesis if they have their own knee joint (transtibial amputation)
obesity risk
obesity often results in diabetes and contributes to dysvascular disease. A minor injury to the lower extremity of the diabetic can result in infection and amputation.
Amputation prevention for the diabetic client
focuses on control of diabetes, proper foot care, and foot screening to reduce the risk of foot ulcers and amputation
diabetic foot care
begins with daily foot inspection for discoloration and open areas of skin. But screening by a healthcare provider at least every six months includes the use of a monofiliment tto detect changes in sensation of the feet. It is applied to several locations on the bottom of the foot with enough pressure to bend filament. With eyes closed, the client asks to indicate if they can feel the monofilament. Lack of feeling indicates lack of sensation and possible diabetic neuropathy.
Other studies include foot and ankle systolic blood pressure, vibration perception threshold, and thermal sense testing. A decrease in circulation may also result in subsequent or sequential amputations involving the same limb. A bypass may have to be done in order to improve blood flow
clients with poor circulation are at risk for amputation of the remaining leg within 3 to 5 years of
the first leg
risk factors for amputation also includes
advanced age, young age, and poly trauma.
Common effects of aging that could affect success with rehab of the older adults with an amputation include
changes in cardiopulmonary capacity reduced neuromuscular coordination visual and hearing impairments weakened musculature limited range of motion changes in memory, learning, executive function, and behavior
Other considerations include multiple comorbidities such as heart failure and pulmonary disease which decrease the available energy that can affect rehab outcomes. They may also have dual diagnoses such as blindness and imputation. These problems are a factor in determining if the client will be a prosthetic candidate or not.
A geriatric client with bilateral amputations may not be a candidate for bilateral prosthesis due to the energy required to walk and a higher risk for falls
true.
They may however be fitted with the prosthesis to enable transfers.
Geriatric clients are at a higher risk for complications such as
depression, pressure ulcers, falls, and infections
with pediatric clients and amputations
the parents make the decision about surgical amputation for the child and often go through the stages of grief the lost when and future consequences.
Training maay be incorporated into play therapy. The child will require multiple evaluations and changes in prosthetic devices due to growth and development.
Poly trauma is defined as
to a more injuries to physical regions or organ systems, one of which may be life-threatening, resulting in physical, cognitive, psychosocial, psychological impairments and functional disability. They may have to have more than one imputation. Traumatic amputation should be evaluated for other injuries that will affect their ability to participate and we have.
Depression, fear, anxiety, changes in body image, and role alterations are some of the common issues faced by those with a new amputation
true.
Outward signs of depression include
anger, crying, tremors, clenched fists, pursed lips
Less obvious signs include withdrawal, denial increase, loss of appetite, insomnia, decreased energy, weight gain or loss, headache, chronic pain, and thoughts of suicide
with amputations, the client is often grieving not only the loss of the body part but also
the loss of function and the loss of independence.
clients express fear and go three grieving process: denial, anger, are getting, and acceptance.
There may be decreased energy, fatigue, weight gain or loss, restlessness, irritability, chronic pain, and fear of intimacy.
it is important to note the family has the willingness, resources, and abilities to help meet the needs of the client
this is true for amputation
the role of amputation rehabilitation team is to assist the client and family to cope and adapt to the new changes of the amputation and to provide the knowledge and skills necessary for self-care
true
preoperative education for amputations
bed mobility, use of ambulatory aids such as a Walker, crutches, or wheelchair; and care of the residual limb to prevent contractures and pressure sores.
if a prosthesis is available, the client is observed with and without the prosthesis
gait deviations should be noted and any prosthetic issues identified should be corrected
that mobility is one of the first things assessed by the physical therapist
to be able to roll and delay prone independently can essentially determine the client prognosis in terms of other high-level activities such as walking. Transfer is out of the bed, toilet, tub, and car are all tasks that need to be practiced by the client to live as independently and safely as possible
care of the residual limb
teach them to check their skin of the residual land after the amputation especially when they are in the gait training fees while using a prosthesis. This is important for those with diabetes because they may be unable to feel pain and other types of sensation to their plan.
A knee immobilizer is first issued by the surgeon for below the knee amputation to help prevent
knee flexure contractures and to protect the land in case of a fall or impact. A knee immobilizeris a long orthopedic brace that prevents those medial or lateral movement and prevents flexion or extension
a rigid dressing is
a hard plastic device that also serves to protect the freshly sutured limb while maintaining the extension
managing edema in amputations
edema of the residual limb is a challenge for the treatment team. Edema is present to some extent and it makes bidding of the prosthesis challenging. If the person with an amputation has a rigid dressing and it has been removed, compression of the lamb for a prosthesis is provided prepares the residual limb.
The use of elastic soft dressing is often used in lieu of a shrinker sock to manage edema. When using a soft dressing or elastic bandage, care should be taken to reapply at regular intervals about every four hours. Shrinker Sock generally maintain their position and function for a longer period
Ace wrapping is performed once the client is out of the
frigid dressing. Read wrapping of the limb should occur every 3 to 4 hours. Once there is no longer drainage and the incision is healed, shrinker stocks for the residual limb or stump shrinker’s are ordered for edema control and for reshaping the limb
stump shrinker’s are made of elastic and should be washed daily with warm water. They are worn all day until liners are issued.
A liner is shaped like a residual limb and is of a thicker material. It is donned with the prosthetic. Once the client begins to use a liner and starts gait training using a prosthesis your she is instructed to wear the liner during the day and the shrinker at night
clients are encouraged to buy a_________ so that they can continually monitor their plans for any redness or abrasions
handheld mirror
an exercise program is initiated when the client is medically stable in amputations
lower extremity exercises are given to both sides. Strengthening exercises focus on the extensors of the hip and knee and the hip abductors which act to stabilize the pelvis during gait. Examples of initial exercises include quad sets, bridges, supine hip abduction, abductor pillow squeezes, single knee to chest stretch, and supine internal rotation
positions to avoid for the client with below the knee amputation
prolonged flexion and external rotation at the hip and knee flexion
positions to avoid for above the knee amputation
flexion, abduction, and external rotation of the hip
Proning, in amputations, is essential to prevent
hip flexure contractures. Clients are urged to lie prone which is on their stomach, beginning for 5 min. at a time, a pillow under the head may be added for greater comfort to the lower back. Clients are to progress from being as tolerated, up to 20 min. for 3 to 4 times a day. Laying supine, and especially sleeping, with their affected leg on a pillow should be avoided –> Leads to need flexure contractures for below the knee invitation and it leads to hip flexure contractures for above the knee amputation. They will not be able to use the prosthetic if these contractures occur.
Determining if the client is a candidate for prosthetic use
client is motivated to learn and has the skills necessary for self-care
client and/or family are able and willing to learn and have the skills for self-care
there is absence of hip or knee contractures
other medical problems such as respiratory, cardiac, stroke, or visual problems will not interfere with use of prosthetic limb.
Just because a person is not a candidate for gait training with a prosthesis does not mean he or she will not receive any physical therapy.
Prosthetics can be fabricated for cosmetic purposes or if they are doing transfers only
Phantom limb pain
the feeling of pain in a lamb or portion of a lamb that is no longer there
methods to help reduce phantom limb pain
massage, gentle stroking of the land, tapping on the residual limb, and ice, meds which include opioid analgesics, antidepressants, anticonvulsants, and benzodiazepines.
Alternative modalities include biofeedback, transcutaneous electrical nerve stimulation (TENS), hypnosis and acupuncture
There may also be residual limb pain especially to palpation. Other bodily pains can also affect a person’s gait and functional ability
complications of limb healing
cardiac disease, diabetes, renal disease, smoking, and physiological problems can influence wound heali. Ischemia or infection may result in residual limb skin breakdown H
comorbidities and amputations
cardiopulmonary deconditioning may result from bed rest even before any amputation surgery. Deconditioning refers to a decline in ability to perform functional daily activities due to a prolonged period of inactivity. Past medical history is of any cardiac or pulmonary disease can affect outcomes after amputation, and a diagnosis of peripheral vascular disease will assess the level amputation required
The age of the patient and the level of amputation are two most significant predictors of functional outcomes
preventing secondary complications and amputations
falls, skin breakdown, and additional complications related to prosthetic use.
1 in 5 patients with lower extremity amputations would experience a fall during inpatient rehabilitation. It is important for him or her to now have to get up as independently as possible. A fall early in the recovery process can lead to the opening of the sutures and the need for revision by the surgeon. protecting the residual limb is of utmost importance, so clients are given a rigid protector to protect the land when they are out of bed.
Redness, rashes, and skin lesions must be treated seriously. Clients are taught to inspect their skin before and after putting or taking off a prosthetic. It should be noted if their skin integrity is compromised especially along bony prominences and weight-bearing areas. The prosthetic can be modified to accommodate
the amputated client is usually first be trained on the parallel bars and then advances to a
front wheeled walker. If the client ambulate as well they may progress to bilateral auxiliary crutches, a single crutch, a single point cane, and finally to know assistive devices.
Outpatient care is commonly used for the amputee because
rehabilitation of the amputee is a long process. This may mean that the person goes home in a wheelchair level and comes back to therapy for prosthetic training to achieve a normalized gait.
Prosthetics
not everyone is a candidate for prosthetic. The amputee must have adequate strength, range of motion, and control of the proximal joints of both lens. Balance, fear, pain, attitude, and proprioception which is the knowledge of the position of limb and joint in space. Each play a role in determining the appropriateness of a prosthetic. Other key factors include the level of the imputation, the condition of the residual land, and overall health and fitness. Individual goals of a person with the name patient was the considered. If a person with an amputation is able to ambulate on crutches or walkers before amputation here she will be able to function with a prosthetic
fitting a prosthesis soon after the suture line has healed helps to combat
edema, reduces the possibility of contracture, generally improves overall physical condition, and improves psychological well-being.
The socket of the prosthesis is the part that contracts and contains the residual limb
it provides a means for transferring the weight of the body to the ground through the prosthesis. The shape of socket is critical to both comfort and function.
A prosthetic stock is typically worn between the socket and residual land to provide for
ventilation and general comfort. It should be put in the laundry daily.
