Mobility Flashcards
RN role for mobility
prevent immobility, maintain or promote best function
Peripheral neurovascular assessment components
color, temp, cap refill, pulses, and edema
Peripheral Neurologic neurovascular assessment
sensation, motor function (strength and ROM), pain
Neurovascular assessment 7 P’s
- paresthesias
- pain
- pressure
- pallor
- paralysis
- polar (temp)
- pulse
Muscle strength assessment
5- moves against full resistance
4- moves against gravity and some resistance
3- moves against gravity but no resistance
2- moves when no gravity resistance required
1- trace of movement
0- no muscle contraction
Muscle ROM assessment
- full
- slightly limited
- limited
- severely limited
- none
Open fracture grading
- grade 1- clean wound <1 cm long
- grade II- larger wound without extensive tissue damage or avulsions
- grade III- highly contaminated and has extensive soft tissue damage. It may be accompanied baby traumatic amputation and is the most severe
Fracture Clinical Manifestations (6)
- pain
- deformity
- shortening
- crepitus
- edema and ecchymosis
- loss of function
What is crepitus?
sensation or sound heard on palpation (like rice crispies)
Fractures emergency management and what do to specifically for an open fracture
- assess neurovascular status before and after splinting
- splint fractured part and joint
- traction for presurgical stabilization, decrease of muscle spasms
- xray
- open fracture: cover w/ sterile dressing; no reduction attempt
What does reduction mean?
bone alignment
What is a closed reduction?
casts, splint
what is an open reduction?
surgical procedure, internal or external fixation
What to do for an external fixation of open reduction fracture?
monitor wound, skin and drainage for s/s of infection; neurovascular assessment priority
Maintaining and restoring function (4)
- neurovascular assessment
- maintain reduction and immobolization
- elevate extremity and control edema
- encourage participation in ADLs
Nursing management of open fracture (4)
- neurovascular assessment, prevent infection
- Irrigation and debridement, bone grafting, external fixation, wound left open
- extremity elevated, ice
- exercises to minimize atrophy *
What is the goal of traction?
decrease pain and muscle spasms
Do you move the weights on a buck’s traction?
NO
What does buck’s traction do for the patient?
they are Able to lift their upper body and non-affected hip
What is the priority for an immobilization cast?
neurovascular assessment; assess distal to cast –> notify changes in baseline (cool, numb, tingling, decreased pulse)
-elevate to promote venous return
Patient education for closed fracture
nutrition (protein iron, vitamin D), exercises, assistive devices, self-care, medications, home environment modifications
Nursing management for closed fracture
- ice/cold packs for pain control (decrease inflammation)
- cast for 6-8 weeks
for immobilization casts what does unrelieved or disproportionate pain a sign of? what to do?
- sign of complication (cast too tight, pressure ulcers, compartment syndrome, infection)
- contact provider immediately; prepare to open cast for additional assessment
What not to do w/ casts?
no pulling out padding or scratching with a tool (can cause skin breakdown and infection)
When can a cast be removed?
only if the bone can stand mild stress
What parts of nutrition are important for someone with an immobilization cast?
protein, vitamins, Ca, P, Mg
Fracture healing process
hematoma formation –> fibrocartilaginous callus formation –> bony callus formation –> bone remodeling
3 fracture healing early complications
- shock: fluid loss
- compartment syndrome
- fat embolism syndrome (FES)
Hypovolemic shock (due to, what to do, address pain after what?)
- due to fluid loss: fast assessment and treatment
- stabilize fracture
- restore volume and gas exchange
- address pain AFTER neurovascular assessment (ensure proper circulation)
Compartment syndrome s/s
- leg swollen, tight, pale and shiny
- deep, throbbing/unbearable pain
In compartment syndrome the swollen muscle ….
compresses blood vessels and nerves in the leg
Compartment syndrome causes a decrease in blood flow due to compartment edema leading to ….
ischemic necrosis
What is compartment syndrome?
decreased circulation due to edema
Compartment syndrome is an EMERGENCY. What should the nurse due frequently?
neurovascular assessment
Compartment syndrome can be relieved by fasciomomy. what is that?
surgical decompression
What is a fat embolism?
fat globules from the injured limb occlude circulation of the lungs/ heart/ and brain
s/s FES
hypoxia, tachypnea, petechial rash, headache, agitation, ALOC
FES requires …
emergency care
Higher risk of VTE during …
long or ortho surgeries
How to prevent VTE (5)
-increased fluid intake, isometric exercises, ambulation as early as possible, antiembolic stockings, pneumatic compression devices
pulmonary embolism is …
sudden due to blood vessel occlusion
s/s PE
SOB, tachypnea, decreased O2 sat
What to do if someone is having PE?
give O2 and call for help
How to manage PE?
symptomatic management, possible fibrinolytic therapy
Joint replacement or injury correction postop care (8)
- neurovascular assessment (PRIORITY)
- VS (pain), dressing, CBC (Hg, WBC, platelets), electrolytes, INR, APTT/PTT
- post op day 1: ice for decreased inflammation
- monitor/prophylaxis for VTE: DVT/PE
- ensure fluid balance (I/O)
- blood conservation system (constavac: may collect and rein fuse blood
- monitor for infection
- early ambulation, use walker, partial weight bearing
Post op hip replacement care (6)
- may need abduction pillow or other immobilization devices
- turning patient: logrolling to maintain neutral alignment
- keep flexion angle <90 degrees, neutral position
- no tying shoes, siting in low chairs (sitting surface must be higher than knee height-raised toilet seat)
- no twisting at the hip, crossing legs at knee or ankle
- use assistive devices to dress, undress, and for socks and shoes (sip on)
What does an abduction pillow fo?
maintaining neutral alignment of hip preventing dislocation
What is phantom pain?
disrupted nerve pathways sending information to the brain
How to treat phantom pain
tx w/ meds (IV/PO opioids, NSAIDs)
Compression dressings
molds limb, need to maintain continuous pressure; pad sensitive areas, necessary to prepare limb for prosthesis
Above the knee amputation post op care
lay flat/prone 30-45 min daily- promotes extension of limb and maintenance of ROM
Discharge requirement for pt that received an amputation
patient able to safely use assistive devices
Osteoporosis risk factors (7)
genetics, age, nutrition, physical exercise, lifestyle choices, medications, comorbidities
Osteoporosis risk factors- age (4)
- postmenopause
- advanced age
- low testosterone in men
- decreased calcitonin
Osteoporosis risk factors-genetics (4)
- caucasion or asian
- female
- family hx
- small frame
Osteoporosis risk factors-nutrition (4)
- low calcium intake
- low vitamin D intake
- high phosphate intake (carbonated beverages)
- Inadequate calories
Osteoporosis risk factors- physical exercise (3)
- sedentary
- lack of weight-bearing exercise
- low weight and BMI
Osteoporosis risk factors- lifestyle choices (4)
- caffeine
- alcohol
- smoking
- lack of exposure to sunlight
Osteoporosis risk factors- medications (4)
-corticosteroids, anti seizure medications, heparin, thyroid hormone
Osteoporosis risk factors- comorbidities (4)
- anorexia nervosa
- hyperthyroidism
- malabsorption syndrome
- kidney failure
Osteoporosis dx
bone mineral density test- DEXA, WHO fracture risk assessment tool (FRAX)
Osteoporosis education
- nutrition rich in CA: dairy, greens, sardines, salmon, almonds
- weight bearing physical activity
RN roll in osteoporosis
-prevention of disease and fractures
Osteomyelitis
severe bone and surrounding tissue infection and inflammation
s/s osteomyelitis
unbearable pain, edema, leukocytosis, increased ESR (labs may be normal for chronic states)
may lead to sepsis: chills, fever, tachycardia
osteomyelitis can progress to ___ which is ___
sequestra, separate bone tissue with low perfusion
Sequestra does not cause an increase in ___
WBC
IF low perfusion, antibiotics cannot
reach and treat infection
osteoarthritis:
- non-inflammatory disorder of synovial joints
- joint cartilage break down
- narrowed joint space: decreased movement
Risks for osteoarthritis (3)
- obesity
- older age
- repetitive movement
Osteoarthritis collaborative care
- activity/exercise modification, weight loss
- NSAIDs (individual response varies), acetaminophen, capsaicin
- NO SYSTEMIC CORTICOSTEROIDS
2019 study for use of NSAIDs in OA
uncreased r/o cardiovascular disease (including ischemic heart disease and CHF) and stroke
Rheumatoid Arthritis (RA)
systemic autoimmune disease (bilateral s/s)
