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)
