Musculoskeletal Flashcards
What is the most common cause of musculoskeletal injury?
traumatic event
What is the teaching related to prevention of musculoskeletal problems in the older adult?
- use ramps in buildings and at street corners.
- eliminate scatter rugs
- treat pain and osteoarthritis
- use a walker or cane to help with walking
- eat the amount and type of food to prevent excess weight which adds stress to joints
- get regular and frequent exercise
- supportive shoes
- gradually initiate activities to promote coordination. Rise slowly.
- avoid walking on uneven surfaces and wet floors.
What are clinical manifestations of a sprain or strain?
pain, edema, decrease function, and contusion
usually self-limiting
**hemarthrosis (bleeding into joint space) can occur
What are acute interventions for sprains and strains?
- stop activity
- apply ice (30 on, 15 off) for vasoconstriction
- compression (30 on, 15 off)
- heat: 24-48 hrs after injury (20-30 on, break)
- rest initially, then use limb!! (protect the joint w/brace, cast, splint
What are the clinical manifestation of a dislocation?
Deformity Hip = shorter and often externally rotated Local pain Tenderness Loss of function Swelling
What are some complications of dislocations? (4)
open joint injuries
intra-articular fracture - break that crosses into the surface of a joint
avascular necrosis - bone cell death from lack of blood supply, common reason for joint replacements in younger people
compartment syndrome
nursing interventions for dislocations are:
Pain relief Support and protect injury Motion restriction after immobilization Rehabilitation program Gentle ROM Exercise program to restore joint to original ROM Gradual return to activities teach: joints can be predisposed to repeated dislocations
What are s/s of carpal tunnel syndrome?
Weakness
Burning pain
Impaired sensation
Clumsiness in fine hand movements
Often seen during pregnancy, premenstrual, menopause – hormones involved
DM and hypothyroidism have higher incidence
What is done to manage carpal tunnel syndrome?
Prevention education
Stop the aggravating movement - Ergonomic changes
Corticosteroid injections (short term relief)
Surgery - Outpatient and endoscopic surgery
*Neurovascular assessment key postoperatively
In fingers distal to surgical site
Rehab takes up to 7 weeks
What are the clinical manifestations of a fracture?
Pain Decreased function Inability to bear weight Guarding (against movement) May or may not have deformity
If suspect fracture: immobilize and ice!!!!
What is done for realignment of a CLOSED reduction fracture?
non-surgical, manual realignment
traction and counetrtraction!!!
local or general anesthesia
immobilization afterwards!!!
What is done for realignment of a OPEN reduction fracture (ORIF)?
Surgery, internal fixation
Risk for infection
Early ROM to prevent adhesions!!
Early ambulation!!
ROM following ORIF (open reduction internal fixation) usually involves Continuous Passive Motion
- Machines that help prevent adhesions
- More rapid healing of the articular cartilage
- Possible decreased incidence of later posttraumatic arthritis
What is the purpose of traction and counetrtraction?
#1 - REDUCE PAIN AND MUSCLE SPASM immobilize joint/bone reduce fracture dislocation treat a pathologic joint condition
What is skin traction and what does the nurse assess for?
Short term (48-72 hrs) Tape, boot, splints applied to skin 5-10 lb weights
Assess for SKIN BREAKDOWN!!
What is skeletal traction and what does the nurse assess for?
Long term pull to maintain alignment
Pin or wire inserted into bone
5-45 lbs
Assess for RISK FOR INFECTION (into bone) and COMPLICATIONS OF IMMOBILITY!!
What are the nursing interventions for traction and countertraction?
Maintain countertraction => elevate end of bed (so pt not pulled to end of bed)
Maintain continuous traction
Keep weights off the floor
Other:
(1) skin care
(2) pin care
(3) prevent infection
(4) positioning
(5) exercise as permitted
(6) psychosocial needs
What can the nurse do if the edges of a cast bother a patient?
petal the edges
What are the DO’s and DON’Ts of cast care?
DO
- Frequent neurovascular assessments
- Apply ice (1st 24 hrs)
- Elevate above heart (1st 48 hours)
- Exercise joints above and below cast
- Use hair dryer on cool setting for itching
- Check with provider before getting wet, and dry thoroughly after getting wet
- Report increasing pain despite elevation, ice, and analgesia => Cast could be too tight – leading to Compartment Syndrome
- Report swelling associated with pain and any discoloration or movement
- Report burning or tingling under cast – Sign of Infection
- Report sores or foul odor under cast – Sign of Infection
- Teach cast removal and alteration is appearance of extremity (esp for kids)
DON’T
- Elevate if compartment syndrome
- Get plaster wet
- Remove padding
- Insert objects inside cast
- Bear weight for 48 hours
- Cover cast with plastic for prolonged period
What is nursing care for a sling?
It supports and elevates arm.
- Contraindicated with proximal humerus fracture
- Ensure axillary is padded and no undue pressure on neck
- Encourage movement of fingers and non-immobilized joints
Superior Mesenteric Artery Syndrome (Cast syndrome)
S/S: distended abdomen, N/V
Assess bowel sounds
Treat with gastric decompression
Don’t confuse with compartment syndrome
6 small meals a day (so stomach not too full)
What is a body jacket indicated for? What does the nurse monitor for?
Immobilization and support for stable spine injuries
Monitor for Superior Mesenteric Artery Syndrome (Cast syndrome)
(1) S/S: distended abdomen, N/V
(2) Assess bowel sounds
(3) Treat with gastric decompression
(4) Don’t confuse with compartment syndrome
(5) 6 small meals a day (so stomach not too full)
Do’s and Don’ts of lower extremity immobilization?
DO:
elevate extremity above heart
observe for compartment syndrome and increased pressure
DON’T
place in dependent position
Hip Spica Cast interventions
assess for cast syndrome
-6 small meals a day so stomach is not too full
teaching: positioning for getting on/off bedpan
What is external fixation used for?
apply traction, compress fracture fragments, and immobilize when a cast is not appropriate
What are nursing interventions for external fixation
assess: pin loosening and infection
Pin site care: cleaning with hydrogen peroxide and saline rinses
teaching: signs of infection and pins loosening
What is nutrition for fractures?
Protein, vitamins, minerals, fluid, fiber
Body jacket and hip spica: 6 small meals a day (so stomach not too full)
A neuromuscular assessment includes what?
Peripheral vascular
(a) Color and temperature
(b) Capillary refill
(c) Pulses
(d) Edema
Peripheral neurologic
(a) Sensation and motor function
(b) Pain
What are nursing teachings and measures for fractures?
Health promotion
(1) Teach safety precautions
(2) Advocate to decrease injury
(3) Encourage moderate exercise
(4) Safe environment to reduce falls
(5) Calcium and vit D
Other nursing measures
(1) Constipation – increase fiber and fluids
(2) Renal calculi
(3) Cardiopulmonary deconditioning (ambulation, PT)
(4) DVT/Pulmonary emboli prevention: heparin, TED hose, PCD)
(5) Teaching for Assistive devices
- Discourage reaching for support!
- Use transfer belt for stability when teaching how to use device
What is preoperative and postoperative nursing care for fractures?
Preoperative management
(1) Immobilization
(2) Assistive devices
(3) Expected activity limitations
(4) Assure needs will be met
(5) Pain medication, and teaching on how to take
Postoperative management
(1) Monitor vitals
(2) General principles of nursing care
(3) Frequent neurovascular assessments (distal to dressing/cast)
(4) Minimize pain and discomfort
(5) Monitor for bleeding or drainage
- Asepetic technique
- Blood salvage and reinfusion (joint surgery)
What are complications that occur with fractures?
infection compartment syndrome VTE Fat embolism Hip fractures in elderly
Infection and fractures:
High incidence in open fractures and soft tissue injuries
- Devitalized and contaminated tissue are ideal medium for pathogens
- Prevention is key
- Can become chronic
Interventions
(1) Aggressive surgical debridement
(2) Possible closure of wound
(3) Closed suction drainage (# drains if multiple drains)
(4) Skin grafting
(5) Antibiotics (irrigation, impregnated beads, and IV)
compartment syndrome s/s:
6 P’s: Pain Pressure Paresthesia (numbness & tingling) Pallor Paralysis Pulselessness
Also urine can be dark =>muscle cells in urine
compartment syndrome care:
(1) Early recognition via regular neurovascular assessments
(a) Notify if pain unrelieved by drugs or out of proportion to injury
(2) Assess Urine output and kidney function
(3) NO ELEVATION above heart
(4) NO ICE
(5) Loosen bandage, split (bivalve) cast
(6) Reduce traction weight
(7) Fasciotomy (cut to relieve pressure)
S/S of Fat Embolisms:
(1) Symptoms w/in 24-48 hours
(2) Respiratory and neurologic symptoms
(3) Petechiae (neck, chest wall, axilla, buccal membrane, conjunctive)
(4) May be rapid and acute
(5) Pt expresses a feeling of impending disaster
(6) Skin color changes in a short time – pallor to cyanosis
(7) Pt may become comatose
(8) Fat cells in blood, urine, or sputum
(9) Decrease PaO2 <60 mmHg
* *This is the 1st sign so watch pulse Ox
(10) ST segment changes on EKG indicating cardiac complications
(11) Decrease platelet count and hematocrit levels
(12) Prolonged prothrombin time
(13) Chest x-ray = white out
Care for Fat Embolism:
Prevention:
Careful immobilization of a long-bone fracture – MOST important prevention
**Usually happens before they get to a hospital – paramedics, EMT’s, etc
Management (symptom related and supportive):
(a) Cough and deep breathe
(b) Minimize pt movement
(c) Oxygen/intubate/mechanical ventilation
(d) Corticosteroids (controversial)
What are clinical manifestations of a hip fracture in the elderly?
External rotation
Muscle spasms
Shortening of affected extremity
Severe pain
What is patient teaching for a hip replacement?
- Keep hip in neutral position (walking, sitting, or lying)
- Foam abduction pillow placed between legs for 6 weeks
- Use elevated toilet seats
- Use shower chair
- Notify surgeon if severe pain, deformity, or loss of function occurs
- Inform dentist so prophylactic antibiotics can be given
- Do not cross knees or ankles
- Do not put on shoes w/o long handled shoe horn for 4-6 weeks
What is the most important nursing assessment after a hip replacement?
neurovascular assessments distal to the surgery
Also: PT begins day 1 postop Home care: 1. Pain 2. Infection 3. DVT prevention 4. Anticoagulation therapy (lovenox)
What is nursing care for a knee replacement?
IMMEDIATELY POSTOPERATIVELY (in recovery room)
- Knee is placed in a continuous passive motion machine
- Anti-embolytic stockings
- PCD (pneumatic compression device)
What are joint surgery complications?
infection and DVT
What is nursing care to prevent joint surgery complications?
- NV assessment
- Anticoagulation therapy
- Pain management
- Antibiotic administration
- Early ambulation
LOS (length of stay): 3-5 days
Stable vertebral fractures are usually due to what?
osteoporosis
What is the goal when someone has a stable vertebral fracture?
Keep spine in alignment!!!
(1) If cervical, cervical collar may be needed
(2) Some may need halo vest
What assessments should be made with stable vertebral fractures?
Vital signs, GI/GU function, NV checks distal to injury
What is treatment for stable vertebral fractures?
(1) Support
(2) Heat
(3) Traction
(4) Keep spine straight when turning
(a) log-rolling: will often need 2 people to keep pt stable/even
(5) Brace or jacket may be needed
(6) Possible outpatient procedures (vertebroplasty, kyphoplasty)
What is important nursing interventions regarding facial fractures?
AIRWAY is primary concern
ALWAYS have suction available!!
Treat all patients with facial injuries as if they also have C-Spine injury as well: Until ruled out => Collar on!
Soft tissue damage makes assessment of facial fractures more difficult d/t swelling
What is nursing care and teaching regarding a mandible fracture?
- *Safety issue:
1. Wire cutters at bedside at ALL times
2. Tracheostomy tray at bedside
3. Oral suctioning ready (and teach pt)
Teach pt when to cut when to cut wires at home
Oral hygiene: warm saline
Liquid diet for 4-6 weeks, until wires come off
What is the goal of an amputation?
preserve extremity length and function while removing all infected, pathologic or ischemic tissue
What should an amputee report?
change in skin color or temperature, decrease or absence of sensation in the feet and/or toes, tingling, burning pain, or lesion
They should also control any comorbidities such as diabetes or PVD, and inspect their extremity daily if they have these conditions
Phantom Limb Sensation
Occurs in 80% of amputees and pts need to forewarned
Teach before surgery about this as they can be very disappointed “it didn’t work”
May complain of feelings of coldness, heaviness, cramping, shooting, burning, or crushing pain
Can cause much anxiety
Symptoms usually subside as recovery and ambulation progress
The pain can become chronic
Treatment: Opioids for pain, Mirror therapy
What is postoperative management of an amputation?
Prevention and detection of complications are key nursing responsibilities:
Monitor VS, dressings, monitor surgical site
Prosthetics may be considered, sometimes immediate, sometimes delayed
- Some rehabilitation will most likely be needed (PT/OT), for use of prosthetics, transfers, exercising, conditioning, ROM
Avoid sitting in chair > 1 hour
- To maintain ROM for residual limb
Compression bandage: supports soft tissue, reduces edema, hastens healing, minimizes pain, promotes residual limb shrinkage
- Can be an elastic roll or an elastic stocking fit tightly over the residual limb
Avoid dangling residual limb– can increase edema
Discharge education: residual limb care, ambulation, prevention of contractures, recognition of complications, exercise, follow-up care
What is patient instructions post amputation?
- Inspect the residual limb daily for signs of skin irritation, especially redness, rubbed areas, and odor. Pay particular attention to areas prone to pressure.
- Do not use the prosthesis if an irritation develops. Have the area checked by your health care provider or the prosthetist before using the prosthesis again.
- Wash the residual limb thoroughly each night with warm water and a bacteriostatic soap. Rinse thoroughly and dry gently. Expose the residual limb to the air for 20 minutes after cleaning.
- Do not use any substance such as lotions, alcohol, powders, or oil on the residual limb unless prescribed by your health care provider.
- Wear only a residual limb sock that is in good condition and supplied by the prosthetist.
- Change the residual limb sock daily. Launder in a mild soap, squeeze, and lay flat to dry.
- Use your prescribed pain management techniques if needed.
- Perform range-of-motion exercises to all joints daily. Perform general strengthening exercises including the upper extremities daily.
- Do not elevate the residual limb on a pillow.
- Lie on abdomen with your hip straight for 30 minutes 3 to 4 times daily.
- Only one not intuitive
- Prevents contractures
