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Musculoskeletal Lecture Flashcards

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1
Q

If someone has a new fracture what will be their chief complaint

A

Pain

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2
Q

So if they are in pain what are you going to do?

A

Give them IV pain medication. (PCA)opioids preferably.. Morphine is better. Demerol ok. if they do not get relief within 20-30 min give them some moreApply ice to decrease pain and swelling.Elevate to decrease throbbing

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3
Q

You must avoid demerol in the elderly because of why?

A

risk for seizures. Elderly is anything over 60-65

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4
Q

If a patient has a pelvic fracture what are they at risk for?

A

Internal organ damage. So there is also a risk for bleeding and hypovolemic shock. That can all be happening and all of that bleeding is hidden. We don’t see it until they have bled out into their abdomen.

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5
Q

What are the 3 things that can cause fractures?

A
  1. Pathalogic/Spontaneous 2. Fatigue/Stress fractures3. Compression fractures
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6
Q

Pathalogic/Spontaneous

A

where the bone just breaks such as in osteoporosis.

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7
Q

Fatigue/Stress fractures

A

rom excessive strain or stress on a bone. This is seen in athletes.

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8
Q

Compression fractures

A

are from application of loading force on the long axis. See most in long bones or spine.

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9
Q

Stage 1-

A

occurs within the first day to 3 days after the injury. The hematoma will form.

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10
Q

Stage 2-

A

occurs within 3-days to 2 weeks. This this cast time. Granulation tissue is starting to move in.

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11
Q

Stage 3 -

A

From 2-6 weeks we get new vascular tissue. And the non bony union begins to come together.

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12
Q

Stage 4-

A

3-6 months.

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13
Q

Stage 5-

A

remodels and can take up to a year. Finally you get the complete bone healing but the bone will always be weaker.

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14
Q

What are the 2 things that can interfere with bone healing?

A

bone cancerPagets disease

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15
Q

If there is traction, your goal and task and what should cause you great alarm is

A

the weights that are attached to the traction. If they are on the floor, the patient is not in traction. You must get the weights up off of the floor and realign the patient I the bed. It takes 3 people to realign someone that is in traction.

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16
Q

For it to be considered pure skeletal traction. There has to be pins into the bone. If this occurs..what is the risk?

A

Infection. There will always be some ooozing from these sites so pin care is paramount. Clean it with 1/2 strength peroxide and saline. Clean the pin sites every 4 hours. They should never be crusty. If they are red and warm there is inflammation and possible infection. It is certainly an infection if there is pus or purulent drainage coming from the site. If this occurs, you need to culture it.

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17
Q

Acute compartment syndrome is usually seen where?

A

in the lower legs and the forearms.

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18
Q

The primary symptom that you are going to see with acute compartment syndrome is

A

numbness and tingling. Additional findings are cool, pale, extremities.This is caused by edema getting trapped within muscular compartments. And it is pressing on nerves and blood vessels.

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19
Q

If not corrected acute compartment syndrome can lead to which 4 things?

A
  1. an infection. 2. Decreased motor function, 3. contractures forming4. the release of myoglobin.
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20
Q

What is myoglobin?

A

It is a protein that is a result of muscular breakdown.

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21
Q

What happens if a patient has too much myoglobin?

A

If we have to much myoglobin the patient can develop what we call myoglobinuric renal failure or myoglobinurea. This is potentially fatal and can lead to acute renal failure.

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22
Q

What is another potential cause for myoglobinurea.

A

rhabdomylosis

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23
Q

myoglobinuric renal failure or myoglobinurea signs and symptoms-

A

ologuric- less than 400 ml in 24 hours. So what you are going to do is monitor the urine output specifically for discoloration. It will look like tea.

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24
Q

Crush Syndrome-

A

example. Car wreck and passenger is ejected and car rolls on top of them. Patient can be conscious and talking but when the weight is removed the patient loses consciousness. That is part of the crush syndrome. Hemorrhage and edema is definitely going to be there. The real problem is not when the body gets crushed it is when we let the pressure off. That is when patient can bleed out and when the nerves wake up and you get severe numbness tingling and pain.

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25
Crush Syndrome management-
early recognition, adequate IV fluids. Diuretics, Low dose dopamine to enhance renal perfusion. Monitor for:acute compartment syndrome... Low fluids... high potassium because of cellular rupture and kidney issues. Rhabdomylysis, tubular necrosis and acute renal failure with dark brown urine. Hypovolemic shock from damage to blood vessels and arteries. This is really seen with pelvic fractures due to damage to internal organs.
26
What is the priority action for a patient with crush syndrome?
****Your priority action is to measure the blood pressure frequently. Insert a foley catheter especially if pelvic fracture.turn the patient every 2 hours.
27
Treatment plan for Crush syndrome
Same as hypovolemic shock. stage 2- give iv fluids LRStage 3- Give LR and Blood stage IV,, use volume expanders and vasoactive drips Specifically I want you to know dopamine. And what is dopamine really supposed to do? Increases cardiac output. ***oxygen, ringers lactate which is a crystalloid , and dopamine…
28
Fat Embolism-
this is where fat globules are released from the yellow bone marrow. This can happen at stage 2 bone healing...it clogs the small blood vessels..They come from long bones and pelvic fractures....It doesn’t necessarily have to be a fracture...you can also see this type of issue if a patient has had any type of total joint replacement.
29
If there is a long bone fracture and the patient goes into respiratory distress. What is the first thing that you should be thinking?
Fat Embolism.Give the patient oxygen and then call the doctor.
30
Fat Embolism Presentation-
O2 related issues. Decreased level of consciousness, anxiety, respiratory distress, tachynpea, hemoptosis. What are you going to do? Oxygen....give them some oxygen then call the doctor.
31
VTE- Veno-thrombo Embolism-
is another issue related to pelvic fractures. Other risk factors are obese. smokers. oral contraceptives advanced age, hemostasis, heart disease. All of this can tie into VTE’s and infection.
32
Osteomylitis-
Bone infection. Typically seen within open fractures not closed ones or anytime there is hardware used.
33
What key factor allows the nurse to differentiate between pulmonary edema caused by a fat embolus versus a blood clot?
Petechiae, only a fat emboli will cause this.
34
Cast care-
cover the rough edges with tape. Keep open access to the wounds by keeping windows in place to see what is going on. 1-2 fingers between the cast and the skin. It can be bi-valved..meaning I have put it on, let it dry and cut it in 1/2 and velcrow them together, use a fracture bedpan.
35
Arm cast-
elevate it while in bed. Use a sling while out of bed. Monitor for frozen shoulder. Teach to exercise the shoulder. Even if full arm cast. Young people will be better at this.
36
Leg cast-
Weight bearing use a cast shoe. Elevate the leg while in bed or In a chair.
37
Body or spika cast-
he body cast encircles the trunk and can cause respiratory constriction. There is risk for-skin breakdown atelectasis, pneumonia, constipation, joint contractures and cast syndrome.
38
Cast syndrome- Superic-mesinary artery syndrome-
Partial or complete upper intestional obstruction. This causes the patient to vomit after they eat. These patients are at risk for aspiration. If this happens you need to cut a window at the area of the duodenum to relive the pressure.
39
If the patient is in a spika cast from the nipple level down what must you have?
Something to cut it. Because if there was an emergency you must be able to get it off especially to do CPR.
40
Cast complications-
infection, impaired circulation, peripheral nerve damage, skin breakdown, pneumonia, VTE, atrophy
41
Eternal Fixation-
weights must be off of the floor and proper body alignment is key.
42
The purpose for external fixation and traction is
to realign the bones
43
If there is serous and serous-sanguinous drainage..
clean it..
44
If the site is swollen, red, crusty.
obtain a culture and then clean it...These patients are very high risk for infections.
45
The best method of changing the sheets on a fracture patient in traction is
top to bottom.
46
Do not puncture the mattress with the pins
To do this place bone wax on the pins.
47
The most important thing for the fracture patient is pain management.
True
48
Amputation-
removal of part of the body. Psyhco-social aspects are worse than the physical aspects.
49
Causes of Amputations
It can be done as a surgical therapy for arterial peripheral vascular disease and it can also be traumatic in nature.Other causes are peripheral vascular disease.Osteogenic-sarcoma, Gerentologic considerations- that is diabetic neuropathies, decreased immune responses, infections, compartment syndrome, cold exposure. Frost bite. Vasoconstrictors.
50
There are some alterations in mobility that you need to be aware of..
If patients lose their small toes it is not such a big deal. You can still get around. If you lose the hallux or the great toe there is significant deficit. The patient will not be able to walk anymore.
51
Who is most likely to lose toes?
Diabetics and women (from shoes), homeless,
52
If the patient loses their mid foot-
they can weight bear without a prothesis and they have reduced pain. Each of those we call disarticulations.
53
Disarticulations are
resections of an extremity through the joint. So if I take off the small toe that is called a digital disarticulation. If I take it off at the mid-foot it is called a metatarsal disarticulation.
54
BKA-
Below knee amputation
55
AKA-
Above the knee amputation.
56
Hip Disarticulations-
leg comes off at the hip.
57
Hemi-pelvectomies-
take entire 1/2 of the hip off. From the pelvis down.
58
There are 2 types of methods of removing body parts.
One is called the guillotine which is an open surface method. There is straight cut no flaps. Then there is closed style or flap style.Most prefer a closed style removal because then there is a flap. So that you can put a prosthetic on it.
59
The one thing about a closed style is that it must be infection free.
If you use a closed flap method and the patient has an infection they will lose another part of their leg or arm. If the patient has an infection they will do the open or guillotine style amputation to promote drainage.
60
Either way (open or closed) the patient has the same amputation risks:
Hemorrhage, infection, phantom limb pain, neuromas, flexion contractors and psychological maladjustment.
61
For Hemorrhaging-
elevate and pressure
62
Infection-
Monitor them for fever, monitor WBC, look at the site for puss in drainage,
63
Phantom Limb pain-
give calcitonin Beta blockers for constant burning sensation (Propranolol) , give anti-epileptics for knife like or sharp pain such as carbazepine and gabapentin). Give antispazmotics for muscle cramping and spasms. Such as Baclofen.
64
for constant burning sensation give
Beta BlockersPropranolol
65
for knife like or sharp pain give
give anti-epileptics carbazepine and gabapentin
66
for muscle cramping and spasms
Give antispasmodicsSuch as Baclofen
67
Neuroma-
small tumor that develops on the exposed nerve. That can be a cause of severe pain for these patients. Use neuromuscular stabilizer Gabapentin.
68
Flexion contractures-
make sure that the patients are moving the residual limb to avoid frozen joints.
69
Psychological maladjustment
reinforce that they are the same person that they were inside. Just because I have removed an arm or a leg doesn’t change who they are. Don’t offer them false hope. Do not say stump stay residual limb.
70
Who is most likely to have amputations-
african americans, native americans, hispanics, cardiovascular disease risk patients.
71
Who is at risk for traumatic injury amputations-
young caucasians.
72
Patient gets their fingers cut off what do you do-
#1 call EMS, assess the airway and breathing, apply direct pressure to the site, elevate the extremity, wrap the fingers in dry sterile gauze clan cloth and place in water tight bag, place that bag into ice water, If it is semidetached do not snap it off.
73
Collaboratively-
ou are going to assess these patients...neuro vascular status, psychosocial status, family reactions, Psych- coping. Religious spiritual and coping beliefs because some cultures have issues with loss of body parts.
74
Segmental limb blood pressures-
Check the ankle pressure, check the knee pressure, and hip pressure, How do you check a hip pressure? If you can palpate a pulse than the MAP is at least 60. Check BP in Popateal and dorsalis pedis or posterial tibial.
75
Ankle Brachial index-
compare the ankle to the brachial pulse. This gives you an indication of vascular stability. But the best way to do it now is ultrasound.
76
Interventions- site checks=
pink and non-discolored, warm but not hot, with a palpable proximal pulse,
77
If I have lost mid arm where is my palpable proximal pulse?
Brachial. If they have lost further up the arm, the palpable proximal pulse is axillary.
78
Pain management is your other key intervention. There are 3 types of pain management that I want you to consider.
1. Residual limb pain 2. Phantom limb pain-3. Regional pain syndrome-
79
1. Residual limb pain-
treat that like any other pain.
80
2. Phantom limb pain-
never deny that the person has pain and you never say to them “You don’t have a limb there anymore so you can’t have pain”
81
3. Regional pain syndrome-
extremely painful to the point where it will effect vital signs. It takes priority for all first treatments. So if you have multiple patients and one has regional pain syndrome they become your priority patient. See them first with goal being to treat the pain. To do this you must first recognize that the pain is real, then handle the residual limb carefully, don’t allow them to stand and hop to the chair.
82
Opioids are not the first line treatment for phantom limb pain.
So give calcitonin. Beta blockers for constant burning sensation (Propranolol) , give anti-epileptics for knife like or sharp pain such as carbazepine and gabapentin). Give antispazmotics for muscle cramping and spasms. Such as Baclofen.
83
Phantom Limb Pain Management complementary therapies-
TENS, Ultrasound, Massage, Heat, Relaxation, Heat, Biofeedback, Relaxation, Hypnosis, Psychotherapy.
84
Prevent infection
with broad spectrum antibiotics. They will have drains in place that need to be removed within 48-72 hours and they are called pinrose drains. Surgeon will remove the first dressing and also the drains. Inspect for inflammation and healing...any drainage...change the soft dressing everyday until the staples are removed and then it does not need a dressing. (ACE bandage) wrapped in a figure 8 technique.
85
Promote mobility-
begin strength training with these patients on post op day 3. That is to prepare for prothesis. Have them push residual limb into the mattress and then have them lift it up. (range of motion)
86
There should be no pillow between the knees.
This allows the patient to be able to due the buttocks squeeze exercise.
87
If they can hemodynamically handle it, flip the onto their belly (prone)
every 3-4 hours for 20-30 min to stretch the hamstrings and prevent it from drawing up.
88
To prepare for the prosthesis,
a certified prothetic orthotist, a good pair of shoes for the fitting. They will put the bandages on quite tight because eventually all of the swelling will go down.
89
Promote positive image and lifestyle adaptation-
Meet with rehabilitated amputee- someone who has gone through it.how to address remaining limb- residual limballow time to discuss feelings-realistic outcome goals, limb care- daily bathing and inspection don't sleep with prothetic on

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