Nurb Test 1: musculoskeletal Flashcards
- uncoordinated, neurological injury or disease , all over the place
Ataxic gait
Thoracic=
lumbar=
Lateral=preadolescents 12-14, feet together back to you look at shoulder height, hip height, scapula
posture
kyphosis
lordosis
scoliosis
– Parkinson’s gate: stiff, rigid, shuffle gate, few minutes to get going=faster they go wobble, turn little by little
Festinating gait
- scissor gate, cross one leg over another, neurological or trauma cause
Spastic gait
- lift knee and thigh pretty high to lift foot off the ground then slam down the heel= foot drop nerve damage
Steppage gait
= stand with feet together eyes closed norm=little sway
Balance- Romberg test
Upper extremity: pinky and thumb together =____, ___=palm up, pronation=palms down
Lower extremity: _____= lay flat, take on heel to the opposite knee run down front of shin to foot Norm=good contact *stroke assessment
Accuracy of Movement
Coordination: opposition supination pronation heel shin test
- do on own Ex: flexion and extension
active motion
we help move flexion and extension, don’t force beyond comfort
Goniometer=measure flexion and extension
passive motion
A. =away from midline B. =toward midline C. = circle D. = pull foot in E. =point toes
abduction adduction circumduction dorsiflexion plantar flexion
stand with feet together, holds hands up supination (palms up)
Positive pronator- turns hand over and drift
Muscle Strength
Pronator Drift-
- needle to aspirate fluid and run labs Fluid- colorless, yellowish -Thick purulent=infection -Darker yellow=gout -Blood=bleeding in joint
Arthrocentesis
twisting force to a ligament, injury to the ligament
mild- 1st degree, few fibers have injuries
second degree- partial tearing
severe- 3rd degree, completely torn ligament
Soft Tissue Injuries: Sprains-
pulling or stretching of a tendon or muscle
mild- mild pulled muscle
2nd- partial tear fiber
3rd- complete tear
Soft Tissue Injuries: Strains-
- Pain, Edema, Decreased function, Contusion
Soft Tissue Injuries: Sprains/Strains Clinical Manifestations
- Take time to warm up, walk then stretch
- Stretching, Strengthening, Balance
Health Promotion/ prevention strain sprain
(RICE) Rest- may need crutch Ice-vasoconstriction=slow fluid Compression-decrease swelling Elevation-decrease swelling Analgesia-nsaids
strain sprain
intervention
- -injury to the joint, bleeding in the cavity, extra pressure, swelling might hinder blood supply
- -ligament pulls fragment of the bone away when torn
- check placement of the bone
Soft Tissue Injuries: Sprains/Strains Complications
- hemarthrosis
- avulsion fracture
- dislocation
Deformity Ex: hip=externally rotated and turned in
Pain, Tenderness, Loss of Function, Swelling
-Is an emergency don’t want to lose blood flow, seek medical help
Clinical Manifestations dislocation ***
- Interarticular fracture
- Avascular necrosis=death of the bone, quick intervention to prevent
- Neurovascular damage
- Compartment syndrome
Complications
dislocation
(realignment) manually putting it back in place
- go in surgically realign
- after in alignment, certain amount of time to heal, not too long bc lose flexibility
- asap, want to do strengthening, at risk to happen again bc already stretched
Collaborative care Closed reduction open reduction immobilization rehab
- Monitor neurovascular status
- Pain relief
- Protection of joint
Nursing Management dislocation
-tendons, ligaments, and muscles causing tears that become inflamed over time, reinjuring
Concern- keep hurting, over time scaring and will cause chronic pain
Soft Tissue Injuries: Repetitive Strain Injury
Inflammation, Pain, Weakness, Numbness, Impaired motor function over time
sx repetitive strain
- Modification of equipment & activity, sport=rest
- Pain mgt= nonsteroid nsaid, heat= after 72 hours ice=start 1st 48 to 72 hours
- Physical therapy
tx repetitive strain
- Repetitive movements, cyst, rheumatoid arthritis, or tumor of the wrist effects the median nerve
- transverse ligament can become inflamed or damage pressing down on the median nerve
Soft Tissue Injuries: Carpal Tunnel Syndrome
-Weakness, Burning pain, Numbness=outer part of thumb 1st, 2nd, and part of third finger, Impaired sensation, Clumsiness with fine movements, Tingling
sx carpal tunnel syndrome
1, : hold the back of the palms together for a minute pain if have
2. = tap over wrist area, will cause pain
assessment carpal tunnel syndrome
phalen
tinnel
Elimination of aggravating movements
Splinting=won’t correct, help support
Corticosteroid injections- beginning onset, decrease compression
Surgical decompression- open the transverse ligament, endoscopic, will need physical therapy for 4-6 weeks, outpatient
Collaborative Care
carpal tunnel syndrome
-Tight space with 4 tendons, and 4 muscles/ injury not a lot of room for swelling
1. =swelling inflammation causes the pain, can lead to tear
2. injury fall with outstretched arm
Sx: pain, weakness
Soft Tissue Injuries: Rotator Cuff Injury
impingement
Tear
: can’t hold up or not too long, can’t sleep on that side
2. Reach around see if sharp pain in shoulder
DX: mri, ct scan
Assessment: 1. drop arm test
rotator cuff injury
rest, ice, heat, NSAIDs, corticosteroids, PT
Collaborative Care
Conservative therapy:
rotator cuff injury
- suture and correct tendons
- remove the acromion process, will open up the cavity, can be proactive to prevent a tear/ shave down clavicle
Postop- pt after= loss range of motion, will be immobilized for a time period
Surgical repair: Athroscopy
Acromioplasty
rotator cuff injury
sits on top of you tibia, provides support and shock absorption, fibrous cartilage, won’t heal on own
. Soft Tissue Injuries: Meniscus Injury-
tenderness, pain, mild swelling, click or pop of knee, catches=loose cartilage
DX: MRI, arthoscopy
TX: surgical repair
Meniscal tear S&Sx:
fluid on the knee, milk knee forward toward thigh, tap see wave if fluid present
Assessments: meniscal tear
1. Patella Tap Test/Balloon Sign:
lay supine, pull knee and foot up, externally and internal rotate, listen for popping
- McMurray’s Test-
meniscal tear
pain, swelling, bruising, loss of function, muscle spasms, prepadious=popping
Fractures
Sx:
Communication with external enviro - fracture and skin isn’t broken - skin isn’t intact Anatomic location-mid shaft Stability- stable: sides are in alignment, unstable displaced: side of bone not in alignment with fracture Type
open closed classification
bone fragment pulled away with ligament
Avulsion-
- more than two pieces of bone
Comminuted
out of alignment
Displaced-
- usually in peds, fracture one side and won’t go all the way through
Greenstick
-one bone fragment driven into each other
Impacted
- fracture of a joint, into the joint =concerned with range of motion
Interarticular
-runs up and down
Longitudinal
- in a diagonal direction
Oblique
- happens bc other disease process ex: cancer, cyst of bone
Pathologic
- twisted and diagonal
Spiral
- in legs mostly, on feet a lot or running, weight bearing
. Stress
straight across
Transverse-
Newborn-infant=weeks to heal, Elderly=weeks, Adult weeks
: how large bone is Ex: femur longer than 5th finger/ closer to blood supply might heal quicker
-children able to squeeze out/ anyway that can impair healing
- prevent, slows healing
-better more the body will heal
-post menopausal= low estrogen low remolding
Ex: peripheral vascular, diabetes
Fracture Healing Factors Influencing Age: 3-6 6-8 4-6 site immobilization infection nutrition hormones systemic disease
taking longer than normal
Fracture Healing Complications:
1. Delayed Union-
- fracture is not mending at all
Intervention: electrical stimulation/ non get will have surgery
- Nonunion
-bone has rejoined and healing/ not aligned
Intervention-osteotomy=refracture to realign
- Malunion
-high risk over 1st year, go to therapy, happens a lot with kids
- Refracture
- Electrical stimulation-stimulates bone cells, increases their activity
- Pulsed electromagnetic field (PEMF)
Treatment
-Delayed/nonunion
1st realign, 2nd immobilize, 3rd restore function-therapy
A. -realignment, bone out of joint, fracture fragments aren’t in align
Manual alignment
B. - can be any extremity, surgical incision to realign
Collaborative Care: Fracture Reduction
Closed Reduction
Open Reduction
-immobilize and heal, pins directly into the bone on the outside
. External Fixation
-screws, plates inside the body to hold in place
- Internal Fixation
- application of a pulling force to an injured or diseased part of the body while counter pull in the opposite direction
- take off, will use manual to prevent pain till reapplied
Collaborative Care: Traction
Prevent or reduce muscle spasm bc it cramps and is contracted
Align the bone
Immobilize joint for healing and prevent pain, opens joint
Reduce a fracture or dislocation
Expand a joint space
Purpose: traction
Pulling force applied by a person, down and out (hip=pull by ankle)
Manual traction-
-Pull force to soft tissue via boots, splints, foam boots, pelvic slings/ appliance goes directly to appliance instead of bone Ex: bucks, cervical halter, pelvic sling
Skin traction
Pull force to bone by wire, pins, screws, or tongs/directly into the bone
Skeletal traction
Nursing Management: Traction
- -try to have at all times, have rn support the leg when moving/don’t take off to change and move pt
- -straight in bed, supine, watch extremities=no internal or external rotation
- -not against weight or pully/ weight off floor
- opposite pull from the weight, increase=raise foot of the bed if off lower extremity/ upper extremity=raise head of bed
- -check the pully line, straight
- -assess signs of infection, check hospital policy method for pin care is chlorhexidine left open to air
- -physical therapy with every extremity that isn’t fractured from day 1, will be weak from laying in bed
- high risk for skin breakdown, skin dry
- all pt except neck and spine, will help to move
- -keep clean
continous alignment resistance opposing traction line of pull skeletal pin muscle strengthening inspect trapeze hygeine
- above and below fracture, more significant may have to go higher
Materials: plaster, synthetic (polyurethane, fiberglass)=dry quick
-moisten roll and apply then dry/cotton wrap around bony prominences ie: elbow and wrist
Fracture Immobilization Casts
: complete drying 24-72 hrs
May need petaling of edges once dry, ends can crumble, can take tape around the edges
Plaster cast
: lightweight, immediate immobilization, relatively waterproof
Synthetic cast
Types of Casts
4. -belly and one leg
5-belly and both legs, no bar to pull could break, challenging to move go to restroom, harder for kids=not potty trained, infant diaper inside and larger diaper outside
6. -only toes showing
Types of Casts
- Short arm
- Long arm
- Body jacket
- Single hip spica-belly and one leg
- Double hip spica-belly and both legs, no bar to pull could break, challenging to move go to restroom, harder for kids=not potty trained, infant diaper inside and larger diaper outside
- Long leg-only toes showing
- Short leg
- emergency=call doc right away, eadjust fit with brace, open up abd window or refit abdominal= pressing on mesenteric artery causing gastric distention- causes it to become tighter causing nausea, vomiting, decrease bowl sounds,
- sitting in belly bc no blood supply
Cast syndrome
-ng tube to stop vomiting, call doctor
Cast syndrome Intervention
- Neurovascular assessments
- Elevation & ice initially-to help with swelling for 48-72 hours
- Exercise joints above and below cast
- Padding for rough edges- if you smell odor can be an infection, skin break down
- Want to keep open to air, careful with touching can leave indent, don’t get wet
- know directions with water, cover get in shower
Nursing Management: Cast Care
Plaster
Fiberglass
Instructions regarding water
Do not insert items into cast to scratch
S & Sx to report- pain increase, tingling, smell odor,
MD appts-follow up apt, removed by physician
Pt teaching:casts
- Splints
- proper fit, knee cap open, 1st 24 , off at night
- -watch fitting, rubbing or cutting into neck, 90 degree angle, fingers sticking out, have wiggle fingers often
Collaborative Care: Fracture Immobilization
immobilizer
slings
Muscle Relaxants- with hip fractures
cyclobenzaprine (Flexeril)
carisoprodol (Soma)
-for pain keep on schedule first couple of days around the clock to have therapy you need, pca 1st 24 hours will switch to oral
Analgesics
- Protein (1g/kg of body weight) increase, supplement with protein drinks/Vitamins (B, C, D)/ Calcium/Phosphorus/Magnesium
- Adequate fluid intake 2000-3000 ml/day-bowls, contraindicated for renal patient
- High fiber-bowls
- Body jacket and hip spica: 6 sm meals/day
Collaborative Care: Nutritional Therapy
- Treat life threatening injuries first
- Ensure airway, breathing, circulation
- Control external bleeding
- Splint joints above and below fracture, don’t get it out of position, leave it where it is, elevate/ leave bone protruding
- Do not attempt to straighten
- Obtain brief history: if lose consciousness, name, allergies, medical problems
Nursing Management Initial assessment/interventions:
initial injury, before or after surgery
- different from normal, didn’t work=nv issues
- able to move toes now can’t, differences
- numbness and tingling, change
- all, distal to injury Ex: femur-pedal pulse
- color changes, purple, white, red
- in space, unable to assess
Nursing Management Neurovascular Assessment-pain paralysis paresthesia pulses pallor pressure
sensation and motion
- tell me were I touch
- last part(distal)of small finger
- distal surface of the index finger
- in between thumb and finger - motion:
- spread fingers (abduction)
- move thumb and wrist (hyperextension)
- opposition=thumb and pinky touch
Nursing Management: Neurovascular Assessment of Upper Extremities-
ulnar
median
radial
ulnar
radial
medial
- Sensation
- between 1st and second toe
- medial and lateral, touch sole of foot - motion:
- dorsiflex ankle
= plantar flex ankle, extend toes
Nursing Management: Neurovascular Assessment of Lower Extremities
peroneal
tibial
peroneal
tibial
-orthostatic easily=bp drop/ pass out, partly because they are immobile and there is such a large fluid loss, watch hemoglobin=blood loss, watch pt on antihypertensive=don’t blindly give
Intervention- get up slowly, easy walk, not to far
Cardiopulmonary post op complication fx surgery
- not good fluid intake, high levels of calcium in the blood from the fracture, can lead to acute renal problems
Renal Calculi post op fx surgery
cardiopulmonay
constipation
renal calculi
dvt/pulmonary embol
post op complication fx
-High incidence in open fractures
-Surgical debridement and irrigation needed with open fractures
Tx: IV antibiotics for 3-7 days post op, tetanus shot
Complications of Fractures: Infection
-important because it can be devastating very quickly, long term effects, buildup of pressure in bone= cause pressure and blockage
Complications of Fractures: Compartment Syndrome
. =to tight of fit with brace or cast, or to high of traction
- 6 hours can cause irreversible damage
decreased compartment size
- too much internal, bleeding and fluid
- both have same effect edema- blood flow back/venous, arterial flow to the extremity=not getting oxygen or nutrients to the area=now can have ischemia, eventually can have ischemia lead to necrosis and loss of function
- increased compartmental content
Complications of Fractures: Compartment Syndrome Clinical Manifestations (6 P’s):
- Paresthesia
- Pain- 1st onset different
- Pressure
- Pallor
- Paralysis
- Pulselessness-advanced, later
- caused from muscle damage, myloglobin is released and can cause a clog in kidneys causing renal failure
- leading to amputation-can’t be brought back
Complications of compartment syndrome
- Rhabdomyolysis
- necrosis
- look external 1st
- Avoid elevation and ice (vasoconstrict)- remove constrict blood flow
- Loosen bandages, casts=bicave-open up leave bottom part in it to immobilize, -external
- Decrease traction wt-external
- Surgical decompression (Fasciotomy)- internal problem, open the skin to give room in the area to not compress, open for a few days, dressing on top
Complications of Fractures: Compartment Syndrome Collaborative Care
- Contributing Factors- Immobility, Vascular restriction
- Prevention- Compression stocking, Sequential compression devices (SCD’s), Exercise program, Prophylactic anticoagulants
C. Complications of Fractures Venous Thrombosis
-Disruption of blood supply to bone that causes death of bone tissue, will require surgical intervention=cut out dead bone and graft
Avascular Necrosis
-high risk because lipids are release in blood stream from fracture, settle in small capillaries and clogs them up, stop flow of blood, can burst and rupture
Complications of Fractures: Fat Embolism Syndrome
: tachypnea, cyanosis, dyspnea, decreased saturation
: chest pain, tachycardia
: (brain) restlessness, confusion, memory loss, HA
: pallor to cyanosis, petechial
fat embolism syndrome respiratory cardiovascular cns skin
Respiratory support-o2, vent
Hydration
Hemodynamic stabilization
Corticosteroids-occasionally, decrease immune response
Collaborative Care
fat embolism syndrome
-femur head
Types: Capital, Subcapital, Transcervical
-replacement required
Tx: replace femoral head and acetabulum, one or the other can do a hemiarthroplastiy
-=total weight bearing, lasts 20-25 years
- =partial weight bearing, used bc pt is younger, longer to heal
Intracapsular hip fx
Total hip
Cement
Porous
-outside femur head
A. Intertrochanteric
B. Subtrochanteric
-open reduction, pens/ plates=partial weight bearing
. Extracapsular hip fx
- don’t bend past 90 degrees or don’t lift feet up
- no internal rotation, no twisting
- keep legs apart=abduction
Fractures of Specific Sites: Collaborative Care Hip
-usually from chronic arthritis
Fracture: Closed reduction & casting or internal fixation with screws
-replacing knee joint
-PT: immediately, extension and flexion back as quick as possible
-start in extension then gradually goes to preset level of flexion, stay in device for two hours, then rest two hours
Placement- knee is not bent, bar by hip, bend in knee is at place of bend of foot, foot is at the back of machine, foot is up and high
-no strength in quad because it is cut 2 people, one hold while other put machine under
-Watch groin area for skin breakdown=padding, wash cloth
-Wt bearing: cement=full weight bearing immediately following
Fractures of Specific Sites Knee
Total
Cpm
-Caused by direct force
TX: ORIF,
traction, casting
-ROM on uninvolved extremities
-Isometric exercises for affected extremityFractures of Specific Sites Femoral Shaft
TX: Closed reduction & cast
ORIF
External fixator
-Maintain quadriceps strength and upper body
-Fractures of Specific SitesTibia Fx
-highest mortality
A. -actually pulls the pelvis apart
B. - the bones are still inplace but fractured
Sx: bruising on abd, unusually movement,
Pelvis fx
open book
closed book
TX: depends on how severe
-bed rest, 6 weeks, limited weight bearing
-one fracture site
two or more fracture sites, nondisplaced
: Traction, skeletal traction, surgery, casting
pelvis fx conservative\ complex Stable Unstable
Complication: highly vascular area, a lot of blood clots=watch hemoglobin/ punctures
- Assess: bowels, peritonitis, bladder function, vertebrea and neurological problems
- Interventions: log roll, deal with pain
pelvic fx
fragment has not moved into or cause injury
-dislocation or fragment that has moved into spinal cord
Nursing Care: Log roll- 2 ppl one at head, keep inline, pillows under, move as one unit
-No trapeze
-Maintain ordered traction
Vertebrae Fx
Stable
unstable
- Carful of other injuries, Monitor ABC’s
- Assess for spinal injury-moving head and neck be careful
- Assess for eye injury-watch for signs of rupturing
Fractures of Specific Sites Facial fx
–runs along the gum line, wired between the teeth, bars to hold immobilize 4-6 weeks, can open a little
1. Monitor respiratory status
2. Wire cutters available-emergency, needed to intubate/never cut unless necessary/ with resp arrest
-vomiting=roll on pt side to avoid aspiration
3. Suctioning- aspiration, through nares if needed
4. Trach trey at bedside- just in case
5. Oral hygiene-rinse, swabs
6. Establish communication method-chalk board, pen paper, signals= hard to talk
7. Adequate nutrition- mouth is closed, liquid diet= high protein
-can cause constipation= air with straw, not enough fiber
Intervention: stool softener, moving
Mandible fx
- Gradual onset: pvd, infection
- Loss of sensation
- Inadequate circulation
- Pallor
- Infection
- Pain initially, then will have less as it progress
. Clinical Manifestations amputation
(guillotine)- incision will be along the line of the extremity, left open to allow to drain= usually infection, close later
Open Amputation
(flap)-amputate then pull skin around the end of the extremity making a flap, incision line is on the back, so there is not pressure on the incision, not done initial can get this done as a second procedure
Closed Amputation
- Upper body conditioning
- Prosthesis fitting
- Assess & provide intervention for:
A. Bleeding-initially okay, a lot after surgery= one of the suture is lose, apply pressure dressing, notify doctor
B. Swelling-uncomfortable, prevent with compression wraps, elevate=1st 48 hours is okay, after limb needs to be dropped down to not contract
C. Infection
D. Pain
E. Phantom limb pain- 1. roll towel up and pull forward to show brain this is where it stops
F. Contractures-prevent, important, dev won’t be able to use a prosthesis
G. Compression=shrink down site to help mold and be able to mold for prosthesis
H. Avoid sitting in chair for to long, no more than one hour
I. Lay in prone position = to extend and stretch hip joint to prevent contracture for a while
J. Stump care
Amputations Collaborative/Nursing Care:
-important takes 40 percent more energy to walk if below knee 60 percent if above the knee/ progress to prosthesis, want to maintain mobility
Upper body conditioning
prevent breakdown, teach to inspect the area routinely, redness, irritation, thoroughly dry area, massage the area, leave open to area, stump socks
Stump care-
phenomenon, sensation that limb is still there/ 80 percent experience initially, will subside over time, some can still have chronic pain/
- burning, cramping throbbing pain
- help train the brain, nerve impulses are still being sent
phantom limb pain
- for fracture, cast, traction
- child dev can cause developmental regression: want to keep them moving and studying
- Muscular, Skeletal, Metabolism, Cardiovascular, Respiratory, Gastrointestinal, Skin, Urinary
Peds Physical Effects of Immobility
- Scared and anxious, afraid
- try to distract
- Decrease Environmental stimuli - Increase Feelings of frustration, helplessness, anxiety
- Depression
- Anger, aggressive behavior
- Developmental regression
Peds Psychologic Effects of Immobility
Most common: radial head at elbow
- The longer of joint the longer recovery will take
- Toddlers can see of the hip when they fall
- complication watch blood supply
Peds Dislocation
-Common injury in children
Rare in infants, except with MVA
Physical abuse= x-ray with multiple fractures healing at different rates
Clavicle most frequently broken bone in childhood, especially in those less than 10 years
School age: bike, sports injuries
Peds Fractures
- fractures or injury of the growth plate
-effect on length of the bone
-may need additional types of tx if not healing the right way
Sx-realign, pin
Epiphyseal Injuries
Avoid small toys, objects, … in the cast Safe feeding and positioning -cast fit in car seat Challenges with diaper changes-use pediatric size diaper to put inside cast, larger diaper inside the cast Reassure during cast removal
Peds Casts: Nursing Care
- imperfict fit, hip bone will not sit in there correctly
2. - partial femoral head not incotact with acetabulum capsule
3. - no contact - want to assess early
Developmental Dysplasia of the Hip (DDH)- different degrees
- dysplasia
- subluxation
- dislocation
Shortened limb on affected side
Restricted abduction of hip on affected side
Unequal gluteal folds when infant prone
: abduct infant leg feel slide back in place
: abduct legs feel femoral head slide back words
- lay on back, look at the level of the knee, one knee will be higher than the other
Clinical Manifestations DDh
Positive Ortolani test
Positive Barlow test
Allis
– tabular harness, keeps the femoral head in contact with the acetabular capsal, stability, immobilization/
-kept in 24 hours a day go to doc apt 1-2 weeks, don’t readjust harness
Collaborative/Nursing Care-earlier the better
Newborn -6months
perform surgery with reduction, alignment of hip, double spica cast 2-4 months
6 to 18 mo.-ddh
