Podcast
Questions and Answers
What is a key consideration regarding bone changes in older adults?
What is a key consideration regarding bone changes in older adults?
- Older adults are less prone to skeletal fractures.
- An inactive lifestyle increases muscle strength and bone mass.
- Increased bone density due to calcium supplements.
- Women over 45 may experience a decrease in cortical bone. (correct)
Which assessment finding is associated with kyphosis?
Which assessment finding is associated with kyphosis?
- Exaggerated lumbar curve.
- Lateral curvature of the spine.
- Abnormal rounding of the lower back.
- Increased forward curvature of the thoracic spine. (correct)
A physician orders a diagnostic arthroscopy test. Which task falls under the nurse's responsibilities?
A physician orders a diagnostic arthroscopy test. Which task falls under the nurse's responsibilities?
- Providing routine post-procedure wound care. (correct)
- Performing the arthroscopy at the bedside.
- Explaining bone density results to the patient.
- Inserting the arthroscope into the joint.
What is the primary focus of fracture reduction?
What is the primary focus of fracture reduction?
Which of the following is an indicator of an open fracture rather than a closed fracture?
Which of the following is an indicator of an open fracture rather than a closed fracture?
A patient with a fractured tibia is being discharged with an external fixator. Which instruction should the health care provider include in the discharge teaching?
A patient with a fractured tibia is being discharged with an external fixator. Which instruction should the health care provider include in the discharge teaching?
Which of the following are appropriate interventions for a patient in skeletal traction?
Which of the following are appropriate interventions for a patient in skeletal traction?
A patient with a fractured femur is prescribed baclofen. What condition is the medication treating?
A patient with a fractured femur is prescribed baclofen. What condition is the medication treating?
What should the nurse prioritize when a patient with an arm cast consistently reports pain?
What should the nurse prioritize when a patient with an arm cast consistently reports pain?
Avascular necrosis is a potential complication following a fracture. What is the underlying cause of this condition?
Avascular necrosis is a potential complication following a fracture. What is the underlying cause of this condition?
A patient with a long bone fracture is at risk for fat embolism. What clinical manifestation indicates a fat embolism?
A patient with a long bone fracture is at risk for fat embolism. What clinical manifestation indicates a fat embolism?
Which intervention is most appropriate for a patient in skeletal traction to prevent skin breakdown?
Which intervention is most appropriate for a patient in skeletal traction to prevent skin breakdown?
In the immediate postoperative period following a total hip arthroplasty using the posterior approach, what should the nurse emphasize to the client?
In the immediate postoperative period following a total hip arthroplasty using the posterior approach, what should the nurse emphasize to the client?
What is an advantage of using an anterior surgical approach for total hip replacement?
What is an advantage of using an anterior surgical approach for total hip replacement?
Which nursing intervention should be prioritized when caring for a client following a total knee arthroplasty?
Which nursing intervention should be prioritized when caring for a client following a total knee arthroplasty?
A nurse is educating a patient on preventing osteoporosis. Which is a key preventative measure?
A nurse is educating a patient on preventing osteoporosis. Which is a key preventative measure?
A patient is prescribed alendronate for treatment of osteoporosis. Which demonstrates proper education about this medication category?
A patient is prescribed alendronate for treatment of osteoporosis. Which demonstrates proper education about this medication category?
Which intervention should the nurse prioritize for a hip fracture client with an order for ORIF?
Which intervention should the nurse prioritize for a hip fracture client with an order for ORIF?
A patient is being treated for osteomyelitis. What indicates appropriate understanding of the treatment?
A patient is being treated for osteomyelitis. What indicates appropriate understanding of the treatment?
What is the priority nursing intervention for a client who reports persistent pain, swelling, and difficulty moving an extremity?
What is the priority nursing intervention for a client who reports persistent pain, swelling, and difficulty moving an extremity?
A client reports pain, specifically after ambulating. The X-ray reveals a soft tissue injury with no bone involvement. What injury does the client have?
A client reports pain, specifically after ambulating. The X-ray reveals a soft tissue injury with no bone involvement. What injury does the client have?
Following a total hip arthroplasty using the posterior approach, what is the rationale for proper body alignment?
Following a total hip arthroplasty using the posterior approach, what is the rationale for proper body alignment?
Which client should not use NSAIDs?
Which client should not use NSAIDs?
You administered an opioid to a client, what clinical indicator requires the nurse to hold the medication?
You administered an opioid to a client, what clinical indicator requires the nurse to hold the medication?
A client with a new AKA is complaining of pain in his foot. What is the most appropriate nursing action?
A client with a new AKA is complaining of pain in his foot. What is the most appropriate nursing action?
Which of the following is the most common type of amputation that requires a flap?
Which of the following is the most common type of amputation that requires a flap?
Why is stump care after an amputation so important?
Why is stump care after an amputation so important?
A client reports a pain level of 8 out of 10 three days after a below the knee amputation. What should the nurse prioritize?
A client reports a pain level of 8 out of 10 three days after a below the knee amputation. What should the nurse prioritize?
What is the most important preventative measure that should be taught to the client with osteomyelitis?
What is the most important preventative measure that should be taught to the client with osteomyelitis?
A football player is diagnosed with elbow tendinitis after a game. What is an action taken to provide relief?
A football player is diagnosed with elbow tendinitis after a game. What is an action taken to provide relief?
Which of the following are clinical manifestations of dislocation and subluxation?
Which of the following are clinical manifestations of dislocation and subluxation?
What is the generic name for Tylenol?
What is the generic name for Tylenol?
Osteoporosis is a bone disease where the bones become brittle and can break under stress. What are the main nonpharmacological methods that help prevent osteoporosis?
Osteoporosis is a bone disease where the bones become brittle and can break under stress. What are the main nonpharmacological methods that help prevent osteoporosis?
Before wrapping an amputated stump with a bandage, what nursing assessment is most important?
Before wrapping an amputated stump with a bandage, what nursing assessment is most important?
Osteomyelitis is a bone infection of the bone that requires what type of treatments?
Osteomyelitis is a bone infection of the bone that requires what type of treatments?
A boy with a fractured arm comes into the emergency department. The mother says she gave him Aspirin earlier this morning. Is it ok for the boy to take Aspirin?
A boy with a fractured arm comes into the emergency department. The mother says she gave him Aspirin earlier this morning. Is it ok for the boy to take Aspirin?
What is the general recommendation before giving patients non-steroidal anti-inflammatory drugs?
What is the general recommendation before giving patients non-steroidal anti-inflammatory drugs?
A client has a black box warning for opioids. The hospital is recommending what for drug abuse?
A client has a black box warning for opioids. The hospital is recommending what for drug abuse?
Your client with a hip fracture is in severe pain after sustaining a fall 2 days ago. The doctor has prescribed Morphine intravenously. What would you educate your client about this drug?
Your client with a hip fracture is in severe pain after sustaining a fall 2 days ago. The doctor has prescribed Morphine intravenously. What would you educate your client about this drug?
Your client is taking Coumadin (warfarin) for DVT after a total hip replacement. The doctor has scheduled them for Ketorolac (Toradol) for their inflammation. What is your next best nursing intervention?
Your client is taking Coumadin (warfarin) for DVT after a total hip replacement. The doctor has scheduled them for Ketorolac (Toradol) for their inflammation. What is your next best nursing intervention?
Your client has been recently diagnosed with a rotator cuff tear. Which diagnostic test will the doctor order?
Your client has been recently diagnosed with a rotator cuff tear. Which diagnostic test will the doctor order?
During a physical assessment, which finding would be most concerning to the nurse related to potential neurovascular compromise?
During a physical assessment, which finding would be most concerning to the nurse related to potential neurovascular compromise?
A client is scheduled for an arthrocentesis. The nurse explains that this diagnostic test is used primarily to:
A client is scheduled for an arthrocentesis. The nurse explains that this diagnostic test is used primarily to:
Which laboratory result would the nurse anticipate to be elevated in a client diagnosed with osteomyelitis?
Which laboratory result would the nurse anticipate to be elevated in a client diagnosed with osteomyelitis?
A client has a compound fracture of the left tibia after a motorcycle accident. On admission to the ER, what is the nurse's priority action?
A client has a compound fracture of the left tibia after a motorcycle accident. On admission to the ER, what is the nurse's priority action?
A patient with a fractured femur is placed in skeletal traction. What is the rationale behind this intervention?
A patient with a fractured femur is placed in skeletal traction. What is the rationale behind this intervention?
What assessment is crucial to perform on a client after application of a cast to the lower extremity immediately?
What assessment is crucial to perform on a client after application of a cast to the lower extremity immediately?
A client being treated for a bone fracture develops signs and symptoms of compartment syndrome. Which intervention is the priority?
A client being treated for a bone fracture develops signs and symptoms of compartment syndrome. Which intervention is the priority?
Which of the following is a potential early complication following a fracture?
Which of the following is a potential early complication following a fracture?
A nurse is caring for a client following a total hip arthroplasty using a posterior approach. What information should the nurse include in the teaching?
A nurse is caring for a client following a total hip arthroplasty using a posterior approach. What information should the nurse include in the teaching?
A client is recovering from a total hip arthroplasty via the anterior approach. Which activity would the nurse encourage?
A client is recovering from a total hip arthroplasty via the anterior approach. Which activity would the nurse encourage?
A client is post-operative following a total knee arthroplasty. Which nursing intervention is most important for preventing post-operative complications?
A client is post-operative following a total knee arthroplasty. Which nursing intervention is most important for preventing post-operative complications?
Which dietary modification is most important for the nurse to recommend to a client at risk for osteoporosis?
Which dietary modification is most important for the nurse to recommend to a client at risk for osteoporosis?
Which statement indicates that the client understands how to safely take alendronate?
Which statement indicates that the client understands how to safely take alendronate?
After surgical repair of a hip fracture, an elderly client is reluctant to ambulate due to pain. What is the most appropriate nursing intervention?
After surgical repair of a hip fracture, an elderly client is reluctant to ambulate due to pain. What is the most appropriate nursing intervention?
A client is diagnosed with osteomyelitis. What is the most important information for the nurse to reinforce with the client?
A client is diagnosed with osteomyelitis. What is the most important information for the nurse to reinforce with the client?
A client reports pain, swelling, and decreased range of motion in the right knee following a sports injury. Based on these findings, what is an appropriate nursing diagnosis?
A client reports pain, swelling, and decreased range of motion in the right knee following a sports injury. Based on these findings, what is an appropriate nursing diagnosis?
The nurse is caring for a client who has undergone a transtibial amputation. What is the rationale for wrapping the stump with a compression bandage?
The nurse is caring for a client who has undergone a transtibial amputation. What is the rationale for wrapping the stump with a compression bandage?
The nurse is educating a client with a rotator cuff tear about managing their injury. Which statement indicates a need for further teaching?
The nurse is educating a client with a rotator cuff tear about managing their injury. Which statement indicates a need for further teaching?
A nurse is caring for a client taking an opioid analgesic for chronic pain. Which common side effect should the nurse include in the teaching?
A nurse is caring for a client taking an opioid analgesic for chronic pain. Which common side effect should the nurse include in the teaching?
A client is prescribed an opioid analgesic. What other medication should the nurse anticipate being prescribed?
A client is prescribed an opioid analgesic. What other medication should the nurse anticipate being prescribed?
A client is prescribed Morphine for pain management. Which instruction should the nurse include in the teaching?
A client is prescribed Morphine for pain management. Which instruction should the nurse include in the teaching?
What should the nurse monitor when a patient is prescribed ketorolac?
What should the nurse monitor when a patient is prescribed ketorolac?
A client receiving opioid analgesics experiences a decrease in respiratory rate. Which medication should the nurse prepare to administer?
A client receiving opioid analgesics experiences a decrease in respiratory rate. Which medication should the nurse prepare to administer?
A client with osteomyelitis is receiving antibiotics at home. Which teaching point is most important?
A client with osteomyelitis is receiving antibiotics at home. Which teaching point is most important?
A male client, 70 years old, has been diagnosed with osteoporosis. He asks the nurse, "Since I'm a man, is this a misdiagnosis?" What is the nurse's best response?
A male client, 70 years old, has been diagnosed with osteoporosis. He asks the nurse, "Since I'm a man, is this a misdiagnosis?" What is the nurse's best response?
A patient with a bone fracture is at risk for hypovolemic shock. The nurse understands that this condition can result from
A patient with a bone fracture is at risk for hypovolemic shock. The nurse understands that this condition can result from
A nurse is assessing a patient who is going to get a brace. What should the nurse assess?
A nurse is assessing a patient who is going to get a brace. What should the nurse assess?
A client post amputation is at risk for a joint contracture. What nursing intervention can the nurse implement into the plan of care?
A client post amputation is at risk for a joint contracture. What nursing intervention can the nurse implement into the plan of care?
A client with a bone fracture is at risk for fat embolism. What should the nurse do to improve oxygenation?
A client with a bone fracture is at risk for fat embolism. What should the nurse do to improve oxygenation?
The patient who has just undergone a total hip replacement via the posterior approach is requesting to be turned to their side to allow for pressure relief. How should the nurse repond?
The patient who has just undergone a total hip replacement via the posterior approach is requesting to be turned to their side to allow for pressure relief. How should the nurse repond?
When assessing a client with a musculoskeletal disorder, the nurse notes crepitus in the right knee joint. What physiological process causes this finding?
When assessing a client with a musculoskeletal disorder, the nurse notes crepitus in the right knee joint. What physiological process causes this finding?
A client is scheduled for a bone scan to evaluate for metastatic disease. What pre-procedure teaching should the nurse provide?
A client is scheduled for a bone scan to evaluate for metastatic disease. What pre-procedure teaching should the nurse provide?
A client presents with a suspected bone fracture. What diagnostic imaging study should be ordered first to confirm the diagnosis?
A client presents with a suspected bone fracture. What diagnostic imaging study should be ordered first to confirm the diagnosis?
A patient with a fractured femur is being treated with skeletal traction. Why is maintaining proper body alignment a crucial nursing intervention?
A patient with a fractured femur is being treated with skeletal traction. Why is maintaining proper body alignment a crucial nursing intervention?
A client with a long leg cast reports intense itching underneath the cast. What intervention should the nurse recommend to this client?
A client with a long leg cast reports intense itching underneath the cast. What intervention should the nurse recommend to this client?
Following a fall, an older adult client is diagnosed with a hip fracture. What assessment finding would the nurse expect to observe?
Following a fall, an older adult client is diagnosed with a hip fracture. What assessment finding would the nurse expect to observe?
An elderly client with a hip fracture is scheduled for an open reduction and internal fixation (ORIF). What is the primary goal of this surgical procedure?
An elderly client with a hip fracture is scheduled for an open reduction and internal fixation (ORIF). What is the primary goal of this surgical procedure?
A patient is recovering from a total hip arthroplasty using a posterior approach. What activity should the nurse teach the client to avoid?
A patient is recovering from a total hip arthroplasty using a posterior approach. What activity should the nurse teach the client to avoid?
What nursing intervention should the nurse prioritize for a patient using a continuous passive motion machine (CPM) following a total knee arthroplasty?
What nursing intervention should the nurse prioritize for a patient using a continuous passive motion machine (CPM) following a total knee arthroplasty?
A client is diagnosed with osteoporosis. What dietary recommendation is most important for the nurse to provide?
A client is diagnosed with osteoporosis. What dietary recommendation is most important for the nurse to provide?
Which statement indicates proper understanding of alendronate (Fosamax) administration for a patient with osteoporosis?
Which statement indicates proper understanding of alendronate (Fosamax) administration for a patient with osteoporosis?
A nurse is caring for a client with osteomyelitis. What laboratory result would the nurse expect to be elevated?
A nurse is caring for a client with osteomyelitis. What laboratory result would the nurse expect to be elevated?
For a patient with osteomyelitis, what nursing intervention should be implemented to improve the patient's physical mobility?
For a patient with osteomyelitis, what nursing intervention should be implemented to improve the patient's physical mobility?
A client receiving opioid analgesics reports constipation. What intervention should the nurse initiate?
A client receiving opioid analgesics reports constipation. What intervention should the nurse initiate?
A client is prescribed an opioid analgesic for pain management. What medication should the nurse anticipate being prescribed concurrently to counteract a common side effect?
A client is prescribed an opioid analgesic for pain management. What medication should the nurse anticipate being prescribed concurrently to counteract a common side effect?
A client is prescribed morphine for pain management. Which instruction should the nurse include in the teaching regarding this medication?
A client is prescribed morphine for pain management. Which instruction should the nurse include in the teaching regarding this medication?
A client recovering from a musculoskeletal injury is prescribed ketorolac (Toradol) for pain. What laboratory value should the nurse monitor?
A client recovering from a musculoskeletal injury is prescribed ketorolac (Toradol) for pain. What laboratory value should the nurse monitor?
A client with an elbow injury is diagnosed with a strain. Which intervention should the nurse implement first?
A client with an elbow injury is diagnosed with a strain. Which intervention should the nurse implement first?
What clinical finding is a primary indicator of a joint dislocation that requires immediate intervention?
What clinical finding is a primary indicator of a joint dislocation that requires immediate intervention?
What is the primary nursing consideration related to a client diagnosed with a bone tumor?
What is the primary nursing consideration related to a client diagnosed with a bone tumor?
Flashcards
Bone density and age
Bone density and age
Women >45 yrs of age have a 9%-10% decrease in cortical bone.
Fracture risk
Fracture risk
Older adults are more prone to skeletal fractures.
How to reduce bone loss
How to reduce bone loss
An active lifestyle delays the decline in muscle strength and bone mass.
Causes of height loss
Causes of height loss
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Estrogen deficiency
Estrogen deficiency
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Fracture defined
Fracture defined
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Fracture treatment
Fracture treatment
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Closed fracture
Closed fracture
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Open fracture
Open fracture
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Closed Reduction
Closed Reduction
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Open Reduction
Open Reduction
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Cast
Cast
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Contoured Splints
Contoured Splints
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Braces
Braces
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TLSO Brace uses
TLSO Brace uses
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6 P's for Neuro assessment
6 P's for Neuro assessment
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Clinical Indications for testing
Clinical Indications for testing
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Clinical Indications for testing
Clinical Indications for testing
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Manifestations of fractures
Manifestations of fractures
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Early complications
Early complications
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Shock defined
Shock defined
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Signs of Shock
Signs of Shock
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Fat Embolism
Fat Embolism
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Opioid Analgesics
Opioid Analgesics
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CNS effects: Opioids
CNS effects: Opioids
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GI effects: Opioids
GI effects: Opioids
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Opioid contraindications
Opioid contraindications
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Physical Exercise
Physical Exercise
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What is Osteoporosis?
What is Osteoporosis?
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Osteoporosis Prevention
Osteoporosis Prevention
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Bone Tumor-Metastatic common sites
Bone Tumor-Metastatic common sites
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Osteomyelitis Acute presentation
Osteomyelitis Acute presentation
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Osteomyelitis Chronic presentation
Osteomyelitis Chronic presentation
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Bursitis/ Tendonitis cause
Bursitis/ Tendonitis cause
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NSAID USE
NSAID USE
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Salicylates uses
Salicylates uses
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Salicylates functions
Salicylates functions
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Salicylates contraindications
Salicylates contraindications
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Amputation Sites
Amputation Sites
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NURSING ASSESSMENT signs on patients with Amputation
NURSING ASSESSMENT signs on patients with Amputation
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What are the main concern on Amputation recovery phase?
What are the main concern on Amputation recovery phase?
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What are the major steps of relief of pain?
What are the major steps of relief of pain?
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What could you expect as risk on patients on amputation that might affect mobility?
What could you expect as risk on patients on amputation that might affect mobility?
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Study Notes
- Crystal Yelle RN-MSN is the author of the material
- Sharing and copyright infringement of QCC faculty's intellectual property is prohibited
Required Readings
- Hinkle: Chapters 35, 36, and 37 are required reading
- Karch: Chapters 16 and 26 are required reading
- Kaplan Focused review: Kaplan Musculoskeletal System A is required reading
History and Physical Assessment
- Assess personal & family history
- Assess general health and maintenance
- Assess socioeconomic factors
- Note medications
- Assess patient function and ability
Aging Considerations Impacting Activity and Rest
- Bones
- Muscles
- Joints
- Ligaments
General Gerontologic Considerations
- Women over 45 have a 9-10% decrease in cortical bone
- Older adults are more prone to skeletal fractures
- Active lifestyles delay the decline in muscle strength and bone mass
- Thinning and dryness of intervertebral disc fibrocartilage causes compression, leading to a height loss of 1 1/2 - 3 inches
- Estrogen deficiency during menopause is a leading osteoporosis factor
Physical Assessment Components
- Skin
- Muscle strength and size
- Neurovascular status
- Bone integrity
- Posture and gait
- Joint function
- Pain, altered sensations
Spinal Abnormalities
- Kyphosis
- Scoliosis
- Lordosis
Scenario Question
- Question: An older adult patient has increased forward curvature of the thoracic spine
- Question: What term is used to describe this common finding?
- Options: Lordosis, Scoliosis, Osteoporosis, or Kyphosis
Diagnostic Tests
- Blood and urine tests
- Imaging procedures
- Arthroscopy
- Biopsy
- Arthrocentesis
- Electromyography
- Bone scan and densitometry
- Synovial fluid analysis
Imaging Studies
- Radiography
- Computed Tomography (CT scan)
- Magnetic Resonance Imaging (MRI)
- Positron Emission Tomography (PET scan)
Diagnostic Tests Overview
- Arthrography
- Bone Densitometry
- Bone Scan
- Arthroscopy
- Arthrocentesis
- Electromyography
- Biopsy
- Laboratory Studies
Clinical Indications for Testing
- Tests can study changes in bone structure
- Tests can assess tumors, soft tissue injury, and fractures
- Tests can visualize torn muscles, ligaments, cartilage, and herniated disks
- Tests can identify the cause of unexplained joint pain and joint disease progression and evaluate bone mineral density
Nursing Interventions related to Diagnostic Testing
- MRI
- Arthrography
- Bone scan
- Arthroscopy
- Arthrocentesis
- Electromyography
- Biopsy
Selected Orthopedic Conditions
- Fractured hip
- Total joint replacement (hip, knee)
- Amputations
- Bursitis
- Osteomyelitis
- Osteoporosis
- Cancer of the bone
Fractures: Causes and Characteristics
- Fractures involve a break in the bone caused by a pathological condition, injury, or trauma
- The main objective is to realign the bone to its original position through reduction
- Fractures are categorized as simple, closed, or compound
- A closed or simple fracture means the bone is broken, but the skin is not penetrated
- An open or compound fracture means the bone is broken and protrudes through the skin
Clinical Manifestations of Fractures
- Pain
- Loss of function/Excessive movement
- Deformity
- Shortening
- Crepitus
- Swelling and Discoloration
- Soft tissue swelling/Bruising
- Positive X-ray
Emergency Management of Fractures
- Immobilization
- Assess Neurovascular Status
- Splinting
- Cover open fractures
- Assess for Shock
- The fracture MUST BE REDUCED ASAP!!
Medical and Surgical Management of Fractures
- Closed Reduction involves restoring the bone to its normal position via external manipulation
- Open Reduction involves surgically exposing and realigning the bone
Treatment for Fractures
- Internal Fixation
- External Fixation
Casts: Immobilization and Uses
- Casts are rigid, external immobilizing devices
- Immobilizing a reduced fracture is a main use of casts
- Casts can correct a deformity
- Casts can apply uniform pressure to soft tissues
- Casts can support and stabilize weakened joints
- Casts can be nonplaster (fiberglass) or plaster of Paris
Splints and Braces
- Contoured splints are for conditions that don't require rigid immobilization
- Contoured splints are for those in which swelling may be anticipated
- Contoured splints are for those who require special skin care
- Braces provide support, control movement, and prevent additional injury
TLSO Brace: Indications and Use Cases
- Post-operative stabilization of the spine
- Compression fractures
- Slippage of one vertebrae over another
- Stable lumbar/thoracic fractures and musculoskeletal injuries
Assessment for Brace Application
- Assessment of the patient is needed before application
- Neurovascular status monitoring is needed and watching for potential complications
- Lacerations and abrasions should be treated before applying a cast, brace, or splint
- Information should be provided on the treatment's purpose
- The patient should be prepared by explaining the procedure
Post-Placement Assessment for Braces/Casts
- Assess for neurovascular changes using the "6 Ps"
- Pain
- Poikilothermia (takes on ambient temperature)
- Pallor
- Pulselessness
- Paresthesia paralysis
- Monitor and treat pain
Compartment Syndrome
- Compartment Syndrome is a serious complication
- Diagnosis involves clinical assessment of the 6 Ps
- Pain is the early indicator
Potential Complications of Fractures: Early and Delayed
- Early complications: shock, fat embolism, compartment syndrome, VTE, PE
- Delayed complications: delayed union, malunion, and nonunion, avascular necrosis of bone, complex regional pain syndrome (CRPS), and heterotrophic ossification
Patient Scenario: Arm Cast and Pain
- Question: A patient with an arm cast reports pain in the extremity
- Question: What is a priority nursing action to reduce complications?
Avascular Necrosis of Bone
- Avascular necrosis occurs when bone loses its blood supply and dies
- This is common in femoral neck fractures (intracapsular)
- If the neck of the femur is fractured, a hemiarthroplasty is typically recommended to avoid avascular necrosis
Fat Embolism
- Fat globules are released from bone marrow
- This is often due to multiple trauma
- The symptoms are often a triad: Hypoxemia, Neurocompromise, and Petechial rash
- Treatment involves improvement in oxygenation and cardiovascular function
Shock
- Hypovolemic or Traumatic Shock
- Hemorrhage and loss of extracellular fluid into damaged tissue
- Fracture - extremities, thorax, pelvis, spine can cause Shock
External Fixation Devices
- Screws are placed into the bone above and below the fracture
- A device is attached to the screws from outside the skin
- This device may adjusted to realign the bone
Traction: Purpose and Types
- Traction involves applying pulling force to a body part
- Purposes: reduce muscle spasms, reduce, align, and immobilize fractures, reduce deformity, and increase space between opposing forces
- Skin traction like Buck's Traction and Russell's Traction
- Skeletal traction
Nursing Interventions for Traction
- Proper application and maintenance of traction
- Monitor for complications of skin breakdown, nerve damage, and circulatory impairment
- Maintain body alignment
- Assess pressure points in the skin every 8 hours
- Shift position regularly
- Use special mattresses or pressure reduction devices
- Perform active foot and leg exercises every hour
Centrally Acting Skeletal Muscle Relaxants: Baclofen
- Baclofen (Lioresal) is used for muscle spasticity associated with neuromuscular disorders
- Baclofen is a CNS depressant
Baclofen: Contraindications and Adverse Effects
- Contraindications: CNS depression, Allergy, History of epilepsy, Renal dysfunction
- Adverse Effects: Drowsiness, dizziness, Fatigue, weakness, Headache, insomnia, Nausea, dry mouth, anorexia, constipation, Hypotension and arthymias
Potential Complications with a Patient in Traction
- Pressure ulcer
- Atelectasis and pneumonia
- Constipation
- Anorexia
- Urinary stasis/Infection
- DVT/venous stasis
Hip Fracture: Causes, Findings, and Surgical Options
- Cause: Trauma, falls, osteoporosis
- Findings: Pain in affected limb, affected limb appears shorter and externally rotated, diagnostic X-ray reveals hip fracture
- Surgery: Open Reduction and internal fixation or Hemiarthroplasty
Nursing Interventions for Hip Fractures
- Orient patient to and stabilize the environment
- Provide for patient safety
- Encourage participation in self-care
- Encourage coughing and deep breathing exercises
- Ensure adequate hydration
- Apply TED hose or SCDs as prescribed
- Encourage ankle exercises
Surgical Repair of Fractures
- Open Reduction Internal Fixation (ORIF)
- Surgical procedure to correct joint dysfunction
- Arthroplasty
- Hemiarthroplasty
Surgical Management of Hip Fractures
- Extracapsular hip fractures: treated with open reduction and internal fixation (nail or a rod)
- Intracapsular hip fractures: treated with hemiarthroplasty (partial hip replacement)
Traditional Posterior Hip Surgery
- Patients typically lie on their side or front
- Incision on side or back of leg
- Surgeon detaches muscles, disrupts tissue
- Surgeon relies on post-operative x-ray to check component placement & leg length
Posterior Approach Complications
- Hip flexion is restricted to less than 90 degrees
- No adduction is allowed
- An abductive wedge should be used
- Patients should turn in bed to unaffected side
- Transfer out of bed (OOB) toward unaffected side; return to bed toward surgical side
- Partial weight bearing is usually allowed
Anterior Approach to Hip Surgery
- Patients lie on their back
- Incision on the front of the leg
- No detachment of muscles and minimal tissue disruption
- Surgeon can check component placement & leg length during the procedure
Benefits of the Anterior Approach
- Faster post op recovery
- No dislocation precautions
- No need for special equipment postop
- Less disruptive
- Posterior structures and abductors are left intact
Nursing Interventions Post-Hip Surgery:
- Preventing Dislocation of Hip Prosthesis
- Mobility and ambulation
- Drain use postoperatively
- Prevention of infection
- Prevention of DVT
- Patient education and rehabilitation
Patient Scenario: Total Hip Replacement Assistance
- Question: A nurse cares for a patient with a total hp replacement
- Question: How should the nurse assist the patient to turn?
Total Knee Arthroplasty
- Knee replacement means resurfacing the arthritic joint with metal-on-plastic joint prosthesis
Nursing Diagnosis
- Pain
- Risk for Peripheral Neurovascular Dysfunction
- Impaired Physical Mobility
Potential Post-Op Complications
- Hypovolemic shock
- Atelectasis
- Pneumonia
- Urinary retention
- Infection
- Thromboembolism: DVT or PE
- Constipation or fecal impaction
Nursing Diagnoses Post-Op
- Acute pain
- Risk for peripheral neurovascular dysfunction
- Risk for ineffective therapeutic regimen management
- Impaired physical mobility
- Risk for situational low self-esteem and disturbed body image
Patients with Knee Replacements
- CPM (continuous passive motion)
- Physical therapy
- Acute rehab
CPM Device
- The CPM (continuous passive motion) device for knee replacement patients
Factors Promoting and Impeding Healing
- Promoting: Adequate blood supply, adequate immobilization, approximation of fracture fragments, minimal soft tissue damage, no infection, proper nutrition, exercise, hormones, local application of electrical currents, and bone grafts
- Impeding: Extensive local trauma, tissue swelling, infection, metabolic disease, medications, bone loss, local malignancy/radiation, and corticosteroids
Post-Op Assessments
- Pain
- Vital signs, including respirations and breath sounds
- LOC
- Neurovascular status and tissue perfusion
- Signs and symptoms of bleeding: wound drainage
- Mobility and understanding of mobility restrictions
- Bowel sounds and bowel elimination
- Urinary output
- Signs and symptoms of complications: DVT or infection
Acetaminophen
- Acetaminophen is metabolized in the liver; a small amount remains in the body as a toxic metabolite
- An acute or chronic overdose of Acetaminophen can result in liver damage or fatal liver necrosis
- Acetaminophen is available in tablet, liquid, and rectal suppository form
Acetaminophen Toxicity
- To prevent toxicity, the maximum daily dose of Acetaminophen is 4 grams from all sources
- Overdose causes hepatotoxicity
- Overdose may be accidental or intentional
- Signs/symptoms are nonspecific
- Gastric lavage and activated charcoal can help treat Acetaminophen overdose
- Acetylcysteine (Mucomyst) is an antidote
Opioid Analgesics: Pain Relief Mechanism
- Opioid Analgesics relieve moderate to severe pain by inhibiting pain signal transmission from the periphery to the brain
- Opioid Analgesics are well absorbed with PO, IM, and SubQ administration
- Opioid Analgesics are metabolized in the liver, and metabolites are excreted in urine
- Liver or renal impairment can interfere with excretion
Pharmacological Effects of Opioids
- CNS effects: Analgesia, CNS depression, decreased mental and physical activity, respiratory depression, N/V, and pupil constriction
- GI effects: Slow motility, constipation, bowel and biliary spasm
- These are also the basis for side effects/adverse reactions !!
Opioid Mechanism of Action
- Opioids relieve pain by binding to opioid receptors
- Opioids Block transmission of pain impulses across synapses "Gate theory"
- Opioids are listed as Schedule II Drugs
- Federal Narcotic laws apply
Indications for Opioid Use
- Primary use to reduce pain
- Diagnostic procedures can use Opioids
- GI Disorders: diarrhea can be treated with Opioids
- Severe unproductive cough can be treated with Opioids
- Pre- and postoperative settings
- Opioids promote sedation
- Opioids decrease anxiety
- Opioids facilitate anesthesia induction
- Opioids decrease the amount of anesthesia needed
Morphine: Use and Administration
- Morphine is for moderate to severe pain
- Maximum analgesia after 10-20 minutes (IV)
- Maximum analgesia after 30 minutes (IM)
- Maximum analgesia after 60-90 minutes (SubQ)
- Oral administration of immediate release produces peak activity in about 60 minutes
- Duration of action is 5-7 hours
Other Opioid Analgesics
- Codeine- Tylenol #3 (Acetaminophen)
- Hydrocodone - Vicodin (Acetaminophen)
- Hydromorphone - (Dilaudid)
- Oxycodone - Oxycontin
- Percocet (Acetaminophen)
- Meperidine – Demerol
- Meperidine should be short term only due to neurotoxicity
Opioid Antagonists: Naloxone and Nalmefene
- Naloxone (Narcan) blocks physiologic effects of opioids
- Nalmefene (Revex) is newer and has a longer duration of action
Opioid Dosing Guidelines
- Opioid doses should be reduced for clients already receiving CNS depressants
- Dosages often differ according to the route of administration
- Dosages should be changed when opioids are changed
- Opioids may be given routinely or prn
Opioid Contraindications
- Existing respiratory depression
- Chronic lung disease
- Liver or kidney disease
- Prostatic hypertrophy
- Increased intracranial pressure
- Hypersensitivity to opioids
Black Box Warnings: Opioid Analgesics
- Present with all opioid analgesics
- This is because of potentially fatal adverse effects and the risk of drug abuse
- Analgesics with the warnings include Fentanyl, hydromorphone, methadone, oxycodone, and oxymorphone
Nursing Interventions for Pain Management
- Administration of medications
- Use alternative methods of pain relief
- Create specific individualized strategies to control pain
- Muscle setting; ankle and calf-pumping exercises
- Measures to ensure adequate nutrition and hydration
- Skin care measures, including frequent turning and positioning
- Follow physical therapy and rehabilitation programs
Osteoporosis: Prevalence and Bone Changes
- Osteoporosis is the most prevalent bone disease in the world; more than 1.5 million osteoporotic fractures occur each year
- Bone becomes porous, brittle, and fragile and breaks easily under stress
Risk Factors for Osteoporosis
- Genetics: Caucasian or Asian, female, family history, and small frame
- Age: Postmenopause, advanced age, low testosterone in men, and decreased calcitonin
- Nutrition: Low calcium intake, low vitamin D intake, high phosphate intake (carbonated beverages), and inadequate calories
- Physical exercise: Sedentary behaviors, lack of weight-bearing exercise, low weight, and low body mass index
- Lifestyle choices: Caffeine, alcohol, smoking, and lack of exposure to sunlight
- Medications: Corticosteroids, antiseizure medications, heparin, and thyroid hormone
- Comorbidity: Anorexia nervosa, hyperthyroidism, malabsorption syndrome, and kidney failure
Osteoporosis Prevention
- Balance of diet high in calcium and vitamin D throughout life
- To ensure adequate calcium intake, use calcium supplements and take in divided doses with vitamin C
- Regular weight-bearing exercises: 20 to 30 minutes a day
Pharmacologic Therapy for Osteoporosis
- Calcium and vitamin D
- Bisphosphonates
- Calcitonin
- Estrogen agonists/antagonists
- Parathyroid hormone
- Receptor activator of nuclear factor kappa-B ligand inhibitors
- Follow Table 41-1
Treatment for Osteoporosis: Biphosphonates
- Biphosphonates
- Alendronate (Fosamax)
- Ibandronate (Boniva)
- Risedronate (Actonel)
- Side effects are GI upset
- Caution should be exercised when taking
Osteomyelitis: Definition and Causes
- Osteomyelitis is an infection of the bone
- Osteomyelitis is caused by:
- Extension of soft tissue infection
- Direct bone contamination
- Bloodborne spread from another site of infection
Assessment/Diagnosis: Osteomyelitis
- MRI is needed
- CBC - measures increase in WBC and Sedimentation Rate
- Wound cultures/ blood cultures - can identify appropriate antibiotic treatment
Medical and Surgical Management of Osteomyelitis
- Surgical debridement of necrotic tissue
- Bone grafts can stimulate bone growth for the debrided cavity
- Nursing interventions-include education of impaired mobility
- Nursing interventions include prevention of further injury and/or fracture, and pain management
Nursing Assessment for Osteomyelitis
- Risk factors
- Signs and symptoms of infection, localized pain, edema, erythema, fever, and drainage
- The patient must be able to adhere to the prescribed therapeutic regimen which often involves antibiotic therapy
Clinical Presentation of Osteomyelitis
- Acute: Sudden onset with symptoms of sepsis (chills, fever, and increased pulse) and an Infected area that is painful, tender, and swollen
- Chronic: Continuously draining area, low grade temperature, pain, and swelling
Nursing Interventions: Osteomyelitis
- Relieving pain
- Improving physical mobility
- Prophylactic antibiotics
- Encouraging adequate hydration, vitamins, and protein
- Administering and monitoring antibiotic therapy
- Patient and family education
- Referral for home health care
Bone Tumors: Benign
- Benign Bone Tumors: generally slow growing, present few symptoms
- Bone cysts: expanding lesions within the bone
- Osteoid osteoma: Painful tumor in children and young adults
- Osteoclastomas: benign during along periods, may invade local tissue and cause destruction
Bone Tumors: Malignant (Primary)
- Primary tumors
- Osteosarcoma-most common and most often fatal
- Chondrosarcoma, Ewing sarcoma, fibrosarcoma
- Soft tissue sarcomas
- Liposarcoma, fibrosarcoma of soft tissue, rhabdomyosarcoma
- Prognosis depends on the type and whether the tumor has metastasized
Bone Tumor-Metastatic (Secondary)
- More common than primary bone tumors
- Common primary sites that metastasize: kidney, prostate, lung, breast, ovary, and thyroid
- Treatment is palliative in nature
- Goal: relieve pain and promote quality of life
Malignant Bone Tumors
- Client C/o Persistent pain and swelling and difficulty moving the extremity
- Diagnostic options: X-ray, MRI, and bone scan with biopsy and blood work
- Surgical removal often includes amputating the extremity or bone sparing procedures
- Radiation and chemotherapy
Nursing Interventions: Bone Tumors
- Patient and family education regarding, diagnosis, disease process, and treatment
- Prevention of pathologic fractures
- Promoting proper nutrition Provide adequate hydration
- Use strict aseptic technique
Traumatic Injuries
- Strain
- Contusion
- Sprains
Skeletal Muscle Strain: Description
- Strain involves injury to the muscle or tendon that is caused by excessive use or over exertion.
Sprain: Description
- Sprain usually treated with: RICE: Rest Ice, Compression and Elevation
- Immobilization
- NSAIDS
- Analgesics
- Massage can provide relief
Dislocation & Subluxation:
- Dislocation & Subluxation often cause Pain & tenderness, obvious deformity, swelling, and discoloration
- Patients often experience a Loss of function
Medical and Surgical Treatment: Dislocation & Subluxation
- Immobilization of the joint
- Administer analgesics
- Elevate the limb
- Cold packs
- Neurovascular assessment
Injuries to Upper and Lower Extremities: Rotator Cuff Tear
- Rotator cuff tear
- Diagnosis often means using an X-ray/ MRI
- Often requires treatment
Bursitis/ Tendonitis: Causes
- Causes-trauma, infection, secondary effects of Gout and and Rheumatoid Arthritis
- Pain with movement of a joint is common
- Bursitis/ Tendonitis affects the elbow and shoulder are common sites
- Diagnosing requires X-rays as calcification or aspiration of fluid shows signs and symptoms of infection or urate crystals
Medical and Surgical Interventions/Nursing Interventions: Bursitis/ Tendonitis
- Rest the joint
- Administer NSAIDS or Salicylates
- Corticosteroid injection into the affected joint can reduce inflammation
- Provide Education and implement mild ROM exercise regimens
NSAID'S (NON-STEROIDAL ANTI-INFLAMMATORY DRUGS)
- Inhibit prostaglandin synthesis and COX-1 and COX-2 enzyme synthesis
- Relieve pain by acting centrally and peripherally to block pain impulse transmission
- Relieve fever by decreasing hypothalamic response and resetting "thermostat” at a lower level
- Aspirin and nonselective NSAIDs also have antiplatelet effect
Indications for NSAID Use
- For Inflammatory disorders with mild to moderate pain
- To Block inflammation before all signs & symptoms can develop
- As an Antipyretic
- To suppress platelet aggregation
NSAID Preparations
- Ibuprofen (Motrin, Advil)
- Indomethacin (Indocin)
- Ketorolac (Toradol): parenteral
- Naproxen sodium (Naprosyn)
Contraindications for NSAID Use
- Allergy
- CV dysfunction & hypertension
- Liver impairment
- Increased risk of serious Gl adverse events
- Hypersensitivity to ASA
- Chronic alcohol abuse
- Children and adolescents
- Pregnancy
Salicylates: Mechanism and Use Cases
- Are Anti-inflammatory
- Are Antipyretic
- Are Analgesic
- Inhibit the synthesis of prostaglandins (involved heavily in inflammation)
- Indicated for mild to moderate pain, fever, and inflammatory conditions
Salicylates: Contraindications
- Allergy
- Bleeding abnormalities
- Impaired renal function
- Chicken pox & influenza
- Pregnant or breastfeeding
Reye Syndrome
- Reye Syndrome can occur in childeren
- Do not give Aspirin to treat childeren with the flu
General NSAID'S and Salicylates Nursing Considerations
- Give with food
- Watch for Gl effects- NVD, GI bleeding
- Watch for petechiae, bruising, epistaxis, etc
Amputations: Description and Prevalence
- Amputation is the total or partial surgical removal of an extremity
- 80% of amputations involve lower extremities
Amputation Sites
- Amputation Sites can be
- below the knee (BКА)
- above the knee (AKA)
- below the elbow (BE)
- above the elbow (AE)
- The Most common type in the upper and lower extremity is flap amputation
Amputation: Nursing Assessment
- Neurovascular status and function of affected extremity or residual limb and of unaffected extremity
- Signs and symptoms of infection
- Nutritional status
- Concurrent health problems
- Psychological status and coping
Nursing Diagnoses: Amputations
- Acute pain
- Impaired skin integrity
- Disturbed body image
- Grieving
- Self-care deficit
- Impaired physical mobility
Potential Amputation Complications
- Postoperative hemorrhage
- Infection
- Skin breakdown
- Phantom limb pain
- Joint contracture
- Osteomyelitis
- Stump neuroma-cut ends of nerves become entangled in the healing scar
Amputation: Nursing Interventions
- Relief of pain through Administering analgesic or other medications as prescribed, changing position, Putting a light sand bag on residual limb, and creating Alternative methods of pain relief with distraction and/or TENS unit
- Promoting wound healing by handling the limb gently and Residual limb shaping
Amputation: Resolving Grief and Enhancing Body Image
- Nurse should encourage the patient to look at, feel, and care for the residual limb
- Provide support and listen
- Encourage communication and expression of feelings creating an accepting, supportive atmosphere
- Help patient set realistic goals
- Help the patient resume self-care and independence
- Make a Referral to counselors and support groups
Achieving Physical Mobility: Interventions
- Proper positioning of limb, avoid abduction, external rotation and flexion
- To encourage healing the patient should turn frequently and assume prone positioning if possible
- Use of assistive devices for mobility
- Encouragement of ROM exercises
- Encouragement of Muscle strengthening exercises
- Providing "Preprosthetic care" such as proper bandaging, massage, and "toughening” of the residual limb
Stump Care and Bandaging
- Follow the physician's recommendations for caring for the stump, applying a dressing, washing it, and elevation
- Do not apply OTC ointments or creams
- Adhere to the plan of scheduled exercises as outlined by the Physical Therapist
Patient Scenario: Amputation Patient Self-Image
- Question: A nurse is caring for a patient who has had an Amputation
- Question: What interventions can the nurse provide to foster a positive self-image?
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