Final Exam Topics MS2 SW PDF

Final Exam Topics and guide to study 11.13.24 (70% new topics: chapters 36, 37, 55, 56; 30% old topics: Cardiovascular, Respiratory, and reproductive disorders) = Comprehensive Final Musculoskeletal 1. Low back pain - What is it? Causes/risk factors? Signs and symptom...

Final Exam Topics and guide to study 11.13.24 (70% new topics: chapters 36, 37, 55, 56; 30% old topics: Cardiovascular, Respiratory, and reproductive disorders) = Comprehensive Final Musculoskeletal 1. Low back pain - What is it? Causes/risk factors? Signs and symptoms? Assessment and diagnostic findings? Treatment? Low back pain ○ Caused by one of many musculoskeletal problems: acute lumbosacral strain, unstable lumbosacral ligaments and weak muscles, intervertebral disc problems, and unequal leg length. ○ Gerontologic Considerations: osteoporotic vertebral fractures, osteoarthritis of the spine, & spinal stenosis. ○ Obesity, postural problems, structural problems, and overstretching of the spinal supports may result in back pain. ○ Stress and anxiety can evoke muscle spasms and pain. Pathophysiology: ○ The spinal cord is considered a rod of constructed rigid units (known as the vertebrae) and flexible units (the intervertebral discs) held together by complex facet joints, multiple ligaments, and paravertebral muscles. ○ Allows for flexibility and protection of the spinal cord. ○ The fibrocartilage becomes dense and irregularly shaped over time. ○ Disc degeneration is a common cause of back pain. The lower lumbar discs, L4–5 and L5–S1, are subject to the greatest mechanical stress and the greatest degenerative changes. ○ Disc protrusion or facet joint changes can cause pressure on nerve roots as they leave the spinal canal, which results in pain that radiates along the nerve. Clinical Manifestations (S/S): ○ Acute back pain - < than 3 months ○ Chronic back pain - > than 3 months or longer without improvement ○ Radiculopathy - pain radiating from a diseased spinal nerve root; pain radiating down leg. ○ Sciatica - pain radiating from an inflamed sciatic nerve ○ Gait, spinal mobility, reflexes, leg length, leg motor strength, and sensory perception may be affected. ○ PE shows paravertebral muscle spasm - greatly increased muscle tone of the back postural muscles w/ loss of normal lumbar curve and possible spinal deformity. Assessment/Diagnostics: ○ Focused history and PE - observation of pt, gait evaluation, and neurologic testing. Location, severity, duration, characteristics, radiation, leg weakness How the pain occurred and has been managed by the patient Work and recreational activities Spinal curvature, back and limb symmetry Palpate paraspinal muscles Movement ability and effects on ADLs - determine limitations DTRs, sensation (paraesthesia), and muscle strength Assess posture, position changes, and gait Back & leg pain on straight leg raising (with the patient supine, the patient’s leg is lifted upward with the knee extended) suggests nerve root involvement. Findings can show nonspecific lumbar strain or serious issues such as spinal fracture, cancer, infection, or neurologic deficit. Presence of bruising, older age, prolonged use of corticosteroids - increase risk of fracture of  posttraumatic injury. Monitor for older person abuse. ○ Another cause of low back pain: Cauda equina syndrome - MEDICAL EMERGENCY! Compression of the cauda equina, the bundle of spinal nerves that arise from the lower portion of the spinal cord. When compressed, pt will show S/S of severe/progressive neurologic deficit, bowel/bladder dysfunction, & saddle anesthesia Saddle anesthesia - paresthesia in the perineal, inner thigh, or buttock region that may be asymmetrical Requires immediate referral to ED for pt to receive treatment to relieve underlying cause before nerve damage occurs. TX: surgical removal of vertebral fragments, decompression of tumor mass Medical management: ○ Most back is self-limited & may resolve in 4-6 weeks with analgesics, rest, and avoidance of strain. ○ Based on initial assessment findings indicating nonspecific back symptoms, the patient is reassured that the pain is not due to a serious condition and x-rays or other imaging modalities are not necessary. ○ Systemic corticosteroids and acetaminophen are not effective in fully alleviating acute low back pain. ○ Management focuses on relief of discomfort, activity modification, and patient education. ○ Use of NSAIDs and short term muscle relaxants (cyclobenzaprine) - for acute low back pain. ○ Tricyclic antidepressants (amitriptyline), dual action serotonin-norepinephrine reuptake inhibitors (duloxetine) or atypical anticonvulsant medications (gabapentin - rx’ed for radiculopathy pain) - chronic low back pain. Reduction of pain by 30% less than baseline is the goal. ○ Short term course of opioids (1-2 weeks) - acute moderate to severe cases of low back pain Not used in older adults, those with kidney disease, or those who avoid NSAIDs due to GI upset. ○ Nonpharmacologic tx: use of thermal applications (hot or cold) & spinal manipulation (chiropractic therapy) Cognitive-behavioral therapy (e.g., biofeedback), exercise regimens, spinal manipulation, physical therapy, acupuncture, massage, and yoga are all effective nonpharmacologic interventions for treating chronic low back pain. ○ Avoid twisting, bending, lifting, and reaching—all of which stress the back. ○ Change position frequently. ○ Sitting should be limited to 20 to 50 minutes based on level of comfort. ○ Absolute bed rest is no longer recommended - no effective and result in deconditioning ○ Typical activities of daily living (ADLs) should be resumed as soon as possible. ○ A quick return to normal activities and a program of low-stress aerobic exercise are recommended. ○ Conditioning exercises for both back and trunk muscles are begun after about 2 weeks to help prevent  recurrence of pain. ○ Active motion activities such as walking have a beneficial impact on outcomes. Nursing Management: ○ Nurse will ask pt to describe discomfort ( location, severity, duration, characteristics, radiation, and weakness in legs) Description of pain and how it occurred How pt dealt with pain Observation of pt’s posture, position changes, and gait Pts movements may be guarded, with back kept as still as possible; pt may sit and stand in unusual position, leaning away from painful side, and may need assistance with undressing for physical exam ○ Avoid prolonged bed rest; avoid prone positioning - lordosis ○ Use a medium to firm, non sagging mattress (bed board may be used); no supportive evidence of the use of firm mattress. ○ Lumbar flexion is increased by elevating HOB & thorax 30 degrees with use of pillow or foam wedge and slight flexion of the knees supported by pillow. ○ Pt may assume lateral position with knees and hips flexed (curled position) w/ pillow between the knees and legs & pillow supporting the head. ○ Pt to get out of bed by rolling on one side and placing legs down while pushing the torso up, keeping back straight ○ Exercise program gradually initiated - low stress aerobic exercises - short walks, swimming. Helps reduce lordosis, increase flexibility, and reduce stain on back Hyperextension exercises to strengthen paravertebral muscles Flexion exercises to increase back movement & strength Isometric flexion exercises to strengthen trunk muscles ○ Use of good body mechanics and posture to avoid recurrent back pain Proper posture can be verified by looking in a mirror to see whether the chest is up, the abdomen is tucked in (contracted - giving a feeling of upward pull), gluteal muscles contract (giving a downward pull), and the shoulders are down and relaxed. When sitting, the knees and hips should be flexed, with the knees in level with the hips or higher to minimize lordosis. The feet should be flat on the floor or supported on a raised surface. Patients should avoid sitting on stools or chairs that do not provide firm back support. The nurse instructs the patient in the safe and correct way to lift objects—using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles. With feet placed hip-width apart to provide a wide base of support, the patient should bend the knees, tighten the abdominal muscles, and lift the object close to the body with a smooth motion, avoiding twisting and jarring motions. 2. Osteoarthritis - What is it? Causes/risk factors? Signs and symptoms? Assessment and diagnostic findings? Treatment? Osteoarthritis (OA) is a noninflammatory degenerative disorder of the joints. The most common form of joint disease and is sometimes also called degenerative joint disease. Classified as primary (idiopathic) or secondary (resulting from previous joint injury of inflammatory disease). ○ Primary OA can occur as an end result of autoimmune disorder where joint destruction occurs but DOES NOT INVOLVE autoimmunity or inflammation. ○ OA is limited to affect joints; no systemic symptoms Causes/Risk factors: ○ Older age (65 yrs and up), female gender (Hispanic and African American), and obesity (most prominent risk factor) ○ Certain occupations (requiring laborious tasks) , engaging in sports activities, hx of previous injuries, muscle weakness, genetic predisposition. Pathophysiology: ○ With OA, articular cartilage (lubricated, smooth tissue that protects the bone from damage and physical activity) breaks down, leading to underlying bone and eventual formation of osteophytes (bone spurs) that protrude into the joint space. ○ Joint space is narrowed, leading to decreased joint movement and potential for more damage and progressively degenerate.  Clinical Manifestations (S/S): ○ Pain, stiffness, and functional impairment. ○ Joint pain is aggravated by movement or exercise and relieved by rest. ○ Morning stiffness - lasting less than 30 minutes ○ Onset is routinely insidious, progressing over multiple years ○ Affected joint may be enlarged with decreased ROM ○ Most often occurring in weight bearing joints - hips, knees, cervical & lumbar spine, proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints. PIP and DIP joint involvement causes enlargements of DIP (Heberden's nodes) and PIP (Bouchard’s nodes) joints ○ Crepitus may be palpated, especially over the knee ○ Joint effusion (inflammation sign) is mild Assessment/Diagnostics: ○ Blood tests and examination of joint fluid used to rule out autoimmune cause for joint pain such as RA. Not useful in diagnosis of OA. ○ X-Ray: show narrowing of the joint space, osteophyte formation, and dense, thickened subchondral bone. Medical management: ○ The goals of management are to decrease pain and stiffness and to maintain or, when possible, improve joint mobility. ○ Use of exercise in the form of cardiovascular aerobic exercise and lower extremity strength training - found to prevent OA progression and decrease symptoms of OA. ○ Weight loss - decreases excess load on joint ○ Use of occupational and physical therapy ○ Wedged insoles, knee braces, and other modalities are being evaluated as possible therapies aimed at treating the abnormalities in biomechanics found in OA. ○ The use of orthotic devices (e.g., splints, braces) and walking aids (e.g., canes) can improve pain and function by decreasing force on the affected joint. ○ Use of alternative therapies such as massage, yoga, pulsed electromagnetic fields, transcutaneous electrical nerve stimulation (TENS), and music therapy. ○ Pharmacologic management of OA is directed toward symptom management and pain control: Medication selection based on pt’s needs, stage of disease, and risk of side effects Used in conjunction with nonpharmacologic strategies. Initial analgesic therapy - acetaminophen Use of NSAIDs and COX-2 enzyme blockers COX-2 enzyme blockers - used with caution due to risk of cardiovascular disease and GI upset. Nonopioids - Tramadol Opioids (for severe cases) and intra-articular corticosteroids  Topical analgesics - Capsaicin and methylsalicylate Topical diclofenac sodium gel for use of OA joint pain in hands and knees Methotrexate and colchicine (typically used for RA & gout) may be considered. Glucosamine and chondroitin Viscosupplementation - injection of gel-like substances (hyaluronates) into joint (intra-articular) - supplement the viscous properties of synovial fluid; aim to prevent loss of cartilage and repair chondral defects Nursing Management: ○ Pain management and optimal functional ability are the major goals of nursing interventions. ○ Weight loss and exercise are important approaches to lessen pain and disability - especially if pt is overweight and has a sedentary lifestyle. ○ Use of canes or assistive devices for ambulation. ○ Exercises such as walking should begin in moderation and increase gradually. ○ Plan exercise for time of day when pain is least severe or use of an analgesic agent prior to exercise. 3. Goal for a client with osteoarthritis? The goals of management are to decrease pain and stiffness and to maintain or, when possible, improve joint mobility and function. Exercise, especially in the form of cardiovascular aerobic exercise and lower extremity strength training, has been found to prevent OA progression and decrease symptoms of OA. Along with exercise, weight loss, which in turn decreases excess load on the joint, can also be extremely beneficial. 4. Osteoporosis - What is it? Causes/risk factors? Signs and symptoms? Assessment and diagnostic findings? Treatment? Role of Bisphosphonates? Action? Side effects? How to administer it? Patient education? Medication: Alendronate; Role and calcium and vitamin D/action and side effect Osteoporosis: characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength. ○ The rate of bone resorption that is maintained by osteoclasts is greater than the rate of bone formation that is maintained by osteoblasts, resulting in a reduced total bone mass. ○ The bones become progressively porous, brittle, and fragile. Causes/Risk Factors: ○ Small-framed women at greatest risk; Asian/Caucasian women at high risk ○ African American women due to prevalence of sickle cell, autoimmune diseases, poor calcium intake due to lactose intolerance. ○ Use of aromatase inhibitors - risk for women with breast cancer. ○ Bariartic surgery due to bypass of duodenum (where calcium is absorbed). ○ Medications: anticonvulsants (phenytoin), thyroid replacement agents (levothyroxine), antiestrogens (medroxyprogesterone), androgen inhibitors (leuprolide), selective serotonin receptor inhibitors (SSRIs; fluoxetine) and proton pump inhibitors (esomeprazole) place patients at risk. ○ Caffeine and carbonated soft drinks. ○ Impaired glucose tolerance and diabetes  Clinical Manifestations (S/S): ○ Fractures easily under stress Thoracic, lumbar spine, hip fractures, Colles fractures of the wrist ○ Kyphosis (Dowager hump) Loss of height Postural changes result in relaxation of abdominal muscles and protruding abdomen. Pulmonary insufficiency Increase risk of falls due to balance issues. ○ Decrease calcitonin & estrogen Calcitonin: inhibits bone resorption and promotes bone formation Estrogen: inhibits bone breakdown ○ Increase PTH Increases bone turnover and resorption Assessment/Diagnostics: ○ Osteoporosis is diagnosed by dual-energy x-ray absorptiometry (DEXA), which provides information about BMD at the spine and hip. Reported as T-scores (the number of standard deviations above or below the average BMD value for a 30 yr old healthy adult of same sex). Recommended for women older than 65, postmenopausal older than 50 , and all people who have had a fracture possibly due to osteoporosis. ○ BMD studies - assess response to therapy & recommended 3 months post op of osteoporotic fracture. ○ Fracture Risk Assessment Tool (FRAX) - female fracture risk ○ Male Osteoporosis Risk estimation Score (MORES) - more gender specific evaluation for males (better than FRAX for males) ○ Risk scores are based on BMD, personal and family history of fractures, BMI, gender, age, and secondary factors such as medication use, smoking, and history of rheumatoid disease. ○ Laboratory studies: Serum calcium, phosphate, alkaline phosphatase (ALP), urine calcium excretion, urinary hydroxyproline excretion, hematocrit, erythrocyte sedimentation rate (ESR) & x-ray performed to rule out other possible causes.  Low testosterone may be a cause for men. Medical Management: ○ A diet rich in calcium & vitamin D - protects against skeletal demineralization Three glasses of skimmed vitamin D enriched milk, cheese, dairy products, steamed broccoli, canned salmon with bones. Daily intake of vitamin D 400-1000 IU daily and calcium 1000 mg (men) - 1200 mg (women) daily. Split into 2 doses; do not take as single dose due to S/S of abdominal distention and constipation. ○ Regular weight bearing exercises promotes bone formation 20-30 minutes aerobic, bone-stressong exercise daily (not swimming) Weight training stimulates an increase in BMD. ○ Pharmacologic Therapy: Bisphosphonates, calcitonin, estrogen agonist/antagonists, and receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitors. Bisphosphonate Therapy: No longer recommended for patients who only have evidence of osteopenia without reaching the precise DEXA scores that define osteoporosis. Given an empty stomach, only with water, and person must sit upright for at least 30 minutes after ingestion. GI/esophageal risks: gastritis, ulceration, and GI bleeding. Contraindicated in Barrett esophagus, low serum calcium levels, and pregnancy. A-Fib reported with long term use; rare side effects of osteonecrosis of the jaw (with IV use) and subtrochanteric fractures.  Fracture Management: ○ Osteoporotic compression fractures of the vertebrae are managed conservatively. ○ Pts referred to an osteoporosis specialist. ○ Percutaneous vertebroplasty or kyphoplasty Injection of polymethylmethacrylate [PMMA] bone cement into the fractured vertebra, followed by inflation of a pressurized balloon to restore the shape of the affected vertebra, Provide relief of acute pain and improve QOL. might contribute to complications such as alterations in spinal mechanics. Contraindicated in infection, multiple old fractures, and coagulopathies. 5. Osteomyelitis - -What is it? Causes/risk factors? Signs and symptoms? Assessment and diagnostic findings? Treatment? Osteomyelitis: an infection of the bone that results in inflammation, necrosis, and formation of new bone. Patients at Risk for Osteomyelitis: ○ Older adults, those who are poorly nourished or obese. ○ Impaired immune systems, those with chronic illnesses (diabetes, RA), those receiving long-term corticosteroid therapy or immunosuppressive agents, and those using illicit IV drugs. Clinical Manifestations (S/S): acute onset of S/S (localized pain, edema, erythema, fever) or recurrent drainage of an infected sinus with associated pain, edema, & low-grade fever. ○ Bloodborne: Acute onset, usually sudden with clinical and laboratory manifestations of sepsis (chills, high dever, rapid pulse, general malaise). ○ Bone, periosteum, & soft tissue: Infected area becomes warm, painful, swollen, and tender to touch. Constant, pulsating pain that intensifies with movement due to accumulation of pressure and purulent material (pus). ○ Non healing ulcer over infected bone with connecting sinus that will be draining pus ○ Diabetic osteomyelitis: May present as non healing fracture Micro/macrovascular pathophysiologic changes, impaired immune response - exacerbate spread of infection to other sources. Foot ulcer more than 2 cm in diameter Assessment/Diagnostics:  ○ Definitive diagnosis: Radioisotope bone scans and MRI ○ Early X-ray findings: soft tissue edema ○ In 2-3 weeks after, areas of periosteal elevation and necrosis may be evident. ○ Blood studies reveal leukocytosis (elevated WBC than normal) and elevated ESR; Wound blood cultures performed - 50% come back positive ○ Chronic osteomyelitis: Large, irregular cavities, raised periosteum, sequestrum, or dense bone formations are seen on x-ray. Bone scans performed to identify areas of infection. WBC/ESR are normal Anemia may be evident with chronic infection Blood cultures/sinus drainage unreliable to identify causative organisms. Bone cultures aspirated from uninfected skin. Medical Management: The initial goal of therapy is to control and halt the infective process. ○ Supportive measures initiated: hydration, diet high in vitamins and protein, correction of anemia. ○ Affected area is immobilized to decrease discomfort and prevent pathologic fracture. ○ Pharmacologic Therapy: Long-term IV antibiotic therapy due to bones being avascular and less accessible to the body's natural immune system. Continues for 6-12 weeks. As infection is controlled, can move over to oral antibiotics ○ Surgical Management: Surgical debridement needed if unresponsive to antibiotic therapy. Surgical débridement weakens the bone, internal fixation or external supportive devices may be needed to stabilize or support the bone to prevent pathologic fracture Infected bone is surgically exposed, purulent and necrotic material is removed and the area is irrigated with sterile saline solution. Wound irrigation using sterile physiologic saline solution may be performed for extended periods if the debris remains; not extended longer than 1 week. Sequestrectomy: removal of enough involucrum to enable surgeon to remove sequestrum Saucerization: sufficient bone removed to convert a deep cavity into a shallow saucer. All dead, infected bone and cartilage is removed to allow for permanent healing. Closed suction irrigation systems may be used to remove debris. Wound is closed tightly to obliterate dead space or packed with cancellous bone graft, and closed later by granulation or grafting. Large defect: cavity may be filled with vascularized bone transfer or muscle flap. Muscle flap: muscle is moved from an adjacent area with blood supply intact. 6. Know the different causes of osteomyelitis (hematogenous/contiguous focus/osteo with vascular insufficiency, Diabetic osteomyelitis). Most common organism? Hematogenous osteomyelitis: due to blood borne spread of infection Contiguous-focus osteomyelitis: from contamination from bone surgery (with use of hardware insertion), open fracture, or traumatic injury (gunshot wound). Osteomyelitis with vascular insufficiency: most common among patients with diabetes and  peripheral vascular disease; affecting the feet. Most common organisms: Staphylococcus aureus and a variety that is methicillin resistant (MRSA - methicillin resistant staphylococcus). ○ Other causative organisms: Streptococci, Enterococci, Pseudomonas , Proteus, E. Coli 7. Gout only (chapter 34) What is Gout? Definition: A common inflammatory arthritis affecting 3.9% of the U.S. population, predominantly men (3-4x more than women). Prevalence: Rising due to aging, increased BMI, alcohol use, hypertension, diuretic use, and fructose-rich beverage consumption. Comorbidities: Associated with cardiovascular disease, hypertension, dyslipidemia, diabetes, osteoarthritis, and kidney disease. Pathophysiology Hyperuricemia: ○ Uric acid, a by-product of purine metabolism, accumulates due to excessive production or impaired kidney excretion. ○ Levels >6.8 mg/dL increase risk of urate crystal formation. Inflammatory Process: ○ Macrophages phagocytize urate crystals, secreting interleukin-1β, triggering inflammation. ○ Exacerbated by alcohol and purine-rich meals. Crystal Deposits: Tophi in peripheral tissues and renal complications like kidney stones. Clinical Manifestations Stages: ○ Asymptomatic hyperuricemia. ○ Acute gouty arthritis: Severe joint inflammation, commonly in the big toe. ○ Intercritical gout: Symptom-free intervals. ○ Chronic tophaceous gout: Frequent attacks and tophi development. Symptoms: ○ Sudden nighttime onset with severe pain, redness, and swelling. ○ Triggers include trauma, alcohol, fasting, medications, and stress. Risk Factors High purine diet (organ meats, shellfish). Obesity, alcohol, diuretics, and certain medications. Genetic predispositions or conditions increasing cell turnover (e.g., leukemia).  Treatment Acute Gout: ○ Medications: Colchicine, NSAIDs (e.g., indomethacin), corticosteroids. Chronic Management: ○ Xanthine oxidase inhibitors: Allopurinol, febuxostat. ○ Uricosurics: Probenecid for increasing uric acid excretion. ○ Lifestyle Changes: Low-purine diet, weight loss, reduced alcohol intake, medication adjustment. ○ Advanced cases: Pegloticase for refractory gout. IL-1 Blockers: Anakinra for inflammation. Nursing Management Educate patients using verbal and written materials. Promote dietary changes: Limit purine-rich foods and alcohol. Stress medication adherence to prevent acute attacks. Pain management during flare-ups and avoidance of triggers 8. Arthroplasty Definition: Surgical removal of an unhealthy joint, replaced with metal or synthetic materials. ○ Commonly used in moderate to severe osteoarthritis (OA), rheumatoid arthritis (RA), trauma, congenital deformities, or fractures leading to avascular necrosis. ○ Joints most frequently replaced: hip, knee, and fingers; less commonly, shoulder, elbow, wrist, and ankle. Types of Joint Arthroplasty: ○ Total Joint Arthroplasty (TJA): Replacement of all components of an articulating joint. Materials: Metal (stainless steel, titanium), high-density polyethylene. Fixation methods: Cemented: Uses bone cement (polymethylmethacrylate). Cementless: Relies on bone growth into implant surfaces. Hybrid: Combines cemented and cementless techniques. Goals: ○ Relieve pain. ○ Restore joint motion. ○ Improve functional status and quality of life. Key Innovations: ○ Minimally invasive techniques. ○ Enhanced biomaterials. ○ Postoperative rehabilitation protocols. ○ Multimodal analgesia for faster recovery. Common Complications: ○ Infection, venous thromboembolism (VTE), neurovascular compromise, and prosthesis loosening. ○ Specific complications: dislocation, excessive drainage, or heterotopic ossification. Preoperative and Intraoperative Nursing Management Blood Loss Prevention:  ○ Treat anemia preoperatively (e.g., epoetin alfa, iron supplements). ○ Use of pneumatic tourniquets, red blood cell salvage, and antifibrinolytics like tranexamic acid. VTE Prevention: ○ Assess risk factors (age, obesity, history of VTE). ○ Prophylactic anticoagulants (e.g., low-molecular-weight heparin). Infection Prevention: ○ Screen for and manage infections preoperatively. ○ Use antiseptic skin preparation and prophylactic antibiotics. ○ Consider antibiotic-loaded bone cement. Postoperative Care Early physical therapy within 24 hours for improved recovery. Monitor for complications such as dislocation, infection, and pressure injuries. Educate patients about expectations and rehabilitation goals. 9. Hip Fracture Hip fracture is a debilitating condition in older adults, particularly women. More than 300,000 adults older than 65 years of age sustain a hip fracture requiring hospitalization; 95% of these result from falls. Hip fractures are classified by anatomic location and fracture type: ○ Extracapsular fractures: extending from the base of the femoral neck to the area just distal to the lesser trochanter; are fractures of the trochanteric, intertrochanteric, and subtrochanteric region. ○ Intracapsular fracture: fractures of the femoral head and neck; higher rate of nonunion and malunion and femoral neck may become ischemic. ○ Periprosthetic fracture: fractures to the regions surrounding prosthetics joints which are increasing due to the growing number patients having previously had total joint replacements Causes/Risk Factors: ○ Contributing factors for falls and resultant hip fracture include ○ Weak quadriceps muscles, slowed reflexes, osteoporosis ○ Poor vision, diminished balance, general frailty due to age ○ Conditions that produce decreased cerebral arterial perfusion and cognitive impairment (e.g., transient ischemic attacks, anemia, thromboemboli, cardiovascular disease) ○ Medications may cause orthostasis and instability in older adults. Polypharmacy Antihypertensive agents, diuretics, beta-blockers, sedatives and hypnotics, neuroleptics and antipsychotics, antidepressants, benzodiazepines, opioid analgesics, and NSAIDs. Clinical Manifestations (S/S): ○ Pain over outer thigh or in groin ○ Limited ROM ○ Discomfort with attempt to flex or rotate hip ○ Femoral neck fracture: leg may be shortened, adducted, and externally rotated Pt cannot move leg without a significant increase in pain. Pt most comfortable with leg slightly flexed in external rotation ○ Extracapsular: extremity shortened, externally rotated to greater degree, muscle spasms -  cannot have extremity in neutral position, ecchymosis. ○ Impacted intracapsular femoral neck: moderate discomfort (even with movement), may be able to bear weight, may not demonstrate obvious shortening or rotational changes. ○ The diagnosis is confirmed by x-ray. Medical Management: ○ Surgery ○ Nonoperative management may be considered in some older patients with advanced comorbidities or cognitive impairment; certain types of fractures may be sufficiently stable to benefit from nonoperative treatment. Buck’s extension traction - temporary measure; reduced muscle spasm, immobilize extremity, relieve pain ○ The goal of surgical treatment for hip fractures is to obtain a satisfactory fixation so that the patient can be mobilized quickly and avoid secondary medical complications. Open/closed reduction of fracture Internal fixation Hemiarthroplasty (replacement of the femoral head with a prosthesis) Closed reduction with percutaneous stabilization for an intracapsular fracture. Total hip arthroplasty (i.e., replacement of both the femoral head and acetabulum). Surgical intervention carried out ASAP. Nursing Management: ○ Attention is given to pain management, prevention of secondary medical problems, and early mobilization of the patient so that independent functioning can be restored. ○ 1st 24-48 hrs: relief of pain and prevention of complications, continuous neurovascular checks. Deep breathing and dorsiflexion, plantarflexion exercises every 1-2 hrs. Thigh high anti-embolism stockings or pneumatic compression devices used Anticoagulants given to prevent formation of VTE Nurse monitors hydration, nutritional status, and urine output ○ Repositioning patient: Comfortable and safest way to turn pt is to turn to uninjured side Standard method involves placing a pillow between the patient’s legs to keep the affected leg in an abducted position. Proper alignment and supported abduction are maintained while turning.  ○ Promoting Exercise: Exercise as much as possible with the use of over bed trapeze Helps strengthen the arms and shoulders in preparation for protected ambulation. 1st post-op day: pt transfer to chair with assistance and begins assisted ambulation; amount of weight bearing depends on stability of fracture reduction. Safe use of ambulatory aids and fall preventions (appropriate footwear, proper lighting, removal of throw rugs, getting rid of clutter). Hip flexion and internal rotation restrictions apply only if the patient has had a hemiarthroplasty or total arthroplasty. Some modifications in the home may be needed, such as installation of elevated toilet seats and grab bars. ○ Monitoring/Managing Potential Complications: Neurovascular complications may occur from direct injury or edema in the area that causes compression of nerves and blood vessels. Must do constant neurovascular checks. Prevent VTE - encourage intake of fluids, ankle + foot exercises, use of anti-embolism stockings, pneumatic compression devices, and prophylactic anticoagulant therapy are indicated and should be prescribed. Coughing and deep-breathing exercises, intermittent changes of position, and the use of an incentive spirometer may help prevent respiratory complications. Pain must be treated with analgesic agents, typically opioids - help with breathing exercises. The nurse assesses breath sounds to detect adventitious or diminished sounds. Skin breakdown: use of elastic hip wrap dressing or elastic tape to prevent blisters, proper skin care on bony prominences to relieve pressure, & high-density foam mattresses to help distribute pressure. Loss of bladder control - cath removed within 24 hours post op of sx; if pt doesn’t void within 6 hours of removal of cath or has s/s of urinary retention - a bladder scan is performed and intermittent cath may be indicated. Delayed complications of hip fractures include infection, nonunion, and AVN of the femoral head Infection suspected with complaints of constant hip pain and elevated ESR. 10. All Fractures - What is it? Causes/risk factors? Signs and symptoms? Assessment and diagnostic findings? Treatment? Simple fracture? Open Fracture? RICE /Immobilization; How to treat a close vs an open fracture Fracture: a complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent. ○ Occur when bone is subjected to stress greater than it can absorb. Causes: ○ Direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions.  Types of Fractures: ○ Closed Fracture (simple): one that doesn't cause a break in the skin. ○ Open Fracture (compound/complex): one in which skin or mucous membrane wound extends to the fractured bone. Classified into three categories based on the extent of soft-tissue injury and size of corresponding skin wounds. Type I: clean wound less than 1 cm long and simple fracture pattern. Type II: larger wound with minimal soft tissue damage and no flaps or avulsions. Type III (A, B, C subtypes): considered the most severe, highly contaminated, and has extensive soft tissue damage, it involves vascular injury or traumatic amputation. ○ Intra-articular fracture: extends into the joint surface of the bone.  Clinical Manifestations (S/S): ○ Acute pain Pain is continuous and increases in severity until bone fragments are immobilized; the injured area becomes numb & surrounding muscles flaccid. Muscle spasms begin within 30 minutes, result in more intense pain - minimize further movement of fracture fragments or result in further bony fragmentation or malalignment. ○ Loss of function Cannot function properly because muscle depends on integrity of the bones to which they are attached; pain contributes to loss of function. Abnormal movement (false motion) may be present. ○ Deformity Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg causes a deformity that is detectable when the limb is compared with the uninjured extremity. ○ Shortening of extremity  Due to compression of the fractured bone; muscle spasms can cause distal and proximal site of fracture to overlap = shortening of extremity. ○ Crepitus Crumbling sensation may be felt or heard when palpated; caused by rubbing of the bone fragments against each other. ○ Localized Edema and Ecchymosis Resulting due to trauma and bleeding into tissues; may not develop for several hours or within an hour depending on severity of fracture. Assessment/Diagnostics: ○ MRI or arthroscopy will identify the fracture and confirm the diagnosis ○ Diagnosis made by symptoms and radiography If fracture is nondisplaced - X-ray will not always reveal fracture because cartilage is non radiopaque. Emergency Management: ○ The body part must be immobilized before the patient is moved. ○ Adequate splitting is essential. ○ Joints proximal and distal to the fracture must be immobilized to prevent movement of fracture fragments. ○ Neurovascular status distal to injury should be assessed before and after splinting to determine peripheral tissue perfusion and nerve function. ○ Open Fracture: Wound covered with sterile dressing to achieve homeostasis and prevent contamination of deeper tissues. Medical Management: ○ Fracture Reduction: Restoration of bone fragments to anatomic realignment and positioning with immobilization. Closed or open reduction may be used to reduce fracture. Reduction of fracture ASAP to prevent loss of electricity from tissues through infiltration by edema or hemorrhage. ○ Closed Reduction: Accomplished by bringing bone fragments into anatomic alignment through manipulation and manual traction. (Skin or skeletal traction) Realigning without cutting. Held in aligned position while cast, splint, or other device is applied. Immobilization maintains reduction and stabilizes extremity for bone healing. Reduction under anesthesia with percutaneous pinning may be used. X-rays obtained to verify alignment. ○ Open Reduction: Surgical approach; bone fragments are anatomically aligned Internal fixation devices (pins, wires, screws, plates, nails, or rods) may be used to hold bone fragments in position until bone healing occurs. Ensure firm approximation and fixation of bony fragments. Open reduction internal fixation (ORIF) - common x for severe fractures. ○ Immobilization: After reduction of fracture, bone fragments must be immobilized to maintain proper positioning and alignment until union occurs. Internal or external fixation may be used.  External fixation: bandages, casts, splints, continuous traction, and external fixators. RICE - Rest, Ice, Compression, Elevation ○ Nursing Management: Pt w/ Closed Fracture: No opening in the skin at the fracture site. Educate patients on controlling edema and pain. Educate on doing exercises of unaffected muscle and increase strength of muscles needed for transferring and using assistive devices (crutches, walkers, utensils). Modify home for safety, removing floor rugs or any obstructions in the walking path. Monitor self care, medications, potential complications, and need for health supervision. Average fracture healing may take 6-8 weeks. Pt w/ Open Fractures: Risk for osteomyelitis, tetanus, and gas gangrene. Prevent infection of wound, soft tissue, and bone & promote healing of bone and soft tissue. IV antibiotics are given, with IM tetanus toxoid as indicated. Wound irrigation w/ sterile solution and debridement (removal of tissues and foreign material) initiated in OR ASAP. Wounds are cultured, bone grafting performed to fill areas of bone defects. Bone is reduced and stabilized w/ external fixation and the wound is left open. Heavily contaminated wounds are left unsutured and treated with vacuum-assisted closures (VACs) to facilitate wound drainage. ○ Wound irrigation and debridement may be repeated. Extremity elevated to prevent edema, neurovascular checks assessed frequently (every 2 to 4 hrs), temperature monitored regularly, & for signs of infection. 11. Contusion/Sprain/Strain/Dislocation/subluxation - use of RICE for soft tissue injuries Contusion: a soft tissue injury produced by blunt force, such as a blow, kick, or fall, causing small blood vessels to rupture and bleed into soft tissues (ecchymosis or bruising). ○ Hematoma may develop from bleeding at the site of impact, leaving black and blue appearance. ○ May be minor or severe, isolated or with other injuries. ○ S/S: pain, swelling, discoloration. May limit ROM near injury, injured muscles may feel weak and stiff. Resolve in 1-2 weeks; severe contusions may take more time. Strain: an injury to a muscle or tendon from overuse, overstretching, or excessive stress; it is commonly known as a muscle pull. ○ Occur normally in tendons of foot, leg (hamstring), and back. ○ Can be acute or chronic Acute - single injurious accident Chronic - repetitive injuries; may result from improper care of acute strains.  1st degree: mild stretching of the muscle or tendon with no loss of ROM. 2nd degree: moderate stretching and/or partial tearing of the muscle or tendon. S/S: acute pain, tenderness at site w. increased pain with passive ROM, edema, muscle spasm, and ecchymosis. 3rd degree: severe muscle or tendon stretching with rupturing and complete tearing of the involved tissue. S/S: immediate pain (tearing, snapping, or burning), muscle spasm, ecchymosis, edema, and loss of function, X-ray to rule out avulsion fracture; MRI & U/S to identify tendon injury. Sprain: an injury to the ligaments and tendons that surround a joint. ○ Caused by twisting motion or hyperextension (forcible) of a joint. ○ Ligaments stabilize and support the body’s joints while permitting mobility. ○ Severity of sprain is graded by how bad the ligament has been damaged and if joint is unstable. Grade I: stretching or slight tearing in some fibers of the ligament and mild, localized hematoma formation. S/S: mild pain, edema, and local tenderness. Grade II: more severe and involves partial tearing of the ligament. S/S: increased pain with motion, edema, tenderness, joint instability, ecchymosis, and partial loss of normal joint function. Grade III: a complete tear or rupture of the ligament; may cause avulsion of bone. S/S: severe pain, edema, tenderness, ecchymosis, and abnormal joint motion. ○ Medical Management: Guided by the severity of injury and the goal of protecting from further injury. Use of NSAIDs for pain management. Neurovascular checks (motor, sensory, and vascular function) of injured extremity performed every 15 minutes for first 1-2 hrs, then every 30 minutes, until stable. Protection of area from further injury with support of affected area (use of sling, brace, splinting, taping, or compression bandages). Severe sprain/strain - immobilization by split, brace, or cast may be necessary to provide stability. Control pain, bleeding, and inflammation with the RICE method: Rest, Ice, Compression, and Elevation. Rest - prevents additional injury and promotes healing. Ice - intermittent application of cold/ice packs for the 1st 24-72 hours to produce vasoconstriction - decreases edema, bleeding, and discomfort. ○ Do not place cold packs for longer than 20 minutes at a time - avoid skin/tissue damage. Compression - use of elastic bandage to control bleeding, reduce edema, provide support of injured tissue. Elevation - at or above heart level controls swelling. Dislocation: the articular surfaces of the distal and proximal bones that form the joint are no longer in anatomic alignment (not in contact). ○ Complete dislocation - bone is out of joint. ○ Acute traumatic dislocations are orthopedic emergencies because the associated joint structures, blood supply, and nerves are displaced and may be entrapped with extensive pressure on them Subluxation: a partial or incomplete dislocation and does not cause as much deformity as a  complete dislocation. ○ Medical Management: The main treatment priorities are to avoid neurovascular complications and reduce the joint as atraumatically as possible. Affected joints must be immobilized; dislocation is reduced so displaced parts are back in the correct anatomic position - to preserve joint function. Immobilized with splint, cast, or traction. Analgesia, muscle relaxants, and possibly anesthesia are used to facilitate closed reduction. Neurovascular checks every 15 minutes until stable. After reduction and if the joint is stable - begin active and passive movement to preserve ROM and restore strength. 12. Complications of fractures: Shock (know vital signs), deep vein thrombosis, compartment syndrome, fat embolism, avascular necrosis of the hip, complex regional pain syndrome, heterotrophic ossification, pressure injuries, disuse syndrome nonunion, malunion, delayed union; Early Complications: ○ Shock: hypovolemic or traumatic shock resulting from hemorrhage in patients with pelvic fractures and in patients with displaced or open femoral fracture where femoral artery is torn by bone fragments. V/S: hypotensions, tachycardia, cool/clammy skin, weak pulse. TX: Stabilizing the fracture to prevent further hemorrhage, restoring blood volume and circulation (IV fluids and transfusions), relieving the patient’s pain, providing proper immobilization, and protecting the patient from further injury. ○ Fat Embolism Syndrome: describes the clinical manifestations that occur when fat emboli enter circulation following orthopedic trauma, especially long bone ( femur) and pelvic fractures. Occlude small blood vessels that supply lungs, brain, kidneys, and other organs. Onset is rapid, within 24-72 hrs; may occur up to a week after injury. S/S (CLASSIC TRIAD): hypoxemia, neurologic compromise, and a petechial rash RR - hypoxia, tachypnea, dyspnea & w/ tachycardia, substernal chest pain, low-grade fever, crackles, respiratory failure; X-ray may show ARDS or may be normal. Petechial rash - develop 2-3 days after onset of symptoms; located on chest/mucous membranes due to microcirculation and/or thrombocytopenia. Neuro - restlessness, agitation, seizure, focal deficits, and encephalopathy. TX: Prevention & supportive; no specific tx for FES Fluid resuscitation, oxygenation, vasopressors, mechanical ventilation, & sometimes corticosteroids. ○ Acute Compartment Syndrome: a time-sensitive surgical emergency, is characterized by the elevation of pressure within an anatomic compartment that is above normal perfusion pressure. Increased volume (blood, edema) & decreased compartment size = impaired tissue perfusion, causing cell death, tissue necrosis and permanent dysfunction. Common cause: tibial fractures May take up to 48 hrs for symptoms to present.  Assessment/Diagnostic: Five Ps - pain, pallor, pulselessness, paresthesia, paralysis Pt may have severe pain, considered a cardinal symptom - deep & burning, unrelieved by medications Nerve ischemia and edema, diminished sensation followed by complete numbness Motor weakness (late sign) of nerve ischemia; paralysis (late sign) due to prolonged ischemia and neurovascular injury. Peripheral circulation is evaluated by assessing color, temperature, capillary refill time, edema, and pulses. ○ Cyanotic nail beds - venous congestion ○ Pallor/dusky & cold digits, prolong capillary refill time, & diminished pulses = impaired arterial perfusion. ○ Pulselessness (late sign) ○ Palpation of muscle - swollen, hard, skin taut and shiny Orthopedic surgeon to monitor pressure w/ handheld direct injection device into muscle compartment - normal pressure is < 8 mm Hg; prolonged pressure of > 30 mm Hg = irreversible change. Medical Management: Goal: relieving all external pressure on the compartment. Orthopedic surgeon notified ASAP if suspected. Delay of tx can cause = permanent nerve and muscle damage, necrosis, infection, rhabdomyolysis with acute kidney injury, and amputation Conservative measures first to restore tissue perfusion and relieve pain, if that doesn’t work, move on to: ○ Fasciotomy: surgical decompression with excision of the fascia; considered definitive treatment to relieve constrictive muscle fascia. After, the wound is not sutured but left open to allow muscle tissue to expand; covered with moist, sterile dressings or artificial skin. ○ Negative-pressure wound therapy (VAC): using vacuum dressing to be effective in removing fluids and decrease times to primary closure. Affected arm or leg is sprained in functional position and elevated at heart level; prescribed intermittent passive ROM exercises In 2 to 3 days, when the swelling has resolved and tissue perfusion has been restored, the wound is débrided and closed (possibly with skin grafts). ○ Deep Vein Thrombosis: Blood clot formation in the deep vein due to immobility. Associated with reduced skeletal muscle contractions and bed rest. Patients with fractures of the lower extremities and pelvis are at high risk for VTE. S/S: calf swelling, redness, tenderness, warmth Tx: early ambulation, anticoagulants, compression stockings. ○ Delayed Union/Nonunion/Malunion: Delayed union: healing doesn’t occur within the expected timeframe for location  and type of fracture. Nonunion: incomplete healing of fracture and results from failure of the ends of fractured bone to unite Malunion: healing of a fractured bone in a malaligned (deformed) position. TX: Nonsurgical treatment modalities include low-intensity pulsed ultrasound and externally applied electrical bone growth stimulators. Electrical stimulation techniques enhance the process of bone healing by exposure of osteoblasts to electromagnetic fields, which stimulate the secretion of growth factors. Avascular Necrosis ○ Definition: death of tissue due to insufficient blood supply. ○ Symptoms: Persistent pain and limited motion. Progressive; pt. develops pain with movement that progresses to pain at rest. ○ History & physical examination: x-rays, CT scans, & bone scans. ○ Goal: preserve native joints for as long as possible; Conservative & surgical interventions. Activity modification, administration of analgesics, and partial weight bearing of the affected region. Revascularize affected areas by drilling the avascular segment or using a bone marrow graft. ○ Management: o Joint replacement surgery. Complex Regional Pain Syndrome (CRPS) ○ Definition: Chronic pain syndrome after injury; regional pain in a limb that is disproportionate following a fracture, soft tissue injury, or surgery = exaggerated pain - touch hand slightly - OMG pain ○ Symptoms: Severe pain, local edema, hyperesthesia, stiffness, discoloration, vasomotor skin changes (fluctuating warm, red, dry, cold, sweaty, cyanotic); trophic changes: glossy, shiny skin, changes in hair & nail growth. ○ Treatment: Early effective pain relief with NSAIDs, topical anesthetics ( lidocaine patches), corticosteroids, & opioids; Anticonvulsant agents (gabapentin) & antidepressant agents. Sympathetic nerve blocks, neural stimulation, and intrathecal delivery. Therapeutic listening, initiation of relaxation techniques and behavior modification, referral for rehabilitation therapy, & mental health referral for depression/anxiety. Heterotrophic Ossification ○ Definition: Abnormal bone formation in soft tissues; benign bone growth in an atypical location (soft tissue). Pain & joint stiffness = decreased ROM. ○ Symptoms: Stiffness, reduced mobility. ○ Management: NSAIDs, physical therapy. Surgery to remove bone growth & restore function if unresolved Disuse Syndrome  ○ Definition: Muscle atrophy and joint stiffness due to immobility & loss of strength. ○ Management: Treatment: Isometric exercises (hourly while pt. is awake); muscle setting exercises (quadriceps & gluteal setting exercises). Instruct pt. with a leg or arm cast to splint or brace to “push down” the knee or to “make a fist.” Helps reduce muscle atrophy & maintain strength. Early mobilization, physical therapy. 13. Elbow fractures and Volkman contracture Elbow Fractures Commonly occur due to trauma such as falls or direct blows. Can result in injury to the brachial artery or median nerve. Monitor regularly for neurovascular compromise and signs of compartment syndrome Complications: o Volkmann Contracture: (an acute compartment syndrome) ▪ Antecubital swelling or damage to the brachial artery = contracture (shortening) of the forearm muscles. ▪ A serious complication caused by ischemia to the forearm muscles. ▪ Results in permanent flexion deformity of the wrist and fingers. Volkmann Contracture Causes: o Prolonged pressure or improper splinting/casting leading to decreased blood flow. Symptoms: o Severe pain unrelieved by medication. o Pallor, pulselessness, paresthesia in the affected limb. o Stiffness and claw-like deformity of the hand. Management: o Immediate intervention to relieve pressure (e.g., fasciotomy). o Proper splinting to avoid excessive pressure. o Active exercises and ROM are encouraged to prevent limitation of joint movement after immobilization and healing (4 to 6 weeks for nondisplaced, casted) or after internal fixation (about 1 week). 14. Amputations: Know how to care for a patient with amputation -complications -Positioning post amputation; Treatment for phantom limb pain Amputation is the removal of a body part by a surgical procedure or trauma. The objective of surgery is to conserve as much limb length as needed to preserve function and possibly to achieve a good prosthetic fit. Site and extent of amputation determined by: ○ Circulation in area (necrosis present or not) ○ Degree of tissue loss, viability of tissues ○ Functional usefulness ○ Presence of infection. Care of a Patient with Amputation Complications 1. Postoperative Hemorrhage: ○ Monitor for slow or massive bleeding. Keep a tourniquet bedside to control hemorrhage.  2. Infection: ○ Antibiotic prophylaxis recommended prior for prevention. ○ Signs: fever, purulent drainage. Use aseptic technique for wound care. ○ S/S infection or gangrene: enlarged lymph nodes, fever, purulent discharges; do C/S for appropriate antibiotic tx 3. Skin Breakdown: ○ Proper dressing and care to prevent irritation or breakdown. 4. Phantom Limb Pain: ○ Pain perceived in the amputated section ○ Pain feels like crushing, burning, or tingling. Acknowledge pain as real and provide appropriate interventions. ○ May last seconds to hours; can continue up to 2 years. 5. Joint Contractures: ○ Caused by positioning and a protective flexion withdrawal pattern associated with pain and muscle imbalance ○ Avoid positioning the residual limb on a pillow; use prone positioning regularly to stretch muscles. ○ Turn from side to side & to assume a prone position, 20 to 30 minutes several times per day to stretch the flexor muscles & to prevent flexion contracture of the hip. ○ Legs should remain close together to prevent an abduction deformity. ○ Early post-op ROM exercises - hip and knee exercises for patients with BKAs and hip exercises for patients with AKAs. ○ Upper limbs, trunk, and abdominal muscles are exercised and strengthened. 6. Depression & anxiety Positioning Post-Amputation Avoid flexion contractures: Do not elevate the residual limb on pillows. Use prone positioning: 20–30 minutes several times daily to prevent hip contractures. Keep legs close together to prevent abduction deformities. Early range-of-motion (ROM) and strengthening exercises are crucial. Treatment for Phantom Limb Pain The objective of treatment is to achieve healing of the amputation wound, the result being a nontender residual limb with healthy skin for prosthetic use 1. Medications: ○ Acetaminophen, NSAIDs, Opioids for pain relief. ○ Beta-blockers for dull, burning discomfort. ○ Anticonvulsants (gabapentin) for stabbing, cramping pain. ○ NMDA receptor antagonist (ketamine infusion) ○ Tricyclic antidepressants for mood and coping. 2. Non-Medical Treatments: ○ Mirror therapy: Visual feedback to reduce perceived pain. ○ Transcutaneous Electrical Nerve Stimulation (TENS). ○ Relaxation and distraction techniques. (Massage, biofeedback, acupuncture, repositioning, virtual reality, and neuromodulation).  Wound Healing Assessed every 8-12 hrs post-op for edema. Neurovascular assessments (5 Ps) Use gentle handling and assess regularly for edema or infection. Proper dressing (elastic compression bandage) prevents swelling and facilitates healing. Residual limb shaping (elastic bandages, shrinkers) is critical for prosthetic fitting. Promoting Mobility Regular turning and positioning: Avoid external rotation and abduction. ROM and muscle-strengthening exercises: For both affected and unaffected limbs. Preprosthetic care includes massage, limb toughening, and bandaging. 15. Cast care 16. Traction (skin/buck and skeletal) What is it? How the ropes and pulleys should be with respect to the bed? The weights and their purpose? What to do if a patient develops spasms while in traction? Purpose of line of pull purpose? Role of the nurse in caring for the patient in traction? Muscle setting exercises/gluteal/Quadriceps setting exercises. Traction: uses a pulling force to promote and maintain alignment to an injured part of the body. ○ Applied in two directions; lines of pull are known as vectors of force. ○ Result of pulling force between two lines of vectors of force. Goals of traction: ○ Decreasing muscle spasms and pain ○ Realignment of bone fractures ○ Correcting or preventing deformities. Skin Traction: not frequently used but may be prescribed as a temporary measure to stabilize a fractured leg, control muscle spasms, and immobilize the area before surgery. ○ Pulling forces applied by weights are attached to the patient with velcro, tape, straps, boots, or cuffs. Amount of weight must not exceed the tolerance of skin. No more than 2-3.5 kg (4.5-8 lbs) of traction can be used on the extremity. Pelvic traction limited to 4.5-9 kg (10-20 lbs), depending on pt weight. Bucks traction (applied to lower leg) - most common type of skin traction for select adults with musculoskeletal injury. ○ Bucks Extensions Traction: unilateral or bilateral skin traction of the lower leg. Pull is exerted in one plane when partial or temporary immobilization is desired. Temporary measure to overcome muscle spasms and promote immobilization of hip fractures pts waiting for sx. No data showing any benefit; no improvement in pain or better fraction reduction. To apply: extremity must be elevated and supported under the patient's heel and  knee while foam boot is placed under the leg, with the patient's heel in the heel of the boot. Velcro straps secured around the leg. Excessive pressure avoided over malleolus and proximal fibula during application to prevent pressure injuries and nerve damage. Rope is then affixed to the spreader or footplate over a pulley fastened to the end of the bed and attaches the prescribed weight (2.25-3.5 kg - 5-8 lbs). ○ Weight should hang freely, not touching parts of the bed/floor as this compromises the efficiency of the traction system. ○ Nursing Interventions: Avoid wrinkling and slipping of the traction bandage and to maintain countertraction. Proper positioning must be maintained to keep the lg in neutral position. Assist patients with shifting positions. Skin Breakdown: Identify sensitive, fragile skin; inspect the skin area in contact with tape, foram, or shearing forces every 8 hours (3x daily). Palpate area of traction tapes daily to detect underlying tenderness. Frequent repositioning to alleviate pressure and discomfort due to increased risk of pressure injury. Used advanced static mattresses or overlays to reduce pressure injury risk. Nerve Damage: Skin traction places pressure on peripheral nerves Avoid pressure on the peroneal nerve - passing around the neck of fibula, below the knee where traction is applied - may cause foot drop. ○ Dorsiflexion of foot = good functioning of peroneal nerve. ○ Weakness of dorsiflexion/foot movement = pressure on peroneal nerve. ○ Plantar flexion = functioning tibial nerve. Regularly assess for sensation - moving toes and foot. Investigate immediately any complaint of burning sensation under traction bandage/boot Circulatory Impairment: Assessment of circulation within 15-30 minutes, then every 1-2 hours. ○ Peripheral pulses, color, capillary refill, temperature of finger and toes Manifestations of DVT - calf tenderness, warmth, tenderness, swelling Encourage active foot exercises every hour when awake. Skeletal Traction: often used when continuous traction is desired to immobilize, position, and align a fracture of the femur, tibia, and cervical spine. ○ Used to maintain traction for a significant amount of time, skin traction is not possible, and great weight (11-18 kg, 25-40 lbs) is needed for therapeutic effect. ○ Involves passing a metal pin or wire (e.g., Steinmann pin, Kirschner wire) through the bone (e.g., proximal tibia or distal femur) under local anesthesia, avoiding nerves, blood vessels, muscles, tendons, and joints. Traction applied with use of ropes and weights attached to the end of the pin.  Applied using surgical aseptic technique - site prepared with chlorhexidine solution and local anesthetic given; surgeon makes small incisions and drill sterile pin/wire through the bone. Pt will feel pressure and possibly some pain. The weights are attached to the pin or wire bow by a rope and pulley system that exerts the appropriate amount and direction of pull for effective traction. The weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. ○ Nursing Interventions: Nurses must check traction apparatus to see that ropes are in the wheel grooves of pulleys, ropes are not frayed, weights hang freely, and knots in ropes are tied securely. Evaluate patient positioning, making sure traction force is always in correct alignment with the leg, w/ pt in midline position Help avoid footdrop, inward rotation, and outward rotation. If patient reports severe pain from muscle spasm: the weights may be too heavy, or the patient may need realignment. Pain must be reported to the primary provider if body alignment fails to reduce discomfort. Opioid and nonopioid analgesics may be used to control pain. Muscle relaxants may be prescribed to relieve muscle spasms as needed. Preventing Skin Breakdown: Encourage movement with the use of an assistive device called a trapeze that can be extended overhead within reach of the patient. The trapeze helps the patient move about in bed and move on and off the bedpan. Transparent film, hydrocolloid dressings, or skin sealants may also be applied to bony prominences or critical areas to decrease the force of shearing and friction. Monitored every 8 hours (3x daily). Provide back care and keep the bed dry and free of crumbs and wrinkles if pt unable to move/turn side to side. Use of advanced static mattresses or overlays should be considered - prevent pressure injury Monitoring Neurovascular Status: Monitor and compare peripheral pulses, color, capillary refill, temperature of finger and toes, edema, ability to move, and sensations to the unaffected extremity every hour for the first 24 hours after traction is applied, then every 4 hours after. VTE formation is a significant risk for immobilized pts. ○ Encourage active flexion-extension ankle exercises and isometric contraction of calf muscles (calf-pumping exercises) 10 times an hour while awake. ○ Use of anti-embolism stockings, compression devices, and anticoagulant therapy.  Promoting Exercise: Assist in maintaining muscle strength and tone, and in promoting circulation. Isometric exercises of the immobilized extremity (quadriceps and gluteal setting exercises) are important for maintaining strength in major ambulatory muscles Without exercise, the patient will lose muscle mass and strength, and rehabilitation will be greatly prolonged. 17. Pin Care The goal of providing pin care is to avoid infection and development of osteomyelitis. The nurse never adjusts the clamps on the external fixator frame. It is the primary provider’s responsibility to do so. For the first 48 hours after insertion: site is covered with sterile absorbent, non-stick dressing and a rolled gauze or Ace-type bandage. After this time period, loose cover dressing or no dressing is recommended. Pin site care dependent on: ○ Pins located in areas with soft tissue - at greatest risk for infection. ○ After the first 48-72 hours following pin placement, care should be done daily or weekly. After first 48-72 hrs - serous drainage, skin warmth and mild redness at pin sites are expected; should subside after 72 hrs. ○ Chlorhexidine 2 mg/mL solution is the most effective cleansing solution. Contraindications? - Use sterile saline solution. ○ Strict hand hygiene before/after skeletal pin care. Nurses must assess the site every 8 to 12 hours for S/S of hypersensitivity/allergic reaction, irritation, and infection. ○ Irritation: redness, warmth, serosanguineous drainage - tend to subside after 72 hours. ○ Hypersensitivity/allergic reactions: contact dermatitis, pruritus, urticaria, angioedema ○ Infection: purulent drainage, pain, pin loosening, tenting of skin at pin site, odor, and fever. Prophylactic broad-spectrum IV antibiotics given 24-48 hours post insertion to prevent infection. (No data suggested that it is needed) ○ Readily available antibiotics for minor infections may be used. Crusting at the pin site should be retained as long as the pin site remains uninfected; the crust provides a natural barrier from the external environment, helps prevent bacterial  contamination. If any loose pins are noticed, report to the nurse or PCP at once. 18. Complications of bedrest during traction? Atelectasis and pneumonia/constipation/anorexia/urinary stasis/infection/VTE Atelectasis and Pneumonia: ○ The nurse auscultates pts lungs every 4 to 8 hrs to assess respiratory status; educate on deep breathing & coughing exercises - aids in fully expanding lungs & clearing pulmonary secretions. ○ Therapies (like incentive spirometers) initiated to prevent complications. Constipation and Anorexia: ○ Reduction in GI motility = constipation & anorexia. ○ Diet high in fiber and fluids may help; use of stool softeners, laxatives, suppositories, and enemas for constipation. ○ Include pts food preferences, if appropriate, within rx’ed diet to help w/ anorexia. Urinary Stasis and Infection: ○ Incomplete emptying of bladder due to positioning in bed = urinary stasis and infection. ○ Bedpan may be uncomfortable and limit fluids to minimize the frequency of urination. ○ Nurse will monitor I/O, and the character of urine. ○ Promote adequate hydration and voiding every 3-4 hrs. ○ S/S of UTI - burning/pain on urination, hematuria = notify PCP to start antibiotic therapy. VTE (Venous Thromboembolism) ○ Due to immobility ○ Nurse educates pt how to perform ankle/foot exercises within limits of traction every 1-2 hrs when awake to prevent DVT. ○ Educate families about VTE prevention and care decisions. ○ Encouraged to drink fluids to prevent dehydration and hemoconcentration which contributes to stasis. ○ Monitor for S/S of DVT - unilateral calf tenderness, warmth, redness, swelling (increased calf circumference). ○ The nurse encourages the patient to exercise muscles and joints that are not in traction to prevent deterioration, deconditioning, and venous stasis. ○ PT to design bed exercises to minimize loss of strength. 19. Neurovascular checks -5 Ps: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis; Signs of venous vs arterial insufficiency; How to care for cast/splints; What to do if patient reports pain inside the cast; What to do with swelling in a cast? Hip/Spica cast and complications/Nursing implications Neurovascular Checks, Cast/Splint Care, and Hip/Spica Casts Neurovascular Checks (5 Ps) 1. Pain: Assess for disproportionate or unrelieved pain after intervention. 2. Pallor: Monitor skin color for signs of poor circulation. 3. Pulselessness: Check distal pulses compared to unaffected side. 4. Paresthesia: Ask about numbness or tingling in the extremity. 5. Paralysis: Assess for movement or motor function. Signs of Venous vs. Arterial Insufficiency  Venous: Swelling, discoloration (brownish staining), warm skin, and potential ulcers. Arterial: Cool, pale skin, decreased pulse, pain during activity, and ulcers at pressure points. Cast/Splint Care Do: ○ Elevate the cast for the first 48 hours to reduce swelling. ○ Keep the cast dry and clean. ○ Use a hair dryer (cool setting) for itch relief. Don’t: ○ Insert objects into the cast to scratch. ○ Bear weight until cleared by a healthcare provider. What to Do if Pain is Reported Inside the Cast Action: Report unrelieved pain immediately to the provider; this could indicate compartment syndrome, pressure ulcers, neuromuscular damage, and possible paralysis. ○ Compartment syndrome pain: relentless and not controlled with ice packs, elevation, or pain meds. Splint must be loosened or removed and cast is univalve or bivalve (cut in half longitudinally, on one side or two parallel sides of the cast) = release constriction and inspect the skin. Nurses assist with maintaining limb alignment , and extremity elevated no higher than heart level to maintain arterial perfusion. If pressure not relieved = emergency surgical fasciotomy performed - relieves pressure within muscle compartment. Frequent neurovascular checks performed afterwards. ○ Pressure ulcers: severe burning pain over bony prominences; patient may report painful “hot spot” and tightness in cast; cast may feel warmer (tissue erythema), drainage may stain cast/splint and emit odor. Splint may be loosened or removed and cast is univalve or bivalve or cut a opening (window) (cut in half longitudinally, on one side or two parallel sides of the cast) to inspect, access, and possible treat. Dressing may be applied to exposed skin; cutout of cast replaced and held by elastic compression dressing or tape = prevents window edema. Pain due to edema: controlled with elevation and use of ice/cold packs; placed on each side of the cast (make sure to not indent or wet the cast). What to Do for Swelling in a Cast Elevate the limb above heart level. Apply ice packs around the cast, not directly on it. Hip/Spica Cast: Complications and Nursing Implications Body cast: encases the trunk of the body; used to immobilize the spine  Spica cast: encases portions of one or two extremities Hip spica cast: Encloses the trunk and a lower extremity. A double hip spica cast includes both legs; utilized to treat various fractures of the hip or femur or to correct or maintain the correction of hip deformities after reduction or surgery. ○ Cast remains in place for 4-6 weeks. Complications: a. Superior mesenteric artery syndrome (bowel obstruction) - cast syndrome - rare condition, compression of the third portion of the duodenum between the aorta and superior mesenteric artery. i. Can occur within days to weeks ii. Pts react and feel claustrophobic - increased RR, diaphoresis, dilated pupils, increased HR, elevated BP iii. Nurse will provide secure environment to help with pt anxiety and administer pain & anti-anxiety meds b. Intestinal gases accumulation i. S/S: abdominal distention and discomfort, nausea, and bilious vomiting, which can lead to food aversion, poor intake, malnourishment, and weight loss ii. Pt tx with decompression with NG tube connected to suction, IV fluid therapy until GI motility returns. c. Skin breakdown and nerve compression. Nursing Care: ○ Preparing and positioning the patient, assisting with skin care and hygiene, and monitoring for complications. ○ Regularly check bowel sounds and monitor for abdominal distention. (4-8 hrs) ○ Maintain proper alignment and use pressure-relieving devices. ○ Educate on hygiene and skin care for immobilized areas. 20. Hip prosthesis: How to position a patient in bed and transfer out of bed? Type of toilet seat needed? How to position a patient post total hip replacement (arthroplasty)? IN BED: patient should be in a supine position with the head slightly elevated and the affected leg in a neutral position. ○ The use of an abduction splint, a wedge pillow, or two or three pillows placed between the legs prevent adduction beyond the midline of the body. ○ A cradle boot may be used to prevent leg rotation and to support the heel off the bed, preventing development of a pressure injury. ○ When the nurse turns the patient in bed to the unaffected side, it is important to keep the operative hip in abduction (movement away from the center or median line of the body). The patient should not be turned to the operative side, which could cause dislocation, unless specified by the surgeon. TRANSFERRING IN/OUT OF BED: ○ Limited flexion is maintained during transfers and when sitting. ○ When the patient is initially assisted out of bed, an abduction splint or pillows are kept between the legs. ○ The nurse encourages the patient to keep the affected hip in extension, instructing the patient to pivot on the unaffected leg with assistance by the nurse, who protects the affected hip from adduction (movement toward the center or median line of the body), flexion, internal or external rotation, and excessive weight bearing.  The patient’s hip is never flexed more than 90 degrees, there is no crossing of legs, legs should be kept abducted, do not bring knees close together, avoid sitting in chairs longer than 45 minutes, and using assistive devices when dressing. Avoid tub baths, jogging, lifting heavy loads, and excessive bending and twisting. BEDPAN/TOILET SEAT: When using a fracture bedpan, the nurse instructs the patient to flex the unaffected hip and to use the trapeze to lift the pelvis onto the pan. The patient is also reminded not to flex the affected hip. ○ High-seat (orthopedic) chairs with arm rests, semi-reclining chairs, and raised toilet seats, a toilet seat extender to elevate the toilet seat, are used to minimize hip joint flexion. ○ When sitting, the patient’s hips should be higher than the knees. The patient’s affected leg should not be elevated when sitting. The patient may flex the knee. Integumentary Diagnostic tests: 1. Skin Biopsy, Patch Test, Skin Scrapings, Tzanck Smear, Wood Light Exam (chapter 55) Label all specimens in the room with the patient to ensure no mislabling. Skin Biopsy: performed to obtain tissue for microscopic examination. ○ May be obtained by shave, excision, or by a skin punch instrument that removes a small core of tissue. ○ Used for microscopic (unable to see to the eye), skin nodules, plaques, blisters, & other lesions to rule out malignancy. ○ To aid in diagnosis & perform additional testing such as gram stain for bacteria or periodic acid-schiff (PAS) for fungal elements. Patch Test: performed to identify substances to which the patient has developed an allergy. ○ Involves applying suspected allergens to normal skin under occlusive patches. ○ Patients wear occluded strips (with the allergen agent) on their backs for 48 hours, and the area is assessed after 72 hours. ○ Results: Weak Positive reaction: development of redness, fine elevations, or itching Moderately Positive reaction: fine blisters, papules, and severe itching Strong Positive reaction: blisters, pain, and ulceration. ○ Nurses educate the patients to avoid reactive allergens; which may be hard due to prevalence in the environment.  Skin Scrapings: tissues samples are scraped from suspected fungal lesions with a scalpel blade that has been moistening with oil so scraped skin adheres to the blade. ○ Scraped material is transferred to a glass slide, covered with coverslip, and examined microscopically. ○ Spores & hyphae of dermatophyte infection & infestations such as scabies can be visualized. Tzanck Smear: used to examine cells from blistering conditions such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. ○ Secretions from suspected lesions are applied to a glass slide, stained, and examined. Wood Light Examination: a special lamp that produces long-wave ultraviolet rays, which results in a characteristic blue to dark purple fluorescence. ○ Color of fluorescent light best seen in darkened rooms = helps differentiate epidermal from dermal lesions and hypo and hyperpigmented lesions from normal skin. ○ Light is not harmful to eyes or skin ○ Lesions that contain melanin almost disappear under UV light, lesions that are devoid of melanin increase in whiteness with IV light. Clinical Photographs purpose: ○ Photographs are taken to document the nature and extent of the skin condition and are used to determine progress or improvement resulting from treatment. ○ Used to track the status of moles to document if the characteristics of the mole are changing. ○ Used to check for bony prominences; ensure you have general consent to take photographs 2. Psoriasis Psoriasis: a chronic, autoimmune, inflammatory multisystem disorder of the skin; it may involve the skin, oral cavity, eyes (including the lids, conjunctiva, and corneas), and joints. ○ Char