CDC Musculoskeletal Procedures PDF

Lesson 8 of 10 Lesson 8- Musculoskeletal Procedures After completing this lesson, the student will be able to identify musculoskeletal operating procedures in accordance with prescribed guidance and publications. Apply Skin Traction Skin traction is applied to the skin by heavy adhesive tape, molesk...

Lesson 8 of 10 Lesson 8- Musculoskeletal Procedures After completing this lesson, the student will be able to identify musculoskeletal operating procedures in accordance with prescribed guidance and publications. Apply Skin Traction Skin traction is applied to the skin by heavy adhesive tape, moleskin, or halters connected to weights and pulleys. It is mainly used to relieve pain from muscle spasms and to correct mild deformities. Keep in mind that traction application in the United States is well standardized. In deployed settings, field litters and cots are normally used when treating patients and are not made for traction devices. Pay close attention to the provider’s directions in these situations as they often have to be creative with creating a traction system that will work well for the patient. Types of Skin Traction B UC K 'S E X T E N SI O N R USSE L L'S T R A C T I O N Applied to the leg as temporary treatment for fractures of the upper portion of the shaft or neck of the femur. It is also used for hip fractures and applied to the hip prior to surgery. B UC K 'S E X T E N SI O N R USSE L L'S T R A C T I O N Treats some fractures of the shaft and neck of the femur or hip. May also be used to treat specific types of knee injuries or contractures. To get prepared for using these types of traction, you will begin by setting up the Balkan frame and trapeze if needed. A Balkan frame is used for the placement of pulleys. An overhead trapeze can be attached to the Balkan frame to encourage self-help on the part of the patient. If the mattress is not made of hard-foam rubber or cotton, place a bed board under it to stop patient or devices from sinking into the bed. After you set up the traction unit, be sure to: Balkan frame Pay close attention to the condition of the skin under the traction site. Check pressure points. Ensure tape does not bunch up or wrinkle, causing skin irritation or causing the traction device to slip. Encourage patient to do bed exercises unless contraindicated. Report any abnormal findings immediately. C O NT I NU E Care for External Fixation Device and Pin External fixation is a form of reduction and immobilization used for the management of open, complicated fractures with severe soft-tissue damage. Reduction in layman’s terms means setting the bone. For a broken bone to heal properly, it must be placed back into a normal anatomical position. An open fracture is a break in a bone that connects with a wound in the exterior surface of the skin. With external fixation, pins attached to bone, protrude through the skin and are attached to an external metal frame. The wound may be left open to heal. Some advantages include easier access to wound care, soft tissue reconstruction, and early function of muscles and patient comfort. Repairing bone fracture with external fixation Pin care is indicated for patients in skeletal traction with an external fixation device. It is very important to prevent infection and should be performed two to three times daily. If there is a local policy on pin care, be sure to follow that guidance. Here are some general rules and steps to follow: Gather supplies for sterile procedure. Used the prescribed cleansing agent and use it to soften and remove crusty drainage. Generally hydrogen peroxide, mild soap and water or sterile water and normal saline will work. CONTINUE Scene 1 Slide 1 Continue Next Slide Check the doctor's orders and position of the patient. Prior to cleaning, check the pin and the site surrounding the pin. Small amounts of drainage is normal. The pin should be immobile, clean, and dry. Prevent access for any potential infection. CONTINUE Scene 1 Slide 2 Continue Next Slide Open all containers and supplies and don sterile gloves. Soak the cotton-tipped applicators by pouring the solution over them or dipping the sticks into the solution. Start to cleanse the area at the insertion area and move outward, away from pin site. CONTINUE Scene 1 Slide 3 Continue Next Slide Cleanse and Remove. Cleanse pin sites with sterile, cotton-tipped applicators soaked in hydrogen peroxide or prescribed agent. Remove the crusts using meticulous sterile technique. Use a new applicator for each site. CONTINUE Scene 1 Slide 4 Continue Next Slide Examine all the bony prominences for signs of pressure areas or abrasion. Apply an antimicrobial agent around the pin sites and loosely dress the site with separate gauze sponges. Report any questionable finding to the nurse or provider immediately. START OVER  Scene 1 Slide 5 Continue End of Scenario C O NT I NU E Position Patient with Head Halter/Cervical Tongs Cervical spine injuries are managed by immobilization, early reduction, and stabilization of the vertebral column. This is accomplished with two different forms of cervical traction: skin traction with a head halter or through skeletal traction by using tongs or a halo apparatus. As you learned in EMT training, correct alignment and positioning of the spinal column is of utmost importance for patients with spinal trauma. The same principles apply to the patient who requires cervical traction. Be sure to check traction equipment/set up and that the patient is placed on a firm mattress. Ensure all ropes/pulleys are in alignment; the pull should be aligned with the long axis of the bone. Finally, clear the area of anything that could touch or obstruct the apparatus. Click on the flip cards below to learn more about the difference types of tractions. 1 of 4 Used for cervical spine disorders, such as stabilization of spinal fractures or injuries, muscle contractures, or muscle Head Halter Traction spasms. Holes are drilled in the patient’s skull and the tongs will be affixed to or screwed to the skull. This device can connect to Cervical Tongs bed traction. Care for the tongs is the same as pin care for external fixation devices. 2 of 4 Four pins are fixed to the skull with a halo ring and connected to a removable vest by a metal frame. This device can connect to bed traction, but is used for patients who are able to be mobile. Inspect the skin under the vest, especially for patients who are using this device while connected to bed traction. Halo-vest Device 3 of 4 The primary means of positioning a patient in cervical traction is supine; however, the provider can order for the patient to be in a seated position. It is important to be 4 of 4 careful when controlling cervical alignment throughout the process of positioning. Safe positioning is reliant on stable head control with tongs or other devices. In most cases, patients who require in-hospital cervical traction Patient Positioning for Cervical Traction Head halter traction Cervical tongs will be in a bed designed specifically for this use. Halo-vest device Patient positioning C O NT I NU E Instruct Patients Regarding Isometric, Active Exercises, or Passive-Assisted Exercises As mentioned in the previous unit, exercise is one of the most basic and essential rehabilitative measures necessary for proper body function and muscle tone, that will improve or prevent most conditions related to mobility and immobility. Review the provider’s orders for the patient’s exercises and quantity. As helpful as exercises are, they can also be painful and even dangerous for patients who have heart problems and some musculoskeletal conditions, such as arthritis, fractures, sprains, strains, torn ligaments, and joint dislocations. The provider will specify the type and amount of exercise the patient needs. Of course, a provider’s order for treatment is no guarantee that the patient will not have problems. Stop the exercise and notify the provider or nurse if the patient begins to show signs of pain, resistance, or fatigue. A C T I V E E X E R C I SE S R O M E X E R C I SE S I SO ME T R I C E X E R C I SE S PA SSI V E E X E R C I SE S Active exercises are activities done by the patient. They include active range of motion (ROM) exercises and isometric exercises. A C T I V E E X E R C I SE S R O M E X E R C I SE S I SO ME T R I C E X E R C I SE S PA SSI V E E X E R C I SE S ROM exercises are movements permitted by each joint. Active ROM exercises are done without assistance. If able, encourage patients to do them at least two to five times a day, exercising each joint five times per session. A C T I V E E X E R C I SE S R O M E X E R C I SE S I SO ME T R I C E X E R C I SE S PA SSI V E E X E R C I SE S Isometric exercises are activities that involve muscle contraction without moving body parts; they do not require any equipment and can be done from any position. For example, you can contract placing your palms together in front of your chest and pushing as hard as you can for the time prescribed. These exercises help increase the patient’s strength and endurance for other activities. They are potentially dangerous if done incorrectly. Instruct patients not to hold their breath. Such straining will affect the heartbeat and may cause a heart attack. Also instruct patients not to contract a muscle for a prolonged period. It is recommended for the patient to tighten or contract a muscle group for 10 seconds then release for several seconds; gradually increasing repetitions until the exercise is repeated 8 to 10 times. Another method of isometric exercises is resistive isometric exercises. Resistive isometric exercises require the patient to contract their muscles as they push against a fixed object or resist movement of an object. For example, the patient sits in a chair, places their hands on the seat, and then straightens their arms to lift their hips. A C T I V E E X E R C I SE S R O M E X E R C I SE S I SO ME T R I C E X E R C I SE S PA SSI V E E X E R C I SE S Passive exercises are activities performed by a technician for patients who are unable or not allowed to exercise on their own (e.g. a patient paralyzed from the neck down). These exercises will help maintain muscle tone and joint flexibility, and decrease complications such as decubitus ulcers and contractures. Another method of passive exercise is active-assisted exercise. Active-assisted exercises require some participation from a technician, but only when the patient need assistance. For example, patients recovering from a serious illness or surgery may begin with passive exercises, then progress into doing them on their own, with assistance. Unless contraindicated by the provider’s orders or patient’s condition, encourage patients to do as many exercises as possible on their own. The passive exercises you will be involved with most are range of motion (ROM) exercises. As you may recall from anatomy and physiology, each body joint is capable of certain types of activity. For example, the elbow is a hinge joint, capable of flexion and extension. ROM exercises are movements permitted by each joint. These movements depend on the structure of the joint and differ from one joint to the other. Make sure you move the body parts smoothly and carefully, especially the neck. Some descriptive terms and images are listed for review. Flip the cards to learn more. Abduction Movement away from the center of the body. Adduction Movement toward the center of the body. Extension Straightening a joint or increasing the angle between the body parts that are connected. Flexion Dorsiflexion Bending a joint or decreasing the angle between body parts. Flexing the foot at the ankle by lifting the toes toward the knee. Plantar Flexion Extending the foot at the ankle by pointing the toes downward. Hyperextension Excessive straightening of a joint almost to the point where it is angled backwards. Rotation Circular movement of a body part around a joint. Internal Rotation Rotating a joint toward the midline. External Rotation Rotating a joint away form the midline. Supination Rotating the hand at the wrist so that the palm is facing up. Rotating the hand at the wrist so that the palm is facing down. Pronation Watch the video below to learn some tips on how to remember these common movement terms. Easiest Way to Remember Movement Terms Video Transcript.pdf 157.7 KB Range of Motion (ROM) Exercises ROM exercises serve a number of useful functions. 1 Prevent shortening of muscles, tendons, ligaments, and joint capsules, to decrease the onset of joint stiffness and fixation (ankylosis), and contractures. 2 Prevent adaptive stretching or lengthening of connective tissue around joints. 3 Prevent deformities that limit function. 4 Stimulate circulation and sensory nerve endings. 5 Restore loss of joint function. 6 Maintain or increase muscle strength. 7 Increase endurance. It is recommended to perform ROM exercises two to five times a day, exercising each joint five times per session. Ideally, a physical therapy technician will help the patient with these exercises, but if one is not available, you will assist the patient. There are basic guidelines for you to follow when assisting patients with ROM exercises to help ensure the patient receives full benefit from them, and neither you nor the patient gets injured. The guidelines are as follows: 1 Be familiar with the provider’s orders and the patient’s diagnosis and capabilities. This information will help you decide what exercises are needed and how much the patient can participate. 2 Explain to the patient what you are doing. This is a must for any procedure. Patients will be more likely to relax and participate in activities if they understand what is going on. 3 Use good body mechanics, such as a wide base of support and large muscle groups, when performing these activities. This will conserve your energy and prevent injury and strain. 4 Avoid overexerting the patient or performing exercises to the point of pain. Fatigue and pain will not help the patient and may cause the patient to stop participating. 5 Begin gradually and work slowly. All movements should be smooth and rhythmic. Irregular, jerky movements are uncomfortable for the patient. Move each joint through its normal ROM until you begin to meet resistance. Stop immediately if the patient experiences pain or muscle spasms. 6 Report such reactions to the nurse or provider, and delay further exercises until the patient can be examined. Excessive stretching of joints can cause injuries and even bleeding into joints. If the patient cannot talk, observe the patient’s face for signs of pain as you do the exercise. 7 Support the body part you are moving above and below the joint you are exercising. Cradle or cup the body part and avoid grasping at muscles or tendons. 8 Begin each exercise with the joint in its normal anatomical position and return it to that position at the end of the exercise. 9 Move each joint through its complete ROM, five or six times, slowly, rhythmically, and with control. Repetition is important for joint flexibility, and slow, controlled movements prevent injury. 10 Combine exercises with other activities, such as hygiene and positioning. This will save you time and increase the activity level of the patient. 11 Unless contraindicated, encourage the patient to participate in the exercises. Begin with passive exercises and gradually increase to active-assisted exercises until the patient can do the exercises without help. Recovery will accelerate as the patient becomes more and more independent. Matching Match the following descriptive definitions with the correct term. Movement away from the center of the body. Abduction Movement toward the center of the body. Adduction Straightening a joint or increasing the angle between the body parts that are connected. Extension SUBMIT E ND O F L E S S O N Lesson 9 of 10 Lesson 9- Pre & Post Operative Procedures After completing this lesson, the student will be able to apply pre and post-operative procedures in accordance with prescribed guidance and publications. Universal Protocol (UP) Concept Universal Protocol was established in 2003 by The Joint Commission, known as TJC. The Joint Commission’s Universal Protocol helps prevent errors due to patients undergoing the wrong surgery, or having a procedure performed on the wrong site. Nurses and technicians are responsible for implementing this protocol anytime an invasive surgical procedure is involved, regardless of the clinic, ward or surgical unit the procedure is being performed. This process has multiple steps and principles to include but not limited to the following: 1 Conduct a pre-op verification. All relevant documents and studies are available prior to the start of the procedure, and align with the patients expectations. 2 Marking the site with indelible ink (skin marker) to mark left and right distinction, and multiple structures. 3 Perform a “Time out” and patient consent. Just before you start the procedure, you will perform a time out to verify right patient, right procedure, and right procedure site. The provider, the patient or patient’s legal guardian and a witness will then sign and date. This will be uploaded into the patients’ medical chart. All MTF’s will adhere to the National Patient Safety Guidelines (NPSGs) for UP. These NPSGs are listed on TJC’s website, as well as the knowledge exchange (Kx). Universal Protocol applies to all surgical and nonsurgical invasive procedures as determined by the MTF. Each MTF will ensure compliance by developing facility-specific processes that use the UP surgical checklist, and incorporate elements of the non-operating room procedure verification checklists into established processes. These checklists are located within the Patient Safety Handbook on the Kx. N O N - O PE R AT I N G R O O M O PE R AT I N G R O O M This checklist, Defense Health Agency (DHA) 229 UP procedures, applies to procedures done in non-operating room, such as noninvasive or clinical procedures that are often done in a clinical exam room. Staff must use the checklist to verify the right patient, right procedure and obtain consent from the patient. You will obtain the provider's signature as well as a witness stating the procedure, the risks, expected recovery and symptoms were explained to the patient. At this time you will also perform and annotate prep of supplies, equipment and the surgery site. N O N - O PE R AT I N G R O O M O PE R AT I N G R O O M This form, DHA 228 UP Operating Procedures, is used by operating-room staff prior to the start of the surgery. This is one last check to ensure verification of all resources used before, during and after the surgery. This form provides a more thorough verification of the patient, but also the completion of any and all documents used in assessing the patient throughout the process. Multiple Choice Universal Protocol was established in 2003 by ______________. This protocol helps prevent errors due to patients undergoing the wrong surgery, or having a procedure performed on the wrong site. The Medical Flight The Joint Chief of Staff The Joint Commission National Patient Safety Guidelines SUBMIT Complete the content above before moving on. Anesthesia-Related Safety Measures Blood Pressure The blood pressure reading tells whether the blood is flowing through the vessels with enough force to reach all areas of the body. A change in this force is caused, among other things, by a lowered volume of blood or inadequate pumping action of the heart. When a patient has just returned from the operating room (OR) and you notice that his or her blood pressure begins to drop, consider several possibilities: Is the patient losing blood from a severed blood vessel? Are drugs or the anesthetic agent depressing the action of the heart? Is the patient in shock? Rhythm and rate of heartbeat—When the body tries to compensate for a reduced volume of blood in the circulation, the heart beats faster, thus sending the heart rate up, but each beat is harder to detect because less blood is pressing against the vessel walls. This phenomenon produces a “thready” pulse. Rate and depth of respirations—Respiratory rate can increase because of signals sent out by the brain when its cells are not receiving enough oxygen. Note that many medications used for anesthesia directly depress the respiratory system, resulting in the inability of the patient to breathe on his or her own. This is why the anesthetist must often “bag” the patient by forcing air into the lungs from the breathing bag attached to the gas machine. Sometimes this process is carried out automatically by a ventilator. In some cases, a ventilator is used in the recovery room to assist patients whose chest muscles are not contracting properly or patients who are too depressed to take the deep breaths that fully expand the lungs. In addition to the relaxation produced in chest muscles, general anesthesia can also affect the muscles that control the jaw. When these muscles are relaxed, the lower jaw drops and the tongue falls back in the throat, obstructing the air passage. For this reason, the anesthetist inserts an airway into the mouth after an endotracheal tube is removed. The patient’s lower jaw can be supported by the anesthetist’s hand, or the anesthetist can turn the patient’s head to one side so the lower jaw won’t drop. By maintaining one of these head positions and by a careful suctioning of any foreign body, mucus, vomitus, or blood from the throat, you can usually prevent respiratory obstruction. An open airway is always a necessity, even when oxygen is given because all the oxygen on earth is of no value to a person if the route to the lungs is blocked. Oxygen therapy may be prescribed by the surgeon or anesthetist at the time a patient is brought to the recovery room, or the need for it may develop later. Depression caused by the anesthetic agent or drugs, hemorrhage, shock, or a combination of these, as well as the operative procedure and many other factors can produce hypoxia. By increasing the amount of oxygen taken in with each breath, the body’s needs are supplied until the causative agent or condition either wears off or is corrected. Cardiorespiratory emergencies—Recovery room and unit personnel must be familiar with the treatment of cardiorespiratory emergencies. Intubation material, tracheostomy tray, cardiac arrest tray, defibrillator, pacemaker, and ECG/EKG machine should be easily available. Not only must you locate and set up these items but recognize the symptoms of cardiorespiratory problems and know the initial steps of treatment. For instance, if you suddenly discover that a patient’s vital signs have disappeared, notify anyone who is nearby; then start administering artificial respiration and external cardiac massage. When other team members arrive, stand by and assist them with the form of treatment decided upon by the physician. Temperature and color of the skin—Body temperature and capillary refill are direct indicators of shock. This is due to poor or lack of proper profusion and circulation. If the patient exhibits cold, clammy, and pale skin, this needs to be reported to the nurse or physician immediately. Patient’s level of consciousness (LOC)—to determine the LOC, ask the patient questions. A common practice is to ask his or her name, date, and where he or she is (location). This is considered a fair test of orientation. You also need to check the IV for proper solution and flow rate, drainage of urine, wound drainage tubes, or any other special equipment. Check the dressing that was applied in surgery for any apparent bleeding. It is also important to maintain the patient’s comfort. The administration of pain medication is sometimes necessary in the recovery room. All of the following checks are performed every 15 minutes. Once vital signs are stable and responsiveness has returned, the anesthetist discharges the patient to a nursing unit. Special Precautions Safety measures must be observed in the recovery room to protect Blood pressure can drop because of the anesthetic drug used or because patients from falls or injuries. Patients in the recovery room are able of lowered spinal pressure, and patients can suddenly go into shock. Do to control many body functions and may actually be capable of not ignore patients just because they seem to feel well and can talk to inflicting self-harm because of disorientation during the recovery you. This is also true of patients with regional blocks. They usually process. If patients had a spinal anesthetic, they may be able to remain in the recovery room until vital signs are stable and cleared by a move about just enough to place themselves in a position where physician for transfer. Patients may be transferred to an inpatient unit they could fall. It is important that spinal patients have side rails in before sensation has returned to an anesthetized area but will be place, and careful checks kept on their vital signs. monitored closely for return of full neurovascular function. The precautions observed in the presence of oxygen must be practiced when oxygen therapy is used in the recovery room. This means, of course, that no open flames are allowed. Since smoking is not permitted in the hospital, there should be little need to remind you of this fact, but oxygen tanks should be handled and stored with the same careful consideration used in other areas of the hospital. Septic cases (patient suffering from septicemia) brought to the recovery room should be handled just as any isolation cases throughout the hospital. In many hospitals, however, these patients are returned directly to their units, so there is no danger of the sepsis being transferred to the fresh wounds of the surgical patients. Such cross-contamination is particularly serious for a patient whose body defenses were already lowered by a surgical procedure. Report any abnormal findings of vital signs, airway and breathing to your RN or provider upon recognition, document findings and time in the patient’s chart. Multiple Choice What reading tells whether the blood is flowing through the vessels with enough force to reach all areas of the body? Blood pressure Heart rate Blood oxygen level Incentive spirometer SUBMIT Complete the content above before moving on. Post Op Exercises In many hospitals, surgical patients are introduced to certain postoperative exercises before surgery. This is particularly true of the turning, coughing, and deep-breathing exercises (TC&DB). They are expected to practice to prevent hypostatic pneumonia following anesthesia. Other common postoperative exercises are diaphragmatic breathing and leg and foot exercises. It is very important that you turn or change the patients’ position every two hours. This is vital to improving circulation and relieving pressure areas. Breathing Exercises The chief objective of breathing exercises is to increase or develop the expiratory phase of breathing and to develop the muscles concerned with respiration. Deep-breathing exercises also maintain and cleanse the airway, improve vital capacity, and help to prevent such conditions as atelectasis and postoperative pneumonia. Blow bottles and incentive spirometry are often used in the postoperative or prolonged bed-rest exercise program. The incentive spirometer is an excellent tool for preventing postoperative pneumonia and atelectasis. The incentive spirometer is a piece of equipment that encourages total sustained inhalation of the patient. To use the spirometer, the patient should be in a sitting position. Explain to the patient to first exhale fully, place the mouthpiece in his or her mouth, inhale slowly until the desired goal is reached, hold for three seconds, then relax and slowly exhale. Only one per minute should be performed, allowing the patient to relax. Explain to the patient that the spirometer should be attempted at least 10 times each hour while awake. Coughing Coughing promotes the removal of chest secretions and prevents pneumonia or other possible airway obstructions. Teach the patient to cough by interlacing his or her fingers over a pillow, which is placed over the incision site. Ask the patient to lean forward in a Fowler’s position, inhale with his or her mouth slightly open, and let out three or four sharp hacks. Then, inhale deeply again and give one or two sharp coughs. Have tissues readily available, or a suctioning apparatus, if needed Diaphragmatic Breathing Diaphragmatic or deep breathing is also a useful tool in preventing postoperative complications. Deep breathing is accomplished by inhaling deeply, holding for a five count, then exhaling through pursed lips to a count of 12 to 15. Repeat this 15 times, resting between each set of five. Leg and Foot Exercises Other important preoperative teaching includes leg and foot exercises. Leg and foot exercises can be performed in bed and are very important for maintaining circulation and muscle tone. Tell the patient to practice these exercises prior to surgery: 1. While lying on your back, bend your knee and raise your foot, hold it for a few seconds, and then lower. 2. Lie on your side and move your legs as if riding a bike. 3. Make circles with your big toe. Have the patient perform these exercises five times every three to five hours or as the physician ordered. Multiple Choice It is very important that you turn or change the patients’ position every _____ hours. This is vital to improving circulation and relieving pressure areas. 30 minutes 1 hour 2 hours 2.5 hours SUBMIT E ND O F L E S S O N