MS assessment

Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. The best response by the nurse is:

"CPM increases range of motion of the joint."

The older client asks the nurse how best to maintain strong muscles. The best response by the nurse is:

"Weight-resistance exercises can strengthen muscles."

The nurse is preparing the client for computed tomography. Which information should be given by the nurse?

"You must remain very still during the procedure."

Knots in the rope or the footplate must not touch the pulley or the foot of the bed.

*

Ropes must be unobstructed.

*

Skeletal traction is NEVER interrupted.

*

The patient must be in good body alignment in the center of the bed when traction is applied.

*

Traction must be continuous to be effective in reducing and immobilizing fractures.

*

Weights are not removed unless intermittent traction is prescribed.

*

Weights must hang freely and not rest on the bed or floor.

*

The nurse is providing care to a client following a knee arthroscopy. Which of the following would the nurse expect to include in the client's plan of care?

Administering prescribed analgesic

10 to 20 pounds

Amt of weight to be used for pelvic traction

4.5 to 8 pounds

Amt of weight to be used for traction on an extremity

The nurse would include which of the following in a neurological assessment?

Ask the client to plantar flex the toes

collapse of part of a lung

Atelectasis

Supports the affected extremity off the bed and allows for some patient movement without disruption of the line of pull

Balanced suspension traction

A rigid external immobilizing device that is molded to the contours of the body. Specifically used to immobilize a reduced fracture, to correct a deformity, to apply uniform pressure to underlying soft tissue, or to support and stabilize weakened joints. Generally, permits mobilization of the pt which restricting movement of a body part

Cast

Which of the following is a neurovascular problem caused by pressure within a muscle area that increases to such an extent that microcirculation diminishes?

Compartment Syndrome

After undergoing surgery the previous day for a total knee replacement, a client states that he doesn't feel ready to ambulate yet. What should the nurse do?

Discuss the complications that the client's may experience if he doesn't cooperate with the care plan.

Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure?

Fasciotomy

Composed of water-activated polyurethane materials that have the versatility of the plaster but are lighter in weight, stronger, and more durable. In addition, they are water resistant.

Fiberglass cast

Which assessment finding would cause the nurse to suspect compartment syndrome in the client following a bone biopsy?

Increased diameter of the calf

Can be applied with the hands. When applying a cast, giving skin care under a buck's extension foam boot, or adjusting the traction apparatus.

Manual traction

Maintaining effective traction Maintaining position Preventing skin breakdown Monitoring NV status Providing pin site care Promoting exercise

Nursing Interventions for Skeletal traction

Ensuring Effective Traction Monitoring & managing potential complications skin breakdown nerve damage circulatory impairment

Nursing interventions for skin traction

The nurse recognizes that a referral for genetic counseling is inappropriate for the client with:

Osteoarthritis

The nurse observes the client and notes a shuffling gait. The nurse recognizes this finding is consistent with:

Parkinson's disease

Sterile dressing first 48 hours Then loose or no dressing Clean pin sites w/chlorhexidine Assess for S/S of infection every 8 hours (more drainage, pain, swelling, increased redness)

Pin Care

Made of plater Less costly and achieve a better mold than fiberglass casts; however, they are not as durable and take longer to dry. Requires 24 to 72 hours to dry completely, depending on its thickness and the environmental drying conditions.

Plaster casts

deep breathing, coughing, spirometer

Prevent atelectasis

Applied directly to the bone Used occasionally to treat fractures of the femur, tibia, and the cervical spine. Applied directly to the bone via metal pin or wire that is inserted through the bone distal to the fracture, avoiding nerves, blood vessels, muscles, tendons, and joints.

Skeletal traction

Usually 15 to 25 pounds of weight

Skeletal traction

Traction may be applied to the skin or directly to the bony skeleton. The mode of application is determined by the purpose of the traction.

Skin vs. Skeletal traction

Applies the pulling force in a straight line with the body part resting on the bed. Example is Buck's extension traction

Straight or running traction

The application of a pulling force to a part of the body. Used to minimize muscle spasms; to reduce, align and immobilize ftratures; to reduce deformity; and to increase space between opposing surfaces. Must be applied in the correct direction and magnitude to obtain its therapeutic effects.

TRACTION

Contertraction must be used to achieve effective _____.

Traction

A client is scheduled for a joint replacement surgery. Which action would be most important?

Withhold administration of aspirin before the surgery.

A client who is undergoing skeletal traction complains of pressure on bony areas. Which action would be most appropriate to provide comfort for the client?

changing the client's position within prescribed limits

rhythmic contractions of a muscle

clonus

occurs when there is increased tissue pressure within a limited space (cast) that compromises circulation & function of the tissue within the confined area

compartment syndrome

involuntary twitching of muscle fiber groups

fasciculation

an increased forward curvature of the spine

kyphosis

aka swayback an exaggerated curvature of the lumbar spine

lordosis

The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective?

metal pins with go through my skin to my bone

Burning, tingling sensations or numbness may be caused by pressure on nerves or by circulatory impairment

paresthesias

fluids

prevent anorexia

diet high in fiber, fluids, stool softners

prevent constipation

coughing, deep breathing, lots of fluids

prevent pneumonia

a lateral curving deviation of the spine

scoliosis

A client recently undergoes an invasive joint examination to enable the identification of bone composition. Which of the following signs and symptoms should the nurse monitor in this client? Choose all correct options.

serous drainage swelling & bleeding

Used to control muscle spasms and to immobilize an area before surgery. Is accomplished by using a weight to pull on traction tape or on a foam boot attached to the skin. Amt of weight must not exceed the tolerance of the skin.

skin traction

Used primarily as a short term intervention until other modalities, such as external or internal fixation are possible. Reduces the risk of disuse syndrome & minimize the length of hospitalization, often allowing the pat to be cared for in the home setting.

traction

Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated.

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