N250: Musculoskeletal

Emergency Care of the Patient With an Extremity Frac

1. Assess the patient's airway, breathing, and circulation and perform a quick head-to-toe assessment. 2. Remove the patient's clothing (cut if necessary) to inspect the affected area while supporting the area above and below the injury. Do not remove shoes because this can cause increased trauma unless the foot or ankle is injured. 3. Remove jewelry on the affected extremity in case of swelling. 4. Apply direct pressure on the area if there is bleeding and pressure over the proximal artery nearest the fracture. 5. Keep the patient warm and in a supine position. 6. Check the neurovascular status of the area distal to the fracture, including temperature, color, sensation, movement, and capillary refill. Compare affected and unaffected limbs. 7. Immobilize the extremity by splinting; include joints above and below the fracture site. Recheck circulation after splinting. 8. Cover any open areas with a dressing (preferably sterile).

A nursing assistant (NA) is assigned to care for a client who had a cemented total knee arthroplasty. Which statement by the NA indicates a need for further teaching and supervision by the nurse? A. "I'll keep an abduction pillow in place at all times." B. "I'll tell the client not to place a pillow under the surgical knee." C. "I'll apply ice packs to decrease swelling in the knee as ordered." D. "I'll check to make sure the client's leg is not rotated."

A

What is the nurse's priority when doing an admission for a client who returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry. B. Check the surgical dressing to ensure that it is intact. C. Assess neurovascular assessment in the affected arm. D. Monitor intake and output.

A

Which assessment findings will the nurse expect for the client with late-stage rheumatoid arthritis? Select all that apply. A. Bony nodes in finger joints B. Subcutaneous nodules C. Severe weight loss D. Joint deformity E. Thrombocytosis

A, B, C, D, E

Which additional assessment data will the nurse collect frterm-25om an older Euro-American (white) woman to determine the client's risk for osteoporosis? Select all that apply. A. Tobacco use, especially smoking B. Alcohol use each day C. Exercise and activity level D. Dietary intake of vitamin D E. Use of calcium supplements F. Medication history

A, B, C, D, E, F

A nurse is performing a musculoskeletal assessment on an older adult living independently. What normal physiologic changes of aging does the nurse expect? Select all that apply. A. Muscle atrophy B. Slowed movement C. Scoliosis D. Arthritis E. Widened gait

A, B, D, E

The primary health care provider prescribes acetaminophen for a client with osteoarthritis. Which health teaching will the nurse provide for the client regarding this drug? Select all that apply. A. "Don't take more than 3000-4000 mg of this drug each day." B. "Stop taking the drug if unusual bleeding occurs and call your primary health care provider." C. "Tell your primary health care provider if you notice any yellowing of your skin or eyes." D. "Expect fluid accumulation in your legs and feet that usually gets worse during the day." E. "Check over-the-counter drugs to see if they contain acetaminophen."

A, C, E

A client had a left anterior total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? Select all that apply. A. "Avoid extending your left hip behind you when you sit." B. "Do not flex your hips more than 90 degrees when toileting." C. "You may cross your legs to be more comfortable in a chair." D. "Avoid twisting your body when moving or performing ADLs." E. "Stand on your right leg and pivot into the chair when getting out of bed."

A, D, E

Describe management of complications of fractures: a. Acute compartment syndrome b. Crush syndrome c. Fat embolism d. Venous thromboembolism e. Infection f. Hypovolemic shock g. Chronic complications

ACUTE COMPARTMENT SYNDROME Increased pressure -> reduced circulation Pain, difficult to control Progressive edema & tightness Impairment to CMS Loss of function/limb tx: fasciotomy CRUSH SYNDROME FAT EMBOLISM Dyspnea, chest pn, dec O2 sats, change in metal acuity, tachycardia, fever, inc. cap permeability (petechiae to axillary/upper body), dx: x-ray tx: like PE INFECTION HYPOVOLEMIC SHOCK Bone is very vascular. Therefore bleeding is a risk with bone injury. CHRONIC COMPLICATIONS Avascular necrosis, delayed bone healing, and chronic regional pain syndrome

A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse's best initial action? A. Remove the splint to reduce skin pressure. B. Perform a neurovascular assessment. C. Report the client's concern to the primary health care provider. D. Inspect the skin under the elastic bandage.

B

A client has a synthetic cast placed for a right wrist fracture in the emergency department. Which priority health teaching is important for the nurse to provide for this client before returning home? Select all that apply. A. "Keep your right arm below the level of your heart as often as possible." B. "Use an ice pack for the first 24 hours to decrease tissue swelling." C. "Move the fingers of the right hand frequently to promote blood flow." D. "Report coolness or discoloration of your right hand to your doctor." E. "Don't place any device under the cast to scratch the skin if it itches."

B, C, D, E

The nurse performs an admission assessment for an older adult following a fractured hip repair. Which priority client assessment findings will require the nurse to collaborate with members of the interprofessional health team? Select all that apply. A. Mild dependent edema in both ankles when sitting B. Chest pain when ambulating with the walker C. Lack of appetite and weight loss D. Report of joint pain at a 8 on a 0-10 intensity scale E. Dry and itchy skin over legs and arms

BCD

The nurse is preparing to give medications to a group of clients. Which drug is not appropriate to treat the disease with which it is matched? A. Rheumatoid arthritis—leflunomide B. Osteoarthritis—acetaminophen C. Acute gout—allopurinol D. Systemic lupus erythematosus—prednisone

C Allopurinol is for chronic gout.

b. Traumatic musculoskeletal injuries including: carpal tunnel syndrome

Causes: RA, positioning/overuse, obesity, females>male s/s: pain, paresthesia, weakness Dx: exam, EMG/NCT Tx: splint, NSAIDs, steroid injections, surgery to decompress nerve

A client returns to the postanesthesia care unit (PACU) after an arthroscopy to repair a knee injury. What is the nurse's priority when caring for this client? A. Perform passive range-of-motion exercises. B. Keep the affected leg immobilized. C. Ensure that the patient uses the patient-controlled analgesia (PCA) pump. D. Check the neurovascular status of the affected leg and foot.

D

A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A. "The pain will go away after the swelling decreases." B. "That's phantom limb pain, and every amputee has that." C. "Your foot has been amputated, so it's in your head." D. "On a scale of 0 to 10, how would you rate your pain?"

D

Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for further teaching by the nurse? A. "I'm going to continue having my DXA scans as my doctor orders." B. "I'll drink only a half glass of wine occasionally to help me sleep." C. "I plan to increase calcium and vitamin D foods in my diet." D. "I'm going to jog every day for at least 30 minutes."

D

Distinguish how culture and social background impact care of the patient experiencing disruption of the musculoskeletal system.

Determine the availability of support systems for the patient. The major support system is typically the family or significant others; those who do not have these support systems are more likely to develop depression. Ask patients what is important to them and gives meaning to their lives. Identify the patient's cultural, spiritual, and/or religious needs and refer to an appropriate health care team member as needed. Assess sexuality and intimacy needs.

b. Traumatic musculoskeletal injuries including: dislocation, subluxation,

Dislocation= Abnormal separation of a joint Subluxation= partial separation sudden trauma can cause trauma to surrounding tissues: tendons, ligaments, muscles, nerves s/s: intense pn, joint instability, deformity, weakness, erythema, bruising, stiffness, guarding confirmed by x-ray. traction used to pull back into place. pre and post reduction films. midazolam sometimes given.

b. Traumatic musculoskeletal injuries including: strain & sprain joint injuries,

Excessive stretching of a ligament 1. RICE 2. Immobilize 3. Immobilize 4-6 weeks; surgery Management: Cold 24-48 hrs, then heat Anti-inflammatory meds Limit activity Muscle relaxants Elevate extremity

b. Traumatic musculoskeletal injuries including: fractures,

FRACTURES: Causes: trauma, osteoporosis, genes Types: Stable: bony ends line up Comminuted: bone shatters >3 places Open/compound: boney end pierces through skin Transverse: horizontal Oblique: angle Compression: bones compress upon each other Tx: immobilize. Preserve function. Health promotion: • Osteoporosis screening and self-management education (see Chapter 50) • Fall prevention (see Chapter 3) • Home safety assessment and modification, if needed • Dangers of drinking and driving • Helmet use when riding bicycles, motorcycles, and other small motorized vehicles/devices Emergency Care of the Patient With an Extremity Fracture 1. Assess the patient's airway, breathing, and circulation and perform a quick head-to-toe assessment. 2. Remove the patient's clothing (cut if necessary) to inspect the affected area while supporting the area above and below the injury. Do not remove shoes because this can cause increased trauma unless the foot or ankle is injured. 3. Remove jewelry on the affected extremity in case of swelling. 4. Apply direct pressure on the area if there is bleeding and pressure over the proximal artery nearest the fracture. 5. Keep the patient warm and in a supine position. 6. Check the neurovascular status of the area distal to the fracture, including temperature, color, sensation, movement, and capillary refill. Compare affected and unaffected limbs. 7. Immobilize the extremity by splinting; include joints above and below the fracture site. Recheck circulation after splinting. 8. Cover any open areas with a dressing (preferably sterile).

d. Back pain

Muscle strain Muscle spasm Disc degeneration Herniated disc Spondylolysis = degeneration of Spinal column Spondylolisthesis = slippage/displacement of one vertebra compared to another Spinal stenosis = abnormal narrowing Compression fx: break in vertebra resulting from pressure. Risks: obesity, smoking, osteoporosis, arthritis, trauma Prevetion: wt control, exercise, body mechanics, ergonomics, posture s/s: pain (constant/intermittent) radiculopathy - dermatomal pattern weakness paresthesia bowel/bladder issues Dx: MRI, CT, Myelogram, EMG, DXA Non-Sug tx: PT, muscle relaxants, antionvulsants, NSAIDs, Opiates, Braces, Steroid injection, massage, acupuncture, chiropractor, TENS, spinal stimulators Surgical tx: Preop: movement restrictions - no BLT, potential complications Types: discectomy, laminectomy, spinal fusion, inter body cage fusion, kyphoplasty Post care: vitals, neuro!, bowel/bladder mgmt, pn mgmt, drain mgmt, log rolling, prevent lung complications (IS), prevent VTE

Nursing Care for Patients Having Vertebroplasty or Kyphoplasty

Provide preprocedure care, including: • Check the patient's coagulation laboratory test results; platelet count should be more than 100,000/mm3. • Make sure that all anticoagulant drugs were discontinued as requested by the physician. • Assess and document the patient's neurologic status, especially extremity movement and sensation. • Assess the patient's pain level. • Assess the patient's ability to lie prone for at least 1 hour. • Establish an IV line in a size suitable for surgery and take vital signs. Provide postprocedure care, including: • Place the patient in a flat supine position for 1 to 2 hours or as requested by the physician. • Monitor and record vital signs and frequent neurologic assessments; report any change immediately to the physician. • Apply an ice pack to the puncture site if needed to relieve pain. • Assess the patient's pain level and compare it with the preoperative level; give mild analgesic as needed. • Monitor for complications such as bleeding at the puncture site or shortness of breath; report these findings immediately if they occur. • Assist the patient with ambulation. Before discharge, teach the patient and family the following: • The patient should avoid driving or operating machinery for the first 24 hours because of drugs used during the procedure. • Monitor the puncture site for signs of infection, such as redness, pain, swelling, or drainage. • Keep the dressing dry and remove it the next day. • The patient should begin usual activities, including walking, the next day and should slowly increase activity level over the next few days.

Chapter 18 Key Points

Safe and Effective Care Environment • Collaborate with the health care team to manage chronic pain and increase MOBILITY for patients with arthritis and other CTDs. • Provide information about community resources for patients, especially professional organizations such as the Arthritis Foundation and Lupus Foundation. • Teach patients to prevent joint trauma and reduce weight as needed to help prevent osteoarthritis. • Recall that a combination of environmental, genetic, and immune risk factors can cause arthritis and other connective tissue diseases. • Reinforce the importance of good health practices such as adequate sleep, proper nutrition, regular exercise, and stress-management techniques for patients with arthritis and other CTDs. • Teach patients with arthritis which exercises to do (Chart 18-5), joint protection techniques (Chart 18-6), and energy conservation guidelines (Chart 18-10). • Remind patients with gout to avoid factors that trigger an attack such as aspirin, organ meats, and alcohol. • Recognize that patients with rheumatoid arthritis (RA) may have body image disturbance as a result of potentially deforming joint involvement and nodules. • Encourage patients with arthritis and connective tissue diseases to discuss their chronic illness and identify coping strategies that have previously been successful. • Be aware that chronic, painful diseases affect the patient's quality of life and role performance. • Be aware that most of the connective tissue diseases and arthritic disorders have a genetic basis as part of their etiology; most are also classified as autoimmune diseases and have remissions and exacerbations. • Differentiate OA as primarily a joint problem that can affect one or more joints and RA as a systemic disease that presents as a bilateral symmetric joint inflammation. • Realize that older patients have OA more than younger patients; younger patients have RA more than older adults. Other differences between the two diseases are summarized in Table 18-1. • Teach patients who have osteoarthritis (OA) or are prone to the disease to lose weight (if obese), avoid trauma, and limit strenuous weight-bearing activities. • Instruct patients with arthritic pain to use multiple modalities for pain relief, including ice/heat, rest, positioning, integrative therapies, and drug therapy as prescribed. • Teach patients to monitor and report side and adverse effects of drugs used to treat OA and other connective tissue diseases. • Assess patients with rheumatoid arthritis for early or late signs and symptoms as listed in Chart 18-7. • Teach patients who are taking hydroxychloroquine to have frequent (every 6 months) eye examinations to monitor for retinal changes. • Remind patients to avoid crowds and other possible sources of infection when they are taking drugs that decrease IMMUNITY. • Implement interventions for patients having total joint arthroplasty (TJA) to prevent venous thromboembolitic complications (e.g., anticoagulants, exercises, sequential compression devices); observe the patient for bleeding when he or she is taking anticoagulants. • Be careful when positioning a patient after a total hip arthroplasty (THA) to prevent dislocation; do not hyperflex the hips or adduct the legs (see Chart 18-3). • Be aware that disease-modifying antirheumatic drugs (DMARDs) and biological response modifiers (BRMs) slow the progression of connective tissue diseases, especially RA and SLE. • Teach patients receiving BRMs and other disease-modifying agents to avoid crowds and people with infections; opportunistic pathogens may cause serious infections or death. Check the patient's PPD test or history of tuberculosis before starting any of these drugs (see Chart 18-9). • Monitor and interpret laboratory test results for patients with autoimmune connective tissue diseases as highlighted in Chart 18-8. • Prioritize care by assessing for swallowing ability in patients who have SSc; collaborate with the dietitian for food modifications if needed. • Monitor for acute joint pain and inflammation in patients with a history of gout; the great toe and other small joints are most typically affected. • Be aware that arthritis often accompanies other diseases such as psoriasis and Crohn's disease.

Chapter 6: Key Points

Safe and Effective Care Environment • Recall that rehabilitation is the process of learning to live with chronic and disabling conditions; the role of the rehabilitation nurse is outlined in Table 6-1. • Collaborate with members of the interprofessional rehabilitation team, including physicians, nurse practitioners, staff nurses, physiotherapists, occupational therapists, dietitians, and speech/language pathologists; the patient and family are the center of and members of the team. QSEN: Teamwork and Collaboration • Know that acute (short-term) rehabilitation care occurs in a variety of settings, including inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) in either a nursing home or hospital. Health Care Organizations • Delegate and supervise selected nursing tasks such as reporting reddened skin areas as part of quality care for the rehabilitation patient. • After assessing the home environment, the case manager, OT, and/or rehabilitation nurse make recommendations to the patient and family about home modifications. QSEN: Teamwork and Collaboration • Use evidence-based safe patient handling practices such as using mechanical lifts and working with other team members when assessing and moving patients to prevent injury and improve mobility. QSEN: Evidence-Based Practice; Safety • Recall that the rehabilitation therapists teach patients transfer, bed mobility, and gait training techniques (see Chart 6-1). • Encourage the patient to be as independent as possible when performing ADLs and safe mobility skills. Health Promotion and Maintenance • In coordination with the PT and OT, assess the patient's ability to perform ADLs, IADLs, and MOBILITY skills using a functional assessment process. QSEN: Teamwork and Collaboration • Prevent complications of immobility for clients, and teach them how to prevent complications by using interventions discussed in Chapter 2. Examples include pressure injuries, urinary calculi, constipation, and venous thromboembolism. QSEN: Evidence-Based Practice Psychosocial Integrity • Assess the patient's self-esteem and changes in body image caused by chronic or disabling health problems. • Assess the patient's COGNITION to screen for depression, delirium, and dementia using tools such as the Confusion Assessment Method (CAM), especially for older adults. QSEN: Safety • Assess the patient's and family's response to chronic and disabling conditions, including feelings of loss and grief. • Assist patients in coping with their loss and assess the availability of support systems, especially for older adults. QSEN: Patient-Centered Care Physiological Integrity • Assess rehabilitation patients as outlined in Table 6-2 to help plan appropriate collaborative care. • Review the Functional Independence Measure (FIM) system as one tool used to assess functional ability of the patient in rehabilitation, including the need for assistive/adaptive devices. • Assess patients in rehabilitation for risk factors that make them likely to develop skin breakdown; interventions to prevent skin problems include repositioning and adequate NUTRITION. QSEN: Quality Improvement • Patients with neurogenic bladder and bowel ELIMINATION problems are managed by training programs; overactive (spastic or reflex) and underactive (hypotonic or flaccid) elimination problems are managed differently (see Tables 6-5 and 6-6). • In collaboration with the rehabilitation therapists, evaluate the ability of clients to use assistive/adaptive devices to promote independence. QSEN: Teamwork and Collaboration • Determine patient and family needs regarding discharge to home or other community-based setting.

Stages of bone healing

Stages of Bone Healing When a bone is fractured, the body immediately begins the healing process to repair the injury and restore the body's equilibrium. Fractures heal in five stages that are a continuous process and not single stages. • In stage one, within 24 to 72 hours after the injury, a hematoma forms at the site of the fracture because bone is extremely vascular. • Stage two occurs in 3 days to 2 weeks when granulation tissue begins to invade the hematoma. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. • Stage three of bone healing occurs as a result of vascular and cellular proliferation. The fracture site is surrounded by new vascular tissue known as a callus (within 3 to 6 weeks). Callus formation is the beginning of a nonbony union. • As healing continues in stage four, the callus is gradually resorbed and transformed into bone. This stage usually takes 3 to 8 weeks. • During the fifth and final stage of healing, consolidation and remodeling of bone continue to meet mechanical demands. This process may start as early as 4 to 6 weeks after fracture and can continue for up to 1 year, depending on the severity of the injury and the age and health of the patient. Fig. 51-2 summarizes the stages of bone healing.

Describe nursing care of patient with immobilization devices: a. Traction b. External fixators c. Casts d. Halo devices

primary nursing concern is assessment and prevention of neurovascular dysfunction or compromise. Assess and document the patient's neurovascular status every hour for the first 24 hours and every 1 to 4 hours thereafter TRACTION monitor O2. rub the patient's sternum and encourage him or her to breathe Use pressure-reduction measures and monitor for indications of impaired TISSUE INTEGRITY. Pin site care is also an important part of nursing management to prevent infection. Keep pin sites clean and document the nature of any drainage. Check traction equipment frequently to ensure its proper functioning When patients are in traction, weights usually are not removed without a prescription. They should not be lifted manually or allowed to rest on the floor. Weights should be freely hanging at all times. Teach this important point to unlicensed assistive personnel (UAP) on the unit, to other personnel such as those in the radiology department, and to visitors. Inspect the skin at least every 8 hours for signs of irritation or inflammation. When possible, remove the belt or boot that is used for skin traction every 8 hours to inspect under the device. EXTERNAL FIXATORS pay particular attention to the pin sites for signs of inflammation or infection CASTS Check to ensure that any type of cast is not too tight and frequently monitor and document neurovascular status—usually every hour for the first 24 hours after application if the patient is hospitalized. You should be able to insert a finger between the cast and the skin. Teach the patient to apply ice for the first 24 to 36 hours to reduce swelling and inflammation. HALO DEVICES

Describe etiology, epidemiology, pathophysiology, clinical manifestations & management of the following musculoskeletal disorders: a. Degenerative joint disease including osteoarthritis

progressive deterioration and loss of cartilage and bone in one or more joints Risk factors: Aging Genetic factor (possible) Obesity Trauma Occupation Female (2 : 1) May be unilateral, single joint Affects weight-bearing joints and hands, spine Metacarpophalangeal joints spared Nonsystemic Drug tx: NSAIDs (short-term use), Acetaminophen, Other analgesics Health Promotion and Maintenance Based on the etiology of OA, teach patients to: • Maintain proper nutrition to prevent obesity. • Take care to avoid injuries, especially those that can occur from professional or amateur sports. • Take adequate work breaks to rest joints in jobs where repetitive motion is common. • Stay active and maintain a healthy lifestyle. Teach the patient to position joints in their functional position

Describe the prevention, recognition and treatment of complications of immobilization

skin breakdown, pneumonia, atelectasis, thromboembolism, and constipation, contractures

Apply principles of infection control when caring for patients with musculoskeletal disorders.

wash hands

Chapter 50: Key Points

• Collaborate with interprofessional team members when assessing patients with osteoporosis for risk for falls. • Teach the patient with CELLULAR REGULATION problems (e.g., osteoporosis) and his or her family about evidence-based home safety modifications and the need to create a hazard-free environment. • Refer to The Joint Commission for information about National Patient Safety Goals related to fall injury prevention. • Develop a teaching plan for patients at risk for osteoporosis to minimize risk factors, such as stopping smoking, decreasing alcohol intake, exercising regularly, and increasing dietary calcium and vitamin D foods; for many patients, calcium and vitamin D supplementation is needed to achieve normal serum levels (see Chart 50-1). • Remind patients at risk for osteoporosis to have regular screening tests, such as the DXA scan, as needed. • Refer patients with musculoskeletal problems to appropriate community resources, such as the National Osteoporosis Foundation (NOF). • Recognize that osteoporosis can be primary or secondary (see Table 50-2). Remind patients taking bisphosphonates (BPs) to take them early in the morning, at least 30 to 60 minutes before breakfast, with a full glass of water, and to remain sitting upright during that time to prevent esophagitis, a common complication of BP therapy (also see Chart 50-2). • Recall that most patients are unaware that they have osteoporosis until they experience a fracture, the most common complication of the disease. • Recognize that patients with osteopenia and osteoporosis usually have decreased calcium and vitamin D levels. • Assess for signs and symptoms of osteomyelitis as outlined in Chart 50-3. • Use clinical judgment to prioritize care for patients with osteomyelitis, including maintaining Contact Precautions for open wounds. For patients having surgical intervention, assess the affected extremity for neurovascular status to ensure adequate tissue PERFUSION. • In collaboration with the health care team (physical therapist, occupational therapist, neurologist), provide supportive care for patients with bone cancer to improve MOBILITY and function.

Chapter 51: Key Points

• Collaborate with physical and occupational therapists for care of patients with fractures to improve MOBILITY and muscle strength. • Remember that the priority care for patients with fractures and amputations is to maintain PERFUSION, improve COMFORT, and prevent impaired MOBILITY. • Monitor for potentially life-threatening complications of fractures, including hemorrhage, venous thromboembolism, fat embolism syndrome, acute compartment syndrome, and infection (see Charts 51-1 and 51-2). • Teach people to avoid musculoskeletal injury by treating or preventing osteoporosis (see Chapter 50), being cautious when walking to prevent a fall, wearing supportive shoes, avoiding dangerous sports or activities, and decreasing time spent doing repetitive stress activities, such as using a computer keyboard. • Several community organizations, such as the Amputee Coalition of America, are available to help patients and their families cope with the loss of a body part. • Teach patients and their family members and significant others how to care for casts or traction at home. • In collaboration with the interprofessional health team, reinforce teaching for ambulating with crutches, walkers, or canes; and teach exercises to patients with leg amputation to prevent hip flexion contractures. • Provide special care for older adults with hip fractures, including preventing heel pressure injuries and promoting early ambulation to prevent complications of immobility. • For patients with severe trauma or amputation, assess coping skills and encourage verbalization. • Recognize that the patient having an amputation may need to adjust to an altered lifestyle but can be active and productive. • Be aware that open fractures cause a higher risk for infection than do closed fractures; use strict aseptic technique when providing wound management. • Recognize that fat embolism syndrome is different from pulmonary (blood clot) embolism as outlined in Chart 51-2. • Provide emergency care of the patient with a fracture as described in Chart 51-4. • Identify the patient at risk for acute compartment syndrome; loosen bandages or request that the patient's cast be cut if neurovascular compromise is assessed; notify the health care provider immediately. • As a priority, document neurovascular status frequently in patients with musculoskeletal injury, traction, or cast as described in Chart 51-3 and manage impaired comfort adequately. • Provide evidence-based appropriate cast care, depending on the type of cast (plaster or synthetic); check for pressure necrosis under the cast by feeling for heat, assessing the patient's pain level, and smelling the cast for an unpleasant odor. • Provide pin care for patients with skeletal traction or external fixation; assess for signs and symptoms of infection at the pin sites. • Provide postoperative care for the patient having a fracture repair, including promoting MOBILITY and monitoring for complications of immobility. • Provide evidence-based care for patients having a vertebroplasty or kyphoplasty as described in Chart 51-6. • Provide emergency care for a patient having a traumatic amputation in the community. Call 911, assess the patient for ABCs, apply direct pressure on the amputation site, and elevate the extremity above the patient's heart to decrease bleeding. For finger parts, wrap the amputated part with a clean cloth and place in a sealed bag, which is lowered into ice water. • After surgery, assess for and promptly manage phantom limb pain in the patient who has an amputation; collaborate with specialists to incorporate complementary and integrative therapies and drug therapy into the patient's plan of care. • Assess and document neurovascular status frequently after an endoscopic carpal tunnel release. • Assess for and manage chronic regional pain syndrome (CRPS) in patients who have fractures or fracture repair. • Provide emergency care for patients with a sports-related injury as outlined in Chart 51-8. • Recall that carpal tunnel syndrome (CTS) is the most common type of repetitive stress injury (RSI) caused by certain occupations such as computer operators and factory workers. • Many acute musculoskeletal injuries are initially treated by RICE: rest, ice, compression, and elevation. • The priority for managing complex regional pain syndrome (CRPS) is prompt and effective pain relief. Consult with PT, OT, and the pharmacist/pain specialist to determine the most effective pain management plan based on the patient's and family's preferences, values, and beliefs.

Chapter 49: Key Points Review

• Collaborate with the physical and/or occupational therapist to perform a complete musculoskeletal assessment, including gait, muscle strength, COMFORT, and MOBILITY, as indicated. QSEN: Teamwork and Collaboration Health Promotion and Maintenance • Be aware that older adults have physiologic changes that affect their musculoskeletal system, such as decreased bone density and joint cartilage degeneration; plan nursing interventions to ensure patient safety (see Chart 49-1). • Recall that potential patient reactions to musculoskeletal trauma or disease can include anxiety, depression, and/or altered body image and self-concept. • Assess the patient's COMFORT level, including pain intensity, quality, duration, and location. • Assess and interpret the patient's MOBILITY, including gait, posture, and muscle strength status. Clinical Judgment • Interpret the patient's laboratory values that are related to musculoskeletal disease (see Chart 49-2). • Teach the patient that mild impaired COMFORT can be expected during electromyography, a test to assess the electrical potential of muscles and their innervation. • Instruct the patient to report swelling, infection, and increased pain after an arthroscopy. • Ask the patient questions to ensure safety before an MRI (see Chart 49-3). QSEN: Safety • Ask the patient about allergy to contrast media before diagnostic testing such as CT scans. • Evaluate the neurovascular status of the patient's affected extremity after an arthroscopic procedure as the priority for care. QSEN: Safety