Unit 8 Musculoskeletal
Grade 2 open fx
is a larger wound w/o extensive soft tissue damage or avulsions
Grade 3 open fx
is highly contaminated and has extensive soft tissue damage. It may be accompanied by traumatic amputation and is the most severe
CRPS nursing mangement
prevention is elevation of extremity after injury or surgery and selection of an immobilization site.
How often should the nurse assess the pin site for skeletal traction?
q 8 hrs at least for signs of inflammation and infection
Which of the following terms refers to an injury to ligaments and other soft tissues of a joint? a) Strain b) Subluxation c) Dislocation d) Sprain
sprain
Most common symptoms of osteomalacia is?
bone pain and tenderness
What is the bandage used for after an amputation?
-To control hemorrhage and bleeding and to contour the stump for prosthesis.
What are three medications that tx Paget's disease?
1.)Calcitonin 2.)biophosphates 3.)plicamycin
What are some complications of amputations?
Hemorrhage, infection, skin breakdown, phantom limb pain.
Lab studies of osteomalacia show
Low serum calcium and phosphorous levels and a moderately elevated ALP. Urine excretion of calcium and creatinine is low.
After bivalving a cast how do you position the extremity?
The extremity is elevated (but no higher than the heart level) to minimize the effect of gravity on perfusion of the tissues
Nursing management directly after an amputation includes?
- elevate extremity for the 1st 24 hrs (helps with bleeding and swelling) After this take pillow out b/c they are at high risk for contractures. Put in prone position to prevent contractures. -will have ace bandage to prevent bleeding and edema and a limb sock
Top 3 nursing diagnosis following amputation surgery
1.)risk for infection 2.)Pain 3.)Skin integrity
What should you ask pt before performing an EMG? (contradictions)
Are you taking anticoagulants? Do you have a skin infection?
Which action would be most important postoperatively for a client who has had a knee or hip replacement?
Assisting in early ambulation
When an infection is blood borne the manifestations include which of the following symptoms? a) Chills b) Hyperactivity c) Hypothermia d) Bradycardia
Chills Explanation: Manifestations include chills, high fever, rapid pulse, and generalized malaise
What are s/s of fat embolism?
Classic triad includes Hypoxemia, neurologic compromise, and a petechial rash. Typically first symptoms are pulmonary that include hypoxia and tachypnea . Other symptoms include crackles, wheezes, precordial chest pain, cough, large amount of thick white sputum, and tachycardia. X-ray will show "snow storm infiltrate". Acute pulmonary edema, acute respiratory distress, and HF may develop. May have headache and mild agitation to delirium and coma.
Grade 1 open fx
Clean wound less than 1cm
Prevention of fat embolism
Immediate immobilization of fractures, including early surgical fixation, minimal fx manipulation, and adequate support for fractured bone during turning and positioning.
Which of the following orthopedic surgeries is done to correct and align a fracture after surgical dissection and exposure of the fracture? a) Joint arthroplasty b) Open reduction c) Total joint arthroplasty d) Arthrodesis
Open reduction Correct Explanation: An open reduction is the correction and alignment of the fracture after surgical dissection and exposure of the fracture. Arthrodesis is immobilizing fusion of a joint. A joint arthroplasty or replacement is the replacement of joint surfaces with metal or synthetic materials. A total joint arthroplasty is the replacement of both the articular surfaces within a joint with metal or synthetic materials
Which of the following statements is accurate regarding care of a plaster cast? a) A dry plaster cast is dull and gray. b) The cast can be dented while it is damp. c) The cast will dry in about 12 hours. d) The cast must be covered with a blanket to keep it moist during the first 24 hours.
The cast can be dented while it is damp. Explanation: The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding.
Which type of fracture involves a break through only part of the cross-section of the bone? a) Oblique b) Comminuted c) Open d) Incomplete
incomplete
What do biophosphates do?
increase bone mass and decrease bone loss by inhibiting osteoclast function
Clinical manifestations of CRPS
severe burning pain, hyperesthesia, local edema, stiffness, discoloration, vasomotor skin changes (i.e. fluctuating warm, red, dry and cold, sweaty, cyanotic) and trophic changes that may include glossy, shiny skin and increased hair and nail growth. Disuse muscle atrophy and bone deossification may occur.
A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care? a) "Keep your right leg elevated above heart level." b) "Use a knitting needle to scratch itches inside the cast." c) "A foul smell from the cast is normal." d) "Cover the cast with a blanket until the cast dries.
"Keep your right leg elevated above heart level." Correct Explanation: The nurse should instruct the client to elevate the leg to promote venous return and prevent edema. The cast shouldn't be covered while drying. Covering the cast will cause heat buildup and prevent air circulation. The client should be instructed not to insert foreign objects into the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection
What are the 2 mainobjectives of management for an open fx?
1.)prevent infection of the wound, soft tissue, and bone 2.) Promote healing of the bone -to prevent infection IV antibiotics are administered immediately and tetanus shot is given. The extremity is elevated to minimize edema
What are 3 significant characteristics of osteoporosis?
1.)reduced bone density 2.)deterioration of bone matrix 3.)diminished bone architectural strength
What hormone inhibits bone reabsorption and increases calcium deposit in the bone?
Calcitonin Calcitonin, secreted by the thyroid gland in response to elevated blood calcium levels, inhibits bone reabsorption and increases the deposit of calcium in the bone. The other answers do not apply. (less)
Which medication directly inhibits osteoclasts thereby reducing bone loss and increasing BMD? a) Vitamin D b) Raloxifene (Evista) c) Teriparatide (Forteo) d) Calcitonin (Miacalcin
Calcitonin (Miacalcin) Correct Explanation: Miacalcin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Evista reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Forteo has been recently approved by the FDA for the treatment of osteoporosis.
The primary deficit in osteromalacia is?
Deficiency in Vit D (calcitrol) which promotes calcium absorption from the GI tract
The client diagnosed with osteosarcoma is scheduled for a surgical amputation. Which nursing diagnosis would be a priority for this client compared with other surgical clients? a) Disturbed body image b) Inadequate nutrition c) Impaired physical mobility d) Risk for infection
Disturbed body image Explanation: Amputation of a body part can result in disturbances in body image.
A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient? a) Spontaneous pneumothorax b) Fat emboli c) Pneumonia d) Cardiac tamponade
Fat emboli Explanation: After fracture of long bones or pelvic bones, or crush injuries, fat emboli frequently form. Fat embolism syndrome (FES) occurs when fat emboli cause morbid clinical manifestations. The classic triad of clinical manifestations of FES include hypoxemia, neurologic compromise, and a petechial rash (NAON, 2007), although not all signs and symptoms manifest at the same time (Tzioupis & Giannoudis, 2011). The typical first manifestations are pulmonary and include hypoxia and tachypnea. Usually are from long bone injuries and crushing injuries. Occurs most frequently in men younger than 40
A 39-year-old softball player has been brought to the ED by his teammates. The client was fielding a fly ball, fell, and injured his hip. He cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would you expect the physician to perform? a) Heat and immobilization b) Joint manipulation and immobilization c) Ice and immobilization d) Analgesia and immobilizatio
Joint manipulation and immobilization Explanation: The physician manipulates the joint or reduces the displaced parts until they return to normal position, then immobilizes the joint with an elastic bandage, cast, or splint for several weeks
Which of the following terms refers to failure of fragments of a fractured bone to heal together? a) Dislocation b) Subluxation c) Nonunion d) Malunion
Nonunion Explanation: When nonunion occurs, the patient complains of persistent discomfort and movement at the fracture site. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Malunion refers to growth of the fragments of a fractured bone in a faulty position, forming an imperfect union
A client's fracture was reduced by surgically exposing the bone and realigning it. The nurse identifies this as which of the following? a) Open reduction b) Buck's traction c) Internal fixation d) Skeletal traction
Open reduction Correct Explanation: In an open reduction, the bone is surgically exposed and realigned. Buck's traction is a type of skin traction that provides pulling on the structures. Skeletal traction is applied directly to the bone using a wire, pin, or cranial tongs. Internal fixation involves the use of metal screws, plates, rods, nails or pins to stabilize a reduced fracture.
An instructor is describing the process of bone development. Which of the following would the instructor describe as being responsible for the process of ossification?
Osteoblasts
What is a early hallmark sign of compartment syndrome?
Pain that intensifies with passive ROM due to accumulation of fluid in the vascular space.
A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall?
Pathologic fracture
Which nursing diagnosis takes highest priority for a client with a compound fracture? a) Risk for infection related to effects of trauma b) Impaired physical mobility related to trauma c) Imbalanced nutrition: Less than body requirements related to immobility d) Activity intolerance related to weight-bearing limitations
Risk for infection related to effects of trauma Explanation: A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.
A client is about to have a cast applied to his left arm. The nurse would alert the client to which of the following as the cast is applied? a) Sensation of weakness b) Arm being moved to various positions c) Sensation of warmth or heat with application d) Increased in pain in left arm
Sensation of warmth or heat with application Correct Explanation: When a cast is applied, the client needs to be aware that he may feel a sensation of warmth or heat due to the material being mixed with water. The client should not feel an increase in pain during the application. The arm will be held in place to ensure proper alignment during the application. The client should not feel weakness in the extremity. This is more commonly experiences after a cast is removed
Which of the following would the nurse expect a physician to use on a short-term basis for a client with an injured body part that does not require rigid immobilization? a) Brace b) Splint c) Skin traction d) Cast
Splint Explanation: A splint immobilizes and supports an injured body part in a functional position and is used when the condition does not require rigid immobilization, causes a large degree of swelling, or requires special skin treatment. Casts and traction provide rigid immobilization. A brace provides support, controls movement, and prevents additional injury for more long-term use
In chronic osteomyelitis, antibiotics are adjunctive therapy in which of the following situations? a) Wound packing b) Surgical debridement c) Wound irrigation d) Vitamin supplements
Surgical debridement Explanation: In chronic osteomyelitis, antibiotics are adjunctive therapy to surgical debridement.
When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the patient is likely demonstrating signs of a) avascular necrosis of bone. b) heterotrophic ossification. c) complex regional pain syndrome. d) a reaction to an internal fixation device.
complex regional pain syndrome. Explanation: CRPS is frequently chronic and occurs most often in women. Avascular necrosis is manifested by pain and limited movement. Pain and decreased function are the prime indicators of reaction to an internal fixation device. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement
Which of the following may occur if a client experiences compartment syndrome in an upper extremity? a) Subluxation b) Volkmann's contracture c) Callus d) Whiplash injury
olkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation
Management of fat embolism
prompt resp support Oxygen started on 100% high flow oxygen and ventilation with PEEP for pulmonary edema may be provided. May use corticosteroids for inflammation and Vasopressors medication to support CV function. Record I&O. *it is managed by maintaining the extremity at the heart level and opening and bivalving the cast, or opening the splint, if one or the other is present. If this does not relieve the pain in one hr a fasciotomy (surgical decompression with excision of the fascia) is indicated to relieve the. *
What is disuse syndrome?
the deterioration of body systems as a result of prescribed or unavoidable MS inactivity. To prevent this do isometric exercises.
A client presents to the emergency department gently holding the left arm, which is slightly swollen and painful to the touch. Based on these findings, the nurse:
Elevates the arm and applies an ice pack Explanation: Treatment of strains and sprains consists of resting and elevating the affected part, applying ice for the first 24 to 48 hours, and applying a compression dressing.
Hypovolemic shock resulting from hemorrhage is more frequently noted in trauma pts with ___________ fractures.
Pelvic
A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct? a) To prevent fractures, the client should avoid strenuous exercise. b) Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. c) Obtaining the recommended daily allowance of calcium requires taking a calcium supplement. d) The recommended daily allowance of calcium may be found in a wide variety of foods.
The recommended daily allowance of calcium may be found in a wide variety of foods. Correct Explanation: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary
Which of the following statements describes external fixation? a) The surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. b) The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. c) The bone is restored to its normal position by external manipulation. d) The bone is surgically exposed and realigned.
The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. Explanation: In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In internal fixation, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. In closed reduction, the bone is restored to its normal position by external manipulation. In open reduction, the bone is surgically exposed and realigned.
A client has undergone arthroscopy. After the procedure, the site where the arthroscope was inserted is covered with a bulky dressing. The client's entire leg is also elevated without flexing the knee. What is the appropriate nursing intervention required in caring for a client who has undergone arthroscopy? a) Provide a gentle massage. b) Apply a cold pack at the insertion site. c) Assist with performing ROM exercises. d) Apply warm compresses to the insertion site.
Apply a cold pack at the insertion site. Correct Explanation: After covering the arthroscope insertion site with a bulky dressing and elevating the client's entire leg, the nurse needs to apply a cold pack at the site to minimize any chances of swelling
A group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify which of the following as an example of skin traction? a) Buck's b) Balanced suspension c) Thomas splint d) Crutchfield tongs
Buck's
What are the first line meds to tx and prevent osteoporosis?
Ca, vit d supplements, biophosphates
Which nursing intervention is appropriate for minimizing muscle spasms in the client with a hip fracture? a) Apply a soft compression dressing. b) Assist the client with use of a trapeze. c) Maintain the internal fixator. d) Maintain Buck's traction.
Maintain Buck's traction
A patient arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the patient to describe the pain? a) Sharp and piercing b) A dull, deep, boring ache c) Similar to "muscle cramps" d) Sore and aching
Sharp and piercing Correct Explanation: The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the patient to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.