Chapter 62 Musculoskeletal Trauma and Orthopedic Surgery

Which statement given by the nurse is true about the removal of degenerated menisci from a joint? 1 "The surgical procedure does not require hospitalization." 2 "Activity is restricted until 72 hours after the surgical procedure." 3 "Passive flexion exercises with a continuous passive motion are recommended." 4 "Perform an isometric muscle-strengthening exercise regimen within the confines of immobilization devices."

Answer: 1 Debridement is the removal of degenerative debris such as loose bodies, osteophytes, joint debris, and degenerated menisci from a joint. This surgical procedure does not require hospitalization. Excessive activity is restricted until 48 hours after the surgical procedure. Passive flexion exercises with a continuous passive motion are recommended during knee arthroplasty. An isometric muscle-strengthening exercise regimen is encouraged within the confines of an immobilization device to reduce muscle atrophy.

Which complication is being addressed when the nurse assists the patient with physical therapy exercises following shoulder surgery? 1 Fibrosis 2 Fat embolism 3 Thromboembolism 4 Compartment syndrome

Answer: 1 Frozen shoulder, or fibrosis of the shoulder capsule, can be prevented by physical therapy after the surgery. Drug therapy is a management technique for fat embolism. Anticoagulants are used as both prevention and treatment for thromboembolism. Compartment syndrome can be prevented through proper assessment techniques and rapid surgical intervention.

Which joint surgery involves removing a slice of bone? 1 Osteotomy 2 Arthroplasty 3 Synovectomy 4 Debridement

Answer: 1 Osteotomy is the removal of a slice of bone to change the alignment of the joint and to improve weight-bearing capacity. Arthroplasty is the reconstruction or replacement of a joint to relieve pain, improve or maintain a range of motion, and correct deformity. Synovectomy is the removal of synovial membrane. It is used as a prophylactic measure and as a palliative treatment for rheumatoid arthritis (RA). Debridement is the removal of degenerative debris such as loose bodies, osteophytes, joint debris, and degenerated menisci from a joint.

An osteoarthritis patient with consistent knee pain undergoes an osteotomy. What would be an expected finding during the postoperative period? 1 Relief from pain 2 Decreased mobility 3 Free movement of the joint 4 Deformity correction of the joint

Answer: 1 When an osteotomy is performed on a patient with osteoarthritis, surgery provides relief from the pain. Mobility is improved after the surgery. A joint cannot be moved as freely after surgery as compared to before the surgery. Deformity can be corrected with a replacement surgery.

The nurse assesses a patient in the preoperative holding area before total hip arthroplasty (THA). The nurse discusses the expected hospital course with the patient and family. Which are important points to discuss with the patient and family before surgery? Select all that apply. 1 The presence of any skin infections 2 Ensuring the procurement of home services 3 Pain tolerance and management preferences 4 Previous medical diagnoses and complications 5 Ensuring the patient has taken his or her Coumadin

Answer: 1, 2, 3, 4 Preoperative management of the THA patient focuses on minimizing postoperative complications. Home care services should be discussed preoperatively in order to be in place at the time of discharge. The nurse will discuss prior medical diagnoses and complications such as venous thromboembolism to prevent this postoperatively. Pain is a large part of any postoperative treatment plan and discussing preferences preoperatively may facilitate improved pain control postoperatively. Patients undergoing surgery should be free of any infection or inflammation, so it is important to note any skin infections anywhere on the body. Patients receiving Coumadin or other anticoagulation therapy usually restart anticoagulation postoperatively, although dosing strategies differ depending on the anticoagulant. This patient would not have taken Coumadin prior to the surgery to reduce the risk for hemorrhage.

A patient with a nonunion of the tibia receives repair via an external fixation. What signs in the patient may indicate infection around the fixator pins? Select all that apply. 1 Pain at the pin site 2 Exudate from the pin site 3 Pin looseness 4 Edema around the pin 5 Pale skin around the pin

Answer: 1, 2, 4 External fixation is often used as an attempt to salvage extremities that otherwise might require amputation. Because the use of an external device is a long-term process, ongoing assessment for pin loosening and infection is critical. Infection is indicated by the presence of pain, exudates, and edema around the pin site. Pin looseness does not indicate infection. In the presence of infection, the skin around the pin site is red (erythematous), not pale.

A patient will undergo debridement of the shoulder joint. After the nurse explains the procedure, the patient asks the nurse what will be removed from the joint. How should the nurse answer? Select all that apply. 1 Joint debris 2 Osteophytes 3 A wedge of bone 4 Synovial membrane 5 Degenerated menisci

Answer: 1, 2, 5 The procedure of debridement involves removing from a joint any devitalized tissue, such as loose bodies, joint debris, degenerated menisci, and osteophytes. This procedure is usually performed on the knee or the shoulder using a fiber optic arthroscope. Removal of synovial membrane is called synovectomy. The removal of a wedge of bone is called osteotomy.

The registered nurse is teaching the student nurse about the aim of surgical procedures on common joints. Which understanding of the student nurse indicates the need for further teaching? 1 Correcting deformity 2 Relieving acute pain 3 Improving joint motions 4 Removing intraarticular erosion

Answer: 2 The alleviation of acute pain would need a pharmacologic therapy. Surgery is aimed at relieving chronic pain, not acute pain. Deformities of the joints are corrected by surgery. Surgery improves joint motion because surgical procedures correct the immobility of joint. Intraarticular erosion is removed with the help of surgery.

While completing an admission history for a patient with osteoarthritis admitted for knee arthroplasty, the nurse asks about the patient's perception of the reason for the admission. The nurse expects the patient to relate which response to this question? 1 Recent knee trauma 2 Debilitating joint pain 3 Repeated knee infections 4 Onset of "frozen" knee joint

Answer: 2 The most common reason for knee arthroplasty is debilitating joint pain despite attempts to manage it with exercise and drug therapy. Recent knee trauma, repeated knee infections, and onset of "frozen" knee joint are not primary indicators for a knee arthroplasty.

A patient with a hip fracture has symptoms such as severe pain and tenderness around the fractured area. What is the prioritized treatment goal following hip arthroplasty? 1 Avoiding adduction of hip 2 Receiving relief from the pain 3 Participating in exercise therapy 4 Understanding the treatment plan

Answer: 2 After a hip arthroplasty, the priority of the treatment is to relieve pain to the patient's stated comfort goal. Abduction, not adduction, of the hip should be maintained postoperatively to avoid displacement of the hip. A physical therapist introduces exercise therapy gradually to restore muscle tone. Quadriceps and muscles about the hip are essential to improve function and range of motion. It is important for the patient to understand and follow the prescribed plan of treatment for a speedy recovery.

A patient has undergone amputation just below the level of the elbow in the right upper limb. The patient states that there is still the sensation of pain in the missing portion one day after surgery. What should the nurse inform the patient? 1 You are having illusions. 2 It is normal to feel this way. 3 You are having hallucinations. 4 You are experiencing delusions.

Answer: 2 After an amputation, the patient may still feel the presence of the amputated part. The nurse should explain to the patient that it is normal to feel this way. This phenomenon, termed phantom limb sensation, occurs in many amputees. Such a sensation is not illusion, delusion, or hallucination.

A patient with osteoarthritis is preparing for a total left-knee arthroplasty. The nurse assesses the patient carefully to be sure that there is no evidence of which sign in the preoperative period? 1 Pain 2 Infection 3 Immobility 4 Inflammation

Answer: 2 It is critical that the patient be free of infection before a total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring extensive surgery. For this reason, the nurse monitors the patient for signs of infection, such as redness, swelling, fever, and increased white blood cell count. Pain, immobility, and inflammation are common findings in the patient with osteoarthritis and would not be contraindications to surgery.

Which postoperative drug class is used in the pain management of joint surgical procedures? 1 Antibiotics 2 Oral opioids 3 Anticoagulants 4 Corticosteroids

Answer: 2 Oral opioids are part of the pharmacologic therapy to manage pain after joint surgical procedures. Antibiotics treat infection after surgery. Anticoagulants treat thromboembolism. Corticosteroids treat fat embolism.

What is the duration of hospitalization for hip arthroplasty? 1 One to two days 2 Three to five days 3 Two to four weeks 4 Six to twelve weeks

Answer: 2 The duration of a hospital stay after hip arthroplasty is three to five days, depending on the patient's course and need for physical therapy. The patient would not recover in one or two days. Two to four weeks or six to twelve weeks of hospitalization would be unnecessary.

The nurse is completing discharge teaching with a patient who has undergone total knee arthroplasty. Which statement would indicate the need for additional teaching? 1 "I will increase intake of vitamins and minerals." 2 "I should expect that my knee may change shape." 3 "I should continue physical therapy as prescribed." 4 "I will report pain or swelling to the health care provider."

Answer: 2 The patient should report a change in the shape of the knee, which could signal the onset of complications. Reporting pain or swelling, continuing physical therapy, and supplementing vitamins and minerals are all correct.

An occupational health nurse is conducting an awareness program to prevent limb amputations. When explaining the risk of amputation, which population group would the nurse indicate as at high risk for amputation? Select all that apply. 1 Patients with ulcerative colitis 2 Patients with diabetes mellitus 3 Patients with myasthenia gravis 4 Patients with chronic osteomyelitis 5 Patients with peripheral vascular disease

Answer: 2, 4, 5 Patients with diabetes mellitus, chronic osteomyelitis, or peripheral vascular disease are predisposed to increased risk of amputation. Controlling these diseases can eliminate or delay the need for amputation. Ulcerative colitis and myasthenia gravis do not lead to gangrene in the limbs or to amputation.

A patient status post right total knee arthroplasty has a prescription to get out of bed to the chair. Which action would the nurse take to protect the knee joint while carrying out the prescription? 1 Use a walker and two-person transfer technique. 2 Transfer the patient to the chair using a mechanical lift. 3 Ensure a knee immobilizer is in place and elevate the leg while sitting. 4 Ask the physical therapist to assist to limit weight bearing while the patient gets out of bed.

Answer: 3 The nurse should apply a knee immobilizer for stability before helping the patient out of bed. This is a standard measure to protect the knee during movement after surgery. A mechanical lift would not be necessary, because the patient can fully weight bear on the unaffected leg. A walker and assistance from the physical therapist may be considered, but the priority action would be to stabilize the knee and elevate it while sitting.

The registered nurse is teaching the student nurse about an ideal candidate for shoulder replacement surgery. Which statement made by the student nurse indicates effective learning? 1 "A patient with acute pain and a history of osteoarthritis" 2 "A patient with acute pain and a history of rheumatoid arthritis" 3 "A patient with severe pain and a history of rheumatoid arthritis." 4 "A patient with humerus fracture and inadequate muscle strength"

Answer: 3 A patient who is suffering from severe pain with a history of rheumatoid arthritis is the best suitable candidate for shoulder replacement surgery. The presence of acute pain with a history of osteoarthritis can be managed through pharmacologic therapy. Similarly, a patient with acute pain and a history of rheumatoid arthritis is not considered for the surgery, because the disease can be managed through drugs. The presence of a humerus fracture and inadequate muscle strength indicates trauma, which would be treated with medication and physiotherapy rather than surgery.

Which joint is considered an ideal site for surgical fusions? 1 Hip joint 2 Knee joint 3 Wrist joint 4 Elbow joint

Answer: 3 Arthrodesis is the surgical fusion of a joint. Common areas of joint fusions are the wrist, ankle, and cervical spine. The hip, knee, and elbow joints are not considered ideal sites for surgical fusion, because fusion of those joints will lead to immobility.

The nurse formulates a nursing diagnosis of impaired physical mobility related to decreased muscle strength for a patient who has undergone a total knee replacement. What is an appropriate nursing intervention for this patient? 1 Weight-bear as tolerated 2 Increase calcium intake to 400 mg daily 3 Encourage isometric exercises every six hours 4 Maintain the leg in an abducted position while supine

Answer: 3 Great emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the day after surgery. The leg does not need to stay in an abducted position, which would be used following hip replacement surgery. The patient should not bear weight on the extremity until instructed to do so by the health care provider. Calcium supplementation will not impact physical mobility.

The nurse is caring for a patient with osteoarthritis who is about to undergo total left knee arthroplasty. The nurse assesses the patient carefully to be sure that there is no evidence of what in the preoperative period? 1 Chronic pain 2 Left knee stiffness 3 Left knee infection 4 Left knee instability

Answer: 3 It is critical that the patient be free of infection before a total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring extensive surgery. For this reason, the nurse monitors the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Chronic pain, knee stiffness, or instability may be present with osteoarthritis and is not a reason to postpone arthroplasty.

Which postoperative care should be included in the nursing care plan of a patient who had surgery on the wrist? 1 Maintaining the strength in the affected extremity 2 Focusing on the patient's communication and adequate nutrition 3 An occupational therapist assisting the patient to perform hand exercises 4 Providing pain management techniques, including epidural or intrathecal analgesia

Answer: 3 The success of any surgery depends largely on the postoperative treatment plan, usually implemented by an occupational therapist. After wrist surgery, hand exercises would be suggested at least three or four times a day for 10 to 12 weeks under the guidance of an occupational therapist. Postoperative care that focuses on patient communication and adequate nutrition would be important for facial fractures. Passive and active exercises performed by the patient help to maintain the strength of the affected extremity; however, they are not specific to postoperative care. Pain management techniques include epidural or intrathecal analgesia. These are common interventions during any joint surgery.

The nurse is caring for a patient who underwent left total knee arthroplasty and has a new prescription to be "up in the chair today before noon." What action should the nurse take to protect the knee joint while carrying out the prescription? 1 Administer a dose of prescribed analgesic before completing the prescription. 2 Ask the physical therapist for a walker to limit weight bearing while getting out of bed. 3 Keep the continuous passive motion machine (CPM) in place while lifting the patient from bed to chair. 4 Put on a knee immobilizer before moving the patient in and out of bed and keep the surgical leg elevated while sitting.

Answer: 4

Which part of the joint enables progression of inflammation to other parts of the joint? 1 Tendons 2 Ligaments 3 Articular cartilage 4 Synovial membrane

Answer: 4 Basic pathologic changes in a joint occur within the synovial membrane. Removal of the thickened synovium prevents extension of the inflammatory process into tendons, ligaments, and adjacent articular cartilage.

A patient with profound osteoarthritis is recommended for total hip arthroplasty (THA). The patient asks why this will relieve the discomfort. What is the nurse's best response? 1 THA will remove degenerative debris from the joint allowing for increased mobility and decreased pain. 2 THA removes a wedge of bone to restore alignment to the joint, alleviating pain and promoting mobility. 3 THA will provide increased mobility for patients with arthritis by reshaping the ball of the femur rather than replacing it. 4 THA can provide significant pain relief for patients with joint deterioration from arthritis by replacing the ball-and-socket joint as well as the upper shaft of the femur.

Answer: 4 An arthroplasty is a procedure that relieves pain and promotes mobility by reconstructing or replacing a joint; a THA removes the ball-and-socket joint and the upper shaft of the femur. A hip resurfacing arthroplasty is an alternative to THA that allows the ball of the joint to be preserved and reshaped. An osteotomy removes a wedge or slice of bone to restore alignment and shift weight-bearing, thus relieving pain. A debridement procedure removes degenerative debris from the join to relieve pain and promote mobility.

A patient with severe osteoarthritis of the left knee has undergone left-knee arthroplasty with prosthetic replacement of the knee joint. After surgery, the nurse expects to include which intervention? 1 Strict bedrest for 24 hours 2 Active range of motion every hour 3 Total knee immobilization for 72 hours 4 Physical therapy to achieve full knee flexion

Answer: 4 The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible. Because this is painful after surgery, the patient requires good pain management and, often, the use of a continuous passive motion (CPM) machine. Hourly range of motion is not necessary, because the patient will already have CPM. Bed rest is not indicated because of the risk of clot formation postoperatively. Knee immobilization should be used when transferring out of bed, but should not be left on.

The nurse is completing discharge teaching with an older adult patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to do what? 1 Avoid crossing his legs 2 Use a toilet elevator on toilet seat 3 Notify future caregivers about the prosthesis 4 Maintain hip in adduction and internal rotation

Answer: 4 The patient should not force the hip into adduction, or force the hip into internal rotation, because these movements could displace the hip replacement. Avoiding crossing the legs, using a toilet elevator on a toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.