MS3 - Ch. 40: Musculoskeletal Care Modalities

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

"CPM increases range of motion of the joint." CPM increases circulation and range of motion of the knee joint.

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

"The client is receiving physical therapy twice per day, so the client doesn't need a continuous passive motion device." Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use.

A client has undergone a leg amputation. What teachings should the nurse offer such a client to prevent abduction deformity? Select all that apply.

-Advise the client to use a trochanter roll. -Advise the client to adduct the stump so it presses against the other leg when the client is lying on the stomach. Use a trochanter roll to prevent external rotation of the hip and knee. Avoid placing pillows between the legs. If the client is lying on the stomach, the nurse should advise the client to adduct the stump so it presses against the other leg. Adduction stretches flexor muscles and prevents abduction deformity. The client should only use an antiembolism stocking on the unaffected leg.

A nurse is caring for a client in skeletal leg traction. Which nursing assessment findings indicate the client has met expected outcomes? Select all that apply.

-Capillary refill less than 3 seconds -Repositions self with trapeze -Peripheral pulses +2 bilaterally -Elbows are free of skin breakdown A capillary refill time of less than 3 seconds, the ability to reposition using a trapeze, peripheral pulses +2 bilaterally, and elbows free of skin breakdown are normal assessments for the nurse to find with a client in skeletal leg traction. An abnormal finding of a deep vein thrombosis include calf tenderness, warmth, redness, and swelling of the affected extremity.

A client returns to the nursing unit following an open reduction with internal fixation of the right hip. Which nursing interventions would be appropriate for the prophylactic treatment of deep vein thrombosis? Select all that apply.

-Increasing fluid intake -Maintaining antiembolic stockings -Administering enoxaparin Increasing fluid intake decreases stasis by lessening hemoconcentration. Antiembolic stockings and administering enoxaparin are standards of care associated with decreasing deep vein thrombosis. Encouraging coughing exercises helps to reduce respiratory complications. Increased fiber intake increases bulk in stool, but does not prevent deep vein thrombosis.

A client with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply.

-Prepare to remove the cast. -Provide support to the injured extremity. The nurse should anticipate immediate removal of the cast and provide support to the injured extremity. Neurovascular status should be assessed more frequently than every 8 hours. If the client's neurovascular status is not improving, then a fasciotomy may be needed. Waiting 8 hours to assess neurovascular status may cause permanent damage to the extremity. To promote arterial blood flow, the arm should be elevated to the heart level, not above. Ice should not be used, as it could further decrease blood flow to the extremity.

An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker?

24 hours Following hip arthroplasty (total hip replacement), patients begin ambulation with the assistance of a walker or crutches within a day after surgery.

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neurovascular integrity Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

A group of students are reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?

Better molding to the client Plaster casts require a longer time for drying, but mold better to the client, and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer-lasting, and breathable.

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

Changing the client's position within prescribed limits. Changing the position of a client within prescribed limits helps relieve pressure on bony areas and promotes comfort. Analgesics help to relive pain but may not help relieve pressure on bony areas. Warm compresses aid blood circulation. The client should not exercise while on traction unless prescribed to regain strength in the affected limb.

The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician?

Crackles in the lung bases Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.

A client with a fractured ankle is having a fiberglass cast applied. The client starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate?

Explain that the sensation being felt is normal and will not burn the client. A fiberglass cast will give off heat when applied. The reaction is a normal, temporary sensation. Heat given off during the application phase of the cast does not burn the skin. By explaining these principles to the client, the nurse can alleviate any anxiety associated with the application of the cast. Because this is a known reaction to the application of the fiberglass cast, it is not necessary to remove the cast. Holding the client may cause more harm to the injury. Antianxiety medications are generally not needed when applying a cast.

A nurse would most likely expect the need for open reduction for a client with which of the following?

Joint fracture An open reduction is required when soft tissue is caught between the ends of the broken pieces of bone, the bone has a wide separation, open fractures are evident, comminuted fractures are present, and the patella or other joints are fractured. It is also done when wound debridement or internal fixation is needed.

The nurse is caring for a client with a spica cast. What is the nurse's priority intervention?

Keep the cast clean and dry. Keeping the cast clean and dry around the perineal opening is a priority. A spica cast has a built-in abduction bar. The client should be positioned on the unaffected side every 2 hours and prone twice a day. A fracture bedpan is easier to use for the client with a spica cast.

A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan?

Maintaining correct body alignment Buck's traction produces realignment by exerting a pulling force on the fractured hip. Therefore, the nurse must maintain correct body alignment. Traction should be continuous; if the weights must be removed, the nurse should apply manual traction until the weights are replaced. The nurse shouldn't use the knee gatch position because it disrupts the constant pulling force needed for alignment. Using the semi-Fowler's position would cause the client to slide in the direction of the traction, defeating the purpose of traction.

Which orthopedic surgery is done to correct and align a fracture after surgical dissection and exposure of the fracture?

Open reduction 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 is an inappropriate nursing diagnosis for the client following casting?

Risk for deficient knowledge: procedure The client needs adequate information before experiencing the procedure. Information about its purpose, the actual steps of the procedure, and the client's role during and after the procedure is essential. Appropriate nursing diagnoses following the procedure would include risk for disuse syndrome, risk for impaired skin integrity, and risk for impaired tissue perfusion.

Which device is designed specifically to initially support and immobilize a body part in a desired position until swelling subsides?

Splint A splint may be applied to a fractured extremity initially until swelling subsides. A brace is an externally applied device to support a body part, control movement, and prevent injury. A CPM device is an instrument that moves a body part to promote healing and circulation. A trapeze is an overhead device to promote client mobility in bed.

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?

Teach the client how to prevent problems caused by immobility. By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.

Which statement is accurate regarding care of a plaster cast?

The cast can be dented while it is damp. 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 statement describes 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 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 variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period?

osteomyelitis Chronic osteomyelitis may occur after persistent infection in the late postoperative period. Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period.

The nurse is admitting a client who is to undergo an open reduction with internal fixation for a fractured femur. About which comment by the client should the nurse be most concerned?

"I was worried I would have an incision and scar." An open reduction involves a surgical dissection for the visualization of the bone ends and fragments. A metal plate and screws are used to correct and stabilize the fracture through internal fixation.

The nurse is caring for a patient with a total hip replacement. How should the nurse allow the patient to turn?

45 degrees onto the unoperated side if the affected hip is kept abducted When the nurse turns the patient in bed to the unaffected side, it is important to keep the operative hip in abduction (movement away from the center or median line of the body). The patient should not be turned to the operative side, which could cause dislocation, unless specified by the surgeon. The patient's hip is never flexed more than 90 degrees.

After undergoing surgery the previous day for a total knee replacement, a client states, "I am not ready to ambulate yet." What should the nurse do?

Discuss the complications that the client may experience if there is lack of cooperation with the care plan. The nurse should discuss the care plan and its rationale with the client. Calling the health care provider to report the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make choices, it's the nurse's responsibility to provide education to help the client make informed decisions. Although the nurse should ultimately document the client's refusal, the nurse should first discuss the care plan with the client.

The client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which complication?

Dislocation of the hip Manifestations of a dislocated hip prosthesis are increased pain at the surgical site, acute groin pain in the affected leg, shortening of the leg, abnormal external or internal rotation, and limited movement of the fractured leg. The client may report a "popping" sensation in the hip.

A client's fracture was reduced by surgically exposing the bone and realigning it. What type of treatment does the nurse identity this as?

Open reduction 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.

The nurse is caring for a client who had a total knee replacement 3 days ago. Which nursing assessment finding requires immediate attention by the nurse?

Drainage from wound suction device = 100 ml Drainage from a wound suction device should be less than 25 ml 48 hours after surgery; 100 ml is an excessive amount and may necessitate opening of the wound to remove the blood.

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?

Pulmonary embolism Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.

When discussing physical activities with the client who has just undergone a right total hip replacement, which instruction should the nurse provide?

"Limit hip flexion to 90 degrees." The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. The hip should not bend more than 90 degrees. Ambulation begins the day following surgery, and weight bearing ambulation may not be restricted, depending on the type of prosthesis.

A client with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate?

Document the findings. Serous drainage and redness at the pin site is an expected finding for 48 to 72 hours after insertion. The nurse should document the findings and continue to monitor the site. The physician does not need to be notified unless other signs and symptoms are present. The fixator does not need to be removed at this time. The greatest concern is infection; assessing the hemoglobin and hematocrit are not relevant to assessing for infection.

A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?

Elevate the affected extremity and use cold applications. Elevating the affected extremity and using cold applications reduce swelling. Deep breathing and coughing helps with maintenance of effective respiratory rate and depth. ROM exercises maintain full ROM of unaffected joints. Antiembolism stockings help prevent deep vein thrombosis (DVT).

A client has undergone an external fixation. Which actions would be the priority for this client?

Maintaining pin care. Pin care is a priority for a client with external fixation, because pin sites are entry points for infection. The nurse should also monitor redness, drainage, and tenderness at the site. Planning the client's diet and monitoring the client's urine output and blood pressure, although necessary, are not as important as maintaining pin care.

The nurse assesses a client after total right hip arthroplasty and observes a shortening of the extremity. The client reports severe pain in the right side of the groin. What is the priority action of the nurse?

Notify the health care provider. If any clinical manifestations of dislocation of the prosthesis occur, including acute groin pain in the affected hip or shortening of the affected extremity, the nurse (or the client, if at home) must immediately notify the surgeon, because the hip must be reduced and stabilized promptly so that the leg does not sustain circulatory and nerve damage. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. As the muscles and joint capsule heal, the chance of dislocation diminishes. Stresses to the new hip joint should be avoided for the first 8 to 12 weeks, when the risk of dislocation is greatest.