Nursing 3 Exam 1 Musculoskeletal and Sensorineural

Avoiding Hip Dislocation After Replacement Surgery Continued

- Limit sitting to 30 minutes at a time—to minimize hip flexion and the risk of prosthetic dislocation and to prevent hip stiffness and flexion contracture. - Do not flex the hip to put on clothing such as pants, stockings, socks, or shoes. Consider Occupational therapy devices for dressing and reaching. - Encourage quadriceps setting and ROM exercises, as directed. - Positions to avoid after total hip replacement are illustrated below.

Continuous Passive Motion Machine

An electrical device used as a supplement or substitute for manual ROM exercise

Closed Angle glaucoma

Angle-closure glaucoma: In angle-closure glaucoma the drainage angle becomes very narrow, hence closed (the drainage angle between the cornea and iris is closed/narrow). Therefore, aqueous humour can't drain down into trabecular meshwork (which is functioning and NOT clogged). This type is rare but if it happens it is requires emergency treatment.

What can a pt do to promote blood flow to a sprain and how long after the injury can they do this intervention?

Applying heat After 2 days, when swelling is no longer likely to increase, applying heat reduces pain and relieves local edema by improving circulation.

How soon should exercise begin to maintain strength in the remaining limb after an amputation?

Exercise of the remaining limb should begin the day after surgery. Exercise is necessary to maintain the muscle tone of the remaining limb. Immediately after surgery, the client usually isn't alert enough to participate and may be in too much pain. Exercise needs to begin before discharge to a rehabilitation center.

External fixators

External fixators are often used to maintain position of unstable fractures when the use of a cast is prohibited or the patient's condition is unstable and precludes a surgical procedure to stabilize the fracture. They can also be used to manage open fractures with soft tissue damage or severe comminuted (crushed or splintered) fractures while permitting active treatment of damaged soft tissues. Crusting may occur at the pin site, this is normal

What devices are used with potential cervical fractures?

If cervical and thoracolumbar spinal injuries are suspected, immobilization of the spine via cervical collar or spinal backboard as well as the avoidance of movement is essential. If moving is necessary, log rolling with the appropriate number of staff is used.

MéNIèRE DISEASE: What is it? Signs & symptoms?

MéNIèRE DISEASE: Inner ear disorder that causes issues with hearing and balance. This caused by a buildup of endolymphatic fluid in the inner ear. Cause is unknown. 3 Key symptoms: Tinnitus, unilateral hearing loss, vertigo Treatment is supportive: Antihistamines, anticholinergics, diuretics, antiemetics

Nursing interventions for Compartment Syndrome

Nursing interventions for Compartment Syndrome: - keep the extremity AT HEART level (NOT below....remember you want to maintain arterial pressure and elevating it above heart level will cause more ischemia) - loosen and remove restrictive items - notify the physician - perform neurovascular checks (6 P's) - prepare the patient for possible bivalvement of the cast, reduction of weight in the traction, or in severe cases fasciotomy.

Open angle glaucoma

Open-angle glaucoma: In open angle glaucoma, the drainage angle is opened (so the angle between the cornea and iris is wide/opened like it should be) but the trabecular meshwork is clogged

The 6 P's in regards to compartment syndrome

Pain: worst with passive touch or movement, elevating the limb, or any pressure, stretching increases the pain. Pain medication is not relieving it. Paresthesia: patient may report it feels like the extremity distal to the fracture feels like it is falling asleep or a "pin and needle" sensation. Can they feel you touch their extremity? ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE! Pallor: Extremity should be pink and have normal capillary refill less than 2 seconds. In CS, it may appear pale or dusky and have a capillary refill greater than 2 seconds. ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE! Paralysis: can the patient move the distal extremity from the fracture or has the movement decreased...this is a bad sign! ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE! Poikilothermia: This occurs when the affected extremity distal from the fracture feels cooler to the touch compared to the unaffected extremity. The extremity can NOT regulate its temperature. Pulselessness: Always mark the pulses with a black marker and have a Doppler available to monitor the sound of the pulse. (this is a late sign in compartment syndrome)

Pin site care for skeletal traction

Pins located in areas with considerable soft tissue should be considered at greatest risk for infection. At sites with mechanically stable bone-pin interfaces, pin care should be done on a daily or weekly basis (after the first 48 to 72 hours, when drainage may be heavy). Chlorhexidine 2 mg/mL solution is considered to be the most effective cleansing solution for pin-site care. Saline should be used if chlorhexidine solution is contraindicated such as those with hypersensitivity to Chlorhexidine gluconate or other formula ingredients. Strict handwashing should always take place before and after skeletal pin-site care.

This is very similar to osteomyelitis but instead of an infection in the bone tissue, the infection occurs in the joint

Septic (Infectious) Arthritis: The patient with acute septic arthritis usually presents with a warm, painful, swollen joint with decreased ROM. The knee is involved in more than 50% of cases Prompt treatment is essential and may save a joint prosthesis for patients who have one. Broad-spectrum IV antibiotics are started promptly and then changed to organism-specific antibiotics after culture results are available. If septic joints are treated promptly, recovery of normal function is expected.

Signs and Symptoms of Angle-closure glaucoma:

Severe eye pain Nausea and vomiting Vision changes: blurred/seeing halos around lights Red eyes Edema of the cornea

Signs and Symptoms of Open-angle Glaucoma

Silent: asymptomatic in early stages...you may have heard it referred to as a "thief of sight". It happens gradually and when the patient notices the s/s the disease has advanced to permanent vision loss. ***No pain*** Loss of peripheral vision: this is side vision (not really noticeable to the patient until they develop tunnel vision)

A _________ is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching, or twisting motion

Sprain

General guidelines for administering eye drops

Stress to the patient the importance of using eye drops exactly as ordered (don't skip days or abruptly stop) More than one med? Space out giving the medications: administer about 3-5 minutes apart so that the first medication can be used by the eye and not washed out by the second medication Eye ointment or eye drops first? Drops then ointment Drops are placed into the lower sac of the eye (conjunctival sac)....NOT directly on the eye via the cornea After instilling each eye drop medication have the patient refrain from blinking but keep the eye closed and perform "punctal occlusion". Use the index finger and gently place pressure at the side of the bridge of the nose (over the tear duct) for about 2-3 minutes.

Key points with skeletal traction

Traction: Aligns the bone with a constant steady pulling action. - Make sure the weights are hanging freely and not on floor - Never remove weights without an MD order - Pin care and monitor for infection (odorous draining, redness, pain) - Neurovascular status: 6 P's - Overhead trapeze bar to move around in bed

ACOUSTIC NEUROMA

What is it? Acoustic neuromas are slow-growing, benign tumors of cranial nerve VIII, usually arising from the Schwann cells of the vestibular portion of the nerve Assessment: The most common assessment findings of patients with acoustic neuromas are unilateral tinnitus and hearing loss with or without vertigo or balance disturbance. If the tumor is large, the trigeminal nerve may be involved resulting in facial paresthesia, hypesthesia (sensitivity to touch), and discomfort. Treatment: Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to radiation or chemotherapy.

Managing an open fracture

With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues. No attempt is made to reduce the fracture, even if one of the bone fragments is protruding through the wound. Tetanus prophylaxis will be administered in the emergency room (ER) if the last known booster was over 5 years ago

Rhabdomyolysis

With trauma injuries, the nurse is alert for rhabdomyolysis, in which the crushing injury causes the breakdown of skeletal muscle, resulting in the release of muscle cell contents, including myoglobin (a protein released from muscle when injury occurs), creatine phosphokinase (CPK), phosphate, enzymes, and potassium, into the systemic circulation. Myoglobin, which gives skeletal muscle its color, is released from the damaged muscle and filtered by the kidney, resulting in brown or tea-colored urine. Myoglobinuria does not occur in the absence of rhabdomyolysis; therefore, when present, it is the best marker and diagnostic cornerstone of rhabdomyolysis

Degrees of strains

1st Degree: Minor edema, tenderness, minimal function loss 2nd Degree: Tearing of muscle tissue, edema, tenderness, BRUISING, "notable loss of load-bearing strength" 3rd Degree: Complete muscle separation. Severe pain and tenderness, severe bruising and edema. Complete loss of function

What is another term for a "Dislocation"?

A "Malpositioned bone"

Nursing Alert about hip dislocation

Nursing Alert The risk of dislocation after THA decreases as time passes without a dislocation. If dislocation occurs, typically it is seen within 6 weeks after surgery and frequently is associated with adhering to postsurgical guidelines.

Interventions for Glaucoma

Trabeculectomy (one common type): decreases IOP pressure in the eyes (used when eye drops or other procedures are not working) Meds: Alpha agonists "idine": eg. Brimonidine Beta blockers Cholinergic (miotics): "Pilocarpine" eye drops

A patient falls while skiing and sustains a supracondylar fracture. What does the nurse know is the most serious complication of a supracondylar fracture of the humerus?

Volkmann's ischemic contracture: The most serious complication of a supracondylar fracture of the humerus is Volkmann contracture (an acute compartment syndrome), which results from antecubital swelling or damage to the brachial artery.

Activities to Promote a Healthy Back when lying

When lying on the side, place a pillow under the head and one between the legs, with the legs flexed at the hips and knees.

Treatments for macular degeneration

"Wet" MD can be treated with "photodynamic" therapy which closes those vessels Teaching: Quit smoking, Wear sunglasses, make home modifications for safety

Cataracts prevention

- Layers of protection: sunglasses - Eat fruits and vegetables in diet - No smoking - Schedule regular eye exams

Amputation key points continued

A person who has had an amputation may experience phantom limb pain soon after surgery or 2 to 3 months later. Phantom limb pain control: beta blockers may relieve dull, burning discomfort; antiseizure medications control stabbing and cramping pain; and tricyclic antidepressants are used to modify pain signals and improve mood and coping ability. If the cast or elastic dressing inadvertently comes off, the nurse must immediately wrap the residual limb with an elastic compression bandage. If this is not done, excessive edema will develop in a short time, resulting in a delay in rehabilitation. The nurse notifies the surgeon if a cast dressing comes off so that another cast can be applied promptly.

What device is used to measure intraocular pressure

A tonometer is used to measure the intraocular pressure. A normal intraocular pressure is about 10-21 mmHg.

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first?

Administer oxygen The client is demonstrating clinical manifestations consistent with a fatty embolus. Administering oxygen is the top priority. Elevating the extremity won't alter the client's condition. Notifying the nursing supervisor may be indicated by facility policy after other immediate actions have been taken. The nurse should contact the health care provider after administering oxygen.

Complications of healing fractures: Delayed Union, Malunion, and Nonunion

Delayed Union, Malunion, and Nonunion When prolonged healing for union of the fracture is noted, it is termed delayed union. The fracture eventually does heal. In malunion, there is a flawed union of fractured bone, whereas nonunion results from failure of the ends of a fractured bone to unite in normal alignment. Patient complaints of persistent discomfort and abnormal movement or instability at the fracture site indicate potential delayed union, malunion, or nonunion.

BENIGN PAROXYSMAL POSITIONAL VERTIGO: Diagnosis and treatment and meds

Diagnosis of BBPV is performed after an ear examination, audiogram, and test of nerve responses and use of the Dix-Hallpike test, also called the Nylen-Barany test. Treatment: Repositioning techniques can be used to treat vertigo, such as the Epley maneuver. The maneuver is designed to reposition the canalith and involves quick movements of the head. Meds: Anticholinergics (scopolamine), antihistamines (meclizine, dimenhydrinate), and benzodiazepines. Meclizine for nausea

Nursing Note about infection and fever

Do not rely on fever as a marker for infection in the elderly. Consider change in the level of consciousness as an indication of suspicion.

Improving mobility post fracture and immobilization

Improving Mobility Every joint and digit that is not immobilized should be exercised and moved through its ROM to maintain function. The nurse encourages the patient to assist in the repositioning, if not contraindicated, by use of the trapeze or bed rail. If a patient has a spica cast (a cast that stabilizes the hips and thighs, also known as a body cast), a stabilizing abduction bar may be incorporated into the cast to maintain the legs in an abducted position

What is cataracts?

It's an eye disorder that occurs when the lens of the eye loses its transparency. As a result, the transmission of light to the retina is affected, which leads to vision impairment. This impairment is described as cloudy, murky visual perception.

What is an open reduction?

Open Reduction. With an open fracture, surgical intervention is needed to align the bone fragments. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) are used to hold the bone fragments in position until bone healing occurs

Cataracts Treatment

Regular eye checkups and changing eye glass prescriptions Anti-glare glasses Education: Protecting eyes from sunrays, magnifying items for better views, and adding more light Surgery: remove the cloudy lens and replace it with an intraocular lens (IOL)

What are the "6 P's"?

Remember "the 6 P's" : Pain (early sign) Paresthesia (can be an early sign too) Pallor Paralysis Poikilothermia (the inability to regulate core body temperature) Pulselessness (late sign)

Halo immobilization

See image

Types of fractures

See image

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client?

With the leg on the affected side abducted: The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs. The nurse should avoid acutely flexing the client's affected hip (for example, by elevating the head of the bed excessively), adducting the leg on the affected side (such as by moving it toward the midline), or externally rotating the affected hip (such as by removing support along the outer side of the leg) because these positions may cause dislocation of the injured hip joint.

Fasciotomy

a surgical incision through the fascia to relieve tension or pressure

Causes of Cataracts

- Aging: Over time the lens starts to lose its transparency and proteins start to stick together on the lens and over time the lens becomes cloudy. - Congenital, example: mom had a rubella infection during 1st trimester - Trauma to the eye - Disease processes: diabetes (uncontrolled diabetes) - Unprotected eye exposure to sunlight - Medications: corticosteroids - Lifestyle: smokers, alcohol consumption, family history

Avoiding Hip Dislocation After Replacement Surgery

- Keep the knees apart at all times. - Put two pillows between the legs when sleeping. - Never cross the legs when seated. - Avoid bending forward when seated in a chair to pick up an object on the floor. - Avoid internal rotation of the hip. - Avoid sitting in a low chair or toilet seat to avoid flexing the hip more than 90 degrees. - Use a high-seated chair and a raised toilet seat; consider handrails by the toilet.

Key points with cast care

- Monitor for compartment syndrome: 6 P's - Monitor for infection - Keep the cast and extremity elevated above the heart level (decreases swelling) - Apply ice packs to the cast for the first 2 days to decrease swelling - Even drying for new cast by turning every 2 hours Use palms of hand to handle (not fingertips) with a new wet plaster cast. ***WHY? Prevents dent formation in the cast by handling with the palms of hand, which can cause skin breakdown overtime. - Use soft tape called moleskin around the edge to prevent skin breakdown - Keep cast dry and never stick anything inside to scratch an itch

Signs and Symptoms of Cataracts

- Not painful and happens gradually - Cloudy/blurry vision (can also have double vision in the affected eye) - Acquiring frequent eye glass prescriptions to help vision - Toned-down colors (washed out and faded) Sensitivity to glare and light

Amputation key points

Amputation is performed at the most distal point that will heal successfully. The site of amputation is determined by two factors: circulation in the body part and functional usefulness (i.e., meets the requirements for the use of a prosthesis). With a traumatic amputation, wrap the wound (stump) with a DRY sterile gauze and place the severed limb in a dry plastic bag, then place the bag into ice water. When wrapping a below-the-knee amputation, we use the "Figure 8" method Watch for "hip flexion contractures", avoid prolonged sitting and have the pt lay prone 20 min daily

What is an IMMEDIATE CONCERN with fractures (Especially in fractures of the extremities, thorax, pelvis, or spine)?

An immediate priority is maintaining hemodynamic stability. Hypovolemic shock, resulting from hemorrhage (both visible and nonvisible blood loss) and from loss of intravascular volume into the interstitial space, may occur in fractures of the extremities, thorax, pelvis, or spine. - Especially in fractures of the femur and pelvis.

BENIGN PAROXYSMAL POSITIONAL VERTIGO

Benign paroxysmal positional vertigo (BPPV) is a brief period of incapacitating vertigo that occurs when the position of the patient's head is changed with respect to gravity, typically by placing the head back with the affected ear turned down. BPPV is thought to be due to the disruption of debris in the labyrinth, termed otoconia (small crystal particles of calcium carbonate that detach and float in the endolymph and cause symptomatology). This is frequently stimulated by head trauma, infection (particularly of the respiratory tract), or other events.

Why are bone infections are more difficult to eradicate than are soft tissue infections? Which bacteria is most commonly seen in osteomyelitis?

Bone infections are more difficult to eradicate than are soft tissue infections because the infected bone is mostly avascular (without blood vessels) and not accessible to the body's natural immune response. Also, there is decreased penetration by antibiotics. Between 70% and 80% of bone infections are caused by Staphylococcus aureus.

Buck's Extension Traction

Buck's extension traction (unilateral or bilateral) is skin traction to the lower leg. The pull is exerted in one plane when partial or temporary immobilization is desired. In general, this form of traction is used to immobilize fractures of the proximal femur before surgical fixation or when only a light traction weight is necessary.

Percutaneous Pinning

Can be part of a closed reduction procedure

What is closed reduction?

Closed Reduction. In most instances, closed reduction is accomplished through manipulation and manual traction. The extremity is held in the desired position while the provider applies a cast, splint, or other device. Reduction under anesthesia with percutaneous pinning may be used. The immobilizing device maintains the reduction and stabilizes the extremity for bone healing.

What is compartment syndrome?

Compartment syndrome is a serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problems with blood flow.

A __________ is an injury to soft tissue produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising).

Contusion

The primary nursing intervention that will control swelling while treating a musculoskeletal injury is...

Elevate the affected area Elevation is used to control swelling. It is facilitated by cold, immobilization, and compression Remember "RICE" Rest Ice Compression Elevation However, Heat can be applied to promote blood flow

Fat Embolism Syndrome (FES)

FES follows trauma in the presence of long bone, pelvic and multiple fractures, and during intramedullary manipulation internal fixation procedures Fat globules released into bloodstream, travel to lungs and brain, cause ischemia and inflammation --Also be deposited on kidney and retina With systemic embolization, the patient appears pale. Petechiae, possibly due to a transient thrombocytopenia, are noted in the buccal membranes and conjunctival sacs, on the hard palate, and over the chest and anterior axillary folds. Critical period: 24-72 hrs. after injury

What measures can be taken to reduce the risk of FES?

Immediate immobilization of fractures (including early surgical fixation), minimal fracture manipulation, adequate support for fractured bones during turning and positioning, and maintenance of fluid and electrolyte balance are measures that may reduce the incidence of fat emboli.

How do we immobilize a possible fractured limb?

Immediately after injury, whenever a fracture is suspected, it is important to immobilize the body part before the patient is moved. If an injured patient must be moved before extremity splints can be applied, support the limb distal and proximal to the fracture site to prevent rotation as well as angular motion.

Joint replacement surgery

JOINT REPLACEMENT SURGERY Joint surgery is one of the most frequently performed orthopedic surgeries. Joint disease, disability, or deformity may necessitate surgical intervention to relieve pain, improve stability, and improve function. Conditions contributing to joint degeneration include osteoarthritis (degenerative joint disease), rheumatoid arthritis, trauma, and congenital deformity. Surgical procedures include excision of damaged and diseased tissue, repair of damaged structures (e.g., ruptured tendon), arthroplasty (replacement of all or part of the joint surfaces), and arthrodesis (immobilizing fusion of a joint).

Safe lifting practices

Lifting Emphasize the importance of the following strategies: When lifting, keep the back straight and hold the load as close to the body as possible. Lift with the large leg muscles, not the back muscles. Use trunk muscles to stabilize the spine. Squat while keeping the back straight when it is necessary to pick up something off the floor. Avoid twisting the trunk of the body, lifting above waist level, and reaching up for any length of time.

Types of macular degeneration

MACULAR DEGENERATION: Central Loss of vision "Dry": Tiny clumps of protein called "Drusen" which grow under the macula which causes the macula to become thinner and dry out. Dry has a slower onset. "Wet": Small vessels that grow under the macula which leaks blood and "fluid" which leads to scarring. Less common but faster onset

Managing an open fracture

Management of an Open Fracture: For patients with open fractures, prompt, thorough wound irrigation and débridement are necessary to remove foreign bodies, obvious debris, and bacteria. Often this is performed in the operating room.

Nursing Alert for total hip replacement surgery

Nursing Alert For total hip replacement surgery (posterior approach) the legs should be slightly abducted. Prevent hip flexion beyond 90 degrees, hip adduction, and internal rotation to avoid dislocation of the hip after joint replacement surgery. For an anterior approach, motions that externally rotate the limb as well as hyperextension and flexion of the hip combined with external rotation are avoided.

___________ is an infection of the bone

Osteomyelitis Osteomyelitis is an infection of the bone; it can be acute or chronic and is usually bacterial in nature. The bone becomes infected in one of three ways: - Extension of soft tissue infection (e.g., infected pressure or vascular ulcer, incisional infection) - Direct bone contamination from bone surgery, open fracture, or traumatic injury (e.g., gunshot wound) - Hematogenous (blood-borne) spread from other sites of infection

Total knee replacement

Postoperatively, the knee is dressed with a compression bandage A wound suction drain removes fluid accumulating in the joint. In general, the surgeon can be expected to remove the drains within 24 hours If a Continuous Passive Motion (CPM) machine is used, the patient's leg is placed in the device and ROM movement usually begins on postoperative day 1 at full extension (0 degrees) and 30 degrees of flexion and generally is advanced 5 to 10 degrees per day until 90 degrees of flexion is achieved at approximately 6 weeks postoperatively

MéNIèRE DISEASE: Procedures and education

Procedures: If the procedure gets bad enough, they can have a labyrinthectomy which unfortunately results in complete hearing loss on the affected side. Teaching: avoid smoking, ETOH, and caffeine. Plus, lower salt intake

Signs, symptoms and treatment of retinal detachment

Separation of the retina from the underlying epithelium. This is caused by vitreous humor building up behind the retina which causes it to detach S/s: - "floaters", flashes of light, and a "Sudden painless sensation of a curtain being drawn over their field of vision - Treatment: emergency surgery,

How does compartment syndrome occur?

This can occur when there is hemorrhaging (bleeding) or swelling present after an injury, like with a bone fracture (or with external factors like a cast being too tight or traction). All this can increase the pressure within the compartments. As the pressure builds, this will cut off the blood supply and nerve function to this muscle. If not corrected within 6 hours, the damage is permanent.

Tools Used to Diagnose Cataracts

Visual Acuity test with Snellen Chart Slit-lamp: helps enlarge the front areas of the eye to allow the doctor to see the structures of the eye for evaluation like the cornea, lens, iris etc. Dilation of the pupils to assess the optic nerve with an ophthalmoscope

A _________ (collection of blood within tissues) develops when the bleeding is sufficient to form an appreciable solid swelling.

hematoma

A ________ ________ , or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. It can occur anywhere within the muscle, but it commonly occurs at the distal muscle-tendon junction

muscle strain

Patients who are at high risk for osteomyelitis include those who are...

poorly nourished, elderly, or obese. Other patients at risk include those with impaired immune systems, those who are IV drug users, those with chronic illnesses (e.g., diabetes, rheumatoid arthritis, neuropathy, and arterial insufficiency), and those receiving long-term corticosteroid therapy or immunosuppressive agents.