Adult care exam 2: Musculoskeletal

Is server joint pain after an arthoscopy a normal finding?

****If they experience severe joint pain afterwards it is a complication and needs to be reported to the provider -This is an invasive procedure so monitor for signs and systems of infection

Emergency Care of Extremity Fracture

***ABCs: circulation above and below the break...possibility of lots of blood loss, quick head to toe assessment -Remove clothing (cut if necessary), inspect area..do not remove shoes because this can cause increased trauma -Remove jewelry in case of swelling -Apply direct pressure if bleeding and pressure on the proximal artery nearest fracture -Keep warm & flat (supine position) -Neurovascular assessment (5 Ps) including temp, color (pallor), sensation (paresthesia), movement (paralysis) , and cap refill (pulse too) Immobilize -Cover open areas (sterile dressing if available) *Look for circulation, movement

Cultural considerations: African americans vs chines americans

***African Americans: greater bone density which makes them LESS likely to have osteoporosis and fractures ***Chinese Americans: less bone density which puts them at GREATER RISK for issues with muskuloskeltal system -Amish: have greater incidence of dwarfism -egyptian americans: shorter in

Monitoring & managing complications

*Compartment syndrome -From too much pressure within a limited space -To relieve, bivalve cast maintain alignment, elevate extremity no higher than heart -If not relieved, may need fasciotomy *Pressure ulcers *Disuse syndrome -Occurs when muscles are not used -Teach patient to tense muscles (isometric) -Should be done each hour while awake

Casts: Nonplaster vs plaster

*Nonplaster -Fiberglass -Light weight, durable -Porous, don't soften when wet -Sets quickly, within minutes *Plaster -Not commonly used today -Requires stocking to be fitted first -Can take 24 hours to dry completely -Education: When Cast is still wet: feels cold & smells musty with gray color. Cast is dry when: firm, odorless and white -HEAT will be felt after cast is applied. Warn patient

Muscle

-Smooth muscle: involuntary, contraction of organs/vessels, ANS -Cardiac: involuntary, ANS -Skeletal: movement, CNS/PNS

Scale for grading muscle strength

5: Normal: ROM unimpaired against gravity with full resistance 4. Good: can complete ROM against gravity with some resistance 3. Fair: can complete ROM against gravity 2. Poor: can complete ROM with gravity eliminated 1. Trace: no joint motion and slight evidence of muscle contractility 0. zero: no evidence of muscle contractility

Patient education for casts /cast removal

*Patient education for casts -Explain exercises (isometric exercises) •Do not scratch or stick anything under the cast •Cushion rough edges to avoid skin irritations **Report the following signs and symptoms: persistent pain/swelling, changes in swelling/sensation/movement/color/temp, and any signs of infection or pressure areas -required follow up care *Cast removal: •Remove dead skin, NO SCRUBBING instead soak the leg; use soaking •Expect weakness, discomfort, and decreased ROM, will take time to get back to day to day, teach exercises in help with ROM -support extremity with pillows or tour orthototic device until strength and movement return, move carefully -exercise slowly •Wear support stockings or elastic bandages to prevent swelling •Assist with ADLs and measures to promote independence

How do you assess for pain and neurovascular assessment complications in any musculoskeletal patient? What are S/S of infection

-5 P'S!!! -Pain, Pallor, Parenthesis, Paralysis, pulse -Asses: posture/gait/weakness/pain/medical and surgical history, current illnesses, family history, mobility and functional ability, psychosocial, muscular strength rating (5 is normal, 0 is absent), -imaging, labs, assess pulses, skin color/temp, numbness/tingling, -dental hygiene, spinal deformities, joint inflammation, flushed skin (Paget's Disease), weight loss, -S/S of infection include: fever, edema, pain, swelling, tenderness, drainage, erythema, foot ulcers

Assessment of patient with amputation

-Assess neurovascular status and function of affected extremity or residual limb and of unaffected extremity -Assess for signs and symptoms of infection -Determine nutritional status -Assess concurrent health problems -Determine psychological status and coping

Carpel túnel syndrom

-Chronic condition due to repeated activity or Repetitive stress injury (RSI) ***Women over age of 50 -Affects median nerve involving first 3 fingers and aspect of fourth -Prevention: Safe work environment Assess: Patient's history Pain, numbness and tingling Pain can radiate to arm, shoulder, neck or chest Phalen's test Tinel's sign Nonsurgical management Surgical Management

Casts: maintaing adequate neurovascular function

-Edema can cause circulatory problems & nerve compression -Monitor Capillary refill time, ask patient to move fingers/toes, ask -if numbness or tingling, compare with other side *Assessments must be frequent - five "P"s -Keep extremity ABOVE heart level -Get at least a finger width of space within the case to avoid compartment syndrome -Call physician if s/sx of neuromuscular problems (5 P's) •Asses the 5 P's frequently, asses for edema, keep extremity below heart level, call provider if there are signs/symptoms of neurovascular problems. •Elevate, ice packs, analgesics. Pain associated with fractures is often relieved by immobilization (if it is not, call provider). Pain can indicate a complication

Resolving Grief and Enhancing Body Image

-Encourage communication and expression of feelings -Create an accepting, supportive atmosphere -Provide support and LISTEN -Encourage the patient to look at, feel, and care for the residual limb -Help the patient set realistic goals ***Help the patient resume self-care and independence -Provide referral to counselors and support groups

Electromyography (EMG)

-Helps diagnose neuromuscular, lower motor neuron, peripheral nerve disorders -Low electrical currents pass through flat electrodes placed along nerve -Mild sedative might be needed as temporary discomfort is common -If needles used, inspect needle sites for hematoma formation -Temporary discomfort, mild sedative needed? *Very painful; provide comfort

Arm & Leg Casts

-May need arm sling when ambulating for comfort -Do not allow sling to pull weight on back of neck -Monitor for Volkmann's contracture: s a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. Passive extension of fingers is restricted and painful. It is excruciatingly painful and disabling. -Leg casts need to be supported on pillows -Apply ice packs 1-2 days ***Tell patient to lie down a few x's per day to allow rest -Watch for signs of damage to peroneal nerve - causes footdrop -Prevent footdrop by supporting the ankle/foot with a pillow in order to keep the foot flexed

Manifestations of fractures

-Pain -Loss of function -Deformity -Shortening of the extremity -Crepitus -Local swelling and discoloration -Diagnosis by symptoms and x-ray -Patient usually reports an injury to the area

Assessment

-Pain (acute/chronic) and/or weakness; Pain: is it morning, afternoon, do you take something to make it feel better? -General inspection of posture, gait -Face and neck...is it symmetical -Spine: Lordosis (abdominal obesity): inward curving of the lower back Scoliosis Kyphosis (older patients) -HAND: a lot of pain can happen here -Hip (groin pain or radiates to knee)...assess where the pain is -Ankles and feet -Range of motion

Achieving physical mobility

-Provide proper positioning of limb; avoid abduction, external rotation, and flexion -Turn the patient frequently; use prone position if possible -Use assistive devices -Implement ROM exercises -Implement muscle strengthening exercises -Provide "preprosthetic care": proper bandaging, massage, and "toughening" of the residual limb

Musculoskeletal functions

-Provides framework for the body -Supports -Assists in movement -Protects -Hematopoiesis -Storage for minerals: -Calcium: 99% in the body found in bone -Phosphorus: 90% in the body found in the bone

Red marrow vs yellow marrow

-Red marrow: Hematopoiesis (formation of blood cells) -Yellow marrow: fat cell storage

Diagnostic assessment

-Standard radiography (X ray):bone density, alignment, swelling & intact -Ultrasonography: Soft tissue, Osteomyelitis, hardware placement (knee hip replacement...make sure its not infected) -Bone density (Hairline fx, bone pain, diffuse metastatic bone disease) -Myelography (Contrast*, HOB: 30-50 degrees) Watch for metformin glucophage. Hold for 24-48 hours -Arthrogram: x-ray with contrast* (MRI more reliable now) Watch for metformin glucophage. Hold for 24-48 hours -Computed tomography (CT, W/WO contrast*): vertebral column/joints -MRI (spinal/knee problems ~ joints, soft tissue, bony tumors), Before getting a MRI...is the patient pregnant, any fragments, implants, pace make stent, can they lie still?chronic kidney disease?can they hear well? Can they communicate? Are they clostorphobic You CAN take patients on ventilator to the MRI Chart 49-3, page 1026

Psychosocial assessment

-Stress: increases cortisol and puts strain on this system -Anxiety -Depression (you can have physical pain with depression) -Poor body image (muscular dystrophy patients, or someone who has had an amputation) -Self esteem (make sure they have a support system at home, and if they don't give them community resources)

Nursing Care: Surgery of the Hand or Wrist

-Surgery is usually an outpatient procedure -Patient teaching is a major nursing need for a patient undergoing outpatient surgery -Neurovascular assessment is vital: every hour for the first 24 hours assess motor function only as prescribed; instruct patient about signs and symptoms to assess and report -Pain control measures: medication, elevation, and intermittent ice or cold -Prevention of infection: keep dressing clean and dry, provide wound care, and assess for signs and symptoms of infection -Assist with ADLs and measures to promote independence

Amputations

-Surgical: often elective -Traumatic: accidents or war -Levels of amputation *Complications: Hemorrhage Infection Phantom limb pain Neuroma Flexion contracture

•What nursing interventions can you implement for prevention measures associated with aging?

-Teach patient safety tips to prevent falls, reinforce need to exercise - especially weight bearing exercise, prevent pressure on boney prominences, teach proper body mechanics; instruct patient to sit in supportive chair with arms, provide moist heat - shower or warm moist compresses, assess ADL's and mobility, teach isometric exercise, do not rush the patient, teach patient to include adequate amounts of Vit. C, D and calcium In their diet

External fixation devices

-Used to manage open fractures with soft-tissue damage -Provide support for complicated or comminuted fractures -Reassure patient concerned by appearance of device -Discomfort is usually minimal, and early mobility may be anticipated with these devices -Elevate to reduce edema -Monitor for signs and symptoms of complications, including infection -Provide pin care -Patient teaching -Never adjust the clamps on your own

Stump care after wound has healed

-assess for skin breakdown -wash, rinse and dry stump daily -do not apply anything to stump (alcohol dries, lotion makes skin too soft) -encourage client to wear prothesis when he gets up and all day to prevent stump swelling

Stump wound care

-elevate stump the first 24 hours -prevent contracture of the joint above the amputation -discuss phantom limb pain analgesics -evaluate healing -compressive dressings *discourage semi fowlers position in client with above knee amp to prevent contractors of the hip

Chronic osteomyelitis

-foot ulcer(s) (most commonly) -sinus tract formation -localized pain -drainage from the affected area

Casts: Used for

-immobilizing fractures -correcting deformity -apply uniform pressure to underlying soft tissue -support & stabilize weakened joints -Improving mobility -Promoting healing of abrasions *When there is Pain: -Elevate, apply cold packs, administer analgesics -Fractures often relieved by immobilization -Unrelieved - call MD - avoid paralysis & necrosis -Pain may be indicative of complication

Compartment syndrome: key features

-increased compartment pressure -increased capillary permeability leading to edema -release of histamine leading to increased edema -pressure on nerve ending causing pain -increased tissue pressure (referred pain to compartment) -decreased tissue perfusion (increased edema) -decreased oxygen to tissues (pallor) -increased production of lactic acid leading unequal pulses and flexed posture -anerobic metabolism (cyanosis) -vasodilation (increased edema) -increased blood flow (tense muscle swelling) -increased tissue pressure (tingling numbness) -increased edema (parathesia) ***muscle ischemia (severe pain UNRELIEVED by drugs) -tissure necrosis (paresis/paralysis ***Looking for unilateral swelling with LOTS of pain ***They will perform faciosty to relieve pressure -recognize early; after 8 hours of established compartment syndrome irreversible changes have occurred to the muscles

Preparing the patient for Magnetic resonance Imaging (MRI)

-is the patient pregnant -does the patient have ferromagnetic fragments or implants such as an older style aneurysm clip? -does the patient have a pacemaker, stent, or electronic implant -Does the patient have CKD (gadolinium contrast agents may cause severe systemic complications is kidneys do not function -can the patient lie still in the supine position for 45 to 60 minutes? (may require sedation ) -does the patient need life support equipment available -can the patient communicate clearly and understand verbal communication -did the patient get any tattoo more than 35 years ago? (if so, metal particles may be in the ink) -is the patient claustrophobic (ask this question for closed MRI scanners, open MRI do not causee claustrophobia) •Painless, non-invasive, no radiation •Creates a magnetic field •Contraindications - pacemakers, metal prosthesis, jewelry/piercings •Client teaching •Lie still for 60-90 mins, earplugs to reduce noise, claustrophobia

Plan of care for patient with amputation: Major goals/ potential complications

-relief of pain -absence of altered sensory perceptions -wound healing -acceptance of altered body image -resolution of grieving processes -restoration of physical mobility and absence of complications *Potential complications -post op hemorrhage -infection -skin breakdown

If Ankle brachial index is less than _______would indicate a decrease in blood flow

0.9

What are the 8 types of fractures

1.Complete ~ entire width of the bone 2. Incomplete ~ does not divide 3. Open or compound ~ break in the skin (high risk for infection) 4. Closed or simple ~ no visible wound 5. Pathologic (spontaneous) ~ can indicate metastatic disease? 6. Fatigue or stress ~ excessive strain 7. Compression ~ older adults w/ osteoporosis 8. comminuted: fragmented

Family and nutritional history

A. Family history and genetic risk: *Osteoporosis has genetic component *Gout has a genetic component B. Nutritional history: -Smoking & Alcohol use/intake 24hr recall -Weight gain/loss (weight puts pressure on your joints) -Obesity -Anoxeria (don't have adequate vitmain D, C, etc)/Bulimia (may be losing their vitamins before they are absorbed)

Bone Maintenance

A. Modeling vs. remodeling (how our musculoskeletal system) maintains homeostasis B.Physical activity - weight bearing activity (esp walking) C. Dietary intake: calcium, milk, dairy, supplements D. Hormones -Vitamin D -Parathormone (PTH) & calcitonin -Growth hormones (giantism, dwarfism, and acrgmegly will be affected in the musculoskeltal system) -Sex hormones

Lab tests

A. Serum Calcium (9.0-10.5mg/dL) *hypercalcemia: metazoic cancers of the bone, pagers disease, bone fractures in the healing stage *hypocalcemia: osteoporosis, ostermalacia; indicates bone loss; could be parathyroid disorder B. Serum Phosphorus (3.0-4.5mg/dL) *Hyperphosphatemia: bone fractures during healing stage, bone tumors, acromegaly *hypophosphatemia: osteomalacia C.Alkaline phosphatase: ALP (30-120units/L) *elevations may indicate metazoic cancers of the bone, pagers disease, osteomalacia D. Serum muscle enzymes: CK-MM **can be elevated in muscle dystrophy *Men:55-170units/L *Women:30-135units/L)

Neurovascular assessment

A. Skin color: inspect the area distal to the injury...no change in pigmentation is a normal finding B. Skin temperature: palpate the area distal to the injury (the dorsum of the hands is the most sensitive to temp...skin should be warm) C. Movement: ask the patient to move the affected area (active motion) or the area distal to the injury (passive motion)..The patient should be able to move without discomfort D. Sensation: Ask the patient if numbness or tingling is present (paresthesia). Palpate with a paper clip (loss of sensation in these areas indicates peroneal nerve or medial nerve damage) E. Pulses: palpate the pulses distal to the injury F. Cap refill (least reliable): press the nail beds distal to the injury G. Pain: ask the patient about the location, nature, and frequency of the pain H. Assess posture and chronic pain *5 Ps: Pain, Pulse, Pallor, Paresthesia (tingling/ numbness...can you feel this), Paralysis (can you move this)

Non surgical Management of osteomyelitis

A. antibiotic therapy B. Splinting -Allow room for swelling *Fewer complications than casting *Swelling is normal from trauma or damage to the skin so allow room when splinting to avoid giving them compartment syndrome C. Closed reduction and immobilization (brace) -Mild sedation -Monitor O2 sat and respirations -Closed reduction is a procedure for putting the pieces of a broken bone back into the right position without surgery. When is it used? Your healthcare provider may use this method if: Your bone is broken in 1 place and the pieces of bone have not gone through the skin

Changes in musculoskeletal system related to aging and related nursing interventions

A.Decreased bone density -Intervention: Teach safety tips to prevent falls. Reinforce need to exercise, especially weight bearing exercises (exercise slows bone loss) B. Increased bone prominence -Intervention: prevent pressure on bone prominence (there is less soft tissue to prevent skin break down) C. **kyphotic posture: widened gait, shift in the center of gravity -Teach proper body mechanics; instruct patient to sit in supportive chairs with arms (correction of posture problems prevents further deformities, patient should support bony structures) D. Cartilage degeneration -provide moist heat such as a shower or warm moist compresses (moist heat increases blood flow to the area) E. decreased ROM range of motion -assess the patients ability to perform ADLs and mobility (The patient may need assistance with self care skills) F. Muscle atrophy (shrinking), decreased strength -Teach isometric exercises (exercises increase muscle strength G. Slowed movement -Do not rush the person; be patient

Aging

Aging: -Puberty: maximum growth -13-35 years: constant formation & destruction -Older Adults: resorption/break down increases, ****older women at GREATER risk for injury!! educate them about fall risk and encourage weight barring exercises (walking, swimming) assess home for fall risk, assess assistance device, ask about ADLs, what they need assistance with and what they are independent with

Patient history

Ask about: -Traumatic injuries/sports injuries -Previous/Current illness/disease (ex: DM because they don't heal quite as well; they are also more sucesptible to acute and chronic osteomelitius ) -ADLs assessment -Physical activity -Occupation: manual labor? Construction? Factory work...heavy lifting, concrete floors, standing all day? Nursing? lol -Allergies: lactose intolerant...how are you getting supplements -Medications: long term steroid use can interfere with bone formation -Ask about tobacco, smokless tobacco (slow healing), alcohol use (malnurished)

A nurse is performing a musculoskeletal assessment on an older adult living independently in a senior housing apartment. What normal physiologic changes of aging does the nurse expect? Select all that apply A. muscle contractures B. slowed movement C. Lordosis D. Antalgic gait E. decreased coordination

B, E

Osteomyelitis

Bone infection -Can occur from Bacteria, virus or fungi (MRSA is the most) in the bone -common... could be from diabetic foot ulcer, or infection introduced during surgery...greater risk from open fractures...think basket ball player :/) -Risk greater w/ open fractures & decrease skin integrity, or surgical repair of fracture -pathogen invasion> tissue inflamation >Edema > exudate > ischemia > necrotic bone = cycle of infection **Most chronic patients are your diabetic patients -Look for fever greater than 101, Signs of infection, bone pain, localized pain, drainage -Hip and knee patients are very susceptible to osteomyelitis -can be acute or chronic

Ligaments

Bone to Bone

Bones are composed of

Composed of cells, protein matrix, & mineral deposits: Haversian System •Very Vascular: microscopic blood vessels & main artery. •TBF of 200-400ml/min •Three types of cells: osteoblasts Build up), osteocytes, & osteoclasts (tear down) •Bone formation called osteogenesis •Red marrow: Hematopoiesis •Yellow marrow: fat cell storage

Complications of fractures: delayed complications

Delayed union & nonunion (if it hasn't healed after 6 months) -Tibia in older adults can be delayed union or nonunion *When a broken bone fails to heal it is called a "nonunion." A "delayed union" is when a fracture takes longer than usual to heal. -Avascular necrosis common in hip fracture patients -Complex regional pain syndrome syndrome

Key features of PE: fat embolism

FAT EMBOLISM: obstruction of the pulmonary vascular bed by fat globules **95% from fractures of the long bones (humerus,femur); occurs usually within 48 hours of injury *Assessment findings: altered mental status (earliest sign) -Increased respirations, pulse, temp -Chest pain, dyspnea, crackles -decreased SaO2 -petechiae (50-60%) late sign -retinal hemorrhage (not common) -mild thrombocytopenia *Treatment: bed rest, gentle handling, oxygen, hydration (IV fluids), possibly steroid therapy, fracture immobilization

Arthroscopy

Fiberoptic tube inserted into joint for direct visualization *Patient must be able to flex knee; exercises prescribed for range of motion prior to and after surgery *Evaluate neuromuscular status of affected limb frequently (5 P's) -Analgesics are prescribed -Monitor for complications 5 P's QH per policy Dishcarge instructions *Can be used for diagnosis or surgical intervention -Can be knee or shoulder...if its knee they have to be able to flex that knee ****If they experience severe joint pain afterwards it is a complication and needs to be reported to the provider -This is an invasive procedure so monitor for signs and systems of infection

Tendons

Muscle to Bone

Osteoclasts vs osteoblasts

Osteoclasts: tear down Osteoblasts: build up

Bone Healing and the 6 stages

Process of regeneration ~ begins Immediately after a fracture *Occurs in six stages - Hematoma & inflammation (first 24 - 72 hrs) -Angiogenesis & cartilage formation (3 days - 2 wks) - Cartilage calcification (3 - 6 wks) - Cartilage removal (3 - 8 wks) -Bone formation/Remodeling (up to 1 yr) *Considerations: Age of patient, Severity of trauma, type of bone injured, infections at site, or avascular necrosis (AVN) *Disease: PVD, Arteriosclerosis, Malnutrition, DM

Care of client in traction

T: temperature (extremity infectiojn R: ropes hang freely A: alignment C: circulation check (5 P's) T: Type and location of fracture I: Increase fluid intake O: overhead trapeze N: No weights on bed or floor

Traction

The application of pulling force to a part of the body *Purposes: -Reduce muscle spasms -Reduce, align, and immobilize fractures -Reduce deformity -Increase space between opposing forces -Used as a short-term intervention until other modalities are possible

Those at risk for bone disease

Vegan patients, Lactose intolerant patients (ask them how they get their calcium intake), The elderly because they are at risk for poor nutrition, -malnutrition, alcoholic, lower income patients , patients with liver or renal disease, inflammatory bowl disorders, and malabsorption...educate them to get vitamin D: sunlight ***Female post menopausal patients are very sucesptible to osteoporosis and calcium loss, so educate them to include supplements

Bone types: •Irregular bones

carpal bones & inner ear

Bone types: Long bones

femur, humerus

Acute osteomyelitis

fever, temp usually above 101 -swelling around the affected area -erythema of the affected area -tenderness of the affected area -bone pain that is constant, localized, and pulsating; intensitifies with movement *Complications: •Bacteremia - potentially life threatening/septic shock, need both anaerobic and aerobic blood cultures •Surgical and non-surgical management: antibiotics to surgical procedures to deride and reconstruct the bone

Break or disruption in continuity of a bone

fracture

Calcitonin is released when there is a

high serum calcium level; it decreases serum calcium -It does so through renal excretion and by inhibiting the activity of osteoclasts, which are the cells responsible for breaking down bone. When bone is broken down, the calcium contained in the bone is released into the bloodstream. *Therefore, the inhibition of the osteoclasts by calcitonin directly reduces the amount of calcium released into the blood

For dull pain give

inderal

Complex regional pain syndrome or Reflex Sympathetic dystrophy (RSD)

is poorly understood and results in chronic pain. There is a genetic component -Triad of Symptoms include: •ANS: color, temperature, sensitivity, sweating, edema •Motor symptoms: paresis, muscle spasms, decrease function •Sensory: intense burning pain -Nursing care: •Pain control! Physical and occupational therapy, Peripheral & spinal neurostimulation, Nerve block •Coping skills: psychosocial •Alternative therapy (yoga)

For muscle spasm give

lioresal and give antidepressant

Pth is activated when there is a

low serum calcium level; it is going to increase the serum calcium level by osteoclastic activity increase...breaking down calcium in the bone to release it into our blood stream -bone resorption aka the process by which osteoclasts break down the tissue in bones and release the minerals, resulting in a transfer of calcium from bone tissue to the blood. *Goal is to increase serum calcium to optimal level

Joints

movement and flexibility of the body

For sharp stabbing burning pain give

neurontin or lyrica

Can a patient lye supine for a myelography?

no the patient will lie face down during examination aka prone

Key features of PE: blood clot embolism

obstruction of the pulmonary artery by a blood blot or clots **85% from DVT in the legs or pelvis; can occur anytime Assessment findings: same as fat embolism EXCEPT NO PETECHIAE Treatment: preventative measures (leg exercises, anti embolism stockings, SCDd), bed rest, oxygen, possible mechanical ventilation, anticoagulants, thrombolytics, possible surgery; pulmonary embolectomy, vena cava umbrella

Bone formation is called

osteogenesis

Bone types: •Short bones

phalanges

Bone types: •Flat bones

scapula (contain blood forming cells)

Arthroscopy interventions:

•NPO 8-12 hrs before, •Informed consent •Pain med as prescribed post procedure •Elastic wrap 2-4 days post procedure •Walking without weight bearing permitted once sensation returns but activity must be limited for 1-4 days •Elevate/ice extremity to minimize swelling

Interventions for an amputation patient

•Positions for stump care? •Relief of pain •Administer analgesic or other medications as prescribed •Change position •Put a light sandbag on residual limb •Alternative methods of pain relief: distraction; TENS unit *Pain may be an expression of grief and altered body image •Promote wound healing •Handle limb gently Provide residual limb shaping Collaborative care- PT, OT, Dietary, psychosocial/chaplain

S/S of PE

•SOB, tachycardia, sudden sharp chest pain that worsens with deep breathing/coughing, rapid breathing, sweating, anxiety, coughing up blood/pink foamy mucous, fainting, dizziness, lightheadedness, heart palpitations

S/S of DVT

•Unilateral edema, pain in extremity, erythema, calf tenderness, red/discolored skin of affected leg, warm to touch, diminished pulses, Homan's sign (dorsiflexion)

Nursing interventions for PE

• Bedrest 24-48 hrs IN SEMI-FOWLERS • Turn/cough/deep breath • Monitor ABG's, SaO2, incentive spirometer • Vital signs, respiratory status & C/V status - Q1-2hrs/PRN • Assess for internal and external bleeding • Homan's sign • Assess for obvious/occult bruising

Complications of fractures

• Compartment syndrome • Crush injuries • Hypovolemic shock -hemorrage -severe pain -angulation (displacement) • Fat embolism syndrome (12-48hrs post injury looks a lot like a PE except with a fat embolism patient will have petichie on abdominal trunk...this is a late sign) *CALL THE PROVIDER, DON'T LEAVE THE ROOM) • Venous thromboembolism (DVT) • Infection: hot spots, streaking, redness, discoloration, etc •Delayed complications include delayed union/nonunion, avascular necrosis, and complex regional pain syndrome

Nursing interventions for DVT

• Elevate legs, maintaining slight knee flexion, while in bed. • Apply warm, moist compresses to right leg using a 2-hour-on, 2-hour-off schedule around the clock. • Administer prescribed analgesics and evaluate effectiveness. • Explain venous thrombosis and its treatment to pt. • Apply anti embolism stockings as ordered; remove for 30 minutes every 8 hrs • Monitor laboratory values to assess effect of anticoagulant therapy; report values outside desired range. • Assist with progressive ambulation when allowed. • Inspect legs and feet and record findings every 8 hours. • Apply SCD's as ordered • Elevate head of bed • Administer oxygen to ensure efficient tissue perfusion

Preventive Nursing care for a patient in traction

• Properly apply and maintain traction - never remove weights • Monitor for complications of skin breakdown, nerve pressure, and circulatory impairment • Inspect the skin throughout the day • Palpate traction tapes to assess for tenderness • Assess sensation and movement • Assess pulses, color capillary refill, and temperature of fingers or toes • Assess for indicators of DVT • Assess for indicators of infection • Promptly report any alteration in sensation or circulation Provide frequent back care and skin care • Regularly shift position • Special mattresses or other pressure-reduction devices • Perform active foot and leg exercises every hour • Elastic hose, pneumatic compression hose, or anticoagulant therapy may be prescribed

•What are indications and nursing interventions with a patient in traction and/or an external fixator?

• Whenever traction is applied, a counterforce must be applied; frequently the patient's body weight and positioning in bed supply the counterforce • Traction must be continuous to reduce and immobilize fractures • Skeletal traction is never interrupted • Weights are not removed unless intermittent traction is prescribed • Any factor that reduces pull must be eliminated • Ropes must be unobstructed and weights must hang freely • Knots or the footplate must not touch the foot of the bed • Trapeze to help with movement for patients in skeletal traction (can help you shift in bed better) •Pin care •Exercises to maintain muscle tone and strength

CT

•Dye or no dye? •Informed consent •Explain procedure •Asses for allegories to iodine/shellfish/dye •Remove wigs, hair pins/clips, partial denture plates, •Asses for pacemakers •NPO 4 hours prior if contrast/dye is to be used •Encourage pt to drink fluids to avid renal complications by excreting the dye post procedure