Chapter 40: Musculoskeletal Care Modalities

A client is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm?

Use of isometric exercises Isometric exercises allow for use of the muscle without moving the bone. Doing isometric exercises every hour while the client is awake will help prevent disuse syndrome. Proper use of a sling does not prevent disuse syndrome. The client should not attempt to reposition the arm in the cast. Abduction and adduction of the shoulder will help the shoulder joint but does not require the use of muscles in the lower arm.

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.

A client was playing softball and dislocated four of his fingers when diving for a ball. The physician manipulated the fingers into alignment and applied a splint to maintain alignment. What type of procedure does the nurse document this as?

Closed reduction

Which is an inappropriate use of traction?

Decrease space between opposing structures Traction is done to increase the space between opposing surfaces. Traction is used to minimize muscle spasms, to reduce, align, and immobilize fractures, and to reduce deformity.

The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.)

Decreased sensory function Excruciating pain Loss of motion

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 he doesn't need a continuous passive motion device."

The nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. What type of pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to the surgery?

Anticoagulation therapy

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

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.

Which intervention should the nurse implement with the client who has undergone a hip replacement?

Instruct the client to avoid internal rotation of the leg.

A client is about to have a cast applied to his left arm. The nurse would alert the client to which of the following as the cast is applied?

Sensation of warmth or heat with application. When a cast is applied, the client needs to be aware that he may feel a sensation of warmth or heat due to the material being mixed with water. The client should not feel an increase in pain during the application. The arm will be held in place to ensure proper alignment during the application. The client should not feel weakness in the extremity. This is more commonly experiences after a cast is removed.

Which principle applies to the client in traction?

Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted. To be effective, the weights must hang freely and not rest on the bed or floor. Knots in the rope or the footplate must not touch the pulley or the foot of the bed. Traction must be continuous to be effective in reducing and immobilizing fractures.

A patient had a total left hip arthroplasty. What clinical manifestation would indicate to the nurse that the prosthesis is dislocated?

The left leg is internally rotated.

A group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify which of the following as an example of skin traction?

Buck's An example of skin traction is Buck's traction. Crutchfield tongs, a Thomas splint, or balanced suspension traction are types of skeletal traction.

The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?

Obtaining a culture A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.

Which is not a guideline for avoiding hip dislocation after replacement surgery.

The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.

Which intervention would the nurse implement with the client in skeletal traction? Select all that apply.

Ensure the pins or wires are covered with caps. Position trapeze within the client's reach. Instruct the client on isometric exercises for immobilized extremity.

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.

The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective?

"Metal pins will go through my skin to the bone." In skeletal traction, metal rods or pins are used to apply continuous traction directly to the bone. Weights are used to apply the traction. Casts, external fixators, or splints are used when the traction is discontinued.

A client diagnosed with a right ulnar fracture asks why the cast needs to go all the way up the arm. What is the best response by the nurse?

"The joint above the fracture and below the fracture must be immobilized." Generally, the joints proximal and distal to the fracture are immobilized to promote healing. The purpose is not for the strength to remain consistent; most clients will lose strength. A spica cast would not be ordered for an ulnar fracture. Although immobilizing the joints above and below fractures may shorten healing time, it does not allow for increased mobility.

Upon reporting to work and receiving report, a nurse has been assigned to provide care for three clients. Each of the clients has called out to the nurses' station requesting assistance. Which client should the nurse see first?

A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter

A hip spica cast:

A hip spica cast encloses the trunk and a lower extremity. A double hip spica cast includes both legs. A body cast encircles the trunk. A walking cast is a short or long leg cast reinforced for strength. A long leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed.

Which would be an inappropriate initial pain relief measure for the client with a cast?

Application of a new cast Most pain can be relieved by elevating the casted part of the body, and by applying cold packs as prescribed and administering analgesics. Application of a new cast is usually not necessary.

A client has a Fiberglass cast on the right arm. Which action should the nurse include in the care plan?

Assessing movement and sensation in the fingers of the right hand. The nurse should assess a casted arm every 2 hours for finger movement and sensation to make sure the cast isn't restricting circulation. To reduce the risk of skin breakdown, the nurse should leave a casted arm uncovered, which allows air to circulate through the cast pores to the skin below. Unlike a plaster cast, a Fiberglass cast dries quickly and can be handled without damage soon after application. The nurse should assess the brachial and radial pulses distal to the cast — not the pedal and posterior tibial pulses, which are found in the legs.

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

What is the best action by the nurse to achieve optimal outcomes when caring for a client with a musculoskeletal disorder who is using a cast?

Educate the client on cast care and complications

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 68-year-old female client who had a total hip replacement is to be discharged because her healing is almost complete. Which of the following would be most important for this client?

Exploring factors related to the client's home environment.

The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Farenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which of the following complications?

Hypovolemic shock

The nurse teaches the client which intervention to avoid hip dislocation after replacement surgery?

Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement. The client should be taught to keep the knees apart at all times, to put a pillow between the legs when sleeping, and to avoid bending forward when seated in a chair.

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

Open reduction

A client's fracture was reduced by surgically exposing the bone and realigning it. The nurse identifies this as which of the following?

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.

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

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.

The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fractured tibia. What should the nurse inform the client prior to the cast being removed?

The skin may be covered with a yellowish crust that will shed in a few days.

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.

The client displays manifestations of compartment syndrome. The nurse expects the client to be scheduled for:

A fasciotomy A treatment option for compartment is fasciotomy.

Which would be contraindicated as a component of self-care activities for the client with a cast?

Cover the cast with plastic to insulate it

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

A nurse is caring for a client with a cast on his left arm after sustaining a fracture. Which assessment finding is most significant for this client?

Fingers on the left hand are swollen and cool. Swollen and cool fingers on the left hand are the most significant assessment findings. They represent altered circulation to the hand caused by the cast. A normal radial, not popliteal, pulse should be present in the left arm; the popliteal pulse is found on the leg. Skin irritation is an abnormal assessment finding but it isn't as significant as altered circulation. Minimal pain in the left arm is expected.

A nurse is giving instructions to a client who's going home with a cast on his leg. Which teaching point is most critical?

Reporting signs of impaired circulation. Although all of these points are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. The other options reflect more long-term concerns. The client should learn to use his crutches properly to avoid nerve damage. The client may exercise above and below the cast, as the physician orders. The client should be told not to walk on the cast without the physician's permission.

Which action would be most important postoperatively for a client who has had a knee or hip replacement?

Assisting in early ambulation. An anticoagulant therapy and early ambulation are important for clients who undergo a knee or hip replacement. A CPM machine or crutches may be provided when prescribed. It is important to encourage clients to express their feelings of anxiety or depression. This is more crucial for clients who undergo an amputation rather than for clients who undergo a replacement surgery.

A client has just undergone a leg amputation. The nurse would closely monitor the client for which of the following during the immediate postoperative period?

Hematoma

To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan?

Increase fiber intake. Immobility increases the incidence of constipation. Increasing fiber intake will reduce GI complications. The weights in traction should never be removed. Inactivity results in fewer calories being burned. Increasing calories would be counterproductive. Reducing fluids will increase the likelihood of constipation.

The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is:

Risk for ineffective therapeutic regimen management. The client without adequate support and resources is at risk for ineffective therapeutic regimen management. A total knee replacement may be used to treat avascular necrosis. While an orthopedic client is at risk for disturbed body image and situational low self-esteem, there is no evidence that these exist for this client.

A client is having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied?

Short leg cast A short leg cast extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. A long leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed. A walking cast is a short or long leg cast reinforced for strength. A hip spica cast encloses the trunk and a lower extremity.

Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?

It promotes healing by increasing circulation and movement of the knee joint. A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.

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.

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

"CPM increases range of motion of the joint."

The nurse is caring for a client with a spica cast. A priority nursing intervention is to:

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 in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse?

"A splint is applied when more swelling is expected at the site of injury." Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint. A fracture will swell as part of the inflammation process. The client would not have to stay longer if a fiberglass cast is applied. Fiberglass cast dry in approximately 30 minutes. An orthopedic doctor is not needed to apply the cast. Many nurses and technicians are trained in proper application of a cast. Some fractures may not be treated with a cast but it would not be appropriate to answer with this response because it does not reflect the actual reason for a splint being applied.

A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign?

Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.

Which is an inaccurate principle of traction?

Skeletal traction is interrupted to turn and reposition the client. Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed.

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period?

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

A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for?

Left hip arthroplasty Clients with arthritis, trauma, hip fracture, or a congenital deformity may have an arthroplasty, or reconstruction of the joint. This procedure uses an artificial joint that restores previously lost function and relieves pain. An arthroscopy is not used to reconstruct a diseased hip. A closed reduction is not an invasive surgical procedure and would not be used to reconstruct the hip. An open reduction and internal fixation is not the treatment for reconstruction of the hip related to a diseased hip.

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 instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.)

"Place pillows between your legs when you lay on your side." "Avoid bending forward when sitting in a chair." "Use a raised toilet seat and high-seated chair."

A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?

A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplastyis the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.

A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?

Apply lotions and take warm baths or soaks. The client should be advised to apply lotions and take warm baths or soaks. This will help in softening the skin and removing debris. The client usually sheds this residue in a few days so the client need not consult a skin specialist. It is not advisable to scrub the area vigorously. The client need not avoid exposure to direct sunlight because the area is not photosensitive.

A client with a long arm cast continues to complain of unrelieved throbbing pain even after receiving opioid pain medication. Which is the priority action by the nurse?

Assess for complications. Unrelieved pain can be an indicator of a complication, such as compartment syndrome. Previous opioid drug use should not influence a complete and thorough assessment. Repositioning the client for comfort may be appropriate once all indications of a complication are ruled out. It is appropriate to teach relaxation techniques to help ease the pain, but assessing for a complication remains the highest priority.

A client who is undergoing skeletal traction complains of 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 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 of the following complications?

Dislocation of the hip

The client with a fractured femur is upset and agitated that skeletal traction will be necessary for 6 to 8 weeks. The client states, "How can I stay like this for weeks? I can't even move!" Based on these statements, the nurse would identify which of the following as the most appropriate nursing diagnosis?

Ineffective Coping related to prolonged immobility. The client is displaying clinical manifestations of anxiety and ineffective coping.

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

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.

After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority?

Maintaining traction continuously to ensure its effectiveness. The nurse must maintain skeletal traction continuously to ensure its effectiveness. The nurse should assess skin for breakdown; however, maintaining skeletal traction takes priority. Traction weights must hang freely to be effective; they should never be supported. The nurse should increase, not restrict, the client's fluid and fiber intake (unless contraindicated by a concurrent illness) to prevent constipation associated with complete bed rest.

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

Notify the physician. 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 patient, 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.

Which action by the nurse would be inappropriate for the client following casting?

Protect the cast by covering with a sheet.

A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize?

Right shoulder slopes downward and droops inward.

A patient arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the patient to describe the pain?

Sharp and piercing The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the patient to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.

The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene?

Weights hanging and touching the floor When checking traction equipment, the weights should be freely hanging. Weights that touch the floor require the nurse to intervene. The body should be aligned in an opposite line to the pull of the traction. The ropes should be freely moving over unobstructed pulleys.

A client with a right leg fracture is returning to the orthopedist to have the cast removed. What would the physician prescribe as further treatment?

physical therapy For some time, the limb will need support. An elastic bandage may be wrapped on a leg, the client may use a cane, and an arm may be kept in a sling until progressive active exercise and physical therapy help the client regain normal strength and motion.