Mobility

active ROM

can be evaluated by asking the patient to move each joint through the ROM by themselves if patient cannot actively move a joint through ROM, ask them to relax the muscles in the extremity. hold the part with one hand above and one hand below the joint to be evaluated and allow passive ROM to evaluate joint mobility

To help minimize calcium loss from a hospitalized client's bones, the nurse should

encourage the client to walk in the hall

The nurse is reviewing the medical record and finds orders to apply graduated compression stockings on a client. What is the next action by the nurse?

measure the clients legs

lower-extremity fractures - Hip Fractures (p.1048)

most common injury in older adults osteoporosis is the biggest risk factor for hip fractures

The nurse is caring for an elderly client with a fractured hip who is on bed rest. Which nursing interventions would be included on the plan of care?

turn the client every 2 hours and encourage deep breathing and coughing

The nurse is caring for a client with knee high antiembolism stockings. Which assessment finding does the nurse prioritize as needing notification of the healthcare provider?

unilateral swelling

what nutritional supplements help with mobility?

vitamin D & calcium bisphosponates are antiresorptive agents that slow or stop the reabsorption of calcium from the bone these agents are used to treat osteoporosis

collaborative care with a patient w/ amputation

prosthetists, rehabilitation therapists, psychologists, case managers, and physiatrists

A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches?

"After advancing both crutches the length of one step, move your 'good' leg forward."

The nurse is caring for a client who has been diagnosed with a strained ankle. The client asks the nurse what the difference is between a sprain and a strain. How should the nurse respond?

"Sprains involve injury to the ligaments and strains to tendons or muscles."

interventions for below-knee amputation

1) prevent edema 2) do not allow the residual limb to hang over the edge of the bed 3) discourage long periods of sitting to lessen complications of knee flexion 4) place the client in prone position throughout the day

To control the patient's pain, which order does the nurse anticipate will be given by the provider? A.Morphine 1 to 2 mg IV B.Meperidine 50 mg IM C.Acetaminophen 650 mg by mouth D.Apply ice packs to the right ankle

A

a nurse is preforming a musculoskeletal assessment on an older adult living independently. what normal physiological changes of aging does the nurse expect? A. muscle atrophy B. slowed movement C. scoliosis D. arthritis E. widened gait

A B D E

Which patient statement about self-care indicates a need for further teaching by the nurse? A."I am going to swim at the YWCA." B."Low-fat yogurt is on my grocery list." C."My husband is getting rid of our throw rugs." D."Joining a bowling team will help me exercise."

A Low-Impact

The client has just returned to bed following the first ambulation since abdominal surgery. The client's heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air. The client reports being "a little short of breath," but does not have dizziness or pain. What should the nurse do next?

Allow the client to rest for a few minutes, then re-assess.

The patient is diagnosed with osteoporosis. Which intervention by the nurse would be appropriate? A. Teach her to cut down on her cigarette smoking. B. Recommend walking for 30 minutes three to five times a week. C. Suggest a diet that is high in protein and calcium but low in vitamin D. D. Tell her to include high-impact activities, such as running, in her exercise regimen.

B

The patient's ankle heals, and his cast is removed. What teaching will the nurse provide regarding care for his ankle? A."Scrub your lower leg and ankle to remove dead, scaly skin." B."Wear a support stocking to prevent lower extremity swelling." C."Keep your ankle in a low position to facilitate perfusion to the healed bone." D."Exercise vigorously at least three times a day as directed by the physical therapist."

B

The nurse is caring for an elderly patient who needs help with ADLs. Which is most important for the nurse to understand to avoid injury when implementing care?

Bending and twisting while providing care may cause injury

upper-extremity fractures

Clavicle (splint or bandage); scapula (immobilize); humerus or olecranon(closed reduction with cast/splint); radius and/or ulna (closed reduction with cast); wrist and/or hand (closed reduction with cast)

A client recovering from surgery needs to be ambulated in the room twice a day. For which reason should the nurse question the use of a gait belt when ambulating this client?

Client is recovering from abdominal surgery.

Amputation of lower extremity

Complications: -hemorrhage -infection -phantom limb pain -neuroma -flexion contractures Post-Op Interventions: -mark drainage and bleeding on the dressing if it occurs -evaluation sensation -do not elevate limb on a pillow -FIRST 24 HOURS: elevate the foot of the bed to reduce edema; the keep the bed flat to prevent hip flexion contractures, if prescribed by the HCP -AFTER 24-48 HOURS: position the client prone to stretch the muscles and prevent hip flexion contractures , if prescribed -wash with mild soap -massage the skin toward the suture line if prescribed

The patient tells the nurse that he was jogging to train for a marathon, which has been a lifelong goal. He asks, "Will I ever be able to run a marathon now?" What is the appropriate nursing response? A."The doctor will be able to tell you that." B."Of course, after this heals, you will be fine." C."It is unlikely that your ankle will regain the necessary strength." D."It sounds like you are concerned that you may not be able to achieve your goal."

D

A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. What should the nurse do first?

Draw a mark around the site.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place.

complications of amputation

Hemorrhage Infection Skin breakdown Phantom limb pain Joint contracture

Implantation - Acute Care

Metabolic -Provide high-protein, high-calorie diet with vitamin B and C supplements. Respiratory -Cough and deep breathe every 1 to 2 hours. -Provide chest physiotherapy.

crutch gaits

More than one gait reduces patient's fatigue (different combination of muscles used for each) two-point gait: used w/ partial weight-bearing limitations and w/ bilateral lower extremity prosthesis three-point gait: used for partial weight-bearing or no weight-bearing on the affected leg; requires that the client has strength and balance four-point gait: used if weight-bearing is allowed and 1 foot can be placed in front of the other swing-to gait: used when there is adequate muscle power and balance in the arms and legs swing-through gait: used when there is adequate muscle power and balance in the arms and legs

compression fractures of the spine

Most are associated with osteoporosis rather than acute spinal injury. Multiple hairline fractures result when bone mass diminishes. Nonsurgical management includes bedrest, analgesics, and physical therapy. Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected. after treatment, advise patients to report any s/s of pain or redness at site, do not take a bath for 1 week

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings?

Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application

A client has a leg immobilized in traction. Which observation by the nurse indicates that the client understands actions to take to prevent muscle atrophy?

The client performs isometric exercises to the affected extremity three times per day

spinal stenosis treatment

Treatment = analgesics (e.g., NSAIDs), physical therapy, epidural injections, surgical decompression

A nurse is caring for a pediatric client with scoliosis who has to wear a brace. The nurse should develop a teaching plan with the client to include which instruction?

Wear a form-fitting t-shirt under the brace.

osteoporosis

a chronic disease of cellular regulation in which bone loss causes significant decreased density and possible fracture lack of calcium and estrogen or testosterone calcium levels can be low or normal diagnosed when a person has a T-score at or lower than -2.5 most important exercise is walking for 30 min, 3-5 days a week

what does reduced lung expansion lead to?

atelectasis (an airless state of the alveoli)

Osteomyelitis

bacteria, viruses, or fungi can cause infection in bone inflammation produces an increased vascular leak and edema, often involving the surrounding soft tissues

how does immobility affect the GI?

constipation, reduced appetite, anorexia and impaired nutritional status

what is the most common upper-extremity fracture

distal radius fracture (DRFs) colles fracture: can occur when a person attempts to break a fall by landing on the heal of the outstretched hand when the wrist is extended. often the result of that is called "dinner fork injury) Smith fracture: occurs from a fall on a flexed wrist

How does immobility affect the musculoskeletal system?

osteoporosis

Ankle-Brachial Index (ABI)

ratio of the ankle systolic pressure to the brachial systolic pressure; an objective measurement of arterial disease that provides quantification of the degree of stenosis normal is 0.9 or higher

how does immobility affect the integument system?

reduces perfusion to the tissues and shearing forces damage the skin

how does immobility affect the urinary system?

renal calculi (results from stasis of urine in the renal pelvis and bc of increased circulating serum calcium levels), urinary stasis, and infection bladder loses tone

shear

shearing forces pulling skin layers away from deeper tissue blood vessels become kinked, obstructing circulation

The nurse enters the room to do an initial assessment on a client with a fracture of the femoral head. What would be the expected findings on the affected limb?

shortening of the affected extremity with external rotation

an ultrasound may be used to detect what?

soft-tissue disorders, traumatic joint damage, osteomyelitis, and surgical hardware placement

what are the 3 classifications of joints?

synarthrosis (nonmoveable) amphiarthrosis (slightly moveable) diarthrosis (freely moveable)

how can women slow the process of bone loss?

taking vitamin D and calcium supplements and increasing these nutrients in their diets

self-management for amputation - home care

the limb should be rewrapped 3 times a day with an elastic bandage applied in a figure-eight manner

pulmonary embolism (PE)

the movement of foreign particles (blood clot, air, fat) into the pulmonary circulation Assessment: -Restlessness & apprehension -Sudden onset of dyspnea & chest pain -Cough, hemoptysis, hypoxemia, or crackles Interventions: -Notify HCP immediately -Administer oxygen and other prescriptions; IV anticoagulant therapy may be prescribed

herniated disc

the nucleus of the disk protrudes into the annulus, causing nerve compression cervical disk herniation occurs at the C5 to C6 and C6 to C7 monitor sensory perception bed rest immobilize w/ cervical collar or brace apply heat to reduce muscle spasms and ice to reduce inflammation and swelling maintain head and spine alignment education: -avoid flexing, extending and rotating the neck -avoid prone position and maintain the neck, spine and hips in a neutral position while sleeping -minimize long periods of sitting

body mechanics

the proper use of the body to facilitate lifting and moving and prevent injury

Amputation

the removal of a part of the body

The nurse is planning care for several clients. Which client does the nurse prioritize as being at highest risk for developing a pulmonary embolism?

a client who has fractures of the pelvis and right femur

When the client who has had a hip replacement is lying on the side, the nurse should place pillows or an abductor splint between the legs to prevent:

adduction of the hip joint

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment?

free, easy movement of the joints

To promote early and efficient ambulation for a client after an above-the-knee amputation, the nurse is aware that the leg will need to be positioned in which way?

in functional alignment

health promotion and maintenance for reducing the risk of amputation

lifestyle - eating right, not smoking, maintaining a healthy weight, regular exercise

lower back pain

- Disk herniation - Lumbar muscle strain - Lumbar spinal stenosis - Malingering - Ankylosing Spondylitis - Cancer - AAA

complications of fractures

- avascular necrosi - compartment syndrome - fat embolism - infection & osteomyelitis - pulmonary embolism

body alignment/posture

-Brings body parts into position that promotes optimal balance and body function -Person maintains balance as long as line of gravity passes through center of gravity and base of support

Alkaline Phosphatase (ALP)

30-120 units/L it is an enzyme normally present in blood and increases with bone or liver damage

A 52-year-old man is brought to the ED with a deformed right ankle. He states that he was jogging close to the edge of a hillside, and that he tripped and fell down the hill. There are no openings in the skin. A pulse cannot be obtained by touch to the right foot, which is pale and cool to palpation. The patient rates his pain as an "8" on a 0-to-10 scale. What is the priority nursing action at this time? A.Prepare for reduction. B.Administer pain medication. C.Obtain a Doppler of the right foot pulse. D.Notify the physician of the lack of a pulse in the right foot.

C

types of fractures

Closed/Simple: skin over the fracture remains intact Comminuted: The bone is splintered or crushed Complete: The bone is separated completely by a break into 2 parts Compression: A fractured bone is compressed by another bone Depressed: Bone fragments are driven inward Greenstick: One side of the bone is broken and the other is bent; these fractures occur most commonly in children Impacted: A part of the fractured bone is driven into another bone Incomplete: Fracture line does not extend through the full transverse width of bone Oblique: The fracture line runs at an angle across the axis of the bone Open or Compound: The bone is exposed to air through a break in the skin, and soft tissue injury and infection are common Pathological: The fracture results from weakening of the bone structure by pathological processes such as neoplasia; also called spontaneous fracture Spiral: the break partially encircles bone Transverse: The bone is fractured straight across

A 40-year-old patient has a tight cast on the left lower leg. Which assessment finding would prompt the nurse to assess further for early signs of compartment syndrome? A.Numbness of the toes B.Paralysis of the left leg C.Diminished pulse in the left lower extremity D.Pain more intense than expected based on initial injury

D

The nurse is caring for a patient who sustained a knee injury at work. The nurse explains that which diagnostic test best demonstrates soft tissue damage in the area of the injury? A.Knee x-ray B.Electromyography (EMG) C.Computed tomography (CT) D. Magnetic resonance imaging (MRI)

D

osteosarcoma

the most common bone cancer in children (occurs b/w 10-25 y/o) characterized by injury or normal growing pains limited ROM

A client has a Pearson attachment on the traction setup. What is the purpose of this attachment?

to support the lower portion of the leg

Collaborative interventions -General care guidelines for immobilized patient

•Frequent turning, positioning, alignment •Skin assessment and skin care •Range of motion •Deep breathing •Weight bearing (if possible) •Measures to optimize elimination •Nutrition

fat embolism (priority nursing actions)

1) notify the HCP 2) administer oxygen 3) administer IV fluids as prescribed 4) monitor VS and respiratory status 5) prepare for intubation and mechanical ventilation if necessary indicated by arterial blood gas values 6) CT or X-ray follow up 7) documentation

interventions for above-knee amputation

1) prevent internal or external rotation of the limb 2) place a sandbag, rolled towel, or trochanter roll along the outside of the thigh to prevent external rotation 3) place the client in prone position throughout the day

joint contracture

an abnormal and possibly permanent condition characterized by fixation of the joint

how does a nurse screen for scoliosis?

ask the patient to flex forward from the hips and inspect for a lateral curve in the spine

reduction

closed reduction: nonsurgical intervention preformed by manual manipulation open reduction: involves a surgical intervention; the fracture may be treated w/ internal fixation devices

Remodeling

ongoing maintenance of bone tissue through a process in which new bone tissue replaces existing bone tissue in bone-remodeling units requires adequate nutrition, hormonal regulation and bloody supply

How does immobility affect the respiratory system?

pneumonia, decreased respiratory effort, and decreased oxygenation of blood

what musculoskeletal changes occur with aging?

thinning of vertebral disks shortening of the spinal column onset of kyphosis w/ spinal column compression occur bone density decreases and becomes brittle cartilage becomes rigid and fragile loss of resiliences and elasticity of ligaments muscle mass and tone reduce significantly

compartment syndrome

tough fascia surrounds muscle groups, forming compartments from which arteries, veins, and nerves enter and exit at the opposite ends -occurs when pressure increases within 1 or more compartments, leading to decreased blood flow, tissue ischemia, and neurovascular impairment --- neurovascular damage may be irreversible if not treated within 4-6 hours after the onset Assessment: - unrelieved or increased pain in the limb - tissue that is distal to the involved area becomes pale, dusky, or edematous - pain w/ passive movement - loss of sensation - pulselessness ( a late sign) Interventions: - Notify HCP - Continue to elevate the affected extremity - if severe, assist the HCP with fasciotomy to relieve pressure and restore tissue perfusion - loosen tight dressings or bivalve restrictive cast as prescribed

non-weight bearing pelvis fracture

treatment can be as minimal as bedrest on a firm mattress or bed board patient may need stool softeners bc of hesitancy to move usually heal in 2 months

neuroma

tumor made up of nerve (cells) and forms often in amputations of the upper extremity