Chapter 40: Musculoskeletal Care Modalities

The nurse knows to assess a patient for deep vein thrombosis (DVT) by assessing the lower extremities for: ________, ________, ________, and ________.

unilateral calf tenderness, warmth, redness, swelling

List the danger signs of possible circulatory constriction that the nurse should assess for in a casted extremity.

unrelieved pain, swelling, discoloration, tingling,numbness, inability to move fingers or toes, or any temperature changes

brace

used to provide support, control movement, and prevent additional injury. They are custom-fitted to various parts of the body; thus, they tend to be indicated for longer-term use than splints

A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions? A) Improving the patient's level of function B) Helping the patient come to terms with limitations C) Administering medications safely D) Improving the patient's adherence to treatment

Ans: A Feedback: Improving function is the overarching goal after orthopedic surgery. Some patients may need to come to terms with limitations, but this is not true of every patient. Safe medication administration is imperative, but this is not a goal that guides other aspects of care. Similarly, adherence to treatment is important, but this is motivated by the need to improve functional status.

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? a. Balanced suspension b. Thomas splint c. Crutchfield tongs d. 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.

A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A) "Make sure you don't bring your knees close together." B) "Try to lie as still as possible for the first few days." C) "Try to avoid bending your knees until next week." D) "Keep your legs higher than your chest whenever you can."

Ans: A Feedback: After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the patient's legs do not need to be higher than the level of the chest.

Volkmann's ischemic contracture

is a permanent shortening (contracture) of forearm muscles, usually resulting from injury, that gives rise to a clawlike deformity of the hand, fingers, and wrist

total hip arthroplasty

surgical reconstruction of hip with artificial hip joint

pin site care ____________2 mg/mL solution is the most effective cleansing solution.

Chlorhexidine *If chlorhexidine is contraindicated (due to known sensitivity or skin reaction), saline solution should be used for cleansing.

How is Superior mesenteric artery syndrome treated?

Cutting a window in the abdominal portion of the cast or bivalving the cast may be sufficient to prevent or relieve pressure on the duodenum.

An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker? a. 24 hours b. 72 hours c. 1 week d. 2 to 3 weeks

24

The nurse caring for a postoperative hip replacement patient knows that the patient should not cross their legs at any time for ________ after surgery.

4 months

in surgery is If a wound drainage system is used, drainage of 200 to 500 mL in the first 24 hours is expected; by 48 hours postoperatively, the total drainage in ____ hours usually decreases to 30 mL or less, and the suction device is then removed; drains that remain in place for longer than 24 hours are at an increased risk for contamination, and infection may occur

8

nurse can change pressure of pins in external fixation devices

False, the only person that can do that is the doctor

The nurse is caring for a patient postoperatively following orthopedic surgery. The nurse assesses an oxygen saturation of 89%, confusion, and a rash on the upper torso. What does the nurse suspect is occurring with this patient? a. Polyethylene-induced infection b. Pneumonia c. Fat emboli syndrome d. Disseminated intravascular coagulatio

Fat emboli syndrome

nerve palsy

Momentary loss of function caused when cold is applied to a part that has motor nerves close to the skin.

_______ Symptom may include acute onset of dyspnea, tachycardia, confusion, and pleuritic chest pain

PE

What potential immobility-related complications may develop when a patient is in skeletal traction?

Pressure ulcers, atelectasis, pneumonia, constipation, anorexia, urinary stasisand infection, and venous thromboemboli with PE or DVT

Balanced suspension

Provides the countertraction so that the pulling force of the traction is not altered when the bed or patient is moved

A patient had a total left hip arthroplasty. What clinical manifestation would indicate to the nurse that the prosthesis is dislocated? a. The left leg is internally rotated b. The leg length is the same as the right leg c. The patient has discomfort when moving in the bed d. Diminished peripheral pulses on the affected extremity

The left leg is internally rotated

Volkmann contracture

a serious complication of impaired circulation in thearm. Contracture of the fingers and wrist occurs as the result of obstructedarterial blood flow to the forearm and the hand. The patient is unable toextend the fingers, describes abnormal sensation, and exhibits signs ofdiminished circulation to the hand. Permanent damage develops within a fewhours if action is not taken

fasciotomy

a surgical incision through the fascia to relieve tension or pressure *compartment syndrome

compartment syndrome

involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles

Unrelieved pain for a patient in a cast must be immediately reported to avoid ________, ________, ________, and ________

necrosis, impaired tissue perfusion, pressure ulcer formation, possibleparalysis

Superior mesenteric artery syndrome

occurs when the transverse portion of the duodenum is entrapped between the SMA and aorta, causing symptoms of partial intestinal obstruction.

A nursing goal for a patient with skeletal traction is to avoid infection and the development of ________ at the site of pin insertion

osteomyelitis

Dorsiflexion of the foot demonstrates function of the ___________ nerve.

peroneal

how does primary provider assess for pressure ulcer development in a patient with a cast?

the primary provider may univalve, bivalve, or cut an opening (window) in the cast to allow for inspection, access, and possible treatment

plantar flexion demonstrates function of the __________ nerve

tibial

Meniscectomy

- The most common site for meniscectomy is the knee - the procedure refers to the excision of damaged joint fibrocartilage.

If pressure necrosis occurs, the patient typically reports a very painful ______________ and tightness under the cast. The cast may feel warmer in the affected area, suggesting underlying tissue erythema.

"hot spot"

treatment for DVT

- Blood thinners -Clot busters -Compression stockings

traction principles

- Ensure continuous traction - Maintain counter traction - Body alignment - Apply exact amount of weight prescribed - Ropes move freely through pulleys - Weight hangs freely

The nurse must monitor for signs and symptoms of dislocation of the prosthesis, which include:

- Increased pain at the surgical site, swelling, and immobilization - Acute groin pain in the affected hip or increased discomfort - Shortening of the affected extremity - Abnormal external or internal rotation of the affected extremity - Restricted ability or inability to move the leg - Reported "popping" sensation in the hip

Nursing Management of the Patient With a Body or Spica Cast

- Nursing responsibilities include preparing and positioning the patient, assisting with skin care and hygiene, and monitoring for cast syndrome

A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention? A) Application of a walking boot B) Application of a cast C) Education on how to use crutches D) Passive range of motion exercises

B After skeletal traction is discontinued, internal fixation, casts, or splints are then used to immobilize and support the healing bone. The use of a walking boot, crutches, or ROM exercises could easily damage delicate, remodeled bone.

A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care? A) Apply occlusive dressings to the pin sites. B) Encourage the patient to push up with the elbows when repositioning. C) Encourage the patient to perform isometric exercises once a shift. D) Assess the pin insertion site every 8 hours.

D The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites. The patient should be encouraged to use the overhead trapeze to shift weight for repositioning. Isometric exercises should be done 10 times an hour while awake.

A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign? a. Have the patient extend both hands while the nurse compares the volume of both radial pulses. b. Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. c. Have the patient plantar flex both feet while the nurse performs the blanch test on all of the patient's toes. d. Have the patient squeeze the nurse's hands with their hands to evaluate any difference in strength.

Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg.

List four reasons for a patient to have traction application.

To minimize muscle spasms; to reduce, align, and immobilize fractures; to lessen deformities; and to increase space between opposing surfaces within a joint

how to prevent disuse syndrome?

To prevent this, the nurse instructs the patient to tense or contract muscles (e.g., isometric muscle contraction) without moving the underlying bone

The nurse suspects that a patient with an arm cast has developed a pressure ulcer. Where should the nurse assess for the presence of the ulcer? a. Lateral malleolus b. Olecranon c. Radial styloid d. Ulna styloid

Ulna styloid

_______ is one of the most common and dangerous of all complications occurring in the postoperative orthopedic patient.

VTE

physiologic components of cast syndrome

With decreased physical activity, gastrointestinal motility decreases, and intestinal gases accumulate. The patient exhibits abdominal distention and discomfort, nausea, and vomiting, leading to food aversion, poor intake, and weight loss. This may eventually lead to increased abdominal pressure, and ileus.

An artificial joint for total hip replacement involves an implant that consists of ________, ________, and ________.

an acetabular socket, a femoral shaft, a spherical bal

Splinting

bone immobilization by application of an orthopedic device to the injured body part

psychological components of cast syndrome

- similar to a claustrophobic reaction - acute anxiety reaction characterized by behavioral changes and autonomic responses (e.g., increased respiratory rate, diaphoresis, dilated pupils, increased heart rate, elevated blood pressure).

The nurse expects that ________ of weight can be used for a patient in skeletal traction

25 pounds

After a total hip replacement, the patient is usually able to resume daily activities after ________.

3 months

After a total hip replacement, stair climbing is kept to a minimum for ________ to ________ months.

3 to 6

A nurse is emptying an orthopedic surgery patient's closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse's best action? A) Aspirate a small amount of drainage for culturing. B) Advance the drain 1 to 1.5 cm. C) Irrigate the drain with normal saline. D) Inform the surgeon of this finding.

Ans: D Feedback: The nurse should promptly notify the surgeon of excessive or foul-smelling drainage. It would be inappropriate to advance the drain, irrigate the drain, or aspirate more drainage.

traction

a pull to the arm or leg muscles to bring a bone back into place when it is dislocated or fractured

cast syndrome

a rare cause of small bowel obstruction caused by compression of third part of duodenum from narrowing of the angle between superior mesenteric artery and abdominal aorta resulting in symptoms of duodenal outflow obstruction.

A patient with an arm cast reports pain in the extremity. What is a priority nursing action to reduce the incidence of complications? (Select all that apply.) a. Assess the fingers for color and temperature b. Administer a prescribed analgesic to promote comfort and allay 376 anxiety c. Assess for a pressure sore d. Determine the exact site of the pain e. Cut the cast with a cast saw

a, c, d

Skin traction. Care must be taken to avoid pressure on the peroneal nerve at the point at which it passes around the neck of the fibula just below the knee when traction is applied to the lower extremity. Pressure at this point can cause __________

footdrop.

Benefits of external fixation,

immediate fracture stabilization, minimization of blood loss (as compared touse of internal fixation), increased patient comfort, improved wound care, and promotion of early mobilization and weight-bearing on the affected limb, and active exercise of adjacent uninvolved joints.

Nursing Management of the Patient With an Immobilized Upper Extremity

- The unaffected arm will assume all upper extremity activities. - To control swelling, the immobilized arm is elevated above heart level with a pillow. - When the patient is lying down, the arm is elevated so that each joint is positioned higher than the preceding proximal joint (e.g., elbow higher than the shoulder, hand higher than the elbow).

The "6 Ps" indicative of symptoms of neurovascular compromise are

- pain - poikilothermia (i.e., takes on the ambient temperature) - pallor - pulselessness - paresthesia - paralysis

The nurse monitors the patient in a large body cast for potential physiologic cast syndrome, noting bowel sounds every ___ to ____ hours, and reports abdominal discomfort and distention, nausea, and vomiting to the primary provider.

4 to 8

The nurse is caring for a patient with a total hip replacement. How should the nurse assist the patient to turn? a. 45 degrees onto the unoperated side if the affected hip is kept abducted b. Assist from the prone to the supine position only, and the patient must keep the affected hip extended and abducted c. Any comfortable position is acceptable as long as the affected leg is extended d. Assist to the operative side if the affected hip remains extended

45 degrees onto the unoperated side if the affected hip is kept abducted

Compare the advantages of a fiberglass cast to those of a plaster cast.

A fiberglass cast is light in weight and water resistant. It is more durable than plaster and water resistant

A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur? A) Russell's traction B) Dunlop's traction C) Buck's extension traction D) Cervical head halter

Ans: C Feedback: Buck's extension is used for fractures of the proximal femur. Russell's traction is used for lower leg fractures. Dunlop's traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Cervical head halters are used to stabilize the neck.

avascular necrosis

death of tissue due to insufficient blood supply

Joint arthroplasty

surgical implantation of an artificial joint

spica cast care

- Keep the cast dry. - The edges of the cast should be padded as needed to prevent skin irritation - monitor bowel sounds every 4 to 8 hours - position patient frequently (on their side)

Continuous Passive Motion (CPM)

- promote range of motion, circulation, and healing, and to prevent scar tissue from forming in the knee, which could decrease mobility and increase postoperative pain. * The patient's leg is usually placed in this device immediately after surgery

external fixation devices

- used to manage fractures with soft tissue damage. - Complicated fractures of the humerus, forearm, femur, tibia, and pelvis are managed with external skeletal fixators.

skeletal traction

- used when continuous traction is desired to immobilize, position, and align a fracture of the femur, tibia, and cervical spine. - when traction is to be maintained for a significant amount of time

Joint replacement

A surgical procedure in which a mechanical device, designed to act as a joint, is used to replace a diseased joint; most common joints: hip, knee, shoulder, finger; accurate fitting is essential; excellent pain relief; infection is a post-op concern

The nurse is helping to set up Buck's traction on an orthopedic patient. How often should the nurse assess circulation to the affected leg? A) Within 30 minutes, then every 1 to 2 hours B) Within 30 minutes, then every 4 hours C) Within 30 minutes, then every 8 hours D) Within 30 minutes, then every shift

Ans: A Feedback: After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours.

A nurse is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient's care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses? A) Risk for Impaired Skin Integrity B) Risk for Falls C) Risk for Imbalanced Fluid Volume D) Risk for Aspiration

Ans: A Feedback: Impaired skin integrity is a high-probability risk in patients receiving traction. Falls are not a threat, due to the patient's immobility. There are not normally high risks of fluid imbalance or aspiration associated with traction.

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? A) Knots in the rope should not be resting against pulleys. B) Weights should rest against the bed rails. C) The end of the limb in traction should be braced by the footboard of the bed. D) Skeletal traction may be removed for brief periods to facilitate the patient's independence.

Ans: A Feedback: Knots in the rope should not rest against pulleys, because this interferes with traction. Weights are used to apply the vector of force necessary to achieve effective traction and should hang freely at all times. To avoid interrupting traction, the limb in traction should not rest against anything. Skeletal traction is never interrupted.

A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have aperoneal nerve injury? A) Numbness and burning of the foot B) Pallor to the dorsal surface of the foot C) Visible cyanosis in the toes D) Inadequate capillary refill to the toes

Ans: A Feedback: Peroneal nerve injury may result in numbness, tingling, and burning in the feet. Cyanosis, pallor, and decreased capillary refill are signs of inadequate circulation.

The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patient's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A) Increased warmth of the calf B) Decreased circumference of the calf C) Loss of sensation to the calf D) Pale-appearing calf

Ans: A Feedback: Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.

A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient? A) Keep the patient's hips in abduction at all times. B) Keep hips flexed at no less than 90 degrees. C) Elevate the head of the bed to high Fowler's. D) Seat the patient in a low chair as soon as possible.

Ans: A Feedback: The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The patient's hips should be higher than the knees; as such, high seat chairs should be used.

A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication? A) Obstructed arterial blood flow to the forearm and hand B) Simultaneous pressure on the ulnar and radial nerves C) Irritation of Merkel cells in the patient's skin surfaces D) Uncontrolled muscle spasms in the patient's forearm

Ans: A Feedback: Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. It does not result from nerve pressure, skin irritation, or spasms.

A nurse is reviewing a patient's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation? A) Straining during a bowel movement B) Bending down to put on socks C) Lifting items above shoulder level D) Transferring from a sitting to standing position

Ans: B Feedback: Bending to put on socks or shoes can cause hip dislocation. None of the other listed actions poses a serious threat to the integrity of the new hip.

A patient has recently been admitted to the orthopedic unit following total hip arthroplasty. The patient has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding? A) Inform the primary care provider promptly. B) Document this as an expected assessment finding. C) Limit the patient's fluid intake to 2 liters for the next 24 hours. D) Administer a loop diuretic as ordered.

Ans: B Feedback: Drainage of 200 to 500 mL in the first 24 hours is expected. Consequently, the nurse does not need to inform the physician. Fluid restriction and medication administration are not indicated.

A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action? A) Taking an opioid analgesic as ordered B) Applying a cold pack to the injured site C) Performing passive ROM exercises D) Applying a heating pad to the affected muscle

Ans: B Feedback: Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed. Heat may exacerbate the pain by increasing blood circulation, and ROM exercises would likely be painful. Analgesia is likely necessary, but NSAIDs would be more appropriate than opioids.

The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction? A) Balanced traction can be applied at night and removed during the day. B) Balanced traction allows for greater patient movement and independence than other forms of traction. C) Balanced traction is portable and may accompany the patient's movements. D) Balanced traction facilitates bone remodeling in as little as 4 days.

Ans: B Feedback: Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some patient movement, and facilitates patient independence and nursing care while maintaining effective traction. It is not portable, however, and it cannot be removed. Bone remodeling takes longer than 4 days.

A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement? A) "Actually, patients are only on bed rest for 2 to 3 days before they begin walking with assistance." B) "The physical therapist will likely help you get up using a walker the day after your surgery." C) "Our goal will actually be to have you walking normally within 5 days of your surgery." D) "For the first two weeks after the surgery, you can use a wheelchair to meet your mobility needs."

Ans: B Feedback: Patients post-THA begin ambulation with the assistance of a walker or crutches within a day after surgery. Wheelchairs are not normally utilized. Baseline levels of mobility are not normally achieved until several weeks after surgery, however.

A nurse is assessing a patient who is receiving traction. The nurse's assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding? A) The leg that was assessed is free from DVT. B) The patient's tibial nerve is functional. C) Circulation to the distal extremity is adequate. D) The patient does not have peripheral neurovascular dysfunction.

Ans: B Feedback: Plantar flexion demonstrates function of the tibial nerve. It does not demonstrate the absence of DVT and does not allow the nurse to ascertain adequate circulation. The nurse must perform more assessments on more sites in order to determine an absence of peripheral neurovascular dysfunction.

While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient? A) Risk for Infection B) Risk for Peripheral Neurovascular Dysfunction C) Unilateral Neglect D) Disturbed Kinesthetic Sensory Perception

Ans: B Feedback: The hematoma may cause an interruption of tissue perfusion, so the most appropriate nursing diagnosis is Risk of Peripheral Neurovascular Dysfunction. There is also an associated risk for infection because of the hematoma, but impaired neurovascular function is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than neurovascular status.

A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patient's cast care? A) "Cover the cast with a blanket until the cast dries." B) "Keep your right leg elevated above heart level." C) "Use a clean object to scratch itches inside the cast." D) "A foul smell from the cast is normal after the first few days."

Ans: B Feedback: The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge? A) Patient is able to perform ADLs independently. B) Patient is able to perform transfers safely. C) Patient is able to weight-bear equally on both legs. D) Patient is able to demonstrate full ROM of the affected hip.

Ans: B Feedback: The patient must be able to perform transfers and to use mobility aids safely. Each of the other listed goals is unrealistic for the patient who has undergone recent hip replacement.

A patient has just begun been receiving skeletal traction and the nurse is aware that muscles in the patient's affected limb are spastic. How does this change in muscle tone affect the patient's traction prescription? A) Traction must temporarily be aligned in a slightly different direction. B) Extra weight is needed initially to keep the limb in proper alignment. C) A lighter weight should be initially used. D) Weight will temporarily alternate between heavier and lighter weights.

Ans: B Feedback: The traction weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. Weights never alternate between heavy and light.

A nurse is caring for a patient receiving skeletal traction. Due to the patient's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A) Perform chest physiotherapy once per shift and as needed. B) Teach the patient to perform deep breathing and coughing exercises. C) Administer prophylactic antibiotics as ordered. D) Administer nebulized bronchodilators and corticosteroids as ordered.

Ans: B Feedback: To prevent these complications, the nurse should educate the patient about performing deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. Antibiotics, bronchodilators, and steroids are not used on a preventative basis and chest physiotherapy is unnecessary and implausible for a patient in traction.

A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action? A) Administer pain medication as ordered. B) Assess the surgical site and the affected extremity. C) Reassure the patient that pain is a direct result of increased activity. D) Assess the patient for signs and symptoms of systemic infection.

Ans: B Feedback: Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.

The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction. B) Have the patient reposition himself independently. C) Protect the affected leg from internal rotation. D) Keep the hip flexed by placing pillows under the patient's knee.

Ans: C Feedback: Abduction of the hip helps to prevent dislocation of a new hip joint. Rotation and adduction should be avoided. While the hip may be flexed slightly, it shouldn't exceed 90 degrees and maintenance of flexion isn't necessary. The patient may not be capable of safe independent repositioning at this early stage of recovery.

An elderly patient's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? A) The presence of leg shortening B) The patient's complaints of pain C) Signs of neurovascular compromise D) The presence of internal or external rotation

Ans: C Feedback: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.

A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome

Ans: C Feedback: Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.

A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patient's plan of care. What intervention is most justified in the care of this patient? A) Administration of prophylactic antibiotics B) Total parenteral nutrition (TPN) C) Use of a pressure-relieving mattress D) Use of a Foley catheter until discharge

Ans: C Feedback: Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.

A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A) Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious. B) Give the patient a sterile tongue depressor to use for scratching instead of the pencil. C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists. D) Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.

Ans: C Feedback: Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most patients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Benzodiazepines would not be given for this purpose.

The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk? A) Encourage independence with ADLs whenever possible. B) Monitor the patient's nutritional status closely. C) Teach the patient to perform ankle and foot exercises within the limitations of traction. D) Administer clopidogrel (Plavix) as ordered.

Ans: C Feedback: The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Nutrition is important, but does not directly prevent DVT. Similarly, independence with ADLs should be promoted, but this does not confer significant prevention of DVT, which often affects the lower limbs. Plavix is not normally used for DVT prophylaxis.

A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions? A) Shifting one's weight in bed B) Bearing down while having a bowel movement C) Turning from side to side D) Coughing without splinting

Ans: C Feedback: To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance. Bearing down and coughing do not pose a threat to bone union.

A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient? A) The cast will feel cool to touch for the first 30 minutes. B) The cast should be wrapped snuggly with a towel until the patient gets home. C) The cast should be supported on a board while drying. D) The cast will only have full strength when dry.

Ans: D Feedback: A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength. While drying, the cast should not be placed on a hard surface. The cast will exude heat while it dries and should not be wrapped.

A nurse is caring for a patient who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the patient faces a high risk of what infectious complication? A) Cellulitis B) Septic arthritis C) Sepsis D) Osteomyelitis

Ans: D Feedback: Infection is a risk after any surgery, but it is of particular concern for the postoperative orthopedic patient because of the risk of osteomyelitis. Orthopedic patients do not have an exaggerated risk of cellulitis, sepsis, or septic arthritis when compared to other surgical patients.

A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions? A) Use of a cardiopulmonary bypass machine B) Postoperative blood salvage C) Prophylactic blood transfusion D) Autologous blood donation

Ans: D Feedback: Many patients donate their own blood during the weeks preceding their surgery. Autologous blood donations are cost effective and eliminate many of the risks of transfusion therapy. Orthopedic surgery does not necessitate cardiopulmonary bypass and blood is not salvaged postoperatively. Transfusions are not given prophylactically.

A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session? A) Using crutches efficiently B) Exercising joints above and below the cast, as ordered C) Removing the cast correctly at the end of the treatment period D) Reporting signs of impaired circulation

Ans: D Feedback: Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The patient does not independently remove the cast.

A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient's statements would indicate to the nurse that the patient requires further teaching? A) "I'll need to keep several pillows between my legs at night." B) "I need to remember not to cross my legs. It's such a habit." C) "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." D) "I will need my husband to assist me in getting off the low toilet seat at home."

Ans: D Feedback: To prevent hip dislocation after a total hip replacement, the patient must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the patient to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a patient get dressed without flexing the hips beyond 90 degrees.

A patient with a fractured femur is in balanced suspension traction. The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? A) Place slight additional tension on the traction cords. B) Release the weights and replace them immediately after positioning. C) Reposition the bed instead of repositioning the patient. D) Maintain consistent traction tension while repositioning.

Ans: D Feedback: Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. It would be inappropriate to add tension or release the weights. Moving the bed instead of the patient is not feasible.

physical signs of ____ include pain and tenderness at or below the area of the clot, swelling or tightness of the affected leg, possibly with pitting edema, with either warmth or cooling, and skin discoloration

DVT

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for? a. Atelectasis b. Hypovolemia c. Pulmonary embolism d. Urinary tract infection

Pulmonary embolism

late stages of compartment syndrome

Pulselessness, paresthesia, and complete paralysis are found in the late stages of compartment syndrome

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? a. A dull, deep, boring ache b. Sharp and piercing c. Similar to "muscle cramps" d. Sore and aching

Sharp and piercing

The client is scheduled for a meniscectomy of the right knee. The nurse would plan postoperative care based on what surgical procedure? a. Excision of damaged joint fibrocartilage b. Replacement of one of the articular surfaces of a joint c. Incision and diversion of the muscle fascia d. Replacement of knee with artificial joint

a. The most common site for meniscectomy is the knee; the procedure refers to the excision of damaged joint fibrocartilage.

A patient has a cast removed after bone healing takes place. What should the nurse educate the patient to do after removal? (Select all that apply.) a. Apply an emollient lotion to soften the skin b. Control swelling with elastic bandages, as directed c. Gradually resume activities and exercise d. Use friction to remove dead surface skin by rubbing the area with a towel e. Use a razor to shave the dead skin off

a. Apply an emollient lotion to soften the skin b. Control swelling with elastic bandages, as directed c. Gradually resume activities and exercise

The nurse must never ignore complaints of pain from the patient in a cast. Why?

because of the possibility of problems, such as impaired tissue perfusion, compartment syndrome or pressure ulcer formation.

The nurse assesses for perineal nerve injury by checking the patient's casted leg for the primary symptoms of ________, ________, and ________.

burning, numbness, tingling

Pain associated with _________________________ is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents.

compartment syndrome

Immobilization in a cast, splint, or brace can cause muscle atrophy and loss of strength, and can place patients at risk for _________ syndrome, which is the deterioration of body systems as a result of prescribed or unavoidable musculoskeletal inactivity

disuse syndrome

Arthrodesis

fusion of a joint (most often the wrist or knee) for stabilization and pain relief.

if patient with a cast has severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an _________________________

impending pressure ulcer.

open reduction

involves surgical exposure of the bone and the use of plates, screws, or pins to realign the fragments

The earliest indicator of developing compartment syndrome?

pain that seems out of proportion to the underlying injury and pain on passive stretch of other muscles in the immobilized limb * cast, brace, or splint is too tight

Injury to the _________ nerve as a result of pressure is a cause of footdrop (the inability to maintain the foot in a normally flexed position). Consequently, the patient drags the foot when ambulating.

peroneal

Weakness of dorsiflexion or foot movement and inversion of the foot might indicate pressure on the common ________ nerve.

peroneal

A patient has a long-leg cast applied. Where does the nurse understand a common pressure problem may occur? a. Dorsalis pedis b. Peroneal nerve c. Popliteal artery d. Posterior tibialis

peroneal nerve

close reduction

position the bone in correct alignment and applying a case or splint to maintain the position

Nursing Management of a Patient in a Cast, Splint, or Brace

-Swelling is a concern - before applying assess neurovascular status and skin - patient may require a tetanus booster - Assessments first 24 hours and every 1 to 4 hours thereafter to prevent neurovascular compromise related to edema and/or the device.

Nursing Management of the Patient With an Immobilized Lower Extremity

-leg must be supported on pillows to the level of the heart to control swelling - Cold therapy or ice packs (first 1 to 2 says)

Circulatory assessment consists of:

-peripheral pulses, color, capillary refill, and temperature of the fingers or toes. - Manifestations of deep vein thrombosis (DVT), which include unilateral calf tenderness, warmth, redness, and swelling.

After total hip replacement patients should be instructed to dorsi- and plantar flex the ankles and the toes ____ to ____ times every half hour while awake

10 to 20

The patient may require a tetanus booster if the wound is dirty and if the last known booster was given more than ______ years ago.

5

A patient has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply. A) Preventing additional injury B) Immobilizing prior to surgery C) Providing support D) Controlling movement E) Promoting bone remodeling

Ans: A, C, D Feedback: Braces (i.e., orthoses) are used to provide support, control movement, and prevent additional injury. They are not used to immobilize body parts or to facilitate bone remodeling.

A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patient's dorsalis pedis or posterior tibial pulse and the patient's foot is pale. What is the nurse's most appropriate action? A) Warm the patient's foot and determine whether circulation improves. B) Reposition the patient with the affected foot dependent. C) Reassess the patient's neurovascular status in 15 minutes. D) Promptly inform the primary care provider.

Ans: D Feedback: Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the patient may be of some benefit, but the care provider should be informed first.

the most serious complication of casting and splinting?

Compartment syndrome

Name three major complications of an extremity that is casted, braced, or splinted.

Compartment syndrome, pressure ulcers, and disuse syndrome

A ____ is used to immobilize a reduced fracture, to correct or prevent a deformity (e.g., clubfoot, hip displacement), apply uniform pressure to underlying soft tissue, or support and stabilize weakened joints. Generally, it permit mobilization of the patient while restricting movement of the affected body part.

cast

The most effective cleansing solution for care of a pin site is ________.

chlorhexidine solution

After skin traction is applied, the nurse assesses circulation of the foot within 15 to 30 minutes and then every 1 to 2 hours.

true