musculoskeletal treatment modalities

Total Hip Arthroplasty (THA): Nursing Care

1.Avoid flexion > 90 degrees, adduction, internal and external rotation*** 2.Supine with head slightly elevated and affected leg in neutral position 3.Using abduction pillow 4.Cradle boot 5.Avoid turning pt. on operative side - Keep hip in Abduction when turning

Signs of hip dislocation post surgery

1.Increased pain at surgical site, swelling, and immobilization 2.Acute groin pain in affected hip or Inc. discomfort 3.Shortening of affected extremity 4.Abnormal external or internal rotation of affected extremity 5.Restricted ability or inability to move the leg Reported popping sensation 6. NOTIFY THE PROVIDER ASAP

Patient education for a THA

1.Stair climbing may resume 3-6 weeks following surgery 2.Sexual intercourse typically 3-6 months post op... 3.Using assistive device for during dressing 4.Avoid low chairs and sitting for longer than 45 min at a time 5.Can resume driving often 4-6 weeks post op

Principles of traction

1.Traction must be continuous to be effective in reducing and immobilizing fractures 2.Skeletal traction is never interrupted 3.Weights are not removed unless intermittent traction is prescribed 4.Any factor might reduce the effective pull or alter is resultant line of pull must be eliminated 5.The patient must be in good body alignment in the center of the bed when traction is applied 6.Ropes must remain unobstructed 7.Weights must hand freely and not rest on bed or floor 8.Knots in the rope or foot plate must not touch the pulley or the foot of the bed.

what weeks is a hip dislocation most common?

8-12

A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? a) Prepare the patient for opening or bivalving of the cast. b) Obtain an order for a different analgesic. c) Encourage the patient to wiggle and move the fingers. d) Petal the edges of the patient's cast.

A

The client is in skeletal traction with 20lb of traction applied to a right lower leg fracture. Which intervention should the nurse perform at regular intervals? A.Perform pin care B.Remove the weights C.Reposition the right leg D.Have the client perform active ROM exercise on their legs

A

cool setting of hair dryer=

itchy cast relief

The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene? a) Body aligned opposite to line of traction pull b) Weights hanging and touching the floor c) Pulleys without evidence of the obstruction d) Ropes freely moving over pulleys

B

skeletal traction

surgery

why do we use Buck's traction

temporary measure to reduce fracture and decrease muscle spasms

Fasciotomy for compartment syndrome

unrelieved or if removal not working) •Wound left open •Neurovascular assessment •Possible infection

Splints and Braces

•Splint •Preferred method of immobilization during acute injury and initial Tx. •Can be molded to fit contours of body Allow for swelling*

traction

•Using weights or force •Reduce fracture and relieve muscle spasms •Falling out of favor? •Temporary measure -skeletal -skin

Volkmann's contracture

Condition in which the muscles in the palm side of the forearm shorten, causing the fingers to form a fist and the wrist to bend -late sign of MISSED compartment syndrome

The nurse is caring for a client 6 hours postoperative right total knee replacement. Which data should the nurse report to the surgeon? A.A total of 50 mL of serosanguinous drainage in the Hemovac Drain B.Pain relief after using the PCA pump C.Cool toes, distal pulses palpable, nail beds pale bilaterally- cap refill less than 3 seconds Urine output of 30 mL of dark amber colored urine in 3 hours

d

types of casts

Fiberglass- dries in 30 mins- heat(most common) •Plaster- dries in 24-72 hours - more heat

Nursing Considerations THA: preventing infection

Monitor for SSI or systemic signs of infection

Do we elevate compartment syndrome above the level of the heart?

NO

5 P's of the neuromscular assessment

Pain Pulse Pallor Paresthesia paralysis

Care of client in traction

T- Temperature (Extremity, Infection) R - Ropes hang freely A - Alignment C - Circulation Check (5 P's) T- Type & Location of fracture I - Increase fluide intake O - Overhead trapeze N - No weights on bed or floor

When discussing physical activities with the client who has just undergone a right total hip replacement, which instruction should the nurse provide? a) "Limit hip flexion to 90 degrees." b) "Perform rotation exercises each day." c) "Intermittently cross and uncross your legs several times each day." d) "Avoid weight bearing until the hip is completely healed."

a

what approach has a lesser risk of dislocation?

anterior

Anything that is not compartment syndrome

at or above the level of the heart

what not to use for an itchy cast

coat hanger chopsticks

when the pt is sitting the hips should be

higher than the knees

Nursing Care of Casts, Splints, and Braces: prior to application

•Assess site of injury •Neurovascular status- CSMT/5Ps •Education on why necessary •Lacerations/Abrasions treated prior to casting/splinting •Education on what to expect- heat...

Skeletal Traction

•Directly to the bone via pin or wire •Used when traction is needed for a significant amount of time •Remember Principles of Traction •Do not remove weights unless life-threatening situation**** •Monitor CSMTs / Skin breakdown •Pin Care •Hazards of Immobility (P. 1143- 1144) •Trapeze

Total Knee Replacement (Post)

•Dressing with compression bandage •Ice •Monitor neurovascular status •Encourage flexion of the foot q1h •Monitor surgical wound--- drains? •CPM machine ? •Do not use knee gatch or place pillows behind knee •OOB ASAP •Knee is usually protected

Nursing MGMT of Immobilized Lower Ext

•Elevate leg on pillows to level of heart •Utilize ice packs •Encourage gentle toe and ankle exercises •Observe CSMTs •At risk for foot drop •Education on safe ambulation What is wrong with this picture?

External Fixator- NRSG Care- general

•Encourage isometric exercises and mobilization •Removed once soft tissue injuries heal

Nursing MGMT of Immobilized Upper Ext

•Encourage use of unaffected arm •Elevate arm above heart •Use sling when ambulating •CSMTs •Volkmann's Contracture

NRSG MGMT Bucks Traction (Skin)

•Femur fractures •Prior to application •Skin and Circulatory assessment •Monitor -Skin Breakdown -2 person -Nerve damage -Circulatory Impairment- CSMTs -Encourage active foot exercises

External Fixator

•Femur, forearm, tibia, humerus, pelvis •Surgical procedure •Prepare pt. psychologically •Discomfort should be minimal •Sometimes Pt.'s can even bear weight •Never adjust clamps* •Elevate extremity •Monitor CSMTs

Casts

•Immobilize a reduced fracture •To correct or prevent deformity •Apply uniform pressure to soft tissue •Support and stabilize weakened joints •Mainstay of treatment for fractures •Fiberglass- dries in 30 mins- heat •Plaster- dries in 24-72 hours - more heat •Arms, legs, body, spica

pressure ulcers

•Impaired sensation most at risk •"Pt reports pain and tightness" •Inspect painful areas for drainage •Palpate for warmth •Odor •Window cut in cast

compartment syndrome

•Increased pressure in confined space --> compromised perfusion •Needs Immediate Attention •Extreme Pain - Unrelieved by meds --> Compromised CSMTs ☹ •Complain cast/splint is too tight •Educate pts on signs & symptoms

External Fixator- NRSG Care- Pin Care

•Inspect q shift •Clean at least daily •Clean each pin site separately •Chlorhexidine* or Hydrogen Peroxide •Cotton tip applicator

Getting Cast Removed

•Instruct pt. to not remove themselves •Emotionally support pt. •Support body part after removal •Wash and lubricate skin •Educate pt. on activity level and exercise •Pt will probably be in PT

Joint replacement: arthroplasty

•Joint disease, disability, deformity •Relieve pain, improve stability and function •Hip, Knee (most common) •Shoulder, elbow, wrist, ankle (least common) •Metal and high density polyethylene •Excellent pain relief •Return of motion depends

management of compartment syndrome

•Loosening/removing bandage •Bivalving/Univalving cast •Maintain limb alignment •Limb at heart level / Do not elevate limb higher then heart •Fasciotomy

other nursing considerations for THA

•Managing Pain •Observing anemia

Nursing Considerations THA- wound drainage

•May have surgical drains Monitor drainage on DRSG

disuse syndrome

•Move joints through ROM •Have pt. tense or contract muscles with moving underlying bone •Isometric exercise q1h while awake

Nursing care after application of casts, splints and braces

•Neurovascular Checks****q1h •Compare to opposite extremity •Monitor pain very closely*** •Note increasing pain med requirements & unrelieved pain** ☹ •Elevate Extremity •Ice or cold packs •Notify provider of any signs of decreased circulation ASAP •Observe for infection

skin traction

•Non-surgical •Bucks Most common

Cast syndrome

•Psychological (Claustrophobic Reaction) •Physiologic (Mesenteric artery syndrome) •Monitor Abd pain, distention, nausea, and vomiting, and bowel sounds •May need Abd portion of cast removed •-->NGT / IVF

Nursing MGMT of Body or Spica Cast

•Remain in place for 4-6 weeks •Major concerns for Immobility •Need major ADL support

nursing considerations THA DVT prevention

•SCDs, Pharmacologic, Progressive ambulation •Monitor for S/S of DVT & PE & CSMTs •Dorsi and plantar flex ankles and toes 10-20 times every hour while awake

Nursing Care of THA getting up

•Within a day after surgery •Keep affected leg in extension •Use pillows or abduction pillow •May or may not be able to bear weight - walker / crutches •Use a high seat, semi reclining chair with arms rests •Pt's hips should be higher than knees •Do not elevate legs or cross them •Raised toilet seat •Do not bend at the waist past 90 degrees

Braces

•provide support, control movement, and prevent injury •Used long-term