Skin and Mobility (Exam 4)
Fat Embolism
Cause ARDS S&S include chest pain, hypoxia, foamy sputum, petechial rash,SOB
A client with a fractured fibula has an external fixator device applied. Which interventions to care for this device will the nurse add to the client's plan of care?
Cover sharp fixator pins with caps Elevate the extremity to heart level Monitor neurovascular status q2-4 hrs
Early complications of fractures
DVT/PE Fat embolism Compartment syndrome
The nurse teaches the client which intervention to avoid hip dislocation after replacement surgery?
Do not cross legs while seated Keep the knees apart at all times Put a pillow between the legs when sleeping Avoid bending forward when seated in a chair
The nurse is caring for a client who had a total knee replacement 3 days ago. Which nursing assessment finding requires immediate attention by the nurse?
Drainage from a wound suction device should be less than 25 ml 48 hours after surgery; 100 ml is an excessive amount and may necessitate opening of the wound to remove the blood.
A client with a fractured ulna has a plaster cast applied to the forearm. Which action(s) will the nurse take when caring for the client and cast?
Ensure a free flow of air around the cast. Test cast dryness with the palm of the hand. Determine the cast is dry when it is white and shiny. Do not cover while it is drying because the heat generated by the chemical reaction cannot escape. Handled by only the palms so that indentations in the cast may be prevented. Cloth-covered pillow is preferred to one covered in plastic, which could retain heat and prevent drying.
A nurse is caring for a client after stabilization of a radial fracture. Which actions by the nurse would be appropriate for the client following arm casting?
Handle cast with palms to avoid indentation Circulate air with portable fan Petal/Smooth edges of cast
A nurse is caring for a client 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 client faces a high risk of what infectious complication?
Osteomyelitis
Osteoporosis
RF: low calcium, vitamin D, lack of sunlight, age, smoking, ETOH, caucasian/asian women, menopause, BMI <19, glucocorticoid steroid use, anticonvulsants S&S: fractures, upper back hunch (dowagers hump), loss of 2-3 inches in height, pain on palpation Dx: done density test, DEXA scan (no ca prior)
A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client?
Stress on weakened bone must be avoided
The nurse is caring for the client with chronic osteomyelitis of the jaw with a draining wound. Which client goal is a priority for the client?
The client will experience a tolerable level of pain. The client will demonstrate wound care. The client will maintain adequate nutritional intake. Effective airway clearance is not indicated
The nurse is creating a nursing care plan for a client with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of clients who live with chronic pain should be integrated into care planning?
They can experience acute pain in addition to chronic pain
The client has just been diagnosed with osteomyelitis. What are possible causes of osteomyelitis?
Trauma with open wounds exposed to the environment, surgical contamination, vascular insufficiency (PVD)
After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client?
With the leg on the affected side abducted
Late complications of fractures
avascular necrosis osteomyelitis complex regional pain syndrome delayed union
Osteoarthritis
deterioration of articular cartilage NOT SYMMETRICAL NO WARMTH WORSENS THROUGHOUT THE DAY Herbeden Node (distal) & Bouchards Node (proximal) low impact & strength exercises apply heat/cold compresses and use assisted devices
5 P's
pain, pallor, pulse, parenthesias, paralysis, poikilothermia
Parathyroid Hormone
released in response to low calcium, will increase calcium absorption, and increase osteoclast activity
Compartment syndrome
typically occurs 24-48 hrs after injury s&s = no pain relief from morphine, pain with passive ROM dust appearance, pins and needles, cap refill GREATER than 3 seconds, cooler will need fasciotomy or irreversible muscle pain and damage NI -- perform neurovascular check, loosen/remove restrictive items, notify physician
Thyroid
will release calcitonin in response to high calcium levels in order to decrease osteoclast activity in order to lower calcium levels
The nurse is caring for the client with chronic osteomyelitis of the jaw with a draining wound. Which nursing diagnosis is appropriate for the client?
Acute pain, disturbed body image, imbalanced nutrition Ineffective airway clearance is not indicated
