MedSurg I Musculoskeletal 1

olanjones's version from 2016-10-30 00:32

Soft Tissue

Question Answer
Prevention of sprains & strainsExercise regularly, Always stretch prior to activity, Use protective equipment, Good-fitting footwear, Healthy weight, Good body mechanics
Dislocationthe complete displacement/separation of articulating surfaces; causes severe injury to ligaments around the joint
Subluxationthe partial (or complete) displacement of the joint surface; less severe than dislocation (prob heals faster)
S/S of dislocation/subluxAsymmetrical contour, local pain, tenderness, loss of function, swelling in the joint
Treatment of dislocation/subluxprompt reduction, pain relief, immobilization (protect joint)
Soft tissue Nursing Dx- Alteration in comfort, pain r/t disruption of tissue, edema, muscle spasm, ineffective pain relieft
- Impaired physical mobility r/t discomfort, activity restriction or immobilization device
- Risk for further injury r/t instability of joint

Fractures I

Question Answer
Fracturebreak in bone continuity accompanied by localized tissue inflammation and muscle spasm
Causes of FxTrauma, Osteoporosis, Chronic corticosteroid use
Who is more prone to fx?the elderly (as a result of falls)
Factors that contribute to Fx- Trauma/Falls/Physical Abuse, High-risk lifestyle
- Decreased circulation, Malnutrition, Immunocompromised status
- Osteoporosis, Advanced age
- Infection, Neoplasms, Corticosteroid therapy/Cushings
Fx Manis- Deformity (Cardinal sign)
- Pain/tenderness, Edema/swelling (watch for compartment syndrome)
- Muscle spasm, Loss of function
- Ecchymosis, Crepitation, Possible loss of of pulse/sensation distal to fx
Why do fx have a high potenital for NV injury?Damage from the original trauma, Constriction from cast, Constriction from dressing, Poor positioning
S/S of Hip FxExternal rotation, Shortening of extremity, Severe pain & tenderness (could have avascular necrosis d/t disrupted flow of blood to head of femur) Risk of infection, Risk of bleeding in thigh

Fractures II (Repair/Traction)

Question Answer
Closed Reduction (non-surgical) manual realignment of bone fragments to anatomical position, traction typically applied
Open Reduction(surgical) correction of bone alignment through an incision
Internal Fixationbone realignment using wire, screws, pins, plates, rods or nails
Open Reduction Internal Fixation (ORIF)manipulation of the bone through an incision, stabilization of a fracture by direct fixation via surgical wires, screws, pins, rods, plates or methylmethacrylate (bone glue)
External Fixationfixation of fracture by splints, plastic dressings, transfixation pins, or use of an external fixator
Skin TractionShort term (48 – 72 hours usually, in prep for surgery/skeletal traction) - Tape, boots, or splints are applied directly to the skin to maintain alignment and light weight is used (5-10 lbs). Decreases muscle spasms, maintains alignment
Skeletal TractionLonger term - Nails, pins, wire, tongs inserted into bone (completely or partiallly) and heavier weight is used (4-45 lbs). Aligns and immobilizes the injured body part but also Increases infection risk.
Nursing responsibilities for TractionCMS checks – ALWAYS! Also frequent skin/pin site checks
Maintain alignment, Traction should swing free, Quick-release knots
Never twist the affected area (Use trapeze & unaffected extremities)
NI for traction should addressHealing (nutrition, fluids), Immobility (risk of clots, atelectasis), Skin integrity (prevent pressure areas, teach client how to assess site/pin)
External Fixator pin careInspect site q 4-8 º, Clean pin site (sterile technique) BID with H2O2/NS, Abx ointment (if ordered), Lite dressing/Open to air, Place protective covers over ends of pins
Cast careSmooth edges, Support until dry, Elevate about heart; CMS (cap refill, movement, strength) checks ALWAYS! Outline any drainage (time/date), Infection assessment (heat through cast) - Poss window cut-out to assess underlying wound
Cast care TeachingIce/cold penetrates cast (may use ice pack), Protect from getting wet, Exercise joint above & below cast, DO NOT insert foreign objects under cast
Neurovascular AssessmentSix Ps: Pain, Pulses, Paresthesia, Pallor, Paralysis, Polar
Tx for Hip FxPrior to surgery: Usually Buck’s traction for 24-48 hrs (relieves muscle spasms while the client’s condition stabilizes sufficiently to permit surgery). Normal preop teaching + Teach patient about early ambulation w/ assistive device (ie: walker, crutch) - Let them practice (if possible) pre-operatively
Hip ReplacementReplacement of femur head and repair or replacement of socket – glue used lasts about 10 years (usually replaced d/t pain from arthritis/injury). Advantages: substantial pain relief & improved function/quality of life
Knee ReplacementUsually replaced d/t severe pain from arthritis (but could be from injury)

Fracture Complications

Question Answer
S/S of InfectionGeneral - Fever, ↑WBC, General malaise
Site - Pain, Drainage, Immobility, Hot, Odor
Tx of InfectionRemove contaminated tissue, Keep dressings/wound (may require debridement) - Antibiotics (7-10 days)
Compartment SyndromeIncreased pressure within confined myofascial walls that compresses nerves & blood vessels - Compromises the neurovascular function of tissues within that space
Causes of compartment syndromeTight dressings, Tight casts, Tight splints (Notice a trend?) - Usually occurs 4-12º after device applied
S/S of Compartment syndromeExcessive pain (unrelieved with opiods), pain with passive stretch of the affected extremity muscles, pallor, paresthesia, taut skin on injured site, and late signs: paralysis & pulselessness.
If compartment syndrome is suspectedNotify PCP, Loosen the bandage or cast (cut in half to allow assessment), ↓ traction weight to ↓ external circumferential pressures
Tx for compartment syndromeSurgical decompression (fasciotomy) or opening of the tissues to ensure adequate soft tissue decompression.
Venous Thrombosis (secondary to venous stasis) causesIncorrectly applied cast, Incorrectly applied traction, Prolonged bed rest & immobility
NA for VTHoman’s sign, Warmth, Tenderness, Edema (problem spot is usually calf and/or hip - esp after hip surgery)
NI for VT (prevention)Compression gradient stockings, Mechanical compression devices, Position changes, Exercise of extremities, Prophylactic anticoagulants (enoxaparin, warfarin, heparin, ASA)
Fat Embolismfat released from bone marrow of injured bone (driven out by increase in pressure) enters the circulation through draining veins (may lodge in pulmonary capillaries & result in a PE or lead to ARDS -50% mortality)
Bone fxs associated with fat embolismlong bones, ribs, tibia, & pelvis
S/S of fat embolismChange in mental status (agitation→coma), Petechiae (around eyes, armpits, chest, & neck - distinguishes it from S/S of thrombus/air-type embolus), Oxygen desaturation, Tachycardia. Occurs quickly - 60% within 24º of injury, - 80% within 48º of injury
NI for fat embolismOxygenate (O2 per nasal cannula or mask), ↑HOB, Monitor VS (cont. assessment), IV access, Stay with patient, Notify physician (This is an Emergency - pt usually transferred to ICU)

Nursing Diagnosis for Fracture/Surgery

Question Answer
Impaired MobilityAssist with position changes, Teach use of assistive devices (crutches/walker), Monitor limitations of movement, Ensure proper alignment (esp w/ traction), Teach for home (lying/sitting)
Risk for InfectionPrevention - Teach hand washing to patient & family, Use sterile technique with dressing change, Pin care, Adequate diet & fluids
Frequent assessment for infection - Teach patient & family how to monitor, Teach when to call HCP
Antibiotics - Teach patient to complete regimen when home
High Risk Constipation (d/t decreased mobility)Fiber intake, Fluid intake, Exercise, Stool softeners, Use of laxatives PRN
ND for hip fxRisk for peripheral neurovascular dysfunction, Acute pain, Risk for impaired skin integrity, Impaired physical mobility
Nursing care "Do's" for hipselevated seats (esp. toilet), shower chair, pillow btwn legs for first 8 weeks post surgery, keep hip neutral straight when sitting/walking/lying, notify surgeon of severe pain/deformity/loss of function, inform dentist of prosthesis for dental abx prophy
Nursing care "Don't's for hipsDO NOT force into 90 degree flexion/adduction/internal rotation, DO NOT cross legs/put on own shoes or stocking until 8 weeks post surgery, DO NOT sit in chairs without arms
Knee replacement post-opMaintain joint stability and perform post-op exercises (quad setting, straight leg raises after 24 hrs, use of passive-motion machine to increase degree of flexion & extension)

Low Back Pain

Question Answer
Why is low back pain/injury a common problem?Lumbar region bears most of the body's weight, is the most flexible region of the spine, has poor biomechanical structure, contains nerve roots
Risk factorsLow muscle tone, Excess body weight, Poor posture, Cigarette use, Stress, Repetitive movements/heavy lifting, Vibrations, Prolonged sitting
Two injury typesPrimary injury or injury secondary to other musculoskeletal problem (strains, arthritis/degeneration, disk herniation)
Manis of acute LBP< 4 weeks, Associated with activity that causes stress on the lower back, Symptoms often appear later, ↑ Paravertebral muscle spasms (with tx usually improves within 2 weeks)
How is acute LBP diagnosed?Straight-leg raise (puts all the pressure on the low back), Imaging not usually done unless trauma or systemic disease is suspected
Tx for acute LBPMeds (pain, muscle relaxers), Massage/manipulation, Corset/brace, Epidural steroid inj, Brief rest/or activity (depends on person), Avoid aggravating activities
Manis of chronic LBP> 3 months (or repeated incapacitating episodes), Associated with DDD, ↓ physical exercise, Prior injury, Obesity, Structural/postural abnormalities, Systemic disease, OA (lumbar in patients >50, thoracic/lumbar in younger pts), Aggravated by cold/damp weather
Causes of Herniated Intervertebral DiskAge degeneration, Repeated stress/Trauma to spine (nucleus pulposus herniates and may compress nerve roots/spinal cord - s/s depend on location of herniation)
How is herniated disk diagnosed?Imaging (x-ray, MRI, CT, Myelogram, Discogram, Epidural venogram), EMG (r/o pathologic conditions, determine severity of irritation)
Tx of herniated diskLimitation of spinal movement, Local heat/ice, Ultrasound/massage, Traction, TENS, Meds (Surgery if not responsive or persistent neurological deficit)
Disk surgery typesLaminectomy (most common for lumbar -remove protruding disk), Diskectomy (decompress nerve root), Percutaneous laser diskectomy (outpt - local anesthesia/aid of fluoroscopy) - Metal fixation may be used to provide more stability and ↓ vertebral motion (rods/plates/screws)

Back Pain Nursing Process

Question Answer
Subjective Assessment DataHealth hx, Meds, Surgery, Diet, Other tx, Activity, Elimination, Sleep, Role-relationship (how is it impacting their life)
Objective Assessment DataGuarded movement, Depressed/absent Achilles tendon reflex, Positive straight-leg raise test, Tense/tight para-vertebral muscles, ↓ ROM of spine
Nursing DiagnosisAcute pain, Impaired physical mobility, Chronic pain, Ineffective coping, Ineffective therapeutic regimen/management
Nursing GoalsPain relief, No constipation (risk factors: meds/immobility), Adoption of back-protecting movements, Return to previous activity level (within prescribed restrictions)
Nursing care "Do's" for backsUse foot step/stool during prolonged standing, Sleep either side-lying w/ knees/hips bent or on back with a lift under knees/legs, Sit with knees higher than hips, Exercise 15 mins in AM&PM regularly, Avoid chilling during/after exercising, Appropriate body weight, Local heat/cold application, Lumbar roll/pillow when sitting, Don't smoke
Nursing care "Don't's" for backsDO NOT Lean forward without bending knees/Lift anything above elbow level/Stand in a position for prolonged time, DO NOT Sleep on abdomen/back/ with legs straight out, DO NOT Exercise without consulting PCP
Interventions to strengthen supporting muscles (avoid reinjury)Maintain activity limitations, Promote comfort, Educate about LBP health problems, Teach appropriate back muscle exercises (William’s exercises), Meds, Thermotherapy (ice and heat), Sufficient rest, Weight reduction, Surgery
Nursing Interventions (post spinal sx)CMS checks (compare to pre-op), ROM of extremities & assessment of sensation (comparable with preop), Maintain proper alignment of spine at all times until healing has occurred (Flat bedrest 1-2 days depending on extent of surgery, log rolling patients when turning), Pillows under thighs when supine/Between legs when side-lying, Address patient fear of movement by reassuring that proper technique is being used, Most patients require narcotic opioids (morphine) intravenously

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