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26 Cards in this Set
- Front
- Back
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Pressure builds up in the muscle and cuts off blood supply
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Compartment syndrome |
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1.Reduce, realign, and promote healing of fractured bones. 2. Decrease muscle spasm. 3. Immobilization 4. Treat deformities. 5. Rest joints. 6. Treat dislocations & subluxations. 7. Reduce deformities. 8. Prevent contractures. 9. Expand joint space.
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Purpose of traction |
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T - temperature R - roped hang freely A - alignmentC - circulation check (5 P's) T - type and location of fractureI - increase fluid intakeO - overhead trapezeN - no weights on bed or floor |
Care of client in T.R.A.C.T.I.O.N. |
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Death of bone tissue due to a lack of blood supply |
Define: Avascular necrosis |
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- Fasciotomy may be performed to relieve pressure. - Pack & dress the wound after fasciotomy. |
Emergency care of Acute Compartment Syndrome |
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5 Matching questionsHow should the patient with a fx of the shoulder and/or upper arm be assessed? |
C. The client should be assessed while in a sitting or standing position.
Support the affected arm to promote comfort. |
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Most common type of fractureINCORRECTNo answer given |
THE ANSWERA. Fracture of the HIP |
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Pressure at the point of the peroneal nerve may cause:INCORRECTNo answer given |
THE ANSWERB. Footdrop, leading to inability to dorsiflex the foot |
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Musculoskeletal Assessment - FractureI
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THE ANSWER E. - Change in bone alignment - Alteration in length of extremity - Change in shape of bone- Pain upon movement- Decreased ROM - Crepitation- Ecchymotic skin
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Frequent checking for the 7 P's: |
THE ANSWER D. - Pallor- Pain (unrelieved with analgesics) - Pulse (diminished or absent) - Paresthesia (numbness/burning) - Paralysis Poikilothermia (temperature)
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all patients with seizures have epilepsy? . |
FALSE. Just because a patient has a seizure does not mean they have epilepsy
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- Promote comfort- Assess infection - Promote mobility - Teach safety - Vital signs- Flotation, sheep skin - Nutrition - Vital signs- Monitor eliminationINCORRECTNo answer given
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THE ANSWERMusculoskeletal |
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A nurse is providing instructions to a client receiving Baclofen (Lioresal). Which of the following would be included in the teaching plan?ALimit fluid intake.BHold the medication if diarrhea occurs.CRestrict alcohol intake.DNotify the physician if weakness occurs.
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T |
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nursing care includes interventions such as: Women at higher risk due to osteoporosisINCORRECT |
No answer givenTHE ANSWERWho is at higher risk for hip fracture? Why? DislocationINCORRECTNo answer givenTHE ANSWERWhich is considered an orthopedic emergency - dislocation or subluxation? - Increased pain, swelling- Acute groin pain - Shortening of the leg- External rotation of the leg- Restricted ability or inability to move legINCORRECTNo answer givenTHE ANSWERS&S of a Fractured Hip5 True/False questions 1) Do not stractch under cast with a sharp object. 2) Do not get plaster cast wet. 3) Follow MD's orders for weight bearing. 4) PT will teach: crutch walking, limited weight bearing, transferring, etc. → Percentage of persons with fat embolli that dieINCORRECTNo answer givenTHE ANSWERFalseIt should be → Patient teaching with cast (4) - Involves reduction and immobilization of the affected joint - Administration of analgesics for pain relief will be necessary - After reduction, immobilization device is normally applied in order to prevent further injury → Treatment of dislocation involvesINCORRECTNo answer givenTHE ANSWERTrueIt should be → Treatment of dislocation involves Within 4-6 hr after onset → How the should the patient with a fx of the lower extremities and pelvis be assessed?INCORRECTNo answer givenTHE ANSWERFalseIt should be → After the onset of acute compartment syndrome, how long does it take for neuromuscular damage is irreversible? - Used to decrease painful muscle spasms- Form of skin traction to the LOWER LIMB - Provides for straight pull through a single pulley attached to a crossbar at the foot of the bed - The patient is usually not allowed to turn and must remain flat on his back - Use 5-8 lbs of traction - Used mainly in clients with a fracture hip → Buck's Extension TractionINCORRECTNo answer givenTHE ANSWERTrueIt should be → Buck's Extension Traction - Loss of bone mass (in older women) - Joint & disc cartilage dehydrates causing loss of flexibility- Stooped posture, changing center of gravity - Greater risk for falls - Endocrine changes cause skeletal muscle atrophy- Muscle tone decreases → Changes in older adultINCORRECTNo answer givenTHE ANSWERTrueIt should be → Changes in older adult |
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how does the nurse assess circulation after a cast has been applied to the radius? |
depress the patients nail beds and document the time it takes for the color to return |
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what equipment should the nurse have ready for a patient in a hip spica cast for bowel elimination? |
fracture bedpan |
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A client has Buck's extension traction applied to the right leg. The nurse would plan which of the following interventions to prevent complications of the device? a. Give pin care once a shift. b. Massage the skin of the right leg with lotion every 8 hours. c. Inspect the skin on the right leg at least once every 8 hours. d. Release the weights on the right leg for daily range-of-motion exercises. |
Answer: C. Rationale: Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or Inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction. |
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Nursing interventions for ICP |
-elevate the head of the bed to 30-45 degress to promote venous return-place the neck in neutral position to promote venous drainage-position the patient to avoid flexion of the hips, the waist and the neck and rotations of the head (especially to the right). Avoid extreme hip flexion because this position causes an increase in intraabdominal and intrathoracic pressures which can produce a rise in ICP-restrict fluid intake-have a foley in place if pt. is not alert-perform suctioning only as necessary or for no longer than 10 seconds, with administration of 100% oxygen before and after to prevent decreases in PaO2-use a hypothermia blanket to control body temp ( increased body temperature increases brain damage) |
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Nursing interventions for the patient with MS -provide emotional support |
-be alert to emotional changes and mood swings-maintain planned rest periods-encourage self care as indicated-maintain appropriate bathing temperatures-teach self-catheterization is appropriate-institute bowel control program-help to conserve energy and avoid stress |
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Nursing interventions for the patient with MS |
-provide emotional support -be alert to emotional changes and mood swings-maintain planned rest periods -encourage self care as indicated-maintain appropriate bathing temperatures -teach self-catheterization is appropriate -institute bowel control program-help to conserve energy and avoid stress |
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Why should an MS patient avoid hot baths/showers? |
-Because the heat will often increase weakness-ALSO avoid being outside in the heat |
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Signs of the Parkinson's disease triad |
1.Tremor2.Rigidity3. Bradykinesia (slow or retarded movement) see |
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Rheumatoid arthritis |
-Three time as many women as men - 30- 60 years of age are impacted most often - smoking significantly increased the risk of RA - bacterial and viral diease |
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RA is a systemic disorder |
That affect many organ systems (lungs, heart, blood vessels, muscles, eyes and skin) |
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RA is characterized |
- by a chronic inflammaction of the synovial membrane of the diarthrodial. The freely movable joints - periods of remission and exacerbation - repeated inflammation of the joints and surrounding tissue may lead to gross deformity and loss of function |
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Assessment for RA |
Subjective data:malaise, muscle weakness(grip strength) Loss of appetite Generalized aching and feeling of stiffness (esp in the morning hrs) Objective data: joints for edema Tenderness Subcutaneous modules Limitations in ROM Symmetrical joint involvement Fever |
