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58 Cards in this Set
- Front
- Back
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What do you call a small blood vessels rupture and bleed into soft tissues. The skin remains intact however. What produces this sort of injury? |
Contusion (ecchymosis, buise) |
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Contusion with a large amount of bleeding? |
Hematoma |
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What are the clinical manifestations of contusions? |
(PDs) Pain or tenderness to touch Discoloration of the skin (purple or blue in colour, but when the blood begins to be reabsorbed, it turns a little yellow until it disappears) Swelling |
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Nursing intervention and rationales for contusions? |
Apply ice for 15 to 20 minutes at a time over 12 to 36 hours -> vasoconstricting effects Elevate the extremity involved -> reduces edema and suppresses pain (note that most contusions are resolved in 1 to 2 weeks) |
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What do you call the soft tissue injury when forces are going in opposite directions causing ligaments to overstretch, twits and/or tear. |
sprain |
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Clinical manifestations of a sprain |
Depends on the severity of the sprain: -feeling a pop or tear -pain that increases with motion -edema -contusion (bruising) -> caused by blood vessels rupturing -loss of functional ability of the joint |
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Mise en situation: There is a soccer player that tore the cruciate ligaments in her L knee. What 3 nursing diagnoses could you give her? (using 3 different needs) |
1. UMN for comfort due to pain related to tore cruciate ligament 2. UMN for activity due to decreased mobility related to tore cruciate ligament 3. UMN for safety due to risk of injury related to altered musculoskeletal to tore cruciate ligament |
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Nursing intervention for sprains? |
RICE R-est I-ce C-ompression E-levation |
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Why wouldn't you want to apply ice for more than 20-30 minutes at a time? |
You don't want to do damage to the cells. |
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What is particular about Applying ice to the skin? |
It can't be placed directly to the skin (wrapped in cloth or something) |
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What is the rationale behind RESTING a SPRAIN? |
prevents additional injury promotes healing -limit weight bearing for at least 48 hours |
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What is the rationale behind applying ICE to a SPRAIN? |
-produces vasoconstriction (decreases bleeding and edema) -Reduces perceived pain (reduction of discomfort) |
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What is particular about applying a compression? |
Don't wrap it too tightly to not cut off circulation Also wrap inverse proximodistal |
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What is the rationale behind applying a COMPRESSION to a SPRAIN? |
Control bleeding Stabilize and support the joint Reduce edema Also wrapping reverse proximodistal encourages fluid return |
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What can happen if a joint is immobilized for too long? |
muscle atrophy can occur (in DAYS) |
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What has to be when applying a compression? |
Neurovascular assessment peripheral vascular assessment (color, temp, cap refill, peripheral pulses and edema) peripheral neurological assessment (sensation movement, pain) |
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CTMS |
color temperature movement sensation |
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CWMS |
color warmth movement sensation |
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STMP |
Sensation temperature movement pulse |
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What is particular about ELEVATION in regards to a sprain? |
Above the heart |
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what is the rationale behind ELEVATION in a SPRAIN? |
Promotes venous return to decrease edema and impedes further edema. |
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What might a nurse do to reduce pain and inflammation other than ice? |
NSAIDS
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What should be done after 48 hours after a sprain? |
Heat every 15-20 mins prn -relieve muscle spasms -promote vasodilation -promote absorption of blood and fluid from the area |
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What should be recommended to a patient that had a sprain 2-5 days ago? why? |
To do light activity, use the limb -> promotes circulation and resolves contusion and swelling NOTE: ONLY 1st DEGREE SPRAIN |
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If the sprain if of the 2nd or 3rd degree what might be done? |
An arthroscopic surgery: torn ligaments are sutured together |
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What is the term for microscopic muscle tears that are a result of overstretching muscles and tendons. |
strains |
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Clinical manifestations of a strain? |
Like sprains: Pain Edema bruising decrease in function particular: Muscle spasm Muscle weakness |
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What could the intervention for a need for comfort be? (for a strain) |
RICE NSAIDs Muscle relaxant |
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What could the intervention for activity be? (for a strain) |
Progressive exercises Refer to pt for appropriate exercises |
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What could the intervention for safety be? (for a strain) |
RICE Monitor neurovascular function assistive devices avoid over-activity -> teach pt that the activity should never cause pain or swelling as a result. |
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When is surgery maybe needed in strains? |
3rd degree |
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What is the term used for a temporary displacement of bones from their normal position within the joints? |
dislocation |
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What is a partial dislocation? |
When the dislocation is not complete When the joint is partially dislocated, or subluxed |
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What is this a picture of? |
subluxation or partial dislocation |
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What are the clinical manifestations of a dislocation |
May be not visible deformity -length of the extremity is affected -rotation is affected (limb may be externally rotated) [LISP] Loss of function Immobility or limited movement Swelling Severe pain worsened by motion of the joint |
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Nursing intervention related to a dislocation? |
Prompt attention in the orthopedic emergency -ruptured blood vessels -Avascular necrosis (AVN) -> bone cell death as a result of inadequate blood supply Realign the dislocated portion of the joint (reduction) Immobilize the extremity |
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What intervention should be done in relation to a need of comfort? (dislocation) |
Apply ice (or heat) use appropriate splint or joint immobilizer NSAIDs or other analgesia as ordered |
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What intervention should be done in relation to a need of activity? (dislocation) |
Refer pt for appropriate exercises and ROM |
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What are the intervention should be done in relation to a need of safety? (dislocation) |
[nia] monitor the neurovascular function maintain immobilization as ordered after reduction use assistive devices (sling,crutches) |
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What are the 4 sports related injuries? |
Meniscus injury ACL injury (anterior ligament injury) Rotator cuff injury Tendinitis |
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What muscle is related to the rotator cuff injury? |
Supraspinatus (one of the 4 muscles in the shoulder that control arm movement) |
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Clinical manifestations of a rotator cuff injury? |
Shoulder weakness when lifting/rotating arm Decreased ROM (no abduction and external rotation of the shoulder) Considerable pain (especially when arm is abducted between 60 and 120 degrees) |
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Nursing interventions for a rotator cuff injury? |
Rest the joint limit overhead activity Support shoulder with a sling NSAIDS Some physicians may administer corticosteroid (cortisone) injections into the joint (reduce inflammation) When the acute manifestations subside: -Active exercices that address ROM and strengthen the rotator cuff muscles |
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What is the term used for irritation and inflammation of tendons around a joint (this is a result of an overuse or incorrect use of the area)? |
Tendinitis |
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What are the clinical manifestations of tendinitis? |
Pain over area of inflammation Edema of surrounding soft tissues |
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What are the interventions that should be done to someone experiencing tendinitis? |
Rest Ice NSAIDs Splint/orthosis Steroid injections |
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What is the most common ligament tear? |
ACL ligament (anterior cruciate ligament) |
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How does a ligament tear usually occur? |
Result of hyperextension, internal rotation, extremes of external rotation, and deceleration ACL tears usually happen due to athletic activities |
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What are the clinical manifestations of a ligament tear? |
A loud "pop" or snap can be heard at the time of the injury Pain Severe Edema The knee is unstable Full extension is difficult |
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What are the nursing interventions that should be done in regards to a ligament tear? |
RICE Brace (immobilization NSAIDs Use of crutches Physical therapy (usually surgery) After surgery: Brace Progressive WB Healing takes up to 6-8 months |
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What is the meniscus? How does a meniscus tear affect the joint's function? |
The cartilage that lies on top of the tibia, between the tibia and the femur, and acts as the shock absorber of the knee. Tears leave loose cartilage in the knee joint that may slip between the femur and tibia, preventing full extension of the leg |
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What are the clinical manifestations of a meniscus tear? |
feeling of "pop" or "lock" joint pain stiffness edema (extra synovial fluid is being produced) A clicking or snapping sound can often be heard when the knee is moves, especially when extending the leg that is bearing weight (when walking) |
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What are the nursing interventions related to a meniscus tear? |
RICE Brace NSAIDs and analgesics Crutches Arthroscopy to repair |
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What term is used when there is a nerve problem that occurs when the median nerve is compressed as it passes through the area containing all the tendons coming from the hand? |
Carpal tunnel syndrome |
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What are the clinical manifestations of carpal tunnel syndrome? |
Paresthesia of the thumb, index, and middle finger -subjective feeling (could feel like pins and needles) Weakness (especially of the thumb) Atrophy of the padded area of the palm (below thumb) Burning pain numbness |
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How do you prevent carpal tunnel syndrome? |
Become familiar with the requirements to prevent repetitive stress injuries at the workplace. |
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What are the nursing interventions that should be done in regards to carpal tunnel syndrome? |
NSAIDs Elevation to relieve edema ROM exercises Injections of corticosteroids Application of wrist splint shaking the hands may relieve paresthesias Ergonomic changes |
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Should an injured part be ELEVATED during SLEEP?
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Yes, according to Lewis, to continue to promote venous return and reduce edema.
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