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60 Cards in this Set
- Front
- Back
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Amputation Care (Detailed)
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Assessment of tissue perfusion
Management of pain Drug therapy Complimentary and alternative therapy Prevention of infection Promotion of ambulation prostheses Promotion of body image Promotion of lifestyle adaptations Proper cicruclation to amputated area as well as signs of hemorraging This will be done by checking closest proximal pulse, assessing skin discoloration and temperature of amputated area.This will indicate proper blood flow. Assess for phantom pain or stump pain The nurse will incorporate non-pharmocological treatments like massage, exercise, distraction, etc. Patient will be turned every two hours in order to prevent skin breakdown. The nurse will assess incision site and characteristics of drainage for signs of infection. The nurse will initiate activities involving physical therapy. The nurse will arrange for client to see a certified prosthetist-orthotist. This will assist patient in restoring mobility, dignity and self-sufficiency. The nurse will assess the patients perception of newly amputated area by evaluating verbal and non verbal cues. Preprosthetic care involves several devices. Elastic bandages are prefered due to their ability to decrease edma, as well as protect and shape the limb, help prevent limb from shrinking and allowing easy access to wound for inspection. Teaching prior to to amputation is recommended to make ambulation easier post-operatively. For effectiveness the nurse should change bandage every 4-6 hours and anchor bandage to the most proximal joint. ROM and positioning the client in the prone position every 4 hours for 20-30 minutes help to prevent hip flexion contractures. |
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Developmental dysplasia of the hip (DDH)
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Childhood condition caused by abnormal development of the hip joint. In DDH, the top of the thighbone (femur) does not fit securely into the hip socket (acetabulum). Usually the socket is too shallow, more like a saucer than the deep cup that it should be. This allows the ball at the top of the thighbone (femoral head) to either partly or fully slip out of the socket (dislocate). DDH can affect
one or both hip joints. A baby with DDH may have: A hip joint that feels loose or slips out of place when examined. One leg that appears to be shorter than the other. Extra folds of skin on the inside of the thigh(s). A hip joint that moves differently than the other. A child who is walking may walk on the toes of one foot with the heel up off the floor. The child walks this way because one leg is shorter than the other. Walk with a limp (or waddling gait if both hips are affected). DDH is treated by moving the baby's upper thighbone into the hip socket and keeping it in place while the joint grows. A harness, called a Pavlik harness, is most often used to keep the joint in place in babies younger than 6 months.(After that surgery and casting may be required.) Pavlik harness: -Do not remove the harness and do not adjust the straps for the first 3 to 4 weeks of treatment unless your doctor tells you to. The harness holds the joint in the correct position for normal development. Removing the harness may cause the thighbone to move out of position. Later in your child's treatment, the harness may be removed for short periods of time, such as for bathing or for cleaning the harness. -You can put your child's clothing on under the straps to prevent skin irritation. You can also pad the shoulder straps if needed. When examining an young infant with DDH, the MD/NP/PA performs a specific maneuver called the Ortolani test to actually elicit the "click". This should be done routinely in the hospital and at each well-child check up until the child is at least 4months old. no clothes should be worn under it in the first month because it may affect it's fitting/performance. |
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CONGENITAL CLUB FOOT
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Congenital (true, idiopathic) club foot almost always requires surgical intervention because there is a bony abnormality.
Serial casting is begun shortly after birth. Manipulation and casting are repeated weekly for up to 3 months. If normal alignment is not achieved, the infant will need to have orthopedic surgery. The surgery is usually performed when the child is 6-12 months old. An orthopedic surgeon can lengthen tendons to help ease the foot into a more appropriate position. An infant patient of yours just had the 1st series of casts placed, what d/c teaching will you give the caregiver regarding cast care and assessment? - keep the cast extremity elevated for the first day - observe the extremities for any signs of swelling, discoloration, movement and sensation - resrict strenuous activities but encourage use of muscles - avoid having the affected limb hang down for any length of time (keep elevated as much as possible) - keep path clear for ambulation and never allow the child to put anything inside the cast What would be warning signs of complications to alert the caregiver to report? Complications include: swelling, discoloration, decreased pulses, decreased temperature, or the inablity to move to toes. |
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Types of congenital club foot:
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Talipes varus - inversion of foot
Talipes valgus - eversion of foot Talipes equinus - plantar flexion Talipes calcaneus - dorsiflexion Talipes equinovarus - foot pointed down and inward (most common) Also, may be unilateral (more common) or bilateral |
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Legg-Calve-perthes
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This is a hip disorder that only occurs in children in which the femoral head deteriorates becoming flattened and collapsing because of a lack of blood.
Therapeutic manangement includes bedrest/non-weight bearing activity to reduce inflammation and restore motion. Medication may be given to do the same plus control pain. Traction may also be done to stretch the muscles in that region. Casting and bracing is another intervention that holds the femoral head in the hip socket that limits joint movement to allow the femur to remold itself back into a round shape. Surgery is done also to hold the femoral head in the hip socket. Physical therapy helps keep the hip muscles strong and to promote hip movement. Cruthces /wheelchair is used also in some cases. These interventions all depend on the age of the patient and also the severity of the disorder. |
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Preventative measures for osteoporosis:
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First, insuring a minimum of
1200mg – 1300mg of calcium daily is a good start in replenishing the body's store of calcium needed for bone formation. As well as Vitamin D to ensure the absorption of calcium. Next, a regular routine of exercise, preferably walking, is very good for encouraging the body to build bone mass in the areas where it is needed the most, such as in the hips, a common site of fracture in those with osteoporosis. Fosamax – is recommended for the treatment of osteoporosis in postmenopausal women. It works by inhibiting the part of the process of bone building that actually tears down old bone in exchange for new. |
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TRACTION:
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-application of a pulling force to a portion of the body to provide reduction , alignment, and rest.
-decreases muscle spasms and prevents/corrects deformity/tissue damage. **ONCE TRACTION IS APPLIED, MAINTAIN THE CORRECT BALANCE BETWEEN TRACTION PULL AND COUNTERTRACTION FORCE** Do not remove weights without an order from the doctor and make sure they are always hanging freely and not resting on the floor. |
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SKELETAL TRACTION:
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-pins, wires, tongs, or screws are surgically inserted directly into the bone
-long term use -heavier weights 15 to 30 lbs -aids in bone re-alignment of femur (tibia/fibula) or pelvis SKELETAL TRACTION (fractured tibia) INTERVENTIONS: -assess points of entry of pins/wires/screws for signs of inflammation or infection by monitoring drainage, color, odor, and severe redness. (INFECTION OF THE PIN MAY RESULT IN OSTEOMYELITIS) -check equipment for proper functioning q 8hrs at least. (LOOSENING, FRAYING, FRINGING MAY CAUSE IMPROPER USE/HARM TO CLIENT) -check the weight for consistency with health care provider's order.(THE HEALTH CARE PROVIDER MAY CHANGE THE WEIGHT ORDER WHICH COULD HARM THE CLIENT IF TOO MUCH WEIGHT CAUSING MUSCLE SPASMS) -monitor circulation q hour for the first 24 hours and then q 4 hours after.(CAN CAUSE CIRCULATORY SOMPROMISE AND SUBSEQUENT TISSUE DAMAGE) |
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BUCK'S TRACTION:
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-use of Velcro Boot/belt/halter (primary purpose is to decrease painful muscle spasms
that occur with fractures) -short term use -pulling force limited to 5 to 10 lbs -commonly use = hip fractures or femur preoperative BUCK'S TRACTION (fractured hip) INTERVENTIONS: -inspect the skin at least q hour for signs of irritation or inflammation.(CLIENT AT RISK FOR IMPAIRED SKIN INTEGRITY WHICH CAN LEAD TO ADDITIONAL BREAKS IN SKIN AND INFECTION) |
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osteomyelitis
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Osteomyelitis starts when one or more pathogenic microorganisms
stimulate an inflammatory response in the bone tissue. Inflammation produces an increased vascularity to the area and edema surrounds the soft tissue of the bone. Once this happens vessels become thrombosed and release exudate into the bone tissue. Ischemia (loss of blood flow) to the area starts and necrotic bone results. The dead bone tissue (sequestrum) retards bone healing and causes a superimposed infection, often in the form of bone abscess. This leads to more inflammation, vessel thrombosis and necrosis. In extreme cases the infected area will need to be removed. Nursing intervention for a client with a open wound to the left heel with osteomyelitis: 1.The nurse will assess the wound and change dressing q shift. To assess and prevent further infection, which may delay wound healing. Also complies with standard precautions. 2.The nurse will float the left heal. To prevent further breakdown to the area affected. 3.The nurse will turn patient every 2 hours. To prevent breakdown to other areas of the body. 4.The nurse will educate the patient about the need for good nutrition, including: meeting caloric requirements benefits of vitamins, and protein intake. Good nutrition helps maintain adequate tissue nourishment, perfusion, and oxygenation. 5. The nurse will assess physical symptoms that require pain medication and administer medication as prescribed. Continuous reassessment documents patient’s subjective complaints and behavior with his pain. 6.The nurse will educate the client on when to ask for pain medication. This gives the client a sense of control and encourages compliance. |
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Scoliosis
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#1 Physical assessment findings for scoliosis include: shoulder blades are different heights (one shoulder blade more prominent than the other),head not centered above pelvis,
appearance of raised, prominent hip, rib cages are different heights, uneven waist, changes of look or texture of skin overlying spine, leaning of entire body to one side. #2 The key age group and gender for this condition would be adolescent (10-18 years old) females. 80% of idiopathic scoliosis (no known cause), cases develop in young adults around the onset of puberty. #3 The most common assessment for scoliosis is the Adam’s Forward Bend Test, it involves the patient leaning forward with his or her feet together and bending 90 degrees at the waist. This allows the person doing the examination to see any asymmetry or abnormal curvatures in the back. While this test does not confirm a diagnosis, it can lead to the person going for an x-ray. Some of the abnormal findings include a person having one shoulder higher than the other, an uneven waist or the person leaning to one side instead of straight. #4 There are three main treatments for scoliosis, the first being observation. This involves screening the client a year later if they had small curves when first screened. Chances are the curves will not progress beyond what they are. The second treatment is the use of a brace to provide support and hopefully prevent the curvature from getting worse. The third option for more severe cases is surgery such as posterior spinal fusion with bone grafting. There is another surgery which is performed on the anterior portion through the chest walls. When screening a client for scoliosis, the Adam's test is most commonly used. In addition to visually examining the symmetry of the scapula and hips. The provider will also run his/her fingers down the length of the spine to further exam for any lateral curvature. If any discrepancies are noted, the patient will most likely go for a scoliosis screening x-ray in which the radiologist will measure the degree of curvature of the spine. Generally, if the curvature is <10 degrees we watch and depending on the age of the child (i.e., have they gone through puberty), we will reassess in 1 yr with another x-ray. If the curvature is between 10-15 degrees we will reassess sooner (possibly in 6 months with another x-ray). If the curvature is >15 degrees, most likely that child earns a referral to see a pediatric orthopedic doctor for an evaluation. During puberty, the scoliosis tends to progress more quickly, which is why we may assess these children more frequently. |
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Fracture Care
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Key elements in assessment of patient with newly casted extremity:
Check to ensure that the cast is not too tight and frequently monitor the client's neurovascular status ( usually every hour for 24 hours after casting). A finger should be able to be inserted between cast and skin. Ice may be applied for the first 24-36 hours to reduce welling/inflammation. Assess for complications such as infection ( may have pain and a " hot spot" under cast at infected area), peripheral nerve damage ( monitor for paraesthesia, numbness, tingling, DVT, thrombophlebitis). Smell the cast for mustiness or an unpleasant odor and check for fever. Patients at risk for fracture : Those with osteoporosis- high incidence in elderly , postmenopausal females. Those with osteogenesis imperfecta- a genetic " brittle bone" disorder. Those with bone cancer. Post op- restrictions for total hip and or/hip pinning patient with regards to turning, ROM of affected extremity, bending... Prevention of subluxation ( partial or total dislocation); by corrrect positioning. Upon return from PACU patient should be placed in supine position with head slightly elevated. Place a trapezoid shaped abduction pillow, wedge, sling or splint between the client's legs to prevent adduction beyond the midline of the body. Place and support the affected limb in neutral rotation. Keep heels off bed to prevent skin breakdown. Follow agency policy regarding turning- however, in most cases turning from side to side is safe as long as abduction pillow is in place. Regarding exercise, this is taught by physical therapy and begun in the immediate postop period.These exercises include plantar flexion, dorsiflexion, and circumduction on the feet, gluteal and quadriceps muscle setting and straight leg raises. Additionally, it is important to emphasize to clients that they should not bend the hips more than 90 degrees. So they need to be rather careful not to reach for something or bend down to pick something up. They should be getting up with PT the day after surgery. As nurses, we need to remind them of the importance of not getting out of bed unassisted and not sitting or standing for long periods of time (again, remember the 90 degree rule when sitting) |
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Compartmental syndrome
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Compartmental syndrome can result from trauma, surgery or physical activity.
Sheaths of inelastic fascia that support and partition muscles, blood vessels, and nerves in the body are called compartments. When there is increased pressure in these compartments it causes a severe decrease in circulation to the area, which is called compartmental syndrome. The lower leg and dorsal and volar compartments of the forearem are common sites for compartmental syndrome. Key assessment finding in compartmental syndrome would include: edema, pain with passive motion, and the effected area is usually palpably tense. More serious changes begin to occur if compartmental syndrome is left untreated including cyanosis, tingling, numbness, paresis, and severe pain that is usually untreated by medications. Immediate nursing interventions would include immediately notifiying the physician and initiating steps to relieve pressure such as loosening bandages or obtaining an order to remove a cast. Timing is verything, within four to six hours irreversible damage can occur, and the limb may become useless in 24 to 48 hours. |
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Cast Care
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-The cast should be kept dry. Water weakens plaster casts and may cause skin irritation
beneath the cast. The patient should use two layers of plastic to keep the cast dry while bathing or showering. -To decrease swelling and pain in the first 24–48 hours, the patient should place crushed ice in a plastic bag, covered with a pillow case or towel, on the cast over the injury every 15 minutes per hour while awake. -Dirt, sand, or powder should be kept away from the inside of the cast. Cast boots can be purchased to cover the foot area of a leg cast. -Padding should not be pulled out of the cast. In addition, the patient should not stick coat hangers, knitting needles, or similar items inside the cast in order to scratch itchy skin. -The patient should not break off or trim the edges of the cast without consulting the physician. -The cast should be inspected regularly. If it develops cracks or soft spots, the physician should be notified. -The patient should never attempt to remove the cast. The physician will remove the cast at the appropriate time with a special saw that cuts through the casting material but will not damage skin. |
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hypodermoclysis
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slow infusion of isotonic fluids into the sub-q tissue.
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intrathecal
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medications infused in the spine
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osteophytes
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bone spurs
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synovitis
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synovial inflammation
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subluxation
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partial joint dislocation
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sarcopenia
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muscle loss
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crepitus
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grating sensation caused by irregular cartilage
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osteoarthritis
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degenerative joint disease
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total joint arthroplasty
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surgical creation of a joint
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ostneonecrosis
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bony necrosis secondary to lack of blood flow
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osteotomy
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bone resection
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revision arthroplasty
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bone grafts (allografts) can be placed to fill in the bony defects that result from removing old prosthesis
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subluxation
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partial dislocation
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total hip: post-op
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-supine position w/ hob slightly elevated
-abduction pillow between legs or you can you 2 regular pillows -for devices with straps make sure to loosen q 2 hours -keep clients heels off the bed -support the affected leg in a nuetral rotation Watch for: dislocation infection venous thrombus hypotension or bleeding |
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thrombocytopenia
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decreased platelets
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articulations
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joint surfaces
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hemiarthroplasty
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replacement of part of the joint
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pannus
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vascular granulation tissue composed of inflammatory cells
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hematopoiesis
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production of rbc's
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phalen's manuever
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wrist test for CTS
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ganglion
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cystlike lesion often overlying wrist or joint tendon
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lordosis
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"flat-back" syndrome
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pathologic fracture
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A pathologic fracture results from minimal trauma to a bone weakened by disease
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Which statement regarding a pathologic fracture is true?
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A pathologic fracture results from minimal trauma to a bone weakened by disease
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In the client who has undergone a below-the-knee amputation, which assessment finding would indicate that the limb has adequate tissue perfusion?
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The skin flap is pink and warm to touch.
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What nursing intervention would be most helpful in the prevention of flexion contractures in a client with a below-the-knee amputation?
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Range-of-motion exercises
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What is the pathophysiologic process leading to the development of osteoporosis?
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Rate of osteoclastic activity exceeding the rate of osteoblastic activity
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Which of the following clients is most at risk for secondary osteoporosis?
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55-year-old woman taking prednisone for asthma
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A client has been advised to take supplemental calcium carbonate. What instructions should be given to this client regarding this medication?
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“Take this medication with food.”
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A client with osteoporosis has been prescribed raloxifene (Evista). What laboratory data would suggest an adverse effect of this drug?
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Elevated liver function tests
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Which clinical manifestation would serve to alert the nurse that a client’s osteomyelitis is chronic, rather than acute?
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Ulceration of the skin
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A client is about to begin drug therapy for osteomyelitis. What information regarding this treatment would be most appropriate for the nurse to provide to the client?
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“You will need to undergo treatment with IV antibiotics for several weeks.”
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Which of the following best explains the development of a fat embolism as a complication of a bone fracture?
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The marrow contains fat cells that can be dislodged during injury
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Which age-related change in musculoskeletal structure or function would alert the nurse to an increased risk of fracture?
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Decreased bone density
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The nurse is caring for a client with a fractured femur. What factor in the client’s history may impede healing of the fracture?
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Peripheral vascular disease
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What information should be elicited from the client before the client undergoes an arthrography?
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Allergy to shellfish or iodine
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What assessment should be performed hourly for a client who had an arthroscopy of the right knee 1 hour ago?
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Right pedal pulse
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Which precautions or instructions should be provided to the client who is scheduled to have a bone scan?
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Increase your fluid intake to at least 3000 mL after the test to help clear the radioisotope.”
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The most significant complication of the use of an external fixator on the lower leg for a fractured tibia reduction is which of the following?
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Infection
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A client who sustained a crush injury to the right lower leg in a farm tractor accident complains of numbness and tingling of the affected extremity. The skin of the right leg appears pale and the pedal pulse is weak. What should be the nurse’s first response?
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Notify the physician.
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While assessing an older adult client admitted 2 days ago with a fractured hip, the nurse notes that the client is confused, tachypneic, and restless. What is the nurse’s first action?
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Administer oxygen.
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Which of the following clients is most at risk for deep vein thrombosis?
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60-year-old male smoker with a fractured pelvis
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The most serious complication of a pelvic fracture is which of the following?
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Hypovolemic shock
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A home care nurse is visiting a diabetic client with a new cast on the arm. On assessment, the nurse finds the client’s fingers to be pale, cool, and slightly swollen. What is the nurse’s best first action?
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Elevate the arm above the level of the heart.
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The client for whom skeletal traction is planned asks for an explanation regarding the purpose of this type of traction. What is the nurse’s best response?
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This type of traction will aid in realigning the bone.”
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The nurse notes that the skin around the client’s skeletal traction pin site is swollen, red, and crusty, with dried drainage. What is the nurse’s priority action?
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Notify the physician.
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