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wvcMusc/skeletal IGG
wvc chpt 54 care of patients with musculoskeletal trama
| Question | Answer |
|---|---|
| A ___________is a break or disruption in the continuity of a bone that often affects the human needs for mobility and sensation. It can occur anywhere in the body and at any age | fracture |
| The break is across the entire width of the bone in such a way that the bone is divided into two distinct sections. | Complete fracture. |
| The fracture does not divide the bone into two portions because the break is through only part of the bone. | Incomplete fracture. |
| A__________ fracture does not extend through the skin and therefore has no visible wound | simple |
| How are compound fractures graded | Grade 1 to Grade 3, mild to severe muscle and nerve damage |
| A ______________fracture occurs after minimal trauma to a bone that has been weakened by disease | pathologic (spontaneous) |
| A ______________ fracture results from excessive strain and stress on the bone. | fatigue (stress) fracture |
| This fracture is most common among athletes | fatigue stress fracture |
| _______________are produced by a loading force applied to the long axis of cancellous bone. They commonly occur in the vertebrae of patients with osteoporosis and are extremely painful. | Compression fractures |
| When a bone is fractured, the body ____________ begins the healing process to repair the injury and restore the body's equilibrium. | immediately |
| In how many stages do bones heal? | 5 stages |
| Name the stage that begins within 24 to 72 hours after the injury | Stage 1; a hematoma forms at the site of the fracture because bone is extremely vascular. |
| This stage occurs in 3 days to 2 weeks when granulation tissue begins to invade the hematoma | Stage two: formation of fibrocartilage, providing the foundation for bone healing. |
| This stage is of bone healing occurs as a result of vascular and cellular proliferation. The fracture site is surrounded by new vascular tissue known as a callus (within 2 to 6 weeks) | Stage three Callus formation is the beginning of a non-bony union. |
| In this stage, the callus is gradually resorbed and transformed into bone. | Stage four; may take 3 weeks to 6 months. |
| In this stage, consolidation and remodeling of bone continue to meet mechanical demands | 5th stage of healing,. This process may start as early as 4 to 6 weeks after fracture and can continue for up to 1 year, depending on the severity of the injury. |
| The factors that contribute to healing | the severity of the trauma, the type of bone injured, how the fracture is managed, infections at the fracture site, and ischemic or avascular necrosis (AVN). |
| What materials are necessary for the production of new bone | Calcium, phosphorus, vitamin D, and protein |
| For women, the loss of_______________ decreases the body's ability to form new bone tissue. | estrogen after menopause |
| Chronic diseases such as peripheral vascular diseases and arteriosclerosis effect bone healing, True or False | True, reduce arterial circulation to bone→bone receives less oxygen and fewer nutrients, both of which are needed for repair. |
| ______________ is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. | Acute compartment syndrome (ACS), lower leg and forearm are the most common. |
| Muscle capillaries dilate →↑capillary pressure, they become more permeable (↑histamine by the ischemic muscle tissue) →plasma proteins leak into the interstitial space →edema. Edema ↑pressure on nerve endings and causes pain. Blood flow ↓pulses ↓ | ischemia-edema cycle, paresthesia appears B4 Δ in vascular or motor signs |
| The pathophysiologic changes of increased compartment pressure are sometimes referred to as the | ischemia-edema cycle. |
| Tight, bulky dressings and casts are examples of __________pressure. | external |
| Blood or fluid accumulation in the compartment is a common source of | internal pressure. |
| Are there other ways that ACS can occur? | severe burns, extensive insect bites or snakebites, or massive infiltration of IV fluids |
| Muscle ischemia can be identified by | extreme pain, not relieved by drugs. |
| To monitor for early signs of ACS, what do you assess? | 6 p’s pain, pressure, paralysis, paresthesia, pallor, and pulselessness |
| Capillary refill is an important assessment of perfusion but may not be reliable in an older adult because of | arterial insufficiency |
| Late signs of ACS are | Losses of function and decreased pulses or pulselessness |
| Within __________ hours after the onset of compartment syndrome, neurovascular and muscle damage are irreversible. | 4 to 6 hours |
| The limb can become useless in | 24 to 48 hours. |
| Emergency surgery for ACS is | faciotomy, w/I 4-5 days, debride, skin graph to promote healing |
| Problems resulting from compartment syndrome include | infection, persistent motor weakness in the affected extremity, contracture, and myoglobinuric renal failure. In extreme cases, amputation becomes necessary. |
| __________________of the forearm, which can begin within 12 hours of the pressure increase, result from shortening of the ischemic muscle and from nerve involvement. | Volkmann's contractures |
| Muscle trauma from several different sites causes a release of myoglobin into the blood. Why does this lead to renal failure | the protein clogs the renal tubules |
| How does ACS result in hyperkalemia? | Damaged muscles release protein and K, which cannot be excreted through the kidneys.↑K→cardiac arrest |
| ACS can begin in ________after an injury or take up to 2 days to appear | 6 to 8 hours |
| Crush Syndrom is indicated by | ACS, Hypovolemia, Hyperkalemia, Rhabdomyolysis, Acute tubular necrosis (ATN) resulting from hypovolemia and rhabdomyolysismm,Dark brown urine, Muscle weakness and pain |
| What is the management focus for crush syndrome? | preventing acute tubular necrosis from myoglobin release and cardiac dysrhythmias related to hyperkalemia. |
| How is prevention of ATN achieved? | IV fluids, diuretics, and low-dose dopamine→↑ renal perfusion. A urine output of 100 to 200 mL/hr is the desired outcome. hemodialysis, if potassium levels remain high or kidney failure occurs. |
| Specific causes of CS | Twisting-type injuries•Natural disasters•Work-related injuries•Drug or alcohol overdose, when one or more limbs may be compressed by body weight for a prolonged time•Older adults who fall are unable to get up and lie for a prolonged time |
| Crush syndrome (CS) occurs from | an external crush injury that compresses one or more compartments in the leg, arm, or pelvis. |
| Excessive bleeding from broken bones or affected nearby arteries can lead to | hypovolemic shock |
| Dizziness, light-headedness, decreased blood pressure, tachycardia, pallor, and altered mental status (may be the first sign | hypovolemic shock |
| Fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or other illness. | Fat embolism |
| Fat embolisms occur from | long bone fractures, repair and occasionally knee surgery. Occasionally, with osteomyelitis & other bone diseases. |
| The earliest manifestation of FES is | altered mental status, which is caused by a low arterial oxygen level. |
| Fat embolisms manifest differently, assess for decreased level of consciousness (LOC), such as | drowsiness and sleepiness. |
| What would the nurse monitor the patient for (fat embolism) | anxiety, respiratory distress, tachycardia, tachypnea, fever, and hemoptysis (bloody sputum) & Petechiae (late sign) |
| Where would you notice petechiae? | upper arms, neck, chest or abdomen |
| Fat embolism laboratory findings include | Increased erythrocyte sedimentation rate (ESR)•Decreased serum calcium levels•Decreased red blood cell and platelet counts•Increased serum lipase level |
| What nursing interventions can help reduce the occurrence of a fat embolism? | Prevention of motion at the fracture site and early immobilization |
| What is the definition of fat embolism? | Obstruction of the PULMONARY VASCULAR bed by fat globules from fractures of the long bones; occurs usually within 48 hr |
| What is the definition of blood clot embolism? | Obstruction of the PULMONARY ARTERY by a blood clot or clots from deep vein thrombosis in the legs or pelvis; can occur anytime |
| What are the assessment findings for a FE? | Altered mental status (earliest sign),Increased respirations, pulse, temperature, Chest pain, Dyspnea, Crackles, Decreased SaO2, Petechiae (50%-60%), Retinal hemorrhage (not common), Mild thrombocytopenia |
| What is different about a blood clot embolism’s assessment findings vs a fat embolism? | no petechiae |
| What are treatments for a FE? | Bedrest, gentle handling, oxygen, hydration (IV fluids), possibly steroid therapy, facture immobilization |
| What are treatments for a blood clot embolism? | preventive measures (e.g., leg exercises, antiembolism stockings, SCDs), bedrest, oxygen, possibly mechanical ventilation, anticoagulants, thrombolytics, possible surgery: pulmonary embolectomy, vena cava umbrella |
| This is the most common complication of lower extremity surgery or trauma and the most often fatal complication of musculoskeletal surgery. | Deep vein thrombosis, pulmonary embolism (venous thromboembolism VTE) |
| Risk factors for VTE are? | Cancer or chemotherapy, •Surgical procedure longer than 30 minutes, •History of smoking•Obesity•Heart disease •Prolonged immobility•Oral contraceptives or hormones•History of VTE complications•Older adults (especially with hip fractures) |
| osteomyelitisis | bone infection, is most common with open fractures in which skin integrity is lost and after surgical repair of a fracture |
| Blood supply to the bone is disrupted, leading to the death of bone tissue is called? | Ischemic necrosis is sometimes referred to as aseptic or avascular necrosis (AVN) or osteonecrosis. |
| ______________is a fracture that has not healed within 6 months of injury | Delayed union |
| Certain diseases such as bone cancer and___________ cause pathologic fractures that often do not achieve total healing or union. | Paget's disease |
| Define Paget’s disease | the bone remodeling is disturbed and not synchronized. As a result, the bone that is formed is abnormal, enlarged, not as dense, brittle, and prone to breakage |
| When assessing a patient with a musculoskeletal injury, what seven areas will you assess? | skin color & temperature, movement, sensation, pulses, cap refill and pain |
| What questions regarding history would you ask to a patient with a musculoskeletal injury | when, where, drug use, disease history & occupational/recreational |
| What are you looking for in a physical assessment (fracture) | change in bone alignment, external rotation, shortening, change in bone shape, ROM, grating sound, skin intact, bruising, pallor, temperature, pain, distal pulses, symmetry, |
| Nonsurgical management includes | closed reduction and immobilization with a bandage, splint, cast, or traction |
| For each modality, the primary nursing concern is | assessment and prevention of neurovascular dysfunction or compromise |
| Prevention or minimization of injury or discomfort in the patient with altered sensation includes | Monitor for paresthesia: numbness, tingling, hyperesthesia, and hypoesthesia.•Monitor fit of bracing devices, prostheses, shoes, and clothing.•Administer analgesics, as necessary.•Discuss or identify causes of abnormal sensations or sensation changes. |
| While applying a manual pull, or traction, on the bone, the health care provider moves the bone ends so that they realign is called | closed end reduction |
| What type of non-surgical procedures are used on non-weight baring limbs | splints (thermoplastic) & bandaging |
| _____________is a rigid device that immobilizes the affected body part while allowing other body parts to move. | A cast, used on more complex fractures of the lower extremities |
| When a patient is in bed with an arm cast, teach him or her to | elevate the arm above the heart to reduce swelling |
| Complications resulting from casting that can be serious and life threatening, what are they | infection, circulation impairment, and peripheral nerve damage |
| Assess for complications of immobility, such as | skin breakdown, pneumonia, atelectasis, thromboembolism, and constipation |
| What are some complications to casting besides infection , circulation impairment & pnd | Contraction, osteoartritis & osteoporosis or muscle atrophy |
| Traction is the application of a pulling force to a part of the body to provide reduction, alignment, and rest. It is also used to | decrease muscle spasm (thus relieving pain) and prevent or correct deformity and tissue damage. |
| Bucks traction is performed when and for what purpose? | pre-operative positioning, alignment and immobilizations regarding a hip/femur fracture & dislocation, |
| The five types of traction? | skin, plaster, skeletal, brace & circumferential |
| _______________________________ is one of the most common surgical methods of reducing and immobilizing a fracture. | Open reduction with internal fixation (ORIF) it is often the preferred surgical method for an older adult who is susceptible to the complications of immobility |
| Open reduction allows the surgeon to | directly view the fracture site. |
| Internal fixation uses | metal pins, screws, rods, plates, or prostheses to immobilize the fracture during healing. |
| For patients with an external fixator, pay particular attention to | the pin sites for signs of inflammation or infection |
| Monitor the pin sites at least every _________ hours for drainage, color, odor, and severe redness, which indicate inflammation and possible infection. | 8 to 12 hours |
| The _____________ device is used to gently pull apart the cortex of the bone and stimulate new bone growth | circular external fixation. |
| If the circular external fixation device is being used for filling bone gaps using bone transport or distraction, teach the patient | how to manually turn the four-sided nuts (also called clickers) up to four times a day. |
| Several additional options are available to the physician to promote bone union, such as | electrical bone stimulation, bone grafting, and ultrasound fracture treatment. |
| For patients with chronic, severe pain, opioid and non-opioid drugs are alternated or given together to manage pain both | centrally in the brain and peripherally at the site of injury. |
| Name two types of opioid drugs | morphine, meperidine (Demerol) |
| Why should Demerol never be given to older adults? | because it has toxic metabolites that can cause seizures and other complications |
| Signs of wound infection include | Foul-smelling discharge•Purulent drainage•Fever•Lethargy •Wound-site culture colonization (if wound present)•White blood cell (WBC) elevation (if systemic infection) |
| Interventions for a patient with an open fracture include | First-generation cephalosporins, clindamycin (Cleocin), and ciprofloxacin (Cipro), wound vacs (VAC), surgically repaired using bolts, screws & grafts |
| To prevent pressure on the axillary nerve, there should be two to three finger breadths between the axilla and the top of the crutch when the crutch tip is at least | 6 inches (15 cm) diagonally in front of the foot. |
| The crutch is adjusted so that the elbow is flexed no more than _______ degrees when the palm is on the handle | 30 degrees |
| The cane is placed on the __________side and should create no more than 30 degrees of flexion of the elbow | unaffected side |
| The patient with a fracture is expected to maintain an adequate dietary intake to meet metabolic needs. Indicators include that the patient will have normal | •Nutrient intake •Fluid intake •Serum prealbumin •Hematocrit and hemoglobin |
| What actions would a nurse take in assessing an upper arm fracture | Assess neurovascular status in the affected arm and hand before and after fracture treatment. Monitor for numbness and tingling distal to (below) the injury, which may indicate peripheral nerve damage. |
| What is the most common injury in older adults and one of the most frequently seen injuries in any health care setting or community | Hip Fracture |
| What disease has the biggest risk for hip fractures | osteoporosis |
| What teaching should a nurse include to an older person at risk for hip fracture | risk factors for hip fracture including physiologic aging changes, disease processes, drug therapy, and environmental hazards. |
| Hip fractures include those involving the upper third of the femur and are classified as | intracapsular (within the joint capsule) or extracapsular (outside the joint capsule). |
| A fracture of the femoral neck concern is with disruption of the blood supply to the head of the femur, which can result in | ischemic or avascular necrosis (AVN) of the femoral head. AVN causes death and necrosis of bone tissue and results in pain and decreased mobility. |
| Buck's traction may be applied before hip surgery to help decrease pain associated with | muscle spasm |
| The patient begins ambulating with assistance, when? | the day after surgery to prevent complications associated with immobility |
| Patients who have an ORIF are at risk for | hip dislocation or subluxation. |
| To prevent hip dislocation on a patient with a recent ORIF, be sure to | keep the operative leg in proper alignment. Regular pillows or abduction devices can be used for patients who are confused or restless. |
| Nursing implication for hip fx: Be sure that the patient's heels are up off the bed at all times. Inspect the heels and other high-risk bony prominence areas every | 8 to 12 hours. |
| Fractures of the lower two thirds of the femur are repaired with | ORIF & casting |
| Trauma to the knee is repaired with | closed reduction and casting or internal fixation with screws |
| Tib-fib fractures are repaired with | closed reduction with casting, internal fixation, and external fixation. |
| These forces generally create spiral, transverse, or oblique breaks, which are often difficult to treat and present problems in healing | an ankle fracture |
| Ankle fracture repair uses | A combination of closed and open techniques may be used, depending on the severity and extent of the fracture. An arthrodesis (fusion) may be needed if the bone does not heal. |
| The most commonly fractured ribs are numbers | 4 through 8. |
| The dangers of rib fractures are | puncture of the lungs, heart, or arteries by bone fragments or ends. |
| Because the pelvis is very vascular and is close to major organs and blood vessels, the major focus in fracture management is | associated internal damage |
| Assess for internal abdominal trauma by | checking for blood in the urine and stool and by monitoring the abdomen for the development of rigidity or swelling |
| A system that is particularly useful divides fractures of the pelvis into two broad categories: | non–weight-bearing fractures and weight-bearing fractures. |
| A non–weight-bearing part of the pelvis is, | the pubic rami or the iliac crest |
| A weight-bearing fracture, such as multiple fractures of the | pelvic ring creating instability or a fractured acetabulum |
| Compression fractures result when trabecular or cancellous bone within the vertebra becomes | weakened and causes the vertebral body to collapse. |
| In compression fractures, the patient has | severe pain, deformity (kyphosis), and occasional neurologic compromise. |
| Nonsurgical management vertebral compression fractures includes | bedrest, analgesics, nerve blocks, and physical therapy to maintain muscle strength |
| Painful VCF’s can be treated with what surgical procedures? | vertebroplasty or kyphoplasty |
| Kyphoplasty includes the additional step of | inserting a small balloon into the fracture site and inflating it to contain the cement and to restore height to the vertebra. |
| This procedure is preferred because it reduces the complication of leaking of bone cement outside the vertebral body and it may restore height to decrease kyphosis | kyphoplasty |
| Most are elective and are related to complications of | peripheral vascular disease and arteriosclerosis. |
| Traumatic amputations most often result from | accidents and are the primary cause of upper extremity amputation. |
| What are the five types of LE amputation performed | above the knee, below the knee, syme amputation, toe amputation, mid-foot amputation |
| Midfoot amputations (e.g., the Lisfranc and the Chopart amputations) and the Syme amputation are common procedures for | peripheral vascular disease. |
| In the Syme amputation, most of the foot is removed but the | ankle remains. |
| The incidence of lower extremity amputations is greater in | black and Hispanic populations because the incidence of major diseases leading to amputation, such as diabetes and arteriosclerosis, is greater in these populations. |
| The most common complications of elective or traumatic amputations are | •Hemorrhage• Infection (hypovolemic shock/osteomyelitis)• Phantom limb pain• Neuroma• Flexion contractures |
| When this sensation persists and is unpleasant or painful, it is referred to as | phantom limb pain (PLP) |
| A sensitive tumor consisting of damaged nerve cells—forms most often in amputations of the upper extremity but can occur anywhere | neuroma. |
| Flexion contractures of the hip or knee are seen in patients with | amputations of the lower extremity |
| What nursing interventions can be used as preventative measures for flexion contractures | AROM and proper positioning |
| The typical amputee is | older than 40 years of age, diabetes and smokes |
| When a patient has PVD, assess circulation in other parts of the body | Assess skin color, temperature, sensation, and pulses in both affected and unaffected extremities & cap refill |
| The nurse's primary focus is to monitor for | signs indicating that there is sufficient tissue perfusion but no hemorrhage. |
| What drugs can be used for phantom limb paing | IV infusions of calcitonin (Miacalcin, Calcimar) during the week after amputation can reduce phantom limb pain. |
| The health care provider prescribes other drugs on the basis of the type of PLP the patient experiences. For instance, beta-blocking agents such as | propranolol (Inderal, Apo-Propranolol Detensol) are used for constant, dull, burning pain. |
| Antiepileptic drugs such as | carbamazepine (Tegretol) and gabapentin (Neurontin) may be used for knifelike or sharp burning pain. |
| Antispasmodics such as | baclofen (Lioresal) may be prescribed for muscle spasms or cramping. |
| Many treatments for PLP have been used worldwide, including | •Ultrasound therapy•Massage•Exercises•Biofeedback•Distraction therapy•Hypnosis•Psychotherapy |
| Several devices help shape and shrink the residual limb in preparation for the prosthesis.Rigid, removable dressings are preferred because they | decrease edema, protect and shape the limb, and allow easy access to the wound for inspection. |
| Figure-eight wrapping prevents | restriction of blood flow. Decrease the tightness of the bandages while wrapping in a distal-to-proximal direction. |
| What is the best way to assess an amputee’s concept of the amputation | Ask the patient to describe his or her feelings about changes in body image and self-esteem |
| Proper teaching regarding correct cleansing of the socket and inserts, wearing the correct liners, assessing shoe wear, and a schedule of follow-up care is essential before | discharge |
| Assess the residual limb (amputation) for: | •Adequate circulation•Infection•Healing•Flexion contracture•Dressing/elastic wrap; ADL’s, coping mechs, nutritional status, ambulatory aids |
| It most often results from traumatic musculoskeletal injury and commonly occurs in the feet and hands. | Complex regional pain syndrome (CRPS), formerly called reflex sympathetic dystrophy (RSD) |
| CRPS: The most common symptom includes | continuous, intense pain out of proportion to the tissue injury that gets progressively worse over time instead of better |
| CRPS has how many stages | 3, mild to severe |
| The first priority of management is | pain relief. |
| Many classes of drugs may be used to manage the intense pain. These include | topical analgesics, antiepileptic drugs, antidepressants, corticosteroids, and opioid and non-opioid agents |
| A surgical method to control pain is | Minimally invasive surgical sympathectomy |
| This is a common condition in which the median nerve in the wrist becomes compressed, causing pain and numbness. | Carpel Tunnel Syndrome |
| What causes CTS | group of tendons surrounds the synovium and shares space with the median nerve in the carpal tunnel. When the synovium becomes swollen or thickened, this nerve is compressed. |
| The median nerve supplies motor, sensory, and autonomic function for the | first three fingers of the hand and the palmar aspect of the fourth (ring) finger |
| CTS is a common complication of certain metabolic and connective tissue diseases. For example, | synovitis occurs in patients with rheumatoid arthritis (RA). diabetes mellitus, inadequate blood supply can cause median nerve neuropathy or dysfunction, resulting in CTS. |
| What is the most common type of repetitive stress injury (RSI) | CTS |
| In addition to reports of numbness, patients with carpal tunnel syndrome (CTS) may also have | paresthesia |
| (CTS)Sensory changes usually occur weeks or months before | motor manifestations. |
| What test can doctors used to identify CTS | Phalen's maneuver, produces paresthesia in the median nerve distribution (palmar side of the thumb, index, and middle finger, and half of the ring finger) within 60 seconds. |
| How is Phalen’s maneuver performed | The patient is asked to relax the wrist into flexion or to place the back of the hands together and flex both wrists at the same time |
| In CTS the same sensation can be created by tapping lightly over the area of the median nerve in the wrist | (Tinel's sign). |
| In CTS motor changes begin with a | weak pinch, clumsiness, and difficulty with fine movements |
| When a definitive diagnosis(CTS) is uncertain, the health care provider may request | x-rays, electromyography (EMG) and nerve conduction studies (NCS), magnetic resonance imaging (MRI), and/or ultrasonography. |
| What are the major components of non-surgical treatments (CTS) | Aggressive drug therapy and immobilization of the wrist, a splint |
| What is the most commonly prescribed drug for CTS | NSAIDs, corticosteroids |
| Surgery for CTS can relieve the pressure on the median nerve by | providing nerve decompression |
| The two most common CTS surgeries are | open carpal tunnel release (OCTR) and the newer endoscopic carpal tunnel release (ECTR) |
| When CTS is a complication of rheumatoid arthritis, a | synovectomy (removal of excess synovium) through a small inner-wrist incision may resolve the problem |
| A __________ is excessive stretching of a muscle or tendon when it is weak or unstable. | STRAIN |
| Strains are classified | according to their severity, 1st degree, 2nd degree & 3rd degree (needing surgery) |
| A __________ is excessive stretching of a ligament. Twisting motions from a fall or sports activity typically cause the injury | Sprain |
| Second-degree sprains require | immobilization, such as elastic bandage and an air stirrup ankle brace or splint, and partial weight bearing while the tear heals. |
| For severe ligament damage (third-degree sprain), immobilization for | 4 to 6 weeks is necessary. Arthroscopic surgery may be done, particularly for chronic joint instability. |
| First degree sprain requires | rest and ice |
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