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medsurg exam 4
musculoskeletal pt 1
| Question | Answer |
|---|---|
| Bone Formation aka | Osteogenesis |
| Osteogenesis | Development and Formation of bone |
| what is Osteogenesis influenced by | Calcium Vitamin D Parathyroid hormone (PTH) Calcitonin Blood supply |
| how much calcium should an adult have per day | 1000-2000 mg/day |
| what is vitamin D needed for | to promote Ca uptake |
| types of fractures | torus (buckle) greenstick open (compound) closed displaced non-displaced hairline single segmental comminuted |
| greenstick fractures are more common in | peds |
| first step of bone healing | blood vessels within bone tear, starts to forming a hematoma, inflammation response by vasodilation, inflammatory exudate and WBC migrate to site |
| second step of bone healing | granulated tissue replaces hematoma in 48 hrs, phagocytes remove all debris, osteocytes migrate to cite |
| third step of bone healing | 3-4 weeks to 2-3 months, osteoclasts form new bone, osteoclasts absorb callus, replaced by spongy bone |
| fourth step of bone healing | 3-6 months, healing, remodeling, excess callus removed, new bone laid down along fracture line, as the bone is exposed to everyday stress then spongy bone is replaced by compact bone |
| fracture healing is influenced by | Type of bone fractured Adequacy of blood supply Surface contact of fragments Age and general health status |
| fracture healing for compact vs non displaced | longer for compact bone to heal than non displaced |
| How long to heal | Long bone fractures (femur) up to 3-4 months |
| How long to immobilize | X-ray evidence bone formation with ossification |
| General assessment for fractures | assess the 5 Ps every 1-2 hours |
| what are the 5 Ps | pain, pallor, pulses, paresthesia, paralysis |
| how should the nurse help support a fracture | above and below the fracture, can help decrease pain and muscle spasms |
| you should report | any abnormal immediately |
| a fracture doesn't always just affect the bone | it can damage nerve and blood supply too |
| fracture complications | Compartment syndrome, fat embolism syndrome |
| Compartment syndrome is defined as | pressure within a confined space constricts and entraps the structures within it |
| what happens during compartment syndrome | any swelling inside compartment, blocked and permanent injury, if long enough then muscle can die fascia separates layers and inside contains nerves, vessels, tissue |
| what are the early symptoms of compartment syndrome | severe pain out of proportion to injury pain that is exacerbated by passive stretch of muscle within compartment |
| symptoms of Compartment syndrome | severe pain out of proportion to injury pain that is exacerbated by passive stretch of muscle within compartment paresthesia decreased sensation muscle weakness pallor pulselessness |
| fat embolism syndrome is defined as | fat globules lodge in the pulmonary vascular bed or peripheral circulation. Pressure within the bone marrow rises, exceeds capillary pressure and fat globules leave the bone marrow and enter the blood stream |
| what is the big concern with the fat globules in the blood stream | can travel to brain, lungs, and kidneys or can cause occlusion and decrease blood supply |
| interventions for fat embolism syndrome | early stabilization of bone fractures cough/db treatment monitor fluid/electrolytes cortisol/corticosteroids to decrease inflammatory response of lung tissues and reduce bronchospasms |
| symptoms of fat embolism syndrome | can last few hrs to a few weeks Respiratory insufficiency - ARDS Change in LOC – confusion Thrombocytopenia and petechiae |
| where are Petechiae seen | on skin, soft palate, and conjunctiva |
| Thrombocytopenia activates clotting cascade which then causes | petechiae |
| Respiratory insufficiency - ARDS and fat embolism syndrome | pulmonary circulation is affected which can cause issues like edema |
| two types of casts | fiberglass and plaster |
| purpose of a cast | casts permit mobilization of the patient while restricting movement of a body part |
| fiberglass casts dry and harden within | minutes |
| plaster casts dry and harden within | 24-72 hrs, depending on thickness of the cast |
| what to warn pt of with plaster casts | get warm when mixed with water for approximately 15 minutes so patients need warned of this sensation |
| what do plaster casts need | exposed to the air to facilitate drying and should remain uncovered until hard |
| how should you handle the casts when still drying | with the palms of the hands which avoids denting of the cast and pressure points caused |
| with a cast, avoid putting | putting powder or any objects into it because it you break skin you can cause infection which you then won't be able to see |
| external fixation | screws are placed into the bone above and below the fracture and a device is attached to the screws from outside the skin where it may be adjusted to realign the bone |
| external fixators allow | early mobility |
| for a pt with an external fixator, you must | Perform neurovascular checks Inspect pin site (serous drainage expected) Cover any sharp ends with cork or tape |
| After soft tissue injury healed, | the fixator can be changed to a cast |
| what are external fixators used for and why | severe or comminuted fractures - humerus, forearm, femur, tibia, pelvis they permit active treatment soft tissue injury |
| traction is used to | Reduce, align, immobilize fractures |
| traction works to | Minimize muscle spasms Reduce deformity Increase space between opposing surfaces |
| types of traction | skin and skeletal |
| why is traction not really used anymore | because OR is now open 24/7 |
| russel traction pulls | in both directions (look at slide 17 for pic) |
| skeletal traction has | pins into the bone which provides the traction (look at slide 18 for pic) |
| weights maintain | alignment until the fracture is surgically corrected |
| what is important to remember about the hanging weights | they must be free!! and not on the ground or there will be no pull dr orders the weight |
| bucks traction is | skin traction used for temporary immobilization before fracture fixation (look at slide 19 for pic) |
| with bucks traction, you must make sure | brace is tight or it will not do it's job |
| traction must be | continuous |
| skeletal traction is NEVER | interrupted |
| any factor that might reduce effective pull or alter line of pull must be eliminated: this includes | making sure weights, ropes, knots are hanging freely body alignment is proper |
| primary assessment for traction (becky said know) | neurovascular, make sure distal circulation and sensation are there!! |
| osteomyelitis is | Infection of bone from possible 3 ways |
| 3 possible ways to get osteomyelitis | Direct contamination Continuous Infection Hematogenous |
| Direct contamination ex | gunshot |
| Continuous Infection ex | cellulitis, infection in skin left untreated turns to continuous |
| Hematogenous ex | through blood, pathogens adhere to the blood - common in older people, sickle cell anemia, IV drug use, endocarditis, infected IV site |
| Local signs & symptoms | Draining and ulceration at involved site Swelling, redness, warmth Acute or chronic pain of increasing intensity |
| Systemic signs & symptoms | Increased WBCs Tachycardia Malaise Fever Lymph node involvement N/V (GI issues) |
| who is at risk for osteomyelitis | most common with IV drug users, DM, PVD, and neuropathy |
| how is osteomyelitis managed | surgically or medically |
| home care for osteomyelitis | Wound care IV antibiotics - put in PICC line Pt. must adhere to the schedule |
| PICC line is needed because IV abx are typically | 4-6 weeks |
| what else is done for pts with osteomyelitis | blood cultures and wound cultures surgical debridement if needed |
| causes of amputation | PVD (major cause) traumatic injuries |
| level of amputation | relates to ischemia or type of injury joints preserved as much as possible - for ex, if problem is in foot it will be a BTK amputation |
| types of amputation | open or (guillotine) if infection(osteomyelitis closed with skin flaps |
| goal for recovery: stage 1 | ensure proper healing physical therapy for leg muscles |
| goal for recovery: stage 2 | Wear prosthesis gradually, increasing time with wearing it Begin at or near 6 months when wound is healed |
| goal for recovery: stage 3 | Wear it all the time without pain. Can then fit final prosthesis |
| stage 1 recovery | Stump is elevated the first 24 hrs. to reduce swelling and decrease pain Support the stump in the elevation to avoid flexion contractures |
| during stage 1, pt should | position changes q 2hrs lying prone is encouraged for 20-30 min 2X/day to stretch the hip flexor muscles |
| stage 2 recovery | Ace or stump shrinker/sock for 6 months |
| why is stump wrapped for 6 months during stage 2 | This controls edema, prevents changes in size, stump, pain or fit problems, usually kept wrapped at all times |
| stage 2 recovery stump care | Daily exercises to prevent muscle deformity, remove and reapply bandages daily, massage stump vigorously daily between bandages |
| stage 3 recovery | fit for prosthesis |
| gout is a | metabolic disorder caused by high levels of uric acid in blood |
| in gout, | Plasma becomes supersaturated resulting in the formation of monosodium urate crystals which are then deposited into joints which results in joint inflammation |
| where is gout common | in the big toe, ankle or knee |
| acute gouty arthritis | Abrupt onset at night, severe pain (can't even have a sheet touching), redness, swelling & warmth over affected joint |
| early attacks of acute gouty arthritis | can subside spontaneously over 3-10 days without treatment |
| later attacks of acute gouty arthritis | occur more often, more joint involvement & last longer |
| when is acute pain most common in acute gouty arthritis | at night |
| pts with advanced non treated gout may also develop | formation of tophi in elbows, knees, ankles, finger tendons |
| tophi | chalky deposits of sodium urate (slide 32 for pic) |
| tophi decrease | range of motion but aren't too painful |
| medical management of gout | Hyperuricemia, tophi, joint destruction & renal problems are treated after acute inflammatory process subsides |
| medications for gout | Uricosuric agents Colchicine or NSAID Allopurinol |
| Uricosuric agents | increase excretion of UA from the body |
| Colchicine or NSAID | will relieve acute attacks |
| Allopurinol | is effective in decreasing UA levels |
| with high UA levels, you should also watch for | UA kidney stones!! |
| Nursing Management of gout | Diet restriction with foods high in purines Maintain normal body weight Pain management is critical!! Monitor renal function |
| when will tophi be noted | after the onset of gout within 10 yrs |
Created by:
leh195