Med Surg Exam 3 PDF

Preview

Summary

MED sure 2 exam3 ...

Description

Chapter 39: Assessment of Musculoskeletal Function 





Function of the Musculoskeletal System o Protect vital organs o Mobility and movement o Facilitate return of blood to the heart o Production of blood cells (hematopoiesis) o Reservoir for immature blood cells o Reservoir for vital minerals BONE FORMATION o Osteoblasts --> function in bone formation o Osteocytes --> mature bone cells that function in bone maintenance o Osteoclasts--> Multinuclear cells function in destroying, resorbing, and remodeling bone. o Osteogenesis --> process of bone formation, occurs within the bone o Ossification --> the process of formation of the bone matrix and deposition of minerals o Factors Regulating bone formation: stress, weight bearing, vitamin D, parathyroid hormone, calcitonin, blood supply. o Calcitonin: released in response to TOO MUCH Ca in the blood --> inhibits bone reabsorption. Assessment of the Musculoskeletal System o ADLS o IADL’s (independent activities of daily living) o Health History  Family history of osteoporosis (prevalent in females)  Occupation (on their feet all day?)  Nutrition  Medications (OTC?)  Rheumatoid arthritis  Socioeconomic factors o Pain  Bone pain is the worst  May interfere with sleep  Bone pain: dull, deep, achy  Muscular pain: sore, aching, cramps  Fracture pain: sharp, piercing, relieved by immobility  Rheumatic Disorder pain: WORSE IN THE MORNING.  Tendonitis pain: worse in the morning and eases by midday  Osteoarthritis pain: get progressively worse throughout the day. o Altered sensation  Parenthesias: tingling, burning, or numbness o Physical Assessment 

POSTURE



 

GAIT   

Walking smoothly? Favoring one side? (stroke patients limp because they put more weight on one side) Shuffling? (Parkinson)



BONE INTEGRETY  Symmetry, alignment, abnormal growths, amputations, crepitus



JOINT FUNCTION  Palpate joints  Look for nodules, fluid, cracking sounds (crepitus)  Contracture: shortening of the surrounding joint structures  Effusion: excessive fluid within the capsule (swelling & increased temperature may reflect active inflammation)



MUSCLE STRENGTH & SIZE  Passive or active ROM? (is it painful?)  Hand grasp strength  Atrophy

NEUROLOGICAL STATUS  CMS checks o C-circulation (6 P’s occur if not enough circulation) pain, pallor, pulse, paranesthesia, paralysis, poli (temperature) o M-movement o S-sensation o Do CMS check distal to the cast  *if cast is on leg, check toes Diagnostic Studies o X-ray  Tells you:  if bone is broken  Some info on density  Any erosion or disfigurement  Will take multiple dimensions of the bone (front, side, back, etc.)  Does NOT always give you what you need! o CT scan  W or w/o contrast, gives you better info than the xray  You can see: 



Kyphosis: hump, almost bent over. o Loss of height o Common in woman with osteoporosis Lordosis: bending in lumbar o Common in pregnant women

    o

o

o

o

MRI 

Tumors Ligament changes Tendon changes Basically, everything an XRAY can NOT, but they will NOT do a DT until an x-ray has been done!

Before an MRI, the nurse must remove ALL metal and medicine patches; otherwise they become dangerous projectile objects or cause burn.  People with pacemakers can’t get these  Check allergy for IV contrast and ask women if they're prego  Causes no pain  May take 30-90 minutes Arthrography  Used to identify the cause of unexplained joint pain & progression of joint pain disease  Radiopaque contrast is injected in to the joint cavity to help visualize  Joint is put through ROM to distribute the contrast, while a series of x-rays are taken.  If a tear is present the contrast leaks out of the joint and shows on the x-ray.  Patient Teaching:  May feel Bone Densitometry  Typically, don’t use contrast.  Used to evaluate bone mineral density (BMD) and predicts fracture risks through accurate monitoring of bone density changes in those with osteoporosis undergoing tx.  Pre op:  Assess for allergies (especially if a contrast agent is used)  Assess for contraindications (pregnancy, claustrophobia, metal implants)  Post op:  Pain management  Activity restrictions  Joint mobility Bone scan  Radioscope injected IV then scan 2-3 hours later if there is increased uptake = skeletal disease  Done in nuclear medicine  Can find things earlier than an X-ray  Often uses an isotope  Assess for allergies to radioisotope  Teach the pt.  That they will have a warm flushing sensation (no radioactive hazard)  Clear it out by increasing fluid intake  Empty bladder prior to scan, for a better view of pelvis

Bone scans are performed for:  Metastasis  Primary bone tumors  Osteomyelitis (infection of the bone secondary to fracture)  Osteoarthritis Arthroscopy (she played a video)  Usually preformed in the OR  Procedure allows a direct visualization of a joint through a fiberoptic endoscope  Useful to diagnosis joint disorders, biopsy and tx of joints, biopsy, treatment of tears, defects, and disease may be performed through the arthroscope.  Preop:  Teach pt. About anesthesia forms  Start IV line  Sedate o Spinal anesthetics: numb bottom half o Local: keeps area numb o General: completely asleep  Post op:  Wrap the joint  Apply ice and cool compresses to reduce edema  Extend and elevate the joint to reduce swelling  Assess neurovascular status  Avoid strenuous activity  Pain management  Monitor for bleeding, swelling, and numbness Arthrocentesis  Joint aspiration of synovial fluid from the joint to relive pain or for examination purposes.  USEFUL IN THE DIAGNOSIS OF SEPTIC ARTHRITIS AND OTHER ABNORMALITIES  Involves sterile prep and field and give NSAIDs  Pre-Op:  Hair removal from site  Use of analgesics  Post Op:  Application of ice for 24-48 hours  Possible antibiotic use  Monitor for bleeding, swelling, numbness  RISK FOR INFECTION AFTER  Outcomes:  Improved mobility Electromyography (EMG)  Provides info about the electrical potential of muscles and nerves leading to them  Performed to evaluate muscle weakness, pain, and disability 

o

o

o

   

o

o

Differentiates muscle and nerve problems Needle electrodes are inserted into muscles; responses to electrical stimuli are recorded. Warm compresses may relieve discomfort after the procedure. NURSING INTERVENTION:  Check if pt. Is taking an anticoagulant and assess for active skin infections.  EMG in CONTRAINDICATED for anticoagulant therapy (muscle could bleed) and infection can spread.  Tell pt to avoid using lotion the day of test

Biopsy  May be performed to determine the structure and composition of bone marrow, bone, muscle, or synovium to help diagnose specific diseases.  NURSING INTERVENTIONS:  Educate about procedure and ensure analgesics will be provided  Monitor the biopsy site for edema, bleeding, pain, at the site as well as fever and chills Labs  Alkaline phosphate (Paget’s Disease)  Very rare  Paget- bones, and joints are painful, disfigured  Acidic phosphate is elevated  Alkaline phosphate is elevated during the early fracture healing and in diseases with increased osteoblastic activity.  You see it in: o Pelvis o Lower back o Thigh o Head (hearing loss & headache)  Coagulant Studies  PT, INR, PTT o Bone is very vascular, so you want to detect bleeding  Serum Calcium  Changes with tumors  The bones are most common site for metastasis  Bone cancer can be primary or secondary  The calcium comes out of the bone, and into the blood so pt. Will have HYPERCALCEMIA  When pts. Are on bedrest the Ca in the bone is lost from bone into blood, you will have bone depletion (some type of osteoporosis)  Altered in osteomyelitis, parathyroid dysfunction, Paget’s disease, metastatic bone tumors, or prolonged immobilization.  Thyroid Studies  Calcitonin and PTH

PTH hormone disfunction o The role of this hormone is to detect when serum ca is low and increase Ca levels by getting it out of the bone, and into the blood. o Pt. Will have HIGH PTH levels  Calcitonin: take Ca out of the blood into the bone (opposite) Vitamin D level  Vitamin D has to do with Ca absorption Specific urine  Monitor urine for Ca, excess Ca will be excreted in the urine 

  OSTEOPOSOSIS: 







PATHO: o Bones become porous, brittle, fragile and fracture easily under stress that would not break normal bone.  Hip & spine are the places where you see the most bone loss  Characterized by reduced bone mass, deterioration of bone matrix, and diminished bone Architectual strength. RISK FACTORS: o Small framed elderly women o Asian women o Family history o History of bone fracture o Sedentary lifestyle o Inadequate Ca or vitamin D o Use of corticosteroids (affects Ca absorption) o Post-menopausal women o Men over 60 o Tobacoo and/or alcohol use (reduce osteogenesis) o Malabsorption disorders DIAGNOSTIC FINDINGS: o X-ray o DEXA (duel energy x-ray absorption): provides info about BMD at the spine and hip MEDICAL MANAGEMENT: o Assessment o Diet rich in Ca (1200mg a day) and vitamin D  Too much Ca can cause kidney stones. o Regular weight bearing exercise (promotes bone formation) o Weight training (increased BMD) o Cold climates may make it worse o FALL RISK o PHAMACOLOGIC:  Ca & vitamin D together

Lactose intolerant? People can get vitamin D from... o Broccoli, OJ, leafy greens, canned salmon.  Bisphosphonates (ex. Alendronate)  Hormone therapy --> estrogen agonists NURSING INTERVENTIONS: o Relieve back pain from compression fractures in spine  Positioning, apply heat, back rub o Tell pt. To avoid twisting o Isometric exercises can strengthen trunk o Encourage walking, good body mechanics & good posture o Avoid sudden bending, jarring, and strenuous lifting o High fiber, and increased fluids to improve bowel movements o Educate that one fracture can lead to another 



OSTEOARTHRITIS 

  



PATHO: o Degenerative disease that is localized to joints, o NON- INFLAMMATORY o Gets better with rest o ONLY A LITTLE PAIN IN THE AM and gets better throughout the day o RA can lead to OA because of immobility o Pain in weightbearing joints: fingers, knees, hips, shoulders o Tends to star in your 30’s and peaks in the 50’s and 60’s  Start complaining of knee pain when bent down RISK FACTORS: o Rheumatoid Arthritis (autoimmune, genetic disorder) DIAGNOSTIC FINDINGS: o RADIOLOGICAL MEDICAL MANAGEMENT: o Analgesics (COX 2, opiods) o Anti-inflammatory (ibuprofen) NURSING MANAGEMENT: o Educate:  Lose weight  In soles can help with knee pain  Cold therapy reduces swelling

Chapter 40: Musculoskeletal Care Modalities 

CASTS  Rigid, external immobilizing device  Immobilize a reduced fracture  Correct or prevent a deformity

Apply uniform pressure to underlying soft tissue Can be fiberglass or plaster.  PLASTER: o Less costly and achieve a better mold o Heavy not water resistant o Do not cover plaster cast while it is drying (24- 72) you want the heat to escape.  FIBERGLASS: o LIGHTER IN WEIGHT, STRONGER, AND WATER RESSITANT o Dries within 30 minutes o Nurse should educate pt. That heat is given off when cast is applied, and it may be uncomfortable. SPLINTS & BRACES  Used for simple, stable fractures and tendon injuries  Braces can be custom fit by ortho dr.  Splints: used for stability, good for soft tissue injury. Temporary. Good to maintain a functional position.  Have pressure related complications (skin breaksown)  BRACES: you can but OTC, help control movement and provide support. Indicated for long-term use. NURSING MANAGEMENT:  ASSESSMENT:  Neurovascular assessment prior to splint/cast application  Patient education regarding process  Post cast application: o Assess every hour for first 24 hours and then every 1o 4 hours after--> monitor neurovascular compromise secondary to edema. o Look for 5 P’s o Elevate above the heart for the first 24-48 hours o Immobilize o Cold packs, but DO NOT WET o Tetanus boaster o Observe for systemic infection (color, fever, elevated WBC’s)  Monitor for complications: compartment syndrome, pressure ulcer formation. o Compartment syndrome: serious complication of casting and splinting. Occurs when increased pressure within a confined space compromises blood flow and low tissue perfusion occurs, most often in an extremity. Ischemia and potentially irreversible neuromuscular damage can occur within hours. o Manifestations:  Pale appearance  Cool temp  











 Delayed cap refill  Pain  Complaining that cast is “too tight”  Management: loosen or “bivalve” the cast o Pressure Ulcer: the pt reports painful “hot spot” and tightness under the cast. o Management: bivalve or cut a window in the cast  Explain the purpose, goals, and expectations of the cast  Cast Care: keep dry, do not cover with plastic  Positioning: elevation of extremity, use of slings  Hygiene  Activity and immobility  Tell them to REPORT any s/s of infection  Do not scratch or stick anything under EXTERNAL FIXATORS:  Used to manage complex open fractures with soft tissue damage, complicated fractures of the humerus, forearm, femur, tibia, and pelvis.  Provides external stability while permitting active tx of extensive tissue damage.  Surgical incision of pins throughout the skin and soft tissues into and through the bone  Benefits:  Pt. Comfort, improved wound care, promotion of early mobilization and weight bearing, less blood loss.  There is an increased risk of infection at pin site. NURSING MANAGEMENT:  Pt. Education prior to inserting pins  Elevate at level of heart  Assess the pin site for warmth, redness, drainage. (serous drainage is expected for the first 48-72 hours) every 8-12 hours  PT evaluation  Perform Pin site care  Encourage isometric exercises as tolerated TRACTION:  Uses a pulling force to promote and maintain alignment to an injured part of the body  Goal is to decrease muscle spasms and pain, realign bone fractures and correct/prevent deformities.  Upward or downward traction is to reduce pain  Types of Traction:  Bucks extension traction (straight traction) applies pulling force in a straight line with the body part resting on the bed.  Used to immobilize fractures of the proximal femur and hip BEFORE SURGERY.  THE WEIGHT SHOULD HANG FREELY AND NOT TOUGH THE BED OR FLOOR. ROPES AREIN STRIGHT ALIGNMENT.

BUCKS EXTENTION FRACTION PROVIDES COMFORT BY REDUCING MUSCLE SPASMS AND PROVIDED FRACTURE IMMOBILIZATION. (IT ALSO RELIEVES PAIN)  Skin traction: short term use to stabilize a fractured leg, control muscle spasms, and immobilize an area before surgery. The pulling force is applied by weights that are attached to the client by Velcro, tape, straps, boots or cuffs.  Skeletal traction: never remove the weights!  Manual traction NURSING INTERVERNTIONS:  Avoid wrinkling & slipping of the traction bandage to maintain counteraction  Proper positioning must be maintained to keep the leg in neutral position  The pt should not turn from side to side to prevent bony prominences from moving against each other  Prevent Atelectasis & pneumonia  Encourage coughing and deep breathing  Use of incentive spirometer  Auscultate lungs every 4-8 hours  Constipation  Hydrate  Stool softeners  Early mobilization  Monitor for complication:  Skin breakdown: inspect the skin that is in contact with tape etc. Every 8 hours.  Nerve Damage: skin traction can place pressure and damage peripheral nerves.  Circulatory impairment: neurovascular assessments are a priority. Assess circulation every 15 to 30 minutes and then every 1- 2 hours. 



Chapter 43: Management of patients with Musculoskeletal Disorders      



Contusion: soft tissue injury, hematoma, bruising Stain: injury to muscle or tendon from OVERUSE Sprain: injury to ligaments and tendons that surround a joint, caused by a twisting motion or hyperextensions of a joint 1ST 72 HOURS APPLY COLD AND THEN HEAT ONCE THE INFLAMMATION IS GONE. NO HEATING PAD TO RIGHT ANKLE AFTER SPRAIN NURSING MANAGEMENT: o RICE  R: rest  I: ice  C: compression  E: elevation FRACTURES



complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent. o Occur when the bone is subjected to stress greater than it can absorb o When a bone is broken down, near structure are also affected  Soft tissue edema  Hemorrhage  Joint dislocation  Ruptured tendons  Severed nerves  Damaged blood vessels o TYPES OF FRACTURES:  Complete: Involves a break across the entire cross-section of the bone and is frequently displaced.  Incomplete: GREEN STICK. A break through only part of the cross section of the bone. Most common in kids.  Comminuted: produced various bone fragments (HEAL VERY SLOWLY)  Closed: Simple fracture. Does not cause a break in the skin  Open: Compound or Complex. The skin or mucous membrane extend to the fractured.  Intra-articular: extends into the joint surface of the bone. o CLINICAL MANIFESTATIONS:  Pain-> continuous and increased with movement  Loss of function  Deformity-> displacement, angulation  Shortening-> in fractures of long bones, there is actual shortening of the extremity  Crepitus-> crumbling sensation among palpation  Localized edema o EMERGENCY MANAGEMENT:  1ST IMMOBILIZE  Ex if a finger is hurt bandage to another finger. If arm is hurt bandage to chest.  2nd assess neurovascular status distal to the injury BFORE AND AFTER SPLINTING  Open fractures must be covered with sterile dressing o MEDICAL MANAGEMENT:  Reduction: refers to restoration of the fracture fragments to anatomic alignment  BEFORE: get consent and medicate with analgesics  Closed reduction: bones are brought to their anatomical alignment through manipulation and manual traction. The extremity is held in the aligned position while the physician applies a cast or splint. X-rays are done to assure the bone fragments are aligned  Open reduction: surgical approach through which fracture fragments are aligned (internal fixation device) with pins, wires, screws may be used to hold bone fragments in place until solid bone healing takes place.

o

 LOVENOX IS TOO REDUCE THE RISK OF THROMBUS  DVT IS A COMPLICATION NURSING MANAGEMNET:  Elevate the extremity to heart level (NOT ABOVE) to control swelling and pain  Exercise instruction to maintain health of unaffected muscles  Educate regarding assistive devices  Prevent infections of open fractures  IV antibiotics to prevent osteomyelitis, tetanus, and gangrene  Tetanus boaster  Wound irrigation and debridement  Fractures take about 6-8 weeks to heal  Factors that enhance healing: immobilization, enough blood supply, proper nutrition, hormones  Factors that delay infection, metabolic problems, corticosteroid use, smoker, diabetes, weightbearing prior to approval  COMPLICATIONS:  Hypovolemic shock resulting from hemorrhage  Hemorrhage  Fat embolism Syndrome o CONFUSION IS THE 1ST SIGN OF FAT EMBOLISM o Common in pts. With multiple fractures o At the time of the fracture, fat globules diffuse from bone marrow into the vascular component where they can occlude the small blood vessels that supply the lungs, brain, kidney, and other organs. o Can occur as fast as 12-48 hours. o Clinical Manifestation: Classic triad  Hypoxemia & tachypenia  Neurologic compromise (headache, delirium)  Petechial rash  Fever over 103  Free fat in the urine  Acute tubular necrosis  Subtle personality changes, restlessness, irritability, confusion.  ABGs show PaO2 less than 60  Compartment syndrome: o Extreme limb threatening condition  s/s: sudden decrease in blood flow distal to the injury,...