msk Flashcards
sprains and strains
Sprains (ligaments) and strains (muscles)
nursing interventions: warm up exercises
Most common symptoms: Edema, decreased function, bruising, pain
Immediate care: RICE
Movement of joint while supported
dislocation and subluxation
(thumb, elbow, shoulder, hip and patella)
Most common symptoms: deformity, pain, tenderness, loss of function and swelling
Nursing interventions: dislocation is an orthopaedic emergency: priority is to realign the joint
Nursing management: pain relief, support of joint; extensive rehab program
Patient will be at increased risk of repeat dislocation
carpal tunnel syndrome
Nursing and collaborative care: prevention is best; wrist splints, special keyboards. Corticosteriod injections; surgery (open release or endoscopic carpal tunnel release); outpatient procedure
Months of recovery needed; neurovascular assessment of hand important
rotator cuff injury and meniscus issues
Nursing and collaborative care: treated with ice and heat, rest, NSAIDS, corticosteroids and physio.
Surgery may be required. Avoid ‘frozen’ shoulder. Recovery may take 6 months
anterior cruciate ligament
most common sports injury
Nursing and collaborative care: a positive Lachman test; MRI-shows co-existing conditions. Treatment of intact ACL includes: ice, rest, NSAIDS, elevation
Reconstructive surgery: for complete tear in active patients. Allograft or autograft (hamstring or patellar ) ligament used. Rehab is crucial for functional return of knee—6-8 month recovery
nursing interventions and collaborative care for closed reduction msk fractures
nonsurgical, manual realignment of bone fragments. Traction and countertraction utilized while pt under general anesthesia. Casting immobilizes the injured part to allow healing
nursing interventions and collaborative care for open reduction msk fractures
correction of bone alignment through surgical incision. Internal fixation requires wire, screws, plates, pins. Infection a risk. Continuous passive ROM machines may aid healing.
msk fractures supports
Traction: application of a pulling force to an injured body part. Skin traction (Buck) or skeletal traction.
Risk for skeletal traction: infection and prolonged immobility
Casts: typical with closed reduction; immobilizes joint above or below the fx.
Upper extremities: sugar-tong splint, short arm, long arm, posterior splint
Vertebral injury: body jacket
Lower extremity: long cast, short cast, cylinder cast, Jones dressing or splint. Hip spica cast used in pediatric setting
msk fracture nursing care
Pain medication, muscle relaxants (Robaxin), tetanus immunization and antibiotics (cefazolin) may all be required
Nutritional therapy: adequate protein (1g/kg of body weight); vitamins, calcium, phosphorus, and magnesium necessary for healing
Cast care:
neuro-vascular assessments, observe for edema, compartment syndrome, NO scratching or putting objects inside the cast, keep cast dry.
Cast removal in outpatient setting
Ambulation important: non-weight bearing, touch down weight bearing, toe-touch weight-bearing, partial weight bearing , weight bearing as tolerated, full weight bearing
goals of fracture treatment
Realignment of bone fragments
Immobilization to maintain realignment
Restoration of normal function of injured parts
complications of fractures
Bone infection Bone malunion or nonunion Avascular necrosis Compartment syndrome Deep vein thrombosis Fat embolism Traumatic or hypovolemic shock
fracture infections
High incidence in open fractures and soft tissue injuries
Massive or blunt soft tissue injury often has more serious consequences than fracture.
Devitalized and contaminated tissue is an ideal medium for pathogens.
compartment syndrome
Two basic types of compartment syndrome
↓ compartment size
Resulting from restrictive dressing, splints, casts, excessive traction, or premature closure of fascia
↑ compartment size
Related to fracture, bleeding, edema, chemical response to snakebite, or IV filtration
compartment syndrome occurrence
Early recognition and treatment essential
Ischemia may occur within 4 to 8 hours after onset.
Regular neurovascular assessments
May occur initially or may be delayed for several days
6 P’s of compartment syndrome
Pain: distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle travelling through compartment
Paresthesia: numbness and tingling
Pressure: ↑ in compartment
Pallor: coolness and loss of normal colour of extremity
Paralysis: loss of function
Pulselessness: diminished/absent peripheral pulses
compartment syndrome assessments and signs
Urine output must be assessed because there is a possibility of muscle damage.
Myoglobin released from damaged muscle cells precipitates as a gel-like substance.
Large amounts of myoglobin may result in acute tubular necrosis.
Acute tubular necrosis causes acute renal failure.
Common signs of myoglobinuria
Dark reddish brown urine
Clinical manifestations associated with acute renal failure
fat embolism syndrome
Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury
fat embolism treatment
Early recognition crucial in preventing potentially lethal course
Most patients manifest symptoms 24 to 48 hours after injury.
Clinical course of fat embolus may be rapid and acute.
Patient frequently expresses a feeling of impending disaster.
In a short time skin colour changes from pallor to cyanosis.
Treat symptoms
Use of corticosteroids is controversial but often administered
preoperative care
Day surgery: procedures lasting 2 hrs or less; requires 3-4 hr stay in post anesthesia care unit (PACU)
Pre-Op clinic: decreases surgical delays, reduces pt anxiety through education and answering questions
Instructions for: routine medications on day of surgery, which medications or herbal remedies to stop (ie. Anticoagulants), NPO instructions, pain management options, infection prevention, post-op discharge and care
Day of surgery: OR checklist and consents signed; pre-op meds and IV insertion
Hair clipped, NOT shaved
malignant hypothermia
genetic condition, rare, potential fatal metabolic disease of hyperthermia with rigidity of skeletal muscles. Screened during pre-op for familial hx
hip fracture
70-90% caused by osteoporosis; 95% result from a fall
10% die within the 1st month; 20% at 4 months; 30% at 1 yr
‘fracture of the hip’ defined as proximal 1/3 of femur
Buck traction may be applied pre-surgery
Surgery options: internal fixation devices; partial hip replacement (replacement of femur with prosthesis); total hip replacement (involves both femur and acetabulum)
typical post-op assessments for hip fracture
Typical post-op assessments: vitals, in/out fluids, resp status (deep breathing and coughing, monitoring pain and incision (bleeding or infection). Goal: pt out of bed within 24 hrs
Neuro-vascular assessment: color, T, capillary refill, distal pulses, edema, sensation, motor function, pain
posterior approach for hip fractures
Posterior approach: dislocation prevention needed (first 6 wks)
Precautions: never >900 of hip flexion
Adduction across the midline
Internal rotation
Taking a bath or driving is not allowed for 6 wks
Abductor pillow between pt’s legs prevents adduction
anterior or anterolateral approach for hip fractures
hip muscles left intact; fewer dislocation and infection issues
weight bearing and hip fractures
variable depending on how fragile the fx—full weight bearing may be delayed until 6-12 wks based on x-ray
arthroplasty vs hemiarthroplasty
arthroplasty = reconstruction or replacement of a joint hemiarthroplasty = replacement of a part of the joint
indications for joint replacement
Relieve chronic pain
Improve joint mobility
Correct malalignment
Remove intra-articular causes of erosion
amputation
Older age group: related to diabetes mellitus: atherosclerosis, vascular changes, PVD
Two types: residual limb and disarticulation
Residual limb: closed amputation: anterior skin flap with soft tissue padding over the bony prominence. Skin flap is situated posteriorly.
Disarticulation: through a joint
Body image: psychological and social implications
Phantom limb sensation/pain (neurogenic pain)
amputation aftermath
Prosthesis: pt may weight bear 3 months post-surgery
Proper residual limb bandaging fosters shaping and moulding. Compression bandage : supports soft tissue, reduces edema, minimizes pain, hastens healing, promotes limb shrinkage
Physio essential
Prosthetist: fits limb fit for prosthetic
Walking : below the knee prosthesis requires 40% more energy; above the knee amputation requires 60% more energy
intraoperative care
Circulating nurse role: interprofessional time-out
Not scrubbed, gowned or wearing sterile gloves; documents
Scrub nurse role: scrubbed, gowned, with sterile gloves.
Assists with surgery, instruments, surgical count of equipment
Surgeon and assistant
Anesthesiologist: medications for pain and sedation; intubation
Positioning the pt (Lewis Figure 21-6)
Electrocautery: common equipment used for incisions and cauterizing blood vessels. Requires grounding—pad often placed on thigh of pt
intraoperative: anesthesia
General anesthesia: loss of consciousness, skeletal muscle relaxation, amnesia and analgesia
Local anesthesia: loss of sensation in a specific area, no loss of consciousness; may be achieved through topical, SC, or intracutaneous administration route.
Regional anesthesia: spinal, epidural, peripheral nerve blocks
Procedural (conscious ) sedation: mild depression of consciousness. Patient maintains their airway
postoperative care
PACU (post anesthesia care unit) : Located in close proximity to OR Monitor: ABC’s Serial Vital signs Resp: oxygen status Pain assessment Post-op bleeding GU: urine output Cardiac: ECG delayed ambulation Short stay (a few hours)
OR—to PACU—pt transferred back to day surgery or surgical unit
SBAR handoff report important at each stage
