As clients age, bone and muscle mass decreases; what does this put the client at risk for?
As clients age, there is risk of injury and falls due to osteoporosis and decreased muscle strength.
Always implement falls precautions.
What are the "5 P's" of a neurovascular check?
"5 P's" of a neurovascular check are:
If the client is having these symptoms with a musculoskeletal injury or procedure, intervene right away.
What is worn on the legs after most leg, hip, or knee surgeries?
After leg, hip, or knee surgeries the client will wear compression socks and sequential compression devices to prevent a deep vein thrombosis from forming.
Why is physical therapy and occupational therapy commonly prescribed after many musculoskeletal surgeries and conditions?
PT and OT are commonly prescribed because they work with the client to increase muscle strength, prevent complications such as contractures, and help with how to perform activities of daily living.
What is compartment syndrome?
Compartment syndrome is when there is too much pressure in a cast or enclosed space due to edema.
The client will either get a fasciotomy (cut the skin open) or the cast will be cut off.
What is a contracture?
A contracture is a deformity or stiffness of the muscle, tendon or ligament.
They are commonly caused by immobility.
What is the difference between passive range-of-motion and active range-of-motion exercises?
Passive range-of-motion - is when the nurse moves the limb.
Active range-of-motion - is when the client moves their own limb.
Range of motion exercises prevent contractures and increase joint mobility.
What is a major complication from the fracture of a large bone?
Complication from the fracture of a large bone is a fat embolism such as when a femur or pelvis gets fractured.
A fat embolism is a fat blob that gets released into the bloodstream and can go to the lungs causing respiratory distress.
- respiratory distress and a low oxygen reading
- increased heart rate and low blood pressure
- petechiae rash over the chest caused by fat damaging skin capillaries
- give oxygen
- start IV fluids
- possible intubation
What is COAL in regards to using a cane?
COAL is a way to remember which side of the body the cane is held.
Cane is Opposite of the Affected Leg.
This means to hold the cane on the opposite side of the weak leg. The weak leg and cane go forward at the same time, followed by the good leg.
When the cane is placed on the ground, it takes the weight of the ____ leg.
When the cane is placed on the ground, it takes the weight of the bad leg.
How far away should the cane be held from the body?
Hold the cane 4 - 6 inches (10 -15 cm) away from the level of the hip.
What is the "saying" for using stairs with a cane or crutches?
"Go up with the good, down with the bad"
- The good leg goes up the step first, followed by the cane/crutches and bad leg.
- The bad leg goes down the step first along with the cane/crutches, followed by the good leg.
What are the steps to using a walker?
- put all 4 points on the floor before leaning on it
- move the walker forward
- move the bad leg first
- then the good leg
Where should the height of the walker be?
at the hips
What is a 3-point crutch gait?
A 3-point crutch gait is when there are 3 points on the floor: 2 crutches and 1 leg.
What are a 2-point and 4-point crutch gait?
A 2-point and 4-point crutch gait look very similar. Each looks like the client is walking with crutches.
- The 2-point is a faster walk
- The 4-point is a slower walk and more steady
Click HERE for a crutch gait demonstration video.
What is the difference between partial weight-bearing and full weight-bearing?
Partial weight-bearing - is using 30-50% of the weight
Full weight-bearing - is using 100% of the weight.
What is toe touch (touchdown) weight-bearing?
Toe touch (touchdown) doesn't use any weight, but the toe can touch the floor.
What is weight-bearing as tolerated?
To bear weight on the extremity as tolerated by pain and comfort.
What is an arthrocentesis?
An arthrocentesis is when a needle is used to take fluid out a joint to assess for infection and inflammatory diseases.
Steroids may be injected to decrease inflammation.
What is an arthroscopy?
An arthroscopy is when a camera scope is inserted to see joints and treat or diagnose diseases.
What are the interventions after an arthrocentesis or arthroscopy?
- assess neurovascular status
- wear a compression bandage for up to 4 days
- limit activity for a few days
- assess for infection: fever, increased pain, and edema
What is a bone mineral density test?
A bone mineral density test uses x-rays to measure bone density and diagnose osteoporosis.
All metal objects should be removed before the test.
What is a bone scan?
A bone scan is when a radioactive isotope is injected in the IV to look for abnormalities or masses in bones such as cancer or fractures.
Because radioactivity is used, encourage fluids afterward to flush out kidneys.
What are the interventions after a bone or muscle biopsy?
Interventions after a bone or muscle biopsy:
- monitor for bleeding, swelling, and severe pain
Apply ice packs and elevate site for 24 hours.
What is a sprain?
A sprain is excessive stretching of a ligament.
Sprain or other acute soft tissue
What is a rotator cuff injury?
A rotator cuff injury is a muscle or tendon tear in the shoulder.
Rotator cuff injury
- sling to shoulder
- ice or heat depending on what feels better
- physical therapy
What is a fracture?
A fracture is a break in the bone.
- immobilize with a cast or splint
- neurovascular checks to assess for compartment syndrome
What is an open (compound) fracture?
When the bone has pierced the skin.
Cover wound with a sterile dressing.
What is a closed reduction?
A closed reduction is when the bones of a fracture are manually put back in line.
What is an open reduction?
An open reduction is when the bones from a fracture are surgically put back in place with an internal fixation device.
What is the difference between internal fixation and external fixation?
Internal fixation is when bones are put back in place internally using screws, wires, or pins to stabilize the bone.
External fixation is when bones are put back in place outside of the bone and skin for rigid support of the bone.
What are the specific interventions for pin site care for an external fixation device?
Pin site care:
- clean with normal saline to prevent infection
- some pain, inflammation, and serous drainage is expected
- assess for infection (pus, odor, increased redness or pain)
What is traction?
Traction is using weights to immobilize a fracture, reduce the pain, and realign the bone.
- align client straight in bed
- don't let weights touch the floor
- feet shouldn't touch the footboard
- make sure pulley's work and ropes aren't frayed
- don't release the traction
What is skeletal traction?
Skeletal traction is pins and wires are directly placed in the bone to align the bone.
What is balanced suspension traction?
Balanced suspension traction aligns leg fractures and uses skeletal traction or skin traction.
What is skin traction?
Skin traction is applied to fracture using a boot, sling, or bandage.
What is Buck's skin traction?
Buck's skin traction is for lower limb muscle spasms.
The leg stays flat.
What is Russell's skin traction?
Russell's skin traction is to stabilize the femur before surgery.
The leg is angled up.
What is cervical skin traction?
Cervical skin traction is to stabilize neck injuries.
Signs of a fractured hip are:
- leg is shorter
- leg is externally rotated on the side of the injury
Client will possibly be placed on traction and then possibly get a total hip replacement surgery.
What is the correct position after a hip replacement to prevent dislocation?
Post-hip replacement position is:
- keep legs abducted (apart) using pillows or a wedge
- avoid crossing legs
- keep sitting position in semi-Fowler's or lower
- avoid bending of hips too much
- use a high toilet seat
What is a continuous passive motion machine?
A continuous passive motion machine is used to continuously move the limb to increase range of motion and prevent contractures and scar tissue.
It is typically used after knee replacement surgery.
What is the priority problem when a client has a herniated disc?
Dealing with the pain
What are common signs and symptoms with a herniated disc?
Herniated disc symptoms are due to pinched nerves:
- numbness and tingling
- muscle spasms
- sciatica (nerve pain in the buttocks and leg)
- bowel and bladder dysfunction
What is the priority concern for a client with a cervical herniation?
With cervical herniation, the priority is to check breathing.
The client will also need a collar brace and the body is to be kept midline to prevent further damage to nerves.
What surgeries are performed for a herniated disc?
diskectomy - removal of abnormal disc material
laminectomy - removal of bone
For both surgeries there can be a "fusion" where the bone is fused together.
What are the main interventions for a diskectomy or laminectomy?
- pain meds
- lay flat or slightly elevated
- log roll to turn
- wear a brace
- physical therapy
analgesics (pain meds)
- NSAIDs, acetaminophen, opioids
- NSAIDs and steroids
- lorazepam, benzodiazepine
- Muscle relaxers
- NSAIDs, acetaminophen, opioids
- NSAIDs and steroids
- lorazepam, benzodiazepine
How long does it take for a wet plaster cast to dry?
24 - 72 hours
How is itching relieved when wearing a cast?
Use a hair dryer on a cool setting to relieve itching.
Never place anything inside the cast.
How long does a synthetic cast take to dry?
How should a cast be lifted?
Use the palms to lift the cast, not the fingertips.
How long should a cast be elevated after being applied?
24 - 48 hours
What is the main assessment for a client wearing a cast?
The "5 P's" for a neurovascular assessment and cast:
This is to assess for compartment syndrome.
Osteomyelitis is an infection in the bone.
The client will get a CVAD and antibiotics.
What disease is a common cause of amputations?
Diabetes mellitus is a common cause of amputations due to nerve damage.
What are the priority assessments for a client post-operative amputation?
After an amputation, assess for:
How is an amputated limb wrapped?
Wrap the amputated limb from the lowest area to the highest area to prevent edema.
How is an amputated limb positioned post-operatively?
Amputated limb position:
- elevate for 24 hours to prevent edema
- then lay extremity flat
How are contractures prevented with an amputated leg?
To prevent contractures of an amputated leg, have client lay on stomach 30 minutes a day.
What is phantom pain with amputations?
Phantom pain is when there is pain where the limb used to be.
Phantom pain is treated with opioids and analgesics, but also with alternative therapies such as:
- TENS (transcutaneous electrical nerve stimulation)
Rheumatoid arthritis is a chronic systemic inflammatory disease of the joints that causes pain and immobility.
It is an autoimmune disorder.
What is the characteristic pain symptom with rheumatoid arthritis?
Rheumatoid arthritis: moderate to severe pain, with morning stiffness lasting longer than 30 minutes
Due to systemic inflammation with rheumatoid arthritis, clients can have a low-grade _________, fatigue, and weakness.
Due to systemic inflammation with rheumatoid arthritis, clients can have a low-grade temperature, fatigue, and weakness.
What are swan neck fingers?
Swan neck fingers are how the hands are described for a client with rheumatoid arthritis.
It is due to bending of the joints.
How are the joints described during an acute exacerbation with rheumatoid arthritis?
The joints with an exacerbation with rheumatoid arthritis are tender and have a soft spongy feeling.
The soft joints cause deformities, so joints should be supported during exacerbations.
What labs are elevated with rheumatoid arthritis?
Elevated labs for rheumatoid arthritis are:
- elevated ESR (erythrocyte sedimentation rate) - an indication of inflammation
- positive rheumatoid factor
Meds for rheumatoid arthritis focus on decreasing pain and inflammation:
- DMARDs (disease-modifying antirheumatic drugs)
Osteoarthritis (degenerative joint disease)
Osteoarthritis is the most common arthritis. It is the deterioration of the cartilage in the joints mostly affecting the hips, knees, lower back, and hands. There is pain and immobility.
The cause is not known, but there are risk factors.
Risk factors for osteoarthritis:
- continuous wear and tear of joints due to age
Teach client to keep weight at normal range and to not smoke.
What are the characteristic pain symptoms with osteoarthritis?
Osteoarthritis pain symptoms:
- early symptom: joint pain that is less after resting and worse after activity
- later symptom: pain with slight movement or even at rest
Meds for osteoarthritis focus on decreasing pain and inflammation:
- muscle relaxers for back spasms
- steroid injections in joints
How should inflamed joints be protected for the client with osteoarthritis and rheumatoid arthritis?
Protect joints with osteoarthritis and rheumatoid arthritis:
- immobilize joint with a splint or brace until inflammation subsides
- avoid flexion of the knees and hips; keep in a natural position
- no large pillows under the head or knees
When is hot and cold therapy used for rheumatoid arthritis and osteoarthritis?
- Use moist hot therapy when the joints are not inflamed
- Use cold therapy when there is acute inflammation
What type of exercises should clients with rheumatoid arthritis and osteoarthritis do?
- range-of-motion for joint flexibility
- avoid weights on inflamed joints; light weights are OK when not inflamed
- use splints during acute inflammation to prevent deformity
What health care professional works closely with a client with rheumatoid arthritis and osteoarthritis?
The occupational therapist works with client to use assistive and adaptive devices for activities of daily living.
A physical therapist may also work with this type of client to help with overall movements such as walking and climbing stairs.
What is the last resort treatment for rheumatoid arthritis and osteoarthritis?
Arthroplasty (joint replacement)
Osteoporosis is loss of bone mass leading to pain, fractures, and weakness that occurs most commonly in the wrist, hip, and spine.
- post-menopausal women, especially small-framed Asian or white women
- can occur in men with low testosterone levels
- low calcium intake and malnourished clients
- sedentary lifestyle, use of alcohol, and smoking
What are the characteristic symptoms with osteoporosis?
Symptoms of osteoporosis:
- back and hip pain, especially when lifting things or bending
- decline in height
- problems with balance
What are the interventions for osteoporosis due to the high risk of fractures?
Prevent falls and injuries
- get rid of clutter
- use side rails
- use a cane or walker
- be gentle when turning and repositioning
- do weight-bearing exercises
- Eat a diet high in vitamins and minerals, especially calcium and vitamin D
- drink fluids to prevent kidney stones
- take antiosteoporotic meds
Gout is a systemic condition where there is an increase of uric acid in the blood that causes swelling and inflammation of the joints.
Inflammation is most common in the big toe and hands.
The most common causes of gout are:
- decreased kidney function prevents kidneys from getting rid of uric acid
- a diet high in purines (which break down into uric acid)
- chemotherapy destroys cells that release uric acid into the bloodstream
What are tophi?
Tophi are hard nodules in the skin that are uric acid crystals for those with gout.
What is the recommended diet for a client with gout?
Recommended diet to prevent gout from getting worse:
- low-purine diet: avoid aged foods and limit meat
- avoid organ meats, wines, and aged cheeses
- increase fluids to 2000 mL/day to prevent stone formation
- avoid alcohol (it can increase inflammation)
What are the interventions during an acute flare-up of gout?