NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Musculoskeletal System

Focus topic: Medical–Surgical Nursing

The musculoskeletal system provides the support and protective mechanism of the body. Bones, joints, and skeletal muscles comprise the system.

Medical–Surgical Nursing: Anatomy and Physiology

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Bone Structure

Focus topic: Medical–Surgical Nursing

A. Types of bones.

  • Long: legs, arms.
  • Short: wrists, ankles.
  • Flat: skull, sternum, ribs.
  • Irregular: vertebrae, face, scapulae, pelvic girdle.

B. Bone surfaces.

  • Grooves and holes provide passage for nerves and blood vessels.
  • Protrusions at the ends of the bone form parts of the joints.
  • Shallow depressions and ridges are attachment points for fibrous tissue.

C. Bone function.

  • Support and protect structures of the body skeleton.
  • Provide attachments for muscles that move the skeleton.
  • Central cavity of some bones contains hematopoietic tissue (connective tissue), which forms blood cells.
  • Assist in regulation of calcium and phosphate concentrations.

Medical–Surgical Nursing: Long Bones

Focus topic: Medical–Surgical Nursing

A. Diaphysis: long, central shaft.
B. Epiphysis: the end of a long bone.

  • Covered by hyaline cartilage.
  • Auricular surface: the part of the epiphysis that contacts other bones.

C. Periosteum: adhering sheath of connective tissue covering bone.
D. Internal structures.

  • Central medullary cavity: Contains yellow marrow composed of fat.
  • Surface layer: an ivory-like, dense, compact bone.
  • Cancellous bone: a spongy layer below the surface layer. It contains small cavities that merge with a large central cavity.
  • Red marrow: Consists of hematopoietic tissue, macrophages, and fat cells. Fills the spaces between spongy bone.

Medical–Surgical Nursing: Joints

Focus topic: Medical–Surgical Nursing

Definition: Joints, also called articulations, are regions where two or more bones meet. Joints hold bones together while allowing movement.
A. Classification.

  • Synarthrosis: fibrous or fixed joints (immovable).
  • Amphiarthrosis: cartilaginous or slightly movable joint.
  • Diarthrosis: synovial or freely movable joint.
    a. Ball and socket.
    b. Condyloid.

B. Function.

  • Articulation is the meeting place of two or more joints.
  • Assist in type and range of movement between bones.

C. Synovial fluid.

  • Function.
    a. Lubricate the cartilage.
    b. Cushion shocks.
    c. Provide a nutrient source.
  • Structure.
    a. Fluid formed by the synovial membrane.
    b. Synovial membrane lines the joint capsule, which contains the fluid.

System Assessment
A. Observe for signs of a fracture.

  • Assess for specific type of fracture.
  • Observe all suspected fracture sites for edema, pain, and obvious deformities.

B. Assess for possible complications associated with a cast.
C. Evaluate client for complications associated with joint disorders.
D. Observe for complications of amputation.

  • Observe for presence of phantom limb pain.
  • Assess stump dressings for bleeding and/or signs of infection.

E. Observe for complications of hip surgery.

  • Observe position in bed of clients with hip fractures to identify potential complications associated with hip flexion.
  • Assess for signs of shock and hemorrhage following surgery.
  • Evaluate need for client instruction on exercises, positioning, and crutch walking.
  • Evaluate client’s need for rehabilitation program.

F. Observe circulation, motion, and sensation (CMS) for all orthopedic clients.
G. Assess skin and neurovascular status before, during, and after any immobilizing modality—compare contralateral extremity and baseline data.

Medical–Surgical Nursing

H. Inspect and palpate the client’s bones for any sign of obvious deformity or changes in size or shape. Palpation will elicit pain and tenderness; assess for warmth and crepitation.
I. Measure extremities for length and circumference— compare bilaterally.
J. Assess muscle mass and strength—compare bilaterally.

Medical–Surgical Nursing: Joint and Nerve Diseases

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Rheumatoid Arthritis

Focus topic: Medical–Surgical Nursing

Definition: Chronic, systemic, autoimmune inflammatory disease affecting the joints. Usual onset is from 30 to 50 years of age, but can occur at any age. Etiology unknown; may be autoimmunity, viral, or genetic. Follows course of recurrent exacerbations and remissions.

Assessment
A. Evaluate for bilateral joint involvement (erythema, warm, tender, painful).
B. Assess for insidious onset of malaise, weight loss, paresthesia, stiffness.
C. Assess pain and stiffness early in morning (subsides with moderate activity).
D. Observe for subcutaneous nodules.
E. Assess low-grade temperature.
F. Observe for anemia with fatigue and weakness.
G. Check for pattern of joint involvement—from small joints to knees, spine, etc.
H. Assess for limitation of function and deformities of hands and feet.
I. Laboratory and diagnostic tests.

  • Rheumatoid factor (RF)—present in about 80% of people with rheumatoid arthritis (RA). High levels are associated with progressive disease and poorer prognosis.
  • ANA (antinuclear antibody) titer, CRP (C-reactive protein), and ESR (erythrocyte sedimentation rate) are elevated due to active inflammation.
  • Complete blood count (CBC)—hemoglobin and hematocrit; usually shows anemia.
  • Synovial fluid—shows inflammatory changes: increased turbidity, decreased viscosity, increased protein levels, 3000 to 50,000 white blood cells (WBCs)/μL with polymorphonuclear leukocytes (PMNs) (circulating neutrophils) predominating.
  • X-ray—few changes with early disease. As disease progresses there are joint changes.

Implementation
A. Instruct client on medications and side effects. Chemotherapy reduces inflammation and relieves pain. Once the diagnosis of RA is made, clients should begin treatment with either a nonbiologic or biologic disease modifying antirheumatic drug (DMARD).

  • Nonbiologic DMARDS—may slow or stop progression of joint damage.
    a. The most commonly used:
    (1) Plaquenil (hydroxychloroquine).
    (2) Arava (leflunomide).
    (3) Trexall (methotrexate).
    (4) Azulfidine (sulfasalazine).
    b. Usually taken as pill.
    c. Trexall is sometimes given by injection.
    d. Take from 4 to 6 weeks to begin working, longer to reach full effect.
    e. Suppress the immune system, side effects vary with each medicine.
    f. Serious risks include infection and kidney or liver damage.
    g. Trexall and Arava can cause serious birth defects. Women taking any of these drugs should talk with their doctor before planning pregnancy.
  • Biologic DMARDS
    a. TNF-alpha antagonists:
    (1) Humira (adalimumab).
    (2) Cimzia (certolizumab pegol).
    (3) Enbrel (etanercept).
    (4) Simponi (golimumab).
    (5) Remicade (infliximab).
    b. Given under the skin or by intravenous (IV) injection.
  • The most common side effects seen:
    a. Injection site reactions.
    b. The most significant side effect is increase in the risk of all types of infections, including tuberculosis (TB). Before starting a medication, a TB skin test is usually done.
    c. Treatment with these agents should be stopped while you have an active infection and are taking an antibiotic or if you have a high fever.
    d. Rare neurologic complications and people with multiple sclerosis should not use them.
  • Salicylates.
    a. Acetylsalicylic acid (ASA) most common.
    b. Side effects include tinnitus, gastrointestinal (GI) upset/bleed, prolonged bleeding time.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs).
    a. Butazolidine (phenylbutazone), Indocin (indomethacin), Motrin (ibuprofen), Naprosyn (naproxen), Nalfon (fenoprofen), Ansaid (flurbiprofen).
    b. Side effects include GI disturbances, central nervous system (CNS) manifestations, skin rashes.
  • Antimalarials.
    a. Remission-inducing agents.
    b. May cause ocular toxicity—ophthalmic exam twice yearly indicated.
  • Gold salts (chrysotherapy).
    a. Effective after 3–4 months.
    b. Toxicity can be severe.
  • Alternative to gold is an oral chelating agent, Cuprimine (pencillamine). Drug has an antiinflammatory action.
  • Corticosteroids: adjunct therapy only.
    a. Used during exacerbations or severe involvement.
    b. Low dose to prevent toxicity.
    c. Deltasone (prednisone), Cortef (hydrocortisone).

B. Instruct client how to preserve joint function.
C. Provide rest periods throughout day.
D. Instruct client in diet control.
E. Provide psychological support for altered body image and living with chronic disease.
F. Prevent flexion contractures and promote exercise.

  • Initiate range-of-motion exercises.
  • Avoid weight bearing for inflamed joints.
  • Instruct client to take warm baths.

G. Prepare for surgery if severe joint involvement.

  • Synovectomy.
  • Joint replacement.

Comparison of Rheumatoid Arthritis and Osteoarthritis

Medical–Surgical Nursing

Medical–Surgical Nursing: Osteoarthritis

Focus topic: Medical–Surgical Nursing

Definition: Hypertrophic degeneration of joints. Cartilage that covers the ends of bones disintegrates.

Characteristics
A. Disorder strikes joints that receive the most stress (e.g., knees, toes, lower spine). Distal finger joint involvement is usually seen in women.
B. Pain and stiffness in the joints.

Implementation
A. Instruct client on well-balanced diet.
B. Prevent permanent disability.

  • Plan exercise to prevent joint fixation.
  • Provide exercise periods to increase muscle tone.
  • Control exercise periods to prevent fatigue.

C. Maintain proper positioning.

  • Align and frequently change position to prevent complications.
  • Encourage and support client as frequent movements cause pain.

D. Apply heat for relief of pain.

  • Dry heat with a heat lamp to relieve stiffness.
  • Moist heat with hot tubs, hot towels, or paraffin baths for the hands.

E. Provide adequate rest—10–12 hours per day.
F. Administer medications as ordered and teach client about side effects.

  • Salicylates most common for relief of pain.
  • Side effects of ASA include tinnitus, nausea, and prolonged bleeding time.
  • Anti-inflammatory drugs (cortisone) reduce the effects of inflammation thus decreasing pain, swelling, and stiffness.
  • NSAIDs.
    a. COX-2 inhibitors: Celebrex (celecoxib).
    b. Advil, Motrin, and others (ibuprofen).

G. Physicians now prescribing natural Rx (glucosamine) for pain and stiffness.

Medical–Surgical Nursing: Gout

Focus topic: Medical–Surgical Nursing

Definition: A disease caused by a defect in purine metabolism marked by urate deposits, which cause painful arthritic joints. Affects men over 50 years of age.

Assessment
A. Assess joints (especially big toe) for pain, inflammation, tenderness, presence of urate deposits, and warm to touch.
B. Assess for low-grade temperature.
C. Evaluate serum uric acid and elevated urinary uric acid.

Implementation
A. Maintain bed rest during acute attack.
B. Immobilize inflamed, painful joints.
C. Administer ordered medications.

  • Analgesics for pain.
  • Anti-inflammatory agents.
    a. Colcrys (colchicine) PO or IV every hour × 8 hours until pain subsides or nausea, vomiting, cramping, or diarrhea occurs.
    b. Butazolidine (phenylbutazone) or Indocin (indomethacin) may be used.
    c. Corticosteroids.
  • Zyloprim (allopurinol) to decrease serum uric acid levels.
  • Uricosuric agents to promote uric acid excretion and inhibit uric acid accumulation (probenecid, Anturane [sulfinpyrazone]).

D. Instruct client on low-purine diet and avoidance of alcohol.

  • See Chapter 4 for foods on a low-purine diet.
  • If client is obese, place on weight-reduction diet.

E. Force fluids to at least 2000 mL to prevent stone formation.

Carpal Tunnel Syndrome (Entrapment Neuropathy)
Definition: A syndrome caused by compression of the median nerve as a result of inflammation and swelling of the synovial lining of the tendon sheaths. Most commonly caused by repetitive motion of hand and wrist, also seen in rheumatoid arthritis, diabetes, acromegaly, hyperthyroid, and trauma.

Assessment
A. Pain in the wrist.
B. Numbness and tingling of the fingers, especially the thumb, index finger, and lateral ventral surface of the middle finger.
C. Pain often worse at night, awakens client; may be relieved by shaking hand or massage.
D. Diagnosis.

  • History.
  • Physical exam; positive Tinel’s sign.
  • Electrodiagnostic studies.

Implementation
A. Surgery.

  • Open nerve release—more painful, slow recovery.
  • Endoscopic carpal tunnel release (ECTR)— immediate relief of pain.

B. Activity modification, splinting, injection of steroids, NSAIDs.
C. Alternative therapy: vitamin B6 supplementation.

Medical–Surgical Nursing: Orthopedic and Vascular Conditions

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Osteoporosis

Focus topic: Medical–Surgical Nursing

Definition: Decrease in the amount of bone capable of maintaining structural integrity of the skeleton. Etiology is unknown. Loss of bone mass is associated with aging and increases fragility and risk of fractures.

Characteristics
A. Factors that contribute to condition.

  • Bone remodeling results in increased bone mass until age 35; thereafter, bone mass decreases.
  • 2. Nutritional factors.
    a. Lack of vitamin D.
    b. Deficient calcium (minimum 800 mg; for women with decreased bone mass, 1200 mg).
    c. Low estrogen levels after menopause.
  • Excessive intake of drugs (corticosteroids).
  • Coexisting medical conditions (malabsorption, lactose intolerance, alcohol abuse, renal failure).
  • Immobility causes bone to be reabsorbed faster than it is formed.

B. Diagnostic tests.

  • Routine x-ray when there is 25–45% demineralization.
  • Single-photon absorptiometry identifies degree of bone mass in wrist.
  • Dual-photon absorptiometry identifies bone loss at hip or spine.
  • Laboratory studies exclude other diagnoses.
  • Quantitative computed tomography (QCT) of the spine is the most sensitive test to detect osteoporosis.
  • Dual-energy x-ray absorptiometry (DEXA) of the lumbar spine or hip is the most accurate method for measuring bone density—it is highly accurate and delivers negligible radiation.
  • Serum bone Gla-protein (osteocalcin) is used as a marker for osteoclastic activity and indicates rate of bone turnover. It is most useful to evaluate treatment rather than as an indicator of the severity of the disease.

Assessment
A. Assess for backache with pain radiating around trunk.
B. Evaluate for skeletal deformities.
C. Assess for pathologic fractures.
D. Evaluate lab findings.

  • Serum calcium, phosphorus, and alkaline phosphatase are usually normal.
  • Parathyroid hormone may be elevated.

Implementation
A. Provide pain control.

  • Application of heat/cold.
  • Medications to prevent pain—NSAIDs.

B. Prevent fractures.

  • Instruct in safety factors—watch steps, avoid use of scatter rugs.
  • Keep side rails up to prevent falls.
  • Move gently when turning and positioning.
  • Assist with ambulation if unsteady on feet.

C. Administer medications.

  • Estrogen replacement therapy decreases osteoporosis (Estratab [esterified estrogens], Estraderm [estradiol], Premarin [conjugated estrogens]); use is controversial as these medications may increase risk of cancer.
  • Calcium—prevents osteoporosis; found in milk, dairy products, yogurt, oysters, canned sardines, salmon, dark green leafy vegetables.
  • Miacalcin (calcitonin)—prevents further bone loss and increases bone mass.
  • Fluoride—decreases solubility of bone mineral and rate of bone reabsorption.
  • Fosamax (alendronate)—a form of bisphosphonate. FDA warning—osteonecrosis of the jaw (jaw death) from taking this drug.
  • Calcium and vitamin D—support bone metabolism.

D. Instruct in regular exercise program.

  • Range-of-motion and weight-bearing exercises.
  • Ambulation several times per day.

E. Instruct in good use of body mechanics.
F. Provide diet high in protein, calcium, vitamin D (adequate sunlight); avoid excesses of alcohol and coffee.

Medical–Surgical Nursing: Compartment Syndrome

Focus topic: Medical–Surgical Nursing

Definition: Following an injury that causes swelling, pressure increases in a muscle fascial compartment. Muscles, nerves, and blood vessels are compressed, causing ischemia, and can lead to amputation. This is a surgical emergency. There is no effective nonsurgical treatment.

Characteristics
A. Pressure in the muscle compartment can be increased by edema or hematoma.
B. Stricture around the limb or reperfusion following restoration of blood flow can result in this condition.

Assessment
A. Monitor extremity for

  • Pain—often out of proportion to the injury and unrelieved by narcotics. It increases on active and passive motion or elevation of extremity.
  • Pallor.
  • Paresthesia or numbness.
  • Cold extremity compared to the other extremity.
  • Pulselessness in affected extremity.

Implementation
A. Position limb at level of client’s heart (elevation higher may increase ischemia).
B. Initiate IV line in alternate extremity and administer pain medication.

C. Identify whether break is intracapsular—bone broken inside the joint—or extracapsular—fracture outside the joint.
D. Identify whether fracture is stable or unstable.

  • Stable (nondisplaced)—a fracture in which the bones maintain their anatomic alignment.
  • Unstable (displaced)—a fracture in which the bones move out of correct anatomic alignment.
Medical–Surgical Nursing

Implementation
A. Evaluate type of treatment used for fracture.

  • Traction.
  • Reduction (restoring bone to proper alignment).
    a. Closed reduction.
    (1) Manual manipulation.
    (2) Usually done under anesthesia to reduce pain and relax muscles, thereby preventing complications.
    (3) Cast is usually applied following closed reduction.
    b. Open reduction.
    (1) Surgical intervention.
    (2) Usually treated with internal fixation devices (screws, plates, wires, etc.).
    (3) Following surgery, client can be placed in traction; however, client is usually placed in cast.
  • Cast.

B. Fracture healing.

  • Occurs over several weeks.
  • New bone tissue occurs in region of break.
  • Repair is initiated by migration of blood vessels and connective tissue from periosteum in break area.
  • Dense fibrous tissue fills in the break and forms a callus (temporary union).
  • Types of cells.
    a. Osteoblast: near the broken area.
    b. Chondroblast: farther away from broken area.
  • Cells deposit cartilage between broken surfaces.
  • Cartilage is slowly replaced by mineralized bone tissue, which completes repair.
  • Fractures are a common injury in children even though bones can be bent 45 degrees before breaking.

C. Emergency care of fractures.

  • Immobilize affected extremity to prevent further damage to soft tissue or nerve.
  • If compound fracture is evident, do not attempt to reduce it.
    a. Apply splint.
    b. Cover open wound with sterile dressing.
  • Splinting.
    a. External support is applied around a fracture to immobilize the broken ends.
    b. Materials used: wood, plastic (air splints), magazines.
  • Function of splinting.
    a. Prevent additional trauma.
    b. Reduce pain.
    c. Decrease muscle spasm.
    d. Limit movement.
    e. Prevent complications, such as fat emboli if long bone fracture.

D. Provide specific care for fracture treatment.

  • Traction.
  • Cast.
  • Surgical intervention.
  • Positioning—use of trochanter rolls at the thigh prevents external rotation.

Medical–Surgical Nursing: Traction

Focus topic: Medical–Surgical Nursing

Definition: The application of a pulling force to an injured or diseased part of the body or extremity while countertraction pulls in the opposite direction.

Purposes of Traction
A. Prevent or reduce muscle spasm.
B. Immobilize a joint or part of the body.
C. Reduce a fracture or a dislocation.
D. Treatment of a joint condition.
E. Prevent soft-tissue damage by immobilization.
F. Reduce muscle spasm associated with low back pain or cervical whiplash.
G. Expand joint space during arthroscopic procedures.
H. Expand joint space during major joint reconstruction.

Assessment
A. Assess for type of traction ordered. (See Table 8-6 for types of traction devices.)
B. Skeletal traction.

  • Mechanical traction applied to bone, using pins (Steinmann), wires (Kirschner), or cervical tongs (Crutchfield, Gardner–Wells, halo external fixation).
  • Most often used in fractures of femur, tibia, humerus, cervical spine.
  • Balanced suspension traction.
    a. Thomas’s splint with Pearson attachment is used in conjunction with skin or skeletal traction (used particularly with skeletal traction for fractured femur).
    b. Balanced suspension traction is produced by a counterforce other than the client.

C. Skin traction.

  • Traction applied by use of elastic bandages, moleskin strips, or adhesive.
  • Used most often in alignment or lengthening (for congenital hip displacement, etc.) or to relieve muscle spasms in preoperative hip clients.
  • Most common types.
    a. Russell traction.
    b. Buck’s extension.
    c. Cervical traction (used for whiplashes and cervical spasm).
    (1) Pull is exerted on one plane.
    (2) Used for temporary immobilization.
    d. Pelvic traction (used for low back pain).

D. External fixation devices.

  • Devices used for stabilizing bone or joint.
  • Device has metal frame and percutaneous pins.
  • Provides traction without ropes or weights so client has mobility.

E. Assess for complications of immobility.

F. Assess for signs and symptoms of infection with skeletal traction.
G. Assess condition of skin for possible breakdown.

Types of Traction

Medical–Surgical Nursing

Implementation
A. Check traction equipment.

  • Check the ropes for fraying.
  • Make sure ropes are in the center of the pulley.
  • Check the weights for correct number of pounds and if weights are hanging free.

B. Maintain body alignment through proper care of traction.

  • Ensure that weights remain hanging freely and do not touch the floor.
  • Ensure that pulleys are not obstructed.
  • Check that ropes in the pulley move freely.
  • Secure knot in rope to prevent slipping.
  • Keep client up in bed, in direct line with traction and proper countertraction.
  • Do not remove or lift weights without specific order. (Exceptions are pelvic and cervical traction that clients can remove at intervals.)
  • Cover sharp edges on traction apparatus with hollowed-out rubber balls to prevent injury to personnel.
  • Maintain counterbalance or correct pull.
    a. Pull is exerted against traction in opposite direction (balanced suspension).
    b. Pull is exerted against a fixed point.
    c. Bed is elevated under area involved to provide the countertraction.

C. Provide firm mattress or bed boards.
D. Monitor for complications.

  • Neurovascular compromise; check CMS.
  • Inadequate bone alignment.
  • Skin or soft-tissue injury.
  • Pin-site infection.
  • Osteomyelitis.

E. Provide range-of-motion exercises for unaffected extremities.
F. Prevent foot drop.

  • Provide footplate.
  • Encourage dorsiflexion exercises.

G. Provide overhead trapeze to allow client to assist in activities (turning, moving up in bed, using bedpan, etc.).
H. Prevent complications associated with immobility.

Balanced Skeletal Traction
A. Maintain proper alignment and check traction mechanism.

  • Weights hanging freely, off floor and bed.
  • Knots secure in all ropes.
  • Rope should move freely through pulleys.
  • Pulleys not constrained by knots.

B. Protect skin from excoriation.

  • Check around top of Thomas splint.
  • Pad with cotton wadding or ABDs.

C. Prevent pressure points around the top of Thomas splint keeping client pulled up in bed.
D. Provide pin-site care.

  • Observe pin or tong insertion site for migration or drainage, odors, erythema, edema (usually indication of inflammatory process of infection).
  • Watch for skin breakdown if bandage is used to apply traction.
  • Cover ends of pins or wires with rubber stoppers or cork to prevent injury to nursing personnel or client.
  • Cleanse area surrounding insertion site of pin or tongs with antimicrobial solution. Some physicians order antibiotic ointments to be applied to area or order “no pin-site care.”

E. Maintain at least 20-degree angle from thigh to the bed.
F. Provide footplate to prevent foot drop.
G. Keep heels clear of Pearson attachment to prevent skin breakdown and pressure sores.
H. Position client frequently from side to side (as ordered). Place table on unaffected side.
I. Unless contraindicated, elevate head of bed for comfort and to facilitate adequate respiratory functions.
J. Do not remove traction without a physician’s order.

Halo Traction
A. Complete a neurologic assessment.

  • Cranial, peripheral nerves at base of skull— this area is prone to injury.
  • Check motion and sensation.

B. Check alignment—neck should not be flexed or extended.
C. Safety issues.

  • Keep Allen wrench taped to front of vest in case of emergency (need for cardiopulmonary resuscitation [CPR]).
  • Client is top heavy with limited view—remove obstacles when walking.
  • Have emergency tracheostomy tray and bagvalve mask available on unit.
  • Never use bars of halo brace to move client.

D. Inspect pin site for drainage, crusting or inflammation.
E. Provide skin care under vest.

Skin Traction
A. Buck’s extension.

  • Apply foam boot appliance with Velcro fastener.
  • Attach a foot block with a spreader and rope that goes into a pulley.
  • Attach weight to pulley and hang freely over edge of bed (not more than 8–10 pounds of weight can be applied).
  • Observe and readjust bandages for tightness and smoothness (can cause constriction that leads to edema or even nerve damage).
  • Do not apply Buck’s traction over or under a calf compression device. Foot pumps are allowed to prevent deep vein thrombosis (DVT).

B. Cervical traction.

  • Use head harness (or halter).
    a. Pad chin.
    b. Protect ears from friction rub.
  • Elevate head of bed and attach weights to pulley system over head of bed.
  • Observe for skin breakdown.
    a. Be sure to keep skin dry in areas encased in the halter.
    b. Place back of head on padding.

C. Pelvic traction.

  • Apply girdle snugly over client’s pelvis and iliac crest; attach to weights.
  • Observe for pressure points over iliac crest.
  • Keep client in good alignment.
  • May raise foot of bed slightly (30 cm) to prevent client from slipping down in bed.

External Fixation Devices
A. Check pin site for signs of infection.
B. Provide pin-site care (see p. 376).
C. Check neurovascular status (circulation, motion, and sensation) every 4 hours; client may have extensive soft-tissue and vessel damage.
D. Instruct client to keep extremity elevated if edema is present.

Cast Care
A. After application of cast, allow 24–48 hours for drying. For synthetic cast, allow 30 minutes; 60 minutes for weight bearing.

  • Cast will change from dull to shiny substance when dry.
  • Heat can be applied to assist in drying process.

B. Do not handle cast during drying process, because indentation from fingermarks can cause skin breakdown under cast.
C. Keep extremity elevated to prevent edema and promote venous return.
D. Provide for smooth edges surrounding cast.

  • Smooth edges prevent crumbling and breaking down of edges.
  • Stockinet can be pulled over edge and fastened down with adhesive tape to outside of cast.

E. Observe casted extremity for signs of circulatory impairment. Cast may have to be cut if edematous condition continues.
F. Always observe for signs and symptoms of complications: pain, swelling, discoloration, tingling or numbness, diminished or absent pulse, paralysis, pain, cool to touch.
G. If there is an open, draining area on the affected extremity, a window (cut-out portion of cast) can be utilized for observation and/or irrigation of wound.
H. Keep cast dry.

  • Breaks down when water comes in contact with plaster.
  • Use plastic bags or plastic-coated bed Chux during the bath or when using bedpan, to protect cast material.
  • Synthetic cast can be cleaned—does not easily break down.

I. Utilize isometric exercises to prevent muscle atrophy and to strengthen the muscle. Isometrics prevent joint from being immobilized.
J. Position client with pillows to prevent strain on unaffected areas.
K. Turn every 2 hours to prevent complications. Encourage client to lie on abdomen 4 hours a day.

Complications of Immobilization
A. Prevent respiratory complications.

  • Have client cough and deep-breathe every 2 hours.
  • Turn every 2 hours if not contraindicated.
  • Provide suction if needed.

B. Prevent thrombus and emboli formation.

  • Apply antiembolic stockings.
  • Initiate isometric and isotonic exercises.
  • Start anticoagulation therapy, if indicated.
  • Turn every 2 hours.
  • Observe for signs and symptoms of pulmonary and/or fat emboli.

C. Prevent contractures.

  • Start range-of-motion exercises to affected joints QID, all joints bid.
  • Provide foot board and/or foot cradle.
  • Position and turn every 2 hours.

D. Prevent skin breakdown.

  • Massage with lotion once a day to prevent drying.
  • Use alcohol for back care to toughen skin.
  • Massage elbows, coccyx, heels bid.
  • Turn every 2 hours.
  • Alternate pressure mattress, sheepskin.
  • Use Stryker boots or heel protectors.
  • Use elbow guards.

E. Prevent urinary retention and calculi.

  • Encourage fluids.
  • Monitor intake and output.
  • Administer urinary antiseptic (Mandelamine [methenamine], etc.).
  • Offer bedpan every 4 hours.

F. Prevent constipation.

  • Encourage fluids.
  • Provide high-fiber diet.
  • Administer laxative or enema as ordered.
  • Offer bedpan at same time each day—encourage to establish good bowel habits.

G. Provide psychological support.

  • Allow client to vent about feelings of dependence.
  • Encourage independence when possible (bathing, self-feeding, etc.).
  • Encourage visitors for short time periods.
  • Provide diversionary activities (television, newspapers, etc.).
Medical–Surgical Nursing

Medical–Surgical Nursing: Fractured Ribs

Focus topic: Medical–Surgical Nursing

Assessment
A. Assess lung sounds for pneumothorax or hemothorax.
B. Examine chest excursion for asymmetry.
C. Assess for shock.

  • Monitor vital signs every hour until stable.
  • Check color and warmth every 2 hours.
  • Check level of consciousness (LOC).
  • Observe for restlessness.

D. Evaluate pain and need for analgesic.
E. Evaluate need for chest tubes.

Implementation
A. Provide nursing intervention for shock.

  • Administer oxygen as indicated.
  • Administer IV if signs of shock present.
  • Keep lightly covered.
  • Have chest tube insertion tray available.

B. Relieve pain from muscle spasms and fractures.

  • Give pain medication 30 minutes before any movement.
  • Change position every 2 hours.
  • Use pillows for support.
  • Place client in semi-Fowler’s position.

C. Prevent complications of immobility.

  • Cough and deep-breathe every 2 hours to prevent hypostatic pneumonia.
  • Turn to unaffected side and back every 2 hours.
  • Maintain skin care to prevent pressure sores and circulatory impairment.
    a. Back care.
    b. Heel, elbow, coccyx massage.
  • Institute leg exercises to prevent circulatory impairment.
  • Prevent constipation and flatus.
    a. Insert rectal tube (no more than 20 minutes at a time).
    b. Provide stool softener.
    c. Maintain diet high in bulk and fiber.
    d. Force fluids.
  • Chest strapping is avoided as much as possible because it limits expansion and may lead to pneumonia and atelectasis.

Medical–Surgical Nursing: Hip Conditions

Focus topic: Medical–Surgical Nursing

Characteristics
A. High incidence in elderly group—hip fractures most common cause of traumatic death after age 75.
B. Fractures in the elderly caused by brittle bones (osteoporosis) and frequent falls.
C. Elderly clients with hip fractures frequently have associated medical conditions (cardiovascular, renal disorders).

Assessment
A. Evaluate types of fracture.

  • Intracapsular (within the joint capsule); head or neck of the femur.
    a. Treated by internal fixation—replacement
    of femoral head with a prosthesis.
    b. Occasionally, primary total hip replacement.
    c. Usually placed in skin traction first for immobilization and relief of muscle spasm.
    d. Client can be out of bed without weight bearing in 1–2 days postoperatively (depending on other physical problems).
  • Extracapsular: trochanteric fracture outside the joint.
    a. Fracture of greater trochanter.
    (1) Can be treated by balanced suspension traction if little displacement of bone. Full weight bearing usually in 6–8 weeks, when healing takes place.
    (2) Surgical intervention is necessary if large displacement or extensive softtissue damage; usually internal fixation with wire.
    b. Intertrochanteric fracture.
    (1) Extends from medial region of the junction of the neck and lesser trochanter toward the summit of the greater trochanter.
    (2) Treated initially by balanced suspension traction.
    (3) Surgically treated early due to debilitated physical condition of most of these clients (usually 70 years and older with other system diseases like diabetes, hypertension, etc.).
    (4) Internal fixation used with nail plate, screws, and wire.
    c. Not allowed to flex hip to the side, on the side of the bed, or in a low chair. When hip is flexed, displacement can occur.

B. Assess for complications of immobility.

Implementation
For Clients Other Than Those with Hip Prosthesis
A. Hemovac will usually be in place to drain off excessive blood and fluid accumulation.

  • Compute intake and output.
  • Keep Hemovac compressed to facilitate drainage.

B. Have client perform bed exercises at least four times per day.

  • Flex and extend foot, tense muscles, and straighten knee.
  • Tighten buttocks, straighten knee, and push leg down in bed.
  • Tighten stomach muscles by raising neck and shoulders.
  • Stretch arms to head of bed and deep-breathe.

C. Change positions by raising head of bed.

  • Gatch knees slightly to relieve strain on hips and back.
  • Turn to unaffected side.
  • Pivot into chair within 1–2 days postoperatively.

Hip Prosthesis
A. Replacement of head of femur with prosthesis.
B. Keep affected leg abducted to prevent dislocation of the prosthesis—use Charnley wedge.
C. Make sure hip flexion angle does not exceed 60–80 degrees.
D. Forbid client to flex hip while getting out of bed; forbid client to sit in low chair.

  • Use high stools.
  • Use wheelchairs with adjustable backs.
  • Use commode extenders.

E. Elevate head of bed 30–40 degrees for meals only.
F. Turn client to unaffected side with pillow support between legs.
G. Ambulate in 2–4 days with partial weight bearing.

Total Hip Replacement
A. Replacement of both the acetabulum and the head of the femur with metal or plastic prosthesis.
B. Used in degenerative diseases or when fracture of head of femur has occurred with nonunion.
C. To prevent flexion, keep operative leg in abduction by use of pillows or abductor splints.

  • Positioning is important (every 2 hours).
  • Turn client about 45 degrees with aid of trapeze and pillows. Do not elevate bed more than 30–45 degrees.
  • Do not turn to affected side unless specific orders.
  • Maintain antirotation boot (if indicated) while client is supine, but remove when client is turned.
  • When using fracture bedpan, instruct client to flex unoperated hip and use trapeze.

D. Keep Hemovac in place until drainage has substantially decreased (24–96 hours).

  • By 48 hours, drainage should be 30 mL in 8 hours.
  • Check dressing to ensure patency of Hemovac.
  • Observe drainage for signs of hemorrhage or infection.

E. Prevent edema and thrombus formation from venous stasis.

Medical–Surgical Nursing

  • Incidence of deep vein thrombosis is 45–70%; of these, 20% develop pulmonary emboli.
  • Readjust antiembolic stockings at least every 4–8 hours.
  • Change position frequently by raising and lowering head of bed. When ordered, tilt bed to change positions.
  • Promote leg exercises—flexing feet and ankles.
  • Administer anticoagulants as ordered.

F. Prevent infections—can be fatal in elderly.

  • Monitor prophylactic antibiotics.
  • Remove suction device as soon as possible to prevent infection.
  • Keep dressing clean and dry.

G. Continuous passive motion (CPM) first day postop with increasing degrees of flexion to 90 degrees.
H. Ambulate client carefully at bedside—first or second postoperative day.

  • Do not allow client to bear weight on affected hip.
  • Up with walker second postoperative day.
  • Avoid positions with greater than 90 degrees flexion such as sitting straight up in a chair.
  • Use commode extenders.
  • Use wheelchair with adjustable back.
  • Use high stools.

I. Start physical therapy as ordered.
J. Observe for neurovascular problems in affected leg.

  • Capillary refill response in toes; pedal pulses in feet.
  • Color and temperature in leg and toes.
  • Edema in leg.
  • Pain on passive flexion of foot.
  • Numbness—inability to move leg.
  • Report any signs of dislocation. Note knee flexion, leg appearing longer or shorter than the unaffected limb, turning inward or outward, feeling head of femur in hip area.

FURTHER READING/STUDY:

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