NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Musculoskeletal System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Knee Surgery

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Arthroscopy

Focus topic: Medical–Surgical Nursing

Definition: Small incision in knee joint through which cartilage fragments are removed.

Assessment
A. Assess for pain, tenderness, decreased range of motion, clicking noise—torn cartilage (meniscus).
B. Assess for joint instability and pain—torn ligaments.

Implementation
A. Instruct client in surgical procedure for postoperative care.

  • Arthroscopic meniscectomy—removal of torn cartilage fragments through small incision in knee joint using arthroscope.
  • Open meniscectomy—direct surgical technique to knee joint for repair.

B. Elevate leg to minimize swelling.
C. Start client on quad-setting, straight-leg raise exercises. Should be done for 5 minutes every 30 minutes.

  • Quad-setting: tightening or contracting the muscles of anterior thigh (kneecap is drawn up toward thigh).
  • Straight-leg raising: lifting leg straight off the bed, keeping knee extended and foot in neutral position.

D. Apply ice bags to knee to reduce edema.
E. Ambulate first postoperative day without weight bearing (use three-point, crutch-walking gait).
F. In addition, give routine postoperative care.
G. Monitor for pulmonary embolism—complication of surgery.

Total Knee Arthroplasty
Definition: Implantation of a metallic upper portion that substitutes for the femoral condyles and a high-polymer plastic lower portion that substitutes for the tibial joint surfaces.

Assessment
A. Assess incisional area for drainage.
B. Observe for infection.
C. Observe for circulation, sensation, movement.

Implementation
A. Control pain; client may have epidural or patient controlled analgesia (PCA) for first 24 hours, then oral analgesic.
B. Monitor dressing and drainage if closed-wound drainage system is used.
C. Promote mobility.

  • Continuous passive motion (CPM) may be ordered postop—moderate flexion and extension—increases circulation, movement, and prevents adhesion formation.
  • Have client perform quad-setting and straightleg raise exercises every hour.
  • Have client perform passive range-of-motion exercises.

D. Soft foam knee immobilizer, brace, or splint is usually applied. (Nursing care is same as for any client in a splint.)

  • If hinged splint (Bledsoe) is ordered, do not open or adjust without physician’s order.
  • Assess skin and CMS every 4 hours.

E. Do not dangle to prevent dislocation.
F. Monitor for signs of infection—a serious complication.

  • Clients should remind physicians and dentists about prosthesis for prescribed antibiotics.
  • Infection could occur 3 months or even a year after surgery.

G. Instruct client in crutch walking.
H. Client will be out of bed in 2–3 days.
I. Provide general postoperative care—monitor for pulmonary embolism. Anticoagulant therapy may be ordered prophylactically.

Medical–Surgical Nursing

Medical–Surgical Nursing: Crutch Walking

Focus topic: Medical–Surgical Nursing

A. Measure client for crutches.

  • Distance between axilla and arm pieces on crutches should be two finger widths in axilla space—incorrect measurement could damage brachial plexus.
  • Elbows should be slightly flexed when walking.

B. Teach gait sequence.

  • Four-point; crutch-foot sequence.
    a. Move right crutch; move left foot; move left crutch; move right foot.
    b. Gait is slow, but stable; client can bear weight on each leg.
  • Three-point gait.
    a. Client can bear little or no weight on one leg—two crutches support affected leg.
    b. Move both crutches and affected leg forward; then move unaffected leg forward.

Medical–Surgical Nursing: Diagnostic Test for Problems of the Spine

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Myelogram

Focus topic: Medical–Surgical Nursing

Definition: Contrast medium injected into the subarachnoid space of the spinal column to visualize the spinal cord. If water-soluble contrast is used, the head of the bed must be kept elevated to avoid the possibility of seizure; if oil contrast, client is kept flat.

Medical–Surgical Nursing: Spinal Surgery

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Laminectomy, Discectomy, Etc.

Focus topic: Medical–Surgical Nursing

Definition: Disorders of the vertebrae that require excision of vertebral posterior arch, removal of the nucleus of the disc, or enlargement of the opening between discs.

Characteristics
A. Laminectomy—removal of part of vertebral lamina.
B. Discectomy—removal of the nucleus pulposus of the intervertebral disc (may be performed alone or with laminectomy).
C. Foraminotomy—enlargement of the opening between the disc and the facet joint to remove overgrowth compressing the nerve.
D. Microdiscectomy—microsurgical techniques to remove nucleus pulposus of disc.

Assessment
A. Evaluate for circulatory impairment of extremities.

  • Check blanching.
  • Observe color.
  • Check warmth of lower or upper extremities (depends on surgical site).

B. Observe for sensation and motion in lower extremities (nerve root damage).

  • Assess sensation.
  • Check client’s ability to wiggle toes and move feet; record ability to do plantar flexion, dorsiflexion of feet, toes, and ankles.

C. Observe dressings for spinal fluid leak, hemorrhage, and infection. If present, notify physician.

  • Use Dextrostix to test leakage. If positive for glucose, it is a very strong indicator that this is cerebrospinal fluid (CSF).
  • Leaking CSF increases risk of infection to wound and meninges.

D. Note bowel sounds and bladder function.
E. Observe for respiratory problems—especially with cervical laminectomy.
F. Assess for hematoma formation as manifested by severe incisional pain not relieved by medication. If left untreated, it may cause irreversible neurologic deficits.
G. Assess for laryngeal nerve damage—may cause permanent hoarseness. Impaired ability to swallow puts the client at risk for aspiration.

Implementation
A. Change client’s position every 2 hours (by logrolling) for at least 48 hours.

  • Turn client as one unit by using draw sheet (or pull sheet), placing pillows between legs.
  • Turn client to either side and back (unless contraindicated). Use support mechanisms when on side.

B. Keep NPO until flatus and bowel sounds present.
C. Promote general range-of-motion exercises.
D. Ambulate client or have client lie in bed; sitting puts strain on surgical site.
E. Ambulate in 1–2 days postoperatively, unless contraindicated.

F. Provide general postoperative care.
G. Administer stronger pain medication postop, if on medication for a long time preoperatively.
H. Encourage fluid intake and diet rich in nutrients.

  • Suggest increased intake of fruits and vegetables.
  • Increased fiber to prevent constipation.

I. Encourage use of incentive spirometer.

Medical–Surgical Nursing: Spinal Fusion

Focus topic: Medical–Surgical Nursing

Definition: The fusion of spinous processes—stabilizing the spine by removing bony chips from iliac crest and grafting them to fusion site.

Assessment
A. Assess for spinal fluid leak or hemorrhage.
B. Measure vital signs; identify symptoms of infection.
C. Evaluate for circulatory, motion, sensation impairment.
D. Evaluate bladder and bowel function.

Implementation
A. Maintain postoperative positioning.

  • Some physicians keep client supine for first 8 hours to reduce possibility of compression.
  • Most physicians keep client off back for first 48 hours.

B. Provide ambulation. Starting ambulation varies with physicians, from 3–4 days to 8 weeks, depending on extent of fusion.

  • Brace is applied when client is ambulated.
  • Spine should be immobilized for early healing of bone graft and for new callus to form.

C. Instruct client to not lift, bend, stoop, or sit for prolonged periods for at least 3 months.
D. Inform client grafts are stable by the end of the first year.
E. Explain there are some limitations to flexion of spine, depending on extent of fusion.
F. Provide additional interventions same as for laminectomy.

Medical–Surgical Nursing: Amputation

Focus topic: Medical–Surgical Nursing

Definition: The surgical removal of a limb, a part of a limb, or a portion of a bone elsewhere than at the joint site. Removal of a bone at the joint site is termed disarticulation.

Characteristics
A. Open type (guillotine)—performed when infections are present, wound left open to drain; once infection is cleared, wound is closed.
B. Closed type (flap)—wound is closed with a flap of skin.

Assessment
A. Evaluate dressings for signs of infection or hemorrhage.
B. Observe for signs of a developing necrosis or neuroma in incision.
C. Evaluate for phantom limb pain.
D. Observe for signs of contractures.

Implementation
A. Provide preoperative nursing management.

  • Have client practice lifting buttocks off bed while in sitting position.
  • Provide range of motion to unaffected leg.
  • Inform client about phantom limb sensation.
    a. Pain and feeling that amputated leg is still there; caused by nerves in the stump.
    b. Exercises lessen sensation.

B. Provide postoperative nursing management.

  • Observe stump dressing for signs of hemorrhage, infection, or wound that will not heal.
    a. Keep tourniquet at bedside to control hemorrhage if necessary.
    b. Mark bleeding by circling drainage with pencil and marking date and time.
    c. Elevate foot of bed to prevent hemorrhage and to reduce edema first 24 hours ONLY. (Elevating the stump itself can cause a flexion contracture of hip joint.)
    d. Avoid dependent positioning of stump—to prevent edema and discomfort.
  • Observe for symptoms of a developing necrosis or neuroma in area of incision.
  • Provide stump care.
    a. Rewrap Ace bandage 3–4 times daily.
    b. Wash stump with mild soap and water.
    c. While washing stump, tap and massage skin toward incision line to prevent development of adhesions.
  • Teaching related to stump care.
    a. Below-the-knee amputation—prevent edema formation.
    (1) Do not hang stump over edge of bed.
    (2) Do not sit for long periods of time.
    b. Above-the-knee amputation—prevent external or internal rotation of limb.
    (1) Place rolled towel along outside of thigh to prevent rotation.

(2) Use low-Fowler’s position to provide change in position.
c. Position client with either type of amputation in prone position to stretch flexor muscles and to prevent flexion contractures of hip. Done usually after first 24–48 hours postoperative.
(1) Place pillow under abdomen and stump.
(2) Keep legs close together to prevent abduction.
d. Teach use of ambulatory aids—crutch walking (started when client achieves stable balance) and wheelchair transfer.
e. Prepare stump for prosthesis.
(1) Stump must be conditioned for proper fit.
(2) Shrinking and shaping stump to conical form by applying bandages or an elastic stump shrinker.
(3) A cast readies stump for the prosthesis.
f. Provide care for temporary prosthesis, which is applied until stump has shrunk to permanent state.

  • Recognize and respond to client’s psychological reactions to amputation.
    a. Feelings of loss, grieving.
    b. Loss of independence.
    c. Lowered self-image.
    d. Depression.
  • Continue discussing phantom limb pain with client.
    a. Feelings of pain in the part that has been amputated will eventually disappear.
    b. Occurs more frequently in above-the-knee amputation.
    c. TENS (transcutaneous electrical nerve stimulation) may provide relief.

Medical–Surgical Nursing: Fibromyalgia

Focus topic: Medical–Surgical Nursing

Definition: A syndrome that affects about 2% of the population. The triad of symptoms that are the hallmark of the syndrome include long-lasting, widespread pain (with tender points), sleep disturbances, and fatigue.

Characteristics
A. Cause unknown—may be caused by genetic predisposition,
a stressor such as an acute injury, an illness with fever, surgery, immune system depression, or long-term psychosocial stress (sometimes childhood trauma).
B. Disease is difficult to diagnose because symptoms are common and laboratory results generally are normal.
C. Affects women between the ages of 30 and 50 years, and about 0.5% of men.
D. Central nervous system in people with fibromyalgia is not functioning properly and components of the body’s stress response are responsible for symptoms.

  • Sensory processing: experience great sensitivity not just to pain, but also to loud noises, bright lights, odors, drugs, temperature changes, and chemicals.
  • Substance P: threefold higher concentration in spinal fluid of this chemical that amplifies pain signals.
  • Serotonin: low or processed poorly.
  • HPA (hypothalamic–pituitary–adrenal) axis: several abnormalities in the axis.

Assessment
A. General symptoms: pain and tenderness, noncardiac chest pain, fatigue, sleep disturbance, frequent headaches—may be migraines, cognitive difficulties, irritable bowel syndrome, urinary urgency and frequency, dry eyes and mouth, temporomandibular joint syndrome (TMJ), sensitivity to loud noises, unusual and uncontrollable eye movements.
B. Constitutional symptoms: weight fluctuations, heat and cold intolerance, night sweats, weakness.
C. “Allergic” symptoms: multiple chemical sensitivity, nasal congestion, rhinitis.
D. Depression and anxiety.
E. Painful menstrual periods; itching, burning sensations around the vaginal opening.

Implementation
A. There is no “one” treatment—treatment is geared toward relieving symptoms.
B. Monitor medications.

  • Analgesics: Lyrica (pregabalin) has been shown to reduce pain and improve sleep for up to 6 months; Tylenol (acetaminophen); Ultram (tramadol)—stronger analgesic than acetaminophen, rarely as addictive as narcotics; NSAIDs—often used for pain relief rather than for their anti-inflammatory effects (ASA, Advil, Aleve).
  • Tricyclic antidepressants.
    a. Work by raising the levels of norepinephrine in the brain.
    b. Given in doses lower than required for antidepressant effects—drugs can improve the quality of sleep.
  • 3. Selective serotonin reuptake inhibitors (SSRIs).
    a. Increase amount of serotonin in brain, reducing fatigue and possibly pain.
    b. Often prescribed in combination with a tricyclic antidepressant.

C. Nutrition, vitamin and mineral supplements: limit caffeine, sugar, and alcohol—muscle irritants.
D. Exercise—eases the symptoms of fibromyalgia. Ongoing rehabilitation program maximizes outcomes.
E. Coping skills—techniques to help ease tension, anxiety, and pain.
F. Complementary therapies—massage, movement therapies (such as Pilates), chiropractic manipulations and acupuncture, among others.

FURTHER READING/STUDY:

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