NUR 343 Exam 3 Rubric
The subject matter for the exam has been taken from your assigned textbook readings,
PowerPoints, and classroom lecture/discussion.
**For all of the subject matter listed below, you are expected to understand the
fundamentals—pathophysiology, health assessment, signs & symptoms, Nursing Care,
treatments, patient teaching, Medications, lab values etc. **
Chapter 35 & 36
Know your A&P: Cranial nerves, cerebral lobes,
Glasgow coma scale
Care of pt with EEG, MRI, LP, cerebral
angiography
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Magnetic resonance imaging
‒ The use of magnets precludes a client who has an artificial device
(pacemakers, surgical clips,intravenous access port).
Radiographic Procedures
• Cerebral angiography
‒ There is a risk for bleeding or hematoma formation entry site
‒ Check the insertion site frequently & the affected extremity distal to
the puncture (color, temperature, pulses, capillary refill)
‒ If bleeding occurs, apply pressure over the artery and notify the
provider.
• Computed tomography
• Evoked potentials
• Lumbar puncture
Lumbar puncture LP (spinal tap)
A procedure during which a small amount of CSF is withdrawn to detect the
presence of some diseases (MS &meningitis), infection, and malignancies.
• A lumbar puncture may also be used to reduce CSF pressure, or administer
medication
PRE PROCEDURE
• Instruct the client to void prior to the procedure
• Clients should be positioned to stretch the spinal Canal “cannonball”
position while on one side. CSF is sent to the pathology department for
analysis.
Post Procedure:
• Monitor the puncture site for CSF leakage
• Complete bed rest for several hours to ensure that the site clots and to
decrease the risk of a post-lumbar puncture headache, infection
• Provide fluids for hydration and administer pain medication.
●● Prepare the client for an epidural blood patch to seal the hole in the dura if the
headache persists.
Radiographic Procedures
• Myelography
• Biopsy
Electroencephalography (EEG) assesses the electrical activity of the brain and is
used to determine seizure activity
Glasgow Coma Scale determines the level of consciousness and monitor response to
treatment
• The Glasgow Coma Scale is reported as a number
Brain tumors – lobe location and problem
Meningitis & encephalitis - S&S, Diag,
treatment/Education
The Brain is WRAPPED in THREE LAYERS of CONNECTIVE TISSUE known as
the MENINGES which help protect the brain
1. DURA MATER The OUTER Layer is composed of Thick Connective Tissue.
2. ARACHNOID MATER The THIN, elastic, web-like layer between the DURA
MATER and the PIA MATER.
3. PIA MATER The INNER-most layer, which covers and is bound to the surface of
the brain. It is a FIBROUS LAYER made up of many Blood Vessels which carry
FOOD and OXYGEN to the Brain.
• Cerebrospinal Fluid (CSF) fills space between the meninges. This provides a
protective “cushion” for the brain.
• Clinical Manifestations
• Fever
• Headache
• Altered mental status [ALOC]
• Photophobia
• Chills
• Nausea
• Vomiting
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Nuchal rigidity - stiffness
Brudzinski’s sign (involuntary flexion of the hips in response to passive flexion of
the neck with the patient in a supine position)
Kernig’s sign (pain in the back of the leg [hamstring] and resistance to movement
when the leg is flexed at the hip and then straightened at the knee)
Medical Management – Diagnosis
• Lumbar puncture
• Head C T
Medications
• Long-term antibiotic therapy
Encephalitis (cont)-in the brain-bacteria or viral
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Clinical Manifestations
• Fever
• Neurological deficits
• Headache
• Photophobia
• Phonophobia
• Nuchal rigidity
Medical Management – Diagnosis
• Laboratory tests
• Lumbar puncture
• EEG
• C T scan
• MRI
Nursing Interventions – Actions
• Elevate H O B
• Seizure precautions
• Encourage oral intake
• Dim lights and maintain quiet environment
• Turn and reposition every 2 hours
• Administer stool softeners as needed
Medical Management – Medications
• Antivirals
Parkinson’s – S&S, stages and care
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Clinical Manifestations
• Resting tremors
• Muscle rigidity
• Slowness of movement (bradykinesia)
• Loss of movement (akinesia), postural stability
• Weakness
• Fatigue
• Masklike face
• Shuffling gait
• Uncoordinated movements
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Widening gait
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Nursing Interventions – Actions
• Administer medications as prescribed
• Implement safety precautions
• Facilitate nutritional intake
• Elevate HOB
• Suction equipment at bedside
• Encourage patients to participate in self-care activities
• Facilitate interprofessional collaboration
• Communication strategies
• Movement, safety, ADL, Psychosocial, aspiration. Impaired nutritional
• Low dopamine=slow movement
Alzheimer’s – S&S, stages and care, validation /
reorientation – read your ATI book
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Clinical Manifestations
• Forgetfulness
• Loss in ability to complete tasks
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Forgetfulness that progresses with time
Short-term memory decline
Cognitive impairment
Inability to handle personal finances
Inability to self-manage medications
Motor and verbal skill decline
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Non – pharmacological Rx
Structured – consistent environment
Forgetful about family members/themselves – reminiscence therapy – talk about
something in room that is personal
Avoid distractions / objects kept in same place/ establish a routine
Redirection – speak in short, clear sentences
Validation therapy versus reality orientation
Slow the progress
Risk for physical harm – wander / lost
Frequent walks / exercise/avoid sleeping during day
Seizure activity/ calm voice to redirect
Care giver stress
? Use of restraints
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Chapter 37:
Back/cervical pain –general education / care of
post-op patient
Postoperative Care
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Prevention/assessment of complications
Neurologic assessment; vital signs (usual post op care)
Patient’s ability to void (flat position / pain)
Pain control – pca / DVT prevention
Wound care – assess site bleeding/ drainage
CSF check
Patient positioning/mobility/log roll
Discharge teaching
• Home care management- avoid lifting and driving and to use proper body
mechanics.
Nursing Interventions – Teaching
 Low-back exercises — Stretching and strengthening muscles facilitates reduction of
pain and minimizes future injury. Abdominal strengthening also decreases stress
and strain on the low back.
 Take medications as prescribed — To decrease pain peaks and help promote
activity levels
 Nonpharmacological pain relief measures — To help resume normal functioning
without use of medications that can affect thinking and behavior
 Weight control — Being overweight adds additional stress to back muscles, so being
at ideal body weight may decrease pain and complications associated with LBP.
MS- patho, S&S, types, plan of care, medication
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Multiple Sclerosis (cont)
Pathophysiology
• Breakdown of myelin sheath
• Involves brain and spinal cord
• Patient may complain of noticeable impairment of function
• Myelin can regenerate, and symptoms disappear, resulting in a remission
 MS affects the central nervous system and inflames the white matter in the brain
which creates plaques.
 Usually affects young to middle- aged adults, with onset between 15 and 50 years of
age
 Women affected more than men
 A chronic autoimmune disease that affects the myelin sheath and conduction
pathway of the central nervous system and is a leading cause of neurologic disability
in young adults
 It is a life-long disease with no cure - characterized by periods of remission and
exacerbation of an inflammatory response that results in demyelinization
 The body attacks and destroys the fatty tissue called myelin that insulates an
axon/nerve, resulting in an interruption of impulses between the brain, spinal cord
& body
 If damage is severe, it can also destroy the nerve/axon itself.
MS - Clinical Manifestations
 Numbness or weakness, paralysis of limbs, trunk, and head
 Spasticity of muscles
 Dysarthria, Dysphagia, Nystagmus
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Double or blurred vision - Diplopia
Tingling or pain, Electric shock sensations with head movement
Intention Tremor
Fatigue, very tired
Dizziness
Lack of coordination/balance
Speech problems – especially articulation
 Memory loss
 Other clinical manifestations depression, paranoia, and reduced bowel or
bladder control, euphoria
Medical Management –planning– no cure
 Maximize neuromuscular function
 Maintain independence in activities of daily living for as long as possible
 Optimize psychosocial well-being
 Adjust to the illness
 Reduce factors that precipitate exacerbations
 Help identify triggers and develop ways to avoid them or minimize their effects
 Reassure patient during diagnostic phase
 Assist in dealing with anxiety caused by diagnosis
 Prevent major complications of immobility
Medical Management – Medications
• Beta interferons
• Corticosteroids
• Plasma exchange
• First, medications used to modify the disease course include beta interferons
(interferon beta-1a [Avonex, Betaseron, and Rebif] and interferon beta-1b
[Extavia]),
glatiramer
(Copaxone),
fingolimod
(Gilenya),
and
immunosuppressive agents such as natalizumab (Tysabri) and mitoxantrone
(Novantrone). These medications are used to slow the progression of the
disease. Second, strategies used to treat attacks include corticosteroids and
plasma exchange (plasmapheresis) to decrease the inflammatory and
immunologic factors involved in the exacerbation. The final focus is on
medications used to treat clinical manifestations. Muscle relaxants such as
baclofen (Lioresal and Kemstro) and tizanidine (Zanaflex) decrease spasticity.
Physical therapy is used to help strengthen muscles and improve daily
function. Medications may also be prescribed to help reduce fatigue and to
treat depression, pain, and bladder or bowel problems.
 MS - DRUGS
• Fingolimod (Gilenya) is the first oral immunomodulator approved for the
management of MS.
• Drug therapy, including chemotherapy agents are aimed at relapsing MS
• To control the disease, decrease inflammation and pain, lessen symptoms,
and slow progression.
• Interferon - Avonex
• Glatiramer - Copaxone
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Natalizumab – Tysabri [high risk for anaphylaxis, high risk for opportunistic
infections, damage liver
• Rotate sites / reactions are common/avoid crowds/S&S of infection
http://youtu.be/Naecv3h868c
Drug Therapy
• Corticosteroids
‒ Treat acute exacerbations by reducing edema and inflammation at the
site of demyelination
‒ Do not affect the ultimate outcome or degree of residual neurologic
impairment from exacerbation
• Immunosuppressive Therapy
‒ Because MS is considered an autoimmune disease
‒ Potential benefits counterbalanced against potentially serious side
effects
‒ Antispasmodics (muscle relaxants)
ALS – patho, S&S, teaching
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Pathophysiology
• Upper and lower neurons degenerate and die
• Muscles gradually weaken, atrophy, and twitch
• Loss of ability of brain to initiate muscle movement
 Clinical Manifestations
• Muscle cramps/stiffness/twitching especially hands/feet
• Muscle weakness, slurred speech
• Spasticity
• Flaccidity
• Later signs and symptoms:
• Difficulty chewing and swallowing
• Shortness of breath
• Muscle weakness due to wasting away of muscles
 Causes muscles to become smaller
• Respiratory failure
• Paralysis
Nursing Management – Teaching
Report increased difficulty swallowing or breathing — Indicates disease progression as
motor neuron death and muscle weakness affect the muscles needed to breathe and
swallow
Disease prognosis and process: need for ventilator — Discuss so that patient can make
informed decisions while still having mild symptoms
Communication strategies — To help patient communicate with family and healthcare
providersPatients with ALS face a difficult future. As a progressive disease, ALS eventually
leads to the inability to move and to ventilator dependence. The nurse must help prepare
the patient and family for the disabilities that will result from the degeneration, keep the
patient comfortable and independent for as long as possible, and help prepare the patient
and family for death. The effectiveness of interventions is reflected in the lack of
respiratory compromise, stable body weight, and intact skin. The focus of care needs to be
supporting the patient and his or her family through this difficult process.
Spinal cord tumors – S&S; treatment
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Clinical Manifestations
• Low back pain
• Numbness and tingling
• Weakness in distal extremities
• Urinary incontinence
• Bowel pattern changes
Treatment:
 Although the ideal goal of therapy is to completely remove the tumor, this is
complicated by the type and location of the tumor. Removing some tumors may result
in permanent nerve damage. Treatment options include:
 Monitoring: Often used for small, benign tumors that are not growing or pressing on
surrounding tissues; periodic scans are needed to monitor the tumor.
 Radiation therapy: Used following an operation to eliminate the tumor remnants or
to treat inoperable tumors; often first-line therapy for metastatic tumors
 Stereotactic radiosurgery: Delivers a high dose of targeted radiation; effective in
brain tumors and currently being studied for spinal cord tumors
 Chemotherapy: Has not been proven effective for most spinal cord tumors due to
issues penetrating the blood–brain barrier
 Corticosteroids: To reduce swelling following surgery or during radiation treatments
Chapter 38:
GBS- patho, S&S, care [priority care] Respiratory
- airway
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Pathophysiology
• Immune response
• Lower extremity weakness
• Usually precipitated by infection
Clinical Manifestations
• Symmetrical ascending motor weakness and paralysis
• It starts in the toes, and up it goes; GB – Ground to Brain
Respiratory muscle weakness
Skeletal muscle weakness (often ascending)
Pain
Autonomic manifestations such as sweating and tachycardia
M/Gravis - patho, diagnostics, S&S, education and
care, Myasthenia & Cholinergic crisis, &
anticholinergic drugs used for treatment
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Pathophysiology
• Anti-acetylcholine receptor antibodies prevent binding of acetylcholine
• Decreased acetylcholine sensitivity
Clinical Manifestations
• Ocular
 ptosis and diplopia
• Bulbar
 CN IX, CN X, CN XI, and CN XII
 Problems with phonation, chewing, and swallowing
• Generalized
 Muscular weakness and fatigue worsen with use
Hallmark S/S
• Eye lid drooping (ptosis)
• Impaired speech (dysarthria)
• Difficulty Swallowing (dysphagia)
• Double Vision (dipoplia)
• Easily fatigued, quick recovery with rest
• Waddling gait
Thyroid function
Serological testing
• AChR-binding antibody assay is very specific
• Repetitive Nerve Stimulation test
• decreased muscle response with repetitive stimulation
• The edrophonium or Tensilon test
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Edrophonium, a short-acting anticholinesterase medication, is
administered via IV push. Edrophonium temporarily improves
neuromuscular transmission by inhibiting AChE, which is the enzyme
that degrades ACh after binding to the AChR site. The provider
assesses for improvement of the ptosis. Improvement of muscle
weakness at 2 to 5 minutes followed by a return to baseline over the
next 5 minutes indicates a positive test.
• Side effects, including bronchospasm, bradycardia, and diarrhea.
Increased stimulation of the muscarinic receptors leads to
bradycardia in the heart and bronchospasm in the lungs.
• Atropine is a muscarinic blocker, should be available to reverse any
severe bradycardia that may occur during the edrophonium test
• This test is best performed in a controlled setting in the hospital, such
as an inpatient unit or intensive care unit.
Medical Management – Medications
• Pyridostigmine
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It improves neuromuscular transmission by increasing ACh
stimulation of the AChRs that are available
• Neostigmine
• Immunotherapy
• Azathioprine
• Cyclophosphamide
Complications of MG
• Myasthenic crisis is an exacerbation of MG weakness that provokes an acute
episode of respiratory failure from infection
• Weakness may affect the patient’s ability to protect the airway, tachycardia,
flaccid muscles, and pale and cool skin
• Myasthenic crisis is an emergency that requires intensive care management.
• Intravenous immunoglobulin or plasmapheresis is used to manage the
patient throughout the crisis.
Cholinergic crisis is due to excessive anticholinesterase medication muscle
bradycardia, fasciculations (muscle twitch), sweating, pallor, excessive secretions,
and small pupils
It may be difficult to distinguish which crisis, cholinergic or myasthenic, the patient
is experiencing because both crises have similar clinical features
The Tensilon (edrophonium) test is useful in distinguishing myasthenic from
cholinergic crisis
When Tensilon is administered & muscle strength improves, it is determined to be a
myasthenic crisis
If Tensilon is administered and fasciculations and muscle weakness including the
respiratory muscles, it is a cholinergic crisis – hold all Anticholinesterase
medications
Trigeminal Neuralgia – S&S, treatment
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Clinical Manifestations
• Pain
• Attacks vary in frequency
• Sharp, throbbing, and shock-like pain
• Triggers may include touching an area of the skin or an activity such as
brushing the teeth, drinking a beverage, smiling, or talking.
Medical Management – Medications
• Antiepileptics , antidepression
• Baclofen
• including the use of antiepileptic drugs (AEDs) such as carbamazepine,
oxcarbazepine, or gabapentin. Carbamazepine is the first line of medication
therapy used in the treatment of trigeminal neuralgia, and it works by
reducing the excitability of neurons by inhibiting neuronal sodium channels.
Additionally, baclofen may also be prescribed, particularly in patients with
MS, because it works as a muscle relaxant.
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Surgical Management
• Microvascular decompression
Chapter 53
Diagnostics for msk – dexa, arthroscopy
DEXA – Best tool for measuring bone mineral density is dual xray absorptiometry (DXA)remove metallic objects
 Dual energy X-ray absorptiometry (DXA, previously DEXA)
 Measures bone mineral density (BMD) in the spine, hips and forearm
 BMD determined from the absorption of x-ray beams by bone.
 A T-score equal to or less than -2.5 is indicative of osteoporosis.
 This test is very reliable
Arthroscopy
 Fiberoptic tube is inserted into a joint for direct visualization.
 Client must be able to flex the knee; exercises are prescribed for ROM. Check for
sensation if use the machine to move extremities
 Evaluate the neurovascular status of the affected limb frequently.
 Analgesics are prescribed.
 Monitor for complications.
 Arthroplasty check ATI book, patient care pre-post procedure?
 Long bone fracture: embolism due to fat in the bone: use heparin, SCD
 amputation
Osteomalacia – causes / Fosamax
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Loss of bone related to vitamin D deficiency
Demineralized bone
Increase Vit D rich foods or supplements
• Milk, eggs, swordfish, chicken, liver, enriched breads and cereal products
• Vitamin D in an active form - Ergocalciferol
• Large amounts in a short period of time has shown can correct low Vitamin
D levels.
• 50,000 international units three time a week
• Sun exposure
Paget’s disease – patho & priority care
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Pathophysiology
• Bone is excessively broken down and reformed/ Accelerated bone remodeling
Priority care: Improved functional outcomes
• Pain control helps keep the patient comfortable and promotes optimal levels of
functioning and mobility - heat & massage
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Weight reduction helps with reduction of stress on bones that might be weakened or
misaligned
Serum calcium levels may be lowered due to the treatment with some
bisphosphonates - diet rich in Ca & vit D
Fall risk and gait disturbances — Assess for varus (bow-legged) knees and valgus
(knock-knee) knees, which put patients at greater risk for gait disturbances and
falls. Increase mobility – low impact exercise & Provide training, orthotic shoes,
braces, and other supportive measures including a physical therapy consult
Body image disturbance — Skeletal changes can cause issues associated with
hearing and eating as well as bowing of the tibia, which result in difficulty with
activities of daily living. Physical appearance can change and cause issues associated
with self-esteem
Paget foundation / Osteoporosis / Arthritis society
Osteomyelitis – priority nursing care, education of
pt with osteomyelitis, general care, treatment
Administer IV antibiotics as ordered — Because of the severity of the infection and
the potentially disabling complications, IV antibiotics are indicated and continued
for 4 to 6 weeks.
Administer analgesic therapy as prescribed — Pain that is controlled within a
tolerable level helps the patient achieve a maximal level of function.
Apply thermal therapy as ordered — Thermal therapy (hot and/or cold) has been
shown to reduce pain and increase functionality.
Apply gentle range-of-motion exercises to the joints above and below the affected
site — Exercises for strengthening and flexibility help promote function and prevent
contractures.
Provide training for safe movement with activities of daily living — Patient
population is at great risk for falls with transfers and lifting; use assistive devices
when appropriate.
Provide nutritional support — Adequate ingestion of vitamin C, zinc, iron,
thiamine, folic acid, and protein can help with wound healing and eliminating
infection.
Contact home health agency for home infusion antibiotic therapy — Long-term
antibiotic infusion therapy can safely be managed in the home with the assistance of
a home infusion nurse.
Hip & knee replacement – know everything
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Overview
• Replacement of a severely damaged hip with an artificial joint
• Osteoarthritis, rheumatoid arthritis, femoral neck fractures, failure of
previous reconstructed surgeries, conditions resulting from congenital hip
disease (dysplasia of the hip)
 Total Hip (Arthroplasty) Replacement
 Types
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 Most consist of a metal femoral component topped by a spherical ball fitted
into a plastic acetabular socket
 Selection is made based on the individual client and the one that will provide
the maximum advantage for the client
Medical Management – Diagnosis
• Based on deformity, tissue destruction, and loss of function
• Joint changes, stiffness, pain that limits normal activities, and associated
muscle atrophy are common indicators to be evaluated
• The need for joint replacement is confirmed through radiographical studies
such as an x-ray
• MRI that reveals structure and joint pathology associated with the clinical
indices for a joint replacement.
Complications
• Hypotension
• Bleeding
• Hypovolemia
• Wound site infection
• DVT
• PE
Nursing Interventions – Assessments
• Pain
• Laboratory data
• Neurovascular
• Wound and drainage
Nursing Interventions – Actions
• Administer medication as ordered
• Wound care
• Early mobilization
• Anti-embolic stocking
• Continuous passive range of motion machine
• Proper positioning and turning schedule
Preventing dislocation of the hip prosthesis
• Protect affected hip from adduction, flexion, internal or external rotation,
and, weight-bearing
• Client’s hip should always be higher than the knees (high-seat orthopedic
chair, semi-reclining wheelchair, raised toilet seat
• Never bend at the waist to put on shoes or socks (occupational therapist can
provide client with devices to assist with dressing below the waist)
• Hip precautions - at least 4 months after surgery
• Recognize signs of dislocation
 (Increased pain at surgical site, swelling and immobilization; acute
groin pain in the affected hip or increased discomfort; shortening of
leg; abnormal external or internal rotation; restricted ability or
inability to move leg; reported “popping” sensation in the hip)
• Inform surgeon immediately if dislocation occurs and advise client to do
likewise if at home
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Monitor wound drainage
• Drain with a suction device is usually left in place to drain accumulated fluid
and blood
• Drainage can be as much as 200 – 500 ml in first 24 hours
• After 48 hours, the drainage should decrease to no more than 30 ml q8h
• Depending on the amount of drainage, it may be auto infused after filtered
• Clean incision daily with mild soap and water and dry thoroughly
• Inspect for redness, heat or drainage
Total Hip Arthroplasty Discharge Teaching
• Daily exercise program
 walking but avoid over exertion
 promoting muscle strength and tone
• Maintain abduction & do not sleep on affected side
• Do not cross legs
• Use of assistive devices for dressing – extended handles/shoe horns
• ADLs can be resumed after 3 months
• Stair climbing about 3-6 months as prescribed
• Prevent adduction and flexion of new hip during sexual activity
• Avoid traveling long distance unless able to change position frequently
• Avoid tub baths and driving a car for 4 – 6 weeks after surgery
• Avoid jogging, lifting heavy loads & excessive bending or twisting
• Take Vit D and Ca supplements, bisphosphanates, weight bearing exercises
Bone cancer [Ewing Carcinoma] – care of pt
diagnosed with disease, treatment
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Medical Management – Treatment
• Destroy or remove tumor
• Pain control
Nursing Interventions – Actions
• Administer pain medication as ordered
• Chemotherapy and radiation
• Support and position affected extremities
• Apply thermal therapy as ordered
Interventions
Bone cancer – osteosarcoma most common / metastasizes to lung within 2 years of
treatment
• Surgical intervention – remove tumor
• Radiation- RFA – target with heat, Cryo – target with cold, chemotherapy
• Psychosocial resources – teach how to ambulate, ADLs, altered body image,
stress of Ca, Ca support group
Surgical Management
• Resection of tumor
• Limb salvation
Chapter 54
Spraints and strains – treatment
Treatment of first- and second-degree strains and sprains involves
RICE, a common acronym referring to the treatment plan for strains and sprains.
Rest the injured extremity for as long as 72 hours to allow the ligaments or tendon time to
heal.
Ice applied for no longer than 30 minutes three to five times per day for 24 to 72 hours
after injury. This promotes vasoconstriction and decreases bleeding and fluid collection in the
injured area.
Compression by means of an Ace wrap or similar compression dressing to minimize
further swelling, which can delay healing. The dressing should be wrapped tightly but not
enough to alter neurovascular function. Ensure that circulation, movement, and sensation remain
intact.
Elevate the affected area to minimize dependent swelling
Types of traction – Purpose and care of pt with skeletal /
skin traction; complications
 Application of a pulling force to an injured or diseased body part while counter
traction pulls in the opposite direction
 Purpose:
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Alleviate pain and reduce muscle spasm
immobilize a joint or body part or fracture
provide immobility to prevent soft tissue damage & promote healing
reduce muscle spasm associate with lower back pain or cervical whiplash to
correct deformities
 2 most common types of traction are skin and skeletal:
 Skin - (Buck’s traction, balanced suspension & Russel’s traction)
 Skeletal – halo, crutch field tongs (invasive & penetrates skin
Traction Types: Skin
 Used for short-term treatment [48 – 72 hours] until skeletal traction or surgery is
performed
 Boots or splints are applied directly to the skin to maintain alignment assist with
reduction and help to decrease muscle spasm
 weights are usually limited to 5 – 20 lb (2.3 to 4.5 kg]
 Buck’s traction applied to lower leg
 Maintain straight alignment of ropes/pulleys
 Weights hang free
 Inspect skin for breakdown
 Maintain position for countertraction
 Encourage movement of unaffected area
Nursing Care Skin Traction
 Assess motor function
 Ensure client is able to dorsiflex foot, regularly assess sensation and motion,
report burning sensation under traction bandage or boot, promptly report
impaired motor function)
 Assess circulatory impairment
 Check pulses, color, capillary refills, temperature of fingers and toes
 Observe for indicators of DVT
 eg. unilateral calf tenderness, warmth, redness, swelling
 Encourage active foot exercise q1h
 Proper positioning of leg in neutral position
 Client must not shift from side to side to prevent bony fragments from moving
against one another
 Keeps the injured bone and joint aligned
 A pin or wire is inserted [totally or partially] through the bone to align and
immobilize the injured part
 Weight range from 5 – 45 lb [2.3 to 20.4 kg]
 Major disadvantage is infection
 Prevent complications such as skin breakdown
 prevent shearing and friction, observe skin TID and palpate for tenderness,
turn every 2 hours
Nursing Care: Skeletal Traction
 Client is in the right position and are not slipping down the bed
 Prevent foot drop by supporting foot with foot supports????
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Prevent skin breakdown by encouraging exercise of unaffected limbs
o use of trapeze
 Monitor neurovascular status as mentioned earlier
 Prevent DVT’s
 Provide pin care once or twice per day and cover with light dressing
 Do not remove crusting from pin site because it provides a form of protection
 Report signs and symptoms of infection
 Encourage ROM and isometric exercises of unaffected limb
Principles of Effective Traction
 Skeletal tractions is never interrupted
 Weights are not removed unless intermittent traction is prescribed
 The client must be in good body alignment in the center of the bed when the traction
is applied
 Weights must hang freely and not rest on bed or floor
External fixation – benefits / priority care
 Used to manage open fractures with soft tissue damage
 Provides stability for complicated fractures of the humerus, forearm, femur, tiba
and pelvis
 Nursing care
 include monitoring neurovascular status q2-4h
 assess redness, drainage, swelling, tenderness, pain, and pin intactness
 pin care to prevent infection using separate cotton-tip in chlorhexidine
solution
 The fixation is left in place until the bone heals.
Complication of fractures – assessments and nursing
care of compartment syndrome, PE, rhabdomyolysis
Neurovascular compromise is- compartment syndrome a complication due to any
source of decreased blood flow and oxygenation to the tissues. One cause is the
severing of blood vessels and nerves surrounding the bone by sharp bone fragments
created by a fracture. The use of traction and immediate fracture reduction is vital in
preventing further damage to the neurovasculature.
Venous thromboemboli (VTE) is another possible complication. VTE develop in the
large vessels of the extremities because of extended periods of immobility, traumatic
injuries, cardiac disease, long surgeries, obesity, smoking, and use of oral
contraceptives. Venous thromboemboli can be perpetuated by musculoskeletal
trauma, specifically fractures involving the upper and lower extremities. Clots can
develop in large vessels and hinder circulation or can break apart and travel to the
pulmonary arteries and become pulmonary emboli.
Fat embolism syndrome is a rare complication after orthopedic injury and surgery.
Fat emboli frequently manifest in long bone fractures where particles of the exposed
fatty bone marrow have migrated into the systemic circulation. The particles then
mobilize throughout the body and clog smaller blood vessels, producing generalized
petechiae: small or pinpoint round spots that appear red or purple on the skin. Much
like VTE, fat emboli can travel to and lodge in the pulmonary artery and become
pulmonary emboli.
Traumatic rhabdomyolysis is a potential complication from injuries that result in
compression and tissue ischemia, such as crush injuries. Crush injuries produce
continued compression of muscle tissue that restricts blood flow and precipitates
tissue ischemia. Tissue ischemia catalyzes a vicious cycle of further inflammation,
increased capillary permeability, and the release of more fluid and intracellular
contents into the compartment and circulatory system. Myoglobin is an intracellular
oxygen-binding protein found in skeletal muscle. It is one of the many intracellular
components that spill out of dead muscle cells. Once in the circulatory system,
myoglobin travels to the kidneys and is lodged in the nephrons. As a result, the
kidneys are unable to effectively filter the proteins and fall victim to acute tubular
necrosis and renal failure. Treat with IV fluid

Fat embolism
o Systemic fat globules from fractures that are distributed into tissue and
organs after a traumatic skeletal injury
o Usually occur in fractures of long bones
o Fat enters the systemic circulation and embolize into organs
 eg. brain, lung, heart, kidney
 S & S tend to occur 12 to 72 hours after injury pneumonitis leading to acute
respiratory distress
o the client expresses a feeling of impending doom, pallor and coma
 Treatment: prevention
o careful immobilization of long bone
o fluid resuscitation to prevent hypovolemia
o correction of acidosis; respiratory stabilization (intubation, ventilation)
 Venous thrombosis
o Client is prone to clot formation after a fracture (especially of hip)
o Causes are: immobility, local pressure on vein, incorrect application of casts
or traction
o Treatment:
 compression stockings, sequential compression devices
 passive/active ROM of unaffected limbs
 anticoagulants eg heparin or Lovenox
Compartment Syndrome
 Elevated compartmental pressure compromising neurovascular function within that
space
 Leads to ischemia within 4 – 12 hours after onset
 S & S are 6 Ps
o parasthesia, pain, pressure, pallor, paralysis (or loss of function),
pulselessness (diminished or absent)
o Skin cool to the touch
 Treatment
o No ice or elevation of the injured part
o monitor urine output because of the risk of renal obstruction from
Myoglobin released from damaged muscles
o may need surgery: fasciotomy to decompress the soft tissue
o in severe cases, amputation of the extremity might be warranted]
•
•
•
•
Cast care [leg and arm] – know assessment and
complications - Compartment syndrome: treat with fasciotomy
Immediate
• Avoid covering until dry > 48 hrs, handle with palms & not fingertips
(plaster cast)
• Avoid resting cast on hard surfaces or shard edges
• Keep affected limb elevated above heart on soft surface until dry
• Neurovascular assessment
• parasthesia, pain, pressure, pallor (coolness), paralysis (or loss of function),
pulselessness (diminished or absent)
• Skin cool to the touch – contact health care provider
Intermediate
• When cast is dry, mobilize client
• Encourage prescribed exercises
• Teach pt not to scratch skin under cast (infection)
• If fiberglass gets wet, dry with hairdryer on cool setting
After care
• Wash skin gently
• Apply cornstarch or baby oil
• Client to gradually adjust to movement without cast
• May have some swelling after cast is removed, elevate limb and apply elastic
bandage
Nonsurgical care of pt with carpal tunnel
syndrome, S&S, diag
 Clinical manifestations:
 Weakness [especially thumb]
 Burning pain; numbness or impaired sensation
 Numbness & tingling [awake client at nights]
 Positive Phalen’s test [holding the wrist for 60 seconds produces tingling and
numbness]
 Positive Tinel’s sign [tapping on the wrist cause parasthesia]
 Atrophy [late stages]
 Medical Management – Treatment
o Modification of work environment
o Encourage use of adaptive devices
 [wrist splints; special keyboard pads; workstation modification;
changes in body position; frequent work breaks]
o Ultrasound therapy
o N S A I D’s
o Steroid injections
o Night splinting
Amputations – priority care with BKA, treatment of
phantom pain – Calcitonin
•
Neurovascular status of both limbs: Skin color, temp, sensation and pulses in both
extremities
• Psychological care: Anger [grieving process], readiness for rehab, family’s coping
abilities
• PLP –IV calcitonin helps with PLP – massage, heat, relaxation techniques
• PT – ambulate ASAP, ROM, prosthesis, figure of 8 bandage to shrink limb
• Ensure that residual bandage is properly fitted to assist in shaping the stump for
prosthesis
• Avoid hip flexion for clients with lower limb amputation
• Have client lie on abdomen for 30 minutes 3-4 times per day to aid in hip extension
while prone
• When not wearing a prosthetic limb, the client is discouraged to dangle residual
limb over the bedside to prevent edema
• Prepare for discharge
(care of residual limb; care of prosthesis; ambulation; S & S to report to physician, lifestyle changes, exercise, gait, sexual intercourse, follow-up care)