Angelite Nurses

Health History

1. Presenting problem
1. Muscles: symptoms may include pain, cramping, weakness
2. Bones and joints: symptoms may include stiffness, swelling, pain, redness, heat, limitation of movement
2. Life-style: usual patterns of activity and exercise (limitations in ADL, use of assistive devices such as canes or walkers), nutrition (obesity) and diet, occupation (sedentary, heavy lifting, or pushing)
3. Use of medications: drugs taken for musculoskeletal problems
4. Past medical history: congenital defects, trauma, inflammations, fractures, back pain
5. Family history: arthritis, gout

Physical Examination

1. Inspect for overall body build, posture, and gait.
2. Inspect and palpate joints for swelling, deformity, masses, movement, tenderness, crepitations.
3. Inspect and palpate muscles for size, symmetry, tone, strength.

Laboratory/Diagnostic Tests

1. Hematologic studies
1. Muscle enzymes: CPK, aldolase, SGOT (AST)
2. Erythrocyte sedimentation rate (ESR)
3. Rheumatoid factor
4. Complement fixation
5. Lupus erythematosus cells (LE prep)
6. Antinuclear antibodies (ANA)
7. Anti-DNA
8. C-reactive protein
9. Uric acid
2. X-rays: detect injury to or tumors of bone or soft tissue
3. Bone scan
1. Measures radioactivity in bones 2 hours after IV injection of a radioisotope; detects bone tumors, osteomyelitis.
2. Nursing care
1. Have client void immediately before the procedure.
2. Explain that client must remain still during the scan itself.
4. Arthroscopy
1. Insertion of fiberoptic endoscope (arthroscope) into a joint to visualize it, perform biopsies, or remove loose bodies from the joint
2. Performed in OR using aseptic technique
3. Nursing care
1. Maintain pressure dressing for 24 hours.
2. Advise client to limit activity for several days.
5. Arthrocentesis: insertion of a needle into the joint to aspirate synovial fluid for diagnostic purposes or to remove excess fluid
6. Myelography
1. Lumbar puncture used to withdraw a small amount of CSF, which is replaced with a radiopaque dye; used to detect tumors or herniated intravertebral discs
2. Nursing care: pretest
1. Keep NPO after liquid breakfast.
2. Check for iodine allergy.
3. Confirm that consent form has been signed and explain procedure to client.
3. Nursing care: posttest (see Laboratory/Diagnostic Tests)
1. If oil-based dye (e.g., iophendylate [Pantopaque]) was used, keep client flat for 12 hours.
2. If water-based dye (e.g., metrizamide [Amipaque]) was used
1. elevate head of bed 30°-45° to prevent upward displacement of dye, which may cause meningeal irritation and possibly seizures.
2. institute seizure precautions and do not administer any phenothiazine drugs to client, e.g., prochlorperazine (Compazine).
7. Electromyography
1. Measures and records activity of contracting muscles in response to electrical stimulation; helps differentiate muscle disease from motor neuron dysfunction
2. Nursing care: explain procedure to the client and advise that some discomfort may occur due to needle insertion

Goals
Client will

1. Be free from injury.
2. Be free from complications of immobility.
3. Attain optimal level of mobility.
4. Perform self-care activities at optimal level.
5. Adapt to alterations in body image.
6. Achieve maximum comfort level.

Interventions


Preventing Complications of Immobility
See Table 4.21.


TABLE 4.21 Preventing Complications of Immobility

Range-of-Motion (ROM) Exercises

1. Movement of joint through its full ROM to prevent contractures and increase or maintain muscle tone/strength
2. Types
1. Active: carried out by client; increases and maintains muscle tone; maintains joint mobility
2. Passive: carried out by nurse without assistance from client; maintains joint mobility only; body part not to be moved beyond its existing ROM
3. Active assistive: client moves body part as far as possible and nurse completes remainder of movement
4. Active resistive: contraction of muscles against an opposing force; increases muscle size and strength

Isometric Exercises

1. Active exercise through contraction/relaxation of muscle; no joint movement; length of muscle does not change.
2. Client increases tension in muscle for several seconds and then relaxes.
3. Maintains muscle strength and size.

Assistive Devices for Walking

1. Cane
1. Types: single, straight-legged cane; tripod cane; quad cane.
2. Nursing care: teach client to hold cane in hand opposite affected extremity and to advance cane at the same time the affected leg is moved forward.
2. Walker
1. Mechanical device with four legs for support.
2. Nursing care: teach client to hold upper bars of walker at each side, then to move the walker forward and step into it.
3. Crutches: teaching the client proper use of crutches is an important nursing responsibility.
1. Ensure proper length
1. When client assumes erect position the top of crutch is 2 inches below the axilla, and the tip of each crutch is 6 inches in front and to the side of the feet.
2. Client's elbows should be slightly flexed when hand is on hand grip.
3. Weight should not be borne by the axillae.
2. Crutch gaits
1. Four-point gait: used when weight bearing is allowed on both extremities
1. advance right crutch.
2. step forward with left foot.
3. advance left crutch.
4. step forward with right foot.
2. Two-point gait: typical walking pattern, an acceleration of four-point gait
1. step forward moving both right crutch and left leg simultaneously.
2. step forward moving both left crutch and right leg simultaneously.
3. Three-point gait: used when weight bearing is permitted on one extremity only
1. advance both crutches and affected extremity several inches, maintaining good balance.
2. advance the unaffected leg to the crutches, supporting the weight of the body on the hands.
4. Swing-to gait: used for clients with paralysis of both lower extremities who are unable to lift feet from floor
1. both crutches are placed forward.
2. client swings forward to the crutches.
5. Swing-through gait: same indications as for swing-to gait
1. both crutches are placed forward.
2. client swings body through the crutches.

Care of the Client with a Cast

1. Types of casts: long arm, short arm, long leg, short leg, walking cast with rubber heel, body cast, shoulder spica, hip spica
2. Casting materials
1. Plaster of paris--traditional cast
1. Takes 24-72 hours to dry.
2. Precautions must be taken until cast is dry to prevent dents, which may cause pressure areas.
3. Signs of a dry cast: shiny white, hard, resistant.
4. Must be kept dry since water can ruin a plaster cast.
2. Synthetic casts, e.g., fiberglass
1. Strong, lightweight; sets in about 20 minutes.
2. Can be dried using cast dryer or hair blow-dryer on cool setting; some synthetic casts need special lamp to harden.
3. Water-resistant; however, if cast becomes wet, must be dried thoroughly to prevent skin problems under cast.
3. Cast drying--plaster cast
1. Use palms of hands, not fingertips, to support cast when moving or lifting client.
2. Support cast on rubber- or plastic-protected pillows with cloth pillowcase along length of cast until dry.
3. Turn client every 2 hours to reduce pressure and promote drying.
4. Do not cover the cast until it is dry (may use fan to facilitate drying).
5. Do not use heat lamp or hair dryer on plaster cast.
4. Assessment
1. Perform neurovascular checks to area distal to cast.
1. Report absent or diminished pulse, cyanosis or blanching, coldness, lack of sensation, inability to move fingers or toes, excessive swelling.
2. Report complaints of burning, tingling, or numbness.
2. Note any odor from the cast that may indicate infection.
3. Note any bleeding on cast in a surgical client.
4. Check for "hot spots" that may indicate inflammation under cast.
5. General care
1. Instruct client to wiggle toes or fingers to improve circulation.
2. Elevate affected extremity above heart level to reduce swelling.
3. Apply ice bags to each side of the cast if ordered.
6. Provide client teaching and discharge planning concerning
1. Isometric exercises when cleared with physician
2. Reinforcement of instructions given on crutch walking
3. Do not get cast wet; wrap cast in plastic bag when bathing or take sponge bath
4. If a cast that has already dried and hardened does become wet, may use blow-dryer on low setting over wet spot; if large area of plaster cast becomes wet, call physician
5. Do not scratch or insert foreign bodies under cast; may direct cool air from blow-dryer under cast for itching
6. Recognize and report signs of impaired circulation or of infection
7. Cast cleaning
1. Clean surface soil on plaster cast with a slightly damp cloth; mild soap may be used for synthetic cast
2. To brighten a plaster cast, apply white shoe polish sparingly

Care of the Client in Traction

1. A pulling force exerted on bones to reduce and/or immobilize fractures, reduce muscle spasm, correct or prevent deformities
2. Types.
1. Skin traction: weights are attached to a moleskin or adhesive strip secured by elastic bandage or other special device (e.g., foam rubber boot) used to cover the affected limb.
1. Buck's extension
1. exerts straight pull on affected extremity
2. generally used to temporarily immobilize the leg in a client with a fractured hip
3. shock blocks at the foot of the bed produce countertraction and prevent the client from sliding down in bed
2. Russell traction
1. knee is suspended in a sling attached to a rope and pulley on a Balkan frame, creating upward pull from the knee; weights are attached to foot of bed (as in Buck's extension) creating a horizontal force exerted on the tibia and fibula
2. generally used to stabilize fractures of the femoral shaft while client is awaiting surgery
3. elevating foot of bed slightly provides countertraction
4. head of bed should remain flat
5. foot of bed usually elevated by shock blocks to provide countertraction
3. Cervical traction
1. cervical head halter attached to weights that hang over head of bed
2. used for soft tissue damage or degenerative disc disease of cervical spine to reduce muscle spasm and maintain alignment
3. usually intermittent traction
4. elevate head of bed to provide countertraction
4. Pelvic traction
1. pelvic girdle with extension straps attached to ropes and weights
2. used for low back pain to reduce muscle spasm and maintain alignment
3. usually intermittent traction
4. client in semi-Fowler's position with knee bent
5. secure pelvic girdle around iliac crests
2. Skeletal traction: traction applied directly to the bones using pins, wires, or tongs (e.g., Crutchfield tongs) that are surgically inserted; used for fractured femur, tibia, humerus, cervical spine
3. Balanced suspension traction: produced by a counterforce other than the client's weight; extremity floats or balances in the traction apparatus; client may change position without disturbing the line of traction
4. Thomas splint and Pearson attachment (usually used with skeletal traction in fractures of the femur)
1. Hip should be flexed at 20°
2. Use footplate to prevent foot drop
3. Nursing care
1. Check traction apparatus frequently to ensure that
1. Ropes are aligned and weights are hanging freely.
2. Bed is in proper position.
3. Line of traction is within the long axis of the bone.
2. Maintain client in proper alignment.
1. Align in center of bed.
2. Do not rest affected limb against foot of bed.
3. Perform neurovascular checks to affected extremity.
4. Observe for and prevent foot drop.
1. Provide footplate.
2. Encourage plantarflexion and dorsiflexion exercises.
5. Observe for and prevent deep-vein thrombosis (especially in Russell traction due to pressure on popliteal space).
6. Observe for and prevent skin irritation and breakdown (especially over bony prominences and traction application sites).
1. Russell traction: check popliteal area frequently and pad the sling with felt covered by stockinette or ABDs.
2. Thomas splint: pad top of splint with same material as in Russell traction.
3. Cervical traction: pad chin area and protect ears.
7. Provide pin care for clients in skeletal traction.
1. Usually consists of cleansing and applying antibiotic ointment, but individual agency policies may vary.
2. Observe for any redness, drainage, odor.
8. Assist with ADL; provide overhead trapeze to facilitate moving, using bedpan, etc.
9. Prevent complications of immobility.
10. Encourage active ROM exercises to unaffected extremities.
11. Check carefully for orders about turning.
1. Buck's extension: client may turn to unaffected side (place pillows between legs before turning).
2. Russell traction and balanced suspension traction: client may turn slightly from side to side without turning body below the waist.
3. May need to make bed from head to foot.