MDC1- Module Key Points

● acute= short-lived, localized ○ unavoidable ● chronic= lasts more than 3 months ○ 2 types- cancerous and noncancerous ○ Anxiety and depression associated- no acute pain responses ■ Cutaneous pain : Arises from burning your skin like on a hot iron or from touching a hot pan on the stove. ■ Visceral pain : Caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections. ■ Deep Somatic pain : Originates from the ligaments, tendons, nerves, blood vessels and bones. Examples would be fractures or sprains. ■ Radiating pain : Starts at an origin but extends to other locations. Example: pain from a sore throat might extend to ears and head. ■ Referred pain : Occurs in an area distant from the site of origin. Example: pain from a heart attack might be felt in the left arm or jaw. ■ Phantom pain : Pain that is perceived from an area that has been surgically or traumatically removed. Example: pain from an amputated limb. ■ Neuropathic pain : Results from an injury of one or more nerves. ■ Acute pain : Short duration, rapid onset, and associated with some kind of injury. ■ Chronic pain : Last 6 months or longer and interferes with activities of daily living. ■ Idiopathic pain : Pain that you don ’ t know the exact cause of. ○ Management ■ Pharmacologic and nonpharmacologic ● Priority assessment ○ ABCs ○ Risk Factors associated with ABCs ● Focus pain assessment and follow up – if administering oral pain medication come back 30 to 60 minutes after and evaluate if the intervention worked. ● Promote self-determination and autonomy - letting the client do as much for themselves as they can ● Know the Stages of sleep – ○ 3 stages of Non-REM ■ As the stage of NREM goes up, deeper sleep ● More difficult to wake ■ Vital sign decrease

■ Difficulty falling/staying asleep, awakening too early or not getting a refreshing sleep Module 2 Key points ● Therapeutic Communication ○ Communication : Two-way process of sending and receiving messages using words, sound, expression, body movements, written symbols, and behaviors. ■ Communication is effective when dose involving valuing the interaction and finding the discussion to be important. ■ Verbal communication uses spoken or written words- a conscious act in which the sender is able to select the most effective words to communicate a message. ■ Oral Communication , specifically spoken words. ■ Process of communication : is referred to the act of sending, receiving,interpreting, and reacting to a message ● Sender = source or encoder → person that begins a conversation to deliver a message to another person ● Encoding → refers to the process of selecting words, gestures, tone of voice, signs/symbols to transmit the message. ● Message → verbal/nonverbal communication the senders

● Advocate for clients; you must question care decisions that don't seem right and discuss with coworkers to be assertive ● Use “ I ” statements – I think … ● Nonverbal language is important ● Learn to accept criticism without getting defensive ○ Therapeutic relationship focuses on the health of the client and improving it ○ Therapeutic communication is client-centered communication directed to client's goals ■ Phases: ● Pre-interaction phase - lay the groundwork by gathering info about the client, but do not have direct communication with them ● Orientation phase - begins when you meet the client and introduce yourself, determine your role in the relationship ○ Orientation ends when the relationship has been defined ● Working phase- is where most of the therapeutic communication occurs ○ Nurse communicates caring, the patient express thoughts and feelings- mutual respect is maintained, honest verbal/nonverbal communication is achieved ● Termination phase- ends once client is discharged or end of shift- end of care ■ 5 characteristics of therapeutic communication → Empathy, respect, genuineness, concreteness, confrontation ■ Genuineness and concreteness ● Genuine - honesty ● Concrete- fact ● Barriers to communication ○ Lay persons may be unfamiliar with the healthcare language and find its use intimidating or puzzling. ■ Use medical terms only when you are certain the listener understands them. ○ A person distracted by pain, hunger, or other physiological needs will not receive the message as you intended.

○ Cultural assumptions and habits are unconscious. ○ Culture is diverse ● health disparities among racial and ethnic groups ○ Health status . One general disparity is that, except for Asians, minority groups experience higher rates of illness and death and, in general, poorer health status compared with the white, non- Hispanic population. For example: ■ Infant mortality rates are significantly higher for blacks and American Indians and Alaska Natives, compared with those for whites ■ Blacks and American Indians and Alaska Natives adults have a higher prevalence of asthma, diabetes, and cardiovascular disease. ■ Blacks are eight to 10 times more likely to have higher rates of HIV/AIDS diagnoses than are whites. ○ Quality of care . When compared by socioeconomic status, more than half of high-income households received better care than low-income households. Two-thirds of individuals that are uninsured have shown worse care than privately insured individuals. ■ Disparities have shown slight improvement from 2000 to 2015 but remain for those in low-income households and individuals who are uninsured ○ Access to care . Lack of access to preventive healthcare and language barriers can account for differences in the health disparities. For nonelderly adults, the rate decreased from 17% in 2013 to 11% in 2015, although disparities remain among racial groups. Hispanics experienced the most significant access to care issues, scoring poorer in 75% of measures compared to whites, 50% with blacks, and 28% with Asians. ● Priority assessment ○ Assess for factors that alter a client's ability to receive, process, or transmit information ■ Developmental delays, physical or cognitive impairment, language barriers, hearing/visual impairments, substance abuse ● Client ’ s rights ○ The Right to Be Treated with Respect. ○ The Right to Obtain Your Medical Records. ○ The Right to Privacy of Your Medical Records.

NUR2356 Module 3 Key points ● Education on Infant safety, toddler safety etc.. ○ Infant/Toddler - able to walk and manipulate objects before they have the judgement recognize danger ○ Tacticle Exploration of enviroment ○ Totally dependent on parents ○ Putting things in their mouth, exploring cupboards, stairs, open windows, swimming pools, + other hazards ○ Leading cause of death - motor vehicle accidents, along with drowning, fires, and poisoning ○ Falls, choking, sudden infant death syndrome (SIDS), and ingesting poisons are other critical safety concerns ○ Falls are the primary cause of nonfatal injuries ○ Do not warm formula in the microwave (hotspots) ○ Rearfacing carseats, remain in the car seat while in the vehicle ● Interventions to reduce risk for falls & client safety measures ○ do not use throw rugs, keep areas free of clutter, use ice melt in winter, illuminate the pathway, grab bars, shower chairs, raise toilet seats, hidden cords, firm seating and mattresses, accessible call buttons, low bed positions ● Speak up campaign ○ Performance standards state that patients have the right to receive effective, understandable information ○ The client asks questions to clarify information, participates in their care & decisions, and reads respectable literature about diagnosis and treatment of his condition ● Education on elementary school age children ○ More refined motor coordination and control and improved decision-making skills ○ Ready to try new things with or without practice or training - bone and muscle injuries are more common ○ Falls are the leading cause of nonfatal injuries - (fatal injuries = motor vehicle) ● Dementia clients and safety ○ ● RACE ○ Remove the client, Active the alarm/Alert others, Contain/Confine, Extinguish (if possible)/Evacuate ● Fires – extinguishing, safety ○ PASS - Pull, Aim, Squeeze, Sweep ○ Change batteries in fire alarms 2X/yr ● Priority assessment ○ Ranking criteria according to the degree of threat ■ High Priority - life threatening or destructive effects on the client

○ Severe deviation in care that resulted in avoidable patient death or harm ● Poisoning ○ Young children - poisoned most often by improper storage of household chemicals, medicines and vitamins, and cosmetics ○ Older children/ adolescents - may attempt suicide by overdosing with medicines or be poisoned accidentally when experimenting with recreational or prescription drugs ○ Adults experience poisoning as a result of illegal drug use or misuse or abuse of prescription drugs, especially narcotic medications, tranquilizers, and antidepressants ● OSHA ○ Occupational safety and health administration ○ prevent work-related injuries, illnesses, and deaths ● Incident report ○ Formal record of unusual occurrence or accident ○ An organizational report to that is used to analyze an event, id area for improvement, and formulate strategies to prevent future occurrences ○ Not part of client health record thus should never be referenced in a nurses note or health record ○ Report all errors even if there was not an adverse effect on patient ● National Patient Safety Goals ○ Improve the effectiveness of communication among caregivers ○ Specifically to report critical results of the laboratory and diagnostic procedures to the right person in a timely manner ● Orthostatic Hypotension ○ When blood pressure drops due to position change ○ Have the client sit or lay back down, and have them slowly change positions in the future ● Therapeutic communication ○ Open-ended question ○ Patient-centered care ● SBAR ○ Situation, Background, assessment, recommendation ○ SMART goals ■ Specific, measurable, achievable, relevant, timely

● Problem Urgency - ranking the problem by the degree of threat they pose to the patients life or to the needed treatment - high (life threatening), medium (not a direct threat to life - may cause physical or emotional changes), low (minimal nursing interventions needed) ● Future Consequences ● Patient Preference - higher priority to the problems the patients think are most important as long as it doesnt interfere w survival needs/medical treatments Taxonomy - system for classifying ideas or objects based on characteristics they have in common Goals - the outcome that you hope to achieve, must be precise, descriptive, and clearly stated Nurse-sensitive outcomes - influenced by nursing interventions Respiratory Function interventions. ● Trun, cough, and Deep breath 2 hr. ● Incentive spirometer every 2 hr. while awake encourage client to sit in fowler ’ s position when eating. ● Encourage fluid intake at least 2000m per day unless contraindicated. ● Assess lung, cough and sputum production atleast every shift. Benefits of Regular exercise Cardiovascular System ■ ↑ pumping action of the heart ■ ↑ circulation by increasing the number of capillaries ■ ↑ venous return to the heart ■ ↑ blood volume and hematocrit ■ ↑ high-density lipoprotein (HDL) ■ ↓ low-density lipoprotein (LDL) and total cholesterol ■ ↓ risk of thrombophlebitis ■ ↓ heart rate, heart rate variability, and blood pressure Respiratory System ■ ↑ pulmonary circulation ■ ↑ gas exchange at the alveolar – capillary membrane, and overall aerobic capacity ■ Dilates bronchioles to ↑ ventilation Musculoskeletal System ■ ↑ skeletal development in children ■ ↑ muscle mass, strength, power, and endurance ■ ↑ flexibility

■ ↑ coordination ■ Helps maintain joint structure and function no ■ ↑ bone mass and mineral density ■ ↑ gait speed, stability, and balance ■ ↑ bone mass with aging; reduces risk of osteoporosis ■ ↓ risk of falls and helps older adults maintain an independent lifestyle ■ ↓ reduces risk of osteoarthritis Nervous System ■ ↑ nerve impulse transmission ■ ↑ reaction time ■ ↓ sympathetic response to exercise Endocrine System ■ ↑ sensitivity to insulin at the receptor sites ■ ↑ efficiency of metabolic processes ■ ↑ temperature regulation ■ Facilitates weight management ■ ↓ adipose surrounding organs Gastrointestinal System ■ ↑ appetite ■ ↑ abdominal muscle tone ■ ↓ risk of colon cancer Urinary System ■ ↑ efficiency of kidney function Integumentary System ■ ↑ skin tone as a result of improved circulation Immune System ■ ↓ susceptibility to minor viral illnesses ■ ↓ systemic inflammation Mental Health ■ ↑ energy level ■ ↑ endorphins, which assist with pain control and stress management ■ ↑ self-esteem and body image ■ ↑ nonpharmacological relief of symptoms of anxiety and depression ■ ↑ positive outlook and sense of optimism ■ ↑ clearer thinking and improved memory in older adults ■ ↑ feelings of well-being and diminishes depressive symptoms ■ ↑ social interaction ■ ↓ some stress Overall Health ■ ↑ caloric expenditure to achieve and maintain healthy body weight ■ ↑ overall stamina ■ ↑ sleep time and improves sleep quality ■ ↓ abdominal obesity ■ ↓ fatigue Improving or maintain physical fitness, performance, or health.

Regular exercise or physical activity, sustained for months and years, produces long-term health benefits, including a lower risk for early death, heart disease, stroke, type 2 diabetes, hypertension, hyperlipidemia, metabolic syndrome, colon and breast cancers, and depression. Cardiorespiratory fitness in the middle age years promotes healthy aging and may also lead to increased longevity. Baseline activities; light intensity ADLs, such as standing, walking, and lifting lightweight objects. Exercise (health-enhancing physical activity): More than baseline to produce health enchancing benefits. Type of exercise: Isometric exercise: involve muscle contraction without motion. They are usually preformed against an immovable object. The muscles contract, but the object does not move (wall floor, ect). Each position is held for 6-8 seconds and reported 5-10 times. Effective for developing total straight of a muscle or muscle group. Isotonic exercise: involves movement of the joint during the muscle contraction. Examples are wight training with free weight and calisthenics (push-ups, sit ups, chin up, ect.) Isokinetic exercise: s pecialized apparatus that provide variable resistance to movement. Combines isometric and weight training by providing resilience at a constant, present speed while the muscles move through the full ROM. (GYM machines) Aerobics exercise : acquires energy from metabolic pathways that use oxygen. (jogging, briks walks, and cycling), increase thereby providing exercise to CV system, Anaerobic exercise : occurs when the amount of oxygen taken into the body does not meet the amount of oxygen required to perform the activity. Therefore, the muscles must obtain energy from metabolic pathways that do not use oxygen. Rapid, intense exercises such as lifting heavy objects and sprinting are examples of anaerobic exercise. Proper body mechanics

Allow you to move your body while reducing your risk for injury, especially when assisting patients with moving and ambulating. Body alignment - proper posture (proper posture places the spine in a neutral [resting] position) - allowing the bones, muscles, joints, and ligaments to work at peak efficiency. Balance - line of gravity must pass through your center of gravity and center of gravity must be close to your base of support - the broader the base of support, the lower the center of gravity, and the easier it is to maintain balance The line of Gravity : an imaginary vertical line drawn from the top of the head to through the center of gravity. Center of Gravity: the point which mass is distributed. The center of gravity is below the umbilicus at the top of the pelvis. Base of support : is what holds your body up (feet). Coordination - Smooth movement requires coordination between the nervous system and the musculoskeletal system Cerbral cortex: initiates voluntary movement Cerebelum : coordinates movements: largely responsible for controlling proprioception (the awareness of posture, movement and position. Basal ganglia: located deep on the cerebrum, assist with coordination of movement Damage to any of these structures affects coordination of movement. Joint mobility - person's ability to move within the environment ROM - max movement possible at the joining AROM - active range of motion - performed by the individual without assistance PROM - passive range of motion - patient unable to do ROM unassisted, perform for pt Interventions to reduce contractures

● Perform flexion ● Extension exercises Shearing Injury the patient is at risk for friction and shearing injury from pulling skin across the linens when moving in the bed and chair Effects of immobility of the Body systems (Respiratory, cardiovascular, Integumentary, musculoskeletal, etc.) Musculoskeletal • One of the first systems affected by immobility • Atrophy-10% loss of muscle strength per week. • Wasting of the gastrocnemius, soleus, and leg muscles that control flexion and extension of the hip, knee, and ankle. • Joints become stiff. • Contractures-The strongest muscles (flexors) pull the joints, leading to contractures, or joint ankylosis. Cardiovascular • Venous stasis-Leads to ↑ cardiac and venous stasis. • ↓ Cardiac reserve-Heart rate and stroke volume ↑ to maintain blood pressure. But with immobility, cardiac reserves ↓ , which means the heart is less able to respond to the body ’ s demands. • Edema-Without muscle activity, gravity causes blood to pool, which leads to edema. Fluid in the tissue is more prone to pressure injury. • Risk for thrombosis-Leads to compression and injury of the small vessels in the legs and ↓ clearance of coagulation factors, causing blood to clot faster. Stasis, activation of clotting, and vessel injury (Virchow ’ s triad) are associated with a ↑ risk for deep vein thrombosis (DVT) formation.

• Orthostatic Hypotension-Inactivates the baroreceptors involved with vasoconstriction and dilation; less able to regulate blood pressure. Dizziness and light-headedness occur. Lungs • ↓ Ventilation- ↓ Strength of all muscles and ↓ chest wall expansion, which impairs ventilation. • Pooling in lungs-Shallow respirations; secretions pool in lungs. • Risk for atelectasis or pneumonia-Pooled secretions block air passages and alveoli, ↓ air – gas exchange, and often lead to atelectasis (collapse of air sacs) or pneumonia. Integumentary System • Pressure Injury-Pressure over bony prominences compresses capillaries resulting in ↓ circulation. Tissue hypoxia then damages local tissues. Metabolism • Energy- ↑ Serum lactic acid and ↓ adenosine triphosphate (energy). • Metabolic rate drops-Protein and glycogen synthesis ↓ ; fat stores ↑ . • Glucose intolerance • ↓ Muscle mass • Stress Response-Triggers release of thyroid hormones, epinephrine, norepinephrine, adrenocorticotropic hormone from the pituitary gland, and aldosterone from the kidneys — same as stress response. • ↑ Excretion of calcium-Immobility alters parathyroid function, calcium metabolism, and bone formation. The result is osteoporosis, calcium depletion in joints, and renal calculi (kidney stones). • Risk for fractures with minimal trauma. Gastrointestinal

• Slows peristalsis, leading to constipation, gas, and difficulty evacuating stool from the rectum.Paralytic ileus(cessation of peristalsis) can occur. • Appetite diminishes and digestion slows, often leading to ↓ calorie intake. • Muscle is broken down as a fuel source. Urinary • Supine position inhibits drainage of urine from the kidney and bladder. Urine becomes stagnant — ideal environment for infection. • ↑ Calcium levels and stone formation. • Urinary retention- ↓ muscle tone leads to ↓ bladder tone, which leads to urinary retention. • Bedpan/urinal-Many patients have difficulty voiding in a bedpan or urinal. Psychological Effects • Affect-Moodiness, depression, anxiety, hostility, disturbed sleep, apathy, poor body concept • Cognition- ↓ concentration, recall, and problem-solving • Self-Care-Reduced ability to perform self-care Pressure injury – Risk factors, interventions Risk factors that contribute to pressure injuries are poor nutrition, immobility, moist skin, and reduce perfusion A medication that causes vasoconstriction increases the risk for pressure ulcers because there will be less perfusion to the tissue. Intervention- Change the position as indicated by skin assessment with position change Assess the client pressure ulcer risk Teach client to shift every 15 min if possible Use positioning device as needed

Assess skin and provide skin and perineal care as needed. Flexibility Flexibility Training Stretching before exercise helps warm up the muscles and prevents injury during exercise. Stretching after exercise cools the muscles and limits post-exercise stiffness. As we get older, joints and muscles become stiffer. A regular flexibility program helps maintain mobility as aging occurs. ROM – Passive/Active ROM Active range of motion (AROM) occurs when the patient independently moves his joints through flexion, extension, abduction, adduction, and circular rotation. Patients recovering from illness, injury, or surgery often perform AROM as a rehabilitation procedure. Movement with ADLs also helps to improve joint mobility, circulation, muscular strength and tone. ■ Passive range of motion (PROM) is movement of the joints through their range of motion by another person. Both AROM and PROM improve joint mobility, increase circulation to the area exercised, and help maintain function. However, AROM also improves and respiratory and cardiac function. For an explanation of how to perform PROM, ROM exercises Priority assessment Immobility effects every part of the body system. Priority assessments are airway, breathing and circulation Communication techniques Promoting independence Know your medical terminology – example: hemiplegia Osteoclast - cells that break down old or damaged tissue in bone Osteoblast - repair or build damaged bone to keep skeleton strong

Articulate - two bones come close together to form a joining - covered w smooth articular cartilage Synarthroses - immovable joints (sutures between cranial bones) Amphiarthroses - limited movement (joints between the vertebrae and pubic bones) Diarthroses or synovial joints - freely moveable because of the amount of space between articulating bones - filled w synovial fluid Types: ● Ball-and-socke t - rounded head ball fits into cup like socket allowing movement in all planes and rotation (Shoulder and hip joints) ● Condyloid - oval shaped bone fitting in to an elliptical cavity allowing movement in two planes at right angles to each other (wrist) ● Gliding - flat plane surfaces move past each other (Intervertebral joints) ● Hinge - fits into a cavity, allows flexion and extension (Knee and Elbow) ● Pivot - joint formed by a ring-like object that turns on a pivot, limited to rotation (first vertebrae and the base of the skull) ● Saddle - One bone surface is concave in one direction and convex in the other. The other surface has the opposite construction so that the bones fit together. Movement is possible in two planes at right angles to each other. (Carpal-metacarpal joint of the thumb) Ligaments - tissues that connect most movable joints

Tendons - fibrous connective tissues that attach muscle to the bone Cartilage - smooth, elastic, connective tissue that acts as a cusion around the joints or other parts of the body Skeletal muscle - moves bones and joints Smooth muscles - GI tract or other hollow structures (bladder and blood vessels) Cardiac muscle - contracts spontaneously in the heart Syndactylism- is the fusion of two or more fingers or toes. Most cases involving the hands are treated surgically at an early age to limit the effect on fine motor development. Developmental dysplasia of the hip (DDH)- is a congenital abnormality of the development of the femur, acetabulum, or both that shows as hip dislocation. Foot deformities- Clubfoot (talipes equinovarus), occurs in about 4% of all newborns. Serial cast or surgery may be used to correct the defect and preserve function. Scoliosis- is a lateral curvature of the spine. Congenital- present at birth. Osteogenesis imperfecta-Congenital disorder of bone and connected tissue that is characterized by brittle bones that fracture easily. Usually born with fractures. Achondroplasia- Dwarfism, bones Ossify (prematurely). Atrophy — a decrease in the size of muscle tissue due to lack of use or loss of innervation Clonus — spasmodic contraction of opposing muscles resulting in tremors Flaccidity — a decrease or absence of muscle tone Hemiplegia — paralysis of one side of the body Hypertrophy — increase in the size or bulk of a muscle or organ

Paraplegia — paralysis of the lower portion of the trunk and both legs Paresis — partial or incomplete paralysis Paresthesia — numbness, tingling, or burning due to injury of the nerve(s) innervating the affected area Quadriplegia — paralysis of all four extremities Spasticity — motor disorder characterized by increased muscle tone, exaggerated tendon jerks, and clonus Tremor — involuntary quivering movement of a body part

Proper use of assistive devices – example: Cane, walker Single-ended cane with a half-circle handle for the patient who needs minimal support and is able to negotiate stairs. ■ Single-ended cane with a straight handle for the patient with hand weakness who has good balance. ■ Multiprong canes usually have three or four prongs, and all types have a straight handle. These canes provide a wide base of support and are useful for patients with balance problems. Walkers A walker is a lightweight metal frame device with four legs that provides a wide base of support as a patient ambulates. Some models have wheels that allow the walker to be rolled forward; others have a seat that allows the patient to rest periodically. These walkers are best for patients whose mobility problems are related to fatigue or shortness of breath rather than gait instability. Braces support joints and muscles that cannot independently support the body ’ s weight. They are most commonly used in the lower extremities. Nursing responsibilities include assisting the patient into and out of the brace and monitoring the condition of the skin under the brace. Crutches commonly used for rehabilitation of an injured lower extremity. The purpose of using crutches is to limit or eliminate weight-bearing on the leg(s) by forcing the user to rely on strength in the arms and shoulders for support. ■ Forearm support crutches are more likely to be used by a patient with permanent limitations. They are usually constructed of lightweight aluminum with a hand hold and a forearm support (Fig. 32-19A). ■ Axillary crutches are for both short- and long-term use (Fig. 32-19B). Properly fitted axillary crutches support the body weight in the hands and arms, not the axilla. Bed positions/body positions. Fowler (Sitting) – Semi-Fowler = 30 ° – Promotes respiratory function

– Lowers Diagrams allowing better expansion. – High Fowler = 45-90 ° – Helps with cardiac disfunction – Orthopneic Position : patient leans forward to help with respiration. Used in shortness of breath (SOB) Lateral Positions. The lateral position is a side-lying position with the top hip and knee flexed and placed in front of the rest of the body. The lateral position creates pressure on the lower scapula, ilium, and trochanter but relieves pressure from the heels and sacrum. Lateral recumbent position is side-lying with legs in a straight line Oblique position is an alternative to the lateral position that places less pressure on the trochanter. The patient turns on the side with the top hip and knee flexed; however, the top leg is placed behind the body • Prone (lying on the stomach) – Allows better respiration and chest expansion, and it should be use for short periods of time. – Creates a significant lordosis – Never use in patients with back surgery or injury. • Sims ’ position (lying semi lateral and semi on the stomach) – Semi-prone – Position for suppository, edema administration. Perineal procedures – Facilitates mouth drainage, limits trochanter and sacrum pressure Proper lifting of clients • Transfer board: Wood or plastic device to assist with moving the patient Use assistive devices like a Hoyer lift for transfers and moving the client up in bed. Shearing injuries happen because the client either is dragged up in bed or slides down. When moving a client up in bed, asks the client to fold their arms across the chest and lift their head to prevent hyperextension of the neck.

Acute compartment syndrome (ACS): A serious but uncommon limb-threatening condition in which increased pressure within one or more compartments (that contain muscle, blood vessels, and nerves) reduces circulation to the lower leg or forearm. Amputation: The removal of a part of the body. ankle-brachial index: A measure of blood flow in the lower extremities. It is calculated by dividing ankle systolic pressure by brachial systolic pressure. A normal ABI is 0.9 or higher. avascular necrosis: (also known as osteonecrosis) The death of bone tissue. bone reduction: Realignment of the bone ends for proper healing that is accomplished by a closed (nonsurgical) method or an open (surgical) procedure. Cast: A rigid device (synthetic, or less commonly, plaster) that immobilizes the affected body part while allowing other body parts to move. closed (simple) fracture : A fracture that does not extend through the skin (no visible wound). complex regional pain syndrome (CRPS ) A poorly understood dysfunction of the central and peripheral nervous systems that leads to severe, persistent pain. Ergonomics: The study of how equipment and furniture can be arranged so that people can do work or other activities more efficiently and comfortably without injury. external fixation A surgical procedure in which pins or wires are inserted through the skin and affected bone and then connected to a rigid external frame outside the body to immobilize the fracture during healing. fascia iliaca compartment block (FICB): A regional anesthetic technique to manage pain for patients who have a fractured hip. The anesthetic agent (such as levobupivacaine) blocks the femoral, lateral cutaneous, and obturator nerves while avoiding the risk of injury to the femoral artery and vein. Fasciotomy: A procedure for acute compartment syndrome in which the surgeon cuts through fascia to relieve pressure and tension on vital blood vessels and nerves. fat embolism syndrome (FES): A serious but uncommon complication of fractures in which fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after injury. These globules clog small blood vessels that supply vital organs, most commonly the lungs, and impair organ perfusion.

Fracture: A break or disruption in the continuity of a bone that often affects mobility and causes pain. fragility fracture : A fracture caused by osteoporosis or other disease that weakens bone. internal fixation : A surgical procedure in which metal pins, screws, rods, plates, or prostheses are inserted inside the body to immobilize a fracture during healing. Neuroma: A sensitive tumor consisting of damaged nerve cells that forms most often in patients with amputations of the upper extremity but can occur anywhere. open (compound) fracture : A fracture that extends through the skin, causing a visible wound. opioid-induced constipation (OIC): Constipation that can result from taking opioids for a long period of time. phantom limb pain ( PLP): A persistent altered sensory perception in the amputated body part that is unpleasant or painful. repetitive stress injury (RSI): A fast-growing occupational injury, which occurs in people whose jobs require repetitive hand activities, such as pinching or grasping during wrist flexion; carpal tunnel syndrome (CTS) is the most common RSI. subcutaneous emphysema: The appearance of bubbles under the skin because of air trapping. Traction: The application of a pulling force to a part of the body to provide bone alignment or relief of muscle spasm. Priority and Interrelated Concepts The priority concepts for this chapter are: • Mobility • Perfusion The Mobility concept exemplar for this chapter is Fracture.

The Perfusion concept exemplar for this chapter is Amputation. The interrelated concepts for this chapter are: • Pain • Tissue Integrity • Sensory Perception • Infection Reduce risk for falls Risk for DVT Contribution to musculoskeletal injury Complication of a fracture Priority assessment Manifestation of immobility Client falling/Falls interventions/education Traction Type of fractures Pulmonary embolism Infection – S/S, assessment, data collection, interventions Compartment syndrome Cast care/complication – education Stages of bone healing Sprain – Intervention – RICE Greatest risk for infection/falls Chapter 46: Arthritis - inflammation of one or more joints Assess mobility (due to joint pain or muscle atrophy) & pain (usually seek medical attention bc of pain), does it interfere with ADLs?, pain normally due to joint swelling, cartilage deterioration, or secondary joint inflammation

Osteoarthritis - the progressive deterioration and loss of articular (joint) cartilage and bone in one or more joints. Primary - caused by aging and genetic factors - weight-bearing joints (hips and knees), the shoulders, the vertebral column, and the hands are most commonly affected Secondary - caused by joint injury or obesity Labs - Aspirate of synovial joint to rule out urate crystales (gout), ESR and high-sensitive C-reactive protein (hsCRP) Imagining- X-rays (determines structural changes) and MRIs (determines vertebral or knee involvement) Drug Therapy - No drug therapy can influence the course of OA, Optimal management of patients with OA requires a multimodal approach (combination of therapies) to manage persistent pain - The purpose of drug therapy is to reduce pain and inflammation caused by cartilage destruction, muscle spasm, and/or synovitis. - topical drug application may help with temporary pain relief, prescription lidocaine 5% patches applied on clean, intact skin for 12 hours each day, Topical NSAIDs are considered to be safer and effective no ns ystemic drugs for pain relief, Weak opioid drugs such as tramadol may also be given for patients with OA. Nonpharmacologic interventions - balanced with exercise, joint positioning, heat or cold applications (15-20 MINS!), weight control, and a variety of complementary and integrative therapies Dietary Supplements: Glucosamine may decrease inflammation and chondroitin may strengthen cartilage Surgery- only when drug therapy no longer provides pain control or when mobility is so constricted that the pt cannot participate in ADLs, surgery only preformed to improve mobility total joint arthroplasty (TJA)- Almost any synovial joint of the body can be replaced with a prosthetic system that consists of at least two implants, one for each joint surface – contraindications for TJA are active infection anywhere in the body and rapidly progressive inflammation Total hip arthroplasty (THA), primary is first surgery, revision is any surgery after Preoperative care - assess the patient ’ s level of understanding about the surgery and his or her ability to participate in the postoperative plan of care, identify a joint coach (care partner) can help the patient through the perioperative period and assist with discharge needs Preoperative rehabilitation, or “ prehab, ” is essential to prevent functional decline after surgery and provide a quicker functional recovery

Preventing Postoperative Complications - The most potentially life- threatening and commonly occurring complication after THA is venous thromboembolism (VTE), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE) – Preventive evidence-based postoperative interventions include a combination of pharmacology, ambulation, and compression (PAC) Intermittent pneumatic compression devices, also called bilateral sequential compression devices (SCDs), are also important in preventing VTE by increasing venous blood flow during periods of inactivity An older patient may not have a fever with infection but instead may experience an altered mental state, especially delirium. Managing Postoperative Pain - opioids or multimodal pain management approach is best practice for patients having a major joint arthroplasty Nonpharmacologic methods for acute and chronic pain control, such as cryotherapy and music therapy Promoting Postoperative Mobility and Activity – Depending on the time of day that the surgery is performed, the patient with a THA gets out of bed with assistance the night of surgery to prevent problems related to decreased mobility Hospital readmission after THA – The most common complications of THA surgery that cause readmission to the hospital include thromboembolic problems, such as DVT and stroke; surgical site infection (SSI); and systemic infections, including pneumonia and sepsis Osteophytes -bone spurs caused by irregular bony overgrowth Synovitis - joint inflammation Crepitus - a grating sound caused by the loosened bone and cartilage in a synovial joint, may be felt or heard as the joint goes through the ROM Joint Effusion - excess joint fluid, common when the knees are inflamed The vicious cycle of the disease discourages the movement of painful joints, which may result in contractures, muscle atrophy, and further pain May result in loss of function or decreased mobility Rheumatoid Arthritis- chronic, progressive systemic inflammatory autoimmune disease process that primarily affects the synovial joints. A systemic disease, meaning it can affect any or all parts of the body while affecting many joints. Inflammatory responses similar to those occurring in synovial tissue may occur in any organ or body system in which connective tissue is prevalent. If blood vessel inflammation (vasculitis) occurs, the organ supplied by that

vessel can be affected, leading to eventual failure of the organ or system in late disease. May be acute and severe or slow and progressive. Chapter 47: Fracture: break or disruption in the continuity of a bone that often affects mobility and causes pain. Complete fracture- the break is across the entire width of the bone in such a way that the bone is divided into two distinct sections Incomplete fracture - the fracture does not divide bone into two portions because the break is only part of the bone. Open (compound) and closed (simple) fracture- the extent of associated soft-tissue damage. Fragility fracture - occurs after minimal trauma to a bone that has been weakened by disease. Compression fracture- produced by a loading force applied to the long axis of cancellous bone. Stages of bone formation: Stage 1: hematoma forms at the site of the fracture because bone is extremely vascular. Stage 2: occurs in 3 days to 2 weeks when granulation tissue begins to invade the hematoma. Stage 3: occurs as a result of vascular and cellular proliferation. Stage 4: the callus is gradually reabsorbed and transformed into bone. Stage 5: consolidation and remodeling of bone continue to meet mechanical demands. Common complications of fractures include : DVT and bone or soft tissue infection. Also PE. Osteomyelitis (bone infection)- most common with open fractures in which tissue integrity is altered and after surgical repair of a fracture. Acute compartment syndrome- serious, limb threatening condition in which increased pressure within one or more compartments reduces circulation to the lower leg or forearm. Pressure to the compartment can be from an external or internal source, but fracture is present in most cases of ACS. Tight, bulky dressings and casts are examples of external pressure causes. Blood or fluid accumulation in the compartment is a common source of internal pressure. Patients with ACS may need a surgical procedure known as a fasciotomy.

Long-term problems resulting from compartment syndrome include infection, persistent motor weakness in the affected extremity, contracture, and myoglobinuric renal failure. In extreme cases, amputation becomes necessary. Fat embolism syndrome (FES)- fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury. Globules clog small blood vessels that supply vital organs, most commonly the lungs, and impair organ perfusion. Usually results from fractures or fracture repair but may also occur, although less often, in patients experiencing pancreatitis, osteomyelitis, blunt trauma, or sickle cell disease. The earliest signs and symptoms of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea. Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Nonpalpable, red-brown petechiae may appear over the neck, upper arms, and/or chest. This is usually the last sign to develop. Avascular necrosis, delayed bone healing, and chronic regional pain syndrome are later chronic complications of musculoskeletal trauma. Blood supply to the bone may be disrupted, causing decreased perfusion and death of bone tissue, or avascular necrosis. Delayed union- fracture that has not healed within 6 months of injury. Nonunion- fracture never completely heal Malunion- fracture heals incorrectly. If bone does not heal, he or she typically has persistent pain and decreased mobility from deformity. Complex regional pain syndrome (CRPS)- a poorly understood dysfunction of the central and peripheral nervous systems that leads to severe, persistent pain and other symptoms. Most often results from fractures or other traumatic musculoskeletal injury and commonly occurs in the feet and hands. The primary cause of a fracture is trauma from a motor vehicle crash or fall, especially in older adults. Trauma may be a direct blow to the bone or indirect force from muscle contractions or pulling forces on the bone. sports, vigorous exercise, and malnutrition are contributing factors. Bone disease, such as osteoporosis, increase the risk for a fracture in o lder adults. Shearing and friction damage tissue integrity and cause a high level of wound contamination. Assess all major body systems first for life-threatening complications, especially when patients have head, chest, and/or abdominal trauma.

Pain is usually caused by muscle spasm and edema that result from the fracture. Subcutaneous emphysema- the appearance of bubbles under the skin because of air trapping. Assessment of neurovascular status in patients with musculoskeletal injury box describes the procedure for a neurovascular assessment, which evaluates circulation, movement, and sensation. REMEMBER (CMS)