Med Surg 2 Musc Unit 4

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Med Surg 2 Musc Unit 4
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2013-10-25 15:56:31
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Unit 4
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  1. Describe and identify the physiological function of the musculoskeletal system
    • 1. Smooth muscle (involuntary) is responsible for contractions of organs and blood vessels and is controlled by the ANS.
    • 2. Cardiac muscle (involuntary) is controlled by the ANS and causes contractions of the heart muscle.
    • 3. Skeletal muscle (voluntary) is controlled by the CNS and PNS. The main function is movement of the body and its parts.
  2. Identify the changes of the musculoskeletal system with aging
    Decreased bone density; increased bone prominence; kyphotic posture, widened gait, shift in the center of gravity; cartilage degeneration; decrease ROM; muscle atrophy, decreased strength; slowed movement
  3. Pathophysiology of orthopedic surgery
    used most often to manage the pain of OA and to improve mobility; other disorders include RA, congenital anomalies, trauma, and osteonecrosis (bony necrosis due to lack of blood flow). It is contraindicated if there is an active infection anywhere in the body, advanced osteoporosis, rapidly progressive inflammation. Complications can arise postop if pt has uncontrolled DM or HTN
  4. Total Hip Arthroplasty
    • Primary- first time a pt receives any total joint arthroplasty
    • Revision- any other arthroplasty to include fixing a loose implant.
    • Most often performed on pt older than 60
  5. Preop THA Teaching
    assessing the pt level of understanding abou the surgery and their ability to participate in postop care. Pt education may have occurred weeks or moths before surgery. Pt may be given a notebook or DVD to watch along with written materials. Provide information in multiple ways to include the expectations for preadmission, hospitalization, and posthospitalization with pt and family member.
  6. Preop THA PT/OT; Preop Testing
    PT may have pt practice transfers, positioning, and ambulation. OT may work with PT to assist in exercises or learning to ambulate with and assistive device. OT may also help obtain assistive device to include shower chair, handheld shower, long-handled sponge for bathing, reacher, grabber, or dressing stick, safety bars. Pt needs to visit a dentist before surgery to decrease risk for infection and to tell any future providers they've had a THA. Pt with RA may have cervical XR to be sure they will have subluxation during intubation. Hip XR, CT, and/or MRI is done to assess operative joint and surrounding tissues.
  7. Preop THA VTE/Infection assessment
    VTE risk is assessed and NSAIDs, Vit C & E, and hormone replacement therapy is stopped about 1 week before surgery. Pt is also assessed for possibility of blood transfusion need and Autologonous blood can be banked.To prevent anemia pt can be given epoetin alfa (Epogen, Procrit). Pt needs to shower with antiseptic soap the night before and sleep on clean sheets. Review medications to take in the morning (antihypertensives) and which not to take and to take with a small amount of water.
  8. THA Operation
    • IV antibiotic cephalosporin such as cefazolin (Ancef) started at least 1 hour prior to surgical incision.
    • Pt is placed in the neuroaxial (epidural/spinal) anesthesia position.
  9. Traditional THA
    • An 8 inch longitudinal incision along the anterolateral thigh (more muscle damage, less risk for dislocation).
    • Posterolateral on the thigh and into the buttock incision can be made to try to preserve muscle but may increase the risk for dislocation and sciatic nerve injury
    • 3 days for traditional hospitalization
  10. THA MIS
    • smaller incisions, but cannot be used with patients who are obese or have osteoporosis.
    • Only for primary THA
    • There is less pain, less damage, and shorter recovery
    • 1 day hospitalization
  11. Components of THA
    • Acetabular component and femoral component
    • Non-cemented- bone is smoothed and the components are press-fitted into the prepated bone. Less stable and the weight-bearing status must allow bone to grow into the prosthesis to decrease loosening problems.
    • Cemented- polymethyl methacrylate is used and a closed wound drainage may be placed. Cement can fracture or deteriorate over time, leading to loosening of the prosthesis and lead to need for revision surgery.
  12. Preventing complications form TJA
    • Dislocation- position correctly; for hip, keep leg slightly abducted; for hip, prevent hip flexion beyond 90 degrees; assess for pain, rotation, and extremity shortening; report immediately to the physician
    • Infection-use aseptic technique for wound care and emptying of drains; wash hands thoroughly when caring for patient; culture drainage fluid, if change; monitor temperature; report excessive inflammation or drainage to physician
    • VTE- have pt wear elastic stockings and/or SCDs; teach leg exercises to pt; encourage fluid intake; observe for sign of thrombus (redness, swelling, or pain); observe pt for changes in mental status; administer anticoagulants as prescribed; do not massage legs; do not use knee gatch on bed
    • Hypotension, bleeding, or infection- take vital signs at least every 4 h; observe pt for bleeding; report excessively low BP or bleeding to physician.
  13. Postop Care THA
    Use an abduction pillow or splint to prevent adduction after surgery; keep the heels off the bed; de not rely on fever as sign of infection, monitor mental status; when assisting out of bed, move pt slowly to prevent orthostatic hypotension; encourage deep breathing, coughing, incentive spirometer every 2 hours; get the pt out of bed as soon as permitted; anticipate pain medication needs; expect a temporary change in mental status until anesthesia wears off. Reorient pt frequently
  14. Prevent Hip Dislocation
    • subluxation (partial dislocation) or total dislocation.
    • Abduction devices with straps are placed on patients who are restless or cannot follow instructions.
    • Bed pillows are used to keep the legs abducted. Place the affected leg in neutral rotation. Keep heels off the bed.
    • Avoid flexing the hips greater than 90 degrees.
    • If dislocation occurs the hip is immobilized by an abduction splint.
    • Recovery takes 6 weeks.
  15. Prevent VTE
    • SCDs, antiemoblism stockings
    • Coumadin, Lovenox, or factor Xa inhibitors for 3-6 weeks postop.
    • Lovenox, Fragmin, and Innohep work to inhibit factor Xa.
    • Unfactionated Heparin can cause thrombocytopenia.
    • Assess CBC, platelets, bleeding (stool and bruising)
    • Watch for S/S of neurological dysfunction
    • Fondaparinux, factor Xa inhibiting agent, causes an increase risk for bleeding, no antidote
    • Early ambulation and exercise; leg exercises should begin immediately and continue through rehab to include plantar flexion, dorsiflexion, circumduction of the feet; gluteal and quadriceps muscle setting, and straight-leg raises.
  16. Prevent Infection
    • assess the hip dressing q4h for first 24h then q8-12h after
    • Most care caused by contamination during surgery; S/S such as elevated temp and excessive or foul smelling drainage; elderly may display change in mental status.
    • Obtain a sample of the drainage for C&S
  17. Bleeding and Anemia
    • assess the hip dressing q4h or when vitals are taken. Total amount of drainage is usually <50 ml/8h. Empty drains q shift
    • MIS may not have drain
    • Monitor Hgb and Hct to assess for anemia
    • BP may be lower because of blood loss after surgery.
  18. Neuro compromise
    Monitor neuro assessments frequently for circulation to the affected distal extremity. Check & document color, temp, distal pulses, cap refill, movement, and sensation. Compare with unaffected leg.
  19. Managing Pain
    • Immediate pain control is typically achieved with PCA or epidural morphine. Most patient's do not require parenteral analgesics after the first day.
    • Oral opioids include- Percocet or Tylox then NSAIDs like ketorolac or ibuprofen.
    • Nonpharmocologic-guided imagery
  20. Promoting Mobility and Activity
    • Usually out of bed the night of surgery or within 24 h, depends on physician
    • Avoid flexing hips beyond 90 degrees; raised toilet seats, reclining chairs can prevent hyperflexion; avoid twisting the body or crossing their legs.
    • Cement- usually allowed immediate Partial Weight Bearing (PWB) and progress to Full Weight Bearing (FWB). Toe-touch or minimal weight bearing is permitted for pt with non-cemented.
    • Usually advance to single cane or crutch if they can walk without a severe limp 4-6 weeks postop.
  21. Weight bearing
    • Non-weight-bearing (NWB): The leg must not touch the floor and is not permitted to support any weight at all. The patient may hop on the other leg or use crutches or other devices for mobility. In this grade, 0% of the body weight may be rested on the leg.
    • Touch-down weight-bearing or Toe-touch weight-bearing: The foot or toes may touch the floor (such as to maintain balance), but not support any weight. Do not place actual weight on the affected leg. Imagine having an egg underfoot that one is not to crush.
    • Partial weight-bearing: A small amount of weight may be supported by the affected leg. The weight may be gradually increased up to 50% of the body weight, which would permit the affected person to stand with his body weight evenly supported by both feet (but not to walk).
    • Weight-bearing as tolerated: Usually assigned to people that can support from 50 to 100% of the body weight on the affected leg, the affected person independently chooses the weight supported by the extremity. The amount tolerated may vary according to the circumstances.
    • Full weight-bearing: The leg can now carry 100% of the body weight, which permits normal walking.
  22. Self-management
    • Usually able to return to work in 2 weeks
    • Traditional- 3 day stay; D/C to home, rehab, transitional care unit, or skilled/long term facility before D/C home.
    • Acute rehab usually takes 1-2 weeks or longer
    • Full recovery usually takes 6 weeks or longer
    • Collaborate with case manager to determine best postop placement for pt based on insurance, support system, and needs
  23. THA after D/C
    • Hip-Do not sit or stand for long periods of time; do not cross your legs beyond the midline of your body; do not bed your hips more than 90 degrees; do not twist your body when standing; use an ambulatory aid when walking; use assistive/adaptive devices for dressing; do not put more weight on your affected leg than allowed; resume sex as usual on advice of surgeon
    • Pain Management- Report increased hip pain to the physician immediately; take oral analgesics as prescribed; do not overexert yourself, take frequent rests
    • Incisional care- inspect your hip qd for redness, heat, or drainage and call if any; cleanse your hip incision with mild soap and water qd and dry throughly
    • Other- continue walking and performing leg exercises; do not cross your legs to prevent DVT; report pain, redness, or swelling in your legs immediately; if your are taking an anticoagulant, follow bleeding precautions, report bleeding or excessive bruising immediately; perform postop exercises as instructed
  24. Total Knee Arthroplasty (TKA)
    • Has an expected life span of 20 years or more
    • Obesity increases wear and tear on weight bearing joints, leading to revision surgeries
    • When activity and mobility severely prevent pt from participating in work or activities, this can restore QOL.
    • MIS candidates cannot have severe bone loss, obesity, or previous knee surgery.
  25. Preop TKA
    • Care is the same as THA except for positioning
    • All pt are given verbal and written or video preop instructions. Teach pt about assistive devices, elevated toilet seats, safety handrails, and dressing devices. Teach family where equipment can be purchased and to have it before surgery.
    • Continuous Passive Motion (CPM)- increases joint mobility, explain how to use and what it is
    • Teach pt to shower with antiseptic soap and sleep on clean linen
    • Check on what meds can be taken the morning of surgery and to take with small amount of water
    • Dx testing includes cervical XR for RA pt to determine intubation; knee XR, CT, and/or MRI to assess joint and surrounding tissue
  26. Operative procedure
    • IV cephalosporin at least 1 hour prior to incision
    • Traditional-8 inch central longitudinal incision. Osteotomies of femoral and tibial condyles and posterior patella; femoral component is often non-cemented with a press fit with the tibial component being cemented
    • Jackson Pratt (deflated) or hemovac in place
    • Pressure bandage to decrease edema and bleeding. DO NOT REMOVE IT, REINFORCE IT
    • Monitor color, consistency, and amount of drainage
    • MIS-2 inch and contraindicated in obese pt
  27. Alternative therapy
    intraoperative insertion of Adlea (capsaicin product) directly into joint; can help decrease the need for opioid analgesics postop
  28. Postop Care
    • Similar to THA except for positioning and CPM
    • CPM keeps prosthetic knee in motion and may prevent the formation of scar tissue
    • Ice packs to decrease swelling that would decrease pressure and that would decrease pain
  29. CPM
    • Initially set to 20-30 degrees of flexion and full extension (0 degrees) at two cycles per minute. Observe and document pt response to device and follow surgeon protocol
    • Ensure the machine is well padded; check the cycle and ROM at least q8h; ensure that the joint being moved is properly positioned on the machine; if the pt is confused, place controls to the machine out of reach; assess the pt response to the machine; turn off the machine while pt is having a meal in bed; when the machine is not in use, do not store on the floor
  30. Pain Management
    • Manage pain to provide comfort, increase participation in PT, and improve joint mobility;
    • Peripheral Nerve Blockade (PNB)- injects the femoral or sciatic nerve with local anesthetic; not only decreases pain but allows early participation in  rehab
    • Continuous Femoral Nerve Blockade (CFNB)- perform neuro check q2-4h. Pt should be able to plantar and dorsiflex the affected foot, but not feel pain in the extremity. Check movement, sensation, warmth, color, pulses, and cap refill. S/S of metallic taste, tinnitus, nervousness, slurred speech, bradycardia, hypotension, decreased respirations, seizures need to be reported. Assess pt pain BEFORE the doc leaves
  31. Positioning
    • maintain knee in neutral position and not rotated internally or externally. Surgeon may have knee flat on bed or with one pillow under the calf and foot.
    • Complications to watch for are VTE, infection, anemia, neuro compromise
  32. D/C Goals
    Pt can walk independently with crutches, cane, or walker and has adequate flexion in the operative knee.
  33. Rehab
    • Traditional-2-4 weeks; d/c to home, rehab, transitional unit, skilled/long term facility; Collaborate with case manager for placement; TKA usually takes 6 weeks or longer for full rehab
    • MIS- home in 2 days; pt are partially weight bear unless the prosthesis is not cemented; rehab usually takes 1-2 weeks and can return to work/activities in 2-3 weeks.
  34. Total Shoulder Arthroplasty (TSA)
    decreases arthritic pain and increase ability to perform ADLs. Subluxation or dislocation is a major potential complication; A sling is usually applied to immobilize the joint; perform neuro checks q 4-8h; 1-2 days for pain control; rehab usually takes several months
  35. Total Elbow Arthroplasty (TEA)
    Used for RA; infection and loosening may occur because of extensive tissue cutting during surgery; active and passive ROM; swelling usually resolves in 3-6 mo.; lifting is restricted on long term basis
  36. Foot or Hand joint replacement
    phalangeal joint, metacarpal or metatarsal arthroplasties; without cement because they do not bear weight; edema is controlled by raising the arm; rehab may last for weeks
  37. Wrist
    • pressure dressing removed in 1-2 days and splint is applied. Full function in 6-12 weeks, but lifting may be restricted longer.
    • Ankles not normally performed-Complications are infection, delayed wound healing, nerve injuries, loosening; weight bearing can begin about 6 weeks and rehab for 3 mo
  38. Laminectomy
    • surgical procedure for lumbar disc; excision of part of the posterior arch of the vertebra to gain access to part or the entire protruding disc
    • Spinal stenosis, herniated disc, pressure on spinal nerves, only when med/PT failed or symptoms are bad
    • Symptoms- sever low back and/or leg pain; trouble walking more than a block; leg numbness/weakness; loss of bladder and/or bladder control
    • Recovery- depends on location; 1-4 weeks healing of tissue; 2-3 months to strengthen muscles/adjacent tissue
    • Most D/C within 24h
  39. Open Surgery
    • prevent and assess complication that might occur in first 24 h; vitals q4h for 24h, assess fever and hypotension to indicated bleeding or severe pain; neuro check q4h; check ability to void; out of bed with assistance on the evening of surgery; Pain control with PCA; empty drain (JP drain or Hemovac) q8h and usually removed 24-26h postop
    • Turn pt via log rolling (pt turns as a unit while their back is kept as straight as possible) q2h from side to back and vice versa; instruct pt to keep back straight when out of bed and sit in a straight back chair with feet on the floor; deep breathe q2h; SCDs; inspect iliac and spinal incision dressings for draining and be sure intact; avoid prolonged standing/sitting
  40. Complications
    • CSF leakage- observe clear fluid on or around the dressing; place pt flat; report immediately
    • Fluid volume deficit- monitor I&O, drain output (no more than 250ml/8h ) for first 24h; monitor vitals for hypotension and tachycardia
    • Acute Urinary Retention- assist pt to bathroom or bedside commode asap; assist males to stand asap
    • Paralytic ileus-monitor flatus or stool; assess for abdominal distention, nausea, vomiting
    • Fat Embolism Syndrome (FES)- observe for and report chest pain, dyspnea, anxiety, change in mental status; note petechiae around neck, upper chest, buccal membrane, and conjunctiva; monitor ABGs for decrease PaO2
    • Persistent or progressive lumbar radiculopathy (nerve root pain)-report pain not responsive to opioids; document the location and nature of pain; administer analgesics as prescribed
    • Infection- monitor temp (increased temp or a spike after second postop day is possible infection); report increased pain or swelling at the wound site or legs; give antibiotics as prescribed if infection; use clean technique for dressing changes
    • bowel or bladder incontinence, nerve root damage, paralysis (quadriplegia or paraplegia), CSF leak (if dural sac is breached), infections, postop instability, splitting open of the wound, injury to spinal cord, unstable spine (after multiple), tears in fibrous tissue (covering spinal cord and nerve near spinal cord, may require reoperation)
  41. Home care
    • Regular diet, firm mattress, limits on climbing stairs, daily walking is encouraged, return to work 4-6 weeks or 3-6 mo if physically strenuous, limited to lifting 5 lbs, driving not permitted for several weeks
    • Pain meds (OTC or Narcotics), stool softeners, bed rest not required or recommended, no exercise until cleared, staples/sutures clean and dry (removed 7-14 days after), no tub baths, may shower (blot incision dry and cover with dry dressing), weight reduction, stop smoking, moist heat, strengthening exercises
    • Physical therapy 2 weeks postop, keep all appointments
    • NSAIDs, muscle relaxants
    • Report: fever, chills, redness or drainage from incision, weakness/numbness in lower extremities, difficulty voiding, unrelenting pain
  42. Amputations
    • removal of a part of the body
    • elective related to complications of PVD and arteriosclerosis; result in ischemia in distal areas of lower extremity (DM often cause)
    • traumatic- result from accident and cause of upper extremity amputation; injury that causes severe crushing of tissues or significant blood vessel damage usually results in amputation to preserve function of the residual limb
  43. Levels of amputation
    • Toe- affects balance gait, and push off during walking
    • Midfoot to Syme- PVD- middle of foot and back portion of foot to ankle (Syme most of foot is removed except ankle)
    • Ankle
    • Below the knee
    • Above the knee
    • The higher the level of amputation, the more energy is required for mobility; higher-level is typically done for cancer of the bone, osteomyelitis, or trauma as a last resort
  44. Complications
    • Hemorrhage- major blood vessels are severed, bleeding must be controlled or hypovolemic shock or death
    • Infection- can occur in the wound or bone (osteomyelitis); older malnourished adult and confused is highest risk; prevent infection
    • Phantom Limb Pain- sensation is felt in the amputated part immediately after surgery and is persistent, unpleasant, or painful; Pain is often intense burning, crushing sensation, or cramping; feeling of part is distorted, uncomfortable position; numbness and tingling (phantom limb sensation); triggered by  touching the residual limb or by temp or barometric pressure changes, concurrent illness, fatigue, anxiety or stress; tell pt about possible limb pain
    • neuroma- sensitive tumor consisting of damaged nerve cells that forms most often in amputations of upper extremities; surgery to remove neuroma may be performed but often regrows and is more painful; nerve blocks, steroid injections, and cognitive therapies may help
    • flexion contracture- must be avoided so that pt can ambulate with a prosthetic device; hip or knee; prone position for 30 minutes 3-4xday; Doc can say prone for 60 min 2xday; positioning and active ROM exercises prevent
  45. Health promotion/maintenance
    • typical pt is male, middle-older age with dm and hx of smoking; habits such as healthy weight, regular exercise, and avoiding smoking can prevent dm and poor circulation
    • Young men typically have traumatic due to MVA, industrial equipment or war
  46. Emergency Care
    Call 911; Assess ABC, Apply pressure with dry gauze or cloth; Elevate above the level of the heart; Do not remove dressing; wrap completely in dry sterile gauze or clean cloth, put in watertight plastic bag, place the bag in ice water (never directly on ice) at 1 part ice to 3 parts water. Avoid contact between limb and the water to prevent tissue damage; do not remove semidetached parts.
  47. Assessment
    Neuro status- check for pulses, temperature, color, sensation in both exremities; document discoloration, edema, ulcerations, necrosis, and hair distribution prior to surgery;
  48. Psychosocial Assessment
    • Loss must not be underestimated; pt faces complete permanent loss causing depression or grief; the young pt may be bitter, hostile, and depressed; expect grieving process and if traumatic it may be more difficult; Altered self-concept, body image, self-esteem- assess feelings about themselves and identify which areas need emotional support; attempt to determine the willingness and motivation to withstand prolonged rehab; assess family coping abilities; assess family reaction to surgery or trauma;
    • 888-fake-leg
  49. Dx assessment
    • measurement of segmental limb BP- ankle-brachial index (ABI) is calculated by dividing ankle systolic pressure by brachial systolic pressure. A normal ABI is 1 or more.
    • Doppler ultrasound or laser Doppler flowmetry and transcutaneous oxygen pressure (TcPO2); ultrasound and Doppler measure speed of blood flow to the limb; TcPO2 measures oxygen pressure to indicate blood flow in the limb
    • Above the Knee amputation has the potential for more postop complications than a partial foot amputation
  50. Assessment of Tissue Perfusion
    Primary focus is to monitor for signs of sufficient tissue perfusion but no hemorrhage; Skin should be pink or no lighter or darker than other skin tones; warm but not hot; Should not be bright red; assess closet proximal pulse for presence and strength and compare
  51. Pain
    • Phantom limb pain must be distinguished from stump pain because they are managed differently; recognize that pain is real and interferes with ADLs
    • Opioids are effective for residual limb pain but not PLP; IV calcitonin during the week after amputation can reduce PLP; Beta-blockers (propranolol; Inderal) are used for constant, dull, burning pain; Antiepileptics (tegrotol, Neurontin) may be used for sharp burning or knifelike pain; antispasmodics (baclofen) used for muscle spasms/cramping
    • PLP- ultrasound therapy, massage, heat, biofeedback, relaxation techniques, hypnosis, psychotherapy can be incorporated into plan
  52. Preventing infection
    broad spectrum prophylactic antibiotic immediately before elective surgery; may be continued with traumatic or open wounds; pressure dressings and drains for 48-72h; record appearance, amount, and odor of drainage; a soft dressing is secured by an elastic bandage wrapped firmly around the residual limb
  53. Exercises
    • ROM to prevent flexion contractures (hip and knee), trapeze and overhead frame, firm mattress, prone position q 3-4h, elevation of lower-leg residual limb is controversial
    • turn pt q2h or to turn independently; move pt slowly to prevent muscle spasms; prone position for 20-30 minutes is necessary to prevent hip flexion contractures; pull residual limb close to the other leg and contract the gluteal muscles of the buttock; push the residual limb down toward the bed while supporting with a soft pillow at first, continue with a firmer pillow then hard surface to prepare the limb for prosthesis and reduces incidence of PLP; Elevation of limb is sometimes allowed for first 24-48h; inspect limb daily to ensure that it lies completely flat on the bed
  54. Prosthesis
    • Bring sturdy pair of shoes for fitting; rigid, removable dressings are preferred to decrease edema, protect shape, and allow easy access to wound; Jobst air splint, plastic inflatable device can be used; wrapping with elastic bandages can reduce edema, shrinking the limb, and holding wound dressing in place, reapply q4-6h, use a figure-eight wrap to prevent restriction of blood flow; decrease the tightness of bandages while wrapping in a distal to proximal direction, anchor at highest joint
    • Fit prior to surgery, inspect daily for infection, teach to feel stump every morning and every night; devices help shape and shrink residual limb and help pt adapt, individual fitting of the prosthesis
  55. Promote Body Image
    Use the word stump; assess verbal and nonverbal references to affected area; do not jump to the conclusion that acceptance has occurred; teach pt about available resources
  56. Home Care assessment
    • assess the residual limb for adequate circulation, infection, healing, flexion contracture, dressing/elastic wrap; assess ability to perform ADLs; evaluate the ability to use ambulatory aids and care for prosthetic device; assess nutritional status; assess ability to cope with body image
    • room for wheelchair, teach how to care for limb, rewrap 3xday, shrinker stocking, clean daily with soap and water, inspect daily for inflammation or skin breakdown
  57. Carpal Tunnel Syndrome (CTS)
    • compression of the median nerve causing pain and numbness that occurs when the synovium becomes swollen or thickened; associated with continuous wrist movement; median nerve supplies motor, sensory, and autonomic function for first 3 fingers of the hand and palmar aspect of 4th ring finger; wrist flexion causes nerve impingement, and extension causes increased pressure in the lower portion of the carpal tunnel
    • Excessive hand exercise, edema or hemorrhage into the carpal tunnel, or thrombosis of the median artery can lead to acute CTS. Pt with hand burns or a Colles' fx of the wrist are particularly at risk
    • RA-synovitis or chronic dm, inadequate blood supply can cause median nerve neuropathy or dysfunction
    • Most common type of repetitive stress injury such as pinching or grasping during wrist flexion. Can also result from overuse in sports activities
    • May be congenital that manifests in adulthood, ganglia tophi or lipomas can cause
    • Women older than 50 are more likely; most often affects the dominate hand, children and adolescents from computers
    • OSHA and TJC recommend ergonomicaaly appropriate work stations
  58. Assessment
    • dx made from pat hx and report of pain and numbness without further assessment; pain is worse at night; may radiate to the arm, shoulder and neck, or chest; paresthesia can occur and sensory changes usually occur weeks or months before motor manifestations
    • Motor changes are weak pinch, clumsiness, and difficulty with fine movements that can progress to muscle weakness and wasting
    • Observe for swelling, palpate, skin discoloration, nail changes, or increased or decreased hand sweating; intentional tremors
  59. Dx tests
    • Phalen's wrist test (Phalen's maneuver) produces paresthesia within 60 seconds; relax the wrist into flexion or to place back of the hands together and flex both wrists at the same time
    • tap lightly over the area of the median nerve (Tinel's sign), BP cuff inflated on upper arm can also be used, to cause pain and tingling
    • Okutsu position test- hands in palm to palm position with thumbs extended, move the wrist toward the radial side as far as it can be done and hold that position for 1 minute, pain and tingling can occur
    • Xrays, electromyography (EMG), nerve conduction studies (NCS), and/or ultrasound
    • MRI not generally helpful because of soft tissue
    • NCS reveals nerve dysfunction before muscle atrophy is observed
    • Ultrasound view the cause of the problem
  60. Nonsurgical Management
    • Aggressive drug therapy and immobilization- NSAIDs or injection of corticosteroids; teach to take with meals
    • Splint or hand brace to immobilize hand during the day, night, or both
    • Laser or ultrasound therapy, yoga, or other exercise
  61. Surgical Care
    • Decompression of median nerve- longitudinal division of transverse carpal ligament either through open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR); synovectomy may occur
    • Monitor vitals and check dressing; affected hand/arm above the heart for several days; check neuro status in fingers qh during immediate postop period and encourage movement
    • Hand movement/lifting restrictions for 4-6 weeks; Expect weakness and discomfort for weeks or perhaps months
    • Report changes in neuro status, increased pain and numbness; ensure home assistance

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