Lesson 2
ASSESSMENT

PHYSICAL ASSESSMENT

Management of orthopedic patients begins with an accurate assessment of the patient's specific problems. Important information can be obtained from the patient's history and the physical assessment. An orthopedic nursing assessment should include the following examinations and observations:

a. Observe the patient's posture and gait.

b. Palpate the skin for indication of tenderness, swelling, or increased temperature.

c. Observe for discoloration.

d. Examine the joints, observing for size, shape, alignment, and range of motion.

e. Examine the muscles for strength, movement, and indications of atrophy or contracture.

f. Assess vascular function by "blanching" fingers and toes. Check pulses.

g. Assess neurological function by checking reflexes, sensation, and motor ability.

DIAGNOSTIC ASSESSMENT

a. Radiography is the most widely used procedure for evaluating patients with musculoskeletal disorders. X-rays of a joint may show spur formation, changes in joint structure, or the presence of fluid. X-rays of bone may show bone texture, density, and erosion or other bone changes. Special X-ray techniques include the following.

(1) Tomography, or body section roentgenography, is the recording of internal body structures in a specific plane of tissue. Computerized Axial Tomography, or CAT scan, uses both X-rays and computers to create three-dimensional images that appear on a screen in cross-sectional view.

(2) Myelography outlines the subarachnoid space and may show spinal cord distortions, herniated intervertebral discs, or the presence of lesions. A contrast medium (radiopaque dye, oxygen) is injected into the spinal subarachnoid space by lumbar puncture and X-ray films are taken.

(3) Arthrography involves the injection of radiopaque substance or air into the joint cavity in order to outline the soft tissue structures and joint contour.

b. Arthrocentesis is the insertion of a needle into a joint and the aspiration of synovial fluid for examination.

c. Electromyography (EMG) is the recording of the electrical properties of skeletal muscles in order to study aspects of neuromuscular function and conduction. This test helps determine any abnormal physiology.

d. Thermography is a technique using infrared cameras to photographically portray the degree of heat radiating from the skin surfaces. It is used to investigate underlying pathologic processes.

e. Arthroscopy is visual examination of the interior of a joint by using a small fiberoptic instrument called an arthroscope.

f. Scintiscan is a procedure that provides a two-dimensional representation of the gamma rays emitted by a radioactive isotope, revealing its concentration in specific body tissues. In bone scanning, the patient is given an intravenous injection of bone-seeking radioactive isotope and the body is "scanned" for increased isotope uptake. Increased concentrations of isotope uptake are associated with primary skeletal disease, metastatic bone disease, osteomyelitis, and some types of fractures.

g. Magnetic resonance imaging (MRI) is an imaging process that makes rapid, detailed pictures of body tissue. The patient is placed in a giant, horizontal cylinder and exposed to a magnetic field 15,000 times greater than the earth's natural magnetic field. No discomfort is experienced with this procedure.

NURSING CARE OF PATIENTS UNDERGOING DIAGNOSTIC PROCEDURES

Many diagnostic procedures require minimal nursing intervention. Often, all that is required is that the nursing staff deliver the right patient to the appropriate clinic at the designated time. Nursing personnel should explain the procedure to the patient, reassure him, and, if possible, show him the equipment. When the patient is returned to the ward, his status upon completion of the procedure should be documented by nursing personnel. Some procedures, however, may require a specific patient "prep" beforehand while others may require specific follow-up observations. Nursing personnel should be familiar with the various diagnostic procedures or refer to local departmental standing operating procedures when unsure about preps and follow-up procedures.

Invasive procedures, such as the myelogram, arthrocentesis, and arthroscopy, require the application of sterile dressings over the puncture sites. The puncture sites must be observed for signs and symptoms of infection and the dressings changed in accordance with the physician's orders or local Department of Nursing standing operating procedures. Additionally, the patient may be required to remain on bed rest for a period of time after the procedure.

Basic nursing considerations in the care of patients undergoing diagnostic examinations include the following:

(1) Ensure that any pre-procedural patient prep has been completed.

(2) Have the right patient in the right place at the right time.

(3) Bring previous X-rays, the patient's chart, or any other materials required by the department performing the procedure.

(4) Have an attendant available to remain with the patient, if required by local policy or circumstances.

(5) Comply with post-procedural physician's orders.

(6) Observe the patient for pain and/or other side effects or reactions associated with the procedure.

(7) Enter appropriate documentation of all that has been done in the patient's chart.

PAIN

Most patients with disorders of bones, joints, and muscles experience pain. Orthopedic nursing assessment and management of pain must be individualized as each person will have a different threshold and tolerance for pain.

 Bone pain is described as a deep, dull, boring ache, as opposed to muscle pain, which is described as a soreness or aching.

Increasing pain may indicate an infectious process, malignancy, or vascular problem. Pain that increases only with activity may indicate joint or muscle sprain.

Sharp pain may be related to a bone infection with muscle spasm, pressure on a sensory nerve, or fracture pain, which is both sharp and piercing.

Radiating pain is seen in conditions where pressure is exerted on a nerve root.

 NURSING ASSESSMENT OF ORTHOPEDIC PAIN

a. When assessing and evaluating the patient's pain, you should make the following determinations.

(1) What was the patient doing before the pain began? How did it begin?

(2) How does the patient describe the pain? Is it localized? Does it radiate? Is it continuous or intermittent?

(3) What is the character of the pain? Is it sharp, dull, piercing, shooting, cramping, or throbbing?

(4) What relieves the pain? What makes it worse?

(5) Is the patient's body in proper alignment?

(6) Is the patient experiencing pressure from casts, splints, traction, or other objects?

(7) What is the status of the circulation, sensation, and motor function in the affected area now as compared to previous checks?

b. Careful assessment and evaluation of the patient's pain will allow the nursing staff to determine the appropriate nursing intervention required. The nursing management might involve such actions as repositioning the patient, support or elevation of affected limbs, application of heat or cold, or the administration of analgesics, sedatives, or muscle relaxants as ordered by the physician.

(1) Repositioning. If the patient's body is out of alignment or a limb has moved to an abnormal position, all that may be required is to realign the body or reposition the affected limb. Proper body alignment is a key factor in patient comfort.

(2) Support. An affected limb may require support or elevation on pillows in order to reduce swelling and reduce strain on the associated musculature.

(3) Circulation. Application of heat or cold is useful in promoting circulation and reducing swelling.

(4) Medication. Prescribed medications such as analgesics, sedatives, and muscle relaxants are administered to control pain. (Other nursing measures should be utilized prior to administering medication since relief of pain may be achieved by using one of the simple nursing measures listed above.)

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