CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTRO-INTESTINAL, METABOLISM AND ENDOCRINE…
NCMB316 RLE: ORTHOPEDIC NURSING (Prelim)
DAY 1: Ambulation
AMBULATION
➢ Rationale for this skill:
o To maintain & restore muscle tone, muscle strength
& joint flexibility
o To improve balance
o Improves appetite
o Improves respiratory and circulatory fxn
o Stimulates bowel action
o Enhances patient’s psychological well being
➢ General procedures
o Identify patient, identify his capabilities, the activity
ordered & previous level of activity.
o Determine whether assistive devices are needed
o Take V/S:
a. Pulse
b. Respiration
c. BP
o If pain reliever is indicated before ambulation, be sure
to allow time to take effect before the patient begins
to ambulate
R! so the patient can tolerate the activity
o Set a tentative goal w/ the patient
R! So, the patient can cooperate & may know what to expect
o Check that the area should be litter-free and spill-free.
R! so that the patient does not fall or slip
o Obtain the patient’s robe and non-slip shoes or
slippers
o Monitor the patient carefully for signs of fatigue &
faintness. If this happens, move him/her to a nearest
bed or chair & let him sit w/ head down
R! so that the patient does not fall or slip
o If the patient loses balance, help him regain balance,
but if falling is inevitable, control the descent to the
floor. Do not try to maintain the patient up.
o R! this may cause injury to the nurse
SIMPLE ASSISTED AMBULATION
1. Follow the General procedures
2. Assist the patient to ambulate
A. In most cases, walk on the patient’s weaker or affected
side
R! so that if the patient falters, you can give assistance & support
S! BUT if the patient has poor balance & tends to lean toward the person
assisting…
N! Walk on the patient’s strong side, so that the patient’s weight is shifted to
the strong leg, rather than the weak leg, when he / she leans
B. Support the patient as you walk, but do not allow the
patient to put an arm around your shoulders
R! If the patient starts to fall, the weight could place a twisting strain
on your back & cause you injury
C. Offer support by extending an arm bent at the elbow with
the palm up; the patient can then rest a hand on your arm
R! The nurse can maintain firm support, & the patient can determine
how much support is need
i. Assisting to ambulate with GAIT BELT
➢ also known as a transfer & ambulation belt
➢ this is a strong belt with a safety release buckle
➢ When using this belt, walk on the patient’s weaker side and
slightly behind
o with one hand grasping the belt in the center back
o The other arm may be extended at the patient’s side
for the patient to grasp
➢ Walk slowly & evenly, avoid speeding up/slowing down.
R! It would be difficult for the patient if your gait is uneven
➢ Try to make your step the same as the patient. Synchronize
your steps w/ the patient
R! By using smooth & coordinated movements, you give the patient confidence
in you & diminishes fear of falling
ii. Using a CANE
➢ Designed for those who are able to bear weight on both legs
but have one leg weaker than the other
➢ All canes should have a rubber tip
R! to prevent slipping; inspect the rubber tip regularly
➢ The handle should be at the level of the client’s greater
trochanter; or the height of the cane should be that of the wrist
How-to STAND-UP W/ CONE:
➢ Grasp the cane with one hand, opposite affected leg, for
support
➢ Slide the hips forward in the chair.
➢ Grasp one arm of the chair with the free hand. If the patient
cannot grasp at the same time the armchair & the cane, only
the cane is grasp
➢ Push to a standing position *Encourage this kind of
independence *Give only help that is needed
➢ After standing, pause in place
R! to gain balance and place the cane initially
➢ Balance is best maintained if the cane is placed close to the
foot
R! so the patient remains erect, not bend over
Ambulate with CANE (COAL)
The cane should be held by the hand on the unaffected side so that the
cane & weaker leg can work together w/ each step
➢ Instruct the client to move the cane at the same time as the
affected leg
Cane
Opposite
Affected
Leg
➢ The client’s elbow should be flexed at a 15 to 30˚ angle
➢ Move the cane ahead about 4 to 6 inches to the side of the foot
➢ Move the affected leg ahead opposite the cane
➢ Place the weight on the cane and affected leg
➢ Move the unaffected leg forward
iii. Using a WALKER
➢ Assistive devices used by patients who have at least one
weight-bearing leg & arms strong enough to bear partial weight
➢ May be used by patients w/ generalized weakness & those w/
balance problems
➢ Gives greater support & balance than a cane
➢ 2 TYPES
o Pick Up – more stable, it does not slip when the
patient lean on it
o Rolling – allows a smooth normal gait but is less
steady
➢ Can be adjusted in height
➢ Ideally, they should reach slightly below waist level so that the
handgrips can be grasped w/ comfort & so that the arms are
slightly flexed to give better support
➢ Teach the patient to stand up from a sitting position:
o Place the walker in front (place gait belt if necessary)
o Place both hands of the client in the armchair and
push to a standing position * Give help and
assistance if needed
o Move the hand to the handgrips of the walker one at
a time to maintain balance
➢ The nurse should walk closely behind the client
➢ Teach the GAIT PATTERN:
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 o Move the WALKER & AFFECTED LEG
SIMULTANEOUSLY ahead about 4-6 inches
o Place the weight on the arms for support; if able,
place partial weight on the affected leg, otherwise,
place full weight on the arms
o Move the unaffected leg forward
iv. Crutch Walking
➢ A crutch is a wooden or metal staff used to increase client
mobility
➢ 2 TYPES
o Axillary
▪ most commonly used type, fits under the
axilla w/ the weight being placed on the
handgrips
o Forearm
▪ has a handgrip and a metal cuff that fits
around the arm, is more convenient but
provides less stability than the axillary
crutch
➢ To prevent slipping, crutches have rubber tips, which must be
kept dry
o If the tips are worn or loose, they must be replaced
➢ The crutch must be regularly inspected
o if cracks or bends are present, the person’s weight
will not be properly supported
➢ Crutches are used by:
o Clients unable to bear any weight on one leg
o Clients who can bear partial weight on one leg
o Clients who have full weight bearing on both legs
➢ Procedure:
1. Inform client that you will be assisting w/ ambulation
using crutches
2. Assess client for strength, mobility, ROM, visual acuity,
perceptual difficulties & balance
R! Helps determine the capabilities of client & amount of assistance required
3. Adjust crutches to fit the client.
o With the client supine, measure from the heel to the
axilla minus 2 inches.
o With the client standing, set the crutch position at a
point 2 inches lateral to the client and 4 to 6 in. in
front of the client.
o The crutch pad should fit 1.5 to 2 in. below the axilla
o The hand grip should be adjusted to allow for the
client to have elbows bent at 30° flexion
R! Provides broad base of support for client. Space between the crutch pad and
the axilla prevents pressure on radial nerves (crutch palsy). The elbow flexion
allows for space between the crutch pad and axila
o Lower the height of the bed.
R! Allows client to sit with feet on floor for stability
o Dangle the client at the side of bed for several
minutes *Assess for vertigo
R! Allows for stabilization of BP, thus preventing orthostatic hypotension
o Instruct client to hold the crutches; that is, with elbows
bent 30° and pad 1.5 to 2 in. below the axilla
o Instruct client to position crutches lateral to and
forward of feet *Demonstrate correct positioning
R! Increase client comprehension & cooperation
o Apply the gait belt around the client’s waist if balance
& stability are impaired
R! Provides support; promotes client safety
➢ GAITS of crutch walking
o Four-point gait for weight bearing w/ both legs
▪ Right crutch forward,
▪ Left foot forward,
▪ Left crutch forward, then
▪ Right foot forward
▪ The 4-point gait w/ crutches is very stable
but slow
o Three-point gait for weight bearing w/ one leg
▪ Crutches & weak leg forward together, then
▪ Weight-bearing leg forward
o Two-point gait for weight bearing with both legs
▪ Right crutch and Left foot forward together,
then
▪ Left crutch and Right foot forward together
▪ The 2-point gait requires more balance but
is a faster gait
o Swing-through gait has the pattern of
▪ crutches forward, then
▪ Legs swing forward together.
▪ The swing-through gait has the advantage
of speed; however, it requires good balance
➢ Going UP THE STAIRS with Railing
1. Hold both crutches under one arm.
2. Place the other hand on the railing in front of the body.
3. Raise the unaffected leg to the first step, and pull up with
hand on rail.
4. Pull up the affected leg and advance the crutches to the
level of the affected leg.
5. Repeat the process.
➢ Descending from stairs
1. W/ weight on the unaffected leg, the crutches are placed
on the next lower step, partial weight is placed on the
hands & crutches, & the affected leg is moved to the lower
step
2. Put total weight on crutches & affected leg
3. Move unaffected leg to same step as crutches & affected
leg
a. If railing is present, hold both crutches w/ one
arm, and use the other to grasp the railing
DAY 2: Cast
CAST
➢ a rigid external immobilizing device that is molded to the
contours of the body
➢ Plaster of Paris (gypsum sulfate) mixed with water (swells &
forms into a hard cement)
➢ Purpose:
o permit mobilization of the pt while restricting
movement of a body part
o apply uniform pressure on encased soft tissue
o to immobilize a reduced fracture
o To correct a deformity
➢ Principles in applying plaster cast
o Generally speaking, the joints proximal and distal to
the area to be immobilized are included in the cast
o Provide for maximal comfort & alleviation of
complications
o Application of padding is the first step in the
procedure
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 ▪ Padding materials include the following:
• wadding sheet or
• roll of cotton stockinette
o Maintain desired position throughout cast application
o Use caution in handling of the cast until it has set /
become hardened
▪ It can be applied as a combination, like
stockinette & sheet wadding.
▪ Apply it to include the joint above & joint
below the injured part
▪ Apply it in circular motion & mold it
▪ Support it with the palm
➢ CONTRAINDICATIONS
o Pregnancy (growing size of abdomen, may have
edematous legs and feet)
o Skin disease (lesions, vesicles, infection,
inflammation)
➢ Casting Materials:
o Plaster of Paris
o Synthetic materials
▪ Polyester/ cotton knit
▪ Fiberglass
▪ Thermoplasts
➢ APPLYING A PASTER CAST (CIRCULAR CAST
APPLICATION)
1. Check the doctor's order
2. Inform & prepare the patient for the procedure
3. Explain to the patient & his relative the need for placing
the affected part of the body in a cast
4. Cleanse
o If possible, a good cleansing bath & shampoo is
given to the pt
o The affected part is cleansed thoroughly w/ soap
& water then dried
o If there is a wound, have it dressed accordingly
5. Prepare all things needed for the application
6. Position the extremity (by the doctor)
7. Apply padding including the joints above & below the
fracture line w/ thicker pads on bony prominences
8. Soak the plaster cast into a bucket w/ water,
o Leave undisturbed until bubbles cease
9. Grasp both ends of the cast towards the center without
squeezing it
10. Free the end of the cast & hand it to the operator
11. Apply cast in circular motion
o until the whole area is covered & molding it,
during the process of application, by the palm
12. Handle the cast w/ care
➢ Handle the cast W/ CARE
o Avoid moving patients or transferring w/ wet cast
▪ Avoid moving patients or transferring w/ wet
cast
o The excess plaster cast is trimmed by means of a
trimming knife
▪ Cast spilled on the skin is easily removed
by wiping it with a damp cloth
o To hasten drying, several ways are used:
▪ exposure to open air / electric fan;
▪ exposure to a heat lamp; and
▪ placing the patient in warm room
o Protect the pt from rapid drying of the cast (this will
result to a dry outer layer while the inner layer
remains wet), preventing pneumonia to develop &
preventing body fluid loss from excessive sweating
o Complaints of discomfort should be investigated
▪ appropriate measures be given to bring
about comfort
o Patients in body / spica cast is turned every 4-6 hrs
▪ to promote even drying of the cast
o Edges that are extremely rough, should be trimmed
or smoothed very slightly with a cast knife
▪ Rough edges can be covered with adhesive
petals, esp. if there is no stockinette
underneath the plaster & sheet wadding
o The duration of keeping the body / part of it in cast is
at least one month (may vary among patients)
o Factors that influence the duration are:
▪ age of the patient
▪ part of the body affected
▪ the degree of injury or affection of the part
➢ NSG CARE ON PX ON CAST
During the entire per. that the patient is in cast, your
responsibility is focused on the ff:
o Neuro-vascular checks
▪ The color, motion, temperature & sensation
of toes / fingers should be observed every
30 minutes for several hours (longer if there
is much edema) and then regularly every 3
hours
o Circulatory impairment results in symptoms of
coldness, edema cyanosis, pain, & finally numbness
in the toes / fingers
o Pts in arm & leg cast should be able to move & feel
each toe / finger, because the same nerve does not
innervate each one
▪ All toes & fingers should be checked
o Preservation of the efficiency of the cast
o Maintenance & promotion of the integrity of the
system of the body
o Maintenance of the cleanliness of the cast
➢ TURNING PX IN CAST
o Turning casted trunk & lower extremities must be
done carefully
o The patient must be lifted & not rolled / dumped.
o Support should be provided to the encased part & the
whole body
o The first changing of the patient’s position depends
on the condition of the case & the body area involved
o The first turning usually is to dry the posterior surface
of the cast, provide comfort & protect patients against
respiratory complication
➢ POINTS TO REMEMBER
o After the cast removal, support the part w/ pillow,
maintaining the same position that existed in the cast
o Move the extremity gently
o Observe the skin for any abrasions & plaster sores
o Wash skin w/ mild soap followed by application of oil
and lanolin as prescribed
TYPES OF CAST
➢ Short arm cast
o Extends from below the elbow to the palmar crease,
secured around the base of the thumb.
o If the thumb is included, it is known as a thumb spica
or gauntlet cast
➢ Long arm cast
o Extends from the upper level of the axillary fold to the
proximal palmar crease.
o The elbow usually is immobilized at a right angle.
➢ Fuenster’s Cast
o Wrist and fingers with compound affection
o Radius/ ulna with callus formation
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➢ Long Arm posterior mold
o Radius/ ulna compound affection

➢ Body Cast
➢ Hanging Cast o Lower dorso-lumbar spine
o Shaft of the Humerus

➢ Rizzer’s Jacket
o Scoliosis

➢ Airplane
o Humerus & shoulder joint w/ compound affection

➢ Double hip spica

o Hip and femur

➢ Shoulder Spica
o Humerus & shoulder joint

➢ Double hip spica posterior mold

o Pelvic affection with Callus formation plus 2 femur

➢ Functional Arm Cast

o Humerus (allows abduction and adduction)

➢ 1 ½ hip spica
o Hip and femur

➢ Collar cast
o Cervical affection

➢ 1 ½ hip spica posterior mold

➢ Minerva o Hip and femur with compound fracture
o Upper dorsal cervical spine
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➢ Single hip spica
o Hip and one femur ➢ Basket cast
o Severe leg trauma w/ open wound or inflammation

➢ Posterior mold
o Pelvic bone fracture with Callus Formation

➢ Cylindrical leg cast

o Patella

➢ Pantalon Cast
o Pelvic bone fracture

➢ Quadrilateral / Ischial Bearing Cast

o Shaft of the femur w/ callus formation

➢ Frog cast

➢ Cast Brace
➢ Long leg cast o Fracture of the femur distal 3rd femur
o Tibia and fibula

➢ Long leg posterior mold

o Tibia and fibula compound affection ➢ Short leg cast
o Ankle and foot

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 DAY 3: Traction
TRACTION
➢ It is the act of pulling & drawing w/c is assd w/ counter traction.
➢ Purpose of traction
o To reduce fracture
o To reduce pain & muscle spasm
➢ PTB (Patellar-tendon bearing) o To provide immobilization
o Tibia and fibula w/ callus formation o To maintain good body alignment
o For support
o To prevent further deformity / correct deformity
➢ 3 BASIC TYPES OF TRACTION
1. Manual Traction
o The hands are used to exert a pulling force on the
bone w/c is to be realigned.
o Generally, this is reserved only for very stable
fractures or dislocations prior to splinting or
immobilization in a cast
➢ Delbit Cast o It also may be used prior to the application of skin or
o Tibia and fibula skeletal traction or surgical reduction
o the pulling force is applied by the hands of the
operator. It is a temporary measure sometimes
employed in handling neck injury when a cervical
spine is fractured. It is also used to apply the
necessary pull to an extremity when cast is being
applied

➢ Short Leg posterior mold

o Ankle and foot w/ compound affection

2. Skin Traction
o strips of tape, mole-skin, or other type of commercial
skin traction strips are applied directly to the skin
o Traction boots for leg traction & pelvic belts for spinal
disorders are included in ST
o Tx of children’s fractures & adult fractures /
dislocations that require only a moderate amt of
➢ Internal rotator splint pulling force for a relatively short period
o Post hip operation

o BRYANTS SKIN TRACTION (BST)

▪ Used for femoral fractures, Hip injuries
➢ Boot leg among kids below 3 y/o
o Hip and femoral fracture

➢ Night Splint
o OVERHEAD TRACTION
o Post polio
▪ Supracondylar fracture of the humerus

o BUCK’S EXTENSION
▪ Femur and hip affection
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 o HEAD HALTER TRACTION ▪ Proper position includes keeping the entire
▪ Cervical spine affection body in good alignment. Also, either a
o PELVIC GIRDLE TRACTION solid bottom bed or bed boards must be
▪ Lumbo-sacral affection, herniated nucleus used for all orthopedic patients
purpusus ➢ COUNTERTRACTION
o COTREL TRACTION o For any traction to be effective, there must be
▪ Indicated for scoliosis countertraction
o Traction & countertraction represent forces in
balance; for this reason, the patient should not have
his back raised more than 20 degrees
o No sitting up
➢ FRICTION
o Any type of friction will reduce the efficiency of
traction & hinder the pull. Implications for nsg care
include checking to see that:
▪ The spreader/footplate is not touching the
o HAMMOCK SUSPENSION TRACTION end of the bed
▪ Pelvic affection ▪ The weights are positioned at a reasonable
o Halo Pelvic traction level from the floor; a considerable distance
▪ Scoliosis below the pulley; hanging free of bed; &
o Halo Femoral Traction away fr the patient
▪ Severe scoliosis ▪ All knots are clear of the pulleys
o 90 degrees traction ▪ There is no impingement on the traction
▪ Fraction of the femur cord from bed clothes or any other
o Stove-in-chest-traction apparatus
▪ Severe chest injury with multiple rib ▪ The patient’s heels are not digging into the
fracture mattress
3. Special type of tractions
if any of these conditions are not being met, immediate corrective action is
a. Russel Traction – affection of the femur
indicated
b. Boot leg Cast Traction – Hip and Femural
affection ➢ CONTINUOUS
o In general, for traction to be effective, it should be
continuous
o NEVER remove it without a doctor’s order
➢ LINE OF PULL
o Once established correctly, the line of pull should be
maintained

PROTECTION OF THE CARDIOVASCULAR SYSTEM

4. Skeletal Traction
o Apply skeletal traction by placing a metal pin through
the metaphyseal portion of the bone & apply weight
to the pin
o The pulling force is applied directly to the bone using
pins & wires such as Kirshner's wire, Steinman's pin,
Vinki's skull retractor & crutch field tongs
o It is important to place the pin correctly to avoid injury
to vessels, nerves, joints & growth plates
➢ The nsg goals are to monitor orthostatic tolerance & prevent
venous stasis
o Instructing the patient in hourly ankle rotation, flexion
& extension exercises
o Avoiding / minimizing positions that causes external
pressure on venous walls such as knee gatching /
crossing legs
o Using (on physician order) anti-embolism stockings
or pneumatic sleeves
MAINTENANCE OF NEUROVASCULAR STATUS
➢ Regularly assessing neurovascular status with particular
attention to traction apparatus and pressure areas
➢ Changing the pt’s position w/in the limitations of the traction
every 2 - 4 hours
➢ Report any signs & symptoms of neurovascular compromise to
the attending physician

SKIN CARE
➢ Static positioning in traction cause pressure that impairs
capillary flow to the skin (may lead to tissue necrosis &
pressure sores)
➢ Assessing skin integrity over bony prominences and any areas
of the body which are covered by / attached to traction
apparatus
➢ Massaging potential pressure areas every 2 - 4 hrs.
➢ Using pressure relief devices or pressure relief bed
***If skin breakdown occurs, massage should be discontinued to prevent further
tissue damage

MAINTENANCE OF THE MUSCULOSKELETAL SYSTEM

➢ Have the pt perform regular isometric and/or isotonic exercises
PRINCIPLES: of uninvolved extremities & the involved extremities as
➢ POSITION prescribed by a physician
o The patient should be in the supine position (on ➢ Pulling his/her toes toward his/her nose while pushing his/her
his/her back) knee into the bed

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 ➢ Sitting up in bed and pushing his/her palms against the bed to Procedure phase
raise his/her buttocks off the bed 1. Attach rest splint to the Thomas splint with Pearson
➢ Allowing to perform as many daily activities as possible attachment. Upper part is the Thomas splint, which will support
o Immobility decreases muscle strength, impairs the thigh; lower part is the Pearson attachment w/c will support
skeletal strength, and limits joint mobility the leg
2. Measure the length of thigh rope to the thigh of the pt. Adjust
NOTE: NEVER IGNORE A PX’s COMPLAINTS!!!!!!! the Pearson attachment accdg to the length of the thigh of the
pt. Tie the short (thigh) rope to the medial upright portion of the
- This rule should be followed above everything else.
Thomas splint with slip knot
Traction systems can vary depends on the doctor o to provide privacy to the patient
3. Attach slings to the Thomas splint and Pearson attachment
BALANCED SKELETAL TRACTIONS
Preparation phase Principles in attaching the slings
➢ Check the physician's order ➢ Start from the longest (at least 2) to the Thomas splint and 3 to
➢ Inform & explain the purpose & procedure to the patient - for the Pearson
easy installation & cooperation during the procedure ➢ Smooth side should be touching the patient's skin
➢ Assemble all equipment ➢ Provide at least one to two inches apart between the slings for
➢ PREPARE TRACTION EQUIPMENTS ventilation
1. Orthopedic Bed ➢ It must not be too loose nor too tight enough to support and
follow the contour of the leg
➢ Provide space at the popliteal area to prevent irritation and
provide ventilation
4. Insert the apparatus to the affected leg
o Apply manual traction on the affected leg. Manual
traction should be released after the completion of the
traction weight.
o With the help of assistants - one applying the
manual traction, one lifting the affected leg, one
removing the Braun Bohler, coordinate your
movement. At the count of three, insert the ready
made Thomas splint to the affected leg. Synchronize
the procedure for patient's comfort.
o Instruct the patient to flex the unaffected leg and hold
on to the overhead trapeze.
o There should be continuous traction, so don't remove
the manual traction until the longer rope has been tied
to the Steinman pin or Kirchner's wire holder then to
the traction weight
5. Tie the longer rope on the Steinman’s pin holder with the use
2. Thomas Splint with Pearson attachment. of slip knot then insert the other end of the rope to the third
3. Rest splint pulley, then -tie the traction weight.
4. Slings of variable sizes o Check the groin (inguinal area) if resting on the half
5. Paper clips or safety pins ring - to prevent irritation
6. Ropes - different length 6. Tie the other end of the short rope to the lateral aspect of the
o Short - for the thigh Thomas splint
o Long - for the traction 7. Tie the longest rope to the middle of the short rope with slip
o longest - for the suspension knot. Insert it to the first pulley then hang the suspension
7. Weights and Bags weight, which is half the weight of the traction weight. Anchor
o Suspension weight – is 1/2 lighter than the weight of suspension weight, then insert the rope to the second pulley
the traction. 8. After the second pulley, tie it to the Thomas splint using the
o Traction weight – approximately 10% to of the clove hitch knot then to the Pearson Attachment. Before tying
patient’s body weight the rope to the Thomas splint & Pearson, be sure the rope is
8. Foot rest - to prevent foot drop inside the traction rope for support & prevent the affected leg
from swaying sideways
9. Release suspension weight
10. Apply foot support - using ribbon knot
11. Remove the rest splint
12. To check the efficiency of the traction:
13. Instruct the patient to flex his unaffected leg and hold on the
Overhead Trapeze and swing the affected leg with balanced
skeletal traction

PRINCIPLES OF SKELETAL TRACTION

➢ Position of the patient should be in Dorsal Recumbent or
Supine Position.
➢ Avoidance of friction.
o Weights should be hanging freely.
o Observe for signs of wear and tear on ropes and
bags.
o Rope should run freely along the grove of the pulley.
o Knots should be away from the pulley

REMOVAL OF TRACTION:
1. Attach the rest splint.
2. Anchor the suspension weight.
3. Remove suspension rope.
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 4. Apply manual traction.
5. Remove traction weight, then tie the rope to the rest splint,
Thomas and Pearson using the clove hitch. Patient is ready for
transfer to the stretcher.
6. Instruct the patient to flex his unaffected leg while holding on
the trapeze. Help him slowly to the stretcher.

NURSING CARE OF PX WITH TRACTION

1. Assessment - assess the patient as to level of understanding,
consciousness.
2. Provision of general comfort;
a. skin care - head to toe, focus on the sponging of the
affected extremity
b. Changing of linen
c. Provide bedpan as needed. Serve bedpan on the
unaffected side, provide pillow at the back and
provide privacy.
d. Perineal care.
3. Potential complication
a. Upper respiratory - PNEUMONIA –bronchial tapping
and deep breathing.
b. Bedsore - good perineal. care, proper skin care,
turning left buttocks once in a while.
c. Urinary and kidney problem - good perineal care,
increase fluid intake.
d. Bowel complications – fear of apparatus, no privacy,
lack of fluids, perineal care.
e. Pin site infection - observe for S/S of infection,
loosening pin tract, pus coming out, foul smelling,
fever.
f. Deformity - contracted knee, atrophy of muscles, foot
drop, joint contractures.
4. Provision of Exercises
a. ROM exercises with the use of trapeze.
b. Deep breathing exercises
c. Static quadriceps exercises, alternate contractions &
relaxation of quadriceps muscles
d. Toes pedal exercises
5. Nutritional Status - depending on the status of patient.
6. Psychological Aspect - fear of unknown, fear of death, fear of
the apparatus, fear of losing job financial fear.
7. Provision of supportive therapy: Offer book to read; something
to listen radio or T.V., discover interest
8. Spiritual Aspect - Know his religion, encourage relatives to give
spiritual, communication, visiting chaplain

BRACES
➢ An orthosis or orthopedic appliance that supports or holds in
correct position any movable part of the body and that allows
motion of the part, in contrast to a splint, which prevents motion
of the part

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 DAY4: Neurological Assessment
Promotes swallowing, talking, and
production of digestive juices
XI Spinal Motor Innervates neck muscles
12 CRANIAL NERVES Accessory (sternocleidomastoid and trapezius)
O-hh O-hh O-hh T-o T-ouch A-nd F-eel A G-irls V-agina S-o H-eaven that promote movement of the
shoulders and head rotation
# CRANIAL NERVE TYPE OF FUNCTION Promotes some movement of the
larynx
IMPULSE
XII Hypoglossal Motor Innervates tongue muscles that
I Olfactory Sensory Carries smell impulses from nasal promote the movement of food and
mucous membrane to brain talking
II Optic Sensory Carries visual impulses from eye to
brain
Visual Acuity, Visual Fields, ASSESSMENT
Fundoscopic Exam
III Oculomotor Motor Contracts eye muscles to control CN I – OLFACTORY NERVE
eye movements (interior lateral, ➢ Have client sit in a comfortable position at your eye level
medial, and superior), constricts ➢ Ask the client to clear the nose to remove any mucus
pupils, and elevates eyelids ➢ Close eyes, occlude one nostril, and identify a scented object
that you are holding such as soap, coffee, or vanilla
Cardinal Field of gaze (EOM), ➢ Repeat procedure for the other nostril
eyelid elevation, pupil reaction, ➢ NORMAL
doll’s eye phenomenon o Client correctly identifies scent presented to each
IV Trochlear Motor Contracts one eye muscle to control nostril
inferomedial eye movement EOM o Some older clients’ sense of smell may be decreased
Carries sensory impulses of pain, ➢ ABNORMAL
touch, and temperature from the o Neurogenic Anosmia
face to the brain ▪ inability to smell or identify the correct scent
▪ May indicate:
Influences clenching and lateral jaw • olfactory tract lesion
V Trigeminal Sensory/ movements (biting, chewing) • frontal lobe tumor
Motor • congenital, nasal or sinus
Motor: Strength of temporalis and problems
masseter muscles • nerve tissue injury
• smoking and use of cocaine
Sensory: light touch, superficial
pain and temperature to face, CN II – OPTIC
corneal reflex ➢ Use a Snellen chart to assess vision in each eye
VI Abducens Motor Controls lateral eye movements ➢ Ask the client to read a newspaper or magazine paragraph to
Sensory: assess near vision
Taste, anterior 2/3 of tongue ➢ Assess visual fields of each eye by confrontation
Stimulates secretions from salivary ➢ Use an ophthalmoscope to view the retina and optic disc of
glands (submaxillary and each eye
VII Facial Sensory/ sublingual) Visual Acuity
Motor Stimulates tears from lacrimal ➢ NORMAL
glands o Client has 20/20 vision OD (right eye) and OS (left
eye) – (distance vision)
Motor: ➢ ABNORMAL
Facial movement o difficulty reading Snellen chart
Facial expressions (smiling, o missing letters
frowning, closing eyes) o squinting
Contains sensory fibers for hearing Near Vision
and balance ➢ NORMAL
o reads print at 14 inches without difficulty
VIII Acoustic/ Sensory Cochlear o until the patient is in the late 30s to the late 40s,
Vestibuloco- Gross hearing, Weber and Rinne reading is generally possible at a distance of 14
chlear tests inches
➢ ABNORMAL
Vestibular o reads print by holding closer than 14 inches or holds
Vertigo, equilibrium, nystagmus print farther away as in presbyopia, which occurs with
IX Glossopha- Sensory/ Sensory aging
ryngeal Motor Taste, posterior 1/3 of tongue Visual Fields
Sensory fibers of the pharynx that ➢ NORMAL
result in the gag reflex when o Normal peripheral vision
stimulated ➢ ABNORMAL
o Loss of visual fields may be seen in
Motor ▪ retinal damage or detachment lesions of the
Provides secretory fibers to parotid optic nerve lesions of the parietal cortex
salivary glands
Promotes swallowing movements
X Vagus Sensory/ Carries sensations from the throat,
Motor larynx, heart, lungs, bronchi,
gastrointestinal tract, and
abdominal viscera

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Retina & Optic Disc by Ophthalmoscope
➢ NORMAL
o Optic disc ➢ Tell the client: “I am going to touch your
▪ 1.5 mm forehead, cheeks, and chin with the
▪ round or slightly oval sharp or dull side of this paper clip.
▪ well-defined margins Please close your eyes and tell me if
▪ creamy pink with paler physiologic cup you feel a sharp or dull sensation. Also
o Retina tell me where you feel it”. Vary the
▪ Pink sharp and dull stimulus in the facial
➢ ABNORMAL areas and compare sides. Repeat test
o Papilledema for light touch with a wisp of cotton
o Optic atrophy
CN III, IV, VI – OCULOMOTOR, TROCLEAR, ABDUCENS Test corneal reflex
➢ Inspect margins of the eyelids of each eye ➢ Ask the client to look away and up while you lightly touch the
➢ Assess extraocular movements cornea with a fine wisp of cotton. Repeat on the other side.
➢ Assess pupillary response to light (direct and indirect) and Testing motor function
accommodation in both eyes ➢ NORMAL:
o Temporal and masseter muscles contract bilaterally
➢ ABNORMAL:
o Decreased contraction in one of both sides
o Asymmetric strength in moving the jaw may be seen
with lesion or injury of the 5th cranial nerve
o Pain occurs with clenching of the teeth
Testing Sensory Function
➢ NORMAL:
o Correctly identifies sharp and dull stimuli and light
touch to the forehead, cheeks, and chin
➢ ABNORMAL
o Inability to feel and correctly identify facial stimuli
▪ lesions of the trigeminal nerve
➢ NORMAL ▪ lesions in the spinothalamic tract or
o Eyelid covers about 2mm of the iris posterior columns
o Eyes move in a smooth, coordinated motion in all Testing Corneal reflex
directions (the six cardinal fields) ➢ NORMAL:
o Bilateral illuminated pupils constrict simultaneously o Eyelids blink bilaterally
o Pupil opposite the one illuminated constricts ➢ ABNORMAL
simultaneously o Absent corneal reflex
➢ ABNORMAL ▪ lesions of the trigeminal nerve
o Ptosis (drooping of the eyelid) is seen with weak eye ▪ lesions of the motor part of cranial nerve VII
muscles (facial)
▪ myasthenia gravis
o Possible causes of abN eye movements CN VII – FACIAL
▪ cerebellar disorders
Test motor function
▪ increased ICP
➢ Smile
▪ paralytic strabismus ➢ Frown and wrinkle forehead
o Possible causes of pupil abnormalities
➢ Show teeth
▪ oculomotor nerve paralysis ➢ Puff out cheeks
▪ Argyll Robertson pupils
➢ Purse lips
▪ narcotics abuse ➢ Raise eyebrows
▪ CN III damage
➢ Close eyes tightly against resistance
▪ lesions of the sympathetic nervous ➢ NORMAL:
system
o smiles, frowns, wrinkles forehead, shows teeth, puffs
▪ PNS or CNS dysfunction out cheeks, purses lip, raises eyebrows, and closes
▪ CN V lesion
eyes against resistance
o movements are symmetric
CN V – TRIGEMINAL ➢ ABNORMAL:
Test Motor Function o Inability to close eyes, wrinkle forehead, or raise
➢ Ask the client to clench the teeth while you palpate the forehead along with paralysis of the lower part of the
temporal and masseter muscles for contraction face on the affected side
▪ Bell’s palsy
o Paralysis of the lower part of the face on the opposite
side affected may be seen with a central lesion that
affects the upper motor neurons
▪ Stroke

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Test sensory function
➢ Not routinely tested, if testing is indicated, however, touch the
anterior two-thirds of the tongue with a moistened applicator
dipped in salt, sugar, or lemon juice
➢ ask the client to identify the flavor
➢ If the client is unsuccessful, repeat the test using one of the
other solutions
➢ If needed, repeat the test using the remaining solution
➢ NORMAL:
o Identifies correct flavor
➢ NORMAL:
➢ ABNORMAL
o Symmetric
o Inability to identify flavor on anterior two-thirds of the
o Strong contraction of the trapezius muscles
tongue
➢ ABNORMAL:
▪ Impairment of cranial nerve VII
o Asymmetric muscle contraction or drooping of the
shoulder
CN VIII – ACOUSTIC / VESTIBULOCOCHLEAR ▪ paralysis or muscle weakness due to neck
➢ Test the client’s hearing ability in each ear and perform the injury or torticollis
Weber and Rinne tests to assess the cochlear (auditory) ➢ Ask the client to turn the head against resistance, first to the
component of cranial nerve VIII right then to the left, to assess the sternocleidomastoid muscle
➢ NORMAL:
o strong contraction of sternocleidomastoid muscle on
the side opposite the turned face
➢ ABNORMAL:
o Atrophy with fasciculations may be seen with
peripheral nerve disease

CN XII – HYPOGLOSSAL
Assess strength and mobility of tongue
➢ NORMAL:
➢ Ask the client to protrude tongue, move it to each side against
o Client hears whispered words from 1–2 feet
the resistance of a tongue depressor, and then put it back in
o Weber test: Vibration heard equally well in both ears
the mouth
o Rinne test: AC > BC
➢ NORMAL:
➢ ABNORMAL
o Tongue movement is symmetric and smooth, and
o Vibratory sound lateralizes to good ear in
bilateral strength is apparent
sensorineural loss
➢ ABNORMAL:
o Air conduction is longer than bone conduction
o Fasciculations and atrophy of the tongue
▪ peripheral nerve disease
CN IX, X – GLOSSOPHARYNGEAL, VAGUS o Deviation to the affected side
Test motor function ▪ unilateral lesion
➢ Ask the client to open mouth wide and say “ah” while you use
a tongue depressor on the client’s tongue
➢ NORMAL: LEVEL OF CONSCIOUSNESS
o Uvula and soft palate rise bilaterally and
ALERT
symmetrically on phonation
- Follows commands in a timely fashion
➢ ABNORMAL
LETHARGIC
o Soft palate does not rise
- Appears drowsy, may drift off to sleep during examination
▪ bilateral lesions of cranial nerve X (vagus)
STUPOROUS
o Unilateral rising of the soft palate and deviation of
- Requires vigorous stimulation (shaking, shouting) for a
the uvula to the normal side
response
▪ unilateral lesion of cranial nerve X (vagus)
COMATOSE
Test gag reflex
- Does not respond appropriately to either verbal or painful
➢ touch the posterior pharynx with the tongue depressor
stimuli
➢ NORMAL:
o Gag reflex intact
o Some normal clients may have a reduced or absent GLASSGOWS COMA SCALE
gag reflex May 3 parameters na tinitingnan dito sa Glassgows Coma Scale.
➢ ABNORMAL: Eye- 4
o An absent gag reflex
▪ lesions of cranial nerve IX Verbal - 5
(glossopharyngeal) or X (vagus) Motor – 6

Check ability to swallow

➢ Giving the client a drink of water Note the voice quality also
➢ NORMAL:
o Swallows without difficulty
o No hoarseness noted
➢ ABNORMAL:
o Dysphagia or hoarseness
▪ lesion of cranial nerve IX
(glossopharyngeal) or X (vagus)
neurologic disorder

CN XI – SPINAL ACCESSORY
➢ Ask the client to shrug the shoulders against resistance to
assess the trapezius muscle
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FROM PPT OF MAAM LINA:
EYE OPENING RESPONSE:
Spontaneous Opening 4
To Verbal Command 3
To Pain 2
No Response 1

MOST APPROPRIATE VERBAL RESPONSE

Oriented 5
Confused 4
Inappropriate Words 3
Incoherent 2
No Response 1

MOST INTEGRAL MOTOR RESPONSE (ARM)

Obeys Verbal Commands 6
Localized Pain 5
Withdraws From Pain 4
Flexion (decorticate rigidity) 3
Extension (decerebrate rigidity) 2
No Response 1

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 NEUROLOGICAL PROBLEMS ➢ Strike your thumb with the pointed side of the reflex hammer
AGNOSIA Repeat on the other side
- Visual Agnosia Tactile Agnosia Auditory Agnosia ➢ Evaluates the function of spinal levels C5 and C6
ASTEREOGNOSIS
- Inability to correctly identify objects
AKINESIA
- Complete or partial loss of voluntary muscle movement
APHASIA
- Absence or impairment of ability to communicate through
speech, writing, or signs
APRAXIA
- Inability to carry out learned sequential movements or
commands ➢ NORMAL
CIRCUMLOCUTION o Elbow flexes and contraction of the biceps muscle
- Inability to name object verbally, so patient talks around object o Ranges from 1+ to 3+ Forearm flexes and supinates
or uses gesture to define it o Ranges from 1+ to 3+
DYSARTHRIA ➢ ABNORMAL
- Defective speech; inability to articulate words; impairment of o No response or an exaggerated response
tongue and other muscles needed for speech
DYSPHASIA TRICEPS REFLEX
- Impaired or difficult speech ➢ Ask client to hang arm freely
DYSPHONIA support it w/ non-dominant hand
- Difficulty with quality of voice; hoarseness ➢ Find tendon above the olecranon
NEOLOGISMS process
- Made-up, nonsense, meaningless words ➢ Tap it with the hammer (flat)
PARAPHRASIA Repeat on the other side
- Loss of ability to use words correctly and coherently; words are ➢ Evaluates the function of spinal
jumbled or misused levels C6, C7, and C8
TREMORS ➢ NORMAL:
- Involuntary movement of part of body o Knee extends, quadriceps
INTENSION TREMOR muscle contracts
- Involuntary movement when attempting coordinated o Ranges from 1+ to 3+
movements ➢ ABNORMAL:
FASCICULATION o No response or
- Involuntary contraction or twitching of muscle fibers exaggerated response

REFLEXES PATELLAR REFLEX

➢ Both legs hang freely off the side of the examination table
➢ Find the patellar tendon (below patella)
➢ Strike with hammer (flat)
➢ Repeat on the other side
➢ Gently flex the knee and strike the patella (client’s who cannot
sit up)
➢ Evaluates the function of spinal levels L2, L3, and L4

BRACHIORADIALIS REFLEX
➢ Flex elbow with palm down Find the tendon above the radius
(usually 2 inch above the wrist) Strike with the hammer (flat) ➢ NORMAL:
Repeat on the other side Evaluates spinal levels C5 & C6 o Plantarflexion of the foot
o Ranges from 1+ to 3+
➢ ABNORMAL:
o No response or exaggerated

➢ NORMAL:
o Elbow extends, triceps contracts Ranges from 1+ to
3+
➢ ABNORMAL:
o No response or an exaggerated response
BICEPS REFLEX
➢ Partially bend arm at elbow with palm up
➢ Place your thumb over the biceps tendon

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 ACHILLES REFLEX ➢ NORMAL
➢ Both legs hang freely off the side o Hips and knees remain relaxed and motionless
of the examination table, dorsiflex ➢ ABNORMAL
the foot o Pain and flexion of the hips and knees are positive
➢ Strike the Achilles tendon with Brudzinski’s sign
hammer (flat)
➢ Repeat on the other side
➢ Flex one knee and support that
leg against the other leg, dorsiflex
the foot, tap the tendon using the
flat side (client’s who cannot sit
up)
➢ Evaluates the function of spinal
levels S1 and S2
➢ NORMAL:
o In some older clients,
the Achilles reflex may be absent or difficult to elicit
➢ ABNORMAL
o No response or exaggerated

PLANTAR REFLEX
➢ Stroke lateral aspect of the sole from KERNIG’S SIGN
heel to ball of foot ➢ Flex the client’s leg at both hip and the knee, then straighten
➢ Use the end of the hammer the knee
➢ Repeat on the other side ➢ NORMAL
➢ Evaluates the function of spinal levels o No pain is felt
L4, L5, S1, and S2 ➢ ABNORMAL
➢ NORMAL o Pain and increased resistance to extending the knee
o Flexion of toes are (+) Kernig’s sign
➢ ABNORMAL o When bilateral = suspect meningeal irritation
o Toe adduction – (+)
BABINSKI

ABDOMINAL REFLEX
➢ Lightly stroke the abdomen on each side, above and below
the umbilicus
➢ Evaluates the function of spinal levels T8, T9, and T10 with
the upper abdominal reflex
➢ Spinal levels T10, T11, and T12 with the lower abdominal
reflex
➢ NORMAL
o Abdominal muscles contract; the umbilicus deviates
toward the side being stimulated
o Reflex concealed because of obesity or muscular
stretching from pregnancies NEVER BACK DOWN NEVER WHAT??!! Emzzz goodluck future RN
➢ ABNORMAL
- Lei
o Superficial reflexes may be absent with lower or
upper motor neuron lesions

CREMASTERIC REFLEX
➢ Lightly stroke the inner aspect of the upper thigh
➢ Evaluates the function of spinal levels T12, L1, and L2
➢ NORMAL
o Scrotum elevates on stimulated side
➢ ABNORMAL
o Absence of reflex may indicate motor neuron
disorder
TEST FOR MENINGEAL IRRITATION
Supine
➢ Place hands behind the patient’s head and flex the neck
forward until the chin touches the chest
➢ NORMAL
o Neck is supple; client can easily bend head and
neck forward
➢ ABNORMAL
o Pain in the neck and resistance to flexion can arise
from meningeal inflammation, arthritis, or neck injury

BRUDZINSKI’S SIGN
➢ As you flex the neck watch the clients hips and knees in
reaction to your maneuver

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