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NURS3313 Adult Health > Chapter 37 Management of Patients w/ Musculoskeletal Trauma > Flashcards

Chapter 37 Management of Patients w/ Musculoskeletal Trauma Flashcards

1
Q

Simple (Closed) Fracture

A

Damage to the surrounding tissues but, no skin breakage

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2
Q

Open (Compound) Fracture

A

Broken bone penetrates through the skin

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3
Q

Type I Compound/ Complex Fracture

A

Clean wound < 1 cm long w/ simple fracture pattern

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4
Q

Type II Compound/ Complex Fracture

A

Larger wound w/ minimal soft tissue damage
- No flaps or avulsions

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5
Q

Type III Compound/ Complex Fracture

A

MOST SEVERE!!!!

Highly contaminated & has extensive soft tissue damage
- Involves vascular injury or possibly traumatic amputation

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6
Q

Compression Fracture

A

Occurs when the bone is pressed together (compressed) on itself

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7
Q

Impacted Fracture

A

Fracture in which one bone fragment is pushed into another

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8
Q

Oblique Fracture

A

Fracture at an angle to the bone

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9
Q

Spiral Fracture

A

A fracture in which the bone has been twisted apart

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10
Q

Stress Fracture

A

A small crack in the bone that often develops from chronic, excessive impact

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11
Q

Intra-Articular Fracture

A

Fracture that extends into joint surface of a bone

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12
Q

Fracture Causes

A

Caused by direct blows, crushing forces, sudden twisting
motions, and extreme muscle contractions

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13
Q

Clinical Manifestations of Fractures

A

Acute pain

Loss of function

Deformity

Shortening

Crepitus

Localized edema and ecchymosis

Diagnosis by symptoms and radiography

Patient usually reports an injury to the area

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14
Q

Emergency Management of Fractures

A

Immobilization via splinting or bandaging

Neurovascular assessment to determine adequacy of peripheral tissue perfusion and nerve function

Open fractures: cover with sterile dressing to prevent contamination of deep tissues

-No attempt to reduce fracture

-Splints applied for immobilization

In ED, remove clothing from uninjured side, then injured side; maybe cut away

-Move injured extremity as little as possible to prevent further damage

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15
Q

Medical Management of Fractures

A

Fracture reduction: restoration of the fracture fragments to anatomic alignment and positioning

Closed: Uses manipulation and manual traction

-Traction may be used (skin or skeletal)

Open:Internal fixation devices hold bone fragment in position (metallic pins, wires, screws, plates)

Immobilization

-External (cast, splints) or internal fixation

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16
Q

Closed Reduction

A

Brings the bone fragments into anatomic alignment via manipulation or manual traction

Extremity is held in the aligned position while, cast, splint, or other device is applied
- Immobilizing device maintains the reduction & stabilizes the extremity for bone healing

X-rays are obtained after reduction to verify that the bone fragments are properly aligned

Traction may be used

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17
Q

Open Reduction

A

Bone fragments are anatomically aligned via surgical approach

Internal fixation devices may be used to hold the bone fragments in position until solid bone healing occurs
- Metallic Pins
- Wires
- Screws
- Plates
- Nails
- Rods

These devices may be used to attach to side of bone or inserted through bony fragments or directly into medullary cavity of the bone

Internal fixation devices ensure firm approximation & fixation of bony fragments

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18
Q

Immobilization

A

After fracture has been reduced, the bone fragments must be immobilized & maintained in proper position & alignment until union occurs
- May be accomplished via external or internal fixation
- External fixation: bandages, casts, splints, continuous traction & external fixators

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19
Q

Nursing Management of Fractures: Maintaining & Restoring Function

A

Reduction and immobilization

Elevating injured extremity and applying ice as
prescribed

Neurovascular assessment
- Notify provider IMMEDIATELY if signs of neurovascular compromise develop

Reassurance, position changes, and pain relief
strategies, including use of analgesics

Isometric and muscle setting exercises

Participation in ADLs

Gradual resumption of activities

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20
Q

Nursing Management of Closed Fractures

A

Patient education:

-Reducing edema and pain

-Proper exercises and use assistive devices

-Home environment modification, if necessary

-Safety and self-care

-Medication information

-Monitoring for potential complications and need for follow up care and supervision

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21
Q

Nursing Management of Open Fractures

A

Risk for osteomyelitis, tetanus, and gas gangrene

Objective is to prevent infection

Minimize edema

Frequent pain & neurovascular assessments

Maintain proper alignment

Monitor for complications

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22
Q

Factors that Inhibit Fracture Healing

A

Age > 40 years

Avascular necrosis: No blood flow to bones-> bone tissue dies

Bone loss

Cigarette smoking

Comorbidities (e.g., diabetes,
rheumatoid arthritis)

Corticosteroids, NSAIDs

Extensive local trauma

Inadequate immobilization

Infection

Local malignancy

Malalignment of the fracture fragments

Space or tissue between bone fragments

Weight bearing prior to approval

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23
Q

Avascular Necrosis

A

A disease caused by the temporary or permanent loss of blood supply to bones (bone lacking blood can collapse and die)

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24
Q

Fat Embolism Syndrome (FES)

A

Classic Triad: hypoxemia, neurological compromise, petechial rash 2 days

Fat globules released into bloodstream, travel to lungs and brain, cause ischemia and inflammation

–Also be deposited on kidney and retina

Critical period: 24-72 hrs. after injury

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25
Q

Disseminated intravascular coagulation (DIC)

A

Abnormal blood clotting in small vessels throughout the body that cuts off the supply of oxygen to distal tissues, resulting in damage to body organs

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26
Q

Compartment Syndrome

A

Involves the compression of nerves and blood vessels due to swelling w/in the enclosed space created by the fascia that separates groups of muscles

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27
Q

Compartment Syndrome Monitoring

A

Associated with a tight or rigid cast/splint that constricts a swollen limb

Most serious complication of casting and splinting

Pain is relentless and not controlled by common modalities

Ischemia and potential irreversible damage to soft tissue can occur w/in a few hours if action is not taken Pulselessness, paresthesia, and complete paralysis are late stages

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28
Q

Nursing Interventions for Compartment Syndrome

A

Loosen ace wraps, compression dressings, splints and uni- or bivalving casts

Maintain limb alignment; emergency surgical fasciotomy may be necessary

Frequent neurovascular checks; promptly report changes to provider

Negative-pressure wound therapy

Monitor output, maintain prescribed pressure, and occlusive dressing

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29
Q

Acute Compartment Syndrome

A

Most serious complication of casting & splinting

Occurs when increased pressure w/in confined space (cast, splint) compromises blood flow & tissue perfusion
- Tight/ rigid cast that constricts a swollen limb is associated w/ this complication

Ischemia & potentially irreversible soft tissue damage w/in space can occur w/in couple of hours if action is not taken

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30
Q

Nursing Interventions for Acute Compartment Syndrome

A

If complication is due to a cast/splint being too tight, loosen or remove the splint; Univalve/ bivalve the cast to release constriction & allow for inspection of the skin
- Cast saw is used (uses vibration to cut the cast)

Extremity must be elevated no higher than heart level to maintain arterial perfusion

If pressure & circulation are not relieved, an emergent surgical fasciotomy may be necessary

Monitor & record frequent NV checks

Report changes to provider

31
Q

Univalved Cast

A

Split cast on only 1 side

32
Q

Bivalved Cast

A

2 splits in the cast

33
Q

Delayed Union

A

Prolongation of expected healing time for a fracture

34
Q

Nonunion

A

Failure of the bone ends to grow together

35
Q

Complex Regional Pain Syndrome (CRPS)

A

Disorder of the SNS typically triggered by a surgery or trauma, resulting in pseudomotor and vasomotor changes and disproportionate pain beyond the region of the surgery or injury

36
Q

Heterotopic Ossification

A

Misplaced formation of bone

37
Q

Cast

A

Used to immobilize a reduced fracture, correct or prevent a deformity, apply uniform pressure to underlying soft tissue, or support and stabilize weakened joints

Fit the shape of the injured limb correctly to provide the best support

Permits mobilization of patient while restricting movement of affected body part

38
Q

Short Arm Cast

A

Extends from below the elbow into the palmar crease, secured around the base of the thumb

39
Q

Long Arm Cast

A

Extends from the axillary fold to the proximal palmar crease

Elbow is usually immobilized at a right angle

40
Q

Short Leg Cast

A

Extends from below the knee to the base of the toes

Foot is flexed at a right angle in a neutral position

41
Q

Long Leg Cast

A

Extends from the junction of the upper & middle 1/3 of the thigh to the base of the toes

Knee may be slightly flexed

42
Q

Walking Boot/Cast

A

Protects & supports the foot, ankle, or lower leg by controlling the alignment & reducing movement

Support the user’s weight while walking

43
Q

Body Cast

A

Encircles the trunk

44
Q

Splint

A

Preferred method of fracture immobilization in the acute care setting and initial treatment of fractures

Faster and easier to apply; easily removed, facilitating inspection of the injury site

Often used for simple and stable fractures, sprains, tendon injuries, and other soft tissue injuries.

Can be indicated to provide initial stability for fractures that are unstable while awaiting definitive care

45
Q

Nursing Management of Casts, Splints, or Braces

A

Before cast, splints, or braces are applied, nurse completes an assessment:
- General health
- Presenting s/s
- Emotional status
- Understanding need for the device
- Condition of the body part to be immobilized

Skin lacerations & abrasions secondary to trauma must be taken care of before device is applied
- Thoroughly cleanse & treat the skin as prescribed

NV checks every hour for 1st 24 hrs
- Every 1-4 hrs after for signs of nv compromise

Watch for 5 P’s of NV Compromise!!

NEVER IGNORE c/o pain!!! If pain is unrelieved by analgesics, report IMMEDIATELY to provider!!!
- To avoid avascular necrosis, neuromuscular damage, or possible paralysis

46
Q

Brace

A

Custom-fitted, tend to be indicated for longer-term use than splints

Adjusted for fit, positioning, and motion so that movement is enhanced, any deformities corrected, and discomfort minimized

47
Q

Nursing Assessments for Fractures

A

General Health Assessment
 Signs and symptoms
 Emotional status
 Understand need for device
 Condition of body part to be immobilized

Educational Needs
 Condition, purpose, and expectations of treatment regimen
 Application of cast, splint, or
brace

Physical assessment
 Skin assessment
 Degree and location of swelling, bruising and skin abrasions
 Neurovascular status
 Main concern following application of immobilization device
 Prevention of neurovascular dysfunction or compromise of the affect extremity
 Performed every hour at least for
first 24hrs, then every 1-4hrs
thereafter

48
Q

Nursing Interventions for Fractures

A

Explain what to expect during cast removal

Instruct patient to avoid rubbing and scratching the skin

Patient education on resuming activities and how to control swelling

Upper extremities:
 Suggest devices designed to aid one-handed activities
 Remove arm from sling and elevate frequently
 Prevent complications with surveillance and proper care
 Acute compartment syndrome or Volkmann ischemic contracture

Lower extremities:
 Cold therapy or ice packs as prescribed for 1-2 days
 Elevate immobilized leg when seated
 Toe and ankle exercise for isometric contraction of muscles beneath cast
 In collaboration with PT, instruct patient how to transfer and ambulate
safely with assistive devices (e.g., crutches, walker)

49
Q

Monitor for Pressure Ulcers

A

Patient reports very pain”hot spot” or tightness

Drainage stain on cast/splint w/unpleasant odor

Univalve, bivalve or window by provider to assess development

50
Q

Monitor for Disuse Syndrome

A

Deterioration of body systems resulting from prescribed or unavoidable MS inactivity

Isometric exercises can prevent this; should be performed hourly while awake

51
Q

Traction

A

The application of pulling force to a part of the body

52
Q

Traction Indications & Purposes

A

Purposes:
 Reduce muscle spasms
 Reduce, align, and immobilize fractures
 Reduce deformity
 Increase space between opposing forces

Used as a short-term intervention until other modalities are possible

All traction needs to be applied in two directions. The
lines of pull are “vectors of force.” The result of the
pulling force is between the two lines of the vectors of
force.

53
Q

Principles of Effective Traction

A

Must be continuous to be effective in reducing and
immobilizing fractures

Skeletal traction is NEVER interrupted

Weights not removed unless intermittent traction
is prescribed

Must eliminate any factor that might reduce the
effective pull or alter the resultant line of pull

Patient must be in good body alignment in the center of the bed when applied

Ropes must be unobstructed

Weights must hang freely and not rest on the bed
or floor

Knots in the rope or the footplate must not touch
the pulley or the foot of the bed

54
Q

Skin Traction

A

Pulling mechanisms are attached to skin with adhesive material or elastic bandage (Buck’s extension traction)

55
Q

Skeletal Traction

A

The most effective means of traction, applying to a bone with wire pins or tongs

56
Q

Buck’s Extension Traction

A

Skin traction to the lower leg

Pull is exerted in one plane when partial or temporary immobilization is desired

Used as a temporary measure to overcome muscle spasms & promote immobilization of hip fractures in adult patients waiting for more definitive treatment (surgery)

Extremity is elevated & supported under patient’s heel & knee while foam boot is placed under the leg (patient’s heel is in heel of boot)
- Weights should hang freely

57
Q

Nursing Intervention for Buck’s Traction

A

Avoid wrinkling and slipping of the traction bandage

Maintain countertraction and proper position

Monitor for complications

-Skin breakdown

-Nerve damage

-Circulatory impairment

Circulatory assessment 15-30mins after traction is applied, then q1-2hrs

58
Q

Nursing Interventions for Traction: Monitor & Manage Possible Complications from Immobilization

A

Atelectasis & Pneumonia
- Lung assessments every 4-8 hrs
- Coughing & deep breathing exercises
- Use of incentive spirometry

Constipation & Anorexia
- High fiber diet & fluids stimulate gastric motility
- Minimize/avoid loss of appetite by including food preferences w/in the prescribed therapeutic diet
- Stool softeners, laxatives, suppositories, or enemas may be needed if constipation develops

Urinary Stasis & Infection
- Monitor I/O, characteristics of urine, adequate hydration & void every 3-4 hrs
- Notify provider s/s of infection

Venous Thromboembolism (VTE)
- Promote ankle exercises w/limits of traction therapy every 1-2 hrs when awake
- Encourage fluid intake

59
Q

Nursing Interventions for Traction Complications: Skin Breakdown

A

During initial assessment, watch for sensitive fragile skin
- Common in older adults

Inspect the skin area in contact w/ tape, foam, or shearing forces at least every 8 hrs for signs of inflammation or irritation

Remove foam boots to inspect the skin, ankle, & the Achilles tendon at least 2X a day
- 2nd person is req to support the extremity during inspection & skin care

Palpate the area of traction tapes daily to detect underlying tenderness

Frequent repositioning to alleviate pressure & discomfort
- Patient in supine position is at elevated risk for pressure injury

Use an advanced static mattress or overlays to prevent development of pressure injury

60
Q

Nursing Interventions for Traction: Nerve Damage Complications

A

Skin traction can place pressure on peripheral nerves
- Avoid pressure on peroneal nerve at the point where it passes around the neck of the fibula, below the knee where traction is applied

Pressure at this point can cause foot drop

Regularly question the patient about sensation & ask them to move their toes & feet

IMMEDIATELY investigate c/o BURNING sensation under traction bandage or boots

Weakness of dorsiflexion or foot movement or inversion of the foot -> pressure on the common peroneal nerve

PROMPTLY REPORT altered sensation or impaired motor function

61
Q

Nursing Interventions for Skeletal Traction

A

Preventing skin breakdown

Monitor neurovascular status

Provide pin site care

Promoting exercise

62
Q

The nurse NEVER removes the weights from skeletal traction UNLESS…

A

…a LIFE-THREATENING event occurs

Removing the weights defeats their purpose & may result in patient injury

63
Q

Nursing Interventions for Both Types of Traction

A

Pain management

Prevent pressure injuries

Assess for anxiety

Assist with self-care

Monitor and manage potential complications associated w/immobility:

-Atelectasis and Pneumonia

-Constipation and Anorexia

-Urinary stasis and infection

-Venous Thromboembolism (VTE)

64
Q

Trapeze

A

Overhead assistive device to promote patient mobility in bed

65
Q

Amputation

A

May be congenital or traumatic or caused by conditions
such as progressive peripheral vascular disease, infection, malignant tumor, trauma

Performed to control pain or disease process, improve
function, and improve quality of life

Objective is to conserve as much limb length as needed to preserve function and possibly to achieve a good
prosthetic fit

Health care team needs to communicate a positive attitude to facilitate patient acceptance and participation in rehabilitation

66
Q

Nursing Care Before Amputation Surgery

A

Assess:
- Function and condition of residual limb in traumatic
amputations
- Circulatory status and function on the unaffected
limb
- Signs and symptoms of an infection
- Psychological status (distorted body image and low self-esteem)
- Neurovascular and functional status of the
limb

Identify and Treat:
- Any concurrent health problems
- Medications that may influence management or
delay wound healing

Evaluate:
- Nutritional status and develop post-op nutritional
plan

67
Q

Nursing Implications for Patients w/ Amputations

A

Prevent further loss of circulation to extremity

Promote comfort

Promote optimal level of mobility

Promote independent self-care

Resolve grief & enhance body-image

68
Q

Post-Op Stump Wound Care

A

Measure limb every 8-12hrs

Elevate limb for first 24hrs

Prevent contracture of the joint above amputation

Discuss phantom limb pain

Relieve pain

Promote and evaluate healing

Inspect post-op dressing

Discourage semi-fowler’s position in client with above the knee amputation to prevent contractures of the hip

Monitor for bleeding

Monitor for infection

NV check every 8-12hrs

69
Q

Phantom Limb Pain

A

Pain perceived in an amputated section

70
Q

Stump Care after Wound has Healed

A

Assess for skin breakdown

Wash, rinse & dry stump daily

Do not apply anything to stump unless prescribed

Alcohol-> Dries Lotion-> Skin too soft

Encourage client to wear prosthesis when getting up and all day to prevent stump swelling

71
Q

Which action should the nurse take to evaluate the effectiveness of Buck’s traction for a patient who has a fracture of the RT femur?

A) Assess for hip pain
B) Check for contractures
C) Palpate peripheral pulse
D) Monitor for hip dislocation

A

A) Assess for hip pain

72
Q

A pedestrian who was hit by a car is admitted to the ED w/ possible RT lower leg fractures. Which initial action should the nurse take?

A) Elevate the RT leg
B) Splint the lower leg
C) Assess the pedal pulses
D) Verify tetanus immunization

A

C) Assess the pedal pulses

73
Q

Which patient statement indicates understanding of the nurse’s teaching about a new short-arm synthetic cast?

A) “I can remove the cast in 4 weeks using industrial scissors”
B) “I should avoid moving my fingers until the cast is removed”
C) “I will apply an ice pack to the cast over the fracture site off and on for about 24 hrs”
D) “I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast”

A

C) “I will apply an ice pack to the cast over the fracture site off and on for about 24 hrs”

NURS3313 Adult Health (27 decks)

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