Exam 2, chapter 41/42 Flashcards
A soft tissue injury produced by blunt force such as a blow, kick or fall, that results in bleeding into soft tissues (ecchymosis)?
Contusion
an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress.
Strain (pulled muscle)
A tendon connects?
muscle to bone
Ligament connects?
bone to bone
Sprain
injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching, or twisting motion.
SXS for strains, contusions and sprains
pain edema ecchymosis abnormal joint motion tenderness
first degree strain
tearing of few muscle fibers
minor edema, tenderness, and muscle spasm
no noticeable loss of function
second degree strain
tearing of more muscle fibers edema tenderness' muscle fibers ecchymosis notable loss of load bearing strength of the involved extremity.
Type of strain that involves complete disruption of at least one musculotendinous unit that involves separation of muscle from muscle, muscle from tendon or tendon from bone.
third degree strain
SxS of third degree strain
significant pain muscle spasm ecchymosis edema loss of function
X-ray to rule out avulsion fracture
A break in the continuity of bone caused by direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions?
fracture
Tenderness at the distal tibia (inner ankle) or fibula (outer ankle) is associated with an inversion or eversion injury may indicate?
Fracture
Tx of contusions, strains, and sprains
Rest to prevent additional injury and promotes healing.
Ice intermittent moist or dry cold packs for 20-30 minutes during the 1st 24-48 hours to produce vasoconstriction (decrease bleeding, edema and discomfort).
Compression: elastic compression banage to control bleeding, reduce edema and provides support.
Elevation controls the swelling.
what assessments are important for the nurse to monitor for patients with contusions, strains, and sprains?
Neurovascular status
Circulation (pulses, color, temp, cap refill)
Sensation (awareness of light touch)
Movement (ROM) at the most distal digits.
How many weeks of immobilization before exercise are initiated for patient with severe sprains and strains?
1 to 3 weeks
depending on the severity of injury (contusions, strains, sprains), progressive passive and active exercises may begin in?
2 to 5 days
Spliniting may be used to prevent reinjury in strains and sprains why?
because ligaments and tendons are relatively avascular (bloodless).
a partial dislocation of articulating surface.
subluxation
What happens when a dislocation is not treated promptly?
Avascular necrosis (AVN)
what are some signs and symptoms of a traumatic dislocation?
acute pain
change in contour of the joint
change in lenght of the extremity (shortening of the affected limb)
loss of normal mobility
change in the axis of the dislocated bones.
what should the nurse be alert for when there is a right rib fracture 6 through 12?
liver injuries
which organ will be injured when there is a left rib fractures 9 through 11?
splenic injuries
fractures are described and classified according to?
type
communication or noncommunication with external environment.
anatomic location of fracture on involved bone (humerus, femur, tibia).
stable ( transverse, spiral and greenstick) or unstable (comminuted and oblique)
A fracuture that involves a break across the entire cross-section of the bone and is frequently displaced (removed from its normal position)?
complete fracture
a fracture that produces several bone fragments?
comminuted fracture
A type of fracture caused by compression of vertebrae and are associated frequently with osteoporosis
compression fracture
stress fractures
occurs with repeated bone trauma from athletic activities, most frequently involving the tibia and metatarsals.
a type of fracture that runs across the bone at a diagonal angle of 45 to 60 degrees?
oblique
fractures that do not cause a break in the skin
closed (simple) fractures
Types of fractures in which the skin or mucous membrane extends to the factured bone?
open (compound, or complex) fractures
name some types of fractures
Avulsion comminuted compression greenstick stress transverse spiral pathologic oblique longitudina impacted'
A fracture in which a fragment of bone has been pulled away by a tendon and its attachment
Avulsion
comminuted fracture
bone has splintered into several fragments
a fracture in which bone has been compressed (seen in vertabral fractures)
compression
Greenstick
a fracture in which one side of a bone is broken and the other side is bent
A transverse fracture is straight across the bone shaft True or false?
True
How will a nurse document as the type of fracture that occurs through an area of diseased bone that can occur without trauma or fall?
pathologic (eg; osteoporosis, bone cyst, Paget;s disease, bony metastasis, tumor).
The Dx of a fracture is based on?
pt sympoms
physical signs
X-ray findings
clinical manifestations of a fracture
pain loss of function deformity shortening crepitus (grating, crackling or popping sounds) swelling discoloration Do not all need to be present in every fracture.
The muscle spasms that accompany a fracture begin within?
20 minutes after injury
results in increasing pain intensity
further bony fragmentation or malalignment
what are the causes for delayed ossification?
infections
rest
DM
nutriation
what should the nurse consider when a patient with injury from fracture must be moved before extrmity splint can be applied
support the limb distal and proximal to the fracture site to prevent rotation as well as angular motion.
Stages of fracture union
hematoma (0-3 days) granulation tissue (3-14 days)-osteoid callus formation (2 weeks) ossification (3 weeks to 6 month)-cast removal consolidation (radiologic union) remodeling (1 year)
what are the five warning P’s of neurovascular impairment?
pain paresthesia (numbness and tingling) pressure (increase in compartment) pallor (coolness, paleness ) pulselessness (less than 2 seconds) paralysis (loss of function)
what should the nurse do when there is an open fracture?
cover the wound with a sterile dressing to prevent contamination of deeper tissues.
No attempt is to be made to reduce the fracture even if one of the bone fragments is protruding through the wound.
what prophylaxis will be administered in the ER for a patient with an open fracture?
Tetanus if the last known booster was over 5 years ago.
what is the immediate priority for a patient with fracture?
maintaining hemodynamic stability.
The nurse is aware that bleeding is a common problem with fracture therefore?
watch for sxs of hypovolemic shock such as
thirst
elevated HR, anxiety, restlessness, weak pulse (thready)
decreased BP, UO, pulse pressure
cool, clammy skin
delayed capillary refill
rapid shallow respirations
What are the Tx for shock in a patient with fracture?
stabilizing the fracture
relieving pain
protection
The principles of fracture Tx include
reduction
immobilization
regaining of normal functions and strenght through rehabilitation.
restoration of the fracture fragments to anatomic alignment and rotation?
Reduction
types of reduction
closed and open reduction
nonsurgical, manual realignment of bone fragments to previous anatomic position?
closed reduction
Closed reduction
nonsurgical, manual realignment of bone fragments to previous anatomic position.
traction and countertraction manually applied to bone fragments to restore position, lenght, and alignment.
performed while patient is under local or general anesthesia.
Can the nurse manipulate protruding bone ends?
No
Open reduction
correction of bone alignment through surgical incision.
internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails.
The internal fixation devices ensure firm approximation and fixation of the bony fragments.
open fractures are considered contaminated and carries risk for?
osteomyelitis
tetanus
gas gangrene
what is the objectives for managing open fractures?
prevent infection of the wound, soft tissue, and bone.
promote healing of soft tissue and bone.
be alert for signs and symptons of infection with open fracture.
Elevated temperature tachycardia tachypnea redness, warth, tenderness, purulent drainage at wound site leukocytosis (elevated WBCs)
what is an alternative after fracture reduction?
external fixation
pins are drilled into bone.
held by external metal frame to prevent bone movement.
what are the major goals for the patient with a fracture?
knowledge of the treatment regimen
relief of pain
improved physical mobility
achievement of maximum level of self care
healing of any trauma associated lacerations and abrasion
maintenance of adequate neurovascular function
absence of complications.
The nurse must never ignore complaints of pain from a patient in a cast because of the possibility of problems such as?
impaired tissue perfusion
pressure ulcer formation
pain associated with underlying condition (eg. fracture) is frequently controlled by?
immobilization
pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by?
elevation and, if prescribed, intermittent application of cold packs.
place the ice packs on each side of the cast or fixator.
what is a significant risk for the immobilized patient?
Deep vein thrombosis (DVT)
what should the nurse do to prevent DVT in a patient with fracture?
The nurse encourages the patient to do active flexion-extension foot and ankle exercises and isometric contraction of the claf muscles (calf-pumping exercises) every hour while awake to decrease venous stasis in the unaffected limb.
why should the nurse encourage the patient to move digits and joints distal to fracture injury hourly when awake?
to prevent problems related to inactivity.
with internal fixation, who determines the amount of movement and weight-bearing stress teh extremity can withstand?
surgeon
what are some biologically inert metal devices used for internal fixation?
stainless steel
vitallium
titanium
how will the surgeon evaluate the alignment after metal devices for internal fixation have been applied?
X-ray
how will the nurse teach a patient to prevent infection when using external fixator?
50/50; hydrogen peroxide and saline
what is critical when external fixations are applied?
infection control
what are measures that may reduce the incidence of fat emboli?
immediate immobilization of fractures (early surgical fixation.
minimal fracture manipulation.
adequate support from fractured bones during turing and positioning.
maintenance of fluid and electrolyte balance.
risk factors for fat embolism syndrome
truama
fracture of long bones or pelvic bones
multiple fractures or crushing injuries
onset is rapid, with 24-72 hours of injury
Nursing care for traction
set up by ortho tech
maintain the correct balance between the pulling and counter pull
weighs should be hanging freely.
watch positioning (semi Fowlers, Fowlers).
Do not position pt on affected side
what is an example of a skin traction?
Buck’s traction
use to immobilize fractures of the proximal femur before surgical fixation.
what should the nurse perform before a buck’s traction is applied
inspect the skin for abrasion and circulatory disturbances.
ensures the skin is dry.
what are some complications that may develop as a result of skin traction?
skin breakdown
nerve pressure
circulatory impairment
care of the patient in traction
TRACTION!! Temperature (pt and extremity) Ropes hang freely Alignment Circulation checks Type and location of fracture Increase fluid intake Overhead trapeze No weight on bed or floor
Assessment for patients on traction
check the amount of weight ordered (usually 5 to 10lbs)
if patients reports severe pain, maybe weights are too heavy.
assess neurovascular status (6 Ps!).
skin
Two most common types of traction
skin
skeletal
circulatory impairment in a patient with traction is manifested by
cold skin temperature
decrease peripheral pulses
slow capillary refill time
bluish skin.
DVT a serious circulatory impairment may be manifested by
unilateral calf tenderness
warmth
redness
swelling
Skin traction
used for short term treatment to control muscle spasms and to immobilize an area until skeletal traction or surgery is possible.
Tape, boots or splints applied directly to skin to maintain alignment assist in reduction.
weights 5 to 10 lbs.
how will the nurse assess for correct balance with a skin traction?
weighs should be hanging freely.
the amount of weight applied must not exceed the tolerance of the skin.
How does the skin traction work?
applies a pulling force indirectly onto the bone by pulling on skin.
it short term, light weights (5-10lbs).
Examples of skin traction
Buck’s
Russell’s
Pelvic
cervical
skeletal traction
in place for longer periods
used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia.
provides a long term pull that keeps injured bones and joint aligned.
weight ranges 5-45lbs
Too much weights results in delayed union or nonunion.
who is responsible for adjusting the clamps on the external fixator frame - skeletal traction?
The physician’s responsibility.
Nurse must NEVER make the adjustment.
How will the nurse maintain an effective skeletal traction
check the apparatus at least one per shift to ensure the ropes are in the wheel grooves of the pulleys.
Ropes are not frayed.
weights hang freely.
knots in the rope are tied securely.
what are the major disadvantages of skeletal traction?
infection
osteomyelitis (bone infection)
immobility.
what assessment are the nurse performing on a patient with skeletal traction
skin breakdown
pressure on lower extremity (ischial tuberosity, popliteal space, Achilles’ tendon an heels).
6 P’s
infections (clean pin with Chlorhexidine solution).
which lab may be normal in a patient with chronic osteomyelitis
WBCs
what is the dominant finding in osteomyelitis
pain over the affected bone
osteomyelitis is caused most commonly by which microorganism?
staphylococcus aureus
signs of pin infection
edema purulent drainage erythema excessive warmth tenderness pin loosening odor fever
type of treatment modality that permit mobilization of patient while restricting movement of a body part?
cast
it a rigid external immobilizing device.
risk factors for osteoporosis
age female (caucasian) small bone structure postmenopausal sedentary lifestyle smoking COPD steroid family history Ca deficiency high protein diet excessive caffeine and alcohol intake malignancy hyperthyroidism Rheumatoid arthritis diabetes mellitus (DM) Cushing's disease gastrectomy
How should the nurse care for a wet cast?
using a hair dryer on a cool setting.
Thorough drying is important to prevent skin breakdown.
A wet plaster cast appears?
dull and gray
sounds dull on percussion
feels damp
smells musty
how will a dry plaster cast appear?
white and shiny
resonant to percussion
firm
odorless
Casts
use palms of hand during drying period. edges may be need to be petaled. plaster sets in 15 minutes synthetic casts dry in 15 minutes not strong enough for weight bearing unit 24 to 72 hours.
fresh plaster cast should never be covered with a blanket why?
To allow maximum dissipation of the heat and facilitate drying (24 to 72 hours).
cast use for upper extremities
sugar tong splint
acute writs injuries
injuries that result in significant swelling
posterior splint
Accommodates swelling in fracture extremity post injury.
short arm cast
long arm cast
Body jacket
compresses superior mesenteric artery against duodenum.
sling
what is a disadvantage to the use of body jacket cast?
compresses superior mesenteric artery against duodenum.
in what position should the hand be? in relation to the elbow when using a sling.
The thumb should be pointing up.
injuries to lower extremities are often immobilized by which types of cast?
long leg short leg cylinder jones dressing prefabricated splint or immobilizer
supporting case during hardening
handle with palms of hands
support on firm smooth surface
DO NOT rest on hard surface or on sharp edges.
avoid pressure on cast.
Assessment of the cast
assess the skin around the edges check for hot spots. wet sports. be aware of possible pressure points check for odor make sure it is not too tight-finger in may need to bivalve or cut window
cast care dos
apply ice on fracture site for the first 24 hours.
check with health care provider before getting fiberglass wet.
dry cast after exposure to water.
elevate extremity onto pillows above heat level for first 24 hours.
after initial phase, casted extremity should not be placed in a dependent position because of the possibility of excessive edema.
observe for signs of pressure such as: pain, swelling, compartment syndrome.
move joints above and below cast regularly.
report signs of possible problems.
keep appointment to have fracture and cast checked.
Cast care don’ts
get plaster cast wet. remove any padding insert any objects inside cast bear weight on new cast or 48-72 hours. not all casts are weight-bearing cover cast with plastic for prolonged periods.
how many meals a day should a patient in body jacket and hip spica cast have?
6 small meals to prevent abdomen distention.
dietary requirements for patients in cast
ample protein (1g/kg of body weight) vitamins B, C, D Calcium Phosphorus Magnesium
what can develop as a result of bone demineralization
Renal calculi
patient should have adequate fluid intake 2500ml/day.
cranberry juice or ascorbic acid -prevents UTIs.
High fiber diet with fruits and vegetables -prevents constipation.
what are some nursing diagnoses for patients in cast
impaired physical mobility
risk for peripheral neurovascular dysfunction
acute pain
ineffective therapeutic regimen management
A tough connective tissue that surrounds muscle groups, organs, nerves, blood vessels, bones and internal structures? it does not expand readily.
Fascia
Elevated intracompartmental pressure within a confined myofascial compartment compromises neurovascular function of tissues within that space?
compartment syndrome
type of compartment syndrome resulting from restrictive dressing, splints, casts, excessive traction, or premature closure of fascia?
decrease compartment size
increase compartment size
related to bleeding, edema, chemical response to snakebite or IV filtration.
what is a hallmark sign for compartment syndrome?
pain that occurs or intensifies with passive ROM.
If concerned about neurovascular impairment, notified physician immediately.
The presence of a pulse does not rule out compartment syndrome True or false?
True
pulselessness and pallor are late signs of compartment syndrome.
what are characteristics of impending compartment syndrome?
paresthesia: numbness and tingling
pain: distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through compartment.
Pressure: increase in compartment
Pallor: coolness, and loss of normal color of extremity.
paralysis: loss of function
pulselessness: diminished/absent peripheral pulses.
if a compartment syndrome complication is secondary to a tight bandage or cast, the nurse anticipates that?
The bandage would be loosened or removed and the cast bivalved (cut in half longitudinally).
A surgical procedure in which the skin and affected compartments fascia are opened, allowing the pressure to be relieve and circulation restored?
fasciotomy
fasciotomy
surgical decompression for compartment syndrome
what may be the result for reduction in traction weight?
decrease external circumferential pressure.
susceptible site in the lower extremity for pressure (decubitus) ulcers
heel malleoli dorsum of the foot head of fibula, tibial tuberosity anterior surface of the patella.
The nurse has a high degree of suspicion that a pressure ulcer is developing under a cast or dressing when the patient reports?
pain
tightness in a defined casted area.
Nurse will inspect for drainage, odor, warmth(tissue erythema).
which patients are at hight risk for venous thrombosis
patients with fractures of the lower extremities
pelvis injury
Signs of Venous thrombosis
can present as shock and loss of consciousness. sudden-onset SOB. restlessness increase respiratory rate tachycardia chest pain low grade fever pleuritic pain that increase with inspiration (pulmonary infarct). moderate hypoxemia productive cough of blood-tinged sputum.
presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury
fat embolism (FES) contributory factor in many deaths associated with fractures.
why may fat globules diffuse into the vascular compartment at the time of fracture?
because the pressure is greater than the capillary pressure.
catecholamines elevated by the patient’s stress reaction.
Risk factors for fat embolism syndrome
trauma fracture of long bones pelvic bones multiple fractures crushing injuries
fractures most often causing FES
long bones
ribs
tibia
pelvis
FES is known to occur following
total joint replacement spinal fusion liposuction crush injuries bone marrow transplantation
The cerebral disturbance due to hypoxia and the lodging of fat emboli in the brain is manifested by
mental status changes varying from headache mild agitation confusion delirium coma
what are signs of systemic fat embolization
patient appears pale
petechiae (transient thrombocytopenia) noted in the buccal membranes and conjunctival sacs on the hard palate over the chest and anterior axillary folds.
fat globules transported to lungs cause
hemorrhagic interstitial pneumonitis
initial manifestations of FES occur
24-48 hours after injury
SxS of acute respiratory distress syndrome (ARDS)
chest pain tachypnea cyanosis dyspnea apprehension tachycardia decreased partial pressure of arterial oxygen (PaO2) less than 60 mm Hg-respiratory alkalosis (hyperventilation), later respiratory acidosis (hypoventilation).
Clinical manifestations of FES
may be rapid and acute
patient expresses a feeling of impending disaster.
in a short time skin color changes from pallor to cyanosis
patient may become comatose.
what are the most common causes of death with FES
acute pulmonary edema
ARDS
ARDS
Acute Respiratory Distress Syndrom
FES
Fat embolism syndrome
what will you do as a nurse to prevent a FES?
immediate immobilization of fractures.
minimal fracture manipulation.
adequate support for fractured bones during turing and positioning.
maintenance of F&E balance.
recognizing early indications and report them promptly.
subtle personality changes, restlessness, irritability or confusion in a pt who has sustained a fracture are indication for immediate?
reassessment of vitals O2 saturation lab date physical exam watch out for FES!
Tx for FES
O2 therapy
mechanical ventilation
positive end expiratory pressure (PEEP)
used to maintain arterial oxygenation
corticosteroids via IV for
inflammatory lung reaction and to control cerebral edema.
vasopressor medication to support cardiovascular function
prevent hypotension, shock and interstitial pulmonary edema
bone healing
ossification consolidation remodeling intact peripheral circulation return of skeletal function
splinting
support the affected body part to avoid fracture displacement and soft tissue injury.
move the injured extremity as little as possible to avoid additional injury.
monitor for bleeding at injury site to plan appropriate intervention.
Traction/immobilization care
position in proper body alignment to enhance traction and skeletal function.
maintain traction at all times to prevent misalignment of bone fragments.
monitor circulation, movement and sensation of affected extremity to detect complications of peripheral vascular function.
provide trapeze for movement in bed to reduce complications of immobility.
monitor skin and body prominences for signs of skin breakdown.
administer appropriate skin care at friction points to prevent skin breakdown.
Cast care: wet
expose drying cast to air to promote even drying.
support cast with pillows during the drying period to prevent denting and flattening of the cast.
apply plastic to cast if close to groin to prevent soiling of cast.
mark the circumference of any drainage as a gauge for future assessments.
cast care: maintenance
instruct patient not to scratch skin under the cast with any objects to prevent skin injury and infection.
position cast on pillow to lessen strain on other body parts.
pad rough cast edges and traction connections to prevent skin irritation and breakdown of cast.
positioning
immobilize or support affected body part to prevent pressure and injury.
maintain position and integrity of traction to prevent compression of blood vessels and nerves.
elevate affected limb 20 degrees or greater above the level of the heat to reduce edema by promoting venous return.
if compartment syndrome is suspected elevate extremity no higher than heart level.
Application of a pulling force to an injured or diseased part of body or extremity while counter traction pulls in opposite direction
Traction
Purpose of any traction
Prevent or decrease muscle spasm
Immobilize joint or part of body.
Decrease a fracture or dislocation.
Treat a pathological joint condition.
The removal of a body part, usually an extremity
amputation
what are the s&s of PVD prior to amputation
pale color
temperature
hair loss
pain
close amputation
creates weight bearing residual limb(stump).
skin flap covers stump (suture line not in area of wt bearing.
skin fold firm as to not allow fluid accumulation and thus infection
Open (guillotine) amputation
leaves a surface on limb not covered by skin fold (used for actual or potential infection)
later closed
post op care for amputation
monitor for bleeding/hemorrhage sterile dressing changes avoid flexion proper bandaging stump shaping and molding supports soft tissues reduces edema and pain promotes limb shrinkage healing, and maturation
immediate prosthesis fitting
gradually increase WBAT
promotes early ambulation
psychological benefits
cast is changed at intervals to permit stump inspection to insure the maintenance of adequate fit.
Amputation complications
grieving
phantom limb pain
flexion contractures
Amputation pt family teaching
DO NOT use lotions, alcohol or powders DO NOT sit for > 1hr-avoid hip flexion DO NOT elevate residual limb too high one pillow only only for the 1st 24 hours (prevent flexion contractions of the hip)
surgical excision to gain access to and remove protruding disk
removes entire lamina (bone at the back of spinal canal)
take pressure off the nerve
minimal hospital stay is usually required
Laminectomy
Laminotomy
removes a portion of the lamina
part of a disc or bone spur maybe removed
relieves pressure on nerve
minimal hospital stay is usually required.
uses microscope to allow better visual of disk and disk space to aid in the removal of damaged portion.
helps maintain bony stability of spine
microsurgical diskectomy
Post op spinal surgery
frequently monitor peripheral neurologic signs of extremities.
manage pain appropriately
movement of arms legs and assessment of section should unchanged when compared with preoperative status.
repeat assessment every 2 to 4 hours during 1st 48 hours post surgery.
why NO Anticoagulants with patient with spinal surgery
can cause peri-spinal hematoma which can lead to spinal cord injury.
S&S of CSF leak in patient with spinal surgery
headache
check glucose level (CSF is high)
Good sources of calcium for osteoporosis
milk yogurt turnip greens spinach cottage cheese ice cream sardines
care for the patient with osteoporosis
supplemental vitamin D and Calcium.
exercise should be encouraged to build up and maintain bone mass.
patient should be instructed to quit smoking and cut down on alcohol intake to decrease losing bone mass.
drugs that interfere with calcium.
corticosteroids anti seizure (depakote, Dilantin) aluminum containing antacids heparin certain cancer treatments parathyroid hormone
Drug therapy for osteoporosis
bisphosphonates : Alendronate (Fosamax)
Risedronate (Elvista)
Ibandronate (boniva) (stand or sit for 60 minutes)
take in the morning before eating or drinking
take with full glass of water
must stand or sit upright for 30 minutes
cannot eat or drink during this time (can cause esophagitis, muscle pain, or ocluar problems)
