Fractures Flashcards
Nursing care for pt’s w/ a fracture?
ABC’s, Head-to-toe, Hx, Mechanism of injury,
Direct pressure of bleeding sites,
Immobilization of extremity,
Cover any open areas w/ a dressing (sterile)
What’s a skin traction?
Force applied to soft tissues w/ a weight/pulley system to maintain alignment using splints, bandages or boots (wt. 5-7lb)
What’s a skeletal traction?
Pins, wires, screws are surgically implanted to the bone and weights are attached to hardware pulling in diff directions to maintain alignment (wt. 25lb)
Why is skin traction used?
To keep alignment and decrease muscle spasms
Why is skeletal traction used?
If pt has soft tissue damage or when greater force is needed
What are 2 important things to assess for skin tractions?
Skin integrity and perfusion
What is important to assess for skeletal tractions?
Skin integrity and infection
What are 2 important things to assess for if a pt has a cast?
Hot spots (infection) neurovascular check
What is open reduction and internal fixation (ORIF)?
Surgery used to internally repair a bone fracture into correct alignment, use pins, screws, plates, nails, wires or rods to keep bone in place
What is external fixation?
Screws and pins are placed into bone above/below fracture then attached to metal bar outside of skin
What is electrical bone stimulation?
An electrical current is sent to fracture site, used if site won’t heal properly
Why would electrical bone stimulation be contraindicated?
Upper extremity fracture or pt has a pacemake
What is a intracapsular fracture?
Fracture across head or neck of the femur
What is a extracapsular hip fracture?
Fracture w/in the trochanter region
How will a fracture site appear?
Bruised, externally rotated and shortened
How will a dislocated extremity look?
Internally rotated and shortened
What are the pts biggest complaints in a fracture?
Pain, uncomfortable to sit (most comfortable when flat) muscle spasms
What are the 5 P’s for a neurovascular check?
Pain Pallor Paresthesia Pulses Paralysis
How often do you do a neurovascular check?
Every Time you check VS, in post op more often then q4h when stable
Pre op management for hip fractures?
NPO, IVF (NS, D5 1/2) to prevent dehydration
Pain control intermittent in ED, PCA on unit (bolus of dilaudid)
Xrays, Stabilize extremity (Buck’s traction),
Lab studies (CBC, H/H, BUN/CRT, PT/PTT/INR)
What is general anesthesia?
When pt is knocked out and intubated
What is an epidural used for?
If pt is a high risk pt and unable to handle general anesthesia, is shorter/not intubated
What do you expect in PACU?
Stable VS, consciousness, pain controlled, no N/V
What are some open reduction internal fixation procedures for a hip fracture?
Intramedullary rods (IM rods) Intramedullary nails (IM nails) Plates and screws
What is an arthroplasty?
Prosthesis
What is a hemiarthroplasty?
Replacement of head of femur
Post op care?
Positioning (alignment) w/ legs abducted (V shape)
Wt bearing status (partial)
Ambulation and PT
Complications to monitor for?
Pressure ulcers, atelectasis, dislocation, VTE, PE, compartment syndrome, fat embolism syndrome, infection, bleeding, malunion
What is a Pulmonary embolism?
Obstruction of the pulmonary artery by a blood clot; can occur @ anytime
Name this complication: altered mental status (earliest sign), tachycardia, slight fever, tachypnea, chest pain, dyspnea, crackles, decreased O2 sat, mild thrombocytopenia?
Pulmonary embolism
Whats a clue in a pts history for a pulmonary embolism?
Recent surgery
How do you treat a pulmonary embolism?
Bed rest, O2, anticoagulants, possible thrombolytic therapy, mechanical ventilation, PLT monitoring
What’s a normal aptt in a pt who isn’t receiving an anticoagulant?
25-39
What is the goal of anticoagulation?
1.5-2 times of normal
How often is aptt measures? and what should be done based on those results?
Daily; heparin drip adjusted per orders
What do you measure in a pt taking Coumadin?
INR
Explain compartment syndrome.
Swelling to the extremity prevents circulation of an extremity, histamine is released causing increase in blood flow thats trapped causing nerve tissue death which releases myoglobin that clogs the renal tubules causing renal failure
How long does it take for the loss of a limb to occur in compartment syndrome?
6hrs
What is the treatment for compartment syndrome?
Faciotomy- long incision to release pressure
What is the key sign to compartment syndrome? And a late sign?
Pain out of proportion to extremity; paralysis of limb or pulselessness
How will a pt w/ compartment syndrome present?
Swelling, pressure, cool extremity, decrease to absent pulses, change in sensation/motion
Explain fat embolism syndrome?
Fat globules are released from bone marrow, enter the bloodstream, travel to the pulmonary vascular bed and obstruct
Why doesn’t fat embolism syndrome respond to anticoagulants?
Bc its fat…..duhh!
How long will it take fat embolism syndrome to occur?
12-48hrs
What is the earliest sign of fat embolism syndrome?
Altered mental status due to hypoxia/hypoxemia
What are some key features to fat embolism syndrome?
Hypovolemia, pulmonary edema, capillary permeability, and a “snowstorm” effect on the xray
How will a pt w/ fat embolism syndrome present?
Petechiae rash to upper extremity, cough/bloody frothy sputum, same s/s as PE
True or false. Fat embolism syndrome is curative?
False
What the key nursing actions of fat embolism syndrome?
Gentle handling of extremity, early immobilization, 100%O2 w/ non-rebreather mask Possible mechanical ventilation, Hydration, fluid resuscitation, Possible transfusion/steroids
A low grade temp is expected post op, what temp should ring “infection” and after what time period?
38.5+; 48hrs+ (also have increase HR/decrease BP)
Infection in an elderly pt will appear as what?
A change in mental status
When should you check the dressing postop?
Immediately on arrival to unit from PACU then q4h
Management of bleeding and anemia?
Assessment of hip dressing, measure drainage from surgical drain, BP lower than baseline, autologous transfusion, monitor H/H
What is the average amount of drainage from a surgical drain postop?
50mls/8hrs
What is delayed healing?
Prolonged healing
What is malunion?
Incorrect healing
What is nonunion?
Failure to heal
How are the unions diagnosed and how are they treated?
Xray; surgical intervention and/or electrical stimulation
What are factors that influence functional status after surgery?
Age, balance, cognitive ability, gender, fatigue, pain and complications
What are the best indicators of recovery?
Balance and cognitive ability
What are major risk factors for total hip arthroplasty?
Osteoarthritis (degenerative joint disease)
Decisions to have total hip arthroplasty?
Pain (drugs don’t work) interrupts sleep,
Unable to maintain desired quality of life/ADLs
Pt capable of participating in posop rehab
If a pt has cemented total hip arthroplasty what are the advantages/disadvantages?
Can resume activity faster; can loosen and may need revision surgery
If a pt has noncemented total hip arthroplasty what are the advantages/disadvantages?
Lasts longer (10-15yrs); limits activity for 6wks
What is significant about dental work when considering a total hip arthroplasty?
Can cause infection that can lead to heart damage or complications to prosthetic so get done before
What should a pt receive preop for several wks if a pt is anemic?
Epoetin Alpha to stimulate RBC production to decrease need for transfusion
What hgb level alerts the surgeon for a blood transfusion?
8
What is given preoperatively to have ready that may be needed during surgery?
Autologous blood donation
What is the assessments to check for risk factors of a VTE in preop?
Hx, immobile, underlying clotting disorders, increased age, smoking
What are the 3 rules to teach about exercises and transfers in postop?
No stooping/flexing
No bending at a 90 degree angle
No crossing legs (could cause dislocation)
When should you stop anticoagulants before surgery?
1wk
What kind of soap should a pt shower w/ morning of surgery and what should they not do?
Antibacterial soap/do not shave legs bc could cut self and cause an infection during surgery
Whats another name for an epidural?
Neuroaxial
What are some disadvantages/advantages to a longitudinal incision at the anterolateral thigh?
8-10cm on hip, has more muscle loss, decreases risk of dislocation but has longer recovery
What are some advantages/disadvantages to posterolateral into thigh/buttock?
20-24cm, less muscle involved, higher risk of dislocation
What types of drains are usually used in post op?
Jackson-Pratt/Hemovac
How should a pt be positioned postoperatively?
Supine, head slightly elevated, may have over bed trapeze
A pt should not sit how postoperatively?
No crossing legs or sitting @ 90 degree angle
What could be assessed in post op?
Pain, skin breakdown, 5 P’s, assess for any complications, compare operative leg w/ inoperative leg
What are some low molecular weight heparins used in postop that are all XA inhibitors (clotting factors), cause fewer bleeding complications, and don’t affect PT or aPTT significantly?
Enoxaparin (Lovenox)
Dalteparin (Fragmin)
Tinzoparin (Innohep)
What can low molecular weight heparins cause? So what should you monitor?
Thrombocytopenia; platelets
What should you assess for in a pt taking heparin?
Bleeding to IV site, gums, stools and neuro status
What med should be given 72hrs before discharge? What Heparin antidote is used as well?
Coumadin
Protamine Sulfate
To monitor postop pain what how long may NSAIDs be used for?
Up to 14days
To help w/ progression of activity in postop when should a pt get out of bed?
Day 1
What should be started right away after surgery?
PT eval and PT
How should you assist a pt OOB in postop that prevents hip hyper flexion?
Stand on pt’s affected leg side, pt sits on side of bed (not @ 90degree/no bending @ waist) stand up, pivot on unaffected leg to chair
If pt has cemented implants what should their weight bearing status be?
Usually PWB right away
If a pt has non-cemented implants what should their wt bearing status be?
PWB 1st few wks until bony ingrowth occurs per xray
What special devices should be ordered for a pt post op to help w/ progression of activity and prevent hip hyper flexion?
Elevated toilet seats, firm seat high back wheelchair
How long of a stay will a pt usually stay in postop?
3days
How long does acute rehab usually take? And completion of rehab
Approx. 1-2wks; about 6wks
Safety @ home for pt after surgery?
No clutter/throw rugs! Secure electric/extension cords,
Adequate lighting, accessibility,
Shower chair, elevated toilet seats
What is it called when a spinal disc ruptures allowing the fluid in the disc to leak out and irritate nearby nerves?
Herniated disc
Excess wt, regular heavy lifting, bending and twisting, previous back probs, tall height and bone disorders are risk factors for what?
Herniated discs
Name this type of herniated disc: not compressing a nerve is asymptomatic, if compressing nerve then pain in lower back, buttocks, thigh and leg, numbness/tingling and muscle weakness and may cause sciatica?
Lumbar discs
Name this type of herniated disc: numbness/tingling, muscle spasms, weakness in areas serviced by affected leg, stiff neck, neck and shoulder pain shooting into arm or fingers?
Cervical discs
Treatment for herniated discs?
Pain meds or surgery
What are the 4 classic symptoms of Parkinson’s?
Tremor, rigidity, bradykinesia and postural instability
Where do tremors usually occur in Parkinson’s?
Hand, foot, jaw, legs or pill rolling
What occurs in rigidity in a pt w/ Parkinson’s?
Resistance to move bc of contraction of all skeletal muscles
What occurs in bradykinesia in a pt w/ Parkinson’s?
Slow movements, shorter steps (shuffling gait), no arm swing, decrease blink rate, difficulty swallowing, chewing or w/ speech
What are some nonmotor skills that appear in Parkinson’s?
Fatigue, loss of sense of smell, confusion, memory loss, dementia, slowed thinking
Osteoporosis, osteogenesis imperfecta, Bone CA, inadequate intake of vit D, Ca and phosphate, aging, and trauma are all what?
Risk factors for fractures
