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Nursing Theory > Fractures and Shock > Flashcards

Fractures and Shock Flashcards

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1
Q

What is the musculoskeletal system comprised of?

A
  • muscles
  • bones
  • joints
  • tendons
  • connective tissues
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2
Q

What is the main function of the musculoskeletal system?

A

Mobility and protection of internal organs

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3
Q

What age and gender do injuries in the musculoskeletal system most often occur in?

A

Young males; related to sport injuries

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4
Q

What does soft tissue trauma include?

A
  • sprains
  • strains
  • dislocations
  • subluxations
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5
Q

What is a subluxation?

A

Severe injury of the ligament structures around the joint that cause the joint to be completely displaced from its normal position

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6
Q

What is a subluxation?

A

Partial or incomplete displacement from the joints surface

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7
Q

What does RICE stand for?

A

R - rest
I - ice
C - compression
E - elevation

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8
Q

What is a fracture?

A

A disruption or break in the continuity of the bone

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9
Q

What is a open fracture?

A

The bone protrudes through the skin and is exposed to the external environment

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10
Q

What is a closed fracture?

A

The bone is broken but the skin remains intact

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11
Q

What is a complete fracture?

A

A break is completely through the bone

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12
Q

What is a incomplete fracture?

A

The fracture occurs across the bone shaft but the bone is in one piece

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13
Q

What is a displaced fracture?

A

The two ends of the bone are separated from one another

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14
Q

What does comminuted mean?

A

More than two fragments

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15
Q

What is a non-displaced fracture?

A

The bone, although broken, remains in alignment

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16
Q

What are the six stages of bone healing?

A
  1. fracture hematoma
  2. granulation tissue
  3. callus formation
  4. ossification
  5. consolidation
  6. remodeling
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17
Q

What is stage 1 - fracture hematoma?

A
  • bleeding at the site of the break occurs and a clot forms quickly
  • hematoma fully forms in 72 hours
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18
Q

What is stage 2 - granulation tissue?

A
  • phagocytosis occurs, reabsorbs tissues/cells
  • granulation tissue - new blood vessels, fibroblasts and osteoblasts develop
  • 3-14 days following the injury
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19
Q

What is stage 3 - callus formation?

A
  • minerals develop (calcium, magnesium and phosphorus) help the new bone matrix develop
  • beginning to bind the bone back together
  • can be seen on x-ray
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20
Q

What is stage 4 - ossification?

A
  • new bone continues to develop
  • osteoclasts destroy dead bone
  • 3 weeks to 6 months
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21
Q

What is stage 5 - consolidation?

A
  • ossification continues - evidence of complete bony union

- can take up to a year

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22
Q

What is remodeling?

A
  • excess bone growth is reabsorbed
  • trabecular bone is laid down
  • can take up to a year post injury
  • bone remodels occurring to stress
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23
Q

What are the signs and symptoms of fractures?

A
  • edema
  • pain
  • abnormal positioning of extremity - deformed
  • loss of normal function
  • false movement - movement at fracture site
  • crepitus - palpable or audible crunching as the end of bones rub together
  • discoloration of skin around affected site
  • sensation may be impaired if there is nerve damage
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24
Q

What are the diagnostic tests for fractures?

A
  • x-rays
  • bone scan (checking density)
  • CT scan
  • MRI
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25
Q

What is closed reduction?

A
  • non surgical manual realignment of the bone fragments to the correct anatomical position
  • traction and counter traction is applied to the bone to restore the correct position
  • usually performed while the patient is under local or general anesthesia
  • if simple fracture - casting is applied to maintain alignment while the bone heals
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26
Q

What is traction?

A
  • application of a pulling force to the injury to help get it into alignment
  • to prevent and reduce muscle spasms, immobilize the bone and joint, reduce the dislocation, treat the pathological joint condition
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27
Q

What is skin traction?

A
  • used short term while the patient waits for surgery

- boots or splints are applied to the skin and connected to weights to maintain alignment

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28
Q

What is skeletal traction?

A
  • used for longer periods of time, to align injured bones and joints
  • physician inserts pin or wires into the bone and connects the weights
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29
Q

How do you care for a patient with traction?

A
  • neurovascular checks every 2 hours
  • assess skin for breakdown
  • assess and treat pain
  • ensure traction set up is correct and patient is in alignment
  • if pins are present, meticulous care to prevent infection
  • range of motion; other extremities
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30
Q

What does a thorough neurovascular assessment include?

A
  • skin colour - distal to injury
  • skin temp
  • movement
  • sensation
  • pulses
  • capillary refill
  • pain
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31
Q

What is open reduction and internal fixation?

A
  • surgical procedure to repair fractures

- surgeons often use internal wires, screws, pins, plates, and rods to stabilize and align the fracture

32
Q

What nursing care is needed after a open reduction and internal fixation procedure?

A
  • close observation of vital signs
  • monitor ABC’s
  • neuro-vascular checks of the affected limb
  • monitor for infection
  • routine post-op care
33
Q

What is a external fixator?

A
  • metallic device that is composed of metal pins and screws inserted into bone and attached to the external rods
  • applies traction
  • compressed fracture fragments into alignment
  • used with complex fracture and/or fractures that are not healing
34
Q

What is a cast?

A
  • temporary circumferential immobilization device
  • allows patients to perform many ADL’s
  • application often involved joint above and below the break
  • also restricts tendon and ligament movement
35
Q

When is the cast completely dry and strong enough for weight bearing?

A
  • 24-72 hours later
36
Q

What are some different types of casts?

A
  • short or long arm casts or leg casts
  • body jacket for thoracic or spinal injuries
  • hip spica cast for femoral fractures
37
Q

What nursing care should be done for cast?

A
  • continue to assess for compromised circulation and monitor for compartment syndrome
  • elevate the extremity, especially during the first 24 hours after application
  • can apply ice packs over the areas of injury (keeping the cast dry) during the first 24 hours to reduce swelling and/or pain management
38
Q

What nursing interventions need to be done when caring for a patient with a body jacket cast?

A
  • observation of respiratory status
  • bowel and bladder function
  • areas of pressure over boney prominences
39
Q

What interventions need to be done for a patient with an open fracture?

A
  • need a tetanus immunoglobin booster
  • antibiotics (high risk of infection)
  • well balanced diet to support bone healing
  • ample protein
  • multivitamin - calcium, phosphorus and magnesium
40
Q

What nursing interventions need to be done for elderly patients with fracture?

A
  • increased risk of constipation
  • diet high in fiber with fruits and vegetables
  • adequate fluid intake
41
Q

How many meals should a patient with a hip spica or body jacket eat per day?

A

6 small meals per day

42
Q

What home care need to be communicated to the patient with a cast?

A
  • do not bear weight on the affected extremity until instructed to do so
  • do not allow the cast to get wet
  • do not insert any objects into the cast or remove any padding
  • report any swelling and increased pain, especially when unrelieved with analgesics
  • if cast becomes very loose, it may need to be resized
  • monitor for signs of infection (fever, increased warmth over cast)
43
Q

What patient teaching should be done after the removal of a cast?

A
  • remove scaly, dead skin carefully by soaking (do not scrub)
  • move the extremity carefully
  • expect discomfort, weakness, and decreased ROM
  • support the extremity with pillows or your orthostatic device until strength and movement return
  • exercise slowly as instructed by your physical therapist
  • wear supportive stockings or elastic bandages to prevent swelling (lower extremities)
44
Q

What is a renal calculi?

A
  • a kidney stone
  • can develop as result of bone demineralization
  • increase fluids to 2.5L/day
  • monitor for discomfort/flank pain
  • monitor intake and output
  • daily weights
45
Q

What is compartment syndrome?

A
  • swelling and increased pressure within the compartment around the injury site
  • compromises the function of blood vessels (area becomes so swollen = poor blood flow = ischemia)
  • compresses nerves (neurological pain and loss of function)
46
Q

What are the 6 P’s of compartment syndrome?

A
  • paresthesia (numbness and tingling)
  • pain (not relived by opioids, severe)
  • pressure (inside the compartment)
  • pallor (coolness and loss of colour)
  • paralysis ( loss of function)
  • pulselessness (late sign, cannot palpate peripheral pulse)
47
Q

Why does urine output need to be assessed when compartment syndrome is at risk?

A
  • because myoglobin is released from damaged muscles which cause obstruction in the tubules = acute tubular necrosis = renal failure
  • signs include reddish brown urine and decreased urine output
48
Q

What nursing care needs to be done for someone with compartment syndrome?

A
  • remove or loosen bandage/cast
  • surgical decompression may be needed
  • once the cast or bandage is loosened, then elevate the extremities
  • neurovascular checks every hour
  • pain management
  • if surgery - incision care
  • increased fluids to decrease injury to the kidneys
49
Q

What is venous thrombus/embolism and what is it a complication of?

A
  • patients with pelvis or long leg casts are at increased risk
  • assess for complaints of pain
  • monitor peripheral pulses
  • assess for swelling
  • may need anticoagulants
50
Q

What is a fat embolus and how does it occur?

A
  • after a break in the bone, fat globules may be released into the vascular system
  • occurs more often in long bone fractures
  • triggers an inflammatory response
  • causes mirco-clots which can lead to ischemia
51
Q

What are the signs and symptoms of a fat embolus?

A
  • develop very quickly
  • patient frequently expresses a feeling of impending doom
  • change in level of consciousness - confusion and or restlessness
  • skin changes from pallor to cyanosis
  • SOB - hypoxia
  • hypotension and tachycardia
  • myoglobin in urine - decreased output
52
Q

How to treat a fat embolus?

A
  • directed at prevention - careful handling of long bone fractures
  • reposition the patient with these fractures as little as possible until stabilized
  • fluids - normal saline
  • oxygen therapy
  • replacement of blood volume (if necessary)
  • glucocorticoids
53
Q

What is shock?

A
  • decreased tissue perfusion
  • impaired cellular metabolism
  • whole body response (not a disease process)
  • all organs are affected by shock (they either work harder to obtain oxygenation or adapt to reduced oxygen levels)
54
Q

How is shock categorized?

A
  • by the functional impairment
55
Q

What is low flow shock?

A
  • hypovolemic: decrease in total body fluid

- cardiogenic: direct pump failure

56
Q

What is disruptive shock?

A
  • septic, neurogenic and anaphylactic

- fluids shifted from central vascular spaces to tissues (not returned to vascular system)

57
Q

What is hypovolemic shock?

A
  • occurs when the intravascular fluid is lost and the remaining volume is inadequate to fill the vascular space
58
Q

What are absolute volume losses?

A
  • hemorrhage
  • diabetes insipidus
  • GI loss (vomiting, diarrhea)
  • diuresis
59
Q

What is relative loss?

A
  • fluid shift out of the vascular space into the interstitial space (tissues)
  • ex: sepsis or burns
60
Q

What is disruptive/septic shock?

A
  • sepsis is a systemic inflammatory response to infection
  • severe sepsis is complicated by organ dysfunction
  • septic shock develops due to a widespread infection causing organ failure and dangerously low BP
61
Q

What will the body do to ensure oxygenation for the vital organs during shock?

A

Compensation

62
Q

What are the 4 stages of compensation?

A
  1. initial
  2. compensatory
  3. progressive
  4. refractory
63
Q

What is the initial stage of shock?

A
  • usually not clinically apparent
  • metabolism changes from aerobic to anaerobic (lactic acid production begins)
  • increased HR, mild vasoconstriction
64
Q

What is the compensatory stage of shock?

A
  • decrease in BP (10-15 mmHg)
  • increase in lactic acid production
  • mild acidosis - decrease in pH and hyperkalemia
  • increased HR
  • increased respirations
  • kidneys reabsorb fluid
  • stimulation of thirst
  • decrease in pulse pressure e
65
Q

What is the progressive stage of shock?3

A
  • begins as the compensatory mechanisms fail
  • more aggressive interventions are necessary to prevent the patient from developing multisystem organ dysfunction
  • decreased cellular perfusion (increased anaerobic metabolism)
  • altered capillary permeability (fluids leak into the tissues, less vascular space = hypotension)
  • fluid leaking into alveoli
  • tachycardia - poor cardiac output
  • anoxia of non-vital organs, pallor, cyanosis
  • hypoxia of vital organs (heart, brain, kidney)
  • moderate acidosis, increases lactic acid
  • tissue death is occurring
66
Q

What is the refractory stage of shock?

A
  • high rate of mortality
  • exacerbation of anaerobic metabolism
  • accumulation of lactic acid
  • increased capillary permeability - venous pooling
  • hypotension (worsening of cardiac function, failure of organs)
67
Q

What diagnostic tests are done for shock?

A
  • no one single test to determine shock
  • thorough history and physical
  • lab studies (hemoglobin and hematocrit, lactate level, arterial blood gases-bicarbonate level btwn 21-28mmol/L)
  • 12 lead ECG - heart rate and rhythm
  • radiology (chest x-ray or CT scan)
68
Q

What causes hypovolemic shock?

A
  • trauma
  • surgery
  • dehydration
  • internal hemorrhage
69
Q

In what age group is hypovolemic shock most common?

A

Young people (recent illness, truama)

70
Q

What are the signs and symptoms of cardiovascular hypovolemic shock?

A
  • decreased BP
  • increased HR
  • increased respirations to improve oxygenation
  • increased lactic acid
  • diminished peripheral pulses
    -decreased urine
    late signs;
  • increase in diastolic pressure = narrowing of the pulse pressure
  • systole pressure will decrease and cardiac output will decrease
  • peripheral pulses present with Doppler
  • decreased respirations and increased depth
  • no urine production
71
Q

What interventions should be done for hypovolemic shock?

A
  • oxygen therapy (head of bed no more than 30*)
  • IV therapy (blood and blood products)
  • assess for life threatening injuries
  • control external bleeding w direct pressure
  • urinary catheter, strict input and output
  • NG tube if needed
  • consult HCP if fluid does not bring up BP, may need vasoactive medications
72
Q

What is the cause of sepsis?

A
  • bacterial infection that escapes local control
  • immunological patients: fungal infections can lead to sepsis
  • increase in the number of drug resistant organisms is resulting in more cases of sepsis
  • older adults are more at risk
  • infection control
73
Q

What is local infection?

A
  • infection is confined to a local area
  • immune system responds (inflammatory mediators, WBC’s)
  • WBC’s invade infectious area = vasodilation = increased perfusion
  • results in capillary bed leakage - infectious organisms enters the blood system = systemic infection
  • pathogen uses furl (glucose) in the vascular system to reproduce
  • body responds with widespread inflammation (SIRS)
  • impairs oxygenation and perfusion
74
Q

What is severe sepsis?

A
  • all the tissues are involved - hypoxia - some organs are experiencing death
  • results in a large inflammatory response - vasodilation and blood pooling
  • blood pooling causes micro thrombi to form
  • results in hypoxia and reduced organ function
  • increasing hypoxia = anaerobic metabolism (increasing lactic acid levels) = more toxins in the blood stream
75
Q

What are the labs for sepsis and septic shock?

A
  • assess for presence of bacteria in vascular system - blood cultures
  • increasing serum lactate level
  • normal or low WBC (used for fighting the infection so body is struggling to produce more)
  • C reactive protein - increased initially = indicates inflammation (decreased in septic shock)
  • D- dimer: rises as fibrin clot is broken down
76
Q

What medications can be used for septic shock?

A
  • IV fluid volume - NS or LR
  • antibiotics - vancomycin, aminoglycosides
  • patients are often hyperglycemic; insulin therapy
  • low dose corticosteroids
  • vasoactive medications to support blood pressure
77
Q

What is multi organ dysfunction syndrome (MODS)

A
  • 2 or more organs fail

70% mortality rate

Nursing Theory (6 decks)

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