Fractures and Shock Flashcards
What is the musculoskeletal system comprised of?
- muscles
- bones
- joints
- tendons
- connective tissues
What is the main function of the musculoskeletal system?
Mobility and protection of internal organs
What age and gender do injuries in the musculoskeletal system most often occur in?
Young males; related to sport injuries
What does soft tissue trauma include?
- sprains
- strains
- dislocations
- subluxations
What is a subluxation?
Severe injury of the ligament structures around the joint that cause the joint to be completely displaced from its normal position
What is a subluxation?
Partial or incomplete displacement from the joints surface
What does RICE stand for?
R - rest
I - ice
C - compression
E - elevation
What is a fracture?
A disruption or break in the continuity of the bone
What is a open fracture?
The bone protrudes through the skin and is exposed to the external environment
What is a closed fracture?
The bone is broken but the skin remains intact
What is a complete fracture?
A break is completely through the bone
What is a incomplete fracture?
The fracture occurs across the bone shaft but the bone is in one piece
What is a displaced fracture?
The two ends of the bone are separated from one another
What does comminuted mean?
More than two fragments
What is a non-displaced fracture?
The bone, although broken, remains in alignment
What are the six stages of bone healing?
- fracture hematoma
- granulation tissue
- callus formation
- ossification
- consolidation
- remodeling
What is stage 1 - fracture hematoma?
- bleeding at the site of the break occurs and a clot forms quickly
- hematoma fully forms in 72 hours
What is stage 2 - granulation tissue?
- phagocytosis occurs, reabsorbs tissues/cells
- granulation tissue - new blood vessels, fibroblasts and osteoblasts develop
- 3-14 days following the injury
What is stage 3 - callus formation?
- 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
What is stage 4 - ossification?
- new bone continues to develop
- osteoclasts destroy dead bone
- 3 weeks to 6 months
What is stage 5 - consolidation?
- ossification continues - evidence of complete bony union
- can take up to a year
What is remodeling?
- excess bone growth is reabsorbed
- trabecular bone is laid down
- can take up to a year post injury
- bone remodels occurring to stress
What are the signs and symptoms of fractures?
- 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
What are the diagnostic tests for fractures?
- x-rays
- bone scan (checking density)
- CT scan
- MRI
What is closed reduction?
- 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
What is traction?
- 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
What is skin traction?
- used short term while the patient waits for surgery
- boots or splints are applied to the skin and connected to weights to maintain alignment
What is skeletal traction?
- used for longer periods of time, to align injured bones and joints
- physician inserts pin or wires into the bone and connects the weights
How do you care for a patient with traction?
- 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
What does a thorough neurovascular assessment include?
- skin colour - distal to injury
- skin temp
- movement
- sensation
- pulses
- capillary refill
- pain
What is open reduction and internal fixation?
- surgical procedure to repair fractures
- surgeons often use internal wires, screws, pins, plates, and rods to stabilize and align the fracture
What nursing care is needed after a open reduction and internal fixation procedure?
- close observation of vital signs
- monitor ABC’s
- neuro-vascular checks of the affected limb
- monitor for infection
- routine post-op care
What is a external fixator?
- 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
What is a cast?
- 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
When is the cast completely dry and strong enough for weight bearing?
- 24-72 hours later
What are some different types of casts?
- short or long arm casts or leg casts
- body jacket for thoracic or spinal injuries
- hip spica cast for femoral fractures
What nursing care should be done for cast?
- 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
What nursing interventions need to be done when caring for a patient with a body jacket cast?
- observation of respiratory status
- bowel and bladder function
- areas of pressure over boney prominences
What interventions need to be done for a patient with an open fracture?
- need a tetanus immunoglobin booster
- antibiotics (high risk of infection)
- well balanced diet to support bone healing
- ample protein
- multivitamin - calcium, phosphorus and magnesium
What nursing interventions need to be done for elderly patients with fracture?
- increased risk of constipation
- diet high in fiber with fruits and vegetables
- adequate fluid intake
How many meals should a patient with a hip spica or body jacket eat per day?
6 small meals per day
What home care need to be communicated to the patient with a cast?
- 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)
What patient teaching should be done after the removal of a cast?
- 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)
What is a renal calculi?
- 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
What is compartment syndrome?
- 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)
What are the 6 P’s of compartment syndrome?
- 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)
Why does urine output need to be assessed when compartment syndrome is at risk?
- 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
What nursing care needs to be done for someone with compartment syndrome?
- 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
What is venous thrombus/embolism and what is it a complication of?
- 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
What is a fat embolus and how does it occur?
- 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
What are the signs and symptoms of a fat embolus?
- 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
How to treat a fat embolus?
- 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
What is shock?
- 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)
How is shock categorized?
- by the functional impairment
What is low flow shock?
- hypovolemic: decrease in total body fluid
- cardiogenic: direct pump failure
What is disruptive shock?
- septic, neurogenic and anaphylactic
- fluids shifted from central vascular spaces to tissues (not returned to vascular system)
What is hypovolemic shock?
- occurs when the intravascular fluid is lost and the remaining volume is inadequate to fill the vascular space
What are absolute volume losses?
- hemorrhage
- diabetes insipidus
- GI loss (vomiting, diarrhea)
- diuresis
What is relative loss?
- fluid shift out of the vascular space into the interstitial space (tissues)
- ex: sepsis or burns
What is disruptive/septic shock?
- 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
What will the body do to ensure oxygenation for the vital organs during shock?
Compensation
What are the 4 stages of compensation?
- initial
- compensatory
- progressive
- refractory
What is the initial stage of shock?
- usually not clinically apparent
- metabolism changes from aerobic to anaerobic (lactic acid production begins)
- increased HR, mild vasoconstriction
What is the compensatory stage of shock?
- 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
What is the progressive stage of shock?3
- 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
What is the refractory stage of shock?
- 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)
What diagnostic tests are done for shock?
- 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)
What causes hypovolemic shock?
- trauma
- surgery
- dehydration
- internal hemorrhage
In what age group is hypovolemic shock most common?
Young people (recent illness, truama)
What are the signs and symptoms of cardiovascular hypovolemic shock?
- 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
What interventions should be done for hypovolemic shock?
- 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
What is the cause of sepsis?
- 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
What is local infection?
- 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
What is severe sepsis?
- 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
What are the labs for sepsis and septic shock?
- 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
What medications can be used for septic shock?
- IV fluid volume - NS or LR
- antibiotics - vancomycin, aminoglycosides
- patients are often hyperglycemic; insulin therapy
- low dose corticosteroids
- vasoactive medications to support blood pressure
What is multi organ dysfunction syndrome (MODS)
- 2 or more organs fail
70% mortality rate
