Hip, and Amputations exam 2 Flashcards
Fracture
Break or crack in the bone
Causes of fractures
-Trauma
-twisting, abuse
-Disease process
What age group heals fastest
Children
Average time to heal from a broken bone
3-12 weeks
Open fracture
-Breaks through skin
-Also known as compound
Closed fracture
Doesnt break through skin
Complete fracture
-Separates bone into two
Incomplete fracture
Not broken all the way
Comminuted fracture
Bone is broken into a million fragments
What is a hip fracture
Break in the femur
-Classification depends on the location of the break
-Intracapsular
-Intrertrocaonteric
-Subtrochanteric
-Crack may be displased,or non dsiplaced
Displaced hip fracture
Bone is broken and moved out of place
Nondisplaced hip fracture
Bone broke and stayed in the original location
Intracapsular Hip fracture
Broken on the “neck” of the femur before the actual capsle
-Like right before the ball of the leg
-Repaired by screws into the joint
Intertrochanteric Hip fracture
Broken between the greater and lesser trochanter
-Repaired with screws and plates
Subtrochanteric Hip fracture
Break on the actual femur itself
S+S hip fracture
-Shortening of extremity
-Potential for Neurovascular compromise
-Pain
-Deformity
-Swelling and discoloration
-Crepitus
-Loss of function
-Redness
-Bruising
-Limited movement
Main 3 things with S+S Hip fracture
-Leg is shortened
-Leg is abducted
-Leg is externally rotated
(confirm with Xray/MRI)
Initial treatment of hip fracture
-Stabilize the pt first, see them first
-Immobilize body part
-Assess (Vitals, cognition, neurovascular status)
-DONT TRY TO MOVE LEG
-Get a good history, call provider
-Know lab values/vitals in case the need srgery
-Prep for surgery
Open reduction internal fixation (ORIF) Hip fracture treatment
Surgeon, puts bones back in place with screws and stuff, its stabilization
Surgery Recommended within 24-36 hours of the fracture
Antibiotics are given before and after
DVT precautions
Total hip arthroplasty hip fracture treatment
-Upper femur and socket are completely replaced
Surgery Recommended within 24-36 hours of the fracture
Antibiotics are given before and after
DVT precautions
Partial hip arthoplasty, hip fracture treatment
End of femur is replaced with metal
Surgery Recommended within 24-36 hours of the fracture
Antibiotics are given before and after
DVT precautions
Complications of Hip fracture
-Infection
-Osteomyelitis
-Compartment syndrome, Neurovascular compromise
-Fat embolism and DVT
-aVascular necrosis
-Shock
Osteomyelitis
Bone infection
Compartment syndrome
Increased pressure on individual compartments within fascia, fascia doesn’t expand
-Frequent neurovascular assessments
-6 p’s
-If not reversed within 6 hours you are getting amputated
-Leads to blood and nerve damage and potentially limb compromise
-Pressure builds up and pressures on the nerve and blood vessels
-DIC
Avascular necrosis
Failure of an area to heal, due to poor perfusion leading to death of tissue
5 P’s
Pain, pallor, Paresthesias, Paralysis, pulselessness
Early sign of compartment syndrome
Pain, unrelieved by anesthesia
Late sign of compartment syndrome
Pulselessness
Compartment syndrome mgmt
-Call provider, loosen clothing, remove jewelry
-Keep limb heart level
-surgical mgmt with a fasciotomy, Leave open to air or wound vac
Pre-op mgmt of hip repair
Instruct on use of incentive spirometer, before procedure
Make sure informed consent is signed, if not call the provider to come back and talk
Review labs
-CBC
-Electrolytes
-BUN and creatinine
-Chest x-ray
-ECG
Teach about postoperative care
-Transfusion
-Drains,
-Pain control
-Transfer, PT
-Hip precuations
Post op mgmt of pt with hip repair
-Pain control, may have a PCA
-Prevent joint dislocation
-Assess neurovascular status
-Notify provider of any changes such as swelling, increased join pain, pain, bleeding, infections
-Caring for incisions with daily soap and water cleaning
-PT, will be discharged with PT always
-Monitor for DVT and PE
-Use anti-embolism stockings
-Anticoagulation
-Monitor for bleeding
-Prevent pressure ulcers
-Offload heel with a blanket
-Emotional support
Who takes care of the first dressing change
Surgery, then we can take care of it
Preventing hip dislocation
-Maintain neutral position of the hip
-Trochanter rolls
-Maintain abduction of hips NO CROSSING LEGS
-Ambulatory aids
-Elevated toilet seat
-Straight back arm chairs, avoid flexion
-Avoid turning to the affected side
What degree of flexion should be avoided to prevent hip dislocation
90 Degrees
DONT CROSS LEGS
DONT BEND FORWARD AT THE WAIST OR MOVE LEGS PAST 90 DEGREES
DONT TURN FOOT IN AND OUT EXCESSIVELY
Early ambulation with hip surgery
-Moving within 24 hours after surgery
-Using proper assistive devices
Wound care hips surgery
Dressings
-Drains, record drainage
-Lab values, monitor for anemia, may need transfusion
Infection control
Amputation Definition
-Partial or complete removal of a limb
-Considered a surgical reconstruction procedure
-Used to relieve symptoms, improve quality of life
Number one cause of non-traumatic amputations
Diabetes
How may an an amputation be used to relieve symptoms/preserve life
-Wound may not be healing, osteomyelitis, sepsis, death
What is number one concern with someone with an amputation
Physical stability, including neurovascular status, pain, surgery
-Other needs are second
RN as facilitator,Amputation
-Help pt identify/mobilize/develop personal strengths
-Physical and psych needs
RN as a nurturer, Amputation
Gentle encouragement/support personal strengths
-Celebrate small accomplishments
-Accept the amputation, being able to look at it
RN in unconditional acceptance, Amputation
Empathy, accept as worthy
No strings attached
Medical Amputation
-74% of cases, DIABETES is number one cause
-PVD, pt is not able to get enough blood flow to the extremity
-Cancer
Gangrene
-Infection (Usually lower extremity)
PVD assessment and mgmt
5 P’s
-Skin feels cool
-Molting of skin
-Try and reperfusion extremity first, if that doesnt work you amputate
Trauma amputation
-23% of amputations
-Crashing injuries
-Burns
-More risk of infection as wound bed is not clean
Mgmt of Trauma amputation
-Bring the chunk of flesh you took off to the hospital, first wrap it in gauze, put it in a ziplock bag and put the bag on ice. Flesh should not come into contact with the ice directly
-Elevate the affected extremity as its bleeding
Congenital amputation
Kid is born without an extremity
-3% of amputations
-Can affect upper and lower
How is level of amputation determined
-Preformed at most distal site that will heal
-Needs circulation for healing (Evaluated with doppler flowmetry and angiography)
-Cause of amputation
-What level will provide the most function
-What comorbidities they have that can affect healing
What type of amputation is preferred and why
Below knee amputation as the knee is hella important for movement
Open Guillotine amputation , Indication
Used for infection/ poor surgical risk patient
-Used to chop of the extremity to cut away the diseased part, and once the infection subsides they go in for another surgery
Open guillotine amputation
-Clean cut straight through, like they just sawed it off
-Allows for drainage to promote healing
-Healing by granulation and secondary closure
-Stump closure required after infection subsides
Closed flap amputation
-Skin flap covers the residual limb
Used mostly for vascular disease
-Done after guillotine amputation only after infection subsides
Nursing interventions post op amputation
-Prevention of complications (DVT, PE, Urinary stasis, Pressure ulcers)
-Prevention of hemorrhage (Slow vs massive)
-Pain mgmt
-Prevent infection
-Promote wound healing
-Absence of altered sensory perception (Phantom limb pain)
-Acceptance of altered body image
-Promotion of self care
-Restoration of physical mobility
Pre-op priorites, teaching Amputation
-Teaching coughing, deep breathing (Prevent resp complications)
-Positioning and OOB asap
-Pain control
-Dressing type (Residual limb, rigid cast)
-Placing prone to prevent contractures
Immediate post op nursing interventions, amputation: Hemorrhage
-Massive vessel can be severed, monitor vitals and drainage to see
-Keep tourniquet at bedside
-Also look out for S+S of poor circulation, if there isnt a pulse, notify provider know as that can indicate poor blood flow and can lead to limb death
Immediate post op nursing interventions, amputation: Infection
-Wound care and dressing changes
-Preventing edema (Wrapping the residual limb)
-Traumatic amputations have a high risk of infection as the wound is contaminated with what made the amputation
-S+S of infection, red warmth, fever, leukocytes
-If infection, administer antibiotics as prescribed
-Observe wound and drainage
Immediate post op nursing interventions, amputation: Skin breakdown
-Maintain skin integrity
-Can be from immobilization or poorly fitting device
-Healed limbs should be washed and dried 2x a day, nothing aggressive
-No lotions or oils
-Look for blisters
-Limb sock changed daily, make sure there isnt any wrinkles
-Dont wear prosthetic when leg is irritated
A pt with a leg amputation has a blister on the affected leg, should the pt wear the prosthetic, why or why not
No dont wear your prosthetic when there is a blister as it will only further break down the skin
Immediate post op nursing interventions, amputation: Phantom limb pain
-Pain mgmt
-Keeping pt active
-Kneading massage to desensitize
-Distraction techniques
-Trans-cutaneous electrical nerve stimulation. (TENS)
-Local anesthetic
Immediate post op nursing interventions, amputation: Joint contracture
-Prevent deformity
-Mgmt is done by placing pt prone periodically
Immediate post op nursing interventions, amputation: Neurovascular checks
Circulation
-Sensation
-Movement
-Pulses
5p’s
Discharge and planning goals amputations
-Rehab center
-Use prosthetic
-Alleviating pain, preventing complication
-Safe use of wheelchair and how to maximize function
-Theyre grieving the loss of the limb, help with body images
Phantom limb sensation
-Feels as if limb is still there
-More common in traumatic amputations
-Feels so real that a pt might try and step with it
-May have pain sensation
-Warm cold, itching , burning or actual pain
-May last for up to 2 years, diminishing over time
Cause of phantom limb
Caused by intact peripheral nerves proximal to amputated site that carries messages from the brain to the amputated site
Types of prosthesis: Closed or removable rigid cast
-Applied right after surgery
-Controls edema
-Supports circulation, promotes healing
-Shapes residual limb
-Permits attachment of prosthetic extension and early ambulation
-Fiberglass or plaster
Types of prosthesis: Soft dressing (Stump dressing)
-Secured with elastic bandage, allowing for frequent inspection of wound
-Used for when there is significant wound drainage
-Used in pt who need to AVOID early weight bearing
-May require wound drain systems to prevent hematomas and prevent infection
-Distal to proximal, anchoring to highest joint
-Used for uniform compression, lower pain, shape limb, prevent contracture
What amputation patients should avoid early weight bearing
PVD patients
Amputation Cast care, rigid
-BKA might be cast in surgery
-Used to prevent edema, contractures, decrease pain and provide protection
-Cast is in place for 3-4 weeks
-A window might be placed for inspection of wound
Amputation, Soft dressing cast care
Frequent dressing changes
Inspection of suture
-Proper positioning to prevent edema and contractures
-1st 24 hours only elevate leg on pillow to prevent edema
-After 24 hours position pt on abdomen or flat supine position to prevent contracture and allow future use of prosthesis
-Place them prone to prevent hip contractures
-Dont place pillows between legs
-Dont have pt sitting upright in chair/bed for long prolonged period
Why do we place pt prone in amputations
Prevent hip contractures, straightens out angle of the hip
Stump care and wrapping, pt teaching
Figure 8 patterns to SHAPE it into a cone to fit prosthesis, minimize edema
-Wrap and rewrap, every 4-6 hours for the first 24 hours and then at least once a day
-Preform the wrap with extremity elevated to prevent edema
-ROM exercises
-Wound inspection
Figure 8 technique
Distal to proximal, stump to body
-Reapply 3-5 times a day when first starting out
Amputation Rehab
-Proper positioning of limb, No abduction, external rotation, and flexion
-Turn pt frequently, prone is best
-Assistive devises
-ROM exercises
-Muscle strengthening exercises
-Provide pre-prosthetic care, proper bandaging, massage and toughing of residual limb
-Transfer teqniques for bed, toilet, chair ect.
-Ambulation with crutches, walker, wheel chair
-May need psych support
Emergent care for a fracture
-Stabilize pt, immobilize fracture proximal and distal before moving pt
-Splint extremity
-Check color, sensation, and movement, temp (5 p’s)
-Cover an open fracture with a sterile dressing
Purpose of traction
Pulling the limb to realign the bone
-Done in a closed reduction
-Weights must hang free
mgmt of a fracture
-Reduction
-Elevate and Ice
-Neuro checks 6 p’s
-Position changes, maintain skin integrity
-Skin care
-Infection
-Pain mgmt
-get them moving asap
-Coping
-Edema mgmt
Complications of open fractures
Osteomyelitis, Tetanus, gas gangrene
Early complications of fractures
-Shock (Loss of fluid)
-Fat embolism
-Compartment syndrome
-VTE, DVT
-Infection (osteomyelitis, wound)
-DIC: (Wide spread hemorrhage, little blood clot)
Late complications of fractures
-Union of bone isnt ideal (Delayed, malunion, Nonunion)
- Avascular necrosis,
-Complex regional pain syndrome
-Heteropropic ossification
Heteropropic ossification
Bone grows where bone shouldnt grow, calcification
Shock mgmt
ABC
-Intravascular volume replacement
-Stabilize fracture
-Decrease Pain
-Monitor for further bleeding
-More trauma than expected
Fat embolism signs
-Hypoxia, tachypnea, tachycardia, dysnepea, substernal chest pain, low grade fever, crackles
-Chest X ray (ARDS, or normal)
-Petechial rash
-Neuro changes
-Its a diagnosis of exclusion
Fat embolism triad
-Hypoxemia
-Neuro compromise
-Petechial rash
Fat embolism mgmt
-Supportive
-o2, fluids, vassopressors, vent, steroids
Fat embolism
Occurs after something like a bone break where globules of fat travel to where they arent supposed to go like brain kidney and lungs
Complex regional pain syndrome
-Rare occurs from fracture usually
-Pain in limb is disproportionate to fracture
-Can be reflex systemic dystrophy or causalgia
-Causes, burning pain, local edema, hyperesthesis
-Skin can be warm, red, dry, cool, sweaty, cyanotic, or trophic changes, glossy shinny skin, changes in nails and hair
-Main nursing consideration is no BP or venipuncture
