MS Trauma Questions Flashcards
A female patient with osteoporosis comes to the ED after falling suddenly while opening her car door. She said it felt as though her “leg gave way” and caused her to fall. What type of fracture does this patient likely have?
A.Pathologic (spontaneous)
B.Spiral
C.Impacted
D.Incomplete
Answer: A
break or disruption in continuity of a bone that often affects mobility and sensory perception
Fracture
Break is across the entire width of the bone; bone is divided into two distinct sections
Classified by extent of the break: Complete
Break is only through part of the bone
Classified by extent of the break: Incomplete
skin surface over the broken bone is disrupted and causes an external wound
Classified by the extent of associated soft-tissue damage: Open or compound
does not extend through the skin and therefore has no visible wound
Classified by the extent of associated soft-tissue damage: Closed or simple
Occurs after minimal trauma to a bone that has been weakened by disease: Pagets, osteoporosis
Classified by the cause of fractures: Pathologic (spontaneous)
Results from excessive strain and stress on the bone
Classified by the cause of fractures: Fatigue (stress)
Produced by a loading force applied to the long axis of cancellous bone
Commonly occur in the vertebrae of older patients with osteoporosis
Compressing force
Classified by the cause of fractures: Compression
24 to 72 hours after the injury
Hematoma forms at the site of the fracture because bone is extremely vascular
Stages of bone healing: Stage 1
3 days to 2 weeks after injury
Granulation tissue begins to invade the hematoma
Formation of fibrocartilage
Foundation for bone healing
Stages of bone healing: Stage 2
3-6 weeks
Fracture site is surrounded by new vascular tissue known as a callus
Callus formation is the beginning of a non-bony union occurs
Result of vascular and cellular proliferation
Stages of bone healing: Stage 3
3-8 weeks
Callus is gradually resorbed and transformed into bone
Stages of bone healing: Stage 4
From 4-6 weeks up to 1 year
Bone remodeling
Length of time depends on the severity of the injury and the age and health of the patient
In young, healthy adult bone, healing takes about 4 to 6 weeks
Extent injury can lengthen time
Healing time is lengthened in older adults
3 months or longer
Stages of bone healing: Stage 5
A 30 year-old patient who is hospitalized for repair of a fractured tibia and fibula is experiencing altered mental status. Which complication related to the injury might the patient be experiencing?
A.Hypovolemic shock
B.Fat embolism
C.Acute compartment syndrome
D.Pneumonia
Answer: B
Fat embolism syndrome
Acute compartment syndrome
Crush syndrome
Hypovolemic shock
Venous thromboembolism
Infection
Chronic complications
Complications of fractures
Fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or illness
Globules clog small blood vessels that supply vital organs and impair organ perfusion
Early signs
Petechiae is a classic manifestation, but is usually the last sign to develop
Can result in respiratory failure or death, often from pulmonary edema
Fat embolism syndrome
Altered mental status (earliest sign)
Increased respirations, pulse, and temperature
Chest pain
Dyspnea
Crackles
Low arterial oxygen level
Early signs - Fat embolism syndrome
Increased pressure within one or more compartments reduces circulation to the area
Relieve pressure
Pressure can be from an external or internal
Complication:
Early signs of acute compartment syndrome
Late signs
Acute compartment syndrome
tight, bulky dressings and casts
External - Acute compartment syndrome
blood or fluid accumulation
Internal - Acute compartment syndrome
Infection
Persistent motor weakness
Contracture
Myoglobinuric renal
Amputation in extreme cases
Complication: - Acute compartment syndrome
pressure, paresthesia, pallor, paralysis,
Early signs of acute compartment syndrome - Acute compartment syndrome
pain, cyanosis, decreased pulses, pulselessness (rare), necrosis
Late signs - Acute compartment syndrome
Systemic complication
Results from severe or prolonged pressure, hemorrhage and edema after a severe fracture or crush injury
Myoglobin is released into circulation, where it can occlude the distal renal tubules and result in kidney failure
Rhabdomyolysis: myoglobulin in the bloodstream
Priority of care is to prevent Acute Tubular Necrosis
Crush syndrome
From blood loss
Hypovolemic shock
DVT and PE
Venous thromboembolism
Superficial skin wound infections
Deep wound abscesses
Bone infection (osteomyelitis) - IV antibiotics
Clostridial infections can lead to gas gangrene or tetanus and may result in a loss of an extremity
Infection
From loss of blood supply to the bone
Chronic complications - Ischemic necrosis
Fracture that has not healed within 6 months of injury
Chronic complications - Delayed union
A patient has a fracture of the right wrist. What is an early sign that indicates this patient may be having a complication?
A.Patient loses ability to wiggle fingers without pain
B.Fingers are cold and pale; capillary refill is sluggish
C.Pain is severe and seems out of proportion to injury
D.Patient reports numbness and tingling
Answer: D
AN EARLY SIGN
History
Clinical manifestations
Lab
Imaging
Assessment
Mechanism of injury
Medical history (Hx of DM, osteoporosis, CKD)
Drug history (including substance abuse)
History
Depends on the specific traumatic event
Moderate to severe pain
Edema
Ecchymosis (bruising)
Check for neurovascular compromise
Clinical manifestations
could be rapid and result in neurovascular compromise; acute compartment syndrome
Edema
Bleeding into the underlying soft tissues
Ecchymosis (bruising)
Skin color and temperature – distal to the injury
Movement
Sensation – any numbness or tingling (paresthesia)
Pulses - distal to the fracture site
Capillary refill (least reliable) - compromised from other things as well
need know baseline
Pain
Check for neurovascular compromise
No special laboratory tests are available for assessment of fractures
Hemoglobin and hematocrit
Erythrocyte sedimentation rate (ESR) may be elevated
Increased WBC
Elevated serum calcium and phosphorus
Lab
Low because of bleeding caused by the injury
Hemoglobin and hematocrit - Lab
Indicates inflammatory response
Erythrocyte sedimentation rate (ESR) may be elevated - Lab
Indicates bone infection
Increased WBC - Lab
During healing, bone releases these elements into the blood
Elevated serum calcium and phosphorus - Lab
X-rays: tells if have fracture; gold standard to look at fractures
CT
MRI
Imaging
Useful for fractures of complex structures, e.g., joints, spine, pelvis
CT
Useful in determining the amount of soft tissue injury
MRI
Acute pain related to one or more fractures, soft-tissue damage, muscle spasm, and edema - quite bit pain pain
Risk for neurovascular compromise related to tissue edema and/or bleeding - precandent over pain
Risk for infection related to a wound caused by an open fracture
Impaired physical mobility related to need for bone healing and/or pain - not weight bearing for awhile
Priority nursing diagnoses and collaborative probs
Keep her warm and in a supine position
Check the neurovascular status of the area distal to her fracture
Immobilize and elevate the extremity above the heart level
Partial splint therapy
Ice (24 to 48 hours)
Drug therapy
Not walk until know what going on
What care would you expect for treatment of her fracture?
pain, pallor, pulse, paresthesia, paralysis
Check the neurovascular status of the area distal to her fracture
Assess ABC’s and perform a quick head-to-toe assessment
Remove clothing from the fracture site - swelling
Remove jewelry on the affected extremity
Apply direct pressure on the area if there is bleeding
Keep the patient warm and in a supine position
Check the neurovascular status of the area distal to the fracture
Immobilize the extremity
Cover any open areas with a dressing
Emergency care of the patient with an extremity fracture
temperature, color, sensation, movement, and capillary refill
compare the affected and unaffected limbs
Check the neurovascular status of the area distal to the fracture
preferably sterile
Cover any open areas with a dressing
The nurse is reviewing the orders for a patient who was admitted for 24-hour observation of a leg fracture. A cast is in place. Which order should the nurse question?
A.Oxycodone PO PRN for pain
B.Neurovascular assessments every 8 hours
C.CBC and BMP in the morning
D.Regular diet as tolerated
Answer: B
Done more often; assess often
Closed reduction and immobilization with a bandage, splint, cast, or traction
Cast care
Arms, legs, braces, and body or spica casts. Depending on what pat did
Prevent neurovascular dysfunction or compromise
Elevate extremity higher than the heart
Ice for the first 24 to 48 hours
Drug therapy
Improve physical mobility and prevent complications of impaired mobility
Prevent infection
Nonsurgical management
For small, closed incomplete bone fractures in the hand or foot, reduction is not required
Closed reduction and immobilization with a bandage, splint, cast, or traction
Four primary groups of casts
Cast care
Primary nursing concern
Assess the neurovascular status every hour for the first 24 hours and then every 1-4 hours
Prevent neurovascular dysfunction or compromise
Opioid and non-opioid analgesics, anti-inflammatory drugs, muscle relaxants
Meperidine (Demerol) should never be used for older adults because it has toxic metabolites that can cause seizures and other complications
Drug therapy
Involve PT/OT for exercise and inpt/outpt therapy
Improve physical mobility and prevent complications of impaired mobility
Proper wound care
IV antibiotics depending on type fracture or wounds
Wound vacuum-assisted closure system - VAC: depending on size wound area; heal from inside out; prevent osteomyelitis
Prevent infection
A nurse cares for four patients in casts on the orthopedic unit. Which patient should the nurse prepare for a window procedure?
A.Patient in a full leg cast, toes slightly cool, takes ibuprofen for pain
B.Patient developed pressure ulcer under the cast
C.Patient in a partial cast, toes slightly swollen and warm
D.Patient whose cast became soiled with urine
Answer: B
Window: cut out little piece of cast to look at it - eventually replace it - diff areas of compression getting
If needed to realign the bone for the healing process
Open reduction with internal fixation (ORIF) most common method of reducing and immobilizing a fracture
Surgical management
Open reduction
Internal fixation
External fixation
Open reduction with internal fixation (ORIF) most common method of reducing and immobilizing a fracture
Allows the surgeon to directly view the fracture site
Open reduction
Uses metal pins, screws, rods, plates, or prostheses to immobilize the fracture during healing
After the bone achieves union, the metal hardware may be removed, depending on the location and type of fracture
Might take out hardware
Internal fixation
Pins or wires are inserted through the skin and affected bone and then connected to a rigid external frame
increased risk for pin site infection - good pin care
External fixation
related to complications of peripheral vascular disease, arteriosclerosis
Amputations: Types: Elective
often result of accidents
Amputations: Types: Traumatic
Toe
Mid-foot
Syme
Below-knee
Above-knee
Levels of amputation for lower extremities
most of the foot is removed, but the ankle remains
Syme
Hemorrhage - traumatic
Infection - can be sig
Phantom limb pain
Neuroma
Flexion contractures
Complications of amputations
More common in patients who had chronic limb pain before surgery and less common in those who have traumatic amputations; elective amputations
Sensation is felt in the amputated part immediately after surgery and usually diminishes over time
If sensation persists and is unpleasant or painful, it is referred to as phantom limb pain
Phantom limb pain - Complications of amputations
Sensitive tumor consisting of damaged nerve cells
more common in upper extremity amputations
Neuroma - Complications of amputations
Hip or knee flexion contractures are seen in patients with amputations of the lower extremity
Flexion contractures - Complications of amputations
Emergency care for traumatic amputations
Assess tissue perfusion
Manage pain
Prevent infection
Promote mobility and preparation for prosthesis - want them up and moving
Promote body image and lifestyle adaptation - some psychological concerns: talk about that with them
Interventions
Stop the bleeding, stabilize the patient
Wrap the amputated part (finger, hand, toe) in a clean or sterile cloth
Place it in a water tight sealed plastic bag
Place the bag in ice water – but never amputated part directly on ice
Avoid contact between the body part and the water to prevent tissue damage
Emergency care for traumatic amputations - Interventions
After surgical closure, the skin flap at the end of the remaining limb should be pink in a light-skinned person and not discolored in a dark-skinned patient
Tissue should be warm, but not hot - not show signs of infection
Sig edema
Assess tissue perfusion - Interventions
Pain medications per HCP
IV infusions of calcitonin (Miacalcin, Calcimar) during the week after amputation can reduce phantom limb pain - talk to them about it; not dismiss pain
Massage
Heat
TENS unit
Ultrasound therapy per PT - vibration to deliver heat
Manage pain - Interventions
Which of the following statements identifies the patient as at highest risk for musculoskeletal trauma?
A.“I removed my area rugs at home so that I don’t trip over them”
B.“My mother had osteoporosis, so I am very careful when I ride my motorcycle”
C.“I don’t drink alcohol if I have to drive”
D.“I always wear my helmet when I ride my bicycle.”
Answer: B
Fam history and ride motorcycle
Health teaching should focus on: - SAFETY
Airbags and seatbelts
Osteoporosis screening and self-management
Fall prevention
Home safety assessment and modification, if needed; rugs, not as many steps
Dangers of drinking and driving
Drug safety (prescribed, OTC, illicit)
Older adults and driving - ensure safe to cont that
Helmet use when riding bicycles, motorcycles, all-terrain vehicles (ATVs), and skateboards
Health promotion and maintenance
