T7: Fractures & Amputations Flashcards
fractures
A disruption or break in the continuity of the structure of bone
delayed union
fracture healing process more slowly than expected, healing eventually occurs
nonunion
Fracture fails to heal despite treatment. No x-ray evidence of callus formation.
malunion`
Fracture heals in expected time but in unsatisfactory position, possibly resulting in deformity or dysfunction.
Ex: healed wrist fracture that results in a noticeable deformity or limitation in movement due to the bones healing misaligned
angulation
Fracture heals in abnormal position in relation to midline of structure (type of malunion).
Ex: if a child’s forearm bone fractures and heals at an angle, there might be a visible bend in the arm
Pseudoarthrosis
Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site.
could be a long-standing nonunion of the tibia where there is abnormal movement at the fracture site, indicating pseudoarthrosis.
cross check with book
refracture
New fracture occurs at original fracture site.
myositis ossificans
Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury.
Ex: following a deep thigh bruise or trauma, a person might develop a hard, bone-like mass inside the muscle, which is indicative of myositis ossificans
clinical manifestations of fracture
*Localized pain
*Decreased function
*Inability to bear weight or use
*Guard against movement
*May or may not have deformity
if you suspect a fracture what should you do?
immobilize
overall goals of fracture treatment
*Anatomic realignment (reduction)
*Immobilization
*Restoration of normal or near-normal function
closed reduction
Nonsurgical, manual realignment of bone fragments usually done under local or general anesthesia and is immobilized afterwards
open reduction
correction of bone alignment through a surgical incision.
ORIF
open reduction internal fixation
ORIF facilitates
early ambulation that decreases the risk of complications related to prolonged immobility
when do we put on a cast
AFTER the swelling has gone down
what is the purpose of traction
*Prevent or ↓ pain and muscle spasm
*Immobilize joint or part of body
*Reduce fracture or dislocation
*Treat a pathologic joint condition
what is traction
a device that applies a pulling force on a fractured extremity to attain realignment while counter traction pulls in the opposite direction
skin traction
*Short-term (48-72 hours)
*Tape, boots, or splints applied directly to skin
*Traction weights 5 to 10 pounds
what assessment should be done for skin traction
regular assessment of the skin, pedal pulses and cap refill
buck’s traction
a type of skin traction that is used to immobilize a fracture, prevent hip flexion contractures, and reduce muscle spasms.
femur, hip, knee
skeletal traction
*Long-term pull to maintain alignment
*Pin or wire inserted into bone
*Weights 5 to 45 lbs
what are the major complications of skeletal traction
-infection at the pin insertion site
-effects of prolonged immobility
what is the most important thing to remember about skeletal traction?
-KEEP THE WEIGHTS OFF THE FLOOR
-maintain continuous traction
-elevate the end of the bed
What is a body jacket brace used for?
immobilization and support for stable spine injuries of the thoracic or lumbar spine injuries
when does superior mesenteric artery syndrome (cast syndrome) occur
*occurs if the brace is applied too tightly, which results in compression of the superior mesenteric artery against the duodenum.
clinical manifestations of superior mesenteric artery syndrome (cast syndrome)
Abd pain, pressure, N/V
assessment for patients in a body jacket brace and superior mesenteric artery syndrome
*monitoring respiratory status, bowel and bladder function, and areas of pressure over the bony prominences, especially the iliac crest.
-The brace may need to be adjusted or removed if any complications occur.
what is the treatment for superior mesenteric artery syndrome
includes gastric decompression with a nasogastric (NG) tube and suction
after lower extremity cast/dressing application…
the extremity should be elevated on pillows above heart level for the first 24 hours and DO NOT PLACE IN DEPENDENT POSITION after the initial phase to avoid excess edema
signs of compartment syndrome
pain unrelieved by medication, swelling, cyanosis or pallor of the digits, and decreased pulse and skin temperature
external fixation
*metallic device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals.
what indicated infection of external fixation?
exudate, erythema, tenderness, pain
patient teaching for external fixation
*meticulous pin care.
what is often used for pin care
chlorhexidine 2mg/ml
facial fractures intervention
airway maintenance, suctioning, positioning
what is used if there is an obstruction with a facial injury
tracheostomy
since facial and cervical injuries often occur together, what is the nursing action
-put on a C collar until the C spine is CLEAR
-neuro assessment
what is included in a neuro assessment
*GCS, LOC, EOMs, Pupillary response, grips and pushes
facial fracture surgical care
immobilization of maxilla and mandible with intermaxillary fixation (wire mouth shut)
post op care for intermaxillary fixation
*Airway and Nausea/Vomiting management are priorities (antiemetics)
*Elevate HOB, turn to side to AVOID ASPIRATION IF THERE IS VOMITING
*Oral hygiene
*Communication (white board)
*Pain management
*Nutrition
safety concerns for facial fracture post op
*Scissors
*Wire cutters
*REMOVE if concerns with breathing or airway-home teaching
*Emergency tracheostomy kit
*Suction set up with yankauer tip
*NG tube if persisting vomitus
*Antiemetics
amputation
Removal of an extremity by trauma or surgery
goal of nursing care with amputation
*pain management
*maximum rehabilitation potential
*ability to cope with body image changes
indications for amputation
*circulatory impairment from PVD
*traumatic or thermal injury
*osteomyelitis
*malignant tumors
*extremity infection
what needs to be done with a leg amputation
lay on stomach for 30 minutes everyday (proning) to keep the leg muscle stretched out
Post-Op for amputation
*Watch for hemorrhaging
*Blood loss
*Phantom pain
*Compression bandage
*Tourniquet if life threatening
amputation considerations
*Level of amputation
*Preservation of function
*Weight bearing ability of the stump
*Prosthetic fitting
drug therapy for fracture
*Central and peripheral muscle relaxants
*Tetanus and diphtheria toxoid
*Bone-penetrating antibiotics -Cephalosporin (used prophylactically before surgery)
Central and peripheral muscle relaxants
*Carisoprodol (Soma)
*Cyclobenzaprine (Flexeril)
*Methocarbamol (Robaxin)
hypovolemic shock
shock resulting from blood or fluid loss
Absolute hypovolemia
loss of intravascular fluid volume
what is the goal for hypovolemic shock
stop the bleeding and replace what they needs
causes of hypovolemic shock
*Hemorrhage-injury or trauma
*GI loss (e.g., vomiting, diarrhea)
*Fistula drainage
*Diabetes insipidus
*Hyperglycemia
*Diuresis
a volume loss of what will result in SNS mediated response
15-30%
what do we observe with 15-30% volume loss
*increase in heart rate, CO, and respiratory rate and depth. Stroke volume, central venous pressure (CVP), and PAWP are decreased because of the decreased circulating blood volume.
(Hbg. Hct, tachy, low bp, pale)
clinical manifestation of hypovolemic shock
*Anxiety
*Tachypnea
*Increase in CO, heart rate
*Decrease in stroke volume, PAWP, urinary output
what what point are blood products started for hypovolemic shock
is loss id >30%
Labs for hypovolemic shock
*hemoglobin and hematocrit levels,
*electrolytes, lactate, blood gases,
*central venous oxygenation (SvO2),
*hourly urine outputs
how do we give fluids for those in hypovolemic shock
*One or two large-bore IV catheters , intraosseous access device, or central venous catheter
what fluid is given for hypovolemic shock
*Isotonic crystalloids ( normal saline, lactated Ringers) and colloids (e.g., albumin)
HINT HINT what is the total albumin level
3.5-5.0
what is does albumin do?
it coats inner lining of vessel to prevent fluid from leaking out (so if a person is hemorrhaging they lost albumin)
you do not want a lactic acid…
greater than 4
how is volume expansion/ fluid responsiveness determined
*Vital signs
*Cerebral and abdominal pressures
*Capillary refill
*Skin temperature
*Urine output-foley with urometer
*Monitor trends in BP with an automatic BP cuff or an arterial catheter to assess the patient’s response.
what are the two major complications when large amounts of fluid are required
*Hypothermia
*Coagulopathy
If the patient has persistent hypotension after adequate fluid resuscitation, what is done
must fill the tank first
then vasopressor may be added for vasoconstriction effects (norepi, epi, dopamine)
Nursing Assessment fracture -general
*Apprehension, guarding of injured site
Nursing Assessment fracture- integumentary
*Skin lacerations, pallor and cool skin or bluish and warm skin distal to injury; ecchymosis, hematoma, edema at site of fracture
Nursing Assessment fracture- CV
*Reduced or absent pulse distal to injury, ↓ skin temperature, delayed capillary refill
Nursing Assessment fracture- neurovascular
*Paresthesias, absent or ↓ sensation, hypersensation
Nursing Assessment fracture- musculoskeletal
*Restricted or lost function of affected part; local bony deformities, abnormal angulation; shortening, rotation, or crepitation of affected part; muscle weakness
diagnostics for fracture
*Identification and extent of fracture on x-ray, bone scan, CT scan, or MRI
peripheral vascular assessment includes
color, temperature, capillary refill, peripheral pulses, and edema
peripheral neurologic assessment
sensation, motor function, and pain
compartment syndrome
injury caused when tissues such as blood vessels and nerves are constricted within a space as from swelling or from a tight dressing or cast
Two basic causes of compartment syndrome are
*(1) decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia and
*(2) increased compartment contents related to bleeding, inflammation, edema, or IV infiltration.
what do we do if we measure an extremity and it is bigger?
call the doctor, compartment syndrome!
HINT HINT: SIX P’s of compartment syndrome
*Pain (not managed by opioids)
*Pressure (increasing)
*Paresthesia (numbness and tingling)
*Pallor
*Paralysis
*Pulselessness
what is an early sign of compartment syndrome
paresthesia
why do we assess UO and kidney function for compartment syndrome
because of the possibility of muscle damage (rhabdomyolysis) Myoglobin released from damaged muscle cells precipitates and causes obstruction in renal tubules. This condition results in acute tubular necrosis and acute kidney injury. (look for *dark reddish brown urine and clinical manifestations associated with acute kidney injury.)
interprofessional care for compartment syndrome
*NO elevation above heart
*NO ice
*Surgical decompression (fasciotomy)
interventions for VTE
VTE
*Prophylactic anticoagulant drugs
*Antiembolism stockings
*Sequential compression devices
*ROM exercises
Fat Embolism Syndrome (FES)
*characterized by systemic fat globules from fractures that are distributed into tissues, lungs, and other organs after a traumatic skeletal injury.
The fractures that most often are associated with FES include
long bones, ribs, tibia, and pelvis.
clinical manifestations of Fat Embolism (FES)
*respiratory symptoms: chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and decreased partial pressure of arterial O2 (PaO2).
* neuro symptoms impending doom, memory loss, restlessness, confusion, elevated temperature, and headache
*Petechiae located on the neck, anterior chest wall, axilla, buccal membrane, and conjunctiva of the eye
what is the dead give away for fat emboli
Petechiae located on the neck, anterior chest wall, axilla, buccal membrane, and conjunctiva of the eye
initial interventions for fat emboli
HOB up and O2
lab changes for fat emboli
*Fat cells in blood, urine, or sputum
*↓ PaO2 < 60 mm Hg
*ST segment and T-wave changes
*↓ Platelet count, hematocrit levels
*Elevated ESR
*Chest x-ray →bilateral pulmonary infiltrates
Fat Embolism (FES) Interprofessional Care
*Treatment is directed at prevention
*Careful immobilization and handling of a long bone fracture probably the most important factor in prevention
*Management is supportive and related to symptom management
*Coughing and deep breathing
*Administer O2
*Intubation/ intermittent positive pressure ventilation
