Week 7 - Bone Fractures Flashcards
what is a fracture
- disruption or break in the continuity of the structure of bone
what 4 ways can fractures be classified and what do they mean
- open = skin is broken, bone exposed, soft tissue injury
- closed = skin not ruptures, skin intact
- complete = break completely thru the bone
- incomplete = occurs partly across the bone, bone still in one piece
what are symptoms of fractures (8)
- immediate localized pain
- decreased function
- inability to bear weight
- obvious bone deformity may be present
- extremity immobilized in position it was found
- swelling
- bruising
- crepitation
what is used to diagnose a fracture (3)
- xray
- ct
- MRI
what are the overall goals of fracture treatment (3)
- anatomical realignment of bone fragments = reduction
- immobilization to maintain realignment
- restoration of normal or near normal function of the injured extremity
what are the 2 types of fracture reduction
- open
- closed
what is a closed reduction
- nonsurgical, manual realignment of bone fragments to their previous anatomical position
- often involves traction & countertraction
- usually performed under local or general anasthesia
what is traction
- process of slowly and gently pulling on a fractured or dislocated body part
- application of a pulling force on a fractured extremitity to attain realignment
after closed reduction, what is done
- traction, casting, external fixation, splints, or braces are used to immbolize the injury to maintain alignment until healing occurs
what are 2 types of traction
- skin
- skeletal
what is skin traction
- traction used for short term treatment (48-72 hr) until skeletal traction or surgery is possible
- includes tape, boots, or splints directly applied to the skin
what is skeletal traction
- traction generally in place for longer periods of time
- provides a long term pull that keeps the injured bone and joints aligned
- involves insertion of a pin or wire into the bone
what is a disadvantage associated w skeletal traction (2)
- risk of infection
- prolonged immobility
what is open reduction
- correction of bone alignment thru a surgical incision
- often includes internal fixation of the bone using wires, screws, plates, pins, rods, or nails
what are the disadvantages of open reduction
- risk of infection
- use of anasthesia
what must be done after open reduction (2)
- early initiation of ROM
- use of machines that provide continuous passive motion to joints
what is the benefit of open reduction with internal fixation
- facilitates early ambulation
= decreased r/o complications r/t prolonged immobility
what is countertraction
- pulls in the opposite direction of traction
for traction to be effective, what is required
- countertraction
how is countertraction supplied
- either by pt’s body weight
- pr weights pulling in the opposite direction and may be augmented by elevated the bed
what is imp r/t traction (3)
- must be maintained continuously
- keep weight off the floor
- keep weight moving freely thru pulleys
what is the benefit of casts
- allows the pt to perform many normal ADLs while still providing sufficient immobilization
what are the 2 types of casts
- plaster
- fiberglass
describe how a plaster cast is applied (4)
- pad bony prominences
- plaster immersed in water then wrapped around affected joint
- plaster sets within 15 min
- 24 hr dry period
how long until a plaster cast is strong enough for weight bearing
- 24-72 h
what is important to educate the pt & family about regarding a plaster cast (3)
- do not cover w blanket –> air cannot circulate = heat builds up = risk of burn
- during the drying period, cast should be kept dry, clean and direct pressure avoided
- handle cast gently w open palm while drying to avoid a dent
what are the benefits to using a fiberglass cast (6)
- lightweight
- stronger
- relatively waterproof
- faster-drying than plaster
- porous (less risk of skin problems)
- allows for almost immediate mobilization)
what should be assessed / included in nursing care for casts (3)
- frequent neurovascular assessments (can interfere w circulation & nerve fnxn if too tight)
- pain assessment & management
- assess for signs of complications
what should pts be taught regarding casts in general(12)
- S&S of cast complication
- do not insert any objects inside cast
- do not cover cast w plastic for prolonged periods
- do not bear weight on new cast for 48 h
- when applying ice in first 24 hr, avoid getting cast wet by keeping ice in plastic bag & protecting cast w cloth)
- exercise joints above & below cast
- do not pull out cast padding
- do not scratch inside the cast (risk of skin breakdown & infection)
- apply ice for first 24 hr to reduce swelling
- elevate above lvl of heart for first 48 h
- dry cast thoroughly if exposure w water (blot w towel, hair dryer on low setting)
- check w HCP before getting fiberglass cast wet
when should you not elevate the extremity above the heart
- if compartment syndrome is suspected
if a pt with a cast is experiencing itchiness, what can they do
- hair dryer set on cool setting can be directed under the cast
what are some S&S of cast complications the patient should report to the HCP (7)
- increased pain
- swelling
- discoloration of distal extremity
- pain during movement
- burning or tingling under cast
- sores
- odour under cast
what should you do if a cast has to be removed in an emergency (3)
- remove cast
- maintain immobility
- call dr
what is external fixation
- use of a metallic device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals
- long term process
what is external fixation used for (3)
- traction
- compress fracture fragments
- immobolize reduced fragments when use of a cast or other traction is not available
what is included in care/assessment of external fixation (5)
- assessment for pin loosening
- pin site care & cleaning
- assessment of infection
- vascular assessment (if pin hits nerve)
- pain should decrease w time
what is internal fixation
- surgical insertion of internal fixation devices (pins, plates, rods, screws) at the time of realignment
what should be included in assessment/care for a pt using traction (9)
- if slings used, inspect exposed skin areas regularly
- skin assessment
- skeletal traction pin site cleaning & S&S of infection
- generally keep pt in center of bed in supine position
- monitor for S&S of complications associated w immobility
- frequent pstn changes
- if exercise permitted, encourage participation in simple exercise regimen
- ROM exercise of unaffected joints
- DB&C
- frequent exercise of the trunk
what does pin site care typically include in skeletal traction (3)
- regular removal of exudates w half strength hydrogen peroxide
- rinsing pin sites w normal saline
- drying area w sterile gauze
what drug therapy is typically involved for a pt with fractures (5)
pts with fractures often experience pain associated w muscle spasms
- central & peripheral muscle relaxants
- NSAIDs
- narcotics
- baclofen
- prophylaxis for complications from immobility (clots)
what is are 2 example of a central and peripgeral muscle relaxant
- cyclobenzaprine
- methocarbamol (robaxin)
in an open fracture, there is risk of tetanus if they have not been previously immunized. what is done in this situation
- use of prophylactic bone-penetrating anitbiotics
ex. cefazolin
why is nutrition imp for a pt with a fracture (3)
- proper nutrition is imp for healing
- promote muscle strength and tone
- enhance ambulation
describe nutrition for a pt with a fracture (8)
- ample protein
- vitamins (esp B, C, D)
- calcium
- phosphorus
- magnesium
- 3 well-balanced meals a day
- fluid intake of 2000-3000 mL/day for bowel and bladder function
- high fibre
in what situation would 6 small meals be preferred over 3 large ones for a pt w fracture
- if have skeletal traction, in body jacket, or hip spica bandage
- prevent abdominal pressure & cramping
if a pt comes in w a fracture r/t trauma, what is the priority
- neuro assessment
what assessment should be done in a pt with a fracture? why?
- neurovascular
- the injury can cause nerve or vascular damage, usually distal to the injury
what does a neurovascular assessment include
- peripheral vascular assessment
- peripheral neuro assessment
what is assessed during a neurovascular assessment
- color
- temp
- cap refill
- distal pulses
- edema
- sensation
- motor function
- pain
compare bilat!
what is assessed during a neurovascular assessment (8)
- color
- temp
- cap refill
- distal pulses
- edema
- sensation
- motor function
- pain
compare bilat!
what is included in the intial interventions for a fracture (12)
- treat life-threatening conditions first
- ABCs
- asses for & control external bleeding w pressure or sterile dressing & elevation of the limb
- splint joints above and below injury
- assess neurovascular status
- elevate limb
- apply ice
- manage pain
- obtain radiographs
- admin tetanyus & diptheria prophlyaxis if skin integirty violated
- mark location of pulses
- splint fracture site
what should you NOT do during the initial intervention of a fracture (2)
- do not attempt to straighten out the joint
- do not manipulate the protruding bone ends
what is included in ongoing monitoring of a fracture (6)
- VS
- LOC
- O2 sats
- peripheral pulses
- pain
- monitor for complications
describe the alignment for a pt with a fracture
- midline, neutral position
what are the benefits of traction
- promotes bone healing
- decrease muscle spasm
- prevent further soft tissue & vessel injury
describe preop care if surgery is required to treat the fracture (3)
- educate on immobilization
- assure that pain meds will be available if needed
- clean skin, remove debris & hair (to reduce risk of infection)
describe post op care if surgery is required to treat fractures (5)
- monitor VS
- neurovascular assessment
- proper alignment and positioning
- pain mngmt
- assess & change dressings for bleeding, S&S of infection
what are some potential complications r/t immbolity in a pt with a fracture (5)
- resp complications
- constipation
- renal calculi
- deconditioning of the cardiopulmonary system
- ulcers
what nursing interventions can be done to prevent resp complication (4)
- DB&C
- spirometry
- turning q2h
- ROM exercises
what nursing interventions can be done to prevent constipation in a pt with a fracture (6)
- activity
- high fluid intake (>2500 mL/day)
- diet high in fiber & roughage
- stool softeners
- laxatives
- maintain a regular time for elimination
what nursing interventions can be done to prevent renal calculi r/t the bone demineralization (2)
- fluid intake >2500 mL/day
- cranberry juice
what nursing interventions can prevent or diminish deconditioning of the cardiopulmonary system r/t prolonged bed rest (3)
- permit pt to sit on side of bed
- dangle lower limbs over bedside
- standing transfers
what are potential complications of fractures (5)
- infection (*open fractures)
- compartment syndrome
- pressure ulcers
- clots
- fat emboli
what types of fractures are at high risk of infection
- open & soft tissue injury
what is included in collaborative care of infection (4)
- aggressive treatment w antibiotics (IV, 3-7 days)
- surgical debridement
- irrigation
- diligent wound care & assessments
what is osteomylitis
- severe infection of the bone, bone marrow, and surrounding soft tissue
- requires long time for healing
early infections usually occur when?
- less than 2 weeks after surgery
what are S&S of infection (10)
- increasing local pain
- redness
- swelling
- warmth
- wound drainage
- fever
- disturbed wound healing
- shiny, taut skin
- odour
- decreased sensation
describe the typically infecting organisms
- usually highly virulent
ex. staph, gram (-) bacilli, clostridial infection, tetanus
what is compartment syndrome
- condition in which elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that space
- causes cap perfusion to be less than what is necessary for tissue viability
what are 2 causes of compartment syndrome
- decreased compartment size
- increased compartment contents
what can cause decreased compartment size
- restrictive dressings, splints, casts, excessive traction, premature closure of fascia
what can caused increased compartment contents (3)
- bleeding
- edema
- IV infiltration
what is important r/t compartment syndrome
- prompt, accurate diagnosis to prevent permanent damage to muscles and nerves
what are the signs of compartment syndrome (6)
- parasthesis
- pain (distal to injury, not relieved by opioids)
- poikolethermia (cold)
- pallor, coolness, loss of normal color
- paralysis or loss of function
- pulselessness or diminished peripheral pulses
what are the signs of compartment syndrome (6)
- parasthesis
- pain (distal to injury, not relieved by opioids)
- poikolethermia (cold)
- pallor, coolness, loss of normal color
- paralysis or loss of function
- pulselessness or diminished peripheral pulses
what is usually the first indicator of compartment syndrome
- pain
what should you not do if you suspect compartment syndrome (2)
- elevate above heart lvl (slows arterial perfusion)
- apply cold compress (causes vasoconstriction= exacerbates it)
what should you do if you suspect compartment syndrome or note changes in pts condition (4)
- notify HCP
- may need to loosen or remove bandage, split cast in half
- surgical decompression may be necessary = fasciotomy
- if rlly severe, amputation may required
what is a fasciotomy
- incision between joints thru skin & fascia to immediately release pressure
describe postop care for fasciotomy (2)
- left open for several days to ensure adequate soft tissue decompression
= monitor for infection - monitor healing
what should be done to prevent compartment syndrome (2)
- assess dressing
- neurovascular assessments
describe the risk of venous thromboembolism in pts w fractures; what increases the risk (3)
- veins of lower extremities and pelvis highly susceptible to thrombus formation
- may occur after total hip or knee replacement surgery
- also can occur r/t immobility
what type of fracture causes increased risk of venous thromboembolism
- hip
how is a DVT diagnosed
- US
what should be assessed regarding r/o venous thromboembolism
- legs: swelling, color, measure (Bilaterally)
- S&S of PE
what is included in prevention of venous thromboembolsim in pts w fractures (6)
d/t high risk = prophylactic anticoagulants
- heparin bolus followed by heparin infusion
- warfarin
- LMWH
- fondaparinux
- dalteparin
- oral agents
what oral agents can be used for prevention of DVTs and PE w fractures (3)
- enoxaparin
- apixaban
- Xarelto
what is fat embolism syndrome
- the presence of systemic fat globules from fractures that are distributed into tissues and organs after a traumatic skeletal injury
what are the highest risk fractures for fat emboli (4)
- long bones
- ribs
- tibia
- pelvis
( fat is released from marrow, these bones have high marrow content)
what are symptoms of a fat emboli
- respiratory distress symptoms
what are some examples of resp distress symptoms seen w a fat emboli (11)
- chest pain
- tachypnea
- cyanosis
- dyspnea
- apprehencsion
- tachy
- decreased PaO2
- confusion
- air hunger
- petechiae around neck, chest wall, axilla, buccal membrane, conjuctiva of eye
- changes in mental status
what can be used to diagnose a fat emboli
- xray
what is the prevention of fat emboli (4)
- assess LOC, petechia, resp
- careful immobilization of long bone fracture **
- DB&C
- minimal repositioning before fracture immobilization or stabilization
what is included in treatment of fat emboli (5)
- fluid resus to prevent hypovolemic shock
- correction of acidosis
- replacement of blood loss
- O2
- intubation or positive pressure breathing if supplemental O2 not good enough
describe the severity of pelvic fractures
- ranges from benign to life-threatening depending on how the injury was sustained & the vasc. damage
what risks are associated w pelvic fractures (4)
- can cause serious intra-abdominal injury
- can lacerate an organ (urethra, bladder, colon)
- lacerate a vessel (hemorrhage)
- paralytic ileus
what are signs of a pelvic fracture (5)
- local swelling
- tenderness
- deformity
- unusual pelvic movement
- ecchymosis on abdomen
describe treatment for a stable, nondisplaced pelvic fracture (3)
- may be on bedrest for weeks
- limited intervention
- early mobilization
describe treatment for complex pelvic fractures (6)
- pelvic sling traction
- skeletal traction
- hip spica casts
- external fixation
- open reduction
- may need OR to stabilize pelvic bones
describe care for a pt with a pelvic fracture (5)
- extreme care in handling & moving
- turn onlu when ordered
- assess bowel & urinary function (bc can damage other organs)
- assess distal neurovasc status
- assess & manage pain
what population are hip fractures common in
- older adults
what are signs of hip fractures (3)
- external rotation muscle spasms
- shortening of the affected extremity
- severe pain and tenderness
what is usually required for management of hip fractures
- surgical repair
- may be temporarily immobilized by Buck’s traction until the physician condition has stabilized and surgery can be performed
what should be considered during treatment of a hip fracture
- impact of immobility on their body system –> nutrition, resp, skin, turning
what may be required for treatment of hip fractures
- pinning
- replacement = prosthesis
what is included in preop care for hip fractures (3)
- analgesics
- education on procedure
- encourage use of overhead trapeze bar for position changes
what is the postop care for hip fracture (8)
- monitor VS
- DB&C
- pain meds
- monitor I&O
- monitor & change dressing
- monitor for bleeding & infection
- neurovasc assessment of extremity
- ## ambulation POD 1
what is there risk for after endoprosthesis
- hip dislocation
how can hip dislocation be prevented post- prosthesis
- keep pillows or abductor splint between knees
what is required for pt to be discharged home psotop for hip fractures (3)
- pt must be able to safely demonstrate use of crutches or walker
- ability to transfer in and out of bed
- ability to ascend and descend stairs
what should NOT be done to avoid hip dislocation for femoral head prosthesis (6)
- force hip into greater than 90 degrees of flexion
- force hip into abduction
- force hip into internal rotation
- cross legs at knees
- put on own sheos or stockings until 8 weeks after surgery without adaptive device
- sit on chairs without arms (needed to aid rising to standing position)
what measures should be taken to avoid hip dislocation post femoral head prosthesis (6)
- use an elevated toilet seat
- place chair inside shower or tube & remain seated while washing
- use pillow between legs for first 8 weeks after surgery when lying on the side allowed by surgeon or when supine
- keep hip in neutral, straight pstn when sitting, walking, or lying
- notify surgeon if severe pain, deformity, or loss of function
- inform dentist of presence of prosthesis before dental work so prophylactic antibiotics can be given if indicated
what measures should be taken to avoid hip dislocation post femoral head prosthesis (6)
- use an elevated toilet seat
- place chair inside shower or tube & remain seated while washing
- use pillow between legs for first 8 weeks after surgery when lying on the side allowed by surgeon or when supine
- keep hip in neutral, straight pstn when sitting, walking, or lying
- notify surgeon if severe pain, deformity, or loss of function
- inform dentist of presence of prosthesis before dental work so prophylactic antibiotics can be given if indicated
a nursing diagnosis r/t fractures is impaired physical mobility. what nursing interventions should be done r/t splinting (5)
- apply splint in position injured body part was found, using hands to support injury site, minimizing mvmt, and using assistance of another HCP
- minimize movement
- monitor for bleeding at injury site
- monitor circulation
- identify most approp splint material
a nursing diagnosis r/t fracture is impaired physical mobility. what nursing interventions should be done r/t traction & immobilization care (6)
- position in proper body alignment
- maintain traction at all times
- monitor neurovasc
- provide trapeze for movement in bed
- monitor skin & bony prominences
- admin approp skin care at friction sites
what nursing interventions should be implemented for cast care when it is wet (5)
- handle w palms of hand until dry
- support cast w pillows during drying period (avoid pillow under heel)
- protect cast if close to groin ( prevent soiling)
- mark the circumerence of any drainage
- elevate casted extremity at or above lvl of heart
a nursing diagnosis r.t fractures is risk for peripheral neurovascular dysfunction. what circulatory precautions should be taken (3)
- perform neurovasc assessment
- prevent infection in wounds to avoid further edema and inflamm.
- maintain adequate hydration to prevent clots & increased blood viscosity
what position should be done for a pt with a fracture
- immobilize or supprot affected body part
- maintain position & integirty of traction
- elevate affected limb 20 degrees or greater above level of heart to reduce edema
what peripheral sensation mngmt should be done for pts w fractures (2)
- monitor for parasthesia
- monitor sharp/dull and hot/cold discrimination
a nursing diagnosis r/t fractures is acute pain. what nursing interventions for pain mngmt can be done
- perform assessment of pain
- provide optimal pain relief
- notify HCP or surgeon if pain-relief measures unsuccessful or pt complaining of increase in pain (sign of compartment syndrome)
- teach use of nonpharmacological techniques
what nursing interventions r/t cast care should be provided
- instruct pt not to scratch skin under cast
- offer alternatives to scratching
- position cast on pillow to lessen strain on body parts
- pad rough cast edges and traction connections to prevent skin irritation
- apply ice for 24-36 hrs
- address pain & symptoms of compromised circulation immediately
what can cause pressure ulcers w fractures (4)
- wet/macerated skin
- immobility
- wet chin pads on aspen collar
- if weight not properly offloaded with traction
