Week 7 - Injury Prevention

Question 1

Strains and Sprains

Answer 1

Approximately 50% of work-related injuries are for sprains and strains of muscles and ligaments.

Back (particularly lower back) and ankle injuries are the most commonly occurring injuries, but they can occur in any muscles or ligaments.

Question 2

What is a Strain?

Answer 2

Injury to the muscle as a result of over-stretching of the muscle eg lower back (most common)
Swelling may be present

Question 3

What does it feel like?

Answer 3

Patient may feel a “pop” sensation as the strain injury occurs
Movement may increase the pain
May experience cramping or muscle spasms
May have decreased range of movement

Question 4

How do we treat it?

Answer 4

Rest	
Ice	
Compression	 
Elevation 
   (lay down if it is more comfortable)
Non-steroidal anti-inflammatories 
Begin mobilising after first 24 hours to aid recovery, may be referred to physio
Should be healed within 2 weeks: if not, seek further review

Question 5

Prevention of Strain Injuries

Answer 5

Avoid twisting the torso where possible
Warm up before exercise
Obesity and poor muscle tone increase risk (healthy diet, exercise decrease risk)

Question 6

What is a Sprain?

Answer 6

Ligaments are fibrous bands of tissue that connect two or more bones at a joint and prevent excessive movement of the joint.

A strain is an injury to a ligament (stretch or tear) due to the body part being moved in the wrong direction

Ankle and Knee most common sites for sprains
Swelling, bruising may be seen at the site.
.

Question 7

What does it feel like?

Answer 7

Can be extreme pain on movement

Patient may not be able to weight-bare on the effected limb

Question 8

How do we treat sprains?

Answer 8

Rest (including crutches for legs)
Ice
Compression
Elevation
All for the first 24 hours: do not use heat or massage as a treatment in this first phase

May be referred to physio
Severe ligament tears may require surgery eg cruciate ligament.

Question 9

Prevention of sprains

Answer 9

Take care of surroundings and wear appropriate footwear
Warm up before exercise
Strapping of limbs which are prone to sprains during sport

Question 10

Fractures: how often?

Answer 10

In Australians 35-55 years, men sustain twice as many fractures as women
35-55 years, the fracture rate (persons per 10,000/year) in men was about double the rate in women. (Risk-taking, manual tasks, contact sports)

Question 11

Fractures

Answer 11

Most common (across the lifespan) are hip, spine, distal forearm (Colles), humerus, tibia/fibula, ankle (in decreasing order of rate of occurance

Question 12

Fractures

Answer 12

Any bone can be fractured)(Hip fractures not covered in HOA, as previously covered in HOOA)
The fracture rate between men and women starts to even out after the age of 60, when fractures due to falls and osteoporosis become more common

Question 13

Fracture Prevention

Answer 13

Safety initiatives: MVAs, industrial safety, home handyman safety, farm safety, helmets
Bone health: high calcium diet +- calcium supplements for older adults
Weight-baring exercises increase bone strength
Healthy weight range

Question 14

Types of fracture: closed and stable

Answer 14

The most common, and easiest to treat fractures are closed and stable fractures.
This occurs when the bone stays in its natural alignment when broken, and doesn’t pierce the skin.
For limb fractures, a cast is applied to minimise bone movement during the healing period.

Question 15

Casts: backslab

Answer 15

A backslab cast is applied first, with a bandage to keep in place, to allow for swelling.

Question 16

Full Cast

Answer 16

The patient then returns to the ED or fracture clinic at a later date for a full cast.
The cast will become warm during the chemical process: this is normal (first hour).
Tell the patient to be careful
for the first 24 hours whilst
the plaster sets.

Question 17

Dynacast

Answer 17

Dynacast, and other similar products, are sometimes applied over the plaster of paris cast, to give extra durability. They are sometimes coloured, or
even glow in the dark!

Question 18

key points about cast

Answer 18

Whilst some settings have casts which are advertised by companies to be able to get wet, this is never advisable.

Water under the cast can lead to cast failure, or worse, skin breakdown.

Also, patients shouldn’t poke knitting needles etc down cast to scratch skin

Patients receive slings for arm casts and crutches for leg casts.

Casts generally stay on for 6 weeks, after which they are removed with a plaster saw.

The bone is then X-Rayed to ensure that the bone is completely healed.

Patients generally find it difficult to move that limb for a few days after plaster removal (muscles lose condition)

Patients can get arthritis after fractures, often many years later.

Question 19

Closed and unstable fractures

Answer 19

Sometimes fractured pieces of bones are displaced from each other, and this generally requires surgery to re-align the bones.

Question 20

Pins and screws

Answer 20

It may require temporary or permanent pins and screws for fixation

Question 21

what is an Open fracture

Answer 21

A fracture which pierces the skin.
Can be more complex to fix and increased risk of infection, patient will be
prescribed antibiotics.

Question 22

Potential risks after fractures: Pain

Answer 22

For simple fractures, oral analgesia PRN may suffice. It could be a combination of paracetamol, ibroprufen and oral opiods.
For more complex fractures, the inpatient may be prescribed an opiod via PCA/infusion/epidural

Question 23

Potential Risks: Compartment Syndrome

Answer 23

A full cast can provide a compartment, and this is one of the reasons for backslabs for initial stabilisation.
Skin can also create the compartment.
Swelling after the injury has nowhere to go, and tissue begins to die.

Question 24

key points of Compartment syndrome

Answer 24

Any patient reports of tingling, burning should be reported and documented: may be expected but you should check with the surgeon

Neurovascular observations can detect changes which could indicate compartment syndrome, and therefore should be done for every patient with limb trauma:
Colour Warmth Movement Sensation

Sometimes the treatment can simply be removing the cast, but if the skin is creating the compartment, the patient may require a
fasciotomy

Question 25

Potential Risks: Fatty Embolus

Answer 25

When the bone breaks open, fatty tissue (bone marrow fat) can break off and create an embolus.
The symptoms seen will depend on where the embolus lodges eg Pulmonary Embolus

Question 26

Potential Risks: Delayed or non-union of bones

Answer 26

Sometimes the bone doesn’t knit together properly, and the patient may have to have another cast put on, or have further surgery to encourage bone repair.

Question 27

Potential Risks:Osteomyelitis

Answer 27

The bone can become infected (osteomyelitis). The patient may not become symptomatic for a few weeks.
Requires long-term IV antibiotics (can often be completed with a PICC line in the community, over around 6 weeks)

Question 28

Special Fractures: Femure

Answer 28

For trauma patients who arrive to ED with one leg shorter than the other, or one leg rotated, suspect femoral fracture.
These patients require a Thomas splint and it should not be removed until the patient goes to surgery.

Question 29

Special Fractures: Pelvis

Answer 29

If the patient arrives with pelvic sling, do not remove until the patient goes to theatre.  If you don’t have a sling, a sheet tied around the
   pelvis and feet
   taped together 
   will perform the
   same role

Question 30

Traction

Answer 30

Sometimes Traction is applied to either keep the healing fracture in alignment and/or reduce muscle spasms around the fracture for patient comfort.

Question 31

Special fractures: Spinal Injuries

Answer 31

For trauma patients who have any likelihood that the mechanism of injury could cause a spinal fracture, the C-Spine must be immobilised with sandbags or a collar and the patient must be
log-rolled until cleared by an
orthopaedic registrar/consultant and
not before.

Question 32

The history of pain

Answer 32

Pain management has an extensive history that has concerned people, understandably, over the span of time.

Missing from these historical accounts are inputs from nursing and a patient’s perspective.
Therefore, theoretical perspectives of caring from a nursing perspective are absent within these early accounts.

• This explains the biomedical dominance about pain

> Objectification of pain as solely reliant of underlying physiology and pathology

> Pain was categorised into typologies and compartmentalised into aspects that overtly objective by being measurable

In 1994 Mersky and Bogduk argued that pain was a symptom, to be alleviated in the short term while waiting a diagnosis or cure for underlying cause

Question 33

Definition of pain

Answer 33

Adopted by the international association for the study of pain;
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
(Merskey & Bogduk, 1994, p. 45)

As Melzack and Wall (1996) note however, this definition, like others, is inadequate. To describe pain as unpleasant falls short of the full reality of the experience of pain.

What is missing in the word ‘unpleasant’ is the misery, anguish, desperation and urgency that are part of some pain experiences.
(Melzack & Wall, 1996, p. 45)

Question 34

Pain defined

Answer 34

Most people would agree with the definition of pain as an unpleasant sensory and emotive experience associated with actual or potential tissue damage

Some might argue that no involvement at a tissue level is required for the experience of pain

• Pain can occur contrary to overt bio-medical objectification, when a person is viewed only by medical imagery comprised of scans or details of neuronal pathways and chemical markers with no attention to who they are

A more moderate ideal is that a person’s experience of pain will depend on both the degree of sensory stimulation and how the person perceives their experience

Question 35

Pain theories

Answer 35

Gate control theory from 1965
Pain is a series of impulses
The control and modulation of pain is a lot more complex
Central sensitisation
Explains painful signals that create a cascade of changes in peripheral and central neurons
Manifests as pain hypersensitivity

Question 36

what are the 3 internationally accepted terms used to describe pain

Answer 36

Allodynia
Hyperalgesia
Hyperpathia

Question 37

what is Allodynia

Answer 37

lowered threshold
test by brush wth cotton swab
stimulus and response mode differ
pain from stimulus that does not normally cause pain

Question 38

what is hyperalgesia

Answer 38

increased response
pinprick or test
stimulus and response mode are the same
an increases response to a stimulus that is normally painful

Question 39

what is hyperpathia

Answer 39

Raised threshold and increased response
pinprick or pinch test
stimulus ans response mode may be the same or different
a painful syndrome that is an abnormally painful reaction to a stimulus particularly if it is repeated

Question 40

Accepted standardised definitions

Answer 40

Nociceptive pain – somatic localised pain detected by receptors located within skin, muscles and bone
Visceral pain- poorly localised, detected by receptors located within an organ such as intra-abdominal or liver
Neuropathic pain- stroke, herpetic neuralgia, degenerative diseases of the spine can produce radicular pain, peripheral neuropathy
Headache pain
Other pain conditions myofascial pain, fibromyalgia syndrome as well as chronic back pain

Question 41

what are the 3 common pain definitions

Answer 41

Referred pain
Pain perceived in an area distant from the site of stimuli and often occurs with visceral pain

Phantom pain
Not a phantom sensation
After surgical removal eg mastectomy
Common amongst amputees

Central pain
Related to a lesion in the brain or spinal cord
Produces a high frequency burst of pain
Can produce hyperaesthesia on the side of the body opposite the lesion

Cancer pain
A challenge to manage
Often a combination of any of the previous pain definitions
Cancer Breakthrough pain
Can be persistent and management is palliative pain care

Question 42

Breakthrough pain

Answer 42

The nature of breakthrough pain is that it is not a single entity but can be related to a number of different causes such as cancer, clinical interventions, and concomitant illness.

It can have different patho-physiologies either nociceptive, neuropathic or mixed

Question 43

Neuropathic pain

Answer 43

Neuropathic pain is a clinical description and not a diagnosis.

It covers a spectrum which is defined by the IASP as being pain initiated or caused by a primary lesion or dysfunction in the nervous system

Neuropathic pain can be caused by either a multitude of distinct or co-existing aetiologies, these being toxicity, metabolic disease, trauma, compression, autoimmune disorders, and infection as well as congenital disease like multiple sclerosis
Chemotherapy can induce neuropathic pain and this results from toxicity induced from oncology drugs with the severity and incidence depending on the regime, dose and schedule

Question 44

Onset of pain: precipitated, non-volitional, and procedural.

Answer 44

Common clinical conditions that are associated with pain onset such as orthopaedic injuries from a fall, temporal arteritis, and any bone pain at night as well as vascular compromise
Precipitated pain can be sub-classified into one of three categories.
Volitional incident pain, which is pain that occurs from engaging in voluntary acts such as walking
Non-volitional incident pain which is brought on by involuntary acts such as sneezing and coughing
Procedural pain that is related to therapeutic interventions during care provision, such as wound care or diagnostic tests and interventional procedures

Question 45

Acute pain

Answer 45

Acute pain is defined as a time limited response to trauma, surgery, or other ‘noxious experiences’.
A sudden onset and the type of pain that most people experience
Stimulates flight or fight response
Generally managed post-operatively or post trauma within the acute care setting in either medical or surgical wards

Question 46

Chronic pain

Answer 46

Persistent, or chronic pain is defined as;
Pain that continues past the normal duration of tissue damage or the period of the healing processes, and that lasts for three out of six months.
The term persistent pain is often used interchangeably with chronic pain.

Question 47

Association between acute and chronic pain

Answer 47

If left untreated, acute pain that is associated with surgery, trauma or other conditions, can progress to a state of chronicity

When acute pain is not relieved there may be pathophysiological neural alterations, including peripheral and central neuronal sensitisation, that can evolve into a chronic pain syndrome leading into a disease state

Chronic pain is part of a disease state, and this removes the impetus for a focus on curing and for providing an emphasis on prevention

When chronic pain is viewed as a disease state this also allows the recognition of the sufferers as having poor overall health and a reduced quality of life

Question 48

The older person and chronic pain

Answer 48

The presence of chronic pain can lead to maladaptive physical, psychological, familial and social consequences which can also contribute to further decrease their quality of life
It can also lead to older persons experiencing higher levels of depression, anxiety and reduction of physical activity creating a cycle of increasing isolation socially

Question 49

Why is it so hard for a nurse to assess pain

Answer 49

The perceptions held by people regarding pain vary; this is because values are often based on ideals which are founded individual experiences of health.

Therefore, any idea held about pain will be a cultural reflection of that society

Conversely your perceptions about their pain will also be a cultural reflection of the context, environment and your own cultural reflections

Question 50

Why are peoples pain perceptions so different?

Answer 50

Pain is and always remains a deeply personalised and subjective experience.
Furthermore, not only will a person’s account of pain be subjective, but the reception of their accounts of their pain and its inherent nature will also be received in a subjective manner.
In order to counter this there is a prevailing use of objective measurement for standardisation of pain

Question 51

How much pain is painful?

Answer 51

A pain threshold is defined as the least or minimum intensity that a person will experience or perceive pain, and not the intensity measured as an external event

This means that a stimulus such as a broken bone cannot be a sole measure of pain.

The tolerance level of pain that a person has will be the maximum intensity that, within their subjective experience, they are willing to accept.

Eg for an older person to have pain but still be able to walk to the toilet

Question 52

Pain and dementia

Answer 52

Assessment of pain for those with dementia is a challenge
More so if they are also affected by delirium or depression
What to look out for (observational)
Protective body gestures
Self protection of sore areas
Expression
Sleep pattern
Washing or dressing
Mobility
Communication

Obtain self report if unable to document why self report cannot be used
Search for potential causes of pain
Observe behaviour, list behaviours and use a tool
Proxy reporting- ask the care giver or family member
Attempt an analgesic trial

Use a behavioural pain assessment tool

Question 53

PQRST of pain

Answer 53

P- Provocative factors OR palliative factors
Q- Quality or characteristics
R- Region, pattern of radiation, referal
S- Severity, intensity ( use pain tools)
T- Temporal factors: onset, duration, time to maximum intensity, frequency, daily variation

Question 54

Pain assessment is a social transaction

Answer 54

The accepted gold standard for pain assessment was developed over 46 years ago by McCaffery (1968) who provided the seminal statement that:
“Pain is what the person says it is and exists whenever he or she says it does”
For the older person;
They often will not use the word ‘pain’.
Use other terms like ‘sore, aching, backache’
Can ask if they are uncomfortable
Can ask how bad is the ache- is it stopping you from moving
A lot of people do not have pain at rest

Question 55

Pain assessment tools: No one tool fits all

Answer 55

Numerous types
Visual analogue scales, numerical rating scales and verbal rating scales
Have been in use since ‘50s Hjermstad et al. (2010)
Lichtner et al. (2014) noted that no one pain assessment tool could be recommended for those older persons with dementia,
Concluded that because of a lack of evidence in relation to their reliability, validity and clinical utility.
No-one tool can be recommended for anyone because of a lack of evidence
Need to use a standardised approach consistently
It is known that the verbal response scale, due to its psychometric properties, is better to use and more reliable than that of numerical scale (Hjermstad et al., 2010).

Question 56

EBP and pain scoring

Answer 56

Nurses and patients hold differences of opinion in relation to values attributed to pain score results, due to an incongruence held between them about what numerical rating of pain actually means (Blomqvist, 2003; Coker et al., 2008; Manias, Bucknall, & Botti, 2005; van Dijk et al., 2012; Ware et al., 2015).

Patients indicated that using a numerical value did not provide enough information for;
how they experienced their pain, and
providing a numerical value for their pain was difficult (Eriksson et al., 2014).

Eriksson et al. (2014) study described patients not getting enough information from health care professionals about what the pain score was for,
and that they felt they had to provide an expected response about their pain both at rest and on movement.

Question 57

A singular numerical value for multiple types and sites of pain

Answer 57

Consider this comment made by Suzanne when asked to speak about what it is like to have a nurse ask her to rate her pain,
‘When people [nurses] ask you ‘what is your pain like?’ I have nothing to compare it with. Because it is really hard, I don’t know how to compare one pain with another pain and then rate it? Rate it!? How do you do that? I don’t know. All I do know is that the pain in my foot isn’t or hasn’t been as bad as some of the other pain that I have had, but I can’t rate it’’
Suzanne has central pain from a lesion, neuropathic pain (hyperalgesia) with increasing paralysis on her left side, cancer breakthrough spinal pain, surgical pain ( craniotomy) and pain from a fractured ankle due to a recent fall as well as headache pain from epilepsy

Question 58

Pain management

Answer 58

Effective pain management is a reduction of the intensity of pain that is meaningful for the patient (Hadjistavropoulos et al., 2007).
Involve the older person in their treatment improves their pain control (Katz & Gibson, 2012; Scottish Intercollegiate Guidelines Network, (SIGN) (2008).
Pain management can be delivered by a variety of means, these being pharmacological, non-pharmacological, and cognitive based interventions (Hadjistavropoulos, Hunter, & Fitzgerald, 2009).
Reassessment to determine if the provided pain relief, such as medication, has worked is required

Question 59

Plan pain management

Answer 59

Patient needs to be turned
Experiences pain on turning
What do you do?
Establish a plan
Prepare the patient and the family
Prepare the team
During the procedure
After the procedure

Czaarnecki (2011) Procedural pain management: A position statement with clinical practice recommendations

Question 60

Non-pharmacological

Answer 60

TENS
Heat packs
Cold packs
Massage therapy
CBT (cognitive behavioural therapy)
Complementary medications
Acupuncture
Distraction therapy
Elevation 
Exercise
Yoga, Tai Chi

Question 61

Goals of pain management

Answer 61

An outcome that is acceptable for the older person
Reducing acute pain in a timely manner
Improving and maintaining function
Reducing unwanted impacts of chronic pain
Prioritising pain relief for end of life care