Upgrade to remove ads
Chap 63 Med Surg - Fractures, Hip & Knee replacements, etc.
Terms in this set (89)
displaced fractures are usually what? non-displaced fractures?
displaced are usually comminuted (several fragments/shattered) & non-displaced are usually transverse, spiral or greenstick in which the periosteum is intact across the fracture & bone is still in alignment
stages of healing process (union)?
1. fracture hematoma - occurs w/in 1st 72 hrs. Organization of hematoma into fibrous network w hematoma formation
2. granulation tissue - occurs w/in 3-14 day post injury. Organization of hematoma into fibrous network.
3. callus formation- end of 2nd week of injury, verified w x-ray
4. ossification - cast may removed & limited mobility allowed - bone is in place but fracture still present (3 weeks-6 months)
5.consolidation- fracture closes, ossification continues, x-ray evidence. Up to a year after.
6. remodeling- excess bone reabsorbed, strength is regained little by little. New bone deposited in areas of more stress.
new blood vessels, fibroblasts & osteoblasts. Granulation tissue produces basis for new bone substance called osteoid
new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven about the fracture parts.
types of complications w fracture healing? (7)
Pseudoarthrosis- type of nonunion, false join forms
Malunion- heals in expected time but in unsatisfactory position, could be a deformity
Angulation- type of malunion, heals in abnormal position in relation to midline of structure
Refracture- new fracture at original site
Myositis ossificans - deposition of calcium in muscle tissue
nonsurgical, manual realignment of bone fragments, traction & contertraction are applied?
closed reduction- general or local anesthesia is used
after a closed reduction what needs to be done?
immobilize the site
machines used to prevent extraarticular(outside the joint space) & intraarticular (inside joint space) adhesions?
continuous passive movement machines - they result in faster reconstrcution
which type of reduction facilitates early ambulation?
open reduction internal fixation
open reduction w internal fixation is used for what type of fractures?
how long does skin traction last for?
48-72 hours until skeletal traction or surgery is possible. skin traction can be tape, boots or splints directly on skin
traction weights are limited to how much?
5-10 lbs, a little more if pelvic or cervical traction
assess skin tractions every how many hours?
what does physician insert in order to align or immobilize part?
pins or wires. skeletal is long term to maintain alignment
weight for skeletal tractions?
5-45lbs, too much weight can result in delayed union or nonunion
countertraction is usually supplied by what & can be maintained how?
supplied by patients body weight or weights pulling in opposite direction. Can be augmented by elevating end of bed
it is imperative to do what during countertraction?
maintain continuous traction & keep weights off floor
common tx following closed reduction?
a cast - incorporates joints above & below fracture
slings are contraindicated when...?
when there is proximal humerus fracture. Also encourage movement of fingers (unless contraindicated) to decrease edema.
what should patient be encouraged to do to prevent stiffness & contractures in a sling?
move nonimmobilized joint of upper extremity
what is hip spica cast primarily used for?
femur fractures in kids to immobilize the affected extremity and the trunk securely.
what should be done in lower extremity immobilization?
elevate extremity above heart level for 1st 24 hours, do not place in dependent position & watch for signs of compartment syndrome (increased pressure within confined body space) & excessive edema
what is external fixation?
uses metal pins that are inserted into bones & attached externally to rods to hold bones in place. Used when traction or cast can't be used
what is the protocol for pin care cleaning w external fixation? External fixation used in an attempt to salvage what?
hydrogen peroxide w normal saline. used to salvage extremities that could've been amputated
what is electric bone growth & what are the 3 methods?
used to facilitate healing process by increased calcium uptake, activating bone growth factors & activating intracellular calcium stores. There is non-invasive, semi-invasive & invasive
drugs given to control muscles spasms associated w fractures? Other drug therapy?
soma, flexeril, robaxin. Give tetanus & diphtheria toxoid or tetanus immunoglobulin & antibiotics such as cephalosporin prophylactically.
A condition is which swelling & increased pressure within a limited space compromising blood vessels, nerves or tendons that run through the compartment, can become life threatening?
compartment syndrome, involves pressure in muscle compartment (thick layer of tissue (fascia) separating muscles from e/o)
Fascia is not suppose to expand so the swelling creates pressure on the blood vessels, nerves & tendons.
nursing interventions when using a traction?
As a nurse when using traction, make sure it is the correct weight, make sure it is hanging freely & patient is in correct alignment.
How much protein per kg is necessary in diet? Vitamins for proper healing? Amt of fluids?
1g of protein/kg, vitamins B,C & D & intake of 2000-3000mL/day of fluid
if patient is body jacket, how many meals should they eat?
6 small meals per day to avoid abdominal pressure & cramping
what kind of fractures are considered long term repetitive forces ?
things to include in subjective data?
PMH (trauma, diseases, osteopenia, osteoporosis), meds (corticosteroids, analgesics), surgeries, past injuries, estrogen replacement therapy, calcium supplementation, muscle spasms, weakness to affected area, numbness, tingling. loss of sensation, chronic pain that increases w activity (stress fracture)
things to include in objective data?
General (Apprehension, guarding of injured site), Integumentary, CV (reduced or absent pulse, decreased skin temp, delayed cap refill), Neurovascular
(paresthesias, absent or ↓ sensation, hypersensation), musculoskeletal (restricted or lost function of affected part; local bony deformities, abnormal angulation; shortening, rotation, or crepitation of affected part; muscle weakness),Possible Diagnostic Findings
(Identification and extent of fracture on x-ray, bone scan, CT scan, or MRI)
What area of injury should special emphasis be put?
area distal to site injury.
What 2 things should be assessed during a neurovascular assessment? SLIDE 47
1. the peripheral vascular (nerve or vascular damage, usually distal to injury) look for color & temp, pulses, edema.
2. peripheral neurologic- has to do w the sensation & motor function (have them move fingers, can they feel, paresthesias, etc)
when assessing peripheral neurologic how do you assess upper & lower extremities? What nerves are assessed for upper & lower?
UPPER -the ulnar, median, and radial nerves; abduction and adduction of the fingers, opposition of the fingers, and supination and pronation of the hand.
LOWER- motor function of the peroneal(peroneal nerve on the dorsal part of the foot between the web space of the great and second toes) and tibial nerves (performed by stroking the plantar surface (sole) of the foot.); dorsiflexion and plantar flexion assess
in postoperative management what may be sued to salvage & use a patients own blood?
a blood salvage & reinfusion system. Receives blood in the form of autotransfusion. Blood comes from their joint space or cavity
to prevent hypercalcemia (increases pH of urine) from bone demineralization & constipation what measures can you implement?
give them a fluid intake of 2500mL/day for both & make sure patient mobilizes to prevent constipation
what can you do for a patient w reduced immobility to decrease orthostatic hypotension?
unless contraindicated have them dangle feet over side of bed, have patient perform standing transfers.
when external rotation of hip occurs d/t skin traction on lower extremity what can you do?
place pillow or rolled up towels along great trochanteric region of femur, patient should be in middle of bed in supine position.
for casting care when should ice be applied to fracture site? When should extremity be elevated above the heart? What should frequently be checked?
ice for the 1st 24 hours; keep extremity elevated for 1st 48 hours & neurovascular assessments should be done frequently
what signs related to cast care should be reported to health care provider?
increasing pain, swelling w pain & discoloration, pain during movement, tingling, burning, sores or foul smell
when should you not elevate extremity above heart? During first __ hours weight should not be put on cast.
when compartment syndrome is suspected & for the first 48 hours. Also do not cover cast w plastic for prolonged periods.
5 different degrees of weight bearing ambulation when patient is ready to ambulate?
1. non weight bearing
2. touch down/toe touch (contact w floor but no weight borne)
3. partial weight (25% to 50% of patients weight)
4. weight bearing as tolerated according to patients pain
5. full weight - no limitation
when canes are used which hand is it held in?
the one opposite the injured extremity. The uninjured limb is also advanced last.
direct vs indirect complications of fractures?
direct = bone infection, bone union & avascular necrosis
indirect = blood vessel & nerve damage from compartment syndrome, VTE, fat embolism, hypovolemic shock & rhabdo
what will be high in CBC with osteomyelitis?
the seg rate & WBC. Need a biopsy & culture test to determine cause of infection
Tx of osteomyelitis?
May need surgical debridement & wound vacuum. Need aggressive long term antibiotics, most likely will have a PICC line & will go home w PICC line to continue antibiotic therapy. May need to use beads to help
aggressive surgical debridement is used when?
when there are open fractures - wound cleansed w saline lavage in OR & contused or damaged tissue is surgically removed
to greatly reduce infections post op after an infection in an open wound what can be administered IV?
antibiotics IV for 3-7 days, also impregnated beads
b/c of increased pressure, compartment syndrome presses on what in the body that compromises the tissue within the compartment?
presses on blood vessels, nerves, tendons that run through that compartment
2 basic causes of compartment syndrome?
decreased compartment size from excessive traction, premature fascia closing, splints, etc. or from increased contents r/t inflammation, IV filtration, etc.
most common fractures that could result in compartment syndrome?
distal humerus & proximal tibia but can also happen following knee or leg surgery. Soft tissue injury in areas is a big one as well
how long can it take for ischemia to start taking place in compartment syndrome?
4-8 hours. Compartment syndrome can occur initially or a few days after injury
What are the 6 P's of compartment syndrome?
1. pain distal to the injury that is not relieved by opioid & pain on passive stretch of muscle traveling through the compartment;
2. pressure increases in the compartment;
3. paresthesia (numbness and tingling);
4. pallor, coolness, and loss of normal color of the extremity;
5. paralysis or loss of function; and
6. pulselessness or diminished/absent peripheral pulses.
why should urine be assessed in compartment syndrome?
b/c of possible muscle damage, myoglobin (protein containing heme that carries & stores O2 in muscle cells) released from damaged muscle cells can cause obstruction in renal tubules.
what conditions can result from muscle breakdown secondary to compartment syndrome? s/s?
acute tubular necrosis & acute kidney injury. s/s = dark reddish brown urine
things to do and NOT do in compartment syndrome?
do not elevate above the heart b/c it may lower venous pressure, do not apply ice d/t to vasoconstriction, reduce traction weights & fasciotomy (surgical decompression) may be required. Amputation may be required if severe infection occurs
ways to prevent VTE?
anticoagulation therapy such as warfarin, heparin, etc., anti-embolism stockings, SCD's, ask patient to move extremity of affected area against resistance & ROM exercises on unaffected lower extremities.
Fractures most associated w fat embolisms? surgeries?
long bones, ribs, tibia & pelvis. Also after joint replacement, spinal fusion, liposuction, crush injuries & bone marrow transplantation.
what is considered a contributory factor for deaths assoc. w fractures?
FES (fat embolisms) -systemic fat globules distributed in tissues & organs
2 theories of FES?
1. mechanical - fat from marrow enters systemic circulation & embolizes to organs such as brain, droplets can also produce local ischemia or inflammation
2. biochemical- hormonal changes caused by trauma or sepsis which stimulate release of fatty acids to produce emboli
how long does FES take to manifest? what are some s/s?
24-48 hours. in lungs it could cause ARDS, tachycardia, chest pain, dyspnea, etc. & could cause CNS changes in mental status b/c of hypoxemia such as confusion, elevated temp, headache, etc.
what s/s can help you distinguish fat emboli from other problems?
petechiae located around the neck, anterior chest wall, axilla, buccal membrane, and conjunctiva of the eye helps distinguish fat emboli from other problems.
patient may describe feeling how from fat emboli?
like an impending disaster & patient goes downhill very quickly & can become comatose
diagnostic abnormalities in fat embolism?
Pa02 < 60, fat in blood , urine or sputum, low blood count, ST segment changes, prolonged PT time. Chest xray can show infiltrate called "white out" effect
fat embolism prevention calls for minimization in what with patient?
an injury to the ligamentous structure surrounding a joint, usually caused by a wrenching or twisting motion?
where do most sprains occur?
ankle, wrist, and knee joing
degrees of sprains?
1st degree- mild, involves tears in only a few fibers - mild tenderness & minimal swelling
2nd degree- moderate, partial disruption of the involved tissue w more swelling & tenderness
3rd degree- severe, tearing of ligament, there are a large supply of nerve endings around joint this results in severe pain. Gap in muscle can be apparent or palpated through skin.
excessive stretching of a muscle, the fascial sheath or tendon? Where does this type of injury occur mostly in?
a strain - occur mostly in large muscle groups such as lower back, calf, hamstrings. Can also be classified in 1st, 2nd, and 3rd degree, same concept.
What does RICE stand for and what is it used for?
I- ice applied immediately after injury & not to exceed 20-30 minutes. (heat may also be applied AFTER acute phase of injury, usually after 24-48 hrs)
E- elevation to prevent edema above level of heart, injured part should also be elevated during sleep.
**Can be used in sprain & strains, soft tissue injuries
partial or incomplete displacement of the joint surface?
most obvious clinical manifestation of a dislocation?
deformity. Ex: hip limb an be shorter & often internally rotated
what type of chronic diseases make a person more susceptible to CTS?
persons with DM, peripheral vascular disease, rheumatoid arthritis, woman are also more likely to develop carpel tunnel.
clinical manifestation of CTS? Tinels sign & phanels sign?
numbness, tingling in the distribution of the median nerve.
Tinels sign- tapping over median nerve, positive is a tingling of median nerve over hand
Phalens sign- allow wrists to fall freely for 60 seconds, positive sign = tingling of median nerve over hand
what is an important care implementation to avoid edema?
elevate extremity above heart level to promote venous return & put ice. Do not elevate above heart if compartment syndrome is suspected or give ice b/c can cause vasoconstriction & further exacerbate condition
b/c of high risk of VTE in orthopedic surgery what kind of meds and interventions can you do prophylactically?
give anticoagulant drug (warfarin, LMWH, use SCDS, compression stockings, ask patient to dorsiflexion and planter flex fingers or toes of affected extremity against resistance & do ROM exercises on unaffected lower region.
tx of fat embolism?
EARLY RECOGNITION IS CRUCIAL! careful immobilization, fluid resuscitation to prevent hypovolemic shock, coughing, deep breathing & try not to reposition patient d/t dislodgement possibility of other fat droplets.
how long does it take for s/s of fat embolism to manifest? what are some of the s/s?
24-48 hours maybe earlier if severe. Petechiae d/t decreased oxygenation & continued change in level of consciousness -- these 2 things help distinguish btwn FES & alcohol withdrawal or acute head injury or other problems.
2 types of fractures to the hip? Intra & extra...
1. intraccapsular - are femoral neck fractures. 3 types: 1. capital fracture of head of femur), 2. subcapital (below head of femur), 3. transcervical (fracture of neck & femur)
2. extracapsular - outside joint capsule. 2 types: 1. intertochantic (btwn greater & lesser trochanter), 2. subtrochanteric
in a hip fracture what can be used to relieve painful muscle spasms, used for up 24-48 hours?
care & management of post op for the posterior approach of hip replacements?
more than 90 degrees of flexion, adduction across midline (crossing of legs or ankles) or internal rotation needs to be avoided, so things like putting shoes on, assuming side lying positions incorrectly & using low seats, avoid these activities for up to 6 weeks. Use pillows between knees when patient is turning. Never cross midline.
care & management of post op for the anterior approach of hip replacements?
this approach is more stable in post op and has less complications and very few instructions. Never cross midline
what does lump on buttocks, limb shortening or external rotation in hip replacements?
prosthesis dislocation, tell patient to remain NPO if this occurs. Weight bearing should not be placed on affected extremity for up 6-12 weeks in hip replacements.
some do's and don'ts after a hip replacement? (posterior approach)
do place pillow between legs if supine or lying on non-operative side, inform dentist about prosthesis for prophylactic antibiotics. DO NOT force hip greater than 90 degrees of flexion, put on shoes or stockings without adaptive device, sit on chairs without arms (needed for assistance in sitting)
reconstruction or replacement of a joint to relieve pain, improve or maintain ROM, and correct deformity?
assessing upper extremity strength & joint function is important for pre op care of what?
lower extremity arthroplasty
post op care of arthroplasty?
use of abductor pillows, anticoagulation therapy, analgesia, parenteral antibiotics. D/c planning starts immediately
THIS SET IS OFTEN IN FOLDERS WITH...
Chap 63 Med Surg - Fractures, Amputations, Hip & K…
Hip and Knee Replacement, Osteomyelitis
Nurs 121 Fractures Nursing Management in Alteratio…
Chap 63 Med Surg - Fractures, Amputations, Hip & K…
YOU MIGHT ALSO LIKE...
ADULT HEALTH musculoskeletal system EXAM 4
317 Chapter 62 - Musculoskeletal Trauma…
Músculo Skeletal Part TWO
OTHER SETS BY THIS CREATOR
Combo with "Respiratory/Oxygenation Vocab" and 1 o…
Oxygenation and resp assessment
Combo with "Anti-infective" and 3 others