Chapter 63 Nursing Management Musculoskeletal Trauma and Orthopedic

Soft Tissue Injuries Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Sprains and Strains Sprains and strains Ø Sprain - injury to tendinoligamentous structures surroundin

Sprains and Strains Sprains and strains Ø Nursing implementation • Acute intervention • RICE

Dislocation and Subluxation Dislocation Ø Severe injury of the ligamentous structures hat surround the

Dislocation and Subluxation Clinical Manifestations Ø Deformity, pain, loss of function Collaborative management Orthopedic

Fig. 63 -1 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Bursitis Inflammation of the bursae Clinical manifestations Management Copyright © 2007, 2004, 2000, Mosby,

Fractures A disruption or break in the continuity of the structure of the bone

Fig. 63 -6 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Fig. 63 -7 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Fig. 63 -8 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Fractures Clinical Manifestations History - mechanism of injury Ø Pain Ø Decreased function Ø

Factors Affecting Fracture Healing Age Initial displacement Blood supply to the area Immobilization Infection

Fractures (cont'd) Collaborative care Ø Fracture reduction • Closed reduction - nonsurgical • Open

Fig. 63 -10 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Fractures (cont'd) Collaborative care (cont'd) Ø Fracture immobilization • Casts Types of casts Injuries

Fig. 63 -12 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Fig. 63 -13 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Fig. 63 -14 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Fractures (cont'd) Collaborative care (cont'd) Drug therapy • Pain mgmt • Muscle relaxants •

Nursing Management Fractures Nursing assessment Ø Neurovascular assessment Nursing diagnoses Ø Impaired physical mobility

Nursing Management Fractures Planning Have physiologic healing with no associated complications Ø Obtain satisfactory

Nursing Management Fractures (cont'd) Nursing implementation (cont'd) Ø Acute intervention • Preoperative management §

Nursing Management Fractures (cont'd) Nursing implementation (cont'd) Ø Acute Intervention • Postoperative management •

Nursing Management Fractures (cont'd) Nursing Implementatjon Ø Other measures • Prevention of constipation •

Nursing Management Fractures (cont'd) Nursing Implementatjon Ø Traction • Pin care • Monitor skin

Nursing Management Fractures (cont'd) Nursing implementation (cont'd) Ø Ambulatory and home care • Cast

$Complications of Fractures Infection High risk with open fractures May require debridement, antibiotics Ø$

Complications of Fractures Compartment syndrome A condition in which elevated intracompartmental pressure within a

Complications of Fractures Compartment syndrome Prompt recognition Ø NO ice, elevation Ø Remove constricting

Fig. 63 -15 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

$Complications of Fractures (cont'd) Fat embolism syndrome Highest risk with long bone fractures Ø$

Complications of Fractures (cont'd) Fat embolism syndrome Prevention Ø Early identification Ø Supportive care

Types of Fractures Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Colles’ Fracture Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier

Fracture of the Humerus Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate

Fig. 63 -16 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Fracture of the Pelvis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate

$Fracture of the Hip Refers to a fracture of the proximal third of the$

Fig. 63 -17 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Fig. 63 -18 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Nursing Management Hip Fracture Nursing implementation Ø Preoperative management • Pain management - may

Nursing Management Hip Fracture Nursing implementation Ø Postoperative management • Monitor VS/, I/O •

Nursing Management Hip Fracture Nursing implementation Ø Postoperative management • Mobility • Monitor for

Gerontologic Considerations Hip Fracture Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate

Femoral Shaft Fracture Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Stable Vertebral Fractures Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of

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Sprains and Strains Sprains and strains Ø Sprain - injury to tendinoligamentous structures surroundin the joint Ø Strain - excessive stretching of a muscle and its fascial sheath Ø Nursing implementation • Health promotion Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Dislocation and Subluxation Dislocation Ø Severe injury of the ligamentous structures hat surround the joint; results in complete displacement of articular surfaces of the joint Subluxation Ø Refers to partial or incomplete displacement Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Dislocation and Subluxation Clinical Manifestations Ø Deformity, pain, loss of function Collaborative management Orthopedic emergency - require reduction • Risk of avascular necrosis Ø Pain management Ø Protection of injured join Ø Rehabilitation once reduced Ø Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fractures A disruption or break in the continuity of the structure of the bone Classifications Type (see fig 63 -6) Ø Communication or noncommunication with the external environment: Open vs Closed Ø Anatomic location of the involved bone Ø Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fractures Clinical Manifestations History - mechanism of injury Ø Pain Ø Decreased function Ø Inability to bear weight Ø Deformity Ø Ecchymosis Ø Edema Ø Crepitation Ø Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Factors Affecting Fracture Healing Age Initial displacement Blood supply to the area Immobilization Infection hormones Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fractures (cont'd) Collaborative care Ø Fracture reduction • Closed reduction - nonsurgical • Open reduction - surgical • Traction Skin traction Skeletal traction Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fractures (cont'd) Collaborative care (cont'd) Ø Fracture immobilization • Casts Types of casts Injuries to the lower extremity • External fixation • Internal fixation Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fractures (cont'd) Collaborative care (cont'd) Drug therapy • Pain mgmt • Muscle relaxants • Tetanus booster Ø Nutritional therapy • Protein • Vitamins (B C D) • Calcium • Adequate fluid intake Ø Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Fractures Nursing assessment Ø Neurovascular assessment Nursing diagnoses Ø Impaired physical mobility Ø Risk for infection Ø Risk for peripheral neurovascular dysfunction Ø Acute Pain Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Fractures Planning Have physiologic healing with no associated complications Ø Obtain satisfactory pain relief Ø Achieve maximum rehabilitation potential Ø Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Fractures (cont'd) Nursing implementation (cont'd) Ø Acute intervention • Preoperative management § Immobilization § Assistive devices that will be used § Expected activity limitations after surgery § Assure patients their needs will be met § Assure patients pain medication will be available Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Fractures (cont'd) Nursing implementation (cont'd) Ø Acute Intervention • Postoperative management • Monitor vitals • Frequent neurovascular assessments of affected extremity • Minimize pain and discomfort through proper alignment and positioning Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Fractures (cont'd) Nursing implementation (cont'd) Ø Acute Intervention • Postoperative management • Monitor limitations in movement • Carefully observe dressings or casts for bleeding or drainage • Significant ↑ in size of drainage area should be reported • Measure and assess patency of system and volume of drainage Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Fractures (cont'd) Nursing Implementatjon Ø Other measures • Prevention of constipation • DVT prophylaxis • Movement as able to prevent cardiopulmonary deconditioning Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Fractures (cont'd) Nursing Implementatjon Ø Traction • Pin care • Monitor skin for breakdowin • Correct alignment Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Fractures (cont'd) Nursing implementation (cont'd) Ø Ambulatory and home care • Cast care • Psychosocial problems • Ambulation • Assistive devices Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

$Complications of Fractures Infection High risk with open fractures May require debridement, antibiotics Ø$

Complications of Fractures Infection High risk with open fractures May require debridement, antibiotics Ø Risk of osteomyelitis Ø Ø Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Complications of Fractures Compartment syndrome A condition in which elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that space Ø Manifestations • 6 Ps • Pain Pallor • Paresthesia Paralysis • Pressure Pulselessness Ø Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Complications of Fractures Compartment syndrome Prompt recognition Ø NO ice, elevation Ø Remove constricting dressings Ø Surgical decompression Ø Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

$Complications of Fractures (cont'd) Fat embolism syndrome Highest risk with long bone fractures Ø$

Complications of Fractures (cont'd) Fat embolism syndrome Highest risk with long bone fractures Ø Characterized by the presence of systemic fat globules from fractures that are distributed into the tissues and organs after a traumatic skeletal injury Ø Ø Manifestations - often rapid onset • Often respiratory distress • Neurologic changes • Fever • Petechiae Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Complications of Fractures (cont'd) Fat embolism syndrome Prevention Ø Early identification Ø Supportive care Ø Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

$Fracture of the Hip Refers to a fracture of the proximal third of the$

Fracture of the Hip Refers to a fracture of the proximal third of the femur Manifestations Ø Pain Ø Edema Ø External rotation Ø Shortening of the affected extremity Surgical management is the preferred treatment Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Hip Fracture Nursing implementation Ø Preoperative management • Pain management - may include analgesics and Buck’s traction • Preoperative teaching • Consideration of comorbid conditions • Frequent repositioning to prevent immobility complications Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Hip Fracture Nursing implementation Ø Postoperative management • Monitor VS/, I/O • CMS assessment • Prevention of respiratory complication • Prevention of DVT • Pain management • Proper alignment Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Hip Fracture Nursing implementation Ø Postoperative management • Mobility • Monitor for complication • Hip prosthesis management Table 63 -11 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.