Nursing A ConceptBased Approach to Learning VOLUME ONE
Nursing: A Concept-Based Approach to Learning VOLUME ONE EDITION VOLUME ONE|| SECOND EDITION MODULE 13 Mobility Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Exemplar 13. 2 Fractures Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Overview • Break in continuity of bone § § § Direct blow Crushing force Sudden twisting motion Severe muscle contraction Disease that has weakened bone Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Etiology • Produced by direct or indirect force • Fracture classification § Closed fracture § Open fracture • Fracture line can be oblique, spiral, others • Fracture can be § Complete or incomplete § Stable or unstable Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Etiology, continued • Fractures in children § Direct trauma or bone diseases § Greenstick, spiral fractures more common § Abuse Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Fracture Healing • Three phases § Inflammatory phase § Reparative phase § Remodeling phase • Factors influencing bone healing Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Risk Factors • • • Osteoporosis Bone cancer Lack of vitamin D, calcium, phosphorus Aging Lifestyle choices Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Prevention • Education • Safety equipment • Good lifestyle habits § Increase bone strength and prevent fractures • Safe living environment Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Clinical Manifestations • Fractures often accompanied by soft tissue injury • Manifestations of fracture § § Deformity Pain/tenderness Guarding Hypovolemic shock Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Clinical Manifestations, continued • Manifestations of fracture § § § Ecchymosis Swelling Numbness Crepitus Muscle spasms Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Complications • Compartment syndrome § Acute compartment syndrome § Entrapment of blood vessels limits perfusion • Can result in loss of limb, sepsis § Treatment • Remove tight cast • Fasciotomy § Volkmann contracture • From unresolved compartment syndrome Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Complications, continued • Deep venous thrombosis (DVT) § Three precursors • Venous stasis • Injury to blood vessel walls • Altered blood coagulation § Swelling, leg pain, tenderness, cramping § Prevention: early immobilization of fracture, early ambulation § DVT treatment requires rapid intervention Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Complications, continued • Fat embolism syndrome (FES) § Characterized by neurological dysfunction, pulmonary insufficiency, rash § Risk factors: long bone fracture, major trauma § Manifestations develop within hours to a week § Early stabilization of fracture will prevent Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Complications, continued • Infection § Open fractures § Contamination at time of injury or in surgery § Clostridium may lead to gangrene, cellulitis § Any infection can delay healing Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Complications, continued • Infection § Delayed union, nonunion, malunion • Delayed union is prolonged bone healing • May lead to nonunion: failure of ends to heal • Malunion is incorrect joining of bone fragments • Factors that inhibit healing • Persistent pain Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Lifespan and Cultural Considerations • Children § Long bone fractures resulting from sport and play § Porous bones • Athletes and adults § Stress fractures § Lengthened recovery time • Older adults § Osteoporosis Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Collaboration • • • Requires multiple healthcare professionals Assess client Maintain client comfort Assist with procedures Provide client education Refer client to specialists Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Emergency Care • Immobilize fracture, maintain perfusion, prevent infection • Cover open wounds, control bleeding • Splint fracture to normal alignment • Relieve pain, prevent further damage Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Diagnostic Tests • • History Initial assessment X-rays Blood chemistries, CBC, coagulation studies Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Surgery • Surgery § Indicated for • Direct visualization to repair • Severely comminuted, threatens vascular supply § External fixation with external fixator device § Open reduction and internal fixation (ORIF) Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Pharmacologic Therapy • Analgesics for pain • Severe fractures § Opioids § NSAIDs • Antibiotics • Anticoagulants Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Nonpharmacologic Therapy • Casts and splints § Rigid device to immobilize injured bones • Plaster, fiberglass § Nursing care of client with cast • • Frequent neurovascular assessments Palpate cast for "hot spots" Report any drainage Education § Closed reduction • Application of cast Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Nonpharmacologic Therapy, continued • Traction § § § Manual Skin traction Balanced suspension traction Skeletal traction Nursing interventions for client in traction • Nonpharmacologic pain management § RICE therapy Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Nursing Process • • • Pain management Client teaching Assessment for complications Emotional support Client's needs will depend on location and severity of fracture Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Assessment • Health history • Physical examination § 5 P's of neurovascular assessment • • • Pain Pulses Pallor Paralysis, paresis Paresthesia Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Diagnosis • Risk for Peripheral Neurovascular Dysfunction • Risk for Ineffective Tissue Perfusion • Risk for Infection • Risk for Skin Integrity • Acute Pain Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Diagnosis, continued • • • Impaired Physical Mobility Risk for Disuse Syndrome Deficient Knowledge Disturbed Body Image Anxiety Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Planning • Client obtains pain relief adequate to allow for rest and comfort • Client experiences no complications as a result of fracture or treatment • Client experiences no ongoing loss of function as a result of fracture Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation • Teaching, home care treatments, urgent care § Community health setting • Emergency care • Arrange for transportation • Watch for signs of complication Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Provide Effective Pain Management • Regularly assess client § Pain § Muscle spasms § Swelling • Monitor effectiveness of pain medication • Movement should be gentle and slow • Encourage distraction, noninvasive pain relief Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Maintain Proper Alignment • • • Splint Casts Traction Internal or external fixation Verbal and written instructions for splint/cast care Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Promote Mobility • Promote mobility § Physician orders mobility limitations § Restrictions depend on site, extent • Client should be repositioned every 1 – 2 hours Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Monitor Neurovascular Status Assess 5 P's every 1– 2 hours Assess capillary refill Monitor the extremity for edema, swelling Assess for deep, throbbing, unrelenting pain • Monitor tightness of case • If case tight, prepare for bivalving • • Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Monitor Neurovascular Status, continued • If compartment syndrome suspected § Assist in measuring compartment pressure • Elevate injured extremity above heart • Administer anticoagulant as ordered Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Prevent Infection • • • Follow guidelines for skeletal pin site care Monitor vital signs, lab reports (WBCs) Use sterile technique for dressing changes Assess wound for size, color, drainage Administer antibiotics per physician's order Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Provide Discharge Instructions • • • Cast care Activity restrictions Pain medications Signs of complications Injury prevention Leg fractures § Crutches § Permanent or temporary ramp Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Evaluation • Client regains prior level of function when fracture resolves • Client experiences no complications as a result of treatment • Client explains home care • Client lists symptoms to report immediately Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
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