10.27
TRANSCRIPT
F10 1
Nursing Care of the Adult WithMusculoskeletal Alterations
Lorraine C. Haertel, PhD, RN, CS, ARNPAssistant Professor of Clinical Nursing
F10 2
IntroductionBone FractureBone Healing
Bone Union Complications
F10 3
Pathophysiology
Classification of fractures– Extent of break
• Complete – across entire bone• Incomplete – through part of the bone
– Extent of soft tissue damage• Open – soft tissue injury• Closed – no visible soft tissue injury
– Cause• Pathologic/spontaneous – occurs with minimal trauma due to
weakened bone• Fatigue/stress – i.e., sports injury• Compression – i.e., vertebrae fx due to osteoporosis
F10 4
F10 5
Common Types of Fractures
F10 6
Stages of Bone Healing
Hematoma formation– Occurs 24-72 hours after fx– Inflamed & painful
Hematoma to Granulation Tissue Callus formation
– Beginning of nonbony union Osteoblastic Proliferation
– Callus transformed into bone Bone Remodeling
– Bone is reorganized into former structural arrangement Bone Healing Completed
F10 7
Stages of Bone Healing
F10 8
Complications of Bone Healing– Nonunion
• Failure of healing at fx site– Delayed union
• Bony union does not occur in usual amt of time– Malunion
• Bone union results in deformity Some Causes of Nonunion and Delayed Union
– **Poor blood supply or loss of blood supply– Insufficient nutrients– Insufficient immobilization– Metabolic disorders
F10 9
Complications of Fractures
F10 10
Complications of Fractures
Hemorrhage ShockFat EmbolismTetanusAcute Compartment Syndrome (ACS)Avascular NecrosisInfectionDVT
F10 11
Hemorrhage/Shock– Fxs of long bones & pelvis prone to excessive
bleeding
F10 12
Fat Embolism– High risk - multiple fxs or fx of long bones– Older pt with a hip fx has highest risk– Pulmonary perfusion problems, defective gas exchange– Usually occurs within 48 hours– S&S
• Confusion – an early manifestation due to low arterial oxygen levels in brain
• Restlessness, dyspnea, tachycardia, tachypnea, fever, petechiae, drowsy
– Treatment• Oxygen – administer first, then notify MD• Restore fluid/blood volume to prevent shock
F10 13
Fat Embolism - Petechiae
F10 14
Tetanus– Occurs in open fx & puncture wounds– Administer tetanus toxoid if not previously
given
F10 15
Compartments
F10 16
Pathophysiology of ACS
Acute Compartment Syndrome (ACS)– Increased pressure in compartment(s)– Massive compromise of circulation– Pressure is internal or external– Plasma proteins leak edema– Blood flow decreases– Ischemia – Tissue pales, weak pulses, area tense, pain, cyanosis,
tingling, numbness, paresis, more severe pain. • Notify MD immediately with sx of ACS
F10 17
Nursing and Medical Care of ACS
– Emergency situation – irreversible damage within hours– Compartment pressures can be monitored– Bivalve cast– Fasciotomy to relieve pressure & restore circulation
• Incision through skin & SQ tissue into fascia– Wound care, debride, skin graft– Complications
• Infection• Motor weakness• Contracture• Myoglobinuric renal failure (rhabdomyolysis)
– Hyperkalemia, cardiac dysrhythmias• Amputation in extreme cases
F10 18
Two Months Post-Fasciotomy
F10 19
Completely Healed
F10 20
Avascular Necrosis– Death of bone as result of loss of blood supply
F10 21
Infection (Bone infection/osteomyelitis)– Most common with an open fx
• Skin integrity is lost & organisms gain access easily• Example – pt with open fx of tibia• Broad spectrum intravenous antibiotics, contact isolation, sterile technique for dressing changes
– Acute Osteomyelitis• Temp > 101 degrees• Redness, heat, swelling, pain/tenderness WBC, ESR, inc C-Reactive Protein
– Chronic Osteomyelitis• Skin ulceration with sinus tract formation• Drainage• Pain
– Treatment• IV antibiotics• Sterile dressing changes, packing the wound• Pain medication• Standard or contact isolation• Hyperbaric Oxygen Therapy (HBO)• Bone Grafts
F10 22
Osteomyelitis
F10 23
Osteomyelitis – Bone X-Ray
F10 24
DVT• Often develops in immobile pts
– Lovenox– ASA– Early ambulation– TEDS, SCD, Foot pumps
F10 25
Nursing Process
F10 26
Assessment of Bone Fracture
Assess preceding events– Head injury, spinal cord injury– Remember ABCs when prioritizing
History– Medication history
• Glucocorticoids osteoporosis– Medical history
• Will offer info that may impede healing– For example, hx of PVD arterial circulation to bone bone receives
less oxygen & nutrients • Bone cancer risk for fx
– Diet history• Protein, vitamin C, B complex vitamins• Dietary referral as needed
F10 27
Physical Assessment MS Assessment
– Bone alignment/deformity– Altered length of extremity– Bone shape– Pain
• Muscle spasm– ROM
• Decreased or loss of function– Crepitus/creptitation
• Grating sound when affected part is moved• Created by bone fragments at fx site
– Skin integrity• Intact, ecchymosis, SQ emphysema
– Swelling
F10 28
F10 29
Neurovascular Assessment
– Skin color– Skin temperature– Movement– Sensation– Pulses– Capillary refill– Pain
F10 30
Neurovascular Assessment
Please PulsesRemember, Refill (Capillary)Check Color (Skin)The Temperature (Skin)Motor Movement
– &Sensation SensationPronto Pain
F10 31
Neurovascular Assessment
The 5 Ps (Really 6 Ps)– Pain– Pulse– Paresthesia– Pallor– Paralysis – A 6th P is Pressure when assessing for S&S of ACS
CMS– Circulation
• Color, temp, edema, capillary refill– Motion
• Flexion, extension– Sensation
F10 32
Psychosocial assessmentLabs/Diagnostics
– H&H– ESR
• An increase during fx healing suggests bone infection.• Notify physician
– Serum Ca & PO4
– X-rays– CT scan– Bone scan
F10 33
Nursing Diagnoses
Risk for impaired tissue perfusionPainImpaired physical mobilityRisk for infectionActivity intoleranceRisk for impaired skin integrity
F10 34
Goals
Pain Immobility Perfusion & oxygenation Infection Nutrition Bowel/bladder elimination Bone function Understanding Rehabilitation Minimize anxiety Self-care
F10 35
InterventionsFx Emergency Care in the Community
Fx Emergency Care in Community– First assess for resp distress, bleeding, head injury– Assess fx
• Control bleeding, VS, supine– Neurovascular Monitoring
• Compare to unaffected side– Temperature, color, sensation, movement, capillary refill,
pulses, pain
– Immobilize extremity• Recheck circulation
– Dressing
F10 36
InterventionsED and Hospital Care
In Emergency Department– Reduction – realign bone ends using traction or surgery
• Closed method• Open method
– Immobilization • Bandages, casts, traction, internal/external fixation
In Hospital– NV assessments every 1 hour for first 24 hours– Neurovascular (NV) monitoring q 4 hours once stable
F10 37
Nonsurgical Management of Fractures
F10 38
Nonsurgical Management of Fxs
Closed reduction– Bandages, splints, cast or traction– Be aware of excessive external pressure ACS
Cast– Cast care
• Wet casts– Use palms of hands– Use cloth covered pillow
• Dry Cast– Assess cast not too tight as it is drying– Assess drainage and cast integrity
– Cast complications• Infection• Circulation impairment and peripheral nerve damage• Prolonged immobility complications
F10 39
Traction
Traction– Purposes
• Reduce fx aka realign bones• Dec pain and muscle spasms• Prevent/correct deformities• Promote healing
– Manual Traction– Skin Traction
• Traction wt limited to 5-10 pounds• Risk of skin irritation & pressure problems
– Skeletal Traction• Pins, wires, tongs, screws are surgically inserted into bone to aid in
bone alignment• Traction wt up to 45 pounds
F10 40
Types of Traction
Buck’s Traction– Simplest of LE tractions– Fx of hip or femur preop, prevent hip contractures, hip
dislocation
F10 41
F10 42
Nursing Responsibilities in Traction Care
– Maintain straight alignment of ropes and pulleys– Maintain continuous pull– Assure wts hang free
• Don’t remove wts• Don’t lift wts• Don’t place wts on floor
– Inspect for skin breakdown at least every 8 hours– Encourage movement of unaffected areas– Assess every pt complaint immediately and thoroughly
• For example, c/o pain may not be fracture pain but ACS pain
F10 43
Nursing Responsibilities in Traction Care (Continued)
– Assess skeletal pin site for inflammation, infection, drainage, color, odor, excessive redness• Notify MD if pin site is red, swollen,
crusty with dried blood. Indicates inflammation & possible infection. Can lead to osteomyelitis. Treat immediately.
– Pin care for skeletal tx per hospital policy/ MD order
F10 44
Nursing Responsibilities in Traction Care (Continued)
– Active, passive ROM– Incentive Spirometry (IS)
F10 45
Nursing Responsibilities in Traction Care (Continued)
– Skin assessment– Pin assessment/Pin Care– Pharmacologic Management
• Muscle relaxants– methocarbamol (Robaxin)– cyclobenzapine HCl (Flexeril)– carisoprodol (Soma)
• Analgesics– Nutritional considerations
• Protein, vitamins, calcium, increased fiber, 2-3L fluid intake, diversional activity
F10 46
Surgical Management of Fractures
F10 47
Surgical Management of Fx
Surgical Management– Pre-op care– Operative procedures
• ORIF – open reduction with internal fixation• External fixation
– Post -op• Pain relief medications• Anti-inflammatory meds• Muscle relaxants
F10 48
External Fixation – Tibial Fracture
F10 49
Location of Hip Fractures
Read Articles
in Class Folder
(Transcervical)
F10 50
Clinical Manifestations
External rotationMuscle spasmShortening of
affected extremitySevere painTenderness in
general area Read Articles in Class Folder
F10 51
Surgical Repair
Possible Buck’s tractionOpen reduction internal fixation (ORIF)Hemiarthroplasty
– Generally replacement of the femerol head onlyTotal Hip Arthroplasty (THA)Total Hip Repair (THR)
– Cemented– Uncemented
F10 52
F10 53
ORIF - Hip
F10 54
F10 55
F10 56
F10 57
Pre-Operative Nursing Care
Analgesics & muscle relaxantsPositioningTractionTeaching
– Exercise unaffected leg and both arms– Overhead trapeze– Use opposite side rail to change positions– How to get OOB and chair transfers– Wt bearing status after surgery
F10 58
Post-Operative Nursing Care
Expected postop care initially Risk for NV impairment Assess for other complications
– Dislocation, excessive drainage, tromboembolism, infection Elevate leg when in chair Abductor pillow
– Prevent moving operative leg toward and beyond body’s midline Sandbags Overbead trapeze Walker Meds for comfort PT for ambulation DC criteria
F10 59
Post-Op Hip Precautions
No > 90 degree flexionNo adductionNo internal rotation; do the following activities
– Use long shoehorn, stocking helper– Chairs with arms– Elevated toilet seat– Shower chair– Abduction pillow– Hip in straight position– Dental work; antibiotics before dental work is done
F10 60
Dislocation S&S
PainLimb shorteningExternal rotation
F10 61
Nursing Diagnoses
Risk for peripheral NV dysfunctionPainRisk for infectionImpaired physical mobilityRisk for impaired skin integrity
F10 62
Virtual THA
http://www.edheads.org/activities/hip
F10 63
AmputationSoft Tissue Injuries
F10 64
Amputation
Amputation– UE – most from trauma– LE – PVD secondary to DM, atherosclerosis
• Also, infection (osteomyelitis, gangrene), trauma, cancer, etc.
F10 65
Nursing Interventions - • Stump Care
– Assess tissue perfusion– Prevent infection
• Positioning• Turning• Exercises • Ambulation • Psychological support• Discharge teaching
F10 66
AKA vs. BKA
F10 67
Complications of Amputations
– Hemorrhage– Infection– Contractures– Phantom limb sensation / Phantom limb pain
F10 68
DC and Community Care
– Use of prosthesis– Amputee WC– Refer to
• Social services• Occupational rehab• Home health agency• Pt/Family support groups• National Amputation Foundation (New York)• American Amputee Foundation (Little Rock, AR)
F10 69
Amputee Wheelchair
F10 70
Sports Related Soft Tissue Injuries
– Contusion – a soft tissue injury• S&S - Ecchymosis, hematoma• Tx - Cold for 24 hrs, moist heat, elastic bandage
– Strains – a muscle pull, and;– Sprains – a torn ligament
• S&S - Pain, swelling• Tx - Rest, elevation, ice, heat, elastic bandage, use
– Joint Dislocations – bone surfaces lose contact• S&S - Pain, deformity• Tx - Immobilize, reduction, bandages, splints
F10 71
Review Questions
F10 72
Review Questions
List the signs and symptoms of bone fractures. What lab values do you expect to be altered in a patient
with a fractured bone? What complications may occur after a bone fracture? What risk factors place a patient at risk for a hip fracture? What are the different types of fractures that can occur to
the hip? List the signs and symptoms of a hip fracture. Describe the various types of surgical techniques for a hip
fracture. List factors that may impede the healing of a fractured
femur.
F10 73
Describe the post operative nursing care of a patient after hip surgery.
What complications can occur in a patient after hip surgery? What nursing interventions are appropriate to prevent or treat these complications?
What are the benefits of administering pain medication to the patient who had hip replacement surgery?
What discharge teaching instructions would you give to a patient after hip surgery?
F10 74
Discuss the nursing care of the patient who had an AKA and a BKA.
Explain the different types of tractions discussed in class. What are the nursing responsibilities in caring for a
patient who is in traction? What are the complications a patient may experience who
had a cast applied? Identify common nursing diagnoses for patients who had
a bone fracture, are in traction, have a cast, have an amputation.