Module 13B Fractures- Study Module

A patient presents with a broken right radius and ulna after falling. The nurse is assessing the 5 Ps and asks the patient to wiggle the fingers on the right arm. The patient asks, "Why are you asking me to do this?" Which response by the nurse is appropriate? "I am checking for pulse." "I am checking for numbness." "I am checking for paralysis." "I am checking for paleness."

"I am checking for paralysis." By asking the patient to move their fingers, the nurse is making sure that there is no neurovascular damage distal to the injury. The nurse would assess pulse by comparing the distal pulses (radial pulses in this case) of the affected and unaffected arms. The nurse would assess paleness (pallor) by observing the color of the fingers. The nurse would assess numbness (paresthesia) by asking the patient if their fingers felt numb or tingly.

The nurse is teaching a patient about the importance of nutrition and the role it plays in bone healing. Which statement by the patient indicates an understanding of appropriate breakfast choices to aid bone healing? "I will eat a granola bar with hot tea." "I will eat a bagel with jelly." "I will eat cheese and eggs." "I will eat a fruit plate and black coffee."

"I will eat cheese and eggs." Foods high in calcium and vitamin D are necessary for bone healing. Dairy products, such as milk and yogurt, as well as green leafy vegetables are high in calcium. Foods such as sardines, shrimp, mushrooms, eggs, and tuna are also high in vitamin D. The other food choices consist of carbohydrates and empty calories that will not enhance bone healing.

The nurse is teaching a patient about cast care at home. Which instruction should the nurse include in the teaching? "If severe itching occurs, use a blow dryer on a cool setting." "Use only a blunt device to scratch under the cast." "Apply heat to the cast to relieve pain." "Place baby powder down into the cast to relieve itching."

"If severe itching occurs, use a blow dryer on a cool setting." A hair dryer set on cool may help relieve itching. Nothing should ever be placed in the cast, including powder or blunt objects, because of risk for infection. Heat will not relieve pain; ice should be used.

The nurse is teaching fracture prevention to a community group consisting of parents of school-aged children. Which parent statement indicates the need for additional teaching? "My child is overweight, but that has nothing to do with the risk for fracture." "My son should always wear a helmet while riding his bike." "A seatbelt is necessary, even if we are just driving through our neighborhood." "My child should wear safety pads while skateboarding."

"My child is overweight, but that has nothing to do with the risk for fracture." Being overweight can predispose a child to fractures. Weight control and exercise can promote bone strength. Important safety measures to prevent fractures include wearing seatbelts, helmets, and safety pads.

A patient with a fracture is preoperative for an internal fixation procedure. The nurse is teaching the patient about the risks of continuing to smoke before the surgery. Which statement should the nurse include? "Nicotine prevents calcium reabsorption into the bone, which delays bone union." "Nicotine has been shown to decrease circulation to the bone, leading to delayed healing." "Toxins in cigarettes bind with many drugs, which prevent drug absorption." "The increased blood level of carbon dioxide caused by smoking can cause bone acidosis."

"Nicotine has been shown to decrease circulation to the bone, leading to delayed healing." Nicotine may delay bone healing after a fracture and/or bone surgery because of decreased circulation to the bone. Nicotine does not prevent calcium reabsorption into bone, and toxins do not bind with drugs. Bones do not become acidotic.

The nurse is teaching a patient with a fractured femur about the differences between opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). Which statement by the patient demonstrates an understanding of the teaching? "The NSAID will help with both pain and inflammation." "I will be on a patient-controlled pain pump for several weeks." "I should not drive while taking an NSAID." "The NSAID is much more potent than the opioid."

"The NSAID will help with both pain and inflammation." The NSAID will help with pain and inflammation; the opioid is for severe pain. Unlike NSAIDs, opioids will only be prescribed for a certain period of time to prevent addiction. The opioid is more potent and the patient should not operate a motor vehicle while taking opioids, but may operate a car while taking an NSAID. Both NSAIDs and opioids can be given with a patient-controlled analgesic (PCA) pump, given at scheduled times around the clock, and requested by the patient before pain becomes severe.

A patient with a fracture received pain medication after the application of a right leg cast. Which patient statement indicates a complication and requires immediate notification to the healthcare provider? "My foot appears to be swelling." "I can feel my heartbeat in my foot." "The pain is worse than it was before the pain medication." "I am sweating and itching under the cast."

"The pain is worse than it was before the pain medication." Worsening pain, despite intervention, is a sign that the patient may be developing compression syndrome. Itching and sweating under a cast are expected findings. Swelling of the foot, which could cause the foot to throb or "feel like a heartbeat" is not uncommon and can be remedied by elevating the extremity and by applying ice to the site when possible. Compartment syndrome occurs when edema and swelling cause increased pressure in a muscle compartment, leading to decreased blood flow and potential muscle and nerve damage.

A patient with a femur fracture is placed in traction. The patient asks the nurse, "Why do I need traction?" Which response by the nurse is accurate? "The traction uses an electrical current to heal your bone." "The traction is molded around your injured limb to allow healing." "The traction is used to straighten and stabilize the injury until you can have surgery." "The traction will pull and realign your bone in the correct position."

"The traction will pull and realign your bone in the correct position." Traction applies a straightening or pulling force to return to or maintain the fractured bones in normal anatomic position. Splints are used to stabilize fresh injuries. Electrical bone stimulation uses an electrical current to treat nonhealing bone fractures. A cast is molded around the injured limb to provide support, protection, and immobilization of the fractured bones and surrounding tissue.

A patient presents with severe soft tissue damage to the left leg and an open tibial fracture. The surgeon has assessed the need for surgery to fix the leg using external fixation. The patient asks the nurse what that means. Which is the nurse's best response? "You will have metal rods attached to your leg on the outside until the bone heals." "Your leg has a lot of tissue damage so we have to use external fixation to fix it." "External fixation has a shorter hospital stay than does internal fixation, which is why we're using it." "Wires and screws will be attached directly to your bones to put them back together."

"You will have metal rods attached to your leg on the outside until the bone heals." The best response accurately describes an external fixation device as a metal device attached outside of the leg until the bone heals. Although external fixation is indicated for fractures accompanied with soft tissue damage that prevent internal fixation, the nurse is not directly answering this question if they respond in this manner. The patient asked what external fixation meant. Wires and screws attached directly to the bones describes internal, not external, fixation. Internal fixation has a shorter hospital stay than external fixation. Even if this were not the case, talking about hospital stays does not directly answer the patient's question.

The nurse is teaching safe home practices to an older adult patient who fell and sustained a femur fracture. Which patient statement indicates the need for additional teaching? - "I should use throw rugs to keep me from slipping on the floor." - "I can use a walker or cane if needed for extra stability." - "I should place a rubber mat in the bathtub." - "I should wear nonslip shoes both inside and outside of the house."

- "I should use throw rugs to keep me from slipping on the floor." Throw rugs should not be used because they may increase the risk for falls. Patients should use rubber bath mats in showers and bathtubs and should always wear nonslip shoes. A cane or walker is indicated for extra stability.

The nurse is teaching a patient with a cast about symptoms to monitor after discharge. Which statement by the patient reflects an understanding of complications associated with a cast? - "I shouldn't be able to move my limb." - "My limb should not be pink in color." - "Numbness and tingling should be reported immediately." - "Coolness of the limb is expected."

- "Numbness and tingling should be reported immediately." Paresthesia, due to nerve compression, can result in a loss of sensation or a feeling of "pins and needles" or numbness and tingling. It should be reported immediately as it may indicate nerve or tendon damage. Patients experiencing paresthesia are able to move their limbs. The limb should be pink and warm to touch.

The nurse is administering pain medication to a patient with a radial fracture. The patient asks what the difference is between the opioids being administered and the nonsteroidal anti-inflammatory drugs (NSAIDs) that the patient is used to taking. Which response by the nurse is accurate? - "Only opioids can be given with a patient-controlled pump." - "Unlike NSAIDs, opioids will only be given to you for a limited period of time." - "Unlike NSAIDs, you should request opioids before your pain becomes severe." - "Only opioids can be given at a scheduled time around the clock."

- "Unlike NSAIDs, opioids will only be given to you for a limited period of time." Both NSAIDs and opioids can be given with a patient-controlled analgesic (PCA) pump, given at scheduled times around the clock, and requested by the patient before pain becomes severe. Unlike NSAIDs, opioids will only be prescribed for a certain period of time to prevent addiction. NSAIDs are given for both pain and inflammation.

Teaching points for a cast include:

- Do not apply pressure to the cast before it is dry because dents in the cast may cause pressure injuries. Fiberglass casts dry in less than 1 hour, whereas plaster casts may take up to 48 hours to dry. If the cast becomes damaged, notify a healthcare provider. - Do not get the cast wet, especially if it is a plaster cast. Use plastic or waterproof shields around the cast while showering or bathing. If a fiberglass cast becomes wet, dry it with a blow dryer on the cool setting. - Do not place any objects in the cast. Itching under the cast can be relieved by using a blow dryer on the cool setting. - Keep dirt and other irritants away from the inside of the cast. - Do not remove any part of the cast, including padding and rough edges. - Elevate the injured extremity above the heart as often as possible, and apply ice to the cast to prevent swelling under the cast. - Regularly assess the injured extremity for symptoms of compartment syndrome, including increased pain and swelling, loss of sensation, coolness, and changes in color. If the cast feels as if it is becoming too tight, see a healthcare provider immediately. - Assess the skin around the cast regularly. If the skin becomes raw or looks infected, notify a healthcare provider immediately.

The nurse is caring for a patient with a nonbleeding, closed femur fracture. The healthcare provider wants to evaluate for blood pooling around the fracture and into the surrounding tissue. Which test should the nurse anticipate to be ordered for the patient? - White blood cell count - Bone scan - Hematocrit - X-ray

- Hematocrit Red blood cell indices are used to assess for excessive blood loss and evaluate for anemia. As much as 500 mL of blood can leak into the surrounding tissues as a result of a fractured femur. White blood cell counts would be more useful in determining the presence of infection. X-rays and bone scans are more useful for determining bone damage.

On a casted extremity, it is important for the nurse to assess neurovascular status. For example, if a patient has a cast on the upper extremity, the assessment should include:

- On the hand with the cast, what color are the fingertips? - How do the fingers feel-warm or cold? - Is there feeling in the fingertips? - After pressing down on the fingernail, how many seconds does it take for the nail to turn pink again? - Has the arm been elevated above the level of the heart?

A pediatric patient with a suspected arm fracture is brought to the emergency department by emergency medical service personnel who has already applied a splint. Which intervention will be done initially to evaluate the injury? - Treating pain with opioids - Taking an x-ray of the arm - Removing the splint - Reinforcing the splint

- Removing the splint A splint is an emergency measure that is used to stabilize fresh injuries and reduce mobility. It is removed to perform diagnostic tests on an injured limb to see if further treatment is necessary. It is not necessarily replaced if a more supportive device like a cast is necessary. Velcro straps do make a splint easy to remove, but it is not being removed because emergency medical services applied it incorrectly. A cast is more supportive, not less supportive, than a splint.

Several lifestyle changes can help older adults decrease their risk of fractures that are related to falls. These include the following:

- Start a mild or moderate exercise program to help improve balance and strength. - Wear sensible shoes with nonslip soles and good support both inside and outside the house. - Walk slowly and carefully in areas that may be slippery, including icy or wet surfaces or polished floors. Use a walker or cane if needed for extra stability. Avoid walking in socks or slippers that lack traction. - Ask a healthcare provider or pharmacist how medications may affect balance and alertness or change bone or muscle strength. - Make sure hallways and stairways have adequate lighting, even at night. Make room lights, lamps, and flashlights easily accessible. - Keep rooms free of clutter, including clothing, paper, electric cords, and throw rugs. - Install handrails on stairs and around the toilet and bathtub. Also, place a rubber mat in the tub or shower. - Avoid using a step stool if possible. If necessary, use a sturdy step stool with a wide base and handrail for balance. - Seek treatment for health conditions that may affect bone or muscle strength, neuronal control of muscles, balance, or vision loss.

The nurse is caring for a patient in the clinic with the goal of developing no neurologic complications after a humerus fracture is casted. Which assessment finding indicates that the patient is healing appropriately? - The patient's fingers on the affected extremity have a delayed capillary refill. - The patient's fingers on the affected extremity are cool to the touch. - The patient's fingers on the affected extremity are tingling and numb. - The patient's fingers on the affected extremity are warm and pink.

- The patient's fingers on the affected extremity are warm and pink. It is important for the nurse to assess the neurovascular status of the affected extremity in a fracture, especially if the patient has been casted. The patient's casted extremity (fingers or toes) should be warm, pink, and have full sensation with no tingling or numbness. The patient should also be able to move the fingers or toes of the affected extremity. A delayed capillary refill indicates poor circulation to the affected extremity. This can lead to an emergency, called compartment syndrome.

What are the characteristics of a splint?

A splint provides less support than a cast, but it can be easily adjusted to accommodate swelling and prevent compartment syndrome. - They are made with Velcro straps that allow the splint to be easily removed. - They may also be formed using fiberglass or plaster, then molded to fit the fractured region. - Because of their ability to expand, splints are often used to stabilize fresh injuries before the swelling has subsided, as well as after the reparative phase of healing to allow some movement of the joints.

The nurse is caring for a patient who is two days' postoperative from surgery to repair a fractured femur. The patient says, "I am tired of lying in this bed; I am so uncomfortable." Which is the appropriate intervention by the nurse at this time? Telling the patient that bedrest is the only way to heal quickly and properly Assisting the patient in moving to the chair to elevate the extremity Administering extra pain medication to help the patient sleep and forget the discomfort Calling the healthcare provider for an order for an antianxiety medication

Assisting the patient in moving to the chair to elevate the extremity To minimize discomfort, the nurse can encourage the patient to move frequently; bedrest is not necessary. The patient can also change positions, wiggle the toes of the affected extremity to improve circulation, and ambulate with assistance. It is not appropriate to administer pain medication for the purpose of sleep; additionally, the patient's pain is controlled at this time. An antianxiety medication is inappropriate because it does not address the patient's discomfort.

The nurse is caring for an infant with a suspected fracture of the femur. Which condition puts an infant at risk for fracture of a long bone? Prolonged maternal labor Cesarean birth Birth weight above average Vaginal delivery

Cesarean birth Risks for long bone fractures include cesarean birth, breech birth, and low birth weight.

Fractures in children are caused by these factors

Children often experience long bone fractures as a result of sports and play. Spiral fractures are common in children because of the porous nature of their bones; unexplained midshaft spiral fractures may be an indicator of child abuse. Children often recover quickly from fractures because their bones have a rapid growth rate and the epiphyseal plates have not yet been sealed.

A 7-year-old child is admitted with a fractured skull. The admitting nurse suspects abuse. Which question should the nurse consider to help determine if this is an abusive injury? Does the child tell the same story as the adult? Does the child appear frightened? Do the parents look like they would be abusive? Does the story match the injury?

Does the story match the injury? When a child presents with a fracture that is uncommon for their age group, abuse should be suspected. However, because a fracture does not always imply abuse, the nurse should tactfully interview the patient and caregiver and follow institutional protocols for further investigation when abuse is suspected. During the interview, the nurse should consider this question: Does the story match the injury?

The nurse is assessing a patient who was admitted to the emergency department for a pelvic fracture. After receiving care from the nurse for a couple of hours, the patient reports shortness of breath. Which complication should the nurse suspect? Compartment syndrome Fat embolism Infection Parasthesia

Fat embolism A fat embolism occurs when fat globules released by injured tissue lodge in the pulmonary vasculature, resulting in dyspnea. Compartment syndrome creates pain resulting from pressure when fascia constricts. Paresthesia, which the patient may feel as numbness, tingling, or a burning sensation, indicates nerve or tendon damage. Infection causes warmth, redness, pain, swelling, stiffness, fever, chills, and purulent drainage.

Complications that can occur after a fracture include:

Fat embolism. Infection. Deep vein thrombosis. Compartment syndrome.

The effects of smoking on bone health include the following:

Nicotine affects bone density and the healing process by decreasing circulation through peripheral vasoconstriction. The nonunion rates for those who quit smoking before surgery or after surgery were lower than the smokers who continued to smoke after surgery.

Clinical manifestations of a fracture may include:

Pain due to tissue trauma. Visible fracture on x-ray. Visible deformity if bone is displaced. Swelling from inflammation. Numbness due to nerve damage. Internal or external blood loss, leading to hypovolemic shock or ecchymosis. Crepitus if fractured pieces of bone rub together.

Assessment of neurovascular status is important to detect neurovascular compromise and prevent compartment syndrome. Assessment should follow the 5 Ps of neurovascular assessment. These include:

Pain. Pulses. Pallor. Paresthesia. Paralysis.

The nurse is discussing fall prevention methods with an older adult patient. Which intervention should the nurse include? Placing throw rugs in all rooms Participating in daily weight-bearing exercises Scheduling an eye exam every 2 years Wearing shoes only outside the house

Participating in daily weight-bearing exercises Daily weight-bearing exercises help to reduce falls. Throw rugs should be removed, shoes should be worn inside and outside the home, and an eye exam should be scheduled yearly.

Other complementary methods used for diagnosis of a fracture include:

Patient history. Physical assessment. Other imaging studies such as bone scans, MRI, or CT scans. Blood tests such as blood chemistry studies, complete blood count, and coagulation studies.

The nurse is teaching RICE therapy to a patient with a fractured arm. Which intervention should be implemented for this patient? Propping the patient's arm up on a pillow Encouraging the patient to use their arm as much as possible Applying a tight ACE bandage to the extremity Applying a warm pack to the injured area

Propping the patient's arm up on a pillow As part of RICE therapy, the extremity should be elevated to prevent edema. The arm should also be rested, and ice should be used both to prevent swelling and for pain. A tight ACE bandage could lead to compartment syndrome.

The acronym RICE stands for:

Rest. Ice. Compression. Compression should be enough to provide support for the injured area, as is provided by a cast or splint, but it should not decrease blood flow to the area and cause compartment syndrome. Elevation.

Symptoms of compartment syndrome include:

Severe pain and tenderness. Swelling. Paresthesia. Pallor. Numbness or paralysis. Decreased or absent pulse. Poikilothermia (normalization to room temperature).

Bucks traction:

Skin traction applies force to the soft tissues through a pulley system attached to the bed.

An athlete reports pain in their foot during running, but denies any trauma or known injury. Which type of fracture should the nurse suspect has occurred? Stress Compression Pathologic Depression

Stress A stress fracture is caused by small repetitive forces on the bone that often result from participation in sports or exercise. A compression fracture usually occurs in the vertebrae and is more common in patients with osteoporosis. A pathologic fracture is caused by a disease that weakens the bone such as osteoporosis, bone cancer, and osteogenesis imperfecta. A depression fracture occurs when bone is forced inward; it commonly occurs in the skull.

A patient is admitted with a right radial and ulnar fracture after a motorcycle crash. The nurse is concerned that the patient may have neurovascular dysfunction. Which factor should the nurse assess to determine if the patient has neurovascular dysfunction? History of the traumatic event Chronic illness The 5 Ps The ABCs

The 5 Ps Patients with fractures have problems with acute pain, an increased risk of infections, mobility problems, and an increased risk for neurovascular dysfunction. To assess for neurovascular dysfunction, the nurse would support the injured extremity when moving, assess the 5 Ps (pain, pulses, pallor, paralysis, and paresthesia), assess the nail beds and capillary refill, monitor for edema, assess for increased pain, and monitor the tightness of the cast. The nurse would assess the history of the traumatic event, chronic illness, and the ABCs (airway, bleeding, circulation) during the health history assessment, but these would not assist in assessing for neurovascular dysfunction.

The nurse is planning care for a patient who is admitted with a compound fracture of the tibia. Which is an appropriate goal for this patient? The patient will not demonstrate signs or symptoms of a wound infection. The patient will demonstrate minimal tingling in the affected extremity. The patient will not verbalize the need for pain medication when pain reaches 8/10. The patient will regain most of the function in the affected extremity.

The patient will not demonstrate signs or symptoms of a wound infection. Since this patient has a compound (open) fracture, the broken skin serves as a portal of entry for bacteria. The highest priority for this patient is to prevent infection. The patient should demonstrate no tingling in the affected extremity, as this indicates neurovascular complications. The patient should verbalize the need for pain medication before their pain reaches 8/10 in order to treat it effectively. It is ideal that the patient regain full function of the affected extremity instead of just most function.

The nurse is admitting a patient with a fractured humerus to the orthopedic unit. Which therapy for fractures applies a straightening or pulling force to return to or maintain the fractured bones in its normal anatomic position? Cast Electrical bone stimulation Traction Splint

Traction

Following a motor vehicle accident, a patient reports severe arm pain. The healthcare provider suspects a simple radial fracture. Which test should the nurse initially anticipate to diagnose a fracture? Bone scan X-ray CT scan MRI

X-ray An x-ray is the primary diagnostic test to visualize a fracture. A CT scan, MRI, or bone scan may be ordered after the x-ray to provide further visualization of soft tissue, ligaments, and tendons; however, these are not necessary initially.

Skeletal traction

applies force directly to the bone, such as the traction used here for a humerus fracture.

What is traction?

the application of a pulling force to maintain bone alignment during fracture healing.

In an open fracture... aka...

the bone breaks and protrudes through the skin. This is also called a compound fracture. There is an increased risk of osteomyelitis due to the opening in the skin, which becomes a portal of entry for bacteria.