Ch. 51 Musckuloskeletal Trauma

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? "A callus is quickly deposited and transformed into bone." "A hematoma forms at the site of the fracture." "Cellular and vascular proliferation surround the fracture site." "Granulation tissue reabsorbs the hematoma and deposits new bone."

"A hematoma forms at the site of the fracture." **With a stage 1 fracture, a hematoma forms at the site of the fracture within 24 to 72 hours, because bone is extremely vascular. This action helps prompt the formation of fibrocartilage, providing the foundation for bone healing.Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone.

A client with a fracture asks the nurse about the difference between an open fracture and a simple fracture. Which statement by the nurse is correct? "Simple fracture involves a break in the bone, with skin contusions." "An open fracture does not extend through the skin." "Simple fracture has an increased risk for infection and emboli." "An open fracture involves a break in the bone, with damage to the skin."

"An open fracture involves a break in the bone, with damage to the skin." **The correct statement made by the nurse states that an open fracture involves a break in the bone with damage to the skin.A simple fracture does not extend through the skin. An open fracture, not a simple fracture, has an increased risk for infection.

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? "My spouse will be the only person to change my dressing." "I can't believe that this has happened to me. I can't stand to look at it." "I do not want any visitors while I'm in the hospital." "It will take me some time to get used to this."

"It will take me some time to get used to this." **Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping.Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan? "Use pain medication as prescribed to control pain." "Clean the pin site when any drainage is noticed." "Wear the same clothing that is normally worn." "Apply bacitracin (Neosporin) if signs or symptoms of infection develop around pin sites."

"Use pain medication as prescribed to control pain." **The client would be taught the correct use of prescribed pain medication to control pain adequately.Pin sites must be cleaned at least every 8 hours and as needed to reduce the risk for infection, not when any drainage is noticed. The client will have to adjust the type of clothing worn while the fixation device is in place. If signs and symptoms of infection develop around the pin sites, the client must notify the health care provider immediately. Infection at the pin sites places the client at risk for osteomyelitis.

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan? "Avoid contact sports." "Avoid rigorous exercise." "Wear helmets when riding a motorcycle." "Avoid driving in inclement weather."

"Wear helmets when riding a motorcycle." **Those who ride motorcycles or bicycles should wear helmets to prevent head injury.Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic; it is also opposed to what many health care professionals recommend to maintain health.

A client with peripheral vascular disease will undergo a Syme amputation. What will the nurse teach this patient when providing education about this procedure? "You will be able to bear weight without needing a prosthesis." "This type of procedure results in more pain than others." "The surgeon will remove both the foot and ankle." "This is an above-the-knee type of amputation."

"You will be able to bear weight without needing a prosthesis." **The Syme procedure is commonly used for clients with peripheral vascular disease. The surgery involves only amputation of the foot, making it possible for clients to bear weight without the use of a prosthesis.The Syme procedure involves removal of the foot but not the ankle. There is considerably less pain with this procedure. It is not an above-the-knee procedure.

The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site. 2, 4, 3, 1 3, 4, 1, 2 1, 4, 3, 2 4, 1, 2, 3

3, 4, 1, 2 **First, the airway must be assessed for breathing problems. Second, the nurse should examine the amputation site. Third, the nurse should apply direct pressure to the amputated site. Finally, the extremity should be elevated above the client's heart to decrease bleeding.All of the other sequencing of options is incorrect.

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? Surgical repair of the rotator cuff Prescribed exercises of the affected arm Activity limitations for the affected arm Patient-controlled analgesia with morphine

Activity limitations for the affected arm **The immediate conservative treatment for this client is to limit activity in the injured arm.Surgical intervention is not considered immediate conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 meter) fall. The nurse plans to assess the client for which potential complications? Select all that apply. Acute compartment syndrome (ACS) Fat embolism syndrome (FES) Congestive heart failure Urinary tract infection (UTI) Osteomyelitis

Acute compartment syndrome (ACS) Fat embolism syndrome (FES) Osteomyelitis **ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures.Congestive heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

Avoid musculoskeletal injury by treating or preventing osteoporosis

Being cautious when walking to prevent a fall Wearing supportive shoes Avoiding dangerous sports/activities Decreasing time spent doing repetitive stress activities (ex. Using a keyboard)

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction prior to surgical repair? Balanced skin traction Buck's traction Overhead traction Plaster traction

Buck's traction **Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm.Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.

Emergency care for a pt having a traumatic amputation in the community

Call 911 Assess the pt for ABCs Apply direct pressure on the amputation site Elevate the extremity above the pt's heart to decrease bleeding For finger parts, wrap the amputated part with a clean cloth and place in a sealed bag, which is lowered into ice water

A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? Check the dorsalis pedis pulses. Immobilize the left leg with a splint. Administer the prescribed analgesic. Place a dressing on the affected area.

Check the dorsalis pedis pulses. **The most essential action should be to check the dorsalis pedis pulses. It is necessary to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised.Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area would both be done after the nurse has assessed the client.

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? Removing the wound drain for a client who had an open reduction of a hip fracture 3 days ago. Assessing for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. Teaching a client with a right ankle fracture how to use crutches when transferring and ambulating. Checking the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

Checking the vital signs for a client who was admitted after a total knee replacement 3 hours ago. **Vital sign review is a skill that is within the role of the UAP.Removing a wound drain, assessment, and client teaching are nursing actions that require broader education and are within the scope of practice of licensed nursing staff.

Monitor pts with fractures for these life threatening complications

Hemorrhage Venous thromboembolism Fat embolism syndrome Acute compartment syndrome Infection

A client is in skeletal traction. Which nursing intervention ensures proper care of this client? Ensure that weights are placed on the floor. Ensure that pins are not loose and tighten as needed. Inspect the skin at least every 8 hours. Remove the traction weights only for bathing.

Inspect the skin at least every 8 hours. **The client's skin should be inspected at least every 8 hours for signs of irritation, inflammation, or actual skin breakdown.Weights must never rest on the floor because they will not be effective. They must hang freely at all times. Pin sites would be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Traction weights are not removed for bathing.

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? Keep the client's heels off the bed at all times. Reposition the client every 3 to 4 hours. Administer preventive pain medication before deep-breathing exercises. Prohibit the use of antiembolic stockings.

Keep the client's heels off the bed at all times. **Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area.Repositioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings are not contraindicated for older adults; rather, they help prevent deep vein thrombosis.

Priority care for fractures and amputations

Maintain perfusion, improve comfort, and prevent impaired mobility

A client sustains a fracture of one arm and the provider applies a plaster cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? Monitor neuromuscular status for decreased circulation and sensation in the extremity. Apply a heating pad for 15 to 20 minutes four times daily to help with pain. Check the fit of the cast by inserting a tongue blade between the cast and the skin. Keep the cast covered with a soft towel to help it to dry quickly.

Monitor neuromuscular status for decreased circulation and sensation in the extremity. **The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge.The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. To allow the cast to dry, it should remain uncovered.

The nurse performs a neurovascular assessment on a client with closed multiple fractures of the right humerus who is experiencing increased pain even with maximum ordered doses of morphine. The nurse notes distal capillary refill of 3 seconds and coolness of the hand and fingers. The client reports numbness of the hand and is unable to wiggle the thumb. Which nursing action is indicated? Elevate the extremity. Apply an ice pack to the extremity. Reposition the extremity and recheck in 15-20 minutes. Notify the provider of these findings.

Notify the provider of these findings. **Pain unrelieved by narcotic analgesics and numbness of the affected extremity are signs of neurovascular compromise and should be reported immediately to the provider.Elevating the extremity and applying ice may further compromise blood flow and should be avoided. Compartment syndrome may develop quickly, so the provider should be notified immediately and not in 15 to 20 minutes.

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider immediately if which change occurs? Observation of a large amount of serosanguineous or bloody drainage Mild to moderate pain controlled with prescribed analgesics Absence of erythema and tenderness at the surgical site Ability to flex and extend the right knee

Observation of a large amount of serosanguineous or bloody drainage **A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention.Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client would be able to flex and extend the right knee (limb) after surgery.

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? Select all that apply. Occupational therapist Physical therapist Psychologist Respiratory therapist Speech therapist

Occupational therapist Physical therapist Psychologist **An occupational therapist and a physical therapist will help to enable the client to become more independent in performing activities of daily living. An amputation can be traumatic to the client; loss of a body part should not be underestimated because the client may experience an altered self-concept, so counseling support with a psychologist should be made available to the client.The client does not have a respiratory condition that warrants collaborative care with a respiratory therapist. A speech therapist is not indicated because the client does not have speech impairment.

An older adult client has multiple tibia and fibula fractures of the left extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? Cyclobenzaprine (Flexeril) Ibuprofen (Advil) Meperidine (Demerol) Patient-controlled analgesia (PCA) with morphine

Patient-controlled analgesia (PCA) with morphine **Morphine is an opioid narcotic analgesic and is given through PCA. It is the most appropriate mode of pain management for this type of acute pain associated with multiple injuries.Muscle relaxants such as cyclobenzaprine are effective for treating pain related to muscle spasms, but they are not adequate for this type of acute pain. Ibuprofen is a nonsteroidal anti-inflammatory drug that is used to treat mild to moderate pain. This bone pain is very acute, so ibuprofen would not be sufficient. Meperidine should never be used for older adults because it has toxic metabolites that can cause seizures.

A client undergoes a surgical amputation of a lower extremity after a motor vehicle crash. The client's vital signs are stable. What is a priority nursing action in the early postoperative period to help prevent complications in this client? Fitting the client with a prosthetic device Inspecting the limb stump daily for signs of skin breakdown Positioning and range-of-motion of the affected extremity Teaching the client and family how to apply shrinker stockings

Positioning and range-of-motion of the affected extremity **In the early postoperative period the nurse would properly position the client and provide range-of-motion exercises to help prevent flexion contractures so that the client can ambulate with a prosthetic device later.Clients are not fitted with prosthetic devices until the limb stump is prepared; this is not done in the early postoperative period. Clients are taught to inspect for skin breakdown when the stump has healed. Clients are also taught to apply shrinker stockings as part of home care, not during the early postoperative period.

Treat acute musculoskeletal injuries with RICE

Rest Ice Compression Elevation

Which intervention does the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb? Talking with an amputee close to the client's age who has a similar amputation Drawing a picture of how the client sees him- or herself Talking with a psychiatrist about the amputation Engaging in diversional activities to avoid focusing on the amputation

Talking with an amputee close to the client's age who has a similar amputation **Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation.Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist would not be necessary. Diversional activities do not help the client deal with loss of the limb.

Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? Skin to evaluate lacerations and abrasions. Lungs for bilateral normal breath sounds Pain score and level of alertness Urine dipstick for the presence of red blood cells.

Urine dipstick for the presence of red blood cells. **It is most important for the nurse to monitor for the presence of blood in the urine as well as assessing the abdomen for rigidity. Clients with crushing injuries to the pelvis are at increased risk of internal hemorrhage. Pelvic injuries are the second cause of death from trauma after head injuries.Assessing the skin for external trauma and monitoring pain and alertness will be performed as part of the overall assessment but are not critical nursing actions at this time. Assessing lung sounds is more critical with chest injuries and rib fractures.

A client has a grade III open fracture of the right tibia. To prevent infection, which intervention does the nurse implement? Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab. Use strict aseptic technique when cleaning the site. Leave the site open to the air to keep it dry. Assist the client to shower daily and pat the wound site dry.

Use strict aseptic technique when cleaning the site. **Using aseptic technique is the best way to prevent infection.Chlorhexidine (Hibiclens), 2 mg/mL solution, is the better cleansing solution for pin site care, not Neosporin ointment. A wound of this type should be kept covered, not left open to the air. The wound site of an open fracture must not be exposed to a shower because this violates maintaining aseptic technique.