NUR 221 - Ch 42 WB - patients with musculoskeletal trauma

After an arm fracture, the nurse practitioner advises the patient that pendulum exercises are begun

As soon as tolerated, after a reasonable period of immobilization. The immediacy of physical therapy is essential to a rapid recovery.

Specify the clinical manifestations of a fracture and the Emergency Management of the patient with a fracture.

Describe the principles and methods of fracture reduction, fracture immobilization, and management of open fractures.

Describe the prevention and management of complications of fractures.

Discuss nursing management of the patient with a cast.

Explain the details for each event that occurs in fat embolism syndrome FES ...

... from the release of fat globules to possible heart failure.

The nurse assesses neurovascular status every 4 hours, comparing the affected to the non injured extremity. To assess Integrity of the radial nerve, the nurse would ask the patient to

Extend his forefinger against resistance inability to extend the finger against resistance suggest a radial nerve abnormality. Refer to box 42-4 in the text for assessment activities for the radical, medial, and ulnar nerves.

The nurse should assess for extremity shortening. Explain the cause of this complication.

Extremity shortening occurs due to contraction of the muscles that are attached distal and proximal to the site of the fracture. Bone fragments can overlap by as much as 1 to 2 inches.

A grating sensation caused by the rubbing of bone fragments.

crepitus

A classic indicator of edema and alveolar Hemorrhage associated with FES is

Hyperventilation. Occlusion of the small vessels in the alveoli leads to a pa o2 of less than 80 with an early respiratory alkalosis. The patient experiences hyperventilation in an attempt to get oxygen into the lungs.

Deep vein thrombosis DVT and a pulmonary embolism PE are complications of lower extremity fractures. Two significant diagnostic findings suggestive of a PE are:

Hypoxemia and hypocapnia. Hypoxemia and hypocapnia from tachypnea are two significant signs that can be seen on arterial blood gas measurements. Combined with other symptoms, especially pleuritic chest pain, pronounced dyspnea, and tachycardia, they are considered significant indicators of a PE.

Edema and Hemorrhage occur in the alveoli.

Oxygen transport is impaired and hypoxia occurs

A nurse advises a patient with a casted femur fracture to check for signs of a fat embolism. She tells the patient that the onset of symptoms for FES occur

Within 12 to 48 Hours. The onset of symptoms for a fat embolism is rapid, usually within 12 to 48 hours after injury, but may occur up to 10 days after injury.

Chest x-ray shows snowstorm infiltrate.

Without treatment, acute pulmonary edema, ARDS, and heart failure may develop.

The nurse performed a neurovascular status assessment distal to the injury. List the five areas that need to be evaluated.

Pain, limb temperature, limb pallor, the presence of paresthesia, and the quality of the pulses are noted.

Fat emboli are a major cause of death for patients with fractures. What are the significant signs and symptoms? Select all that apply.

Petechiae possibly due to a transient thrombocytopenia, substernal chest pain, hypoxia. Symptoms of fat embolism are consistent with impaired oxygen transport in the alveoli. Therefore tachycardia and tachypnia would be present along with the other choices.

List the five immediate goals for the treatment of shock.

Treatment of shock consists of preventing additional blood loss by stabilizing the fracture, restoring blood volume and circulation, relieving pain, maintaining adequate splinting, and protecting the patient from further injury and complications.

A 14 year old patient is treated in the emergency room for an acute knee sprain sustained during a soccer game. The nurse reviews discharge instructions with the patient's mother. The instructions cover pain management and swelling reduction for the acute inflammatory stage which lasts

24 to 48 hours rationale rest and Ice applications during the first 24 to 48 hours produced vasoconstriction while decreasing bleeding and edema. After this time, the acute inflammatory stage decreases. Refer to box 42-1 in the text.

Progressive passive and active exercises May begin as early as _____ after a musculoskeletal injury or wait until _____

48 hours, 5 days

A bone fragment is pulled away from a tendon

Avulsion

Fat globules enter the bloodstream.

Bone marrow pressure exceeds capillary pressure. Fat globules diffuse into the vascular compartment.

Bone fragments are splinted into several fragments

Comminuted

Explain the cause of compartment syndrome.

Compartment syndrome occurs when there is increased tissue pressure in a limited space, such as a cast, that compromises the circulation and function of the surrounding tissues.

Today, after application of a cast to treat a fractured femur, the patient tells the orthopedic healthcare provider that he is experiencing severe, deep, and constant pain in his leg. The nurse suspects a diagnosis of

Compartment syndrome. Compartment syndrome refers to the compression of nerves, blood vessels, and muscle within a closed space. This leads to tissue death from lack of oxygenation.

The patient presents to the emergency room with an open fracture of the femur. Which action would the nurse Implement to prevent the most serious complication of an open fracture?

Cover the wound with a sterile dressing to prevent infection. The most important complication of an open fracture is infection. Therefore the wound is covered with a sterile dressing. No attempt is made to reduce the fracture or apply pressure.

The femur fracture that commonly leads to a vascular necrosis or non-union because of an abundant supply of blood vessels in the area is a fracture of the

Femoral neck. A fracture of the neck of the femur may damage the vascular system and the bone will become ischemic. Therefore avascular necrosis is common.

A nurse is assigned to support a patient while a cast is being applied to treat a greenstick fracture. The nurse documents that this fracture is classified as what type of fracture?

Incomplete. Rationale a greenstick fracture involves a breakthrough only part of the cross section of the bone.

After the immediate and painful effects of an injury have passed, treatment efforts are focused on

Preventing fibrosis and atrophy or degeneration of the injured muscles and joint structures

The acronym RICE refers to _____ activities used to treat musculoskeletal injuries

Rest, ice, compression and elevation

Arterial blood gas changes occur.

The partial pressure of oxygen - Pa O2 - drops to <60 mm Hg. An early respiratory alkadosis is followed by a respiratory acidosis.

Describe how the nurse would assess for peroneal nerve damage.

The peroneal nerve is assessed for damage, which may result in foot drop, inability to lift the foot, by checking for sensation of the web between the greater and second toes and increased sensitivity of the dorsal surfaces of the foot. If nerve function is impaired, the patient cannot dorsiflex the great toe and has diminished sensation in the first web space dash between first metatarsal and hallux, big toe.

Tissue harvested from a donor for a recipient

allographt

List three types of pharmacological treatment for a fracture

anti-inflammatory agents, muscle relaxants and analgesics

Replacement of all or part of the joint surfaces

arthroplasty

A soft tissue injury produced by a blunt force.

contusion

Another term for bruising

ecchymosis

Regions of the proximal femur. Identify the parts of the proximal femur, {as illustrated}

extracapsular, intracapsular, trochanteric region, subtrochanteric region

One side of a bone is broken and the other is bent

greenstick

Bleeding into a joint

hemarthrosis

A collection of blood within tissues

hematoma

Replacement of the femoral head with a prosthesis

hemiarthroplasty

Pelvic bones identify the parts of a pelvis {as illustrated}

iliac crest, ilium, ischial spine, ischium, pubis, pubic arch, obturator foramen, symphysis pubis, acetabulum {socket for femur}, anterior superior iliac spine, sacrum

List three principles of fracture treatment

reduction, immobilization, and regaining normal function and strength through rehabilitation

A 19 year old patient presents to the emergency room with an injury to her left ankle that occurred during a high school basketball game she complains of limited motion and pain on walking, which increased over the last 2 hours. The nurse knows that her diagnosis is most likely which of the following?

second-degree sprain rationale a sprain is the result of an injury to ligaments that is caused by a twisting motion. A second-degree sprain is an incomplete tear of the ligament that results and painful weight-bearing. A third-degree sprain involves a complete ligament tear with loss of weight bearing function.

The fracture remains contained without disruption of skin integrity.

simple

A fracture that twists around the bone shaft

spiral

An injury to the ligaments and muscle fibers

sprain

Tissue death due to anoxia and diminished blood supply is known as

avascular necrosis

Case study: Kristen, who is 25 years old, fractured her right femur while skiing for the first time. The ski patrol brought her to the emergency care center at the base of the mountain. A nurse was available to assist the orthopedic surgeon when...

... assessing, stabilizing, and treating the patient. Kristen stated that her pain was a 9 on a scale of 1 to 10. Her skin was cold and clammy her blood pressure was 90 over 60 and her heart rate was 124 beats per minute, week, and thready.

Pulmonary pressure rises.

A large number of small vessels are occluded.

A nurse knows to assess for indicators of hypovolemic shock, and immediate complication of a fracture. What are positive indicators for hypovolemic shock? Select all that apply.

A weak and thready pulse, delayed capillary refill, tachycardia and tachypnia. Refer to box 42-2 in the text for a complete list of the signs and symptoms of hypovolemic shock.

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for

Capillary refill. Assessment for neurovascular impairment includes checking for weak pulses or delayed capillary refill. Normal is less than 2 seconds.

Describe nursing activities for the neurovascular assessment of fractures.

Refer to table 42-2 in the text

Nursing assessment after a closed reduction would include checking for a sign of neurovascular complications. What is the indicator?

Numbness and tingling. Rationale neurovascular assessments are initially done every 15 minutes to make certain that blood supply has not been compromised and nerves are intact. Numbness and tingling may indicate nerve damage.

The nurse advises a 36 year old patient who suffered a severe wrist sprain subsequent to a fall that she can begin Progressive passive and active exercises in

One to two weeks. Rationale depending on the severity of the injury, exercises can begin from 2 to 5 days {mild}, or 1 to 3 weeks {severe}. A sprain takes weeks to months to heal because tendons and ligaments are relatively avascular.

Assessment to quickly identify the presence of infection with an open fracture is an important nursing responsibilities. Which of the following are indicators of an infection? Select all that apply.

Pyrexia, leukocytosis, warm and tender skin. Refer to box 42-3 in the text for the signs and symptoms of infection with an open fracture. The patient would most likely exhibit tachycardia and tachypnia due to the stress of the injury.

The nurse knew to immediately assess for hypovolemic shock. List the signs and symptoms that are indicative of shock.

Refer to box 42-2 in the text

Bone fragments are driven inward.

oblique

This fracture occurs at an angle across the bone.

oblique

List the three potential serious complications of an open fracture

osteomyelitis,tetanus, and gas gangrene

List the seven clinical manifestations of a fracture

pain, loss of function, deformity, shortening, crepitus, swelling, and discoloration

Another term for a false joint

pseudarthrosis

A nurse should assess any sprain or strain for the following six signs and symptoms

swelling, pain, bruising, muscle spasm, tenderness, and abnormal joint motion

A closed fracture of the femur can have an estimated blood loss of

1000 to 1500 milliliters

Distinguish between open and closed reduction.

A closed reduction is accomplished through manipulation and manual traction. The extremity is held in the desired position while the provider applies a cast, splint, or other device. Reduction under anesthesia with percutaneous pinning may be used. With an open fracture, surgical intervention is needed to align the bone fragments. Internal fixation devices - metal pins, wires, screws, plates, nails, or rods - are used to hold the bat bone fragments in position until bone healing occurs.

Explain avascular necrosis of the bone.

Avascular necrosis occurs when the bone loses its blood supply and dies. It may occur after a fracture, with disruption of the blood supply Dash especially of the femoral neck. It is also seen with dislocations, bone transplantation, prolonged high-dose corticosteroids therapy, excessive alcohol intake, cigarette smoking, chronic renal disease, systemic lupus everything mitosis, and other diseases. The divide alized bone may collapse or reabsorb. The patient develops pain and experiences limited movement. X-rays reveal loss of mineralized matrix and structural collapse.

Learning objectives

Differentiate between contusions, strains, sprains, and dislocations.

This is another term for a compound fracture.

open

another term for a pulled muscle

sprain

A partial dislocation

subluxation

A fracture occurs across the bone shaft.

transverse

Pelvic fractures have a high mortality rate. The nurse knows to be conscientious and assessing for the two most serious complications. What are those complications?

Hemorrhage and shock. Bleeding occurs because of blood vessel damage from fracture fragments due to laceration of veins and arteries and possibly a torn iliac artery.

Bone fragments are driven into another bone fragment.

impacted

Explain how fat globules enter the bloodstream, post fracture.

At the time of fracture, fat globules May diffuse into the vascular compartment because the marrow pressure is greater than the capillary pressure or because catecholamines elevated by the patient's stress reaction mobilize fatty acids and promote the development of fat globules in the bloodstream. The onset of symptoms is rapid, usually within 24 to 72 hours of injury.

The primary nursing intervention that will control swelling while treating a musculoskeletal injury is

Elevate the affected area rationale elevation is used to control swelling. It is facilitated by cold, immobilization, and compression. Refer to box 42-1 in the text.