Ch 42: Management of Patients with Musculoskeletal Trauma (1)

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? pg. 1186

"Apply ice packs for the first 24 to 48 hours, then apply heat packs." Explanation: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care? pg. 1194

"Keep your right leg elevated above heart level." Explanation: The nurse should instruct the client to elevate the leg to promote venous return and prevent edema. The cast shouldn't be covered while drying. Covering the cast will cause heat buildup and prevent air circulation. The client should be instructed not to insert foreign objects into the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

A client who has fallen and injured a hip cannot place weight on the leg and is in significant pain. After radiographs indicate intact but malpositioned bones, what would the physician diagnose? pg. 1186

dislocation Explanation: In joint dislocation, radiographic films show intact yet malpositioned bones. Arthrography or arthroscopy may reveal damage to other structures in the joint capsule. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. Sprains are injuries to the ligaments surrounding a joint. A fracture is a break in the continuity of a bone.

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply. pg. 1203

- skin breakdown - wound infection - pneumonia Explanation: After surgery, the nurse implements measures to prevent skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures.

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for: pg. 1194

Capillary refill. Explanation: Assessment for neurovascular impairment includes checking for weak pulses or delayed capillary refill (normal is <2 seconds).

The nurse is caring for a client who was involved in an automobile accident and sustained multiple trauma. The client has a Volkmann's contracture to the right hand. What objective data does the nurse document related to this finding? pg. 1199

Claw-like deformity of the right hand without ability to extend fingers Explanation: A Volkmann's contracture is a claw like deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. The client is unable to extend the fingers and complains of unrelenting pain, particularly if attempting to stretch the hand. Nodule on the knuckles and dislocation are not indicative of Volkmann's contracture.

A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient? pg. 1193

Fat emboli Explanation: After fracture of long bones or pelvic bones, or crush injuries, fat emboli frequently form. Fat embolism syndrome (FES) occurs when fat emboli cause morbid clinical manifestations. The classic triad of clinical manifestations of FES include hypoxemia, neurologic compromise, and a petechial rash (NAON, 2007), although not all signs and symptoms manifest at the same time (Tzioupis & Giannoudis, 2011). The typical first manifestations are pulmonary and include hypoxia and tachypnea.

The type of fracture described as having one side of the bone broken and the other side bent would be: pg. 1190

greenstick. Explanation: A greenstick fracture is the type of fracture described as having one side of the bone broken and the other side bent. An oblique fracture occurs at an angle across the bone. A spiral fracture is a fracture that twists around the shaft of the bone. A transverse fracture is a fracture that is straight across the bone.

A fracture is considered pathologic when it pg. 1190

occurs through an area of diseased bone. Explanation: Pathologic fractures can occur without the trauma of a fall. An avulsion fracture results in a fragment of bone being pulled away by a ligament or tendon and its attachment. A greenstick fracture presents as one side of the bone being broken and the other side being bent. A compound fracture involves damage to the skin or mucous membranes.

Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect? pg. 1194

Compartment syndrome. Explanation: 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.

A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention? pg. 1189

Compound Explanation: A compound fracture is a fracture in which damage also involves the skin or mucous membranes with the risk of infection great. A greenstick fracture is where one side of the bone is broken and the other side is bent; it does not protrude through the skin. An oblique fracture occurs at an angle across the bone but does not protrude through the skin. A spiral fracture twists around the shaft of the bone but does not protrude through the skin.

Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome? pg. 1193

Column B [Heart rate: 116 bpm, Respiratory rate: 32/min; pH: 7.50; CO2: 30 mm Hg; HCO2: 24 mEq/L; PaO2: 55 mm Hg] Explanation: Fat embolism syndrome is characterized by fever, tachycardia, tachypnea, and hypoxia and other manifestations of respiratory failure. Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg, with early respiratory alkalosis and later respiratory acidosis.

A client sustains a fractured right humerus in an automobile accident. The arm is edematous, the client states that he cannot feel or move his fingers, and the nurse does not feel a pulse. What condition should the nurse be concerned about that requires emergency measures? pg. 1194

Compartment syndrome Explanation: Separation of adjacent bones from their articulating joint interferes with normal use and produces a distorted appearance. The injury may disrupt local blood supply to structures such as the joint cartilage, causing degeneration, chronic pain, and restricted movement. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space. The fractured humerus may also be dislocated but is not the result of the impaired circulatory status. Muscle spasms may occur around the fracture site but are not the cause of circulatory impairment. Subluxation is a partial dislocation.

In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor? pg. 1194

Compartment syndrome Explanation: The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a client with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A client with a dislocation does not experience an increased risk of complications such as gastrointestinal bleeding, carpal tunnel syndrome, or ganglion cysts.

Which type of fracture is one in which the skin or mucous membrane wound extends to the fractured bone? pg. 1189

Compound Explanation: A compound fracture is one in which the skin or mucous membrane wound extends to the fractured bone. A complete fracture involves a break across the entire cross section of the bone and is frequently displaced. An incomplete fracture involves a break through only part of the cross section of the bone. A simple fracture is one that does not cause a break in the skin.

Which of the following is a term used to describe a soft tissue injury produced by a blunt force? pg. 1185

Contusion Explanation: A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma develops when the bleeding is sufficient to form an appreciable solid swelling. A strain, or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. A sprain is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching or twisting motion.

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? pg. 1187

Difficulty lying on affected side Explanation: Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.

The nurse caring for a client, who has been treated for a hip fracture, instructs the client not to cross their legs and to have someone assist with tying their shoes. Which additional instruction should the nurse provide to client? pg. 1205

Do not flex the hip more than 90 degrees. Explanation: Proper alignment and supported abduction are encouraged for hip repairs. Flexion of the hip more than 90 degrees can cause damage to the a repaired hip fracture.

Which nursing intervention is essential in caring for a client with compartment syndrome? pg. 1194

Removing all external sources of pressure, such as clothing and jewelry Explanation: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as? pg. 1186

Sprain Explanation: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.