CH. 54

Vasovagal

looses consciousness and BP drops after getting out of bed, trendelenbug

Hematocrit/hemoglobin

35-48%/ 11-16g/dL ○Low indicates bleeding ○Start transfusing hematocrit <22, hemoglobin <8

Fractures

-6 million annually -More common in children and older adults -12-21 high energy. (MVA, bike accidents, contact sports) 65>- low energy. ( falls)

cast care Do's

-Do keep the cast clean and dry at all times. -Do cover the cast with a plastic bag or cast cover for bathing or showering. -Do use a hair dryer on cool air setting to dry the cast if it gets wet by blowing air under the cast. -Do contact the provider if there is any red skin irritation, blisters or sores around the edges of the cast or inside the cast. -Do cover rough edges of the cast with tape to prevent skin irritation. -Do elevate the cast above the heart if increased swelling, pain, numbness, tingling or change in color or circulation are noted. If this does not relieve the symptoms, notify the provider. -Do contact the provider if the cast is damaged, cracked, or extremely wet. The cast will need to be changed.

Cast Care Dont's

-Do not pull out any padding from under the cast. -Do not get the cast wet. For casts that were applied using water resistant cast padding, you may shower or swim in a pool only, but must dry the lining of the cast after you finish with a cool air hair dryer to prevent skin breakdown. -Do not allow the patient to place any objects inside the cast. -Do not apply powder or deodorant to itching areas. Notify the provider if there is persistent itching. -Do not trim or break off any rough edges around the cast. -Do not rest the heel of the leg cast on a pillow or bed. Keep the heel floating off the surface by elevating the leg with a pillow or blanket roll under the calf to prevent sores.

Creatine phosphokinase

26-308U/L ○Elevated indicates muscle trauma/injury ○Can be elevated into the thousands with severe rhabdomyolysis

complications

-Joint instability -Frequent recurrence -Bursitis -Tendonitis -Compartment syndrome

VTE prevention

-compression stockings or SCD's (18hrs/day) -move fingers, toes, ROM -prophylactic anticoagulants (lovenox) *-ambulation (most important and works best). Best to ambulate at least 4-6 times per day walking up and down hallway

Creatinine

.84-1.21 mg/dL ○Elevated indicates renal impairment ○WHY would a trauma patient be at increased risk of kidney problems?

lactate

0.5mmol/L-1 ○Indicator of sepsis/tissue perfusion ○4 GET OFF THE FLOOR

6 p's of neurovascular compromise

1.Passive Pain at Rest 2.Pallor 3.Pressure 4.Paresthesia 5.Paralysis 6.Pulselessness 7.Cant dorifelx toes

stage 1 fracture healing

A hematoma forms around the fracture site within 24 to 72 hours of the initial injury.

The nurse recognizes that the stretching or tearing of a muscle or tendon occurs in which condition? A. Strains B. Dislocations C. Fractures D. Sprains

A. strains

nursing diagnosis for sprains and strains

Acute pain associated with the physical injury • Altered peripheral tissue perfusion associated with edema and vessel damage • Impaired physical mobility associated with the injury

Elective amp

After all measures to preserve the limb have failed. caused by disorders that lead to ischemia and eventual cell death Elective amputations are typically due to vascular compromise secondary to chronic illnesses such as peripheral vascular disease, diabetes, neoplasms, and infections. Risk factors for elective amputations include noncompliance with the diabetic treatment regimen, smoking, and venous stasis ulcers. X rays/CT are done to determine infectious/necrotic tissue to determine where needs to be amputated.

greenstick fracture

An incomplete disruption in which one side of the bone is bent and the other is fractured; generally seen in children because of the flexibility of their bones

Surgical Treatment of 3rd degree sprain

Arthroscopy (using small scope to see and repair) Allograft ACL tear in women common require 4-6 weeks of immobilization

diagnosis of fractures

Assessment. X ray. CT scan. (MRI maybe be used to detect metastasis)

The nurse identifies which pathophysiological finding in a third-degree sprain? A. Stretched muscle or tendon fibers B. Torn/ruptured ligaments C. Torn/ruptured muscle or tendon fibers D. Stretched ligaments

B. Torn/ruptured ligaments

non displaced

Bone fragments are well approximated within the site of disruption.

closed reduction

Bone fragments manually manipulated into alignment Under anesthesia Then casted or splinted

causes of bursitis and tendinitis

Both conditions are typically caused by overuse, repetitive minor impact, or a sudden, more significant impact to the affected area. Areas typically affected include the elbow, hip, shoulder, or knee.

Bursitis

Bursitis is an inflammation of the bursa, a sac located between bone or muscle or tendon that contains lubricating fluid to decrease friction with movement

Avulsion

Caused by the overstretching and tearing of a tendon or ligament, separating a small segment of bone at the insertion site

ribs

Causes: blunt force (MVA's, Assaults), falls. Treatments: pain control. Breathing exercises splinting with pillow

clavicle

Causes: blunt force to the chest, falls with arm out Sports related, falls, MVA Treatments: immobilization, ORIF

Elbow

Causes: blunt force, falls Treatments: closed reduction/casted. ORIF

Humerus

Causes: blunt force, falls on outstretched hand Treatments: closed reduction/splint. ORIF

tibia/fibula

Causes: blunt force, twisting injuries Treatments: closed reduction with cast Open reduction with pins. External fixators.

ankle/foot

Causes: crushing/blunt force trauma Treatments: immobilization with cast/splint ORIF with screws, pins, plates then splint/cast

Radial / ulnar (forearm)

Causes: direct force, falls. Treatment: closed reduction, immobilization. ORIF

pelvis

Causes: falls from heights, MVA's, crushing Treatments: ex fix, ORIF. (nondisplaced= pain control, ambulate as tolerated)

hip

Causes: falls, blunt forces, MVA, chronic illnesses Treatments: ORIF, pins, screws, plates. total or partial hip replacement.

spinal

Causes: falls, flexion/extension, acceleration/deceleration Treatments: Surgical: ORIF, Fusions, Cervical traction, Immobilization Nonsurgical: immobilization: back braces.

femur

Causes: falls, trauma, MVA, MV vs Pedestrian Treatments: traction/immobilization. ORIF. Intramedullary nails.

hand/fingers

Causes: trauma/falls Treatments: immobilization. Pins, screws, plates ORIF. Casts splints

wrist

Causes:blunt force trauma, falls. Treatments: closed reduction, splint/cast. ORIF. pins, screws, external fixators

Meniscal injury symptoms

Clicking Locking Instability Pain Tenderness on the joint line

VTE

Clots develop in deep veins Can dislodge and move into lungs. (PE)

Carpal tunnel

Compression neuropathy Caused by repetitive movements computer operators, musicians, construction workers, and factory workers Women more likely than men

Grade I open fracture

Presence of a puncture wound, minimal injury to the soft tissues, and vasculature remains intact

Depressed

Disruptions in which fragments of bone are forced inward; frequently seen in facial and skull fractures involving blunt trauma

Grade II open fracture

Puncture wound, fragments of broken bone, moderate skin and muscle contusions, and significant wound contamination

stage 3 fracture healing

Granulation tissue develops into a callus (fibrocartilaginous tissue bridging the gap of the fracture) at 2 to 6 weeks. During this stage, the callus initiates the fusion of the bone segments.

Trauma

Happens across the lifespan 60-77% of unintentional injuries are due to musculoskeletal trauma 20-27 million Musculoskeletal injuries ○In the US per year

Compartment syndrome prevention

Ice and elevate, trendelenbug

treatment of carpel tunnel

Ultrasound therapy Steroid injections NSAIDS Carpal tunnel release Splinting

compartment

Fascia surrounding muscle, nerves, blood vessels. Caused by bleeding into the area, and compression from casts, splints, braces.

stage 5 fracture healing

Final stage of bone repair for mechanical function; this typically happens at 4 to 6 weeks and can last as long as a year.

Compression

Fracture caused by excessive force along the axis of cancellous (spongy internal layer of bone) bone, leading to the bone collapsing on itself; representative in vertebral compression fractures from falls of significant heights

Comminuted

Fracture that has several disruptions producing shattered bone fragments within the fracture site

closed (simple) fracture

Fracture that is contained within the skin

Complications of CTS

Imobility Nerve damage Chronic pain.

displaced

Malalignment of bone fragments at the fracture site

Meniscus injuries

Men 2x more likely More likely in congenital abnormalities, joint diseases, insufficient quad control Athletes: soccer, basketball, skiing. Football Increased risk when not stretching before activity Torn with twisting and rotation

pain management

Narcotics and anti-inflammatory medications are effective in controlling pain and inflammation. These medications allow the patient to gradually regain movement and function of the injured area.

Carpal tunnel release

Open (cuts to visualize the ligament) Endoscopic (using an endoscopy camera) Ligament is cut to enlarge the carpal tunnel

populations with weakened bones

Osteogenesis imperfecta, osteoporosis, paget's disease, cushing's disease, anorexia, metastatic cancers, eating disorders.

Assessment of Sprains and Strains

Physical assessment of injured extremity via inspection and palpation: palpate the injured extremity noting the six Ps to include pain, pressure, paralysis, pallor, paresthesia, and pulselessness. Complete the neurovascular assessment by checking movement and sensation.

skeletal traction

Pins are put into a secure bone and weight is applied for realignment At risk for skin injury, ulcers, clotting Given profylaxis and repositioning

symptoms of fat emboli

Resp distress, tachycardia, AMS, anxiety, petechiae rash

Treatment of first- and second-degree strains and sprains involves RICE, a common acronym referring to the treatment plan for strains and sprains:

Rest the injured extremity for as long as 72 hours to allow the ligaments or tendon time to heal. • Ice applied for no longer than 30 minutes three to five times per day for 24 to 72 hours after injury. This promotes vasoconstriction and decreases bleeding and fluid collection in the injured area. • Compression by means of an Ace wrap or similar compression dressing to minimize further swelling, which can delay healing. The dressing should be wrapped tightly but not enough to alter neurovascular function. Ensure that circulation, movement, and sensation remain intact. • Elevate the affected area to minimize dependent swelling.

internal fixation

Screws, plates, nails used to realign the bone

impacted fracture

Segments of bone are wedged into each other at the fracture line.

Grade III open fracture

Severe damage to soft tissues, nerves, muscles, and blood vessels. The open fracture site is considered extremely contaminated and contains numerous comminuted fractures. Risk for infection

tendinitis

Tendinitis is an inflammation of the tendon. Both are more common in people older than 40 because age makes tendons less elastic and more prone to tearing.

Stage 4 of Fracture Healing

The callus is reabsorbed and converted into bone tissue 3 weeks to 6 months from the initial injury.

incomplete fracture

The disruption occurs through part of the bone cortex; however, there is no displacement of bone fragments.

complete fracture

The disruption spans across the width of the bone, causing bone fragments.

oblique fracture

The fracture line occurs usually at a 45-degree angle across the cortex of the bone

spiral fracture

The fracture wraps around the shaft of the bone.

stage 2 fracture healing

The hematoma undergoes a transformation to granulation tissue, which provides the basis for bone healing. This stage occurs 72 hours to 14 days after the initial injury.

Surgical Treatment of 3rd degree strain

Thick suture allograft from healthy tendon/muscle donor graft require 4-6 weeks of immobilization

traumatic amputation

Tourniquet can be applied to help with bleeding for 6 hrs Large bore IV to repleat quickly Amputation is done to stop the hemorrhaging Labs to monitor CBC + lactate Risk factors for traumatic amputations include blunt force trauma obtained in motor vehicle crashes, motorcycle crashes, accidents where the patient is caught between two objects, and pedestrian versus vehicle injuries.

open fractures with contaminated wounds are treated with

antibiotics are implemented to prevent osteomyelitis and other wound infections

diagnosis of sprains and strains

based on a thorough history and physical examination of the affected area and is often confirmed by radiography, ultrasound, or magnetic resonance imaging (MRI). Ultrasounds are low cost and highly effective in identifying strains and sprains, but an MRI may be more definitive in the final diagnosis.

hypovolemia causes

blood loss r/t bone fractures or internal bleeding. Humerus 500-1,500 Elbow, radius, ulna 250-750 Pelvis 750-6,000 Femur 500-3,000 Tibia, fibula 250-1,000

open (compound) fracture

bone protrude through the skin, creating an external wound that exposes the fracture site. Open fractures are graded on the basis of their severity.

other treatment for first and second degree strains and sprains

braces may be used for 4 to 6 weeks and are preferred versus immobilization. Exercise therapy programs may be prescribed and consist of neuromuscular and proprioceptive exercises. NSAIDs are usually prescribed to minimize pain and inflammation.

skull

causes : blunt force. (MVA, assaults, falls) Treatments: (only treated if altered ICP) Burr holes: sterile drilling to release pressure. Craniotomy: skull removed and replaced Craniectomy: skull removed and NOT replaced ORIF: open reduction/internal fixation w/ hardware

rhabdo causes

compression. Tissue ischemia. (crushing injuries) Myoglobin is released from the injured muscle gets lodged in the nephrons of the kidneys Kidneys unable to filter> tubular necrosis >renal failure

tendon

connect muscles to bones

Neurovascular compromise causes

decreased blood flow and oxygen to affected area ○Could be r/t severed vasculature and nerves.

fracture

defined as a disruption, or break, in the continuity of a bone. There are numerous classifications of fractures that can occur throughout the body

First-degree/mild strains

demonstrate minimal inflammation and pain. Symptoms can last for several days, but range of motion (ROM) remains unaffected.

First-degree/mild sprains

demonstrate stretching and/or minimal tearing of ligament fibers. Edema and pain may be evident, but joint function remains intact, and patients are able to ambulate with slight discomfort.

Treatment of compartment syndrome

emergency fasciotomy. elevate, ice, remove splint.

Rhabdo Symptoms

flank pain, tea-colored urine

treatment of rhabdo

fluid resuscitation, monitor renal function

Percutaneous autologous bone marrow grafting

for nonunion (or non healing) Percutaneous bone marrow grafting has some promising research but is not without risk. Donor site morbidity as well as risk for infection re opening the wound

hypovolemia symtoms

hypotension, tachycardia, pallor, sweating, lethargy

Small tears:

ice, NSAIDS, continue daily activities Rest can lead to atrophy

compartment syndrome

impeded blood flow due to edema, bleeding, pressure that can result in death to the damaged muscle/tendon.

Open reduction

incision to observe the fracture

Third-degree/severe sprains

include the complete tearing of a ligament, which renders the patient unable to ambulate because of joint instability. Symptoms include severe pain, ecchymosis, and edema.

Third-degree/severe strains

include the rupture of the muscle or tendon, causing considerable internal bleeding, pain, inflammation, and ecchymosis. Surgical repair may be needed if there is extensive tearing in the muscle or tendon.

sprain

injury to ligaments the stretching or tearing of a ligament resulting from overextension, overexertion, or overstretching Sprains are also classified similar to strains on the basis of severity

strain

injury to muscle or tendon tissue. A strain is the tearing or stretching of a muscle or tendon, often resulting from overextension, overexertion, or overstretching. Strains can be categorized according to their severity

Steinman's test

knee is flexed and extended MRI: to see the extent of tear

Fat emboli causes

long bone fractures Fat from bone marrow travels to the circulatory system Lodges in small vessels, causing petechiae or round bruises Can also become a PE

compartment syndrome

medical emergency, filled with blood and fluid so no oxygen or blood through the limb (swelling,

irrigation and debridement (I & D)

might be needed for open fractures that are contaminated with dirt and foreign matter. External fixation is the application of a series of rods and pins to the area surrounding the fracture, creating an external frame to stabilize and align the displaced fragments.

Hypovolemia Assessment

monitor hematocrit & hemoglobin, monitor for hematomas

Carpal tunnel diagnosis

patient relax his or her hand in the flexed position for 60 seconds or by placing the back of the hands together while flexing both wrists. This compresses the median nerve. Patients with CTS experience numbness and tingling during the Phalen's test. Tinel's sign, tapping the median nerve over the carpal tunnel at the wrist, will also elicit paresthesia over the median nerve region of the wrist IMPORTANT TO RULE OUT C SPINE isSUES

VTE: venous thromboemboli causes

prolonged immobility Long surgeries Cardiac issues Long bone fractures

treatment of hypovolemia

replace the blood and fluid.

when are external fixators used

requently used when there is significant soft-tissue damage at the fracture site External fixator pins and rods into the fracture and outside of the skin.

Second-degree/moderate sprains

result from a moderate amount of tearing in the ligament fibers. The joint remains intact, and the ligament is not completely torn. Increased swelling, ecchymosis, pain, and altered weight-bearing mobility are evident in these patients.

Second-degree/moderate strains

result from actual tearing of the muscle and tendon fibers. This injury is often painful, with severe muscle spasms, extensive inflammation, and ecchymosis that appear several hours or days after the initial injury. Symptoms can last for several weeks.

ligaments

segments of connective tissue that secure bones to bones and bones to cartilage.

Alcohol withdrawal

seizures day 3, confusion, tachycardia, sweating

Menisci-

semilunar shaped cartilage between knee and femur

Mcmurray test

support the knee flexed rotate foot internally and externally to assess for pain, clicking

symptoms of VTE

tachycardia, dyspnea, anxiety, cyanosis, AMS, confusion

log rolling method

the log roll or logrolling is a maneuver used to move a patient without flexing the spinal column. Patient's legs are stretched, the head is held, to immobilize the neck.

Buck's Traction (skin traction)

uses a flexible harness, boot, or belt to secure the extremity while 5 to 10 lb of weight is applied to relieve muscle spasms and maintain the length of the bone . Buck's traction is a form of skin traction commonly used for femur and hip fractures.

WBC

●4.5-11 ○elevated indicates infection ○Low indicates risk for infection

infection

●Causes: open fractures, surgeries, external fixators, hardware ●Symptoms: fever, chills, drainage, erythema, delayed healing, elevated white blood cell counts ●Prevention: prophylactic antibiotics for open fractures, aseptic wound care, sterile technique in the OR. ●Treatment: antibiotics, surgeries ( I&D )

nonunion

●Fractures fail to heal correctly. ●Causes : early removal of splints, misalignment during reduction, inadequate reduction, infection. ●Medication causes: NSAIDS, steroids, aspirin ●Conditions: smoking, anemia, diabetes ●Treatment: surgery using bone grafts

Amputation complications

●Hemorrhage: ○r/t destruction of large vessels ○Tourniquet should be applied ASAP!! ●Infection: ○r/t vascular wounds ○Traumatic amputations ●Contractures: ○r/t lack of range of motion exercises

Arthroscopic surgery

●Menisci removed ●Menisci repaired with dissolving sutures Ambulation encouraged immediately with crutches 6-8 weeks of therapy

complications

●Neurovascular compromise ●Joint dislocation ●VTE ●Fat embolism ●Rhabdo ●Hypovolemia ●Infection Nonunion

assessment of trauma

●Pain ●Neurovascular assessments ●Skin assessments ●neurocognitive/Glascow coma scale ●Respiratory status

Nursing diagnosis

●Pain ●Risk for infection ●Ineffective airway clearance ●Impaired mobility ●Activity intolerance ●Impaired skin integrity ●Bleeding ●Fluid volume deficit ●Grief Ineffective coping

Amputation complications

●Phantom limb pain: ○Tingling, burning pain perceived in the limb that has been removed ○Exacerbated by stress, illness, touching, nerves ○Treated with gabapentin ○Mirror therapy ●Neuromas: ○Regenerated nerve axons at the end of the residual limb ○Prosthetic may not fit ○May require surgery

amputation

●Severing or removing of body part ●Can happen at time of injury or after to preserve function ●r/t necrosis of the wound due to lack of oxygen and presence of bacteria ●If not addressed it can lead to systemic infection and multisystem organ failure

Education

●Surgical expectations ●Pain control (pharmaceutical and non pharmaceutical) ●New medication regimens ●New equipment (casts, external fixators, splints, braces) ●How to prevent complications ○Anticoagulants, infection prevention, weight bearing status ○Stool softeners ●Signs and symptoms of complications ●When to seek medical attention