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Fractures/Musculoskeletal disorders 1
Musculoskeletal disordersAssessment A. Health History 1. Elicit
a description of the present illness and chief complaint a. Onset
b. Course c. Duration d. Location e. Precipitating and alleviating
factors f. Cardinal signs and symptoms
Moderate to severe pain Inability to move body part Localized
edema Altered sensation to the affected part Contour deformity and
asymmetry Contusions
2. Explore the clients history for risk factorsa. Medical
conditions (TB, DM, gout, arthritis) or medications that would
cause
dizziness, falls or injuriesb. Pediatric illnesses &
immunizations (tetanus & polio) c. Environmental or physical
conditions or unsafe behavior that would cause
injuries, especially related to job environment & recreation
d. History of infrequent exercise and sedentary life
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Fractures/Musculoskeletal disorders 2
e. Three generation family history of musculoskeletal problems
(arthritis &
gout) f. Diet
3. Physical Examination a. Note upright body alignment including
posture b. Assess bone discrepancies, including contour, length,
alignment and symmetryc. Assess the clients ability to move each
joint through its range-of-motion, noting
smoothness, pain, crepitus, and clicks d. Note the clients gait,
including coordination, rhythm, stride and balance e. Assess the
joint alignment, including symmetry, size, shape, contour,
stability, tenderness, heat and swellingf. Hyperthrophy, atrophy,
and spasms
B. Nursing diagnoses a. Painb. Ineffective tissue perfusion
(specify)
c. Impaired physical mobility d. Risk for infection e. Risk for
injuryf. Self-care deficit (specify)
g. Deficient knowledge h. Anxiety
C. Implementation a. Perform neurovascular assessment (six Ps)1.
Assess pain
Rate scale (0-10)
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Take action: use nonpharmacologic interventions like relaxation
technique, massage and guided imagery
2. Assess pulses (pulselessness indicates disruption of arterial
blood flow)
Assess various locations, including radial, brachial, pedal,
posterior tibial, popliteal, and femoral pulses. Always mark pulses
with an X. Document pulse strength using a scale of 0 to 4+: 0, no
pulse; 1+, weak; 2+, normal; 3+, strong; 4+, bounding
3. Assess for pallor (disruption of blood flow)
Check capillary refill time should be less than 3 seconds
4. Assess for paresthesia (nerve function may be disrupted by
nerve
compression) Determine whether client experiences numbness,
tingling Determine whether the client can ascertain dull or sharp
touch sensation
5. Assess for paralysis (increasing edema causes nerve
compression)
Determine whether the client can move and lift the affected
extremity Ascertain whether the client can push the affected
extremity against pressure
6. Assess for polar (which indicates disrupted arterial blood
flow)
Determine whether the clients extremity feels cool or has a
bluish color Note whether the client complains of cold
extremity
b. Provide pain relief Elevate the injured extremity above the
level of the clients heart for the first 24 hours as ordered
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Fractures/Musculoskeletal disorders 4
Apply cold packs as ordered for 15-20 minutes intermittently the
1 st 24 hours vasoconstricting effects of cold retard extravasation
of blood and lymph (edema) and suppress pain After 24 hours, apply
mild heat (15-30 minutes, 4 times daily) to promote absorption
c. Promote mobility
Assist the client with active and passive range-of-motion
exercises for unaffected body parts to help maintain function
d. Prevent infection
Monitor clients vital signs Assess for signs or symptoms of
infection Monitor WBC count
e. Protect client from injury Instruct the client in and have
him demonstrate safe transfer, ambulating and sitting techniques to
prevent further injury from the immobilization
f. Promote the clients participation in self-care activities
within limitation of the injury and treatment regimen
g. Minimize anxiety
FRACTURES: A traumatic injury interrupting bone continuity
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Types:1. Closed, simple, uncomplicated fractures do not cause
break in the skin 2. Open, compound, complicated fractures involve
trauma to surrounding tissue
and a break in the skin3. Incomplete fractures partial
cross-sectional breaks with incomplete bone
disruption4. Complete fractures are complete cross-sectional
breaks severing the periosteum
Patterns of Fracture5. Comminuted fractures produce several
breaks of the bone, producing splinter
fragments6. Spiral (torsion) fractures involve a fracture
twisting around the shaft of the bone 7. Transverse fractures occur
straight across the bone 8. Oblique fractures occur at an angle
across the bone (less than a transverse)
Fracture types (1)
Etiology: 1. Crushing force or direct blow 2. Sudden twisting
motion 3. Extremely forceful muscle contraction
Assessment Findings a. Painb. Edema (due to localization of
serous fluid at the fracture site and extravasation of
blood into surrounding tissues) c. Tendernessd. Abnormal
movement and crepitus (grating sound heard when fractured limb
is
moved)
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e. Loss of functionf. Ecchymoses (results from subcuataneous
bleeding at the fracture site) g. Visible deformity (caused by
muscle spasms leading to limb shortening, a rotational
deformity, or angulation)h. Paresthesia (damage to peripheral
nerves)
i. Altered Neurovascular Status Injured muscle, blood vessels,
nerves. Compression of structures resulting in ischemia. Findings:
o Progressive uncontrollable pain o Pain on passive movement o
Altered sensations (paresthesia) o Loss of active motion o
Diminished capillary refill response, diminished distal pulse o
Pallo
j. Shock Bone is very vascular. Overt hemorrhage through open
wound. Covert hemorrhage into soft tissues (especially with femoral
fracture) or body cavity, as with pelvic fracture. May be fatal if
not detected. Nursing Assessment
Ask patient how the fracture occurred - mechanism of injury
important in determining possible associated injuries. Ask patient
to describe location, character, and intensity of pain to help
determine possible source of discomfort. To aid in evaluation of
neurovascular status ask patient to describe sensations in injured
extremity. To assess functional mobility observe patient's ability
to change position. Note patient's emotional status and behavior -
indicators of ability to cope with stress of injury. Assess
patient's support system; identify current and potential sources of
support, assistance, and caregiving. Review findings on past and
present health status to aid in formulating care plan. Conduct
physical examination. o Examine skin for lacerations, abrasions,
ecchymosis, edema, and temperature. o Auscultate lungs to establish
baseline assessment of respiratory function. o Assess pulses and
blood pressure; assess peripheral tissue perfusion, especially in
injured extremity, to establish circulatory status baseline. o
Determine neurologic status (sensations and movement) of extremity
distal to injury. o Note length, alignment, and immobilization of
injured extremity. o Evaluate behavior and cognitive functioning of
patient to determine ability to participate in care planning and
patient education activities.
NURSING ALERT
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Change in behavior or cerebral functioning may be an early
indicator of cerebral anoxia from shock or pulmonary or fat emboli.
Nursing Diagnosis
Risk for Deficient Fluid Volume related to hemorrhage and shock
Impaired Gas Exchange related to immobility and potential pulmonary
emboli or fat emboli Risk for Peripheral Neurovascular Dysfunction
Risk for Injury related to thromboembolism Acute or Chronic Pain
related to injury Risk for Infection related to open fracture or
surgical intervention Bathing or Hygiene Self-Care Deficit related
to immobility Impaired Physical Mobility related to
injury/treatment modality Risk for Disuse Syndrome related to
injury and immobilization Risk for Posttrauma Syndrome related to
cause of injury
Nursing Interventions Evaluating for Hemorrhage and Shock
Monitor vital signs as frequently as clinical condition
indicates, observing for hypotension, elevated pulse, widening
pulse pressure, cold clammy skin, restlessness, pallor. Watch for
evidence of hemorrhage on dressings or in drainage containers.
Review laboratory data; report abnormal values. Administer
prescribed fluids/blood to maintain circulating volume. Monitor
intake and output.
Monitoring for Impaired Gas Exchange
Evaluate changes in mental status and restlessness that may
indicate hypoxia. Review diagnostic evaluation data - especially
ABG values and chest X-ray. Position to enhance respiratory effort.
Report any sudden or progressive changes in respiratory status.
Encourage coughing and deep breathing to promote lung expansion and
diminish pooling of pulmonary secretions. Monitor pulse oximetry.
Administer oxygen as prescribed. Maintain cervical spine
precautions if spinal injury is suspected.
Preventing Neurovascular Compromise
Monitor neurovascular status for compression of nerve,
diminished circulation, development of compartment syndrome. o Pain
- progressive, localized, deep throbbing, persistent, unrelieved by
immobilization and medications o Pain on passive stretch o Weakness
progressing to paralysis o Altered sensation, hypothesia,
paresthesia o Poor capillary refill (> 3 seconds)
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Fractures/Musculoskeletal disorders 8
Skin color - pale, cyanotic Elevated compartment pressure -
palpable tightness of muscle compartment Pulselessness - late sign
Reduce swelling. o Elevate injured extremity Relieve pressure
caused by immobilizing device as prescribed (such as bivalving
cast, rewrapping elastic bandage, or splinting device). Relieve
pressure on skin to prevent development of pressure sore. o
Frequent repositioning. o Skin care - do not massage bony
prominences. o Special mattresses.o o o
NURSING ALERT Monitoring the neurovascular integrity of the
injured extremity is essential. Development of compartment syndrome
(increased tissue pressure causing hypoxemia) leads to permanent
loss of function in 6 to 8 hours. This situation must be identified
and managed promptly. Preventing Development of Thromboembolism
Encourage active and passive ankle exercises. Use elastic
stockings, foot pumps, or sequential compression devices, as
prescribed. Elevate legs to prevent stasis, avoiding pressure on
blood vessels. Encourage mobility; change position frequently;
encourage ambulation. Administer anticoagulants as prescribed.
Monitor for development of thrombophlebitis. o Note complaint of
pain and tenderness in calf. o Report calf pain. o Report increased
size and temperature of calf.
Relieving Pain
Perform a comprehensive pain assessment. o Have patient describe
the pain, location, characteristics (dull, sharp, continuous,
throbbing, bony, radiating, aching). o Ask patient what causes the
pain, makes the pain worse, relieves the pain. Evaluate patient for
proper body alignment, pressure from equipment (casts, traction,
splints, appliances). Initiate activities to prevent or modify
pain. o Assist patient with pain-reduction techniques - cutaneous
stimulation, distraction, guided imagery, TENS, biofeedback. o
Immobilize injured part. o Position patient in correct alignment. o
Support splinted fracture above and below fracture when
repositioning or moving patient. o Reposition patient with slow and
steady motion; use additional personnel as needed. o Elevate
painful extremity to diminish venous congestion. o Apply heat or
cold modalities as prescribed. Heat versus cold is controversial. o
Modify environment to facilitate rest and relaxation. o Administer
prescribed pharmaceuticals as indicated. Encourage use of less
potent drugs as severity of discomfort decreases.
Monitoring for Development of Infection
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Fractures/Musculoskeletal disorders 9
Clean, debride, and irrigate open fracture wound as prescribed
as soon as possible to minimize risk of infection. o All open
fractures are contaminated. o Begin prescribed antibiotic therapy
promptly after wound culture obtained. Use sterile technique during
dressing changes to minimize infection of wound, soft tissues, and
bone. Evaluate patient for elevation of temperature every 4 hours.
Note and report elevated white blood cell (WBC) counts. Report
areas of inflammation and swelling around incision or open wound.
Report purulent odiferous drainage. Obtain specimens for culture
and sensitivity to determine causative organism. Administer
antibiotic therapy as prescribed.
Promoting Adequate Hygiene
Encourage participation in care. Arrange patient area and
personal items for patient convenience and to promote independence.
Modify activities to facilitate maximum independence within
prescribed limits. Allow time for patient to accomplish task. Teach
safe use of mobility and necessary aids. Assist with ADLs as
needed. Teach family how to assist patient while promoting
independence in self-care.
Promoting Physical Mobility
Perform active and passive exercises to all nonimmobilized
joints. Encourage patient participation in frequent position
changes, maintaining support to fracture during position changes.
Minimize prolonged periods of physical inactivity, encouraging
ambulation when prescribed. Administer prescribed analgesics
judiciously to decrease pain associated with movement. Methods o
Closed reductiono o o
Bony fragments are brought into apposition (ends in contact) by
manipulation and manual traction restoring alignment. May be done
under anesthesia for pain relief and muscle relaxation. Cast or
splint applied to immobilize extremity and maintain reduction
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Traction the act of pulling or drawing which is associated with
countertraction o Traction may be used to reduce the fracture or to
maintain alignment of bone fragments until healing occurso
Principles:
a. Position should be supine b. Avoid friction c. Allow weights
to hang freely apply traction continuously or intermittently d.
There should be an adequate countertraction e. The line of pull
should be in line with the deformity
Types:
a. Skin traction: weights attached to adhesive, which is applied
to the skin
Longitudinal force load: 5-7 lbs
Accomplished by applying a light force that pulls on tape,
sponge rubber, or special device (boot, cervical halter, pelvic
belt) that is in contact with the skin. The pulling force is
transmitted to the musculoskeletal structures. Skin traction is
used as a temporary measure in adults to control muscle spasm and
pain. Bucks extension exerts a straight pull on the leg when a
client fractures a hip
Indication: Fractured femur and hip
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Bryants traction both lower limbs extended vertically; used to
align
fractured femurs in young children Indication: Femoral
fractures, hip injuries (for children below 4 years old)
Russel traction: balanced traction in which the lower leg is
supported in a
hammock attached to a rope and pulleys on a Balkan frame Used to
treat fractures of the femur
b. Skeletal traction applied to the bone Uses 7-10 lbs.
Steinmann pin or Kirschners wire may be inserted through the bone
and skin Weights are then attached to a spreader, which is attached
to both ends of the pin or wire ( may be used in conjunction with a
cast)
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Care of Client with Traction: Nursing Assessment
Assess for pain, deformity, swelling, motor and sensory
function, and circulatory status of the affected extremity. Assess
skin condition of the affected extremity, under skin traction and
around skeletal traction, as well as over body prominences
throughout the body. Assess traction equipment for safety and
effectiveness. o The patient is placed on a firm mattress. o The
ropes and the pulleys should be in alignment. o The pull should be
in line with the long axis of the bone. o Any factor that might
reduce the pull or alter its direction must be eliminated. Weights
should hang freely. Ropes should be unobstructed and not in contact
with the bed or equipment. Help the patient to pull himself or
herself up in bed at frequent intervals. o The amount of weight
applied in skin traction must not exceed the tolerance of the skin.
The condition of the skin must be inspected frequently. o Cover
exposed sharp ends of skeletal pins with cork or other pin covering
to protect patient and caregivers from injury. Assess emotional
reaction to condition and traction. Assess understanding of the
treatment plan.
NURSING ALERT Traction is not accomplished if the knot in the
rope or the footplate is touching the pulley or the foot of the bed
or if the weights are resting on the floor. Never remove the
weights when repositioning the patient who is in skeletal traction
because this will interrupt the line of pull and cause the patient
considerable pain. Nursing Diagnoses
Impaired Physical Mobility related to traction therapy and
underlying pathology Risk for Impaired Skin Integrity related to
pressure on soft tissues Risk for Infection related to bacterial
invasion at skeletal traction site Ineffective Tissue Perfusion:
Peripheral related to injury or traction therapy
Nursing Interventions Minimizing the Effects of Immobility
Encourage active exercise of uninvolved muscles and joints to
maintain strength and function. Dorsiflex feet hourly to avoid
development of footdrop and aid in venous return. Encourage deep
breathing hourly to facilitate expansion of lungs and movement of
respiratory secretions. Auscultate lung fields twice per day.
Encourage fluid intake of 2,000 to 2,500 mL daily. Provide balanced
high-fiber diet rich in protein; avoid excessive calcium intake.
Establish bowel routine through use of diet and stool softeners,
laxatives, and enemas, as prescribed. Prevent pressure on the calf,
and evaluate twice daily for the development of
thrombophlebitis.
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Check traction apparatus at repeated intervals - the traction
must be continuous to be effective, unless prescribed as
intermittent, as with pelvic traction.
NURSING ALERT Every complaint of the patient in traction should
be investigated immediately to prevent injury. Maintaining Skin
Integrity
Examine bony prominences frequently for evidence of pressure or
friction irritation. Observe for skin irritation around the
traction bandage. Observe for pressure at traction, and skin
contact points. Report complaint of burning sensation under
traction. Relieve pressure without disrupting traction
effectiveness. o Ensure that linens and clothing are wrinkle free.
Special care must be given to the back every two hours because the
patient maintains a supine position. o Have patient use trapeze to
pull self up and relieve back pressure. o Provide backrubs.
Avoiding Infection at Pin Site
Monitor vital signs for fever or tachycardia. Watch for signs of
infection, especially around the pin tract. o The pin should be
immobile in the bone, and the skin wound should be dry. Small
amount of serous oozing from pin site may occur. o If infection is
suspected, percuss gently over the tibia; this may elicit pain if
infection is developing. o Assess for other signs of infection:
heat, redness, fever. If directed, clean the pin tract with sterile
applicators and prescribed solution/ointment to clear drainage at
the entrance of tract and around the pin, because plugging at this
site can predispose to bacterial invasion of the tract and
bone.
Promoting Tissue Perfusion
Assess motor and sensory function of specific nerves that might
be compromised. o Peroneal nerve - have patient point great toe
toward nose; check sensation on dorsum of foot; presence of
footdrop. o Radial nerve - have patient extend thumb; check
sensation in web between thumb and index finger. Determine adequacy
of circulation (eg, color, temperature, motion, capillary refill of
peripheral fingers or toes). Report promptly if change in
neurovascular status is identified.
Patient Education and Health Maintenance
Teach the patient the purpose of traction therapy. Delineate
limitations of activity necessary to maintain effective traction.
Teach use of patient aids (eg, trapeze). Instruct the patient not
to adjust or modify traction apparatus.
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Instruct the patient in activities designed to minimize effects
of immobility on body systems. Teach the patient necessity for
reporting changes in sensations, pain, movement. c. Open reduction
with internal fixation (ORIF) a. Operative intervention to achieve
reduction, alignment, and stabilization. Bone fragments are
directly visualized. Internal fixation devices (metal pins, wires,
screws, plates, nails, rods) used to hold bone fragments in
position until solid bone healing occurs (may be removed when bone
is healed). After closure of the wound, splints or casts may be
used for additional stabilization and support. b. Endoprosthetic
replacement Replacement of a fracture fragment with an implanted
metal device. Used when fracture disrupts nutrition of the bone or
treatment of choice is bony replacement.d. Open Reduction with
External fixation device- when fractures accompany
soft tissue injury Stabilization of complex and open fracture
with use of a metal frame and pin system. Permits active treatment
of injured soft tissue.
CASTS A cast is an immobilizing device made up of layers of
plaster or fiberglass (wateractivated polyurethane resin) bandages
molded to the body part that it encases. Purposes To immobilize and
hold bone fragments in reduction To apply uniform compression of
soft tissues To permit early mobilization To correct and prevent
deformities To support and stabilize weak joints Types of Casts a.
Short-arm Cast Extends from below the elbow to the proximal palmar
crease.
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b. Gauntlet Cast Extends from below the elbow to the proximal
palmar crease, including the thumb (thumb spica).
c. Long-arm Cast Extends from upper level of axillary fold to
proximal palmar crease; elbow usually immobilized at right
angle.
d. Short-leg Cast Extends from below knee to base of toes.
e. Long-leg Cast Extends from upper thigh to the base of toes;
foot is at right angle in a neutral position.
f. Body Cast Encircles the trunk stabilizing the spine.
g. Spica Cast Incorporates the trunk and extremity. Shoulder
spica cast - a body jacket that encloses trunk, shoulder, and
elbow. Hip spica cast - encloses trunk and a lower extremity.
Single hip spica - extends from nipple line to include pelvis
and extends to include pelvis and one thigh.o
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Double hip spica - extends from nipple line or upper abdomen to
include pelvis and extends to include both thighs and lower legs. o
One-and-a-half hip spica - extends from upper abdomen, includes one
entire leg, and extends to the knee of the other.o
Complications of Casts
Pressure of cast on neurovascular and bony structures causes
necrosis, pressure sores, and nerve palsies. Compartment syndrome -
trauma or surgery affecting an extremity will produce swelling
(result of hemorrhage from bone and surrounding tissue and of
tissue edema). Vascular insufficiency and nerve and muscle
compression due to unrelieved swelling can cause irreversible
damage to an extremity.
Immobility and confinement in a cast, particularly a body cast,
can result in multisystem problems. o Nausea, vomiting, and
abdominal distention associated with cast syndrome (superior
mesenteric artery syndrome, resulting in diminished blood flow to
the bowel), adynamic ileus, and possible intestinal obstruction. o
Acute anxiety reaction symptoms (ie, behavioral changes and
autonomic responses - increased respiratory and heart rate,
elevated blood pressure, diaphoresis) associated with confinement
in a space. o Thrombophlebitis and possible pulmonary emboli
associated with immobility and ineffective circulation (eg, venous
stasis). o Respiratory atelectasis and pneumonia associated with
ineffective respiratory effort. o Urinary tract infection (UTI) -
renal and bladder calculi associated with urinary stasis, low fluid
intake, and calcium excretion associated with immobility. o
Anorexia and constipation associated with decreased activity. o
Psychological reaction (eg, depression) associated with immobility,
dependence, and loss of control.
Nursing Assessment
Assess neurovascular status of the extremity with a cast for
signs of compromise. o Pain. o Swelling. o Discoloration - pale or
blue. o Cool skin distal to injury. o Tingling or numbness
(paresthesia). o Pain on passive extension (muscle stretch). o Slow
capillary refill; diminished or absent pulse. o Paralysis. Assess
skin integrity of casted extremity. Be alert for: o Severe initial
pain over bony prominences; this is a warning symptom of an
impending pressure sore. Pain increases when ulceration occurs. o
Odor. o Drainage on cast. Carefully assess for positioning and
potential pressure sites of the casted extremity Assess
cardiovascular, respiratory, and GI systems for possible
complications of immobility. Assess psychological reaction to
illness, cast, and immobility.
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Nursing Interventions Maintaining Adequate Tissue Perfusion
Elevate the extremity on cloth-covered pillow above the level of
the heart. Keep the heel off the mattress. Avoid resting cast on
hard surfaces or sharp edges that can cause denting or flattening
of the cast and consequent pressure sores. Handle moist cast with
palms of hands. Turn patient every 2 hours while cast dries. Assess
neurovascular status hourly during the first 24 hours, then less
frequently as condition warrants and swelling resolves. Observe for
signs of circulatory impairment:
change in skin color and temperature wet spots drainage under
the cast hot spots areas of the cast feels warmer than the other
sections may indicate infection or necrosis numbness or tingling
unrelieved pain decrease in pedal pulses prolonged blanching of
toes after compression or inability to move toes
If symptoms of neurovascular compromise occur: o Notify health
care provider immediately. o Bivalve the cast - split cast on each
side over its full length into two halves. If symptoms of pressure
area occur, cast may be windowed (hole cut in it) so the skin at
the pain point can be examined and treated.
Minimizing the Effects of Immobility
Encourage the patient to move about as normally as possible.
Encourage compliance with prescribed exercises to avoid muscle
atrophy and loss of strength. o Active ROM for every joint that is
not immobilized at regular and frequent intervals. o Isometric
exercises for the muscles of the casted extremity. Instruct patient
to alternately contract and relax muscles without moving affected
part. Reposition and turn patient frequently. Avoid pressure behind
knees, which reduces venous return and predisposes to
thromboembolism. Use antiembolism stockings as prescribed.
Administer prophylactic anticoagulants as prescribed. Encourage
deep-breathing exercises and coughing at regular intervals to
prevent atelectasis and pneumonia. Observe for symptoms of cast
syndrome - nausea, vomiting, abdominal distention, abdominal pain,
and decreased bowel sounds.
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Encourage patient to drink liberal quantities of fluid - to
avoid urinary infection and calculi secondary to immobility.
Preventing Disuse Syndrome
Teach and encourage isometric exercises to diminish muscle
atrophy. Encourage use of immobilized extremity within prescribed
limits.
NURSING ALERT Cast syndrome (superior mesenteric artery
syndrome) is a rare sequela of body cast application, yet it is a
potentially fatal complication. It is important to teach patients
about this syndrome because this can develop as late as several
weeks after cast application Complications Complications Associated
with Immobility
Muscle atrophy, loss of muscle strength and endurance Loss of
ROM due to joint contracture Pressure sores at bony prominences
from immobilizing device pressing on skin Diminished respiratory,
cardiovascular, GI function, resulting in possible pooling of
respiratory secretions, orthostatic hypotension, ileus, anorexia,
and constipation Psychosocial compromise resulting in feelings of
isolation and depression.
Other Acute Complications
Venous stasis and thromboembolism Neurovascular compromise
Infection especially with open fractures Shock due to significant
hemorrhage related to trauma or as a postoperative complication Fat
Emboli Syndrome Associated with embolization of marrow or tissue
fat or platelets and free fatty acids to the pulmonary capillaries,
producing rapid onset of symptoms develops within 24-72 hours after
fracture o
common in long bones, pelvis, ribs, sternum, vertebrae, clavicle
ARDS results from deposition of embolic fat in the pulmonary
circulation Clinical manifestations: o Respiratory distress -
tachypnea, hypoxemia, crackles, wheezes, acute pulmonary edema o
Mental disturbances - irritability, restlessness, confusion,
disorientation, stupor, coma due to systemic embolization, and
severe hypoxia o Fever o Petechiae in buccal membranes, hard
palate, conjunctival sacs, chest, anterior axillary folds, due to
occlusion of capillaries
NURSING ALERT Restlessness, confusion, irritability, and
disorientation may be the first signs of fat embolism syndrome.
Confirm hypoxia with arterial blood gas (ABG) analysis. Young
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adults (ages 20 to 30) and older adults (ages 60 to 70) with
multiple fractures or fractures of long bones or pelvis are
particularly susceptible to development of fat emboli. Bone Union
Problems Delayed union (takes longer to heal than average for type
of fracture) Nonunion (fractured bone fails to unite) Malunion
(union occurs but is faulty misaligned)
Amputation a. b.c.
Removal of a body part as a result of trauma or surgical
intervention Necessitated by: malignant tumor, trauma, arterial
insufficiency Types: 1. 2. BKA (below the knee amputation) AKA
(above the knee amputation)
Nursing Care: 1. Provide care preoperatively a. Initiation of
exercises preoperatively b. Coughing and deep breathing exercises
c. Emotional support for anticipated alteration in body image 2.
Monitor vital signs and stump dressing for signs of hemorrhage 3.
Elevate stump for 12-24 hours to decrease edema; remove pillow
after this time for functional alignment and prevent contractures
4. Provide stump care a. Maintain elastic bandage to shrink and
shape stump in preparation for prosthesis b. When wound is healed,
wash stump daily, avoiding use of oils which might cause
macerations c. Apply pressure to the end of the stump with
progressively firmer surfaces to toughen stump d. Encourage patient
to move the stump e. Place the patient with a lower extremity
amputation in a prone position twice daily to stretch the flexor
muscles and prevent hip flexion contractures
5. Teach patient about phantom limb sensation Phantom limb:
physiologic reaction of the nerves in the stump causing an
unpleasant feeling that the limb is still there
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Phantom limb pain: when the unpleasant feelings become painful
or disagreeable 6. Encourage family to participate in care 7. Allow
clients to express emotional reactions
Specific Care for Patient in Spica or Body Cast Positioning
Place a bedboard under the mattress for uniform support of the
body. Support the curves of the cast with cloth-covered flexible
pillowsprevents cracking and flat spots while cast is drying. o
Place three pillows crosswise on bed for body cast. o Place one
pillow crosswise at the waist and two pillows lengthwise for
affected leg for spica cast. If both legs are involved, use two
additional pillows. Encourage the patient to maintain physiologic
position by: o Using the overhead trapeze. o Placing good foot flat
on bed and pushing down while lifting himself or herself up on the
trapeze. o Avoiding twisting motions. o Avoiding positions that
produce pressure on groin, back, chest, and abdomen.
Turning
Move the patient to the side of the bed using a steady, even
pulling motion. Place pillows along the other side of the bedone
for the chest and two (lengthwise) for the legs. Instruct the
patient to place arms at side or above head. Turn the patient as a
unit. Avoid twisting the patient in the cast. Turn the patient
toward the leg not encased in plaster or toward the unoperated side
if both legs are in plaster. o One nurse stands at other side of
bed to receive the patient's shoulders. o Second nurse supports leg
in plaster while the third nurse supports the patient's back as he
or she is turned. o Turn the patient in body cast to a prone
position twice daily - provides postural drainage of bronchial
tree; relieves pressure on back. Keep the cast level by elevating
the lumbar sacral area with a small pillow when the head of the bed
is elevated.
NURSING ALERT Do not grasp cross bar of spica cast to move the
patient. The purpose of the bar is to maintain the integrity of the
cast.
Hygienic Care
Provide hygienic care of the patient.
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Protect cast from soiling. o Cover perineum with a towel and
apply spray (lacquer-type) to perineal area of cast. Tuck 4-inch
(10-cm) strips of thin polyethylene sheeting under perineal area of
cast and tape to cast exterior. Replace when soiling occurs. o
Clean outside of cast with slightly damp or dry, clean cloth. Roll
the patient onto fracture bedpan; use small pillow in lumbosacral
area for support.
Skin Care
Inspect skin for signs of irritation: o Around cast edge. o
Under castpull skin taut and inspect under cast, using a flashlight
for illumination. Reach up under cast, and massage accessible skin.
Protect the toes from the pressure of the bedding.
Patient Education and Health Maintenance in Patients with Cast
Neurovascular Status
Instruct patient to check neurovascular status and to control
swelling. o Watch for signs and symptoms of circulatory
disturbance, including blueness or paleness of fingernails or
toenails accompanied by pain and tightness, numbness, cold or
tingling sensation. o Elevate affected extremity, and wiggle
fingers/toes. o Apply ice bags as prescribed (one-third to one-half
full) to each side of the cast, making sure they do not make
indentations in plaster. o Call health care provider promptly if
excessive swelling, paresthesia, persistent pain, pain on passive
stretch, or paralysis occurs. Instruct patient to alternate
ambulation with periods of elevation to the cast when seated.
Encourage the patient to lie down several times daily with cast
elevated.
Exercise
Instruct patient to actively exercise every joint that is not
immobilized and to perform isometric exercises (contract muscles
without moving joint) of those immobilized to maintain muscle
strength and to prevent atrophy. Tell patient to perform hourly
when awake: o Leg cast - Push down on the popliteal (knee) space,
hold it, relax, repeat. Move toes back and forth; bend toes down,
then pull them back. o Arm cast - Make a fist, hold it, relax,
repeat. Move shoulders.
Cast Care
Advise to avoid getting cast wet, especially padding under
castcauses skin breakdown as plaster cast becomes soft. Warn
against covering a leg cast with plastic or rubber boots because
this causes condensation and wetting of the cast. Instruct to avoid
weight bearing or stress on plaster cast for 24 hours. Instruct to
report to health care provider if the cast cracks or breaks;
instruct the patient not to try to fix it. Teach how to clean the
cast: o Remove surface soil with slightly damp cloth. o Rub soiled
areas with household scouring powder. o Wipe off residual moisture.
Therapeutic Intervention
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1. Open reduction with plates and screw to hold fracture in
alignment a. Internal fixation b. External fixation2. Closed
reduction manual traction to move the fragments and restore
bone
alignment 3. Application of cast to maintain alignment and
immobilize the limb
e. Care of Client with Cast
Observe for signs of circulatory impairment: change in skin
color and temperature o wet spots drainage under the casto
hot spots areas of the cast feels warmer than the other sections
may indicate infection or necrosis
numbness or tingling unrelieved pain decrease in pedal pulses
prolonged blanching of toes after compression or inability to move
toes compartment syndrome Protect the cast from damage until dry by
elevating it on a pillow; handle with palms of hands only Promote
drying of cast by leaving it uncovered; light may be used with care
to promote drying Maintain bed rest until the cast is dry and
ambulation is permitted Observe for hemorrhage and measure extent
of drainage on cast when present Observe for irritation caused by
rough cast edges Observe for swelling and notify the physician if
necessary Administer analgesics judiciously and report unrelieved
pain Observe for signs of infection
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4. Application of an external fixation device when fractures
accompany soft tissue injury 5. Amputation f. Removal of a body
part as a result of trauma or surgical intervention g. Necessitated
by: malignant tumor, trauma, arterial insufficiency h. Types: 3.
BKA (below the knee amputation) 4. AKA (above the knee amputation)
Nursing Care: 8. Provide care preoperatively d. Initiation of
exercises preoperatively e. Coughing and deep breathing exercises
f. Emotional support for anticipated alteration in body image 9.
Monitor vital signs and stump dressing for signs of hemorrhage 10.
Elevate stump for 12-24 hours to decrease edema; remove pillow
after this time for functional alignment and prevent contractures
11. Provide stump care f. Maintain elastic bandage to shrink and
shape stump in preparation for prosthesis g. When wound is healed,
wash stump daily, avoiding use of oils which might cause
macerations h. Apply pressure to the end of the stump with
progressively firmer surfaces to toughen stump i. Encourage patient
to move the stumpj.
Place the patient with a lower extremity amputation in a prone
position twice daily to stretch the flexor muscles and prevent hip
flexion contractures
12. Teach patient about phantom limb sensation Phantom limb:
physiologic reaction of the nerves in the stump causing an
unpleasant feeling that the limb is still there Phantom limb pain:
when the unpleasant feelings become painful or disagreeable 13.
Encourage family to participate in care 14. Allow clients to
express emotional reactions
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CRUTCH INSTRUCTIONS General Information: When using your
crutches, beware of ice or snow under your crutch tips. Be careful
on wet or waxed floors, smooth cement floors, and small rugs. Take
care not to trip over telephone and extension cords, toys, or pets.
Avoid crowds. Instructions: 1. 2. 3. 4. Walking: Place both
crutches in front of you at the same time. Put them about 1 inch in
front and 6 to 8 inches to the side of your toes. Lean on your
hands, not your underarms. The top of the crutches should hit about
2 inches below your underarm. Keep your elbows bent as you use the
crutches. Keep your injured leg off the floor by bending your knee.
Take a step with your crutches. Then, swing your uninjured foot
between the crutches landing heel first. Going Up the Stairs: Face
the stairs. Put the crutches close to the first step. Push on the
crutches with your elbows straight and put your uninjured leg on
the first step. Bring both crutches up on the stair at the same
time. If using a railing, put both crutches under the other arm.
Going Down the Stairs: Stand with the toes of your uninjured leg
close to the edge of the step. Bend the knee of your uninjured leg.
Slowly lower both crutches onto the next step. Lean on your
crutches. Slowly lower your uninjured leg on to the same step.
Place both crutches under the other arm when using a railing.
Sitting in a Chair:
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5.
Turn and back up to the chair until you feel the edge of it
against the back of your legs. Keep your injured leg forward.
Remove your crutches from under your arms. Sit while bending your
uninjured knee. Hold the chair so it doesnt move out from under
you. Getting up from a Chair: Sit on the edge of your chair. Put
your uninjured foot close to the chair. Push up with your hands
using the crutches or arms of the chair. Put your weight on your
uninjured foot as you get up. Keep your injured leg bent at the
knee and off the floor.
Crutches: A "How-To" Guide Sizing Your Crutches Walking with
Crutches Managing Chairs with Crutches Managing Stairs Without
Crutches Important Rules for Safety and Comfort It takes some
coordination to get around on crutches. To make sure you use your
crutches correctly, please read these instructions and follow them
carefully. Sizing Your Crutches Even if you've already been fitted
for crutches, make sure your crutch pads and handgrips are set at
the proper distance, as follows:
Crutch pad distance from armpits. The crutch pads (tops of
crutches) should be 1.5" to 2" (about two finger widths) below the
armpits, with the shoulders relaxed. Handgrip. Place it so your
elbow is flexed about 15 to 30 degreesenough so you can fully
extend your elbow when you take a step. Crutch length (top to
bottom). The total crutch length should equal the distance from
your armpit to about 6" in front of a shoe.
Walking with Crutches (Non-Weight-Bearing) If your foot and
ankle surgeon has told you to avoid ALL weight-bearing, it is
important to follow these instructions carefully. You will need
sufficient upper body strength to support all your weight with just
your arms and shoulders.
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The Tripod Position The tripod position is the position in which
you stand when using crutches. It is also the position in which you
begin walking. To get into the tripod position, place the crutch
tips about 4" to 6" to the side and front of each foot, then stand
on your "good" foot (the one that is weight-bearing). To walk with
crutches: 1. Begin in the tripod positionand remember, keep all
your weight on your "good" (weight-bearing) foot. 2. Advance both
crutches and the affected foot/leg. 3. Move the "good"
weight-bearing foot/leg forward (beyond the crutches). 4. Advance
both crutches, and then the affected foot/leg.5. Repeat steps #3
and #4.
Managing Chairs with Crutches To get into and out of a chair
safely: 1. Make sure the chair is stable and will not roll or
slideand it must have arms and back support. 2. Stand with the
backs of your legs touching the front of the seat. 3. Place both
crutches in one hand, grasping them by the handgrips. 4. Hold on to
the crutches (on one side) and the chair arm (on the other side)
for balance and stability while lowering yourself to a seated
positionor raising yourself from the chair if you're getting up.
Managing Stairs Without Crutches The safest way to go up and down
stairs is to use your seatnot your crutches. To go up stairs: 1.
Seat yourself on a low step. 2. Move your crutches upstairs by one
of these methods:
If distance and reach allow, place the crutches at the top of
the staircase. If this isn't possible, place crutches as far up the
stairs as you canthen move them to
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the top as you progress up the stairs. 3. In the seated
position, reach behind you with both arms. 4. Use your arms and
weight-bearing foot/leg to lift yourself up one step. 5. Repeat
this process one step at a time. (Remember to move the crutches to
the top of the staircase if you haven't already done so.) To go
down stairs: 1. Seat yourself on the top step. 2. Move your
crutches downstairs by sliding them to the lowest possible point on
the stairwaythen continue to move them down as you progress down
the stairs. 3. In the seated position, reach behind you with both
arms. 4. Use your arms and weight-bearing foot/leg to lift yourself
down one step. 5. Repeat this process one step at a time. (Remember
to move the crutches to the bottom of the staircase if you haven't
already done so.) Important Rules for Safety and Comfort Don't look
down. Look straight ahead as you normally do when you walk. Don't
use crutches if you feel dizzy or drowsy. Don't walk on slippery
surfaces. Avoid snowy, icy, or rainy conditions. Don't put any
weight on your foot if your doctor has so advised. Do make sure
your crutches have rubber tips. Do wear well-fitting, low-heel
shoes (or shoe). Do position the crutch handgrips correctly (see
"Sizing Your Crutches") Do keep the crutch pads 112" to 2" below
your armpits. Do call your foot and ankle surgeon if you have any
questions or difficulties.
Measurement of crutches:
The top of the crutches should be at least two finger widths
deep from the armpit (make sure the shoulders are relaxed). When
the arm is hanging straight down, the hand piece should be at the
level of the wrist.
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Hold the top part of the crutch firmly between the chest and the
inside of the upper arm. Do not allow the top of the crutch to push
up into the armpit. It is possible to damage nerves and blood
vessels with constant pressure. Support the weight with the hands
on the hand rests. The hand rests should be padded. When standing
still, it will be safer to stand with the crutches slightly ahead
and apart. Remember, do not let the top of the crutches push up
into the armpit; stand straight.
Walking (non-weight bearing):
Put the crutches forward about one step's length. Push down on
the crutches with the hands, hold the "bad" leg up from the floor,
and squeeze the top of the crutches between the chest and arm.
Swing the "good" leg forward. Be careful not to go too far. Now
step on the "good" leg.
Walking (partial-weight bearing):
Put the crutches forward about one step's length. Put the "bad"
leg forward; level with the crutch tips. Take most of the weight by
pushing down on the handgrips, squeezing the top of the crutches
between the chest and arm. Take a step with the "good" leg. Make
steps of equal length.
Sit to stand:
Make sure to keep the crutches nearby so they can be reached
when needed. Hold the hand grips of both crutches in one hand. Use
the crutches with one hand and the side of the chair with the other
hand. Make sure the chair is stable. If necessary, have someone
stand behind you. Stretch the "bad" leg out straight. Push on
chair, crutches, and the "good" leg; stand up. Keep the weight off
the "bad" leg. Balance. Place the crutches in place for
walking.
Stand to sit:
Walk straight up to the chair. When a step away from the chair,
turn until your back is toward the chair using the "good" leg and
the crutches. (Move the crutches, then step, crutches, step...a
little at a time.) Never pivot. Move backwards until the chair
touches the back of the "good" leg. Remove the crutches from under
the arms. Hold both crutches in one hand and reach for the chair
with the other hand. Stretch the "bad" leg out in front. Sit down
slowly.
Stairs:
Use one crutch and the stair rail if present (only if the
railing is stable and there is someone to carry the other crutch).
Use two crutches if there is no stair rail. It does not matter
which side the stair rail is on. If both crutches can be held in
one hand safely, you can use both crutches on one side and the
railing on the other.
Up stairs:
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Walk close to the first stair and hold onto the stair rail. Hold
onto the rail with one hand and the crutch with the other hand.
Push down on the stair rail and the crutch and step up with the
"good" leg. If not allowed to place weight on the "bad" leg, hop up
with the "good" leg. Bring the "bad" leg and the crutches up beside
the "good" leg. Remember, the "good" leg goes up first and the
crutches move with the "bad" leg.
Down stairs:
Walk to the edge of the stairs in the same way. Place the "bad"
leg and the crutches down on the step below; support weight by
leaning on the crutches and the stair rail. Bring the "good" leg
down. Remember the "bad" leg goes down first and the crutches move
with the "bad" leg. Use the same rules when going up and down curbs
or doorsteps.
Precautions:
Take care on slick or wet surfaces (i.e., the kitchen and
bathroom). Be careful of throw rugs; they should be taken up. Never
hop around holding on to furniture; it may slide or fall. Keep the
crutches near you so they are always in reach. Wear low-heeled
shoes that will not slip off (i.e., sneakers). For the first few
days, a strong belt may be worn to allow someone to assist you. Be
careful of ramps or slopes, as it is a little harder to walk. If
falling, throw the crutches out to the side and use your arms to
break your fall. To get up, get into a sitting position. Back up to
a stool or low chair. Put your hands backwards on to the chair.
Bend the "good" leg up. Pull with your hands and push with the
"good" leg to get up onto the chair. If not allowed to take weight
on the "bad" leg, hop up with the "good" leg. Do not remove any
parts from your crutches, including the rubber tips.
Helpful hints:
A bedside toilet may be used. Ask teachers in school to let your
child out of class a little early to avoid crowds on the stairs.
Keep the "bad" leg up on a stool when sitting. Carry schoolbooks in
a backpack to leave both hands free. Avoid leaning on the underarm
pieces.
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