NUR Ch. 62: Fracture Study Guide - Healing, Immobilization, and Complications, Exams of Nursing

Download NUR Ch. 62: Fracture Study Guide - Healing, Immobilization, and Complications and more Exams Nursing in PDF only on Docsity! NUR CHAPTER 62 FRACTURE STUDY GUIDE REVIEW 2024 NEW UPDATE Fractures • Disruption or break in continuity of structure of bone • Majority of fractures from traumatic injuries • Some fractures secondary to disease process o Cancer or osteoporosis (pathologic fractures) Classification According to External Environment • Fractures can be classified as open (formerly called compound) or closed (formerly called simple) depending on communication or noncommunication with the external environment (Fig. 62-6). o In an open fracture the skin is broken, exposing the bone and causing soft tissue injury. ▪ Usually are also complete and displaced. o In a closed fracture the skin has not been ruptured and remains intact. Classification • Complete or incomplete o Complete: break is completely through bone o Incomplete: bone is still in one piece. ▪ occurs partly across a bone shaft but the bone is still intact. ▪ often the result of bending or crushing forces applied to a bone. • Based on direction of fracture line – know these and how they look like. o Linear o Oblique o Transverse - line of the fracture extends across the bone shaft at a right angle to the longitudinal axis. o Longitudinal o Spiral – the line of the fracture extends in a spiral direction along the shaft of the bone. ▪ Common in abuse. Classification According to Location Types of fractures. A, Transverse fracture is a fracture in which the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis. B, Spiral fracture is a fracture in which the line of the fracture extends in a spiral direction along the shaft of the bone. – associated with abuse C, Greenstick fracture is an incomplete fracture with one side splintered and the other side bent. D, Comminuted fracture is a fracture with more than two fragments. The smaller fragments appear to be floating. E, Oblique fracture is a fracture in which the line of the fracture extends in an oblique direction. F, Pathologic fracture is a spontaneous fracture at the site of a bone disease – spontaneous from cancer or osteoporosis. G, Stress fracture is a fracture that occurs in normal or abnormal bone that is subject to repeated stress, such as from jogging or running. Classification • Displaced or nondisplaced o Displaced: two ends separated from one another ▪ Often comminuted or oblique o Nondisplaced: periosteum is intact and bone is aligned. ▪ Usually transverse, spiral , or greenstick Clinical Manifestations • Localized pain • Decreased function • Inability to bear weight or use • Guard against movement • May or may not have deformity Immobilize if suspect fracture!!!! Fracture Healing • Multistage healing process (union) 1. Fracture hematoma: When a fracture occurs, bleeding creates a hematoma that surrounds the ends of the fragments. Occurs in the first 72 hours after injury. o Skin traction o Skeletal traction Skin traction • Short-term (48-72 hours) until skeletal traction or surgery is possible. • Tape, boots, or splints applied directly to skin to maintain alignment, primarily to help diminish muscle spasms in the injured extremity. • Traction weights 5 to 10 pounds • Skin assessment and prevention of breakdown imperative o Assess key pressure points every 2 to 4 hours. ❖ A Buck's traction boot is a type of skin traction used preoperatively for the patient with a hip fracture to prevent hip flexion contractures, and reduce muscle spasms. o make sure skin remains intact, especially backside. Help them move around. They usually have trapeze. Skeletal traction • Long-term pull to maintain alignment • Pin or wire inserted into bone and weights are attached to align and immobilize the injured body part. • Weights 5 to 45 lbs • Risk for infection – higher than skin because of break of skin • Complications of immobility • Maintain countertraction, typically the patient’s own body weight o Elevate end of bed • Maintain continuous traction • Keep weights off the floor and moving freely through the pulleys. ❖ Balanced Suspension Traction - One of the more common types of skeletal traction Fracture Immobilization • Cast – common following closed reduction. o temporary circumferential immobilization device o Allows patient to perform many normal activities of daily living o Made of various materials - natural (plaster of Paris), synthetic acrylic, fiberglass- free, latex-free polymer, or a hybrid of materials. o Typically incorporates joints above and below fracture o Cover affected part with stockinette and padding o Immerse plaster of paris material in warm water, wrap and mold it – mold with palm and not with fingertips which causes areas of friction. ▪ Sets in 15 minutes ▪ 24-72 hours before weight bearing ▪ Do not cover – risk for burn ▪ No direct pressure; petal edges ❖ Make sure it doesn’t get wet, or clt is not shoving anything inside the cast or applying lotion. o Synthetic casting materials (thermolabile plastic, thermoplastic resins, polyurethane, and fiberglass) - being used more than plaster ▪ Lightweight, stronger, waterproof ▪ Early weight bearing – walk around early. Keep extremity elevated and not in dependent position for too long (use splint) ▪ Activated by submersion in cool or tepid water, then molded ❖ Clt should not have tingling, numbness, or pain. Make sure they don’t have the ext hanging down. Upper Extremity Immobilization • Types of casts o Sugar-tong splint - typically used for acute wrist injuries or injuries that may result in significant swelling. o Posterior splint o Short arm cast - often used for the treatment of stable wrist or metacarpal fractures. An aluminum finger splint can be incorporated into the short arm cast for concurrent treatment of phalangeal injuries. This cast provides wrist immobilization and permits unrestricted elbow motion. o Long arm cast - commonly used for stable forearm or elbow fractures and unstable wrist fractures. It is similar to the short arm cast but extends to the proximal humerus, restricting motion at the wrist and elbow. • Sling to elevate and support arm o Contraindicated with proximal humerus fracture • Sling o To support and elevate arm o Contraindicated with proximal humerus fracture o Ensures axillary area is well padded o No undue pressure on posterior neck o Encourage movement of fingers and nonimmobilized joints Vertebral Immobilization • Body jacket brace o Immobilization and support for stable spine injuries o Monitor for superior mesenteric artery syndrome (cast syndrome) ▪ This condition occurs if the brace is applied too tightly, which results in compression of the superior mesenteric artery against the duodenum. ▪ The patient generally complains of abdominal pain, abdominal pressure, nausea, and vomiting. ▪ Assess the abdomen for decreased bowel sounds (a window in the brace may be left over the umbilicus) – make sure patient eats more frequent small meals. ▪ Treatment includes gastric decompression with a nasogastric (NG) tube and suction. ▪ Assessment also includes monitoring respiratory status, bowel and bladder function, and areas of pressure over the bony prominences, especially the iliac crest. The brace may need to be adjusted or removed if any complications occur. Lower Extremity Immobilization • Long leg cast - unstable ankle fracture, soft tissue injuries, a fractured tibia, and knee injuries. The cast usually extends from the base of the toes to the groin and gluteal crease. • Short leg cast - stable ankle and foot injuries. • Cylinder cast – knee injuries or fractures, extends from the groin to the malleoli of the ankle. • Robert Jones dressing - may be used temporarily to limit mobility of a joint. It is composed of soft padding materials (absorption dressing and cotton sheet wadding), splints, and an elastic wrap or bias-cut stockinette. Lower Extremity Immobilization • Elevate extremity above heart • Do not place in a dependent position • Observe for signs of compartment syndrome and increased pressure • Hip spica cast – common for femur fractures. Now used for femur fractures in children to immobilize the affected extremity and trunk. o Single spica o Double spica • Assess patient for same problems as body jacket brace – don’t eat big meals, and report abdominal discomfort. External Fixation - metallic device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals. • Metal pins and rods • Applies traction • Compresses fracture fragments • Immobilizes and holds fracture fragments in place • Assess for pin loosening and infection - exudate, erythema, tenderness, and pain/ may require removal of the device • Patient teaching – look at site every day, maintain clean. • Pin site care Nursing Planning • Overall Goals o Healing with no associated complications o Satisfactory pain relief – may not be zero, but at least tolerable. o Maximal rehabilitation Nursing Implementation • Health Promotion o Teach safety precautions – remove rug out of way. o Advocate to decrease injuries o Encourage moderate exercise o Safe environment to reduce falls o Calcium and vitamin D intake • Acute Care o Patients with fractures can be treated in the emergency department or a physician’s office o Patients are released home, or they may require hospitalization (if surgery is needed) ❖ ER – immobilize and send to x-ray ❖ Ice – don’t do continuous. Ice is vasoconstrictor and helps with swelling and pain muscle spasms. Preoperative Care • Patient Teaching o Immobilization o Assistive devices - know teaching for crutches. o Expected activity limitations o Assure that needs will be met o Pain medication Postoperative Care • Monitor vitals • General principles of nursing care • Frequent neurovascular assessments • Minimize pain and discomfort • Monitor for bleeding or drainage o Aseptic technique o Blood salvage and reinfusion Other Measures • Prevent complications of immobility o Constipation – due to opioids and immobilization. o Renal calculi – in dehydrated patients and immobile. o Cardiopulmonary deconditioning o DVT/pulmonary emboli – SCD for prophylaxis, or lovenox. Traction • Inspect exposed skin • Monitor pin sites for infection • Pin site care per policy • Proper positioning • Exercise as permitted • Psychosocial needs Ambulatory Care Cast Care • Do o Frequent neurovascular assessments o Apply ice for first 24 hours (20 on 20 off – not continuous) o Elevate above heart for first 48 hours o Exercise joints above and below o Use hair dryer on cool setting for itching and if cast gets wet. o Check with health care provider before getting wet o Dry thoroughly after getting wet o Report increasing pain despite elevation, ice, and analgesia o Report swelling associated with pain and discoloration OR movement o Report burning or tingling under cast o Report sores or foul odor under cast • Do not o Elevate if compartment syndrome o Get plaster cast wet o Remove padding o Insert objects inside cast o Bear weight for 48 hours o Cover cast with plastic for prolonged period ❖ Know about fat embolism, compartment syndrome, use of crutches. Ambulatory care – cast care • Validate understanding of cast care instructions • Follow-up phone call • Teach cast removal and possible alterations in appearance of extremity • Psychosocial problems o Dependence in performing ADLs o Family separation o Finances o Inability to work o Potential disability • Ambulation o Reinforce physical therapist’s instructions o Mobility training o Instruction in use of assistive aids o Pain management • Degrees of weight-bearing o Non–weight-bearing o Touch-down/toe-touch weight-bearing o Partial–weight-bearing o Weight bearing as tolerated o Full–weight-bearing ambulation Assistive Devices • Devices for ambulation range from a cane to a walker or crutches • Technique for use varies • Use transfer belt for stability when teaching how to use • Discourage from reaching for support • Upper arm strength required ❖ The technique for using assistive ambulation devices varies. The involved limb is usually advanced at the same time or immediately after the advance of the device. The uninvolved limb is advanced last. In almost all cases, canes are held in the hand opposite the involved extremity. Evaluation • Report satisfactory pain management • Appropriate care of cast or immobilizer • No peripheral neurovascular dysfunction • Uncomplicated bone healing Complications of Fractures • Majority heal without complication • Death is usually the result of o Damage to underlying organs and vascular structures ▪ Bone infection, malunion, vascular necrosis. • May be direct or indirect Infection • High incidence in open fractures and soft tissue injuries • Devitalized and contaminated tissue an ideal medium for pathogens • Prevention key • Can lead to chronic osteomyelitis ❖ Patient who just had fracture and suddenly shows AMS, any sign of hypoxemia. Fat Embolism (FES) Interprofessional Care • Treatment is directed at prevention – immediate immobilization. Reposition patient as less as possible. • Careful immobilization and handling of a long bone fracture probably the most important factor in prevention • Management is supportive and related to symptom management • Coughing and deep breathing • Administer O2 – nasal canula. • Intubation/ intermittent positive pressure ventilation 1. A plaster splint is applied with an elastic bandage to the leg of a patient with a fractured tibia in preparation for open reduction and internal fixation. The patient complains of increasing pain in the affected leg and foot that is not relieved by loosening of the elastic bandage. The most appropriate action by the nurse is to a. elevate the leg on two pillows. b. apply ice over the fracture site. c. notify the health care provider. d. perform neurovascular assessment of the foot. Rationale: Prompt, accurate diagnosis of compartment syndrome is critical. Prevention or early recognition is the key. Regular neurovascular assessments should be performed and documented on all patients with fractures, but especially those with injury of the distal humerus or proximal tibia or soft tissue disruption in these areas. Early recognition and treatment of compartment syndrome is essential to avoid permanent damage to muscles and nerves. One or more of the following six Ps are characteristic of compartment syndrome: (1) paresthesia (numbness and tingling); (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle, traveling through the compartment; (3) pressure increases in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness or diminished/absent peripheral pulses. Carefully assess the location, quality, and intensity of the pain (see Chapter 10). Evaluate the patient’s level of pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. After completion of the neurovascular assessment, the nurse should notify the health care provider immediately of a patient’s changing condition. 2. A patient has a severely sprained ankle from a sports injury. What should the nurse teach the patient prior to discharge from the urgent care center? a. Alternate cold and heat for 30 minutes each until symptoms are relieved. b. Apply cold for 20 to 30 minutes with breaks of 10 to 15 minutes during the first 2 days. c. Use continuous cold for the first 24 hours and then continuous heat until the symptoms are relieved. d. Apply continuous heat to the ankle for the first 24 hours and then continuous cold until the symptoms are relieved. Rationale: If an injury occurs, immediate care focuses on (1) stopping the activity and limiting movement, (2) applying ice compresses to the injured area, (3) compressing the involved extremity, (4) elevating the extremity, and (5) providing analgesia as necessary. These interventions will decrease local inflammation and pain for most musculoskeletal injuries. Cold (cryotherapy) in several forms can be used to produce hypothermia to the involved part. Physiologic changes that occur in soft tissue as a result of the use of cold include vasoconstriction and reduction in the transmission and perception of nerve pain impulses. These changes result in analgesia and anesthesia, reduction of muscle spasm without changes in muscular strength or endurance, reduction of local edema and inflammation, and reduction of local metabolic requirements. Cold is most useful when applied immediately after the injury has occurred. Ice applications should not exceed 20 to 30 minutes per application, and ice should not be applied directly to the skin. After the acute phase (usually 24 to 48 hours), warm, moist heat may be applied to the affected part to reduce swelling and provide comfort. Heat applications should not exceed 20 to 30 minutes, allowing a “cool-down” time between applications.