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nurs 128 test 2 chapter 54

Terms

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callus
nonbony union at fracture site
granulation
vascular and cellular proliferation
hematoma
mass of clotted blood at fracture site
remodeling
process of bone building and resorption
conditions that have a high risk for Acute Compartment Syndrome
1. Impact (lower legs caught between bumpers of two cars) 2. Massive infiltration of IV Fluid 3. Multiple Insect Bites 4. Severe Burns
Early sign of complication with a fracture
Numbness and tingling
how do you assess motor function after an injury?
have the patient move the most distal area ie = wrist injury, have them move their fingers
What do you do first if a patient in traction complains of severe pain?
assess the patient's body alignment
A patient in a leg cast reports worsening pain that is unrelieved by medication, the toes are cool and capillary refill is sluggish. what does this indicate?
Acute compartment syndrome
What labs do you need to monitor if their is a risk for crush syndrome?
Serum Potassium and myoglobin in urine
what is an early sign of fat embolism syndrome?
change in mental status
Sequence of bone healing
1. Hematoma Formation 2. Hematoma to granulation tissue 3. Osteoblastic proliferation 4. Callus formation 5. Bone remodeling
assessing Traction Equipment
Inspect ropes and knots for fraying or loosening every 8 to 12 hours. Check the amount of weight being used against what is being prescribed Observe the equipment for proper functioning
types of fractures
Complete fracture - break across entire width of bone Incomplete fracture - does not divide bone into two portions Open (Compound) Fracture - ranges from skin damage to actual bone protusion depending on severity Closed (Simple) Fracture - does not extend throughthe skin Pathologic (spontaneous) fracture - bone was previously weakened by disease (osteoporosis) Fatigue (stress) fracture - excessive strain and stress on bone (athletes) Compression Fractures - produced by loading force applied to the long axis of cancellous bone
delayed union
incomplete fracture healing within 6 months
fat embolism
fat globules released from the yellow bone marrow into the blood stream
crush syndrome
ecternal crush injury that compresses one or more compartments in the leg, arm, or pelvis
osteomyelitis
bone infection
avascular necrosis
disrupted blood supply to bone, resulting in the death of bone tissue
Nonunion
lack of fracture healing , never heal
what type of technique is used when doing dressing changes for an open fracture?
strict aseptic technique
plaster traction
combines skeletal traction and a plaster cast
brace traction
exerts a pull for correction of alignment deformities
skin traction
involves the use of fabric fastener boot (Bucks), belt, or halter, which is secured around a body part. traction needs to be maintained constantly
circumferential traction
uses a belt around the body
skeletal traction
pins, wires, tongs, or screws surgically inserted directly into bone. easier to reposition moves with limb and joint
phantom limb pain medications
calcitonin (Calcimar) , gabapentin (Neurontin), antispasmodic
how often should you remove the belt and check skin for a patient in circumferential traction?
every 8 hours
treatment of first degree sprain
Rest, elevate sprain, apply compression bandage for a few days to reduce swelling and provide support
dislocation
joint surfaces not approximated
sprain
injury to a ligament
strain
excessive stretching of muscle or tendon
subluxation
partial joint surface separation
complications of fractures
acute compartment syndrome crush syndrome hypovolemic shock fat embolism syndrome venous thromboembolism infection chronic complications - ischemic necrosis, delated union
Acute compartment syndrome ( ACS )
A serious condition in which increased pressure within a compartment compromises circulation to the area. Can be from internal or external source. • Blood or fluid accumulate in compartment • Causes: reduction of compartment size (i.e. cast too tight, bulky dressings), an increase in muscle compartment contents because of edema or hemorrhage i.e. crushing injuries • Forearm and leg- most often involved • Neuromuscular damage is irreversible in 4-6 hours; limb useless in 24-48 hours can also occur in patients with burns, extensive insect bites, snake bites, massive infiltration of IV Fluids
Monitor for early signs of ACS (acute compartment syndrome) "Six P's"
Pain Pressure Paralysis Paresthesia Pallor Pulselessness **ACS can begin 6 to 8 hours after an injury or take up to 2 days to appear, if suspected notify physican immediately and implement interventions to relieve pressure**
Fasciotomy
surgical procedure to treat ACS - opening of the fascia in the affected compartment, wound is left open and packed for 4 to 5 days, then surgeon debrides wound and may apply skin graft to promote healing
Complications of ACS (acute compartment syndrome)
Infection which could lead to amputation, motor weakness that is not reversibile, contractures, and myoglobinuric renal failure which can be fatal.
Crush Syndrome (CS)
1. External crush injury 2. Life threatening 3. Systemic complications due to hemorrhage and edema 4. Acute Syndrome: high potassium. Rhabdomyolosis - the death of the skeletal muscle cells from this causes actual muscle cell rupture -and the myoglobin from this trauma/destruction ends up in the bloodstream as the body tries to clean up the scene. Myoglobin is just too big to be passed through the renal tubules and actually plugs them up so they cannot function.
Crush Syndrome Signs & Symptoms
ACS, hypovolemia, hyperkalemia, rhabdomyolysis, acute tubular necrosis (ATN), dark brown urine, muscle weakness and pain
Fat Embolism Syndrome FES
This is a complication of a fracture. It is associated with fractures of the long bones, multiple fractures or crushing injuries. This usually occurs within 24-72 hours. This can affect the lungs. Fat escapes from the long bone and circulates in blood system most commonly to the lungs. Can result in death from pulmonary edema *Earliest manifestation of FES is altered mental status**
Signs and Symptoms of FES ( fat embolism Syndrome)
altered mental status, anxiety, respiratory distress, techycardia, tachypnea, fever, hemoptysis, Petechiae (rash), labs = increased erythrocyte sedimentation rate, decreased serum calcium, decreased red blood cells and platelet counts, increased serum lipase level
treatment / prevention of fat embolism
Bedrest, gentle handling, oxygen, hydration (IV Fluids), possible steroid therapy, fracture immobilization
venous thromboembolism VTE
includes DVT (deep vein thrombosis) and PE (pulmonary embolism) *It is the most common complication of lower extremity surgery or trauma and the most often fatal complication of musculoskeletal surgery* Factors that contribute to VTE : Cancer or chemotherapy, surgery over 30 minutes, smoking, obesity, heart disease, prolonged immobility, oral contraceptives or hormones, history of VTE, older adults
Osteomyelitis
This is an infection of the bone that may spread to surrounding tissues. Infection typically follows an injury or surgery & is the result of bacteria, virus or fungi. Most common causative agent is Stphaylococcus aureus., S & S of this is constant pain in affected area (will worsen w/movement), edema, decreased mobility of joint, refusal to use limb, limping, redness at site of injury & fever.
Emergency care for patients with extremity fracture
1. Airway, breathing, circulation, head to toe 2. remove clothing 3. remove jewelry 4. apply pressure if bleeding or to proximal artery 5. keep patient warm and supine 6. check neurovascular status 7. immobilize extremity 8. cover open areas with dressing
Carpal Tunnel Syndrome
Condition that results from compression of the median nerve within the carpal tunnel at the wrist, characterized by pain, numbness, and tingling in the wrist and fingers and weak grip; commonly seen as a result of repetitive stress such as typing, will have a postive Tinel's Sign
Tinel's sign
The patient is positioned in sitting or standing. The therapist taps over the volar aspect of the patient's wrist. A positive test is indicated by tingling in the thumb, index finger, middle finger, and lateral half of the ring finger distal to the contact site at the wrist. A positive test may be indicative of carpal tunnel syndrome due to median nerve compression.
Hip Fracture
**Osteoporosis is the biggest risk factor for hip fractures** Intracapsular or extracapsular It is the most common injury in older adults and has a high mortality rate. treatment - surgery with ORIF, ambulate day after surgery, use pillows to maintain abduction
ORIF - open reduction with internal fixation
one of the most common methods of reducing and immobilizing a fracture. ORIF permits early mobilization Open reduction allows the surgeon to directly view the fracture site Internal Fixation - uses metal pins, screws, rods, ect to immobilize the fracture during healing. After the bone achieves union the hardware may be removed or stay in depending on the fracture
External Fixation
a system in which pins or wries are inserted through the skin and affected bone the connected to a rigid external frame Advantages : minimal blood loss compared to internal fixation, allows early ambulation and exercise while relieving pain, maintains alignment of closed fractures that will not maintain position in a cast. *monitor pin sites every 8 to 12 hours*
Procedures for Nonunion
1. Electrical bone stimulation - uses magnetic coils applied on the skin or over a cast to deliver a pulsed magnetic field - 6 months of treatment 2. Bone Grafting - replace diseased bonw or increase bone tissue for joint replacement 3. Bone Banking - donation of femoral heads, ect. 4. Low-Intensity pulsed ultrasound - used for slow healing fractures or new fractures as an alternative to surgery. treatment is 20 mins a day.
Meperidine
should never be used for older adults because it has toxic metabolitesthat can cause seizures and other complications. most hospitals do not use this medication at all.
assistive devices
crutches and canes - make sure elbow is not flexed more than 30 degrees for either. make sure there is 1-2 inches from top of crutches to armpit and that cane is placed on unaffected side.
Upper Extremity Fractures
1. Clavical - self healing, splint or bandage for immobilization. (falling on out steched hand) 2. Scapular - not common, can cause serious internal trauma. shoulder put in immobilizer for 2 to 4 weeks 3. Proximal Humerus- common in older adult. impact injury requires sling, a displaced fracture requires ORIF 4. Elbow - common in adults - treated with closed reduction and cast, for displaced fractures - ORIF 5.Colles' (wrist) fracture - common in older women with osteoporosis, results from fall on out steched hand- splint or cast 6 to 8 weeks 6. radius & ulna - usually broke together treat with closed or open reduction 7. wrist and hand - closed reduction and cast
Lower Extremity Fractures
1. lower 2/3 of the femur - usually from auto crash, usually does not cast, treat with ORIF or skeletal traction, followed by a leg brace or cast. can take 6 months to heal 2. Patellar - from direct impact, treat with closed reduction and casting or internal fixation with screws and knee immobilizer 3. lower leg usually involves both tibia and fibula - treat with closed reduction and casting, internal fixation, and external fixation
Compression Fractures of the spine
most are associated with Osteoporosis, metastatic bone cancer, and multiple myeloma severe pain, deformity and possible neurological compromise nonsurg treat - bedrest, analgesics & PT surgery - preferred kyphoplasty - bone cemet is injected
myeloma
a tumor of the bone marrow (usually malignant) composed of cells normally found in bone marrow
Pelvic fractures
*associated internal damage the cheif concern - venous oozing and arterial bleeding, hypovolemic shock, blood in urine, abdominal swelling* non-weight bearing fracture - pubic rami or iliac crst - bedrest or bed board, very painful Weight bearing - pelvic ring or acetabulum - external fixation, ORIF or both
Complications of Amputations
Hemorrhage, infection, phantom imb pain, neuroma, flexion contracture
Phantom Limb Pain
must distinguish from stump pain first intense pain burning, crushing, or cramping, or feeling limb is in a distorted position **opioids NOT as effective for this type of pain** Treat with - beta blockers (constant dull, burning pain), antiepileptic (knife-like or sharp burning pain) antispasmodics (muscle spasms or cramping) IV calcitonin (reduces PLP during first week) alternative therapies - ultrasound therapy, massage, exercise, biofeedback, distraction, hypnosis, psychotherapy
Exercise After Amputation
ROM to prevent contractures Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours for 20 mins elevation of limb is controversial
wrapping to prepare stump for prosthesis
use a figure 8 wrapping pattern to prevent restriction of blood flow, reapply every 4 to 6 hours this helps shape and shrink stump
cast complications
Infection (pressure necrosis) Circulation and peripheral nerve damage from pressure skin breakdown contracture of joint OA & osteoporosis Muscle Atrophy
Complex regional pain syndrome (CRPS)
-poorly understood dysfunction of the CNS and peripheral NS usually resulting from traumatic musculoskeletal injury and common in feet and hands -intense, debilitating pain, atrophy, autonomic dysfunction and motor impairment -3stages 1.locally severe, burning pain, edema, vasospasm and muscle spasm 2.more severe burning pain, edema, atrophy, osteeoporosis 3.intractable pain, marked muscle atrophy, severely limited mobility, comtractures
intractable pain
pain that is unrelenting and can't be managed
mgmt of CRPS
***pain mgmt -topical analgesics, antieleptic drugs, antidepressants, corticosteroidsm and opiod and non opioid agends -nonpharm methods-relaxation -maintain adequate ROM -skincare gentle w/minimal stimulation (esp while turning) -sympathetic nerve block-IV phentolamine or IV anesthetics -Endoscopic thoracic sympathectomy-cutting of sympathetic nerve branches through small axillary incision -Psychotherapy-counseling
Knee injuries-meniscus
-cartilage in knee joint acting as shock absorbers-but can tear -cause:twisting knee, placing foot firmly on floor Dx technique-McMurray test Tx-meniscectomy-arthroscopy Postop-same as others and teaching pt/fam what to look for -leg exercises done immediately for strengthening and to prevent bloot clot and reduce swelling -knee immobilizer -elevate leg, apply ice and limit weight bearing
Knee injury:ligaments
-anterior cruciate ligament (ACL) is torn, snap is felt, knee gives wat, swelling, and stiffness and pain follow -confirmed by MRI -Tx-nonsurg=braces, exercises and limiting activities -Txsurg-reattach torn portion via arthroscopy or possibly need reconstruction or implants ---brace/immobilizer -Complete healing at least 6-9 months
tendon ruptures
-rupture of Achilles is common in athletic adults -in oder adults-quad tendons from a fall -for severe damage-surgical repair followed by immobilization in brace or cast for 6-8 wks -tendon transplant may be needed if severe enough (tendon taken from own body)
dislocation vs subluxation
d-ends of 2 or more bones are moved away from each other s-when joint is not completely dislocated or is just partally dislocated
Manifestations and Tx of dislocations and subluxations
-S/Sx=pain, immobility, alteration in contour of joint, deviation of length of extremity, and rotation of extremity Tx=closed reduction where joint forced back to normal anatomical position -joint immobilized until healing occurs
Strains
excessive stretching of a MUSCLE or TENDON when it is weak or unstable...aka pulled muscles 1st degree=mild inflammation, bruising and tenderness 2nd degree=tearing of muscle-muscle may be impaired 3rd degree=ruptured muscle or tendon where separation of muscle or tendon from muscle or bone-severe pain and disability -TX-cold and heat, limited exercise and activity, antiinflammatories, muscle relaxants and poss. surg.
sprain
excessive stretching of LIGAMENT usually from twisting -1st degree=tearing of few fibers of ligament, function not impaired; Tx=RICE (rest, ice 24-48h, compression w/bandage, elevation) -2nd degree=more fibers are torn but joint remains stable -Tx-immobilization, partial weight bearing as tear heals -3rd degree=marked instability of the joint -Tx-immobilization for 4-6 weeks, poss. surg.
rotator cuff injury
-the musculotendinous (rotator) cuff of the shoulfer to stabilize head of humerous during shoulder abduction -tear d/t sports for younger ppl, or excessive "wear and tear" for older adults or falls -drop arm test-cant abduct the arm (it just drops) -TX-therapy w/NSAIDS, PT, sling or immobilizer support, ice/heat application -Surgery when conservative therapies dont work. -postop-arm imobilized for weeks but pendulum exercises begin 3-4 days after-active exercises in 2 weeks -may not have full func for several months

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