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Structural Disability


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-Cirulation: color, temp, cap refill, pulse
-Motion: weak, paralysis
-Sensation: parasthesis, unrelenting pain, or pain with passive stretch, numbness or absence of feeling
Musculoskeletal Trauma
-Contusions: blunt force, bruising of the brain surface
-Strain: muscle that has been overstretched
-Sprain: ligament trauma
-Dislocation: bone displaced from normal location
-Subluxation: incomplete dislocation
-Factures:Any break in the continuity of the bone
-R: rest (not using affected part)
-I: ice (20-30min intermittenly) for first 24-48hours of injury then switch to heat
-C: Compression: wrapping with ace wrap from distal to proximal
-E: elevation above level of heart if possible
S/S fracture
-Decreased function
-Change in mobility
-Crepitus (sounds of rice crispies, hair rubbed together)
Types of Fractures
-Closed (simple)
-Open (compound)
-Comminuted (3 or more pieces)
-Greenstick (usually seen in kids)
-Impacted (bones are pushed together)
-Pathologic (underlying bone disorder)
Early, Systemic Complication of Fractures
-Shock: from hemorrhage
-Fat embolism
-Compartment Syndrome
-Thromboembolism/pulmonary embolism
-Disseminated Intravascular Coagulopathy (DIC): bleeding disorder
-Infection: open fractures or surgical interventions (breaks in skin)
Fat Embolism
-Fat globules may move into the blood because the marrow pressure is greater than the capillary pressure, usually occurs 24-72hours bone fracture
-S/S: SOB, coughing, thick white sputum, tachypnea, tachycardia, crackles or wheezes, confusion, mental status change
Tx: O2, steroids, immobilize fractures, maintain F&E balance
Dx: ABG, Chest X-Ray,
Compartment Syndrome
-A complication that develops when tissue perfusion in the muscles is less than that required for tissue viability, not enough O2 to tissues and nerves
-S/S: changes in CMS, pt complains of deep throbbing unrelenting pain that cannot be controlled by opioids, when muscle is stretched pain increases, loss of sensation and absence of feeling
-D/T: a reduction in the size of the muscle compartment because the enclosing muscle fascia is too tight or a cast or dressing is constrictive; an increase in muscle compartment contents because of edema or hemorrhage associated with a variety of problems; permanent damage occurs in anoxic tissue in just 6 hours
Tx: Raise extremity, relieve constriction,
Prevention: raise extremity above heart, check casts and dressing not too tight, fasciotomy: (done within 1 hour after other methods if not relieved) surgical decompression with excision of the fibrous membrane that covers and seperates muscles, passive ROM q4-6hours
Nursing Care of Fractures
-CMS checking
-Avoid unnecessary movement
Medical Treatment of Fractures
-Immobilization until healed
*external fixation
*internal fixation
Nursing Assessments and Casts
Types of Cast:
*Plaster of Paris
-5Ps and CMS checks
*pulse, pallor, pain, paralysis, parathesias
-Alert to prevent complications
-Assess specific peripheral nerves that could be damaged by cast pressure
Complications of Casts
-Compartment Syndrome
-Disuse Syndrome
-Prssure Ulcers
-Nerve Damage
-The application of a pulling force to a part of the body while a counter traction pulls in the opposite direction
-Helps to establish proper alignment
-Helps to immobilize extremity
-Can correct deformities
Principles of Traction
-Maintain established line of pull and continuous line of pull
-Prevent Friction
-Maintain counter traction
-Maintain body alignment
Types of Traction
-Manual: never done anymore unless emergancy situation
-Skin: pulling force to skin with tape or traction straps; types:
*Buck's, Russell, Bryant's, Dunlop's, Pelvic Sling, Pelvic Belt
-Skeletal: a pin or wire is inserted directly into the bone
Buck's Traction
-Decreases muscle spasms and aligns while waiting for surgery
-5-8 pounds
-Concerns include heel pressure, place small towel under ankle to help get heel off of bed
For a fracture at the elbow
Nursing Care for Traction Patient
-Avoid pressure
-Monitor neurovascular status-CMS checks
-Pain control
-Encourage use of trapeze
-Educate pt to decrease anxiety
-Pin site care for skeletal traction (NS for cleaning unless ordered otherwise)
Maxillo-Facial Trauma
-Mandibular fracture
-Interal Maxillary fixation post-op care:
*Wire cutters in room
*Prevent vomiting
*Provide oral care
*Meet caloric and fluid needs
*Promote communication
Rheumatic Diseases
-Over 100 different types
-Affects skeletal muscles, bones, ligaments, tendons, and joints
-Periods of remission and exacerbation
-S/S: systemic inflammation, low grade fever, erthrocyte sedementation rate increases (sed rate = 20)
Diffuse Connective Tissue Disorders (CTD)
-Ststemic Lupus Erthrematosus (SLE)
-Rheumatoid Arthritis
-Polymyalgia Rheumatica
-Systemic insoluble collagen accumulates affects major organs
*C: calcium deposits in the skin
*R: Raynaud's (low circulation to hands and feet)
*E: esophogeal hardening
*S: scleradactyly (hardening of the digits)
*T: Telangiectasis (vascular lesion)
Treament for Scleroderma
-Moderate exercise
-Control HTN, NSAIDS, Penicillamine to decrease skin thickening
-Dx is not simple: ANA (antinuclear antibodies) and skin biopsy with CREST syndrome
S/S Scleroderma
-Mask like face
-Drawn pursed lips
-Shiny skin over cheecks and forehead
-Atrophy of the muscles of the temple and face
Systemic Lupus Erythematosus
-Autoimmune disease: genetic, hormonal, environmental causes
-S/S: Skin changes, butterfly rash, musculoskeletal changes, affects heart, lungs, kidneys, and brain. Thought to be due to an abnomral suppressor T-cell function
-Dx: +ANA, anemia, thrombocytopenia, leukocytosis or leukopenia
-Tx: corticosteroids
Rheumatoid Arthritis
-Chronic, systemic progessive
-Symmetric, proximal, synovial joint involvement
-S/S: depression, bilateral reddened and swollen joints, ulnar drift (d/t continued steroid use), joint deformity
-Remissions and exacerbations
-Dx: arthrocentesis cloudy synovial fluid, RA factor, increased ESR, x-ray shows progression, +ANA
-Tx: ASA, Cox-2 inhibitors, NSAIDS, steroids, gold preps, penicillamine, antimalarials
-Methotrexate: inhibits DNA synthesis by supressing the immune system
-A defect in purine metabolism (crystal induced arthropathy)ua>7
-Genetic defect
-Symptoms: recurrent attacks of joint pain, swelling, and inflammation
-Men >30 age in hospital have increased occurance of developing gout
-Big toe usually involved
-Tx: colchine or NSAIDs for acute pain
-Brobenecid: prohibits renal reabosorption of uric acid
-Mlopurinol: prohibits production of uric acid
-Cutlacine: provents uric acid from depositing in joints
-Cartilage in joints cracks and wears
-S/S: pain, stiffness, functional impairment
-Dx: physical assessment, x-ray shows loss of joint cartilage
-Tx: rest and support for affected joints, ROM and postural exercises
-NSAIDs, and corticosteroid intrarticular injection
-Loss of bone mass
-S/S: compression fractures, dowager's hump
-Risk factors:
Joint Replacement
-Surgical removal of diseased/deformed joint replaced with an artificial joint
-Total hip replacement (THA):
*Complications: dislocation!, nerve injury, infection, thromboembolism, bleeding, fat emboli
*Post-op care: PT, positioning, wound care and drainage, pain control, immobility care, hip precautions for 6 months
-Total knee replacement (TKA)
*Complications: nerve injury, infection, thromboembolism, fat emboli (less likely)
*Post-op care: PT, continuous passive motion (CPM)
Hip Precautions
Fill in later
-Reasons: circulatory impairment, accidents, bone tumor, osteomyelitis
-Types: below the knee (BKA), above the knee (AKA)
-Nursing care:
*need consent to dispose of limb
*Assess for: hemmorrhage, infection, pain control, psychosocial adjustment, incision healing
-Limb care: elevate FOB and limb for 24hours only, limb shrink wrap, skin care
Pressure Ulcers
-Compression or collapse of the blood vessel, starving the area of blood supply
-At Risk:
-Pressure points:
Wound Assessment of Pressure Ulcers
-Size and depth
*I: red to dusky blue-grey (non blanching)
*II: break in skin epidermis or dermis
*III: into subcutaneous layer
*IV: muscle and maybe bone
-Condition of tissue
-Signs of infection
Prevention of Pressure Ulcers (Decubiti)
-By knowing what actually causes them
-Turning and positioning properly
-Good nutrition
-Identify pts that are at risk
Wound Care for Pressure Ulcers
-Wound cleansing
-Surgical Repair
-Ultimate trauma
-Affects all organs
-Types: thermal, chemical, electrical, flame
-Prognosis depends on 3 itmes:
*Depth of burn
*Size of burn
*Parts of body affected
Characteristics of Burn Depth
-Superficial partial thickness
*1st degree: epidermis may involve part of the dermis
-Deep partial thickness
*2nd degree: epidermis, upper layers of dermis and involves deeper dermis
-Full thickness
*3rd degree: entire dermis, may involve muscle, bone, nerves, etc.
Size of Burn: Rule of Nines
-Each Arm:9%
-Anterior Chest:18%
-Posterior Chest:18%
-Each Anterior Leg:9%
-Each Posterior Leg:9%
Phases of Burn Injury
-Acute Phase
-Rehab Phase
Emergent Phase of Burn Injury
-Onset: 24-36 hours
*airway, breathing, circulation
*Stop burn, extinguish and apply cool water
*Remove restrictive clothing
*Cover the wounds
*Chemical burns: continuous rinse
*IV catheter with 16-18 gauge
*Nasogastric tube if >25% BSA
*Indwelling urinary catheter
-F&E Knowledge:
*Plasma leaks through capillaries d/t increase in capillary permeability
*Results in hemodynamic instability
*Fluids shift from to
*Cardiac output decreased therefore decreased BP
*Sympathetic NS releases ca
*Increased vaso
*Increased perl
-look at pg 1708
Acute Phase of Burn Injury
-48-72 hours later
-Respiratory/Circulatory status
*temp >100.6, check ABGs with any distress think ET tube
-F&E balance/PA catheters
*expect diuresis, may need blood products
-GI function: NG prevents vomiting
-Burn wound care
-Nutritional support
-Pain control
-Major cause of Death in acute phase is due to septic shock
Rehap Process of Burn Injury
-Parts of body affected present serious complications for rehab
-Psychosocial impact: body image and self concept
-Prevention of contractures and scarring
-Teaching self care
Back Injuries
-Lumbar area most affected
-Intervertebral disc disease
*Sharp shooting pain
*Follows sciatic nerve frequently
*Lumbar damage creates weakness in legs
*Muscle relaxants
*Bedrest, often not recommended anymore
Spinal Surgery
-Laminectomy: Removal of the bone between the spinal process and facet pedicle junction to expose the neural elements in the spinal canal, relieve compression of the cord and roots
-Fusion: to bridge over the defective disk to stabilize the spine and reduce the rate of recurrence
-Discectomy: removal of herniated or extruded fragments of intervertebral disk
-Complications: damage to the nerve root, spinal cord, carotid or vertebral artery injury
-Anterior approach: lumbar and cervical
-Posterior approach
Post-op Care of Spinal Surgery
-Alignment of the spinal column is critical
-Log roll patient
-CMS check
-Pain control
-Teach pt good body mechanics

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