1
Q
What is the musculoskeletal system comprised of?
A
- muscles
- bones
- joints
- tendons
- connective tissues
2
Q
What is the main function of the musculoskeletal system?
A
Mobility and protection of internal organs
3
Q
What age and gender do injuries in the musculoskeletal system most often occur in?
A
Young males; related to sport injuries
4
Q
What does soft tissue trauma include?
A
- sprains
- strains
- dislocations
- subluxations
5
Q
What is a subluxation?
A
Severe injury of the ligament structures around the joint that cause the joint to be completely displaced from its normal position
6
Q
What is a subluxation?
A
Partial or incomplete displacement from the joints surface
7
Q
What does RICE stand for?
A
R - rest
I - ice
C - compression
E - elevation
8
Q
What is a fracture?
A
A disruption or break in the continuity of the bone
9
Q
What is a open fracture?
A
The bone protrudes through the skin and is exposed to the external environment
10
Q
What is a closed fracture?
A
The bone is broken but the skin remains intact
11
Q
What is a complete fracture?
A
A break is completely through the bone
12
Q
What is a incomplete fracture?
A
The fracture occurs across the bone shaft but the bone is in one piece
13
Q
What is a displaced fracture?
A
The two ends of the bone are separated from one another
14
Q
What does comminuted mean?
A
More than two fragments
15
Q
What is a non-displaced fracture?
A
The bone, although broken, remains in alignment
16
Q
What are the six stages of bone healing?
A
- fracture hematoma
- granulation tissue
- callus formation
- ossification
- consolidation
- remodeling
17
Q
What is stage 1 - fracture hematoma?
A
- bleeding at the site of the break occurs and a clot forms quickly
- hematoma fully forms in 72 hours
18
Q
What is stage 2 - granulation tissue?
A
- phagocytosis occurs, reabsorbs tissues/cells
- granulation tissue - new blood vessels, fibroblasts and osteoblasts develop
- 3-14 days following the injury
19
Q
What is stage 3 - callus formation?
A
- minerals develop (calcium, magnesium and phosphorus) help the new bone matrix develop
- beginning to bind the bone back together
- can be seen on x-ray
20
Q
What is stage 4 - ossification?
A
- new bone continues to develop
- osteoclasts destroy dead bone
- 3 weeks to 6 months
21
Q
What is stage 5 - consolidation?
A
- ossification continues - evidence of complete bony union
- can take up to a year
22
Q
What is remodeling?
A
- excess bone growth is reabsorbed
- trabecular bone is laid down
- can take up to a year post injury
- bone remodels occurring to stress
23
Q
What are the signs and symptoms of fractures?
A
- edema
- pain
- abnormal positioning of extremity - deformed
- loss of normal function
- false movement - movement at fracture site
- crepitus - palpable or audible crunching as the end of bones rub together
- discoloration of skin around affected site
- sensation may be impaired if there is nerve damage
24
Q
What are the diagnostic tests for fractures?
A
- x-rays
- bone scan (checking density)
- CT scan
- MRI
25
What is closed reduction?
- non surgical manual realignment of the bone fragments to the correct anatomical position
- traction and counter traction is applied to the bone to restore the correct position
- usually performed while the patient is under local or general anesthesia
- if simple fracture - casting is applied to maintain alignment while the bone heals
26
What is traction?
- application of a pulling force to the injury to help get it into alignment
- to prevent and reduce muscle spasms, immobilize the bone and joint, reduce the dislocation, treat the pathological joint condition
27
What is skin traction?
- used short term while the patient waits for surgery
| - boots or splints are applied to the skin and connected to weights to maintain alignment
28
What is skeletal traction?
- used for longer periods of time, to align injured bones and joints
- physician inserts pin or wires into the bone and connects the weights
29
How do you care for a patient with traction?
- neurovascular checks every 2 hours
- assess skin for breakdown
- assess and treat pain
- ensure traction set up is correct and patient is in alignment
- if pins are present, meticulous care to prevent infection
- range of motion; other extremities
30
What does a thorough neurovascular assessment include?
- skin colour - distal to injury
- skin temp
- movement
- sensation
- pulses
- capillary refill
- pain
31
What is open reduction and internal fixation?
- surgical procedure to repair fractures
| - surgeons often use internal wires, screws, pins, plates, and rods to stabilize and align the fracture
32
What nursing care is needed after a open reduction and internal fixation procedure?
- close observation of vital signs
- monitor ABC's
- neuro-vascular checks of the affected limb
- monitor for infection
- routine post-op care
33
What is a external fixator?
- metallic device that is composed of metal pins and screws inserted into bone and attached to the external rods
- applies traction
- compressed fracture fragments into alignment
- used with complex fracture and/or fractures that are not healing
34
What is a cast?
- temporary circumferential immobilization device
- allows patients to perform many ADL's
- application often involved joint above and below the break
- also restricts tendon and ligament movement
35
When is the cast completely dry and strong enough for weight bearing?
- 24-72 hours later
36
What are some different types of casts?
- short or long arm casts or leg casts
- body jacket for thoracic or spinal injuries
- hip spica cast for femoral fractures
37
What nursing care should be done for cast?
- continue to assess for compromised circulation and monitor for compartment syndrome
- elevate the extremity, especially during the first 24 hours after application
- can apply ice packs over the areas of injury (keeping the cast dry) during the first 24 hours to reduce swelling and/or pain management
38
What nursing interventions need to be done when caring for a patient with a body jacket cast?
- observation of respiratory status
- bowel and bladder function
- areas of pressure over boney prominences
39
What interventions need to be done for a patient with an open fracture?
- need a tetanus immunoglobin booster
- antibiotics (high risk of infection)
- well balanced diet to support bone healing
- ample protein
- multivitamin - calcium, phosphorus and magnesium
40
What nursing interventions need to be done for elderly patients with fracture?
- increased risk of constipation
- diet high in fiber with fruits and vegetables
- adequate fluid intake
41
How many meals should a patient with a hip spica or body jacket eat per day?
6 small meals per day
42
What home care need to be communicated to the patient with a cast?
- do not bear weight on the affected extremity until instructed to do so
- do not allow the cast to get wet
- do not insert any objects into the cast or remove any padding
- report any swelling and increased pain, especially when unrelieved with analgesics
- if cast becomes very loose, it may need to be resized
- monitor for signs of infection (fever, increased warmth over cast)
43
What patient teaching should be done after the removal of a cast?
- remove scaly, dead skin carefully by soaking (do not scrub)
- move the extremity carefully
- expect discomfort, weakness, and decreased ROM
- support the extremity with pillows or your orthostatic device until strength and movement return
- exercise slowly as instructed by your physical therapist
- wear supportive stockings or elastic bandages to prevent swelling (lower extremities)
44
What is a renal calculi?
- a kidney stone
- can develop as result of bone demineralization
- increase fluids to 2.5L/day
- monitor for discomfort/flank pain
- monitor intake and output
- daily weights
45
What is compartment syndrome?
- swelling and increased pressure within the compartment around the injury site
- compromises the function of blood vessels (area becomes so swollen = poor blood flow = ischemia)
- compresses nerves (neurological pain and loss of function)
46
What are the 6 P's of compartment syndrome?
- paresthesia (numbness and tingling)
- pain (not relived by opioids, severe)
- pressure (inside the compartment)
- pallor (coolness and loss of colour)
- paralysis ( loss of function)
- pulselessness (late sign, cannot palpate peripheral pulse)
47
Why does urine output need to be assessed when compartment syndrome is at risk?
- because myoglobin is released from damaged muscles which cause obstruction in the tubules = acute tubular necrosis = renal failure
- signs include reddish brown urine and decreased urine output
48
What nursing care needs to be done for someone with compartment syndrome?
- remove or loosen bandage/cast
- surgical decompression may be needed
- once the cast or bandage is loosened, then elevate the extremities
- neurovascular checks every hour
- pain management
- if surgery - incision care
- increased fluids to decrease injury to the kidneys
49
What is venous thrombus/embolism and what is it a complication of?
- patients with pelvis or long leg casts are at increased risk
- assess for complaints of pain
- monitor peripheral pulses
- assess for swelling
- may need anticoagulants
50
What is a fat embolus and how does it occur?
- after a break in the bone, fat globules may be released into the vascular system
- occurs more often in long bone fractures
- triggers an inflammatory response
- causes mirco-clots which can lead to ischemia
51
What are the signs and symptoms of a fat embolus?
- develop very quickly
- patient frequently expresses a feeling of impending doom
- change in level of consciousness - confusion and or restlessness
- skin changes from pallor to cyanosis
- SOB - hypoxia
- hypotension and tachycardia
- myoglobin in urine - decreased output
52
How to treat a fat embolus?
- directed at prevention - careful handling of long bone fractures
- reposition the patient with these fractures as little as possible until stabilized
- fluids - normal saline
- oxygen therapy
- replacement of blood volume (if necessary)
- glucocorticoids
53
What is shock?
- decreased tissue perfusion
- impaired cellular metabolism
- whole body response (not a disease process)
- all organs are affected by shock (they either work harder to obtain oxygenation or adapt to reduced oxygen levels)
54
How is shock categorized?
- by the functional impairment
55
What is low flow shock?
- hypovolemic: decrease in total body fluid
| - cardiogenic: direct pump failure
56
What is disruptive shock?
- septic, neurogenic and anaphylactic
| - fluids shifted from central vascular spaces to tissues (not returned to vascular system)
57
What is hypovolemic shock?
- occurs when the intravascular fluid is lost and the remaining volume is inadequate to fill the vascular space
58
What are absolute volume losses?
- hemorrhage
- diabetes insipidus
- GI loss (vomiting, diarrhea)
- diuresis
59
What is relative loss?
- fluid shift out of the vascular space into the interstitial space (tissues)
- ex: sepsis or burns
60
What is disruptive/septic shock?
- sepsis is a systemic inflammatory response to infection
- severe sepsis is complicated by organ dysfunction
- septic shock develops due to a widespread infection causing organ failure and dangerously low BP
61
What will the body do to ensure oxygenation for the vital organs during shock?
Compensation
62
What are the 4 stages of compensation?
1. initial
2. compensatory
3. progressive
4. refractory
63
What is the initial stage of shock?
- usually not clinically apparent
- metabolism changes from aerobic to anaerobic (lactic acid production begins)
- increased HR, mild vasoconstriction
64
What is the compensatory stage of shock?
- decrease in BP (10-15 mmHg)
- increase in lactic acid production
- mild acidosis - decrease in pH and hyperkalemia
- increased HR
- increased respirations
- kidneys reabsorb fluid
- stimulation of thirst
- decrease in pulse pressure e
65
What is the progressive stage of shock?3
- begins as the compensatory mechanisms fail
- more aggressive interventions are necessary to prevent the patient from developing multisystem organ dysfunction
- decreased cellular perfusion (increased anaerobic metabolism)
- altered capillary permeability (fluids leak into the tissues, less vascular space = hypotension)
- fluid leaking into alveoli
- tachycardia - poor cardiac output
- anoxia of non-vital organs, pallor, cyanosis
- hypoxia of vital organs (heart, brain, kidney)
- moderate acidosis, increases lactic acid
- tissue death is occurring
66
What is the refractory stage of shock?
- high rate of mortality
- exacerbation of anaerobic metabolism
- accumulation of lactic acid
- increased capillary permeability - venous pooling
- hypotension (worsening of cardiac function, failure of organs)
67
What diagnostic tests are done for shock?
- no one single test to determine shock
- thorough history and physical
- lab studies (hemoglobin and hematocrit, lactate level, arterial blood gases-bicarbonate level btwn 21-28mmol/L)
- 12 lead ECG - heart rate and rhythm
- radiology (chest x-ray or CT scan)
68
What causes hypovolemic shock?
- trauma
- surgery
- dehydration
- internal hemorrhage
69
In what age group is hypovolemic shock most common?
Young people (recent illness, truama)
70
What are the signs and symptoms of cardiovascular hypovolemic shock?
- decreased BP
- increased HR
- increased respirations to improve oxygenation
- increased lactic acid
- diminished peripheral pulses
-decreased urine
late signs;
- increase in diastolic pressure = narrowing of the pulse pressure
- systole pressure will decrease and cardiac output will decrease
- peripheral pulses present with Doppler
- decreased respirations and increased depth
- no urine production
71
What interventions should be done for hypovolemic shock?
- oxygen therapy (head of bed no more than 30*)
- IV therapy (blood and blood products)
- assess for life threatening injuries
- control external bleeding w direct pressure
- urinary catheter, strict input and output
- NG tube if needed
- consult HCP if fluid does not bring up BP, may need vasoactive medications
72
What is the cause of sepsis?
- bacterial infection that escapes local control
- immunological patients: fungal infections can lead to sepsis
- increase in the number of drug resistant organisms is resulting in more cases of sepsis
- older adults are more at risk
- infection control
73
What is local infection?
- infection is confined to a local area
- immune system responds (inflammatory mediators, WBC's)
- WBC's invade infectious area = vasodilation = increased perfusion
- results in capillary bed leakage - infectious organisms enters the blood system = systemic infection
- pathogen uses furl (glucose) in the vascular system to reproduce
- body responds with widespread inflammation (SIRS)
- impairs oxygenation and perfusion
74
What is severe sepsis?
- all the tissues are involved - hypoxia - some organs are experiencing death
- results in a large inflammatory response - vasodilation and blood pooling
- blood pooling causes micro thrombi to form
- results in hypoxia and reduced organ function
- increasing hypoxia = anaerobic metabolism (increasing lactic acid levels) = more toxins in the blood stream
75
What are the labs for sepsis and septic shock?
- assess for presence of bacteria in vascular system - blood cultures
- increasing serum lactate level
- normal or low WBC (used for fighting the infection so body is struggling to produce more)
- C reactive protein - increased initially = indicates inflammation (decreased in septic shock)
- D- dimer: rises as fibrin clot is broken down
76
What medications can be used for septic shock?
- IV fluid volume - NS or LR
- antibiotics - vancomycin, aminoglycosides
- patients are often hyperglycemic; insulin therapy
- low dose corticosteroids
- vasoactive medications to support blood pressure
77
What is multi organ dysfunction syndrome (MODS)
- 2 or more organs fail
| 70% mortality rate
