1
Q
Bones: Three Layers
A
- Periosteum
- Compact bone
- Medullary Canal: Red and yellow bone marrow & fat cells
2
Q
Bone surroundings
A
Muscles:
- Tendons- muscle to bone
- Ligaments- bone to bone
3
Q
Sprains
A
- Trauma to a joint
- Tearing of ligaments
- Often due to twisting injury
4
Q
Strains
A
- Trauma to muscle or tendon
- Often due to excessive stretching or overexertion
5
Q
S&S of sprains and strains
A
- Swelling/edema; tiny hemorrhages occur within the disrupted tissues
- Superficial bruising or hemarthrosis (bleeding into a joint)
- Pain; Sprains usually more painful D/T the area having large numbers of nerve endings
- Limitation of movement
6
Q
Treatment of Sprains/Strains
A
- Rest
- Ice (v muscle spasms) - no longer than 20 min
- Compression
- Elevate
- Movement
- Anti-inflammatory drugs- slow down bone healing
- Go to heat after 24 hours (20 min at a time)- heat helps body absorb lactic acid and get away from injury
7
Q
Coban
A
Bandage with more stretchiness and sticks to itself- (start at bottom and work your way up)
8
Q
Fractures (Causes)
A
- Trauma: falls, accidents
- Weak bones
- Movement disorders
- Long term steroid use: Osteoarthritis, total hip/knee prematurely, demineralization, and could ^ glucose levels
9
Q
Pathophysiology of Fractures
A
- Force to bone & muscle causes break in structure of bone
- Nearby blood vessels break causing bleeding into area, creating swelling & pain
- Nearby muscles go into spasm, causing more bleeding/pain & swelling
- Spasms may cause fractured ends to move, causing more bleeding and swelling (even if you don’t tear muscles; If you don’t stop spasms. could cause misalignment
10
Q
S&S of fractures
A
-Edema
-Pain
-Muscle spasms
-Deformity
-Ecchymosis
-Loss of function
-Crepitation (feels like bubble wrap)
-Numbness
-Hypovolemic shock
(S&S are mostly the same for sprain, strain, & fracture so you can only tell by an x-ray)
11
Q
Diagnostic Tests
A
X-rays
CAT scan- no need unless its in your back
MRI- no need unless its in your back
Bone Scan- nuclear med scan; injected with nuclear stuff and start looking for uptake in x-ray
12
Q
Stages of Healing
A
- Fracture hematoma
- Granulation tissue
- Callus
- Ossification- when cast comes off (4-6 weeks); teach pt. it’s still not completely healed
- Consolidation
- Remodeling; about 6 months to remodel
13
Q
Complications with fractures: Delayed Union
A
healing does not occur within normal expected time frame
14
Q
Complications with fractures: Non-union
A
Fracture never heals; two ends of bone do not fuse together
15
Q
Complications with fractures: Infection
A
Can be seen in open fractures or any fracture with surgical intervention; can lead to delayed union or non-union
16
Q
Complications with fractures: Avascular Necrosis
A
An interruption in blood supply to bony tissue, which results in death of bone (most common with steroid use
S&S; pain and decreased sensation
17
Q
Complications with fractures: Compartment syndrome
A
- Increase in tissue pressure which results in a v blood supply (swelling, edema)-impaired tissue perfusion
1. internal pressure
2. external pressure
3. pressure on nerves, blood vessels
4. decreased blood flow to injury
5. increased pressure on nerves
6. pain/immobility
18
Q
S&S of compartment syndrome
A
- Progressively increased pain (not relieved by narcotics)
- loss of sensation
- loss of function
- pale, cool skin
- decreased or absent pulses
19
Q
Treatment of compartment syndrome
A
Fix cause; stop bleeding or remove tight cast
-Fasiotomy: make incision into fascia to open up compartment space & decrease pressure
(can lead to tissue death and amputation)
-If you have any idea that it’s compartment syndrome, put pt. on NPO to get ready for OR
20
Q
Complications with fractures: Venous Thrombosis
A
- D/T prolonged bedrest & immobility
- Prevent with TED hose, SCD (assess pressure (40-45), inflating & deflating), ROM exercises, daily ASA or Heparin or Lovenox
21
Q
Complications with fractures: Fat embolism
A
- just as deadly as venous thrombosis if not more
- condition in which fat globules are released from the marrow of the broken bone into the blood stream
- Occurs in first 48 hours after injury
- Seen in big fractures
22
Q
Fat Embolism (where it occurs)
A
- Fractures from the long bones, ribs, tibia, pelvis, joint replacement, & spinal fusions most often are the cause
- Migrates to lungs, brain, heart, or kidneys
- Symptoms depend on location where fat embolism traveled
- *Prevention is important because it’s hard to treat
23
Q
Fat Embolism: treatment
A
- Hydration
- correction of acid/base
- replacement of blood loss
- Immobilization of fracture until stabilized
- respiratory support: O2, mechanical ventilation if ARDS develops
24
Q
Fat Embolism: S&S
A
Confusion, ^RR, crackles (fluid in lungs), Petechia (really small pinpoint rash- not raised, purplish red)
25
Fracture Management: First Aid
- Splint in position found
- Decrease movement
- Elevate
- Ice
26
Fracture Management: Closed Reduction
Bones are manually moved into position
27
Fracture Management: Open Reduction
Incision made at fracture site so bones can be internally put into alignment (OR; plates and screws)
28
Fracture Management: Immobilization (3 ways to do this:)
- Process of keeping the bone ends together
1. External fixation
2. Internal fixation
3. Traction
29
Fracture Management: Traction- 2 types
1. Skin: treatment attached to skin directly- wrap & have pulley's & weights
2. Skeletal: Metal pins placed in bone distal to fracture, pin attached to metal bow & weights added to pull on bone to keep alignment (infection prone)
30
Casts (how made)
Plaster cast material is immersed in warm water & wrapped around, soft, thick, cast padding
-Synthetic material is immersed in cool water
-Plaster & fiber glass hardens within 15 min
-Cannot weight bear for 24-72 hours
(x-ray after cast is applied)
31
Casts: Handling and care of a fresh cast
- Never cover a fresh cast with a blanket because air cannot circulate & heat builds up as it dries and sets (cast gives off heat and heat needs to escape)
- Handle with palms of hands until dry
- Synthetic casts are lightweight and waterproof (pads arent waterproof)
- Splint is applied when a lot of edema is expected
32
Casts: Assessing
- Assess edges for any pressure on skin
- Use 5 P's to assess area distal to cast (pain, pallor, paralysis, paresthesia, pulselessness)
- OR assess w/ CMS- circulation, movement, sensation
- If core is casted, assessment of breathing patterns, & bladder and bowel function are necessary
(cap refill, movement, temp, color)-to make sure cast isn't too tight
33
Casts: Teaching
- Encourage patient to actively move non-immobilized joints to prevent stiffness & contractures
- After casting, extremity should be elevated with pillows about heart level for first 24 hours to decrease edema
34
Slings (assessment, pt. teaching)
- If short term, flex elbow are 80 degrees (hand slightly higher than elbow)
- Thumb should be facing upward or inward
- Inspect axilla for skin breakdown
- Check for undue pressure around neck
- Movement of fingers should be encouraged to enhance circulation & decrease edema
35
Crutches (pt. teaching) (NOT ON EXAM 3)
Three types: Axillary, Lofstrand, & Platform
* Weight is borne by the muscles of the shoulder girdle & upper extremities
- PT usually measures for crutch placement
- Weight of body should be borne by the arms, not axillae (overtime could cause numbness in brachial plexus)
- Maintain posture
- Each step should be confortable stride
36
Crutches (Assessment & instructions) (NOT ON EXAM 3)
- Inspect crutch tips regularly
- Wear rubber sole shoes
* Going down stairs, move crutch and affected leg first
* Going up stairs, place weight on crutches & move unaffected leg onto step
- Chairs that have armrests & are supported by a wall are safest for transfer in and out of chair
- When getting into or out of a chair, the pt. hold the crutches on the affected side
37
What are External Fixators?
- Metal pins inserted into the bone proximal & distal to fracture
- The pins are then attached together with external rods in order to keep the extremity aligned & completely immobile
* Most often used for nonunion or complex fractures with extensive soft tissue damage
* Long term
38
External Fixators (Pin care)
Risk for infection is high because microorganisms can enter bone around the pin insertion sites (check temp. every morning)
- Meticulous pin care necessary
- Pin care done 2x/day with either Chlorahexidine or half-strength hydrogen peroxide with normal saline
39
External Fixators (S&S of nerve damage)
*If numbness, tingling, severe pain, etc post-op, tell physician immediately (nerves may have been drilled through
40
Internal Fixation (ORIF) (what is it, alignment, post-op)
- Use of pins, plates, & screws, which are surgically inserted into the bone, after the fracture is reduced manually
- Alignment is verified with the use of fluoroscopy (continuous x-ray machine during procedure) during surgery
* Usually have a splint on post-op and first dressing is done by surgery
41
Bone Nailing
* Used in femurs
| - A lot of post-op pain
42
compound fractures
AKA open fractures (skin broken with bone protruding out)
- Wound culture done
- Requires surgical intervention
43
Osteomyelitis (S&S)
(Bone infection)
- Temperature rise
- swelling
- redness that spreads
- uncontrolled pain
- ^ in drainage, and then start to see drainage change
- ^WBC
44
Osteomyelitis (treatment)
Antibiotics- know if working if symptoms go down
45
Traction
A steady pull by weights to keep the bone ends in position
-Decreases likelihood of non-union
-decreases muscle spasms
-traction is now used as a hold over until you're in surgery
(Assess pedal pulses & cap refill when you put boot on)
**Assess boots and weights every 8 hours
46
Skin Traction
- may be used first 24-48 hours until ORIF can be performed
- Tape, boot, or splint is applied directly to the skin
- Weight is 5-10 pounds
- EX- buck russels, Bryant's, Girdle, and head halter
* Weight is attached slowly
47
Skeletal Traction
Pin inserted through bone and then attached to weights using metal bows
-Weight ranges from 5-45 pounds
48
Traction Care
```
T- emperature
R- opes
A- lignment
C- irculation
T- ype and location of fracture
I- ncrease fluid intake
O- verhead trapeze
N- o weight on floor
```
- Forces must be pulling in opposite direction to prevent pt. from sliding to the end or side of the bed
* need 4 people to assist when moving pt. (make sure weights stay in place
49
Effects of Immobility: Musculoskeletal
- Bones demineralize without weight bearing activity
- Muscles atrophy losing their normal strength and function
* Contractures form, limiting joint mobility (ROM)
- Collagen tissues at the joint become ankylosed (solid, hard)
50
Effects of Immobility: Circulation
- v cardiac reserve (intercostals and heart deconditioned)
- Increased use of valsalva maneuver
- Orthostatic hypotension
- Venous Dilation & stasis (v venous pooling)
- Dependent edema
- Thrombus formation
51
Lovanox
Inject WITH bubble (prevent drug from coming back up)- make sure bubble is at top
* anticoagulant therapy indicated to help reduce the risk of developing DVT
52
Effects of Immobility: Aeration
- v respiratory movements
- pooling of pulmonary secretions
- atelectasis
- hypostatic pneumonia
53
Effects of Immobility: Nutrition
- v metabolic rate
- negative nitrogen balance
- change in intake habits
- negative Ca balance
- bone demineralization
54
Effects of Immobility: Elimination GU
- urinary stasis
- urinary retention
- UTI
- Renal calculi
55
Effects of Immobility: Elimination GI
- v GI motility
| * Constipation
56
Effects of Immobility: Sensation/Perception
- Reduced skin turgor
| - Skin breakdown
57
Effects of Immobility: Anxiety
- v self esteem
- altered perception of time
- v ability to problem solve and make decisions
- feelings of loss of control
- v social and motor development in children
58
Immobility assessment
-To assess for activity tolerance look at HR, strength, & rhythm;
respiratory rate, depth, and rhythm;
& BP
-get baseline during activity, immediately after activity, and 5 min after activity
59
Immobility assessment: the activity should be stopped if the following are noticed
- sudden facial pallor
- feelings of dizziness of weakness
- changes in LOC
- diastolic BP change of 10 mmHG or more
- HR or RR that significantly exceeds baseline
- change in HR or RR from reg to irregular
- Weakening of pulse
- Dyspnea, SOB or chest pain
60
Mobility nursing diagnoses
- Risk for or actual activity intolerance
- Impaired physical mobility
- Fear (of falling)
- Ineffective coping
- Low self-esteem
- Powerlessness
- Risk for injury
- Self-care deficit
- ineffective airway clearance
- Risk for infection
- Altered tissue perfusion
- Constipation
- Altered nutrition
61
What is an amputation
The partial or complete surgical removal of a limb as the result of a crushing injury, intolerable pain, gangrene, vascular obstruction, uncontrolled infection, or congenital anomalies
62
Three Major Causes of an Amputation
Medical: 74%: diabetes, PVD, cancer, gangrene, and infection
Trauma: 23%: Crushing, burns, frost bite
Congenital: 3%
63
Risk Factors of an amputation
- Age 65 or older
- Diabetes
- Heart Disease
- Smoking
- Lack of exercise
- Poor nutrition
- Race: African Americans, Hispanics, Native Americans
64
Statistics about Amputations
1. 2 million people in the US in 1996
* More than half were the result of diabetes
* Primary reason: poor circulation
65
Circulation Assessment
Color/Temp
Cap refill
Pulses
Edema
66
Diagnostic Studies: Circulation
- Catheter is inserted into vein and contrast material is injected
- WBC count
* Arteriogran
* Venogram
67
Pre-op teaching for amputation
- discuss level of amputation
- discuss normal feelings of grief and loss
- Phantom limb sensations
- dressing process
- pain control
- rehabilitation goals
- discharge plans
68
Close Amputation
Used to create a weight bearing extremity. A skin flap with soft tissue covers the bony part of the limb
69
Disarticulation Amputation
Performed at the joint
70
Guillotine or open amputation
leaves the bony end open - not open permanently (for areas that are bleeding)
71
Post-op teaching for amputations: Purpose of Cast:
1. v edema
2, prevent hip and knee contractures (ROM)
3. Help shape the stump for prosthetics later on
72
Post-op teaching for amputations: Positioning
1. elevate 24-48 hours
2. keep flat after 24 hours
3. prone positioning- to prevent hip contractures
* *Bleeding is the #1 complication of amputation (bleeding should be outlined, date, time)
* Perfuse bleeding: vBP ^HR
73
Post-op teaching for amputations: Stump Care
```
Inspection: Discoloration, breaks
Wash with soapy water and dry
Stump Wrapping: Edema up to 4 months
Reapply up to 3x per day
No alcohol
No lotion
```
74
Compression Wraps
Used after profuse bleeding goes down ( to shape stump)
75
Stump Shrinker
- used in place of ACE wrap
- stump socket: casted
- weight change
- cleaning of socket/inspection
**IF wrap comes off, rewrap immediately...do best you can then call physical therapy
76
Phantom Limb Pain
- Knifelike
- Burning
- Squeezing
- 85%
- Dorsi and plantar flexing the foot
* Morphine sometimes doesn't stop phantom limb pain
* PT will have them do muscle relaxation
77
Amitriptyline
(Elavil) anti-depressant but off-use is for neuropathic pain
| *Kidney and liver functions should be watched
78
Gabapentin
Neurontin- prevention of seizures; off-use for neuropathic pain (slows down neuro impulses
* Sedative side effect
* Kidney and liver functions should be watched
79
Pregablin
Lyrica- prevention of seizures also- off use for neuropathic pain
* Sedative side effect
* Kidney and liver functions should be watched
80
Psychological Aspects of amputations
- fear
- denial
- bargaining
- death without funeral
- grief
- anger
- depression
81
How to help: Transition for amputations
- listen
- open communication
- realistic encouragement
- education at the appropriate level
- allow time to vent feelings
- support groups
- be aware of where you are and how you act
82
Prosthesis
- mold of residual limb is taken
- wear all fay to prevent swelling
- limb is covered with stocking
- learning to use is difficult
83
Chronic Low back pain causes
Last for >3 months
- degenerative joint disease
- lack of exercise
- prior injury
- obesity
- Structural and postural abnormalities
- systemic disease
84
Primary prevention for your back
- posture
- lifting
- body mechanics
- rest
- exercise
- weight
85
Herniated Disc
- Nucleated pulposus may rupture, causing acute pain and injury
- compression of the nerve roots and cord
- most common sites or rupture are L4-5 and L5-S1
86
Symptoms of a herniated disc
- low back pain
- radiating down the buttock and below the knee
- sciatic nerve pain
- weakness of the leg, foot, or toes
- Bowel and bladder incontinence
- Impotence
87
Straight Leg test
Back or leg pain may be reproduced by raising the leg and flexing the foot at 90 degrees
**Orders MRI either way
88
Diagnostic tests for Back pain
```
L-spine
MRI
CT
EMG- nerve irritation/neuropathy
Bone Scan
Myelogram: sub arachnoid LP- inject dye
```
89
Myelogram: sub arachnoid LP- nursing implications
Dye injection
- watch for shellfish or iodine allergies
- ask what allergic reaction was
- give Benadryl pre-op IV
- know BUN ad creatinine levels when giving dye
- consent
- large IV - 18 gage
90
Chronic low back pain primary treatment
- low back exercises
- rest
- local heat/cold application
- Pain relievers
- weight reduction
- surgery
91
Conservative treatment of chronic low back pain
-brace
-ultrasound
-massage
-traction
-e-sim/TENS
-physical therapy (weak core)-planks
Epidural injections-small amounts - lasts 2-3 mos
92
E-stim/TENS
Sends impulse to nerve roots that it won't respond anymore, reducing back pain
93
Drug therapy for low back pain
-Saclicylates
-Nonsteroidal antiinflammatory
-skeletal muscle relaxants
Corticosteroids
94
Laminectomy
Surgical removal of part of the posterior arch of the vertebrae to allow for removal of the disc (bones will rub)
95
Discectomy
Micro surgical procedure that allows the surgeon to visualize the disk and disk space better for easier removal of the herniated portion (try to remove only part of the disc)
96
Laser discectomy
Outpatient procedure
The laser is used on the herniated portion of the disc
-not any better than any other way if its a big herniation
-don't have to chip away at the bone
-pt goes home same day and not much post op pain
-ideal for small herniation
97
What is a Spinal Fusion
- used for unstable spinal areas by creating a contiguous vertebrae with a none graft
- fibula or iliac crest
- rods, plates, and screws
- infuse bone graft/cage (regeneration)
( got away from bone grafts and started using donor bones)
*6 mos for bone to solidify
98
Spinal fusion teaching
- TLSO with OOB
- Surgical and graft site if used
- avoid sitting or standing for long periods of time
- encourage walking, lying down, and shifting weight
- no twisting the spine
- T-shirt under brace
- no lifting grater than 10 pounds
99
Spinal plates, screws, and cage
Can't remove screws
100
Disc implant post op care
- vitals Q4
- signs of circulation
- signs of bleeding
- position
- pain--big issue
- emotional support
- safety
- sterile technique
* *signs of infection (very important to catch early)
- compression dressings
- paralytic ileus common,start PO intake slowly
101
Neurovascular assessment: Circulation
- color/temp
- cap refill
- pulses
- edema
102
Neurovascular assessment: motor function
- flexion
- extension
- abduction
- lower extremity strength
- urinary incontinence
103
Neurovascular function: sensation
- pain
- pallor
- parasthesia
- pulselessness
- paralysis
104
Post-op care for disc implant
- proper alignment at all times
- log rolling
- pain control
- Pillows under legs
- neuro checks q2-4
- paralytic ileus
- TCDB/IS q1 while awake
* no trapeze bar at bed
105
Baclofen
Treatment of reversible spasticity due to multiple sclerosis or spinal cord lesion
Unlabeled use: management of pain in trigeminal neuralgia
106
Nursing implications of baclofen
- Observe for drowsiness,dizziness, or ataxia
- May increase serum glucose, alkaline phosphatase, AST, & ALT
- Administer with milk or food to minimize gastric irritation
- Take missed doses within an hour
- Don't stop abruptly as pt will experience withdrawals (d/c over 2 weeks)
- Change positions slowly
- Notify HCP if frequent urge to urinate or painful irritation, constipation, nausea, headache, insomnia, depression, or confusion persists
107
Side effects of baclofen
- seizures (IT)
- dizziness
- drowsiness
- fatigue
- weakness
- nausea
108
Carisoprodol
Adjunct to rest and physical therapy in the treatment of muscle spasm associated with the acute painful musculoskeletal conditions
109
Side effects of carisoprodol
- dizziness
- drowsiness
- agitation
- hypotension
- anaphylactic shock
110
Nursing implications of carisoprodol
- assess for pain, muscle stiffness, and ROM before and periodically throughout therapy
- safety measures. Supervise ambulation and transfer of pts
- administer with food to minimize GI irritation. Give dose at bedtime
- notify HCP if signs of allergy
- missed doses taken within 1 hr
111
Methocarbamol
Adjunctive treatment of muscle spasm associated with acute painful musculoskeletal conditions (with rest and physical therapy)
112
Side effects of methocarbamol
- seizures (IV or IM only)
- dizziness
- drowsiness
- light headedness
- blurred vision
- anorexia
- GI upset
- nausea
- anaphylaxis (IV or IM)
113
Nursing implications for methocarbamol
- assess pt for muscle stiffness, pain, and ROM before and periodically throughout therapy
- monitor pulse and BP every 15 min during parental administration
- assess pt for allergic reactions after parental administration. Keep epinephrine and oxygen on hand in the event of a reaction
- monitor IV site (may cause thrombophlebitis)
- monitor renal function
- supervise ambulation and transfer of pt
- may be crushed and mixed with food or liquids to facilitate swallowing
Exam 3
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