Ortho

Question 0

Fractures

Complications

Answer 0

a. Shock: (Hypovolemic)
b. Fat embolism:
• With what type of fractures do you see this? Long bones, pelvic, crushing
• Symptoms depend on location
Petechia or rash over chest
Conjunctival hemorrhages
Snow storm on CXR patchy infiltrates
Young males are risk takers
First 36 hours
c. Compartmentsyndrome:
d. Healing Concerns:
1) Delayed union:
• Healing doesn’t occur at a normal rate.
2) Non-union:
• Failure of bone ends to unite; may require bone grafting
3) Mal-union: deformity at the fracture site.
• S/S: persistent discomfort with movement

Question 1

Fractures

S/S, tx

Answer 1

1. S/S:
   a. pain and tenderness
   b. Unnatural movement
   c. Deformity(possible)
   d. Shortening of extremity
   • Caused by muscle spasm
   e. Crepitus (bones grating together)
   f. Swelling
   g. Discoloration
   h. Compartment syndrome
2. Tx:
   a. Immobilize the bone ends plus the adjacent joints.
   b. Support fracture above and below site.
   c. Move extremity as little as possible.
   d. Splints help prevent fat emboli and muscle spasm.
   e. Open fractures: cover them
   f. Most important thing neurovascular checks
   g. Neurovascular checks: pulses, color, movement, sensation, capillary refill, temp

Question 2

Compartment syndrome

Answer 2

• Increased pressure within a limited space.
1) Pathophysiology:
• fluid accumulates in the tissue and impairs tissue perfusion. The muscle becomes swollen and hard and the client complains of
severe pain that is not relieved with pain meds.
• Pain unpredictable
pain is disproportionate to the injury.
If undetected may result in nerve damage and possible amputation.
*usually in forearms and quads
Tx:
Preventive measures
• Elevate extremity.
• Soft cast then rigid cast.
• Loosen the cast to restore circulation.
• Be careful in picking the answer “remove cast”.
• Fasciotomy
• Cast cutters to remove cast
Instruct them the cast saw does not touch skin but it does vibrate. (So be a nice nurse☺and warn them)

Question 3

Cast care

Answer 3

a. Ice packs on the side for first 24 hours because cast is still wet.
b. No indentations
c. Use palms for 1st 24 hours–casting material is wet
d. Keep uncovered and allow for air drying.
e. Do not rest cast on a hard surface or sharp edge.
• Rest on soft pillow, no plastic.
f. Mark breakthrough bleeding. Circle area, date and time site.
g. Cover cast close to groin with plastic (once the cast is dry).
h. Neurovascular checks with the 5 Ps.
i. What do you do if your client complains of pain? Neuro vascular checks
• Most pain is relieved by elevation, cold packs and analgesics. (If these things
do not relieve the pain… think complication).

Question 4

Traction info

Answer 4

a. Miscellaneous Information:
• Decreases muscle spasms, reduces, immobilizes
• Should be continuous
• Weights should hang freely.
• Keep client pulled up in bed and centered with good alignment.
• Exercise non-immobilized joints.
• Ropes should move freely and knots should be secure
• Special air filled or foam mattress

Question 5

Skin traction

Answer 5

• Used short term to relieve muscle spasms and immobilize until surgery.
• This is when tape or some type of material is stuck to the skin and the weights pull against it.
• Is the skin penetrated? No
• Type: Buck’s (used most often with hip and femoral fractures)
• Must do good skin assessments. Watch for tears

Question 6

Skeletal traction

Answer 6

• This traction is applied directly to the bone with pins and wires.
• Used when prolonged traction is needed.
• Types: Steinman pins, Crutchfield, Gardner-Wells tongs, Halo vest
• Must monitor the pin sites and do pin care. Sterile technique. Remove crusts.
Is serous drainage okay? Yes. It’s clear

Question 7

Total hip replacement

Answer 7

1. Prep Op Care:
   • Buck’s traction is used frequently pre-op.
2. Post Op Care:
   a. Nursing Considerations:
   • Neurovascular checks
   • Monitor drains (Don’t want fluid to accumulate in the tissues).
   • Firm mattress (joints need support)
   • Over-bed trapeze to build upper body strength
   • Positioning:
   neutral rotation-toes to the ceiling Limit flexion; want extension of hip and Abduction
   • What exercise can the client do while still confined to bed? Isometrics
   • What is the purpose of the trochanter roll? Prevent external rotation
   Document in nurse’s notes.
   • No weight-bearing until ordered by physician.
   • Avoid crossing legs, bending over.
   • Is it okay to sleep on the operated side? No
   • Is hydrating important with this client? Yes
   • Stresses to new hip joint should be minimal in the first 3-6 months.
   • Is it okay to give pain meds in the operative hip? No
   b. Complications:
   1) Dislocation→ circulatory/nerve damage
   • S/S: shortening of leg, abnormal rotation, can’t move extremity, pain
   2) Infection:
   • Prophylactic antibiotics (just like with a heart valve replacement)
   • Remove Foley and drains as soon as possible.
   These will serve as a portal for infection
   3) Avascular Necrosis: (death of tissue due to poor circulation)
   4) Immobility problems
   c. ClientEducation/Rehabilitation:
   • Best exercise? Walking, swimming
   Avoid flexion→ low chairs, traveling long distances, sitting more than 30
   minutes, lifting heavy objects, excessive bending or twisting, stair climbing

Question 8

Total knee replacement

Answer 8

1. CPM: (Continuous Passive Motion)
2. Keeps knee in motion and prevents formation of scar tissue.
3. PT will set machine to gradually increase flexion and extension of knee.
4. Never hyperextend or hyperflex knee.
5. Neurovascular checks.
6. Pain relief.

Question 9

Amputations

Answer 9

1. Miscellaneous Information:
   • Amputations are performed at the most distal point that will heal.
   • The physician tries to preserve the knee and elbow.
2. Immediate Post Op Care:
   a. Keep what at the bedside? Tourniquet
   b. Elevation post op is controversial, because of hip contractures, only elevate for a short time to reduce swelling.
   c. Do not elevate on pillow, elevate foot of bed.
   d. Prevent hip/knee contractures. How? Extension, lie prone
   e. Inspect the residual limb daily to be sure that it lies completely flat on the bed.
   f. Phantom pain
   • What is the first intervention to decrease phantom pain?
   Diversional activity
   • Seen more with AKA’s
   • Usually subsides in 3 months
3. Rehabilitation:
   a. Why is limb shaping important? For prosthesis
   b. How do you want the stump shaped at the end? Cone shaped
   c. What is worn under the prosthesis? Limb sock
   d. Why is it important to strengthen the upper body? Crutches/walker
   e. Is it okay to massage the stump? yes, promotes circulation and decreases tenderness
   f. How do you teach a client to toughen the stump?
   Press into a soft pillow
   Then a firm pillow
   Then the bed
   Then a chair