Chapter 63 Nursing Management Musculoskeletal Trauma and Orthopedic Surgery Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Soft Tissue Injuries

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sprains and Strains  Sprains and strains  Sprain - injury to tendinoligamentous structures surroundin the joint  Strain - excessive stretching of a muscle and its fascial sheath  Nursing implementation Health promotion Health promotion

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sprains and Strains  Sprains and strains  Nursing implementation Acute intervention Acute intervention RICE RICE

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dislocation and Subluxation  Dislocation  Severe injury of the ligamentous structures hat surround the joint; results in complete displacement of articular surfaces of the joint  Subluxation  Refers to partial or incomplete displacement

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dislocation and Subluxation  Clinical Manifestations  Deformity, pain, loss of function  Collaborative management  Orthopedic emergency - require reduction Risk of avascular necrosis Risk of avascular necrosis  Pain management  Protection of injured join  Rehabilitation once reduced

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 63-1

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Bursitis  Inflammation of the bursae  Clinical manifestations  Management

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fractures  A disruption or break in the continuity of the structure of the bone  Classifications  Type (see fig 63-6)  Communication or noncommunication with the external environment: Open vs Closed  Anatomic location of the involved bone

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 63-6

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 63-7

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 63-8

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fractures  Clinical Manifestations  History - mechanism of injury  Pain  Decreased function  Inability to bear weight  Deformity  Ecchymosis  Edema  Crepitation

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Factors Affecting Fracture Healing  Age  Initial displacement  Blood supply to the area  Immobilization  Infection  hormones

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fractures (cont'd)  Collaborative care  Fracture reduction Closed reduction - nonsurgical Closed reduction - nonsurgical Open reduction - surgical Open reduction - surgical Traction Traction  Skin traction  Skeletal traction

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fractures (cont'd)  Collaborative care (cont'd)  Fracture immobilization Casts Casts  Types of casts  Injuries to the lower extremity External fixation External fixation Internal fixation Internal fixation

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fractures (cont'd)  Collaborative care (cont'd)  Drug therapy Pain mgmt Pain mgmt Muscle relaxants Muscle relaxants Tetanus booster Tetanus booster  Nutritional therapy Protein Protein Vitamins (B C D) Vitamins (B C D) Calcium Calcium Adequate fluid intake Adequate fluid intake

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Fractures  Nursing assessment  Neurovascular assessment  Nursing diagnoses  Impaired physical mobility  Risk for infection  Risk for peripheral neurovascular dysfunction  Acute Pain

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Fractures  Planning  Have physiologic healing with no associated complications  Obtain satisfactory pain relief  Achieve maximum rehabilitation potential

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Fractures (cont'd)  Nursing implementation (cont'd)  Acute intervention Preoperative management Preoperative management  Immobilization  Assistive devices that will be used  Expected activity limitations after surgery  Assure patients their needs will be met  Assure patients pain medication will be available

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Fractures (cont'd)  Nursing implementation (cont'd)  Acute Intervention Postoperative management Postoperative management Monitor vitalsMonitor vitals Frequent neurovascular assessments of affected extremityFrequent neurovascular assessments of affected extremity Minimize pain and discomfort through proper alignment and positioningMinimize pain and discomfort through proper alignment and positioning

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Fractures (cont'd)  Nursing implementation (cont'd)  Acute Intervention Postoperative management Postoperative management Monitor limitations in movementMonitor limitations in movement Carefully observe dressings or casts for bleeding or drainageCarefully observe dressings or casts for bleeding or drainage Significant ↑ in size of drainage area should be reportedSignificant ↑ in size of drainage area should be reported Measure and assess patency of system and volume of drainageMeasure and assess patency of system and volume of drainage

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Fractures (cont'd)  Nursing Implementatjon  Other measures Prevention of constipation Prevention of constipation DVT prophylaxis DVT prophylaxis Movement as able to prevent cardiopulmonary deconditioning Movement as able to prevent cardiopulmonary deconditioning

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Fractures (cont'd)  Nursing Implementatjon  Traction Pin care Pin care Monitor skin for breakdowin Monitor skin for breakdowin Correct alignment Correct alignment

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Fractures (cont'd)  Nursing implementation (cont'd)  Ambulatory and home care Cast care Cast care Psychosocial problems Psychosocial problems Ambulation Ambulation Assistive devices Assistive devices

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Fractures  Infection  High risk with open fractures  May require debridement, antibiotics  Risk of osteomyelitis

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Fractures  Compartment syndrome  A condition in which elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that space  Manifestations 6 Ps 6 Ps PainPallor PainPallor ParesthesiaParalysis ParesthesiaParalysis PressurePulselessness PressurePulselessness

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Fractures  Compartment syndrome  Prompt recognition  NO ice, elevation  Remove constricting dressings  Surgical decompression

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Fractures (cont'd)  Fat embolism syndrome  Highest risk with long bone fractures  Characterized by the presence of systemic fat globules from fractures that are distributed into the tissues and organs after a traumatic skeletal injury  Manifestations - often rapid onset Often respiratory distress Often respiratory distress Neurologic changes Neurologic changes Fever Fever Petechiae Petechiae

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Fractures (cont'd)  Fat embolism syndrome  Prevention  Early identification  Supportive care

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Fractures

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Colles’ Fracture

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fracture of the Humerus

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fracture of the Pelvis

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fracture of the Hip  Refers to a fracture of the proximal third of the femur  Manifestations  Pain  Edema  External rotation  Shortening of the affected extremity  Surgical management is the preferred treatment

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Hip Fracture  Nursing implementation  Preoperative management Pain management - may include analgesics and Buck’s traction Pain management - may include analgesics and Buck’s traction Preoperative teaching Preoperative teaching Consideration of comorbid conditions Consideration of comorbid conditions Frequent repositioning to prevent immobility complications Frequent repositioning to prevent immobility complications

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Hip Fracture  Nursing implementation  Postoperative management Monitor VS/, I/O Monitor VS/, I/O CMS assessment CMS assessment Prevention of respiratory complication Prevention of respiratory complication Prevention of DVT Prevention of DVT Pain management Pain management Proper alignment Proper alignment

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Hip Fracture  Nursing implementation  Postoperative management Mobility Mobility Monitor for complication Monitor for complication Hip prosthesis management Hip prosthesis management  Table 63-11

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gerontologic Considerations Hip Fracture

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Femoral Shaft Fracture

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Stable Vertebral Fractures