Part 1: When a fracture becomes an emergency

NUR 433: Adult Health II; MCUSON; Mrs. Cooper

most fractures are not life-threatening except which 3

1. open fracture

2. fracture that causes major blood loss

3. fracture that causes damage to vital organs

an _____ fracture is defined when bone is exposed

open

cover an open fracture with a sterile, _____ dressing

moist

with an open fracture, do not push the _____ back in; _____ it instead

bone; splint

administer IV _____ asap for an open fracture and assess for tetanus

antibiotics

prepare patient to transfer to the OR for _____ with an open fracture

debridement

the _____ can hide up to 1.5 L of blood from a fracture that causes major blood loss

femur

with a fracture that causes major blood loss, the pelvis can _____

exsanguinate

***Exsanguinate means to drain an organism of its blood or to suffer massive, fatal blood loss from the circulatory system

with a fracture that causes major blood loss, external bleeding can occur. apply _____ pressure and then a _____ with the time noted

direct; tourniquet

a fracture to the ribs can cause damage to which vital organ

lungs

a fracture to the pelvis can cause damage to which 3 vital organs

• bladder

• urethra

• colon

***assess ABCDE (airway, breathing, circulation, disability, and exposure) before the deformed limb

for facial and jaw fractures, the _____ is the emergency

airway

one priority for facial and jaw fractures is to treat them as a _____ _____ injury until it is ruled out

cervical spine

for facial and jaw fractures, treat the airway first. list some ways to treat and maintain the airway

• suction

• HOB up

• watch for swelling and bleeding into the airway

for facial and jaw fractures, _____ _____ or _____ needs to be kept at the bedside at all times

wire cutters; scissors

if a patient with a facial or jaw fracture vomits or develops an obstruction, _____ the wires or bands and clear the airway

cut

apply a _____ _____ to decompress the stomach and administer _____ to a patient with a facial and jaw fracture

NG tube; antiemetics

for a patient with a facial and jaw fracture who also has an eye injury, make sure to shield the eye and never remove an _____ object

impaled

3% of adult fractures are _____ fractures which have a high mortality rate

pelvic

survivors of pelvic fractures may still die of _____, FES, or VTE

sepsis

a patient with a pelvic fracture will exhibit cues such as ___ falling, ___ rising, and cool and clammy skin

BP; HR

a patient with a pelvic fracture will exhibit cues such as pelvic, perineal, or flank _____

bruising

a patient with a pelvic fracture will exhibit cues such as leg-length discrepancy and an unstable _____

pelvis

a patient with a pelvic fracture will exhibit cues such as blood at the _____ ______ and hematuria

urinary meatus

a patient with a pelvic fracture will exhibit cues such as _____ _____ and later paralytic ileus

abdominal distension

move a patient with a pelvic fracture as _____ as possible

little

apply a _____ _____ per protocol for a patient with a pelvic fracture

pelvic binder

apply 2 _____-_____ IVs, type and crossmatch, and prepare for a massive transfusion readiness for a patient with a pelvic fracture

large-bore

assess _____ neurovascular checks and bowel and bladder for a patient with a pelvic fracture

distal

_____ _____ is used for damage control for the unstable limb

external fixation

external fixation is used for _____ fractures with heavy soft tissue damage

open

for an unstable pelvis, external fixation provides a _____ and stabilizes and slows bleeding

fram

a patient with external fixation is too unstable for definitive _____

surgery

for a patient with external fixation, assess _____ checks distal to the frame; compartment syndrome can still develop

neurovascular

for a patient with external fixation, assess pin sites for redness, drainage, odor, and loosening. these s/s indicate _____ (osteomyelitis risk)

infection

never lift or turn a patient with external fixation by the _____; do not adjust clamps

frame

administer _____ care per protocol (often with chlorhexidine)

pin

***compartment syndrome is like built up pressure in a closed box. as the box (tight cast or dressing, splint, excessive traction, premature fascial closure) gets smaller, the contents within it increase leading to bleeding, edema, inflammation, IV infiltration, and crush injury

***in compartment syndrome: edema —→ venous occlusion —→ more edema —→ arterial compromise —→ ischemia —→ muscle and nerve death

the highest risks for compartment syndrome include proximal tibia and distal humerus _____, _____ injury, and post-op knee and leg

fractures, crush

_____ can begin within 4-8 h of compartment syndrome and onset can be immediate or days later

ischemia

***when performing a neurovascular check on a patient with compartment syndrome, compare results with the other side, cap refill < 3 s, hourly x 24 h, then per protocol

list the 3 early P’s of compartment syndrome

• pain

• paresthesia

• pressure

pain out of proportion not relieved by _____

opioids

pain on _____ stretch of the muscle

passive

what is paresthesia

numbness, tingling

pressure is tense and firm; compartment pressure > ___ mm Hg

30

act on the _____ P’s for compartment syndrome by calling the provider now

early

list the 3 late P’s for compartment syndrome

• pallor

• paralysis

• pulselessness

what is pallor

coolness

what is the loss of function called

paralysis

the 3 late P’s for compartment syndrome damage may be _____

permanent

nursing action for compartment syndrome: keep limb at _____ level

heart

nursing action for compartment syndrome: no _____

ice

nursing action for compartment syndrome: _____ dressing or bivalve cast per order

loosen

nursing action for compartment syndrome: _____ traction weight

reduce

nursing action for compartment syndrome: prepare for _____

fasciotomy

_____: from crushed muscle to kidney injury

rhabdomyolysis

rhabdomyolysis

1. _____ or _____ muscle

crush; ischemic

rhabdomyolysis:

2. _____ break down

cells

rhabdomyolysis

3. _____ + potassium (K) + creatinine kinase (CK) are released

myoglobin

rhabdomyolysis

4. myoglobin clogs _____ tubules

renal

rhabdomyolysis

5. acute tubular necrosis (ATN) —→ _____ _____ _____

acute kidney injury (AKI)

rhabdomyolysis cues: dark tea or cola-colored _____

urine

rhabdomyolysis cues: _____ urine output, _____ creatinine

falling; rising

rhabdomyolysis cues: very high _____ _____

creatinine kinase (CK)

rhabdomyolysis cues: _____ = peaked T waves and dysrhythmias

hyperkalemia

rhabdomyolysis actions: aggressive _____ _____ to the ordered urine-output goal

IV fluids

rhabdomyolysis actions: strict I&O and _____ urine output

hourly

rhabdomyolysis actions: continuous _____ _____ and _____ checks

cardiac monitoring; potassium

***rhabdomyolysis actions: link to your acute kidney injury (AKI) content: same acute tubular necrosis pathway

list some respiratory s/s of fat embolism syndrome (FES)

• tachypnea

• dyspnea

• hypoxemia (PaO2 < 60)

• chest pain

• ARDS picture

list some neurologic s/s of fat embolisms syndrome (FES)

• restlessness

• confusion

• apprehension

what is often the first cue of fat embolism syndrome (FES)

apprehension

what s/s of fat embolism syndrome appears on the neck, chest, axillae, and conjunctiva and is often absent or fleeting

petechiae

patients with femur, pelvis, tibia, ribs; joint replacement; and crush injury are at risk for _____ _____ _____

fat embolism syndrome (FES)

action for fat embolism syndrome (FES): _____-_____ O2, sit upright, call rapid response

high-flow

action for fat embolism syndrome (FES): prepare for _____ or ECMO if PaO2 can’t be kept up

intubation

action for fat embolism syndrome (FES): _____ care only: no proven role for steroids, heparin, or dextran

supportive

prevention for fat embolism syndrome (FES): _____ early; move the patient as little as possible before stabilization

immobilize