N3: Unit 6: Module 4: Part 1: Care of the Patient with Musculoskeletal Trauma fully solved questions with 100% accurate solutions(Latest Update)

Fractures

A break or disruption in the continuity of the bone

-affects mobility (acute or long term)

-causes discomfort

-can occur anywhere in the body at any age (more likely to occur as we age as the skeletal system and bone structure starts to weaken)

-All of them require patient-centered, inter-professional collaborative care

-Many different kinds/classifications

Complete fracture

the breaks goes through the entire bone

Incomplete fracture

bone is not broken all the way through

displaced fracture

the two main bone fragments are out of alignment

non displaced fracture

the separate fragments are in touch/aligned

comminuted fracture

fracture in which the bone is splintered or crushed

-multiple fragments

-just 2 is not, that is clean break

impacted fracture

fracture in which one bone fragment is pushed into another

greenstick fracture

a fracture with an incomplete break, the bone bends, seen more in kids with more pliable bones

open/compound fracture

broken bone penetrates through the skin

major consideration to the complexity and healing process/risk to the patient

big infection risk

closed/simple fracture

break that does not penetrate the skin

pathologic/spontaneous fracture

occurs when a weakened bone breaks under normal strain

may indicate an underlying condition ex: osteoporosis, malignancies

mechanism of injury

description of damage sustained by bone

-what it looks like

ex: stress (ppl who run), compression (of the vertebrae)

does the description of the injury occurrence match with the actual injury?

oblique fracture

occurs at an angle through the bone

spiral fracture

a fracture in which the bone has been twisted apart

usually occurs when force is exerted on a bone while one end is stationary and the other end twists

sometimes associated with physical abuse, especially young children and elderly

comminuted ulna and radial fractures

the muscles of the arm may simply pull the bone fragments up and away and create more of a gap

avulsion

a fracture in which a fragment of bone has been pulled away by a tendon and it's attachment

compression fracture

occurs when the bone is pressed together (compressed) on itself

seen in vertebral fractures, very common in osteoporosis (getting shorter)

signs and symptoms of a fracture

Often an obvious acute deformity, but not always (ex compression fracture)

Pain (has to be treated adequately to recover)

Loss of function

Shortening of the extremity (often seen in long bones or the hip)

Local swelling and discoloration (expect the swelling to be present for a while, want to try to minimize)

Diagnosis by symptoms, clinical exam, and x-ray (most often), or CT scan (more complex or questioning health of the bone), MRI (looking at surrounding tissues to gauge blood supply)

emergency management

ABC's

-patient's may have other life-threatening problems, especially with major trauma

immobilize the area of injury

-joints distal and proximal to the suspected fracture site must be supported

-don't want to make the situation worse

emergency management of open fractures

often happens pre-hospital

cover with a sterile dressing (if possible) to prevent contamination and minimize the dirt and pathogens that could get into the body

control bleeding if necessary

assess neurovascular status (ongoing intervention, does it seem like the blood supply or nerve supply was injured by the fracture)

remove potential constrictions (clothing is cut away)

secondary survey (what else is going on with the patient; ex: landed so hard they broke their femur but also ruptured their spleen)

shock

acute complication of fractures

r/o other injuries, hemorrhage, damage to arteries from the fracture

-ex: rupture of femoral artery from fracture

immediate assessment: is the person at risk for going into _______ or having some other problem because of the fracture

neurovascular assessment

continual

assessing distal to the injury

-skin color

-skin temperature

-movement distal to the injury

-sensation

-pulses

-capillary refill

-compare extremities

CSM (color/circulation, sensation, movement)

5 P's: pain, pulse, pallor, paresthesia, paralysis

expect edema (some long term)

-shouldn't be increasing in amount

patient assessment/plan

Patient history:

-other problems or conditions that will affect healing?

-other problems or conditions that need to be addressed?

-is the patient's report consistent with the injury? ex: frail elder in wheelchair that did not sustain a fall, does it make sense that they would have a spiral fracture of the arm?

Pain control is crucial

Treatment plan depends on injury and patient condition

-age is a big factor: children and young adults should recover at a slightly faster rate than older adults will

Medical management of fractures

Reduction

-closed

-open

Immobilization

-internal

-external fixation

-May require a surgical procedure to get the bone back in place and they have fixation (various devices, often screws or shafts that are put in place to maintain the bone in alignment so it can heal)

-some fixation devices are temporary, some permanent

Open/compound fractures require treatment to prevent infection

-bone is pierced through the skin

-Tetanus prophylaxis (check status)

-Antibiotics (prophylaxis due to high infection risk)

-Clean of the wound depending on damage

-Closure of the primary wound may be delayed to permit edema, wound drainage, and debridement prn

infection

-high risk with open/compound fractures (osteomyelitis)

-fixation devices (external, screws and rods going through the skin, usually protocol in place where they may be cleaned everyday an abx ointment applied, nursing responsibility to check for sx of infection)

reduction

the term used to make sure the bones are in place/alignment/to get them back into place

closed reduction

done with the patient's limb numbed and orthopedist manipulates the bones to get them back into place

open reduction

requires surgical intervention through the skin to get the bone back into place

internal immobilization

placed in surgery and the skin is closed over

external immobilization

the usage of devices that go right through the skin to immobilize

Venous thromboembolism

complication of fractures

immobility increases risk

look for other risk factors - ex patient takes OC

early mobility is key to prevention

-if they cannot be mobile they may need anticoagulant for prophylaxis

pain

complication of fractures

Opioids often needed

NSAID, acetaminophen, either alone or in combination

-If taking combo agent ex Vicodin (acetaminophen and oxycodone), should be watching if they take any additional acetaminophen, do not want to overdose

Complementary therapies

-guided imagery, relaxation

Effective treatment may prevent development of chronic concern

elevating extremity, ice (even with cast)

Fat embolism

Globules of fat from bone marrow enter the blood stream

usually within 12-48 hours of injury

happens when there is a disruption usually to the long bones of the legs

Fat embolism syndrome

The globules clog vital organs, usually the lung

rare but life threatening

happens the most in young men up until age 40

first see hypoxemia, dyspnea, tachycardia, respiratory distress

red-brown petechial rash in non-dependent areas of the body late development

leads to pulmonary edema, respiratory failure, death

ICU treatment - no specific treatment other than supportive measures

compartment syndrome

increased pressure within sections of the extremities or abdomen, drastically reducing circulation to that area, causes edema which increases ischemia, tissue is at risk of necrosis. Anything that causes swelling can cause this.

Body parts are segmented into areas; muscle and blood supply are contained within fascia, so if there is a trauma/break and you have swelling into the tissue within these compartment, its a closed area and can cause necrosis

see: pain, paresthesia, pallor, pulses weaken, tightly swollen extremity; may/may not develop paralysis if nerve damage

compartment syndrome surgical treatment

Fasciotomy

-cut through the fascia to relieve pressure

-meters can be placed to record the pressure within a compartment

long recovery, may need skin grafts

Crush injuries

Injury in which crushed/pinned against something

ex: a car accident

release of myoglobin from the muscle places the patient at high risk for developing rhabdomyolysis (destruction of muscle cells) and acute kidney injury

other complications include:

-hyperkalemia

-hypovolemia

Avascular necrosis

Death of bone tissue because of a disruption in blood supply to the bone

femoral head of the hip is most common place

this can cause a fracture or be caused by a fracture or trauma to the bone (Acutely)

can also happen overtime

-ex: with a malignancy, chronic alcoholism, long term steroid use

-often have chronic pain in that area

delayed bone healing

takes longer than expected for a bone to heal

can be causes by malunion or nonunion

malunion: the bones are healing, but they were not completely line up/don't stay lined up

-may or may not require surgical intervention

nonunion: the reduction has not been successful and the bone segments are not in contact with each other

complications of fractures

impaired physical mobility

peripheral neurovascular dysfunction

chronic pain

-complex regional pain syndrome

complex regional pain syndrome

usually occurs in an area of the body where there has been some injury and people have a heightened pain after that, some nerve involvement, not well understood

the area can have color changes, diaphoresis, etc.

not a lot of good treatment for it

nursing considerations

What medical-surgical treatment should the nurse expect to occur?

-based on injury

What complications could this fracture cause and teaching

How does this fracture affect mobility? (in healing process and long term)

How does this fracture affect patient safety? (are they safe to go home)

Frequent assessment of neurovascular status

Antibiotics as needed

DVT prophylaxis, especially in acute care setting

continued pain assessment and management

Goal is for patient to achieve optimal level of functioning

What other patient concerns and issues will affect healing?

-may need referral to SW, job concerns, childcare, etc.

what impact does this have on the patient's functioning and wellbeing? ex: older pts and independence/safety

Ensure appropriate discharge teaching

Discharge considerations

Continuing care

-orthopedic follow up

-often PT or OT (OT for below the shoulder, elbow and hand)

Is referral to home services needed?

Does the patient need acute rehab?

Social work needs?

VNA/PT safety assessment