Med Surg 2 Chapter 67 MS and Trauma Exam 4

Age related changes in structure and function:

◦Decrease in muscle mass and muscle strength occurs gradually

◦Elasticity of ligaments, tendons, and cartilage decreases

◦Bone mass decreases

◦Intervertebral disks lose water

◦Posture and gait change

◦Weaker Bones

◦Balance issues

Older gets smaller, can loose 1 and a half to 3 inches.

Always at risk for falls now because of impaired mobility.

Preventive teaching for high-risk persons for falls

•Those with gait instability, vision impairment

•Age-appropriate exercise to help maintain muscle strength and balance

•Adequate calcium and vitamin D for bone health

•Assess living environment for safety risks

•Want to do whatever we can to exercise and keep moving.

•Calcium cannot be absorbed without vitamin D.

•Need to look in their home for things that could cause a fall.

Sprain

injury to ligaments around a joint

◦Classified according to degree of ligament damage

Ligament connects a bone to bone. Sprain injury to ligament.

Ligament connects a

bone to a bone

Strain

excessive stretching of muscle and fascia; may involve tendon

Tendon connected muscle to bone.

Know there is a lot of nerve endings here so can be very painful.

Tendon connects

muscle to bone

Sprains and Strains

•Manifestations similar for both strains and sprains

-Pain, edema, decreased function, and bruising

•Diagnosis: Xray

•Complications

•Treatment

-Self-limiting

-Surgical repair

Nursing management for sprains and strains prevention

•Warm up exercises and stretching

•Strength, balance, and endurance exercises

•Start slowly

Acute care of sprains and strains

•RICE: rest, ice, compression, and elevation

•Rest: Stop activity and limit movement

•Ice (cryotherapy): 24 to 48 hours; 20 minutes at a time

•Compression: elastic bandage; apply distal to proximal

•Elevate: above the heart

•Analgesia

A strain is usually from some type of

repetitive injury, we can treat these by changing the activity. Like pitching and straining arm, have to change by stop doing. Can use compression sleeve.

For a sprain we will

elevate it to decrease swelling. First 24-48 hours is ice, try to keep immobile. Sprain is ligament that connects muscle to bone. If we immobilize we can allow it to rest.

A patient has a severely sprained ankle from a sports injury. What should the nurse teach the patient prior to discharge from the urgent care center?

Apply cold for 20 to 30 minutes with breaks of 10 to 15 minutes during the 1st 2 days.

Teach never put ice directly on the skin, and teach take breaks to avoid injury to skin.

Dislocation

complete displacement or separation of the articular surfaces of the joint.

Related to a joint

Subluxation

partial or incomplete displacement of the joint surface; symptoms less severe

Symptoms of dislocation and subluxation

◦deformity, pain, tenderness, loss of function, swelling

◦Complications—intraarticular fractures and avascular necrosis

◦Diagnosis—x-ray and/or aspiration

Nursing care for dislocation:

•Dislocation is an orthopedic emergency

•Risk of vascular injury or avascular necrosis

•Compartment syndrome

•Management goal

•Realign dislocation to original position

•Closed reduction with anesthesia

•Open reduction

•Followed by immobilization

•Pain management

•Joint protection

•Gentle ROM

•Rehabilitation

•Prevent repeated dislocation

When we get a dislocated joint back in or like a hip surgery, never want them bending more

than 90 degrees because will pop it right back out.

Repetitive Strain Injury (RSI)

◦Injuries from prolonged force or repetitive movements and awkward postures

◦Manifestations

RSI manifestations and treatment

◦Inflammation, swelling, and pain in muscles, tendons, and nerves of the neck, spine, shoulder, forearm, and hand

◦pain, weakness, numbness, or impaired motor function

◦Prevention: education and ergonomics

◦Treatment: Identify precipitating activity

◦Modify equipment or activity

◦Pain management

◦Rest

◦Physical therapy

Like an athlete or key board typer doing something over and over.

Need to take a break from activity or find something different, its inflammation in that area so it needs rest.

Carpal Tunnel Syndrome:

 Caused by compression of the median nerve

 Associated with activities that require continuous wrist movement

 Compression often caused by trauma, edema, cancer, rheumatoid arthritis, or soft tissue masses; hormones

 Increased incidence with diabetes, PVD, RA, and women

Fallon test, hands together cant do long if have it.

Manifestations and Prevention of Carpal Tunnel Syndrome

◦Impaired sensation, pain, numbness, or weakness; clumsiness

◦Late stages

◦Atrophy, recurrent pain, and dysfunction of hand

 Prevention

◦Identify risk factors

◦Adaptive devices

◦Ergonomic changes

Acute care for carpal tunnel syndrome

 relieve compression

◦ Rest/splints

◦PT

◦Corticosteroid injection

◦Change in occupation

◦Surgery  - Open or endoscopic à TEACH INCISION CARE, CSM ASSESSMENT, FULL RECOVERY MAY TAKE MONTHSS

For musculoskeletal issue we usually start with therapy like rest and maybe PT, but it may get to a point where we need to further intervene.

Need to assess the area distal to where you are doing surgery, so like on an elbow you need to check fingers so like color and warmth, sensation that they can feel, cap refill.

Anterior Cruciate Ligament (ACL) Injury

 Knee injuries account for >50% all sports injuries

 Most common knee injury in sports

◦Athlete pivots, lands from jump or stops abruptly; come down on knee, twist, hear a pop followed by acute pain and swelling

◦Partial tear, complete tear, or avulsion

 Diagnosis

◦MRI

Will hear a pop and that indicates there was some type of tear. They will need an MRI because it will allow use to see the soft tissue structures.

ACL nursing care

 Prevention programs to reduce injury

 Conservative treatment

◦Rest, ice, NSAIDs, elevation

◦Ambulation as tolerated with crutches

◦Aspiration of effusion

◦Immobilizer or hinged knee brace

◦PT

◦Surgical treatment

◦Reconstructive

◦Rehabilitation with PT

Try to treat conservatively first. We want surgery as our last option.

Bursitis

 Inflammation of the bursae from repeated or excessive trauma, friction, gout, RA, or infection

◦Hands, elbows, shoulders, knees, and hips

 Symptoms

◦Warmth, pain, swelling, limited ROM

 Treatment

◦Identify and correct cause; rest with immobilization; ice and NSAIDs

◦Surgery: bursectomy

Bursa is small fluid filled sac that cushions joint, itiis meaning inflammation.

The fluid filled sac becomes inflamed, can see this with gout, RA, infection, also can be from excessive use or trauma.

Will complain that joint feels warm, tender, might be swelling, wont be able to move joint as well.

Need to first figure out cause because treatment can be different depending on cause.

Start conservatively first for treatment, can remove problematic tissue as last resort.

Fractures

 Disruption or break in continuity of structure of bone

 Majority of fractures from traumatic injuries

 Some fractures secondary to disease process (pathologic)

Cancer or osteoporosis

Break in a bone.

Might feel crepitus, patient might guard

Greenstick fractures happen to

Kids, their bones are new

Bone healing process:

First there is bleeding and a hematoma forms, then after that we get a fibrous structure around the bone, then get collagen strands that further strengthen where the bone is. The clear out as new bone starts to form, then all nice and healed which is called remodeling.

What factors affect bone healing:

Nutrition, age, infection, poorly controlled blood sugar, smoking, displaced or non displaced, if blood supply to bone or surrounding tissue is compromised it will all take longer to heal.

Fracture types:

 Fractures common problems for older adults; often result in loss of functional ability

◦

◦Trauma to bone or joint

◦Result of pathologic processes

◦Pain and swelling, deformity,

bleeding, loss of function

Pelvic fracture

 Minor to life-threatening

◦Depends on mechanism of injury, vascular damage

◦3% of adult fractures

 High mortality rate

◦May have intraabdominal injury, compartment syndrome, paralytic ileus, sepsis, FES [Fat Embolism Syndrome], or VTE

 Symptoms

◦Abdominal swelling, tenderness, deformity, unusual pelvic movement, and bruising

◦Also check lower extremities

•These bones could break and stab one of our organs. If it did it to our bladder we could see blood in organ, internal bleeding can be caused which causes hypovolemic shock, causing low blood pressure and high heart rate.

•Want to check lower extremities for something like this for circulation because there could be less blood flow down to legs and not being perfused.

Hip fracture:

 Hip fracture

◦Most disabling type of fracture for older adults

◦Frequency is increasing

◦95% result from a fall

◦Significant number of OAs with hip fractures die within 1 year after injury

 Women

◦Suffer 75% of all hip fx

◦Over age 65 due to osteoporosis

Older adults usually will die from even something like this, causes huge risk for blood clots, pressure sores, and pneumonia. Usually more common for women to break. Pain will be behind their knee or in groin usually for hip frac.

Stable vertebral fracture:

 Most often lumbar but can be cervical or thoracic

 Causes: MVA, falls, diving, or sports injuries

◦Compression fractures occur with osteoporosis

◦All spinal fractures considered unstable and with potential complications of displacement and spinal cord damage until diagnostic tests show the fracture is stable

LOG ROLL AS ONE UNIT

Usually caused by someone falling on their bottom or something falls on head and compresses vertebrae.

Any spinal fracture is considered unstable especially if in cervical spine because the nerve that tells our lungs to breathe is right there and can cause someone to not breathe.

When we have an injury to the spine where there might be a fracture we can see bowel and bladder changes. Neurogenic bladder and bowel can come from this so they loose ability to control when they go. If someone from that injury cant use the bathroom, doctor needs to know.

Cement thing provides immediate pain relief.

Traction:

•Pulling force to attain realignment;  countertraction pulls in opposite direction

•Two most common types of traction

-Skin traction

-Skeletal traction

Insert pin or wire into bone, attach some kind of system to a wire and weight pulls it to keep extremity in alignment.

The weights attached need to hang freely so they can pull, never sitting on something or cant work.

Skin traction

◦Short-term (48 to 72 hours)

◦Tape, boots, or splints applied directly to skin to reduce muscle spasms

◦For example, Buck’s traction for or femur fracture

◦Traction weights 5 to 10 pounds

◦Skin assessment and prevention of breakdown imperative

Halo traction:

Need to do pin site care every shift on these patients, a solution we use to clean around them.

Fracture immobilization:

 Casts

◦Temporary after closed reduction

◦Allows patient to perform many normal ADLs while maintaining immobilization

◦Incorporates joints above and below fracture for stabilization during healing

◦Two most common materials

◦Plaster of Paris

◦Fiberglass

If we have an injury we always need to assess distal, if cast on leg need to assess lower extremities to make sure have sensation and perfusion.

Drug therapy for fractures:

Central and peripheral muscle relaxants

-Carisoprodol (Soma)

-Cyclobenzaprine (Flexeril)

• Muscle spasms can cause bones to keep pulling out of place so we will sometimes give muscle relaxers for this.Methocarbamol (Robaxin)

Tetanus and diphtheria toxoid: Given for open fracture when immunization is unknown

Bone-penetrating antibiotics: •Cephalosporins – prophylactically preop

Cephalosporins if we think surgery

Antibiotics as well if we think maybe an infection.

Want to optimize soft tissue and bone healing, 1g per kg body weight for protein. Draw labs to make sure vitamin B C and D are in line. Make sure they stay hydrated.

When someone has a fracture how much protien do they need?

1g per kg body weight per day

Neurovascular assessment:

•Peripheral vascular CSM:

-Color and temperature

-Capillary refill

-Pulses (rate, quality; compare bilaterally)

-Edema

•Peripheral neurologic:

-Sensory function

-Paresthesia or paralysis

-Motor function

-Upper extremities

-Lower extremities

Motor function need to make sure they can do finger taping and aren’t becoming clumsy

Closed reduction fracture

•Nonsurgical, manual realignment of bone fragments

•Traction and countertraction applied

•Under local or general anesthesia

•Immobilization afterwards

•Traction, cast, splint, or brace

Open reduction fractures:

•Surgical incision

•Internal fixation

•Wires, screws, pins, plates, rods, or nails

•Risk for infection

•Facilitates early ambulation

•Reduced risks related to immobility

ORIF: Open reduction and internal fixation

go in, surgical incision, realign bone. Higher risk for infection because opened up. Earlier ambulation because they have been lined up and probably pins put in.

Pre op care for ortho surgery:

Check med history (anticoag, herpin, lovanox, will all need held).

Need to get baseline assessment and assess whatever they are going to surgery for.

Need to be NPO literally cant even have a bite of food.

Need informed consent so doctor has to talk to patient first but nurse job is making sure its signed.

Always need an antibiotic running at time of incision. Usually cepsaw.

If orthopedic surgery or surgery being done on something you have two of, doctor needs to mark the site. You are responsible for making sure leg is marked.

Teach what to expect after surgery.

Patient teaching:

•Immobilization

•Assistive devices 

•Expected activity limitations

•Assure that needs will be met

•Pain medication

Post op care ortho surgery:

•Monitor vitals

•General principles of postoperative care

•Frequent neurovascular assessments

•Be attentive to limitations with turning, positioning, and extremity support

•Minimize pain and discomfort

•Monitor for bleeding or drainage

•Aseptic technique

•Blood salvage and autotransfusion

Usually, vitals every hour after surgery.

Orthopedic surgery will have drainage system, can have draining blood and running it through back into them.

Post op immobility worries: infection at surgical site, constipation (getting narcotics so can make worse), DVT, bed sores, pneumonia

Touch-down/toe-touch weight bearing

•Contact with floor for balance; no weight borne

Partial–weight bearing

•25-50% of weight borne

Weight bearing as tolerated

Based on pain

Short term rehabilitation

◦Transition from dependence to independence with ADLs

Long term rehabilitation:

◦Prevent problems associated with MS injuries: atrophy, contractures, footdrop, pain, muscle spasms

◦Also: family separation, finances, inability to work, potential disability, PTSD, and caregiver support

Complications of fractures:

 Majority heal without complication

 Medical emergencies needing immediate attention required with

◦Open fractures with severe blood loss

◦Fractures that damage vital organs

 Death is usually the result of

◦Damage to underlying organs and vascular structures

◦Complications of fracture or immobility

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. Which initial action would the nurse take?

 Assess the pedal pulses

Infection:

 High incidence in open fractures and soft tissue injuries

 Devitalized and contaminated tissue is an ideal medium for pathogens

◦Clostridium tetani

 Measures to prevent infection and osteomyelitis are important

If we go in and see infection all the way around we debreed it, cut it out. Sometimes leave open so we can keep cleaning out with each dressing change.

Wound vacs can help suction out.

Osteomyelitis is when infection gets in bones, we might put impregnated beads of antibiotics in there to help.

Compartment syndrome:

•Compromises neurovascular function of tissues within that space

•38 compartments in upper and lower extremities

•Associated with fractures with extensive tissue damage and crush injury

•Most common: distal humerus and proximal tibia

•May occur after knee or leg surgery or with prolonged pressure (limb trapped under body)

2 basic causes: restrictive casts doesn’t allow to swell so will create compartment syndrome. Or if a lot of bleeding or IV infiltrates will cause it in that area.

Clinical manifestations of compartment syndrome:

•Early recognition and treatment essential to avoid irreversible damage

•May occur initially with injury or may be delayed several days

•Ischemia can occur within 4 to 8 hours after onset

Six P’s:

•Pain: out of proportion to injury; not managed by opioids; Pressure

•Paresthesia

•Pallor

•Paralysis or loss of function

•Pulselessness

If any six P happen need to notify doctor, if pale or cant move those are late sign

If not caught early we can loose the limb.

If compartment syndrome suspected

•Do not elevate extremity above heart

•Do not apply cold compresses or ice

•Causes vasoconstriction and reduced circulation to already compromised extremity

If have cast probably have to take it off.

May need to do surgical decompression.

When gets really bad we have to amputate.

Treatment of compartment syndrome:

•Relieve pressure

•Surgical decompression (fasciotomy)

•Amputation

No ice because constriction .

Venous Thromboembolism:

•Veins of lower extremities and pelvis highly susceptible to thrombus formation due to venous stasis from muscle inactivity

•Increased risk with hip fracture, total hip/knee replacement

Prophylactic anticoagulant therapy:

10-14 days

•Antiembolism stockings

•Intermittent pneumatic compression devices (SCD’s)

•Exercises

SCDS, ted hose, teach to pump legs periodically, want to get them up as much as we can, and heparin or lovonox.

Fat embolism syndrome:

•Systemic fat globules from fracture that are distributed into tissues and organs (especially lungs and brain)

•Most common with fracture of long bones, ribs, tibia, and pelvis

•May also occur after joint replacement, burns, pancreatitis, liposuction, crush injuries, and bone marrow transplants

•Contributory factor in mortality

Happens because there are fat globulins within the bone, when there's break they get into soft tissue or organs and can go to lung or brain.

What would you see when someone might be having a fat embolism syndrome?

Someone will probably say they are SOB, then we want to check oxygen. Will occur 24-48 hours after injury if its going to happen. RR up, hypoxic. Everything you would see with a PE would be the same

Clinical manifestations of Fat Embolism:

 Clinical course of FES may be rapid and acute

 Pallor can quickly change to cyanosis; comatose

 Fat cells in blood, urine, or sputum

 Decreased PaO₂ to less than 60 mm Hg

 Decreased platelet count, hematocrit levels

 Increased ESR

◦ECG may show ST segment and T-wave changes

◦Chest x-ray may show bilateral pulmonary infiltrates

Fat embolism treatment:

•Most survive FES with few complications

•Management is supportive and related to symptom management

•Respiratory support

•O₂ to treat hypoxia

•ICU care

•ECMO or mechanical ventilation for low PaO₂

•Monitor for pulmonary edema and/or ARDS

Most survive if caught early, try our best to prevent it. If we know someone has a long bone fracture we will try out best to keep it stable to prevent fat from getting on.

Monitor for edema which would sound like crackles in lungs and monitor for respiratory distress.

A plaster splint is applied with an elastic bandage to the leg of a patient with a fractured tibia in preparation for open reduction and internal fixation. The patient reports increasing pain in the affected leg and foot that is not relieved by loosening of the elastic bandage. The 1st  action by the nurse is to:

Perform neurovascular assessment of the foot.

Nursing management for amputation:

•Assessment

-Assess for preexisting illnesses

-Assess vascular and neurologic condition

Clinical problems

-Impaired tissue integrity

-Pain

-Musculoskeletal problem

-Impaired role performance

-Negative self-esteem

Post op care for ortho trauma

◦Crutch walking begins as soon as patient physically able

◦Careful weight bearing as ordered

◦Avoid skin flap injury, delay of tissue healing

◦Patient and caregiver teaching

◦Residual limb care, ambulation, contracture prevention, recognition of complications, exercise, follow-up care

Pre op things we need:

•NPO, consent, baseline assessment, probably have antibiotic ordered that will be started at time incision.

•If patient is on beta blocker and scheduled for surgery, you can give it with a small sip of water. Everything else is held.

Post op we want:

•walking as soon as we can. We leave skin flaps open might be over the wound, we need to assess the flap so we can make sure its not turning dusky, want it pink and moist so we know its perfusing well.

•We teach, if patient has AKA we teach lay on belly a few times a day to help keep leg from contracting up.

Prostheses:

 Not all patients are candidates

◦Significant strength and energy required for ambulation

◦40% more energy for a below-the-knee prosthesis

◦60% more energy for an above-the-knee prosthesis

◦Mobility with a wheelchair may be more realistic

◦Seriously ill patients

Debilitated persons

Not a candidate for prostheses until flap is fully healed. See this a lot with AKA and BKA.

Phantom limb sensations:

 Often worries patients

 MEDICATE FOR PAIN PERCEIVED

 Usually subsides with time

 Can become chronic

 Shooting, burning, or crushing pain and feelings of coldness, heaviness, and cramping

 No single therapy

◦Virtual reality treatment

◦Mirror therapy

◦Theory - visual information replaces sensory feedback in the brain

Need to know weather the foot is there or not you still have to medicate the pain because it still hurts.

Arthroplasty:

Reconstruction or replacement of a joint

Purpose to help restore function, doesn’t take deformity away but just helps to restore func.

•Relieves pain, improves or maintains ROM, and  corrects deformity

Indications for arthroplasty:

•OA, RA, avascular necrosis, congenital deformities or dislocations, other systemic problems

Types of arthroplasty:

•Surgical reshaping of bones

•Replacement of part of joint (hemiarthroplasty)

•Replacement of total joint

Total Hip Arthroplasty (THA) Total Knee Arthroplasty

•Relieves pain and improves function for patients with joint deterioration or hip fractures

•Often performed d/t osteoarthritis –

•Pain management: important for rehabilitation

•Physical therapy: exercises to progress to 90 degrees flexion

•Active ROM or continuous passive motion (CPM) machine

•Early ambulation with full weight bearing before discharge

•Exercises continued at home

Complications of joint surgery:

Infection:

•Common organisms: gram-positive streptococci and staphylococci

•Loosens prosthesis and causes pain

•Prophylaxis: self-contained OR suites, laminar airflow, and antibiotics

VTE

•Anticoagulants

•Intermittent pneumatic compression

•Early ambulation

Arthroscopy Post Op Care:

•Neurovascular assessments

•Administer: anticoagulant and antibiotics

-Teach patient about continuing meds at home.

-Monitoring coagulation studies

•Pain management: analgesia

-May consider epidural, intrathecal, femoral nerve block, PCA, oral opioids, or NSAIDs

•Exercise and mobility; follow protocols

-Reduce risk of complications of decreased mobility

Check distally to surgical site

Warmth, color, pulse, can move, can feel