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110 Cards in this Set
- Front
- Back
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Complications associated with bone fractures
compartment syndrome –a serious condition in which what happens? -most common area that this occurs in (2) |
increased pressure within one or more compartments (area in the body in which muscles, blood vessels, and nerves are contained) reduces circulation to that area.
-the most common site for this problem is in the lower leg and forearm |
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Complications associated with bone fractures
compartment syndrome: increased pressure within one or more compartments reduces circulation to that area. -what happens to the capillaries? |
-capillaries within the muscle dilate, which raises capillary pressure. capillaries then become more permeable because of the release of histamine by the ischemic muscle tissue.
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Complications associated with bone fractures
compartment syndrome -how does edema & pain occur |
as a result, plasma proteins leak into the interstitial fluid space and edema occurs. edema increases pressure on nerve endings and causes pain.
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Complications associated with bone fractures
compartment syndrome -because of the edema, what else is reduced? |
blood flow to the area is reduced and further ischemia results.
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Complications associated with bone fractures
compartment syndrome -what changes occurs before changes in vascular and motor signs? |
sensory deficits or paresthesia usually appear before changes in vascular or motor signs
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Complications associated with bone fractures
compartment syndrome -what does the color of the tissue look like? what happens to the pulses? |
pale
weaken (-the affected area is usually palpably tense and pain occurs with passive motion of the extremity) |
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Complications associated with bone fractures
compartment syndrome --if the condition is not treated, what can occur? |
cyanosis
tingling numbness paresis (loss of movement) severe pain |
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Complications associated with bone fractures
compartment syndrome -can also occur when there is injury or trauma causing |
the problem above the compartment involved, which decreases blood flow to the distal area of injury
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-the pressure to the compartment can be from an external or internal source
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(external: tight bulky dressings and casts) (internal: blood or fluid accumulation in the compartment or edema which increases internal pressure)
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-monitor for early signs of ACS
monitor the 6 P's, which are what?? |
pain (pressure on nerve endings / muscle ischemia )
pressure (increased tissue pressure = clinical findings is referred pain to compartment) paralysis (tissue ncerosis) paresthesia (increased edema / increased tissue pressure) pallor (decreased oxygen to tissues), pulselessness |
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Compartment syndrome
-what may be the first s/s? |
-numbness and tingling or Paresthesias may be the 1st signs of a problem
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Compartment syndrome
-the affected extremity is (pink or pale) and (hot or cool) as a result of: |
- pale and cool as a result
decreased arterial perfusion to the affected area |
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Compartment syndrome
what are 2 late signs |
-loss of function and decreased pulses or pulselessness are late signs
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Compartment syndrome
-within ___ hrs after the onset of compartment syndrome, neurovascular and muscle damage are irreversible. the limb can become useless in 1-2 days. |
4-6
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Compartment syndrome
treatment: |
-the surgeon may perform a fasciotomy, or opening in the fascia, by making an incision through the skin to the affected compartment.
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Compartment syndrome
why perform a fasciotomy? |
this procedure relieves the pressure and restores circulation to the affected area.
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after fasciotomy, the open wound is packed and dressed daily or more until secondary closure occurs in how many days?
what does the surgeon do then? |
usually in 4-5 days.
at that time, the surgeon usually debrides the wound and may apply a skin graft to promote healing |
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complications from compartment syndrome:
-infection results from what? |
from the necrotic tissue may become severe enough that amputation of the limb is needed
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complications from compartment syndrome:
-motor weakness results from what? |
injured nerve is not reversible and the pt may need an orthotic device for assistance in mobility
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complications from compartment syndrome:
-contractures result from |
shortening of the ischemic muscle and from nerve involvement
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complications from compartment syndrome:
myoglobinuric renal failure results from what? |
from muscle breakdown is a fatal complication.
it occurs when large or multiple compartments are involved. injured muscle tissue releases myoglobulin (muscle protein) into the circulation, where it can clog the renal tubules and cause acute renal failure (direct toxic effect on the kidneys). damage to the muscle cells also release K+ which cant be excreted because of renal failure (hyperkalemia can cause cardiac issues) |
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compartment syndrome - treatment?
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Give IV fluids
low dose dopamine foley (monitor I and O) kayexalate (decraese potassium) |
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“Acute Compartment Syndrome” (a rare occurrence) is a serious condition in which increased pressure with one or more compartments causes
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massive compromise of circulation to an area and leads to tissue anoxia
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compartment syndrome:
S/S |
Increased pain & edema
Pain with passive motion Inability to move joints Loss of sensation Pulselessness Notify MD STAT!! |
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compartment syndrome
1st s/s is |
increased pain- you can sedate them but the pain wont get better)
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compartment syndrome
s/s •paralysis •pallor •pulseless •pain: |
•paralysis because of nerve impingement
•pallor because of vessels •pulseless about compression •pain: anoxia (the tissues are screaming for oxygen |
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- hypovolemic shock
what bone fx’s would cause this? |
large bones with a large blood supply (very vascular) like the femur and pelvis would cause this.
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- hypovolemic shock
what 2 things are decreased |
Decreased in mean arterial pressure MAP and loss of oxygen carrying capacity.
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- hypovolemic shock
what labs would be done? |
arterial blood gas (ABG)
which assess oxygenation, respiration, renal and electrolyte homeostasis |
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- hypovolemic shock
Labs: arterial blood gas |
- pH: normal range is 7.35-7.45 (in shock it decreases)
-PaO2: normal 80-100 mm Hg (in shock it decreases) -Paco2: 35-45 mm Hg (in shock it increases) -HCT: 33.5-45 % (H&H levels decrease if shock is caused by hemorrhage..when shock is caused by dehydration or fluid shift, H&H levels are elevated) -HGB:(decrease) 11.5-15.5 |
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hypovolemic shock
-what is seen as the earliest s/s? |
-increased HR
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fat embolism
what is released? |
-fat globules are released from the yellow bone marrow into the bloodstream after a fracture. these globules clog small blood vessels that supply vital organs (lungs and impair organ perfusion).
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fat embolism
-usually occurs when? |
usually occurs within 12-48 hrs after injury or surgery
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fat embolism
-occurs when? - with what type of fractures? |
long bone fractures (greatest risk), or fracture repair, or total joint replacement
fractured hips, fractures of the pelvis (big bones that release the most fat are pelvis, sternum, and femur fractures) |
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fat embolism defined is obstruction of:
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-definition: obstruction of the pulmonary vascular bed by fat globules
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fat embolism
S/S -what is the earliest sign? |
-altered mental status (earliest sign caused by a low arterial oxygen level)
INCREASED restlessness -Chest pain -Dyspnea -Crackles -Decreased Sa02 |
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fat embolism
S/S what happens to respirations? heart rate? temperature? |
-increased RR, HR, Temp
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fat embolism
S/S hypertensive or hypotensive? |
hypotensive
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fat embolism
S/S what appears on the skin? |
Petechial rash over upper chest and neck! Often seen in Fat embolism; physiologic basis is not known!
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fat embolism
S/S -ESR -Calcium -RBC -Platelets -Lipase |
^ESR
decreased Ca+, RBC & Plts, ^Lipase |
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Fat Embolism
-Treatment |
-bed rest: watch for DVT and pulmonary emboli
-once they come back to you, they are usually on an anticoagulant to help prevent a blood clot oxygen IV fluids for hydration fracture immobilization you can’t get rid of a fat emboli – supportive care |
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bone infection: what is it called?
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osteomyelitis
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osteomyelitis
-who is at risk for this to happen? |
-whenever there is trauma to tissues
the most common in open fractures in which skin integrity is lost and after surgical repair of a fracture an infection from another part of the body (staph, MRSA) |
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osteomyelitis
-what 3 things should the nurse asses for |
fever
lymphadenopathy GI disturbances, |
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osteomyelitis
-s/s of this occuring? |
fever above 101
pain can be extreme, it intensifies with movement erythema and edema around fracture and extreme tenderness tachycardia elevated WBC |
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osteomyelitis
-nursing interventions |
aggressive antibiotic treatment
strict aseptic technique with dressing changes (sterile) hyperbaric oxygen therapy debridgement sequestrectomy - removal of outer skin bone grafts, muscle flaps, amputation |
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-Total hip replacement: AKA total hip arthroplasty
why is it done? |
to treat a hip fracture upper third of the femur
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-Total hip replacement: AKA total hip arthroplasty
-Post op care: Maintain leg adduction or abduction? |
Maintain leg abduction to prevent internal or external rotation
it forces the femoral head into the pelvic which helps with restricting and remodeling of the surround tissue |
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-Total hip replacement: AKA total hip arthroplasty
Post Op care: hip flexion angle should not exceed how many degrees? |
Hip flexion angle should NOT exceed 60-80 degrees
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-Total hip replacement: AKA total hip arthroplasty
Post op care the head of the bed should be elevated how many degrees? |
HOB elevated to 30-45 degrees
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-Total hip replacement: AKA total hip arthroplasty
Post op care -use what kind of pillows between the legs |
abduction pillows
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-Total hip replacement: AKA total hip arthroplasty
Post op care -monitor for what? |
infection
hemorrhage circulation, sensation (i.e., neurovascular checks!) Maintain JP drain; empty & record. |
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-Total hip replacement: AKA total hip arthroplasty
Post op care -what do you make sure they wear? -encourage them to do what with their ankles? -instruct patient NOT to do what with their legs? |
TEDS, SCD’s,
encourage flexion & extension of ankles. Instruct patient NOT to cross legs or bend over |
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-Total hip replacement: AKA total hip arthroplasty
Post op care --PT is usually begins on Post-Op Day # 1 -can the patient get out of the bed? |
yes, but stands on unaffected leg; uses cane, or walker for assistance.
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-Total hip replacement: AKA total hip arthroplasty
Post op care -Complication: Dislocation Interventions: |
position correctly, for hip keep leg slightly abducted and prevent hip flexion beyond 90 degrees, assess for pain, rotation, and extremity shortening
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-Total hip replacement: AKA total hip arthroplasty
Post op care -Complication: Infection Interventions |
: use aseptic technique for wound care and emptying of drains, wash hands, culture drainage fluid if there is a change, monitor temp, report excessive inflammation or drainage
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-Total hip replacement: AKA total hip arthroplasty
Post op care Complication: Venous thrombemobolism Interventions: |
have pt wear elastic stockings / SCDs (sequential compression device), teach leg exercises, encourage fluid intake, observe for signs of thrombosis (swelling, redness, pain), observe for change in mental status, administer anticoagulant, do not massage legs
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-Total hip replacement: AKA total hip arthroplasty
Post op care -Complication: hypotension, bleeding, infection Interventions: |
take vitals q4h, observe pt for bleeding, report low BP or bleeding,
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Total hip replacement: AKA total hip arthroplasty
complications: |
pneumonia
stroke DVT pressure ulcers |
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Total hip replacement: AKA total hip arthroplasty
prevention of complications |
incentive sparometer
position every 2h ambulate |
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Total hip replacement: AKA total hip arthroplasty
Treatments |
-Traction is applied to immobilize & ease pain.
-Avoid hip flexion to prevent displacement. -Surgical intervention is “treatment of choice,” – ORIF, internal fixation with nail plate and screws, or ….. -Replacement of femoral head with a prosthesis (Total Hip Replacement) |
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Knee replacement
why is it done: |
to substitute for the femoral condyles and tibial joint surfaces
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Knee replacement
general post op care: maintain JP drain empty and record weight bearing as directed NO dangling of leg, P.T. first day post op monitor for infection |
total knee replacement
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Knee replacement
post op care cold or heat therapy |
cold
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Knee replacement
post op care: maintain the knee in what position? |
maintain the knee in a neutral position and not rotated internally or externally
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CPM (continuous passive motion) machine is used for what
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knee replacement
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Knee replacement
-assessments that you would do: |
infection drainage, circulation, sensation, neurovascular checks CSM pain assessment
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Knee replacement
-why is it done? |
last resort for pain
when drug therapy doesnt work ADLs limited have to be able to participate in PT after surgery |
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Knee replacement
prevention of Complications : |
incentive spirometry, positioning, and ambulation
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What does a CPM machine do?
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continuous passive motion keeps the prosthetic knee in motion and may prevent the formation of scar tissue (the dr or PT presets the CPM machine for the appropriate ROM and cycles per minute)
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CPM also prevents what formation?
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scar formation which could decrease mobility and increase post op pain
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Limb amputation
-When is this done |
most amputations are elective and are related to complications of PVD, arteriosclerosis, diabetes. these complications result in ischemia in distal areas of the lower extremities.
amputation is considered only after other interventions have not restored circulation to the lower extremity |
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Limb amputation
-When is this done traumatic amputations most often result from accidents and are the primary cause of upper extremity amputation |
injury that causes severe crushing of tissues or significant blood vessel damage usually result in amputation to preserve function of the residual limb
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Limb amputation
-Post Op care: monitor for what? evaluate for what? elevate what? |
Monitor for: hemorrhage, infection, s/sx of PE
Evaluate for “Phantom Limb” Pain. Elevate foot of bed for 1st 24 hours as ordered. |
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Limb amputation
-Post Op care: Lying in a what position periodically is preferred |
prone
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What is phantom pain
-sensation is felt in the amputated part that is unpleasant and painful. the pain is often described as |
intense burning, crushing, or cramping.
they experience numbness and tingling. |
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What is phantom pain
the pain is triggered by |
touch the residual limb or temperature or barometric pressure changes, concurrent illness, fatigue, anxiety, or stress, urination,
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How is phantom pain managed?
-recognize that the pain is real and should be managed promptly and completely IV infusions of what can reduce phantom limb pain? |
infusions of calcitonin (Miacalcin and Calcimar) during the week after amputation can reduce phantom limb pain
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How is phantom pain managed?
opioid analgesics? |
-opioid analgesics are not as effective
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How is phantom pain managed?
what meds are used for constant, dull, burning pain? |
-beta blocking agents such as Propranolol (Inderal)
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How is phantom pain managed?
what meds are used for knifelike or sharp burning pain |
-Antiepileptic drugs such as Tegretol and gabapentin may be
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How is phantom pain managed?
what meds may be prescribed for muscle spasms or cramping |
-Antispasmodics
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What do ACE wraps do?
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Reduce edema, shrinking/shapes the limb and holding the wound dressing in place.
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ACE wraps
-for wrapping to be effective, reapply the bandages how often? |
every 4-6 hrs or more often if they become loose.
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ACE wraps
-figure 8 wrapping prevents what? |
figure 8 wrapping prevents restriction of blood flow. decrease the tightness of the bandages while wrapping in a distal to proximal direction
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Assistive devices:
Cane: |
for pt who needs minimal support for an affected leg.
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Assistive devices:
quad cane: |
provides a broader base for the cane, and therefore more support.
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Assistive devices:
crutches: |
most commonly used aid for many musculoskeletal trauma (fractures, sprains, amputations)
Must have strong arm muscles, balance, and coordination. for this reason, crutches are not often used for older adults. walkers and canes preferred |
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Assistive devices:
walker: |
for older pt who need additional support for balance
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Assistive devices:
-when you have a cane, what side should you hold it on? |
good side
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Osteoarthritis (aka: ____________)
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Degenerative Joint Disease
• It is the MOST COMMON form of arthritis & the second most common cause of disability among adults in the U.S. |
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Osteoarthritis
is it an autoimmune disease? |
no
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Osteoarthritis
is it systemic? |
no
Noninflammatory arthritis that is not systemic, |
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Osteoarthritis
• A form of arthritis in which one or many joints undergo degenerative changes, including bony sclerosis, loss of articular cartilage & proliferation of bone spurs (osteophytes) and cartilage in the joint. what are 2 common problems |
joint pain and loss of function n are common problems
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Osteoarthritis
what is it characterized by? |
it is characterized by progressive deterioration and loss of cartilage in 1 or more joints (articular cartilage) primarily weight bearing joints (hips and knees)
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Osteoarthritis is also known as what?
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Known as the “wear and tear” disease
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Osteoarthritis
-what are the common joints affected? |
• Weight-bearing joints (hips and knees), the vertebral column, and the hands are primarily affected, because they are used most often & (except for the hands), bear the mechanical stress of body weight
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Osteoarthritis
what one factor can accelerate the problem |
obesity because of the amount of weight the person is carrying on their joints
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Osteoarthritis
-Inflammation enzymes enhance what? |
Inflammatory enzymes enhance destruction & bone cysts & synovitis are common
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Osteoarthritis
joint deformities are marked by |
immobility, pain, spasm, & inflammation!
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Osteoarthritis
S/S |
•Severe joint pain, problems with ADL’s
•Crepitus (continuous grating sensation caused by irregular cartilage); limited ROM may be felt or heard as the joint goes through ROM •Joint changes –often enlarged & deformed •Joint effusions (excess joint fluid) are common with knees •Muscle atrophy from disuse, loss of function, limping (hip or knee pain may cause the patient to lump and restrict walking distance), difficulty rising after sitting |
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Osteoarthritis
Diagnosis: -tell me about blood work? |
The basic blood work is usually normal, although the WBC’s may be elevated with specific differential elevation
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Osteoarthritis
Diagnosis: -tell me about the ESR |
An elevation in the ESR (erythrocyte sedimentation rate), but it tends to rise with age & infection
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Osteoarthritis
what is the strongest risk factor |
AGE
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Osteoarthritis
-Diagnosis: X ray CT scan |
X-Ray (way to go. Shows misalignment) exams are useful in determining structural joint changes;
a CT scan determines vertebral involvement |
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Osteoarthritis
-Diagnosis: best way |
• MRI (best examination technique to tell whats going on inside) and Bone Scans using technetium show EARLY changes!
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Osteoarthritis
which are the distal interphalangeal joints? |
Heberden’s Nodes
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Osteoarthritis
which are the proximal interphalangeal joints |
Bouchard’s Nodes
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Osteoarthritis
-Pt education The major concern of the pt with OA is pain control -what is the drug of choice? |
acetaminophen is the drug of choice, NSAIDS if that doesn’t work)
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Osteoarthritis
-Pt education Weight control, balanced diet, & rest periods |
DON’T Immobilize joint with splint/brace
encourage ROM to maintain mobility and tone |
