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136 Cards in this Set

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  • Back
Fat embolism syndrome (FES), a serious complication, results from?
a fracture, in which fat globules are released from yellow bone marrow into the bloodstream
Fat embolism syndrome may occur with what conditions (5)?
pancreatitis
diabetic coma
osteomyelitis
blunt trauma
sickle cell anemia
The release of fat emboli is most likely with fractures of 1____ bones or multiple fractures, although a break in any bone with sufficient bone marrow content can cause complication.
1 long
Fat embolism syndrome (FES) can occur at any age or in either gender, but young men between ages 1____ and ____ years and older adults between ages 2_____ and ____ years are at greatest risk.
The older client with a fractured hip has the highest risk, but FES is also common in clients with fractures of 3_____.
1 20 and 40 years
2 70 and 80 years
3 pelvis
What are two theories which have been offered to explain how fat is released from bone marrow?
metabolic theory
mechanical theory
What is the metabolic theory of fat release from bone marrow?
elevated concentration of catecholamines, as a result of trauma, causes mobilization of free fatty acids...this leads to platelet aggregation and the formation of fat globules
What is the mechanical theory of fat release from bone marrow?
pressure within yellow bone marrow is greater than capillary pressure, and therefore fats are released directly from the bone
What happens in both the mechanical and metabolic theories of fat release from bone marrow?
the fat globules are deposited in small blood vessels that supply the major organs of the body, most commonly the lungs
What is the EARLIEST manifestation of FES and what is it caused by?
altered mental status...
caused by low arterial oxygen level
What symptoms follow the EARLIEST manifestation (altered mental status) of FES
respiratory distress
tachycardia
tachypnea
fever
petechiae (macular, measles-
like rash over neck, upper
arms, chest and abdomen...
physiologic basis unknown)
What are lab findings in FES?
increased erythrocyte
sedimentation rate (ESR)
decreased serum calcium
levels
decreased red blood cell
and platelet counts
increased serum lipase level
Fat embolism usually occurs within how many hours of the fracture?
48 hours
Fat embolism may result in?
respiratory failure or death, often from pulmonary edema
When the lungs are affected, the complication may be misdiagnosed as a ____ ____ from a blood clot.
pulmonary embolism
Care of the client with fat embolism is similar to that for those with ____ _____, with the primary exception that FES is not treated with ______ agents
pulmonary emboli

anticoagulant
Define fat embolism?
obstruction of the pulmonary vascular bed by fat globules
Origin of fat embolism?
95% from fractures of the long bones; occurs usually within 48 hours
Assessment findings for fat embolism?
altered mental status
(earliest sign)
increased respirations,
pulse, temperature
chest pain
dyspnea
crackles
decreased Sao2
petechiae (50% to 60%)
retinal hemorrhage (not
common)
mild thrombocytopenia
Treatment of fat embolism?
bedrest
gentle handling
oxygen
hydration (IV fluids)
possibly steroid therapy
fracture immobilization
The PRIMARY cause of a fracture is trauma from a ____ or ____ and is spread over all socioeconomic groups.
MVA
fall
The trauma experienced from a MVA or fall may be a direct blow to the ____ or an indirect force from ____ ____ or pulling forces on the bone. Which sports are contributing factors (3)?
bone
muscle contractions

sports
vigorous exercise
malnutrition
Bone diseases, such as _____, increase the risk of a fracture in older adults
osteoporosis
The incidence of a fracture depends on the ____ of the injury.
location
_____ shaft fractures occur most in young and middle-aged adults.
Femoral
The incidence of ____ ____ (hip) fractures is highest in older adults.
proximal femur
______ fractures are common in adults; the older the person, usually the more proximal the fracture.
Humeral
Fractures of the _____ are typically seen in middle and late adulthood?
wrist (Colles')
It is estimated that more than ____ ____ fractures occur annually in the U.S. as a result of osteoporosis, and occur in middle-aged and older women. By age ____, one in five women has suffered a hip fracture.
1.5 million
80
The introduction of ___ and seatbelts has decreased the number of severe injuries and deaths, but it has increased the number of ____ extremity and ____ fractures, esp in older adults
airbags
ankle
Programs nurses might endorse to help decrease risk of falls are?
osteoporosis screening and
education
fall prevention
home assessment and
modification
drinking and driving
medication safety
older adults and driving
Assessment for fractures?
cause?
specific events leadingn to
injury?
Force (incisional, crush,
acceleration, deceleration,
shearing, or friction)?
Incisional (knife wound) and crush injuries cause ____ and disrupt blood flow to major organs.
hemorrhage
Acceleration or deceleration injuries cause direct trauma to the ____, ____, and ____ when these organs are moved from their fixed locations in the body.
spleen
brain
kidneys
Shearing and friction damage the ____ and cause a high level of wound contamination.
skin
A fall forward often results in _____ fracture of the wrist because the person tries to catch himself or herself with an outstretched hand.
Colles'
Knowing the mechanism of injury helps the nurse to determine whether other types of injury, such as _____ and _____ ____ injury, might be present
head and spinal cord
A medication history, including substance abuse, as a person may sustain injuries due to alcohol or drugs which cause dizziness and loss of balance.
okay
Which disease often do not achieve union?
Paget's disease
bone cancer, too
Occupational, hobbies, sports, jogging, marching band and recreational activities may lead to fractures
okay
Inadequate nutrition contributes to fractures.
okay
The client with a fracture often sustains trauma to other ____ ____; assess all major body systems _____ for life-threatening complications, including head, thoracic, and abdominal injuries
body systems
FIRST
When inspecting the site of a possible fracture, look for a change in ____ ____.
bone alignment
The bone may appear deformed, or a limb may be ____ or ____ rotated.
internally
externally
Accompanying these deviations may be an alteration in the length of 1______ (usually a shortening) or a change in bone 2____.
extremity
shape
During musculoskeletal assessment, ask the client to move the involved body part, but if pain is elicited, _____ the movement immediately. ROM is typically decreased. When the affected part is moved, the nurse may hear _____, a grating sound created by bone fragments.
STOP STOP!!!

crepitation
Observe skin for integrity. If fracture closed, the area over the fracture may be ____
from bleeding into underlying soft tissues.
ecchymotic (bruised)
Define ecchymotic?
bruised
What is condition called when the appearance of bubbles under the skin because of air trapping?
subcutaneous emphysema

(not uncommon but seen later)
_____ at the fracture site is rapid and can result in marked neurovascular compromise
Swelling
Perform a thorough neurovascular assessment and compare the injured area with its _____ counterpart.
symmetric
What is assessed distal to the fracture site?
skin color
temperature
sensation
mobility
pain
pulses
If the fracture involves an extremity, check the nails for _____ ____ by applying pressure to the nail and observing for speed of blood return.
capillary refill
If nails are brittle or thick, the skin _____ to the nail is assessed.
adjacent
Checking for capillary refill is not as reliable as other indicators of ____.
perfusion
A neurovascular assessement evaluates which 3 things?
circulation
movement
sensation
For an open fracture, determine the ( ? ) and the amount of overt bleeding.
degree of soft-tissue damage
If skin is disrupted, palpate with _______ _____ on.
sterile gloves

(if skin not disrupted, it's okay to palpate skin without gloves.)
Clients often complain of moderate to severe pain at the site of the fracture or in an adjacent or 1_____ area.
For example, clients with a fractured hip may have 2___ ____ or pain referred to the back of the 3____.
1 distal
2 groin pain
3 knee
Pain is usually due to ____ ____ and ____ , which result from the fracture.
muscle spasm and edema
In clients with one or more fractured ribs, severe pain occurs when _____ _____ are taken.
deep breaths
Assess ___ status, which may be severely compromised from pain or pneumothorax (air in the pleural cavity).
respiratory
What is a pneumothorax?
air in the pleural cavity
For fractures of the SHOULDER and UPPER ARM, the physical assessement is best done with the client in a 1_____ or ______ position, if possible, so that shoulder drooping or other abnormal positioning can be seen.
Support the affected arm and 2____ the ____ to promote comfort during the assessment. For more distal areas of the arm, the assessment is done with the client in a 3_____ position so that the extremity can be elevated to reduce 4_____.
sitting
1 sitting or standing
2 flex the elbow
3 supine
4 swelling
For assessment of the LOWER EXTREMITIES and PELVIS, place the client in a 1_____ position. A client with an impacted hip fracture may be able to walk for a 2____ time after injury, although not recommended. The client with any type of hip fracture has pain in addition to decreased 3____ in hips.
1 supine
2 short
3 ROM
Some fractures can cause internal organ damage, resulting in _____.
hemorrhage
When a pelvic fracture is suspected, assess (3)?
vital signs
skin color
level of consciousness for
indications of possible
hypovolemic shock
For internal fractures, check the urine for ____, which indicates damage to the urinary system, often the bladder. If the client is unable to void, the nurse suspects damage to the ____.
blood
urethra
Hospitalization is usually not required for a single, uncomplicated fracture, and the client may return to usual daily activities within a _____ days.
few
Healing of a fracture is usually complete in a young adult in ___ to ____ weeks.
4 to 6
In contrast, a client suffering multiple trauma can be hospitalized for ____ and may undergo many surgical procedures, treatments, and prolonged rehabilitation.
weeks
Body image and sexuality may be altered by (3)?
deformity
treatment modalities for
fracture repair
long-term immobilization
Assessment Technique of Neurovascular Status in Clients with Musculoskeletal Injury
Skin color?
Normal findings?
inspect the area distal to the injury...
no change in pigmentation compared with other parts of the body
Assessment Technique of Neurovascular Status in Clients with Musculoskeletal Injury
Skin temperature?
Normal findings?
palpate the area distal to the injury (the dorsum of the hands is most sensitive to temperature)...
the skin is warm....
Assessment Technique of Neurovascular Status in Clients with Musculoskeletal Injury
Movement?
Normal findings?

(there are two)
1. ask the client to move the affected area or the area distal to the injury (active motion)...
the client can move without discomfort

2. move the area distal to the injury (passive motion)...
no difference in comfort compared with active movement
Assessment Technique of Neurovascular Status in Clients with Musculoskeletal Injury
Sensation?
Normal findings?
1. ask the client if numbness or tingling is present (paresthesia)...
no numbness or tingling...

2. palpate with a paper clip (esp the web space between
the first and second toes or the web space between the thumb and forefinger)...
no difference in sensation in the affected and unaffected extremities (loss of sensation in these areas indicates perineal nerve or median nerve damage)
Assessment Technique of Neurovascular Status in Clients with Musculoskeletal Injury
Pulses?
Normal findings?
palpate the pulses distal to the injury...
pulses are strong and easily palpated; no difference in the affected and unaffected extremities
Assessment Technique of Neurovascular Status in Clients with Musculoskeletal Injury
Capillary Refill (least reliable)?
Normal findings?
press the nail beds distal to the injury until blanching occurs (or the skin near the nail if nails are thick and brittle)...
blood returns (return to usual color) within 3 sec.
(5 sec for older clients)
Assessment Technique of Neurovascular Status in Clients with Musculoskeletal Injury
Pain?
Normal Findings?
ask the client about the location, nature, and frequency of the pain...
pain is usually localized and is often described as stabbing or throbbing (pain out of proportion to the injury and unrelieved by analgesics might indicate compartment syndrome)
NO special lab tests are available for assessment of _____.
fractures
Are hematocrit and hemoglobin low or high because of bleeding around the fracture injury?
low
If extensive soft-tissue damage accompanies the fracture, the ( ? ) may be elevated, which indicates the expected inflammatory response.
erythrocyte sedimentation rate (ESR)
If the ESR increases during fracture healing, the client may have a _____ _____.
bone infection
During healing stages, ____ ____ and _____ levels are often increased as the bone releases these elements into the blood.
serum calcium
phosphorus
What two radiographic studies are ordered to confirm a diagnosis of fracture?
standard x-rays
tomograms (CT scan, computed
tomography)

(if no fractures viewed, and patient is symptomatic, then repeat with additional views)
What does the computed tomography show?
fractures of complex structures, such as hip and pelvis...also identifies compression fractures of the spine
Two other diagnostic assessments beside radiographic include?
bone scan (with technetium or gallium)...
MRI
Although not commonly used, a ____ ____ can pick up fractures of small bones or occult fractures easier than conventional x-rays.
In addition, it can better determine fracture complications, such as (3)?
bone scan

delayed bone healing infection
ischemic necrosis.
What is the MRI useful in determining with fractures?
the amount of soft-tissue damage that may have occured with fracture....
visualizing vertebral and skul fractures
Common nursing diagnoses for fractures?
Risk for peripheral neurovascular dysfunction related to?
bone and soft-tissue trauma
Common nursing diagnoses for fractures?
Acute pain related to?
biologic injury (bone disruption, soft-tissue damage, muscle spasm, and edema
Common nursing diagnoses for fractures?
Risk for infection related to?
trauma
Common nursing diagnoses for fractures?
Impaired physical mobility related to?
pain
Common nursing diagnoses for fractures?
Imbalanced nutrition: Less than body requirements related to?
additional metabolic need for healing of bone and soft tissues
Additional Nursing Diagnoses for fractures?
Activity intolerance related to?
pain and impaired mobility
Additional Nursing Diagnoses for fractures?
Constipation related to?
opioids and prolonged immobility (particularly in older adults)
Additional Nursing Diagnoses for fractures?
Ineffective coping related to?
prolonged immobility, hospitalization, or lifestyle changes
Additional Nursing Diagnoses for fractures?
Compromised family coping related to?
prolonged hospitalization or lifestyle changes
Additional Nursing Diagnoses for fractures?
Self-care deficit related to?
pain and immobility
Additional Nursing Diagnoses for fractures?
Disturbed body image related to?
deformity and/or treatment modality
Additional Nursing Diagnoses for fractures?
Sexual dysfunction related to?
pain and immobility
Additional Nursing Diagnoses for fractures?
Disturbed sleep pattern related to?
chronic pain or prolonged hospitalization
Additional Nursing Diagnoses for fractures?
Fear related to?
possible nursing home placement or death (particularly in older adults)
Additional Nursing Diagnoses for fractures?
Impaired skin integrity and impaired tissue integrity related to?
bone injury and immobility
What are some potential problems with SEVERE fractures...potential for?
acute compartment syndrome
hypovolemic shock
fat embolism syndrome
venous thromboembolism
ischemic necrosis
delayed healing, malunion, or
nonunion
Expected outcomes that indicate the fractured area is receiving adequate blood flow through the small vessels of the extremities to maintain tissue function are?
capillary refill
sensation
skin color
muscle function
extremity skin color
pedal pulses
Emergency care of the client with extremity fracture.
Remove the client's 1_____ (cut if necessary) to inspect the affected area while supporting the injured area above and below the injury. ___ ____ ____ because this can cause increased trauma.
1 clothing
2 DON'T REMOVE SHOES
Apply 1____ _____ on the area if there is bleeding and pressure over the 2____ ____ nearest the fracture.
Keep the client warm and in a 3_____ position.
Check the neurovascular status of the area distal to the extremity; ( (5) ? ) Compare affected and unaffected limbs.
Immobilize the extremity by splinting; include joints above and below the fracture site. Recheck circulation after splinting. Cover the affected area with a dressing (preferably 5_____).
1 direct pressure
2 proximal artery
3 supine
4 temperature, color,
sensation, movement, and
capillary refill.
5 sterile
Intervention activities for the client at risk for peripheral neurovascular dysfunction
Circulatory Care (arterial insufficiency/venous insufficiency):
Promotion of arterial and venous circulation.
(List 4 interventions)
perform a comprehensive appraisal of peripheral circulations (e.g. check peripheral pulses, edema, capillary refill, color, and temperature)...
monitor degree of discomfort or pain...
protect the extremity from injury...
place extremity in a dependent position, as appropriate
Intervention activities for the client at risk for peripheral neurovascular dysfunction;
Peripheral sensation management: Prevention or minimization of injury or discomfort in the client with altered sensation.
(List 4 interventions)
monitor for paresthesia:
numbness
tingling
hyperesthesia
hypoesthesia
monitor fit of bracing devices, prostheses, shoes, and clothing...
administer analgesics as
necessary...
discuss or identify causes of abnormal sensations or sensation changes
A fracture can happen anywhere, and it may be accompanied by multiple injuries to vital _____
organs
For any client who experiences trauma, first assess for (3)?
respiratory distress
bleeding head injury
Things for the emergency team to do besides initial care?
Inspect the fracture site for intactness of skin, swelling, and deformity (e.g., 1____ and _____);

palpates the area 2_____ to determine temperature (coolness, decreased sensation, and blanching)

assesses 3_____ pulses by comparing affected and unaffected extremities, if applicable

assesses for motor function by asking the client to move an area distal to the fracture (e.g., if a femoral fracture is suspected, he or she is asked to move the ankle and foot on the affected side; the upper portion of the leg remains immbolized)
1 shortening and rotation
2 lightly
3 distal
An emergency team should immobilize a fractured area by splinting to (3)?
prevent further damage
reduce pain
increase circulation
Any object or device that extends to the joints above and below the fracture can be used as a _____.
splint
At the scene of an accident, the emergency team may need to improvise splinting by using available materials, such as a ____.
board
If the skin is broken, loosely apply a clean (preferably sterile) ____ to prevent further contamination of the wound.
cloth
Neurovascular assessment is rechecked after ______.
splinting
What are 2 methods of reduction or realignment of bone ends for proper healing?
closed method (e.g., traction)...

open (surgical) procedure
Immobilization of a fracture is achieved by?
bandages
casts
traction
internal fixation
external fixation
The health care provider selects the treatment method of a fracture based on (3)?
type
location
extent of fracture
Nonsurgical management typically involves?
closed reduction and immobilization with one or a combination of:
bandage
splint
cast
traction

For each one of these, the nurse's PRIMARY concern is assessment and prevention of neurovascular dysfunction or compromise.
Assess the neurovascular status of the client who has sustained a fracture every 1____ for the first 2____ hours and every 3___ to ____ hours thereafter.
1 hour
2 24
3 4 to 8
Elevate the fractured extremity higher than the 1____, and apply ice for the first 2___ to ___ hours, as appropriate, to reduce edema.
Assess dressings, splints, casts, and traction for neurovascular compromise.
1 heart
2 24 to 48
When caring for a fracture, pay particular attention to EARLY signs and symptoms of ACS by doing a ____ assessment.
pain
The client with early ACS typically complains of severe, diffuse pain that is not relieved by 1______; pain during passive motion is greater than pain during active motion. If the client presents with this complaint, notify the health care provider 2______.
1 analgesics
2 IMMEDIATELY
What is the most common nonsurgical method for managing a simple fracture?
closed reduction
In a closed reduction maneuver, the nurse applies a 1_____ ____, or traction, on the bone, the health care provider manipulates the bone ends so that they 2____.
Anesthesia or analgesia is typically used during this procedure to minimize pain. An x-ray verifies that the bone ends are 3______ before the bone is immobilized
1 manual pull
2 realign
3 approximated
For certain areas of the body, such as the _____ and ____, an elastic bandage or commercial mobilizer may be used to immbolize the bone during healing
scapula
clavicle
Because upper extremity bones do not bear weight, _____ may be sufficient to keep bone fragments in place.
splints
_______, a durable, flexible material for splinting, allows custom fitting to the client's body part.
Thermoplast
The nurse's primary responsibility is to assess the area _____ to the bandage or splint for neurovascular compromise.
distal
The client usually complains of increased discomfort that is not relieved by _____ if the splint or bandage is too tight.
analgesics
______ the need for elevation as appropriate and teach how to assess for circulatory changes.
Reinforce
The client is reminded to keep the device as dry and clean as possible to prevent ____ _____ and _____.
skin breakdown and infection.
For more complex fractures or fractures of the lower extremity, the physician or orthopedic technician applies a cast to hold bone fragments in place after _____.
reduction
Define cast?
a rigid device that immbolizes the affected body part while allowing other body parts to move.