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Musculoskeletal Trauma. Day 2 Chapter 42. Risk Factors. Elderly. Elderly Home Safety. Lighting Rugs Clutter Shoes. Soft Tissue Injury. Contusion  Ecchymosis Black & Blue Purple Brown Yellow Hematoma. Sprain. S&S Ligament injury Pain Joint Instability Edema, discoloration

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Musculoskeletal trauma

Musculoskeletal Trauma

Day 2

Chapter 42


Risk factors
Risk Factors

  • Elderly


Elderly home safety
Elderly Home Safety

  • Lighting

  • Rugs

  • Clutter

  • Shoes


Soft tissue injury
Soft Tissue Injury

  • Contusion 

    • Ecchymosis

      • Black & Blue

      • Purple

      • Brown

      • Yellow

  • Hematoma


Sprain
Sprain

  • S&S

    • Ligament injury

    • Pain

    • Joint Instability

    • Edema, discoloration

    • h pain with movement

  • D/T

    • Twisting


Strain
Strain

  • S&S

    • Muscle tear

    • Pain

    • Edema

    • h pain with muscle contraction


Dx

  • X-ray

  • MRI


Tx goal
Tx Goal

  • i swelling

  • i pain

  • h rest

  • h healing


Tx

  • Rest

  • Ice

    • 48 hrs

  • Heat

    • > 48 hrs

  • Compression dressing

  • Elevate


Tx

  • Support

    • Knee immobilizer

    • Sling

    • Crutches

    • Walker


Meds

  • NSAIDs

  • Analgesics

    • Narcotic


Mr. Rayne Inspain is prescribed NSAID’s due to a grade 2-3 ankle sprain. What would you teach Mr. Inspain about this medication

  • Take as needed with food

  • Take regularly with food

  • Take as needed on an empty stomach

  • Take regularly on an empty stomach


Small group activity
Small Group Activity

  • Generate a list of questions to assess John age 44 injured ankle.


What are the 5 cardinal s s of inflammation
What are the 5 cardinal S&S of inflammation?

  • Pain

  • Redness

  • Swelling / edema

  • Loss of function

  • Heat


Assessment
Assessment

  • Assess

  • Palpate

    • Edema

    • Heat

    • Pain

    • Deformity

    • Crepitus



Report complications
Report Complications

  • Numbness

  • Tingling

  • Weakness

  • i mobility

  • Cool / pale


Fracture
Fracture

  • Break in the continuity of a bone.


Type of fractures
Type of Fractures

Closed

Open

Broken skin

  • Intact skin


Type of fractures1
Type of Fractures

Comminuted

Compression

Crushed

  • Broken into many pieces


Type of fractures2
Type of Fractures

Impacted

Depressed

Pressed inward

  • Ends forced together


Type of fractures3
Type of Fractures

Spiral

Greenstick

Incomplete break

  • Twisted


Fracture healing process
Fracture Healing Process

  • Fx

  • Hematoma 

  • Inflammatory response 

  • Clotting 

  • Phagocytosis 

  • Osteoblasts 

    • Bone Matrix

  • Weight bearing 

  • Osteocytes 

  • Remodeling


Manifestations of fracture
Manifestations of Fracture

  • Deformity

  • Edema, ecchymosis

  • Pain

  • Immobility

  • Numbness

  • Crepitus

  • Muscle spasm


Casts
Casts

  • Rigid external immobilizing device

  • Molds to the contours of the body


Casts1
Casts

  • Purpose

    • Immobilize

    • Correct deformity

    • Apply uniform pressure

    • Support


Types of casts
Types of casts

  • Short arm cast


Types of casts1
Types of casts

  • Long-arm cast


Types of casts2
Types of casts

  • Short-leg cast


Types of casts3
Types of casts

  • Long-leg cast


Types of casts4
Types of casts

  • Walking cast


Types of casts5
Types of casts

  • Body Cast


Types of casts6
Types of casts

  • Shoulder-spica cast


Types of casts7
Types of casts

  • Hip spica cast


Fiberglass casts
Fiberglass Casts

  • Cool-water activated

  • Hardens in minutes

  • Exothermic reaction


Fiberglass casts1
Fiberglass Casts

  • Light weight

  • Water resistant

  • Waterproof?


Fiberglass casts nursing care
Fiberglass casts – NURSING care!

  • Warn!

This is going to get really warm – it wont burn you but it might be a little uncomfortable.



Waterproof fiberglass casts nursing care
Waterproof Fiberglass casts – NURSING care!

  • Drain

  • Dry


Plaster casts
Plaster casts

Pros +

Cons -

i Durability

h drying time

  • i $

  • h mold


Plaster casts1
Plaster Casts

  • Cold water activated

  • Exothermic reaction

  • Rigid

    • 15-20 minutes

  • Fully dry

    • 24-72 hrs

  • Will plaster casts soon be a thing of the past?


Plaster cast warning
Plaster Cast Warning!

  • Do not cover while drying


Splints
Splints

  • Indications

    • Not require rigid immobilization

    • Swelling

    • Skin care

    • Short term


Splint nursing care
Splint – NURSING care

  • Well padded

  • P Circulation


Braces
Braces

  • Indications

    • Support

    • Control movement

    • Prevent additional injury

    • Long term


General nursing management of a client in a cast splint or brace
General Nursing Management of a Client in a Cast, Splint or Brace

  • Before applied:

    • Assessment

      • Holistic

      • Skin

      • Swelling

      • Neurovascular (5P’s)

      • Pain

    • Educate


General nursing management of a client in a cast splint or brace1
General Nursing Management of a Client in a Cast, Splint or Brace

  • NURSING ALERT!

  • A patient’s unrelieved pain must be immediately reported to the physician to avoid possible paralysis and necrosis.


General nursing management of a client in a cast splint or brace2
General Nursing Management of a Client in a Cast, Splint or Brace

  • Pain assessment

    • Elevate

    • Ice

    • Analgesic

    • Immobilize

PAIN

Pressure ulcers

Compartment syndrome


General nursing management of a client in a cast splint or brace3
General Nursing Management of a Client in a Cast, Splint or Brace

  • NURSING ALERT!

  • The nurse must never ignore complaints of pain form the patient in a cast because of the possibility of problems, such as impaired tissue perfusion or pressure ulcer formation.


General nursing management of a client in a cast splint or brace4
General Nursing Management of a Client in a Cast, Splint or Brace

  • ROM to every joint not immobilized!


General nursing management of a client in a cast splint or brace5
General Nursing Management of a Client in a Cast, Splint or Brace

When was your last Tetanus booster?

  • Skin care

    • Treat skin before cast is applied

      • Clean

      • Tx per order


General nursing management of a client in a cast splint or brace6
General Nursing Management of a Client in a Cast, Splint or Brace

  • Tetanus booster

    • q10 yrs

    • If dirty

      • > 5 yrs


General nursing management of a client in a cast splint or brace7
General Nursing Management of a Client in a Cast, Splint or Brace

I wonder if I should report this to the doctor?

  • Skin care

    • With cast

      • Observe

        • S&S of infection

        • Purulent drainage

        • Odor


General nursing management of a client in a cast splint or brace8
General Nursing Management of a Client in a Cast, Splint or Brace

  • Neurovascular Status


Monitoring managing potential complications
Monitoring & Managing Potential Complications

  • Which of the following type of modality is most likely to cause complications?

  • Brace

  • Cast

  • Splint

WHY?


Monitoring managing potential complications1
Monitoring & Managing Potential Complications

  • Compartment Syndrome

  • Pressure ulcers

  • Disuse syndrome


Compartment syndrome
Compartment Syndrome

  • Pathophysiology

    • h Pressure + limited space 

    • i circulation

    • Compression of nerves


Compartment syndrome1
Compartment Syndrome

  • S&S

    • PAIN!

      • passive ROM

      • Not relieve with opiods

    • Paresthesia

    • Pulselessness

    • Pallor

    • Paralysis


Compartment syndrome2
Compartment Syndrome

  • Management

    • Notify MD STAT

    • Bivalve the cast

    • Elevate at heart level


Compartment syndrome3
Compartment Syndrome

  • NURSING ALERT!

  • Compartment Syndrome is managed by maintaining the extremity at the heart level (not above heart level), and bivalving the cast.


Pressure ulcers
Pressure Ulcers

  • Pathophysiology

    • Pressure 

    • Tissue anoxia

    • Ulcer


Pressure ulcer
Pressure Ulcer

  • S&S

    • Pain

    • Warm area on cast

    • Drainage

      • Stain

      • Odor


Pressure ulcer1
Pressure Ulcer

  • Tx

    • Remove, bivalve or window cast

    • If window:

      • replace & secure with compression dressing

      • To prevent “window edema”


Disuse syndrome
Disuse syndrome

  • Prevention

    • Isometric exercises

    • Qhr


Arm slings
Arm slings

  • Distribute weight


Crutches
Crutches

  • Indications

    • Partial weight bearing

    • Non-weight bearing


Crutches1
Crutches

  • Requirement for use

    • Good balance

    • Strong upper body

    • Erect posture


Crutches adjust
Crutches: Adjust

  • Length

    • 5 cm below axilla

    • -40 cm from height

  • Hand grip

    • 20 – 30o elbow flexion


Crutches2
Crutches

  • Down Stairs

    • Crutches

    • Affected leg

    • Unaffected leg


Crutches3
Crutches

  • Up stairs

    • Unaffected leg

    • Crutches & affected


Crutches stairs
Crutches & Stairs

Unaffected

leg

goes

up first

and

down last.


Cane

  • Hold on unaffected side

    • Cane forward

    • Affected leg to cane

    • Stronger leg advances


Walker
Walker

  • Most stable


Transfer from bed to w c
Transfer from bed to W/C

  • W/C

    • Parallel to bed

    • Un-affected side

    • Locked

  • Procedure

    • Stand

    • Pivot

    • Sit


Cast removal
Cast removal -

  • Cast cutter

    • Vibrations

  • Padding cut with scissors


Cast removal1
Cast removal

  • Prepare the client

    • Skin dry & scaly

      • Wash & lube

    • Stiff

      • Support

    • Atrophy

    • Weak

      • Exercises

      • Elevate


Small group questions
Small Group Questions

  • You are giving a client discharge instructions regarding his new plaster long-leg cast. What do you teach him about cast drying?

  • What will you teach your client about controlling swelling and pain?

  • What will you tell the client he needs to report to the physician immediately?

  • What techniques will you teach the client about managing minor skin irritation?

  • What will you teach the client to minimize the complication of disuse syndrome?


T raction
Traction

  • Applying a pulling force


Traction
Traction

  • Purpose

    • i muscle spasms

    • Reduce

    • Immobilize

    • i deformity


Traction rules
Traction Rules

  • Continuous

  • Never interrupted

  • Do not remove weights

  • Good body alignment

  • Unobstructed ropes

  • Weights free hanging

  • Knots not touch pulley


Types of traction
Types of traction

  • Skin Traction

  • Skeletal Traction


Skin traction
Skin traction

  • Purpose

    • Control muscle spasms

    • Immobilize ā surgery


Skin traction1
Skin traction

  • Weight pulls on “boot” attached to skin

  • Extremities

    • 4.5 – 8 lb.

  • Pelvis

    • 10 – 20 lb.


Skin traction2
Skin traction

  • Examples

    • Buck’s traction

      • Lower leg


Skin traction nursing management
Skin Traction: Nursing management

  • Ensure effective traction

    • No wrinkles or slipping of the boot

    • Proper position

    • Do not twist


Skin traction management
Skin traction: Management

  • Skin breakdown

    • Asses skin

    • Provide back care

    • Special mattress


Skin traction management1
Skin traction: Management

  • Nerve damage

    • Avoid pressure on the peroneal nerve 

    • Footdrop=


Skin traction management2
Skin traction: Management

  • Circulatory Impairment

    • Asses circl. w/in

      • 15 min.

    • Assess circl.

      • q1-2 hr.

    • Enc. exercises q1hr

  • Assessment:

    • Peripheral pulses

    • Color

    • Cap. Refill

    • Temp.

    • S&S or DVT

      • Unilateral calf tenderness

      • Warm

      • Red

      • Swelling


Skeletal traction
Skeletal Traction

  • Applied directly to the bone via

    • Pins, wires or tongs

  • Indications

    • Femur

    • Tibia

    • Cervical spine


Skeletal traction1
Skeletal traction:

  • Procedure

    • Pins inserted during surgery

    • Attached to traction


Skeletal traction management
Skeletal traction: Management

  • Maintaining effective traction

    • P apparatus

    • Eval. pt position


Traction nursing management
Traction: Nursing Management

  • NURSING ALERT!

  • The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs. Removal of the weights completely defeats their purpose and may result in injury to the patient.


Skeletal traction management1
Skeletal traction: Management

  • Maintain position

    • Foot = plantar flexion

    • No rotation


Skeletal traction management2
Skeletal traction: Management

  • Prevent skin breakdown

    • Protect elbows & heel

    • Trapeze

    • Asses for redness

    • Back care

    • Pressure reducing mattress


How would you change the bedding of a patient with skeletal leg traction
How would you change the bedding of a patient with skeletal leg traction?

  • Remove the traction and change the linen

  • Turn the patient onto their left side and change the linen on the right side of the bed, then roll the patient over the linen to his right side and finish making the bed on the left side.

  • One nurse changes the linen from the bottom of the bed upward

  • Two nurses change the linen from the top of the bed downward.


Skeletal traction management3
Skeletal traction: Management leg traction?

  • Monitoring neurovascular status

    • P q1hr until stable then q4hr

    • ROM unaffected limb

    • Isometric exercises

    • Anti-embolism stocking

    • Compression devises

    • Anti-coagulant therapy


Skeletal traction management4
Skeletal traction: Management leg traction?

  • Pin care

    • Infection prevention  osteomyelitis

    • 1st 48hrs cover with sterile drsging

    • Clean pins bid


Joint replacement
Joint Replacement leg traction?

  • Indications

    • Pain

    • Disability

  • Caused by

    • Joint degeneration

    • Fractures


Arthroplasty
Arthroplasty leg traction?

  • Surgical removal of a diseased joint &

  • Replacement with prosthetic or artificial components


Common joint repairs
Common joint repairs leg traction?

  • Hip

  • Knees

  • Fingers


Total knee a rthroplasty
Total knee leg traction?Arthroplasty

  • Involves replacement of

    • Distal femoral component

    • Tibial plate

    • Patellar button


Unicondylar knee replacement
Unicondylar leg traction? Knee replacement

  • When only one compartment of the joint is diseased


Unicondylar knee replacement1
Unicondylar leg traction? Knee replacement


Total hip arthroplasty
Total Hip Arthroplasty leg traction?

  • Replacement of

    • Acetabular cup

    • Femoral head

    • Femoral stem


Hemiarthroplasty
Hemiarthroplasty leg traction?

  • Refers to

    • ½ joint replacement

  • Fx of the femoral neck can be treated with the replacement of the femoral component only


General nursing interventions
General Nursing interventions leg traction?

  • Pre-op

    • Health

    • P risk factors for DVT

    • P neurovascular status

    • P infection


Pre op
Pre-OP leg traction?

  • Review labs


Mr. Hip Located is scheduled for a total hip replacement in the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • RBC = 4.1 million/mm3

  • WBC = 7,000/mm3

  • Hgb = 10 g/dL

  • Hct = 37%

  • BUN = WNL

  • Serum Creatinine = WNL

  • Infection

  • Dehydration

  • Anemic

  • Renal failure


Mrs. the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?CantaBendaney is scheduled for a total knee replacement in the morning. Upon reviewing her lab results you note the following. What would the correct interpretation of these results be?

  • RBC = 6.5 million/mm3

  • WBC = 7,000/mm3

  • Hgb = 19 g/dL

  • Hct = 52%

  • BUN = elevated

  • Serum Creatinine = WNL

  • Infection

  • Dehydration

  • Anemic

  • Hemorrhaging

  • Renal failure


Mrs. Olden the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?Ugaly is scheduled for a Arthroplasty in the morning. Upon reviewing her lab results you note the following. What would the correct interpretation of these results be?

  • RBC = 6.5 million/mm3

  • WBC = 14,000/mm3

  • Hgb = 15 g/dL

  • Hct = 37%

  • BUN = WNL

  • Serum Creatinine = WNL

  • Infection

  • Dehydration

  • Anemic

  • Renal failure


General nursing interventions1
General Nursing interventions the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Inform

    • Autologous blood donation

    • Post op environment


Intraprocedure
Intraprocedure the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?:

  • General or spinal anesthesia


Intraprocedure arthroplasty
Intraprocedure the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?: Arthroplasty

  • Replace with artificial joint


Intraprocedure arthroplasty1
Intraprocedure the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?: Arthroplasty

  • Artificial joints have a limited life span

    • 10 – 20 years


Intraprocedure hip arthroplasty
Intraprocedure the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?: Hip Arthroplasty

  • May or may not be “cemented” in place

  • If not

    • Bone grows into the prosthesis to stabilize it

    • Weight bearing is delayed several weeks until femoral shaft has grown into prothesis


Post procedure arthroplasty
Post-procedure: Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Older adult > risk of complications

    • Resp. Infection

    • DVT

    • Hematoma/hemorrhage

    • Infection

    • PE

    • Wound dehiscence


Post procedure arthroplasty1
Post-procedure: the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?Arthroplasty

  • Meds as Rx

    • Analgesics

      • Opiods

      • NSAID’s

    • Antibiotics

    • Anticoagulants

      • Aspirin

      • Heparin

      • Warfarin / Coumadin


Post procedure arthroplasty2
Post-procedure: the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?Arthroplasty

  • Monitor neurovascular status

    • CMS

    • 5 P’s


Post procedure arthroplasty3
Post-procedure: the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?Arthroplasty

  • Monitor for S&S

    • Bleeding

    • Hypovolemia


What v s changes would you indicate post op bleeding
What V/S changes would you indicate post-OP bleeding? the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Pulse

    • h

  • B/P

    • i


Post procedure arthroplasty4
Post-procedure: the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?Arthroplasty

  • Monitor for bleeding

    • dressing

      • Bleeding

      • Drainage

    • Lab values


What laboratory results indicate bleeding hypovolemia
What laboratory results indicate bleeding / the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?hypovolemia?

  • Decreased Hgb

  • Elevated Hct

  • Decreased Na+

  • Elevated BUN


Blood transfusions
Blood transfusions the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Hgb < 9 g/dL


Post procedure arthroplasty preventing dvt s
Post Procedure: Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?Preventing DVT’s

  • Monitor for S&S of PE

    • Acute onset of dyspnea

    • Tachycardia

    • Chest pain


Post procedure arthroplasty preventing dvt s1
Post Procedure: Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?Preventing DVT’s

  • Anticoagulant Rx

  • Anti-embolic stockings

  • Compression device

  • Ankle exercises

  • Early mobilization

  • P.T. & O.T.


Post procedure knee arthroplasty
Post-procedure: Knee Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Continuous passive motion machine

    • h movement

    • i scar tissue


Post procedure knee arthroplasty1
Post-procedure: Knee Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Limit flexion of the knee

    •  contractures

    • No knee gatch

    • No pillow under knees


Post procedure knee arthroplasty2
Post-procedure: Knee Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Ice

    •  i swelling


Post procedure hip arthroplasty
Post-procedure: Hip Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Early Ambulation

    • Transfer from unaffected side into reclining W/C


Post procedure hip arthroplasty1
Post-procedure: Hip Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Weight bearing status is determined by the orthopedic surgeon


Post procedure hip arthroplasty2
Post-procedure: Hip Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

Cemented

Non-cemented

Usually only partial weight bearing for a few weeks

  • Usually partial / full weight bearing as tolerated


Preventing dislocation of the hip prosthesis
Preventing Dislocation of the Hip Prosthesis the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Position

    • Supine

    • HOB slightly h

    • Hip/leg neutral position

    • Abduction device

  • Turn only to unaffected side


Preventing dislocation of the hip prosthesis1
Preventing Dislocation of the Hip Prosthesis the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

Do not turn the client to the operative side  hip dislocation!


Preventing dislocation of the hip prosthesis2
Preventing Dislocation of the Hip Prosthesis the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

DO

DONT

Flex hip > 90o

Low chairs

Cross legs

Internally rotate toes

  • Elevated seat

  • Straight chair w/ arms

  • Abduction pillow

  • Externally rotate toes


S s of hip dislocation
S&S of Hip Dislocation the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Pain

  • “pop”

  • Internal rotation

  • Shortened


Arthroplasty education
Arthroplasty education the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • Physical Therapy


Arthroplasty education1
Arthroplasty education the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • S&S of infection

    • 5 cardinal S&S

    • Purulent drainage

    • Care of incision


Arthroplasty education2
Arthroplasty education the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?

  • S&S of

    • DVT

      • Swelling

      • Redness

      • Calf pain

    • PE

      • SOB

      • Chest pain

    • Bleeding


Knee arthroplasty education
Knee Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?education

  • Dislocation UNCOMMON

  • Limited

    • Kneeling

    • Deep knee bends


Hip arthroplasty education
Hip Arthroplasty the morning. Upon reviewing his lab results you note the following. What would the correct interpretation of these results be?education

  • Prevent dislocation

  • Arrange for home modifications


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