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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

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
slide7
Dx
  • X-ray
  • MRI
tx goal
Tx Goal
  • i swelling
  • i pain
  • h rest
  • h healing
slide9
Tx
  • Rest
  • Ice
    • 48 hrs
  • Heat
    • > 48 hrs
  • Compression dressing
  • Elevate
slide10
Tx
  • Support
    • Knee immobilizer
    • Sling
    • Crutches
    • Walker
slide11
Meds
  • NSAIDs
  • Analgesics
    • Narcotic
slide12
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
slide16
Cap refill
  • Pulses
  • Mobility
  • Sensation
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 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.

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
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.

slide72
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
  • 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
  • Pin care
    • Infection prevention  osteomyelitis
    • 1st 48hrs cover with sterile drsging
    • Clean pins bid
joint replacement
Joint Replacement
  • Indications
    • Pain
    • Disability
  • Caused by
    • Joint degeneration
    • Fractures
arthroplasty
Arthroplasty
  • Surgical removal of a diseased joint &
  • Replacement with prosthetic or artificial components
common joint repairs
Common joint repairs
  • Hip
  • Knees
  • Fingers
total knee a rthroplasty
Total knee Arthroplasty
  • Involves replacement of
    • Distal femoral component
    • Tibial plate
    • Patellar button
unicondylar knee replacement
Unicondylar Knee replacement
  • When only one compartment of the joint is diseased
total hip arthroplasty
Total Hip Arthroplasty
  • Replacement of
    • Acetabular cup
    • Femoral head
    • Femoral stem
hemiarthroplasty
Hemiarthroplasty
  • 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
  • Pre-op
    • Health
    • P risk factors for DVT
    • P neurovascular status
    • P infection
pre op
Pre-OP
  • Review labs
slide108
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
slide109
Mrs. 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
slide110
Mrs. Olden 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
  • Inform
    • Autologous blood donation
    • Post op environment
intraprocedure
Intraprocedure:
  • General or spinal anesthesia
intraprocedure arthroplasty
Intraprocedure: Arthroplasty
  • Replace with artificial joint
intraprocedure arthroplasty1
Intraprocedure: Arthroplasty
  • Artificial joints have a limited life span
    • 10 – 20 years
intraprocedure hip arthroplasty
Intraprocedure: 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
  • Older adult > risk of complications
    • Resp. Infection
    • DVT
    • Hematoma/hemorrhage
    • Infection
    • PE
    • Wound dehiscence
post procedure arthroplasty1
Post-procedure: Arthroplasty
  • Meds as Rx
    • Analgesics
      • Opiods
      • NSAID’s
    • Antibiotics
    • Anticoagulants
      • Aspirin
      • Heparin
      • Warfarin / Coumadin
post procedure arthroplasty2
Post-procedure: Arthroplasty
  • Monitor neurovascular status
    • CMS
    • 5 P’s
post procedure arthroplasty3
Post-procedure: Arthroplasty
  • Monitor for S&S
    • Bleeding
    • Hypovolemia
post procedure arthroplasty4
Post-procedure: Arthroplasty
  • Monitor for bleeding
    • dressing
      • Bleeding
      • Drainage
    • Lab values
what laboratory results indicate bleeding hypovolemia
What laboratory results indicate bleeding / hypovolemia?
  • Decreased Hgb
  • Elevated Hct
  • Decreased Na+
  • Elevated BUN
blood transfusions
Blood transfusions
  • Hgb < 9 g/dL
post procedure arthroplasty preventing dvt s
Post Procedure: ArthroplastyPreventing DVT’s
  • Monitor for S&S of PE
    • Acute onset of dyspnea
    • Tachycardia
    • Chest pain
post procedure arthroplasty preventing dvt s1
Post Procedure: ArthroplastyPreventing 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
  • Continuous passive motion machine
    • h movement
    • i scar tissue
post procedure knee arthroplasty1
Post-procedure: Knee Arthroplasty
  • Limit flexion of the knee
    •  contractures
    • No knee gatch
    • No pillow under knees
post procedure hip arthroplasty
Post-procedure: Hip Arthroplasty
  • Early Ambulation
    • Transfer from unaffected side into reclining W/C
post procedure hip arthroplasty1
Post-procedure: Hip Arthroplasty
  • Weight bearing status is determined by the orthopedic surgeon
post procedure hip arthroplasty2
Post-procedure: Hip Arthroplasty

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
  • 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

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

preventing dislocation of the hip prosthesis2
Preventing Dislocation of the Hip Prosthesis

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
  • Pain
  • “pop”
  • Internal rotation
  • Shortened
arthroplasty education
Arthroplasty education
  • Physical Therapy
arthroplasty education1
Arthroplasty education
  • S&S of infection
    • 5 cardinal S&S
    • Purulent drainage
    • Care of incision
arthroplasty education2
Arthroplasty education
  • S&S of
    • DVT
      • Swelling
      • Redness
      • Calf pain
    • PE
      • SOB
      • Chest pain
    • Bleeding
knee arthroplasty education
Knee Arthroplasty education
  • Dislocation UNCOMMON
  • Limited
    • Kneeling
    • Deep knee bends
hip arthroplasty education
Hip Arthroplasty education
  • Prevent dislocation
  • Arrange for home modifications
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