Complex 2 Exam 2
Types of fractures *** 1. Closed: skin remains intact and does not go through skin
2. Open: bone will go through skin (priority problem = hypovolemia, infection, pain
3. Pathological/spontaneous: d/t bone weakness from a disease process
4. Transverse: straight across
5. Oblique: slanted across
6. Spiral: twisting; abuse
7. Comminuted: break into multi
8. Greenstick: 1 side bent, other side broken; common with children
9. Fissure: hairline
Fractures clinical manifestations *** · Acute pain (immobilization, ice, elevate w analgesics)
· Muscle spams - due to pulling forces of bone due to not being aligned (treat this and pain will
decrease)
· Deformity - internal rotation/shortened extremity
· Crepitus: grating sound
· Local swelling & discoloration/loss of function
· Edema
· Ecchymosis (bleeding in underlying tissue)
· SQ emphysema (LATE finding) = air bubbles under skin
Fractures prioritization *** 1. Maintain ABCs - perfusion is BIG!!
- monitor for bleeding (internal and external)
- PAIN, SENSATION, TEMP, CAP REFILL, MOVEMENT (Check both pulses at same time)
2. Stabilize (Immobilize the injury - prevents further injury)
,- Splint the injury, including the joints distal/proximal to the suspected fracture site & minimize
movement
- Open fracture: cover with sterile dressing to prevent contamination, elevate above heart, ice, admin
ABX
3. Assess neurovascular status before & after splinting
4. Remove clothing/jewelry from affected limb
5. Elevate above heart and apply ice (elevate for first 24-48hrs after cast applied -> peak inflammation)
6. What's the mechanism of injury? - may need tetanus shot
7. Keep them warm = cold NOT GOOD
Pain: both pharm & non-pharm methods
- Opioids, NSAID, muscle relaxants
Fractures complications *** Infection: osteomyelitis (biggest risk in open fractures) culture before abx!!
Impaired Circulation - dependent edema, diminished pulses, cool/pale
DVT/PE
Almost all pts are on DVT prophylaxis→ enoxaparin, positive D-dimer is they have a clot
- Anti-embolism stockings and SCDs to prevent DVTs
Fat embolism (similar to PE): petechial hemorrhage on chest/abdomen/head --> LATE sign (common in
long bone fractures aka femur)
Tx: O2, steroids, vasopressors, fluid replacement, pain/anxiety management - NO CURE
Compartment syndrome = MED EMERGENCY
- Pressure from external: tight cast/dressings
- Pressure internal source: accumulation of bloods/fluids
- edema from blood pulling (edema can't go anywhere -> pressure on nerve endings -> pain) eventually
leads to ischemia
,Fractures nursing interventions *** · RICE: Rest, ice, compress, elevate
· Give FLUIDS!!, analgesics, antibiotics, muscle relaxants, anticoagulants
· Keep pt warm
· Neurovascular - 5 P's - Pain, paresthesia, pallor, pulses, paralysis
· Hemorrhage: watch for bruising/swelling
· Prep pt for immobilization device (cast= effective bc patient can't remove, weights = equal on both
sides, skeletal traction - pin sites = one cotton swab per pin = clear drainage expected)
Amputations prioritization *** 1. ABC - assess circulation/perfusion (skin color, cap refill)
2. Bleeding? Circulation distal to the injury?
- Stop bleeding by applying direct pressure
- Elevate extremity above heart level - no longer than 24 - 48 hrs AFTER surgery
3. Insert 2 large bore IV's - 18 gauge or larger
4. FLUIDS FLUIDS
5.. Monitor VS/pain
- Admin pain meds
6. Determine if limb is salvageable - If the limb is completely detached→ wrap in sterile gauze, put it in a
sealed bag, stick it in ice water and send it w the p
7. Prepare for OR: labs (blood type & cross match) & consents
8. Surgical methods
- Closed: skin flap is sutured over the limb, closing the site
- Open : used when active infection is present; skin flap is not sutured over the end of the limb so that
the infection can drain; closed later
Amputations evaluation *** is blood flowing to the distal portion of the extremity?
- 5 P's will be off: warm/cold, sensation, color - off
- Cap refill
, Are blood vessels damaged?
- use doppler
Amputations post-op interventions *** - Hypovolemia = PRIORITY - measure pulses most proximal
(above) to amputation AT THE SAME TIME
· Assess site for bleeding - have tourniquet at bedside
- Monitor for dehiscence
- Assess surgical site for S/Sx of infection
· Heat, inflammation, drainage
· Systemic: fever, tachycardia, abnormal labs
- Pain - Admin analgesics, non-pharm: positioning, distraction
- Prevent flexion contracture (Inability to straighten extremity)
· Elevate residual limb for the first 24-48hrs hours and avoid elevation after that; ROM exercises; have pt
lie prone for 20-30 min several times a day; avoid prolonged sitting in a chair
- Provider does 1st dressing change after 24-48hr
- Monitor for phantom limb pain
· Tx: calcitonin for the 1st wk, beta-blockers and gabapentin; you can also give baclofen (muscle relaxer),
tell them this is a normal response
Compartment syndrome clinical manifestations *** Medical EMERGENCY
- Damage occurs in 4-6 hrs→ DO NOT put on a cast if there is too much swelling
2 types:
Decreased compartment size (extrinsic)
- Due to tight splint/cast
Treatment: loosen/remove cast
Increased compartment size (intrinsic)
- Due to swelling/bleeding inside
Types of fractures *** 1. Closed: skin remains intact and does not go through skin
2. Open: bone will go through skin (priority problem = hypovolemia, infection, pain
3. Pathological/spontaneous: d/t bone weakness from a disease process
4. Transverse: straight across
5. Oblique: slanted across
6. Spiral: twisting; abuse
7. Comminuted: break into multi
8. Greenstick: 1 side bent, other side broken; common with children
9. Fissure: hairline
Fractures clinical manifestations *** · Acute pain (immobilization, ice, elevate w analgesics)
· Muscle spams - due to pulling forces of bone due to not being aligned (treat this and pain will
decrease)
· Deformity - internal rotation/shortened extremity
· Crepitus: grating sound
· Local swelling & discoloration/loss of function
· Edema
· Ecchymosis (bleeding in underlying tissue)
· SQ emphysema (LATE finding) = air bubbles under skin
Fractures prioritization *** 1. Maintain ABCs - perfusion is BIG!!
- monitor for bleeding (internal and external)
- PAIN, SENSATION, TEMP, CAP REFILL, MOVEMENT (Check both pulses at same time)
2. Stabilize (Immobilize the injury - prevents further injury)
,- Splint the injury, including the joints distal/proximal to the suspected fracture site & minimize
movement
- Open fracture: cover with sterile dressing to prevent contamination, elevate above heart, ice, admin
ABX
3. Assess neurovascular status before & after splinting
4. Remove clothing/jewelry from affected limb
5. Elevate above heart and apply ice (elevate for first 24-48hrs after cast applied -> peak inflammation)
6. What's the mechanism of injury? - may need tetanus shot
7. Keep them warm = cold NOT GOOD
Pain: both pharm & non-pharm methods
- Opioids, NSAID, muscle relaxants
Fractures complications *** Infection: osteomyelitis (biggest risk in open fractures) culture before abx!!
Impaired Circulation - dependent edema, diminished pulses, cool/pale
DVT/PE
Almost all pts are on DVT prophylaxis→ enoxaparin, positive D-dimer is they have a clot
- Anti-embolism stockings and SCDs to prevent DVTs
Fat embolism (similar to PE): petechial hemorrhage on chest/abdomen/head --> LATE sign (common in
long bone fractures aka femur)
Tx: O2, steroids, vasopressors, fluid replacement, pain/anxiety management - NO CURE
Compartment syndrome = MED EMERGENCY
- Pressure from external: tight cast/dressings
- Pressure internal source: accumulation of bloods/fluids
- edema from blood pulling (edema can't go anywhere -> pressure on nerve endings -> pain) eventually
leads to ischemia
,Fractures nursing interventions *** · RICE: Rest, ice, compress, elevate
· Give FLUIDS!!, analgesics, antibiotics, muscle relaxants, anticoagulants
· Keep pt warm
· Neurovascular - 5 P's - Pain, paresthesia, pallor, pulses, paralysis
· Hemorrhage: watch for bruising/swelling
· Prep pt for immobilization device (cast= effective bc patient can't remove, weights = equal on both
sides, skeletal traction - pin sites = one cotton swab per pin = clear drainage expected)
Amputations prioritization *** 1. ABC - assess circulation/perfusion (skin color, cap refill)
2. Bleeding? Circulation distal to the injury?
- Stop bleeding by applying direct pressure
- Elevate extremity above heart level - no longer than 24 - 48 hrs AFTER surgery
3. Insert 2 large bore IV's - 18 gauge or larger
4. FLUIDS FLUIDS
5.. Monitor VS/pain
- Admin pain meds
6. Determine if limb is salvageable - If the limb is completely detached→ wrap in sterile gauze, put it in a
sealed bag, stick it in ice water and send it w the p
7. Prepare for OR: labs (blood type & cross match) & consents
8. Surgical methods
- Closed: skin flap is sutured over the limb, closing the site
- Open : used when active infection is present; skin flap is not sutured over the end of the limb so that
the infection can drain; closed later
Amputations evaluation *** is blood flowing to the distal portion of the extremity?
- 5 P's will be off: warm/cold, sensation, color - off
- Cap refill
, Are blood vessels damaged?
- use doppler
Amputations post-op interventions *** - Hypovolemia = PRIORITY - measure pulses most proximal
(above) to amputation AT THE SAME TIME
· Assess site for bleeding - have tourniquet at bedside
- Monitor for dehiscence
- Assess surgical site for S/Sx of infection
· Heat, inflammation, drainage
· Systemic: fever, tachycardia, abnormal labs
- Pain - Admin analgesics, non-pharm: positioning, distraction
- Prevent flexion contracture (Inability to straighten extremity)
· Elevate residual limb for the first 24-48hrs hours and avoid elevation after that; ROM exercises; have pt
lie prone for 20-30 min several times a day; avoid prolonged sitting in a chair
- Provider does 1st dressing change after 24-48hr
- Monitor for phantom limb pain
· Tx: calcitonin for the 1st wk, beta-blockers and gabapentin; you can also give baclofen (muscle relaxer),
tell them this is a normal response
Compartment syndrome clinical manifestations *** Medical EMERGENCY
- Damage occurs in 4-6 hrs→ DO NOT put on a cast if there is too much swelling
2 types:
Decreased compartment size (extrinsic)
- Due to tight splint/cast
Treatment: loosen/remove cast
Increased compartment size (intrinsic)
- Due to swelling/bleeding inside
