Chapt69-Mgt Pt's Musculoskeletal Trauma
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Transcript of Chapt69-Mgt Pt's Musculoskeletal Trauma
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Chapter 69
Management of Patients withMusculoskeletal Trauma
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Injuries of the Musculoskeletal System
Contusion:soft tissue injury produced by bluntforce
Pain, swelling, and discoloration: ecchymosis
Strain: pulled muscle-injury to themusculocutaneous unit
Pain, edema, muscle spasm, ecchymosis, andloss of function are on a continuum graded 1st ,2nd, and 3rd degree
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Injuries of the Musculoskeletal System(cont.)
Sprain: injury to ligaments and supporting musclefiber around a joint
Joint is tender and movement is painful; edema,disability, and pain increase during the first 2 to3 hours
Dislocation: articular surfaces of the joint are not incontact
A traumatic dislocation is an emergency withpain change in contour, axis, and length of the
limb and loss of mobility
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Common Sports-Related Injuries
Contusions, strains, sprains, and dislocations
Tendonitis: inflammation of a tendon by overuse
Meniscal injuries of the knee occur with excessiverotational stress
Traumatic fractures
Stress fractures
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Knee Ligaments, Tendons, and Menisci
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Prevention of Sports-Related Injuries
Use of proper equipment: running shoes for runners,wrist guards for skaters, etc.
Effective training and conditioning specific for the personand the sport
Stretching prior to engaging in a sport or exercise hasbeen recommended but may not prevent injury
Changes in activity and stresses should occur gradually Time to cool down
Tune in to the body; be aware of limits and capabilities
Modify activities to minimize injury and promote healing
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Occupational-Related Injuries
Common injuries include strains, sprains, contusions,fractures, back injuries, tendonitis, and amputations
Prevention measures include personnel training,proper use of equipment, availability of safety andother types of equipment (patient lifting equipment,back belts), correct use of body mechanics, andinstitutional policies
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Types of Fractures
Complete
Incomplete Closed or simple
Open or compound/complex
Grade I Grade II
Grade III
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Types of Fractures (cont.)
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Types of Fractures (cont.)
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Types of Fractures
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Manifestations of Fracture
Pain
Loss of function
Deformity
Shortening of the extremity
Crepitus
Local swelling and discoloration
Diagnosis by symptoms and x-ray
Patient usually reports an injury to the area
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Emergency Management
Immobilize the body part
Splinting: joints distal and proximal to thesuspected fracture site must be supported andimmobilized
Assess neurovascular status before and after
splinting Open fracture: cover with sterile dressing to
prevent contamination
Do not attempt to reduce the fracture
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Medical Management
Reduction
Closed
Open
Immobilization: internal or external fixation
Open fractures require treatment to prevent infection
Tetanus prophylaxis, antibiotics, and cleaning anddebridement of wound
Closure of the primary wound may be delayed topermit edema, wound drainage, furtherassessment, and debridement if needed
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Techniques of Internal Fixation
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Nursing Management of the PatientWith a Simple Fracture
Assessment: include neurovascular assessment, pain,
activity limitations, patient knowledge, and homeenvironment and support
Goal is to have patient return to usual activities as soonas possible
Patient teaching is a primary intervention as the patientwill usually be cared for in the home setting
See Chart 69-2
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Complications of Fractures
Factors that affect fracture healing: see Chart 69-3
Shock
Fat embolism
Compartment syndrome
Delayed union and nonunion
Avascular necrosis Reaction to internal fixation devices
Complex regional pain syndrome (CRPS)
Heterotrophic ossification
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Cross Sections of Anatomic Compartments
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Wick Catheter Used to MonitorCompartment Pressure
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Bone Healing Stimulator
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Rehabilitation Related toSpecific Fractures
Clavicle
Use of claviclar strap (figure 8) or sling
Exercises
Limitation of activities
Do not elevate arm above shoulder for approximately
6 weeks
Humeral neck and shaft fractures
Slings and bracing
Activity limitations and pendulum exercises
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Fracture of Clavicle andImmobilization Device
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Prescribed Shoulder Exercises(Clavicle Fractures)
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Immobilizers for Proximal HumeralFractures
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Functional Humeral Brace
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Rehabilitation Related toSpecific Fractures
Elbow fractures
Monitor regularly for neurovascular compromise andsigns of compartment syndrome
Consider potential for Volkmann's contracture: seeChart 69-4
Encourage active exercises and ROM to preventlimitation of joint movement after immobilizationand healing (4 to 6 weeks for nondisplaced, casted)or after internal fixation (about 1 week)
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Rehabilitation Related to SpecificFractures (cont.)
Colles fracture
Early functional rehabilitation exercises
Active motion exercises of fingers and shoulder
Pelvic fractures
Management depends upon type and extent offracture and associated injuries
Stable fractures are treated with a few days bedrest and symptom management
Early mobilization reduces problems related to
immobility
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Rehabilitation Related to SpecificFractures (cont.)
Hip fracture
Surgery is usually done to reduce and fixatethe fracture
Care is similar to that of a patient undergoingother orthopedic surgery or hip replacementsurgery
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Pelvic Bones
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Stable Pelvic Fractures
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Unstable Pelvic Fractures
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Regions of the Proximal Femur
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Examples of Internal Fixation forHip Fractures
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Rehabilitation Related toSpecific Fractures
Femoral shaft fractures
Lower leg, foot, and hip exercises to preservemuscle function and improve circulation
Early ambulation stimulates healing
Physical therapy, ambulation, and weight bearingare prescribed
Active and passive knee exercises are begun assoon as possible to prevent restriction of knee
movement
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Rehabilitation Related toSpecific Fractures (cont.)
Uncomplicated rib fractures
Chest strapping is not used
Encouraged to cough and deep breathe
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Femoral Fractures
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Stretch Spica Wrap
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Rehabilitation Related toSpecific Fractures
Thoracolumbar spine fractures
Usually treated conservatively with limited bedrest
Avoid sitting
Progressive ambulation
Emphasize good posture and body mechanics
Implement back strengthening exercises
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Nursing Process
Assessment of thePatient With Fracture of the Hip
Health history and presence of concomitant problems
Pain VS, respiratory status, LOC, and signs and symptoms
of shock
Affected extremity including frequent neurovascular
assessment
Bowel and bladder elimination, bowel sounds, and I&O
Skin condition
Anxiety and coping
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Nursing ProcessDiagnosis of thePatient With Fracture of the Hip
Acute pain
Impaired physical mobility
Impaired skin integrity
Risk for impaired urinary elimination
Risk for ineffective coping
Risk for disturbed thought processes
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Collaborative Problems/PotentialComplications
Hemorrhage
Peripheral neurovascular dysfunction
DVT
Pulmonary complications
Pressure ulcers
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Nursing ProcessPlanning the Care of thePatient With Fracture of the Hip
Major goals include pain relief; achievement of apain-free, functional, and stable hip; healedwound; maintenance of normal urinary eliminationpattern; use of effective coping mechanisms; anoriented patient who participates in decisionmaking; and absence of complications
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Relief of Pain
Administer analgesics as prescribed
Use of Bucks traction as prescribed
Handle extremity gently
Support extremity with pillows and when moving
Position for comfort
Provide frequent position changes
Provide alternative pain relief methods
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Prompting Physical Mobility
Maintain neutral position of hip
Use trochanter rolls
Maintain abduction of hip
Implement isometric, quad-setting, and gluteal-setting exercises
Use trapeze
Use ambulatory aids
Consult with physical therapy
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Interventions Use aseptic technique with dressing changes
Avoid/minimize use of indwelling catheters
Support coping
Provide and reinforce information
Encourage the patient to express concerns
Support coping mechanisms Encourage the patient to participate in decision
making and planning
Consult social services or other supportive services
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Interventions (cont.)
Orient patient to and stabilize the environment
Provide for patient safety
Encourage participation in self-care
Encourage coughing and deep breathing exercises
Ensure adequate hydration
Apply TED hose or SCDs as prescribed
Encourage ankle exercises
Provide patient and family teaching
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Rehabilitation of Patients WithAmputation
Amputation may be congenital, traumatic, or due
to conditions such as progressive peripheralvascular disease, infection, or malignant tumor
Amputation is used to relieve symptoms, improvefunction, and save the person's life
The health care team needs to communicate apositive attitude to facilitate acceptance andparticipation in rehabilitation
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Levels of Amputation
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Rehabilitation Needs
Psychological support
Prosthesis fitting and use
Physical therapy
Vocational/occupational training and counseling
Use a multidisciplinary team approach
Patient teaching: seeChart 69-6
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Collaborative Problems/PotentialComplications
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Nursing ProcessAssessment of thePatient With an Amputation
Assess neurovascular status and function of
affected extremity or residual limb and ofunaffected extremity
Assess for signs and symptoms of infection
Determine nutritional status
Assess concurrent health problems
Determine psychological status and coping
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Nursing ProcessDiagnosis of thePatient With an Amputation
Acute pain
Risk for disturbed sensory perception
Disturbed body image
Ineffective coping
Risk for anticipatory or dysfunctional grieving
Self-care deficit
Impaired physical mobility
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Collaborative Problems/PotentialComplications
Postoperative hemorrhage Infection
Skin breakdown
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Nursing ProcessPlanning the Care of thePatient With an Amputation
Major goals include relief of pain, absence ofaltered sensory perceptions, wound healing,acceptance of altered body image, resolution ofgrieving processes, restoration of physicalmobility, and absence of complications
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Interventions Relief of pain
Administer analgesic or other medications asprescribed
Change position
Put a light sandbag on residual limb
Alternative methods of pain relief: distraction; TENSunit
Pain may be an expression of grief and alteredbody image
Promote wound healing
Handle limb gently
Provide residual limb shaping
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Wrapping of Leg After Above-the-KneeAmputation
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Wrapping of Arm After Above-the-ElbowAmputation
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Resolving Grief and EnhancingBody Image
Encourage communication and expression of feelings
Create an accepting, supportive atmosphere Provide support and listen
Encourage the patient to look at, feel, and care forthe residual limb
Help the patient set realistic goals
Help the patient resume self-care and independence
Provide referral to counselors and support groups
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Achieving Physical Mobility
Provide proper positioning of limb; avoidabduction, external rotation, and flexion
Turn the patient frequently; use prone position ifpossible
Use assistive devices
Implement ROM exercises
Implement muscle strengthening exercises
Provide preprosthetic care: proper bandaging,massage, and toughening of the residual limb