GEMC - Musculoskeletal Emergencies - for Nurses
-
Upload
openmichigan -
Category
Education
-
view
1.338 -
download
0
description
Transcript of GEMC - Musculoskeletal Emergencies - for Nurses
![Page 1: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/1.jpg)
Project: Ghana Emergency Medicine Collaborative Document Title: Musculoskeletal Emergencies and the Nursing Process Author(s): Barbara Demman (University of Michigan), RN 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
1
![Page 2: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/2.jpg)
Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy
Use + Share + Adapt
Make Your Own Assessment
Creative Commons – Attribution License
Creative Commons – Attribution Share Alike License
Creative Commons – Attribution Noncommercial License
Creative Commons – Attribution Noncommercial Share Alike License
GNU – Free Documentation License
Creative Commons – Zero Waiver
Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ
Public Domain – Expired: Works that are no longer protected due to an expired copyright term.
Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105)
Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain.
Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
{ Content the copyright holder, author, or law permits you to use, share and adapt. }
{ Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. }
{ Content Open.Michigan has used under a Fair Use determination. }
2
![Page 3: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/3.jpg)
Func(on of Musculoskeletal System
• Support • Protec(on • Movement and leverage • Storage of mineral salts and fats • Red blood cell produc(on
3
![Page 4: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/4.jpg)
U.S. National Cancer Institute SEER Program, Wikimedia Commons 4
![Page 5: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/5.jpg)
Components of Musculoskeletal system
• Bones • Nerves • Vessels-‐ arteries, veins • Muscles • Tendons-‐ aGach muscle to bone • Ligaments-‐aGach bone to bone • Joints
5
![Page 6: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/6.jpg)
Brian0918, Wikimedia Commons 6
![Page 7: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/7.jpg)
Assessment of Musculoskeletal System
• Primary – Form a general impression, “ABC” – AIRWAY: patency – BREATHING: adequate respira(ons – CIRCULATION: control bleeding, watch for shock
• Secondary – vital signs, physical exam, more detailed exam
7
![Page 8: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/8.jpg)
Assessment of Musculoskeletal System
• Subjec(ve Data: – what the pa(ents says – Pa(ent dialogue – History/informa(on gathering
• Objec(ve Data: – scien(fic data gathered from physical exam and diagnos(c exams
8
![Page 9: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/9.jpg)
Assessment of MS System-‐ Subjec(ve
• Obtain history of injury mechanism of injury (twist, crush, stretch) Circumstances r/t injury Onset-‐ acute vs. chronic Previous diagnos(c exams Methods/dura(on of treatment Relieving/aggrava(ng factors Need for assis(ve devices Interference with Ac(vi(es of Daily Living (ADL’s)
9
![Page 10: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/10.jpg)
Mechanism of Injury
• Significant force is generally required to cause fractures and disloca(ons. – Direct/Indirect/Twis(ng/High-‐energy forces – Assists with an(cipa(on of injuries – A low-‐speed car accident is much less likely to cause a life-‐threatening injury than a rollover accident. A gunshot wound has more poten(al for serious injury than a fisdight.
10
![Page 11: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/11.jpg)
Mechanism of Injury
-‐Was the arm or hand outstretched? • FOOSH-‐ ogen distal radial fx • “Fall On Outstretched Hand”
– At what angle to the body was the arm, shoulder or hand on impact? – Did hyperflexion or hyperextension occur? – Fracture or disloca(on of the area before? – Involved in rigorous athle(c training (overuse injury)?
11
![Page 12: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/12.jpg)
Assessment of MS System-‐ Subjec(ve
• SUBJECTIVE – Pain – Weakness – Deformity – Limita(on of movement – S(ffness – Joint crepita(on
• Medica(ons – What medica(ons directly influence integrity of the MS system?
• An(epilep(cs • Cor(costeroids • chemotherapy
12
![Page 13: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/13.jpg)
Assessment of MS System-‐ Subjec(ve
• Past Health Hx – What disease processes affect the MS system? – TB, poliomyeli(s, infec(ons-‐osteomyeli(s – Diabetes mellitus, – Rickets – Rheumatoid arthri(s, lupus – Gout, osteoarthri(s – Autoimmune disease-‐ steroid use
13
![Page 14: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/14.jpg)
Assessment of MS System-‐ Objec(ve
• INSPECT-‐ swelling/deformity/shortening of limb/bleeding
• PALPATE/FEEL for tenderness and crepitus with movement and temperature.
• Range of Mo(on-‐ Passive and Ac(ve • Muscle-‐Strength Tes(ng, 0-‐5 scale • Neurovascular exam*
– Color, temp, CRT, pulses, edema, sensa(on, motor func(on, nerve involvement
14
![Page 15: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/15.jpg)
Muscle Strength Tes(ng Scale
Source: www.pacificu.edu/optometry/ce/courses/15840/neuroexampg3.cfm 15
![Page 16: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/16.jpg)
Assessment of Neurovascular Status Ensures integrity of injured area
• Parasthesia • Pain • Pressure • Pallor-‐ capillary refill (me < 3 seconds • Paralysis • Pulses-‐ distal to injured extremity
16
![Page 17: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/17.jpg)
17 Source Undetermined
![Page 18: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/18.jpg)
Nursing Care Interven(ons for Musculoskeletal Emergencies
• Frequently assess, document, and report the six Ps (pain, pallor, pulses, pressure, paresthesia, and paralysis).
• REPORT STATUS CHANGES
18
![Page 19: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/19.jpg)
Differen(al diagnosis
• the determina(on of which of two or more diseases with similar symptoms is the one from which the pa(ent is suffering, by a systema(c comparison and contras(ng of the clinical findings.
• Gather all data and create differen(al diagnosis list
• Determines plan of care
19
![Page 20: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/20.jpg)
Musculoskeletal Diagnos(c Studies/Procedures to Aid in Diagnosis
• Radiology Studies – Standard X-‐Ray – Compute Tomography (CT)
• Endoscopy -‐Arthroscopy
• Arteriograms
• Complete blood count with differen(al (CBC)
• Electrolytes • Type and Cross Match • Urinalysis • Wound cultures • Mineral Metabolisms
– Calcium, Phosphate • Serological Studies
– ESR, RF, ANA
20
![Page 21: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/21.jpg)
Skeletal X-‐RAY Studies
• Standard Anterior/Posterior and lateral radiographs, to include the joint above and below the fracture level, are the minimal requirement for most fractures.
21
![Page 22: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/22.jpg)
Nursing Responsibili(es for Diagnos(c Exams
• Remove radiopaque objects • Pain management • Determine pregnancy status • Allergies to Contrast Medium/Iodine/Shell Fish
• Administer an(anxiety if indicated
22
![Page 23: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/23.jpg)
General Nursing Interven(ons/Responsibili(es for MS Emergencies
• Assessment-‐ report status changes • Physician (MD) orders • Pain Management • Prepara(on for diagnos(c exams • Prepara(on for surgical interven(on • Documenta(on • Pa(ent Educa(on
23
![Page 24: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/24.jpg)
Nursing Care Interven(ons for Emergent Musculoskeletal Findings
BLEEDING
• Control bleeding by applying pressure with a sterile dressing. • Avoid hypovolemic shock by administering intravenous fluids and oxygen.
24
![Page 25: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/25.jpg)
Nursing Care Interven(ons for Emergent Musculoskeletal Findings
DEFORMITY • Immobilize above and below the injury site in the most comfortable posi(on with a splint.
• Do not aGempt to straighten the limb or manipulate protruding bone.
25
![Page 26: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/26.jpg)
Nursing Care Interven(ons for Emergent Musculoskeletal Findings
SWELLING • Apply and intermiGently reapply cool packs to the injured area for up to 48 hours if needed.
• Elevate the extremity above the level of the heart.
26
![Page 27: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/27.jpg)
Nursing Care Interven(ons for Emergent Musculoskeletal Findings
PAIN/ANXIETY • Ini(ate oral or intravenous analgesia as soon as possible. • Communicate with pa(ent plan of care and findings
27
![Page 28: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/28.jpg)
Common Drugs used in Musculoskeletal Emergencies
• Pain Control: NSAIDS, Opiates • Infec(on Control: Prophylaxis/Cephalosporin
• Procedural Seda(on: Fentanyl, Versed • Reversals: Naloxone, Flumazenil
28
![Page 29: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/29.jpg)
Non-‐Steroidal An(-‐inflammatory Drugs
• Aspirin, Ibuprofen, Naproxen, Indomethacin, ketorolac, diclofenac
• Use for mild to moderate pain, fever • Decrease pain, decrease inflamma(on • Non-‐opioid • Adverse reac(ons-‐ GI effects, renal effects
29
![Page 30: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/30.jpg)
OPIATES
• Morphine, Codeine, Hydrocodone, Fentanyl • Analgesic, IV, by mouth (PO), transdermal • decreased percep(on of pain, decreased reac(on, increased pain tolerance.
• side effects: seda(on, respiratory depression, cons(pa(on, and a strong sense of euphoria
• Opiate withdrawal symptoms with chronic long term use
30
![Page 31: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/31.jpg)
Procedural Seda(on
• Procedural seda7on refers to a technique of administering seda(ves or dissocia(ve agents, with or without analgesics, to induce a state that allows pa(ents to tolerate unpleasant procedures while maintaining cardiorespiratory func(on and retaining the ability to respond purposefully to verbal commands and/or tac(le s(mula(on.
• Appropriate for adult and pediatric pa(ents. • Ogen used to sedate pa(ents while reducing fractures or disloca(ons http://emssa.org.za/documents/em013.pdf
31
![Page 32: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/32.jpg)
SATS Policy on Procedural Seda(on
• hGp://emssa.org.za/prac(ce-‐guidelines/
32
![Page 33: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/33.jpg)
Pre-‐Procedure Prepara(on and Equipment
• The following equipment should be present (refer to EMSSA Prac(ce Guideline EM006):
• Oxygen and delivery devices (nasal, cannula and face mask) • Suc(on and suc(on catheters • Resuscita(on trolley and defibrillator and intuba(on
equipment • Vital signs monitor (including BP, cardiac monitor and
satura(on) • Posi(ve pressure breathing device • Appropriate size oral airway • Reversal agents
33
![Page 34: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/34.jpg)
MONITORING AND DOCUMENTATION for procedural seda7on
• Assessment of the pa(ent should be done at baseline and every five minutes once the first analgesia/seda(on dose has been administered. The following should be documented:
• Vital signs (BP, HR, RR) • ECG rhythm • Oxygen satura(on • Airway patency • Use of supplemental oxygen or not • Level of consciousness • Pain • Medica(ons given including route, dose and person
administering.
34
![Page 35: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/35.jpg)
Post-‐procedure Discharge Criteria • Vital signs, level of consciousness, cardiovascular and respiratory status have • returned to pre-‐seda(on levels. • A responsible, designated adult is able to accompany pa(ent • The pa(ent/caregiver has received appropriate verbal and wriGen discharge • instruc(ons. • Discharge forms are completed and discharge medica(on has been dispensed. • Pain is adequately controlled. • Nausea/vomi(ng is controlled. • Oxygen satura(on is at pre-‐interven(on status. • No signs or symptoms that may jeopardize the safety of recovery (i.e. Bleeding, • swelling, extreme pain, dizziness etc.) • Follow-‐up for extended care has been provided. • For children: age appropriate responses are present.
35
![Page 36: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/36.jpg)
General MS Documenta(on • Documenta7on Neurovascular assessment and documenta(on shall
include: • a. date and (me of assessment • b. extremity • c. sensa(on (sensory) • d. temperature (distal to pressure point) • e. movement (motor) • f. capillary refill (blanches) • g. pulses • h. color • i. any other per(nent observa(ons (i.e. swelling)
• REPORT ANY PERTINENT CHANGES
36
![Page 37: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/37.jpg)
Pa(ent Educa(on
• Strength exercises • Preven(on • Pain management • Assist devices: cane, crutches, walker • Expected outcomes • When to return for emergencies
37
![Page 38: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/38.jpg)
Review General Nursing Interven(ons/Responsibili(es for MS Emergencies
• Assessment-‐ report status changes • Physician (MD) orders • Pain Management • Educa(on • Prepara(on for diagnos(c exams • Prepara(on for surgical interven(on • Documenta(on • Pa(ent Educa(on
38
![Page 39: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/39.jpg)
Musculoskeletal Disease Topics
• Sog Tissue Injuries • Contusion/Hematoma • Overuse Injuries • Low back pain • Disloca(ons
• Fractures • Amputa(ons • Joint Injuries • Arthri(s
39
![Page 40: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/40.jpg)
Sog Tissue Injuries • Contusion/Hematoma • Disloca(on-‐ Displacement or separa(on of joint ar(cular surfaces with severe ligamentous structure injury
• Subluxa(on-‐ par(al disloca(on
• Shoulders, elbows, patella, hips, fingers • Forceful high impacts/transmissions
40
![Page 41: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/41.jpg)
Contusion/Hematoma
• Contusion/Bruise: capillaries and veins are damaged by trauma, allowing blood to seep into the surrounding inters((al (ssues. skin, subcutaneous (ssue, muscle, or bone. – cerebral, myocardial, pulmonary
• Hematoma: localized collec(on or pocket of blood
41
![Page 42: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/42.jpg)
Bruise versus Contusion
Ksuel, Wikimedia Commons Petr K, Wikimedia Commons 42
![Page 43: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/43.jpg)
Treat a closed sog-‐(ssue injury by applying the mnemonic RICE:
REST: keep pa(ent quiet and comfortable ICE: constrict blood vessels and reduce pain COMPRESS: slow bleeding ELEVATE: raise injured part above level of the heart to decrease swelling * Swelling hurts and delays healing (me
43
![Page 44: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/44.jpg)
Overuse Injuries
• subtle, occurs over (me • Cumula(ve trauma • (ssue damage, micro tears that results from repe((ve demand over the course of (me.
• Stress fracture (runners) • Carpal Tunnel Syndrome • Manual labor occupa(ons • Athle(cs
44
![Page 45: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/45.jpg)
Sprains and Strains • Sprain-‐ ligament injury
– Twis(ng – Ligament: bone to bone
• Strain-‐ Muscle or Tendon injury – Overuse injury – Tendon: muscle to bone
• 1st, 2nd , 3rd degree – Fibrous and muscle tears, swelling, edema, pain, decrease in func(on
• Sprains/Strains not usually visible on x-‐ray but can be as painful as and have similar healing (me as a fracture. 45
![Page 46: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/46.jpg)
Nursing Responsibili(es for sprains and strains
• Assess neurovascular status* • RICE • Apply cold, ice pack acute phase/ager 48 hours heat and cold
• Immobiliza(on • An(cipate x-‐rays • Analgesia as necessary • Educa(on: strength exercises, preven(on • Assist devices: crutches
46
![Page 47: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/47.jpg)
Low Back Pain
Glitzy_queen00, Wikimedia Commons 47
![Page 48: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/48.jpg)
Low Back Pain-‐ Differen(al Diagnosis
• Trauma • Liging something too heavy/overstretching • Nerve/Muscle Irrita(on • Arthri(s, Osteoporosis, Bone disease/lesion • Infec(ons-‐ TB, pyelonephri(s • Pelvic Fracture • Intravenous (IV) drug history use
48
![Page 49: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/49.jpg)
• Pain accompanied by fever or loss of bowel or bladder control, pain when coughing, and progressive weakness in the legs may indicate a pinched nerve or other serious condi(on.
49
![Page 50: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/50.jpg)
Low Back Pain ER Nursing Management
• E(ology of back pain/medical history • Physical exam • Circula(on, movement, and sensa(on of all extremi(es • Pain scale assessment and reassessment within 2 hours ager medica(on or other pain interven(ons.
• Vital signs on admission. • Medicate for pain per MD order • Urine dips(ck per MD order-‐ + blood or +pregnancy +White blood cells (WBC)
• Diagnos(c imaging per MD order
50
![Page 51: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/51.jpg)
Low Back Pain Goals
• Accurate diagnosis • Relieve pain • Increase mobility
51
![Page 52: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/52.jpg)
Disloca(ons
• Bones in a JOINT, become displaced or misaligned
• Obvious deformity-‐ compare to other extremity • Loss of normal joint mo(on • Localized pain, swelling, tenderness • Some(mes a dislocated joint will spontaneously reduce before your assessment. – Confirm the disloca(on by taking a pa(ent history.
52
![Page 53: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/53.jpg)
Disloca(on
– Ligaments usually damaged
– A disloca(on that does not reduce is a serious problem.
– Numbness or impaired circula(on to the limb or digit
• *Risk avascular Necrosis! • Orthopedic Emergency
53
![Page 54: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/54.jpg)
Disloca(on
• Assess pulses and cap refill distal to injury • Range of Mo(on • Obtain x-‐ray to verify disloca(on and assess for fractures related to disloca(on
• Pain management.
54
![Page 55: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/55.jpg)
• The humeral head most commonly dislocates anteriorly.
• Shoulder disloca(ons are very painful. – Stabiliza(on is difficult because any aGempt to bring the arm in toward the chest wall produces pain.
– Splint the joint in whatever posi(on is more comfortable for the pa(ent.
55
![Page 56: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/56.jpg)
Anterior Shoulder Disloca(on
Source undetermined, Pediatric Orthopedics Injuries
![Page 57: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/57.jpg)
Disloca(on: Nursing Management
• Goal: Realign dislocated joint-‐REDUCTION • Expose dislocated joint area • Start Intravenous Access (IV) and IV Fluids • Assist with reduc(on-‐CALM PATIENT! • Possible procedural seda(on • Immobiliza(on-‐ sling, splint • Movement ager reduc(on can lead to further disloca(on
• Pa(ent Educa(on 57
![Page 58: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/58.jpg)
Fractures
• Disrup(on or break in the con(nuity of bone structure
• Open fracture: skin integrity impaired/ bone exposed
• Closed fracture: skin integrity intact • Non-‐displaced: bone s(ll in alignment • Displaced: bone not in alignment
58
![Page 59: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/59.jpg)
Types of Fractures
Source undetermined, SayPeople.com 59
![Page 60: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/60.jpg)
Suspect a Fracture If…
– Deformity – Tenderness – Pain – Guarding – Swelling – Bruising – Crepitus – Exposed fragments – Verified by X-‐ray
60
![Page 61: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/61.jpg)
Fracture Goal and Care
Reduc(on and Immobiliza(on Immobilize: to retain reduc(on or anatomical alignment Reduc(on: medical procedure to restore a fracture or disloca(on to normal alignment. Needed for displaced fractures.
• Reduc(on: – Closed Reduc(on – Open Reduc(on
61
![Page 62: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/62.jpg)
Anatomical Alignment of Fractures
• Closed Reduc(on – Nonsurgical – Trac(on/counter trac(on
– Under local anesthesia (joint block) or conscious seda(ons
Bobjgalindo, Wikimedia Commons 62
![Page 63: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/63.jpg)
Anatomical Alignment of Fractures
• Open Reduc(on – Surgical – Wires, pins, screws – Internal fixa(on – External fixa(on
– *ORIF: Open reduc(on internal fixa(on
Source undetermined, E-Radiography 63
![Page 64: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/64.jpg)
External Fixa(on
• Pin care • Infec(on risk • Pain control
Source undetermined, Journal of Bone and Joint Surgery 64
![Page 65: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/65.jpg)
Nursing Responsibili(es: Fractures • Neurovascular Assessment! • Compartment
Syndrome*** • Pain Management • Immobiliza(on
– Cast set up – Trac(on
• Pre-‐opera(ve du(es
• Open wound care • Tetanus Vaccina(on status
• IV an(bio(cs • Cover wound with sterile dressing
• If impaled object, do not remove but stabilize
65
![Page 66: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/66.jpg)
An(cipate Es(mated Blood Loss with Fractures (EBL)
• Femur fx-‐ 1.5 L • Pelvis fx-‐ 2 L • Thorax-‐ 2L • Humerus-‐ 0.5 L
Hugh Dudley, Primary Surgery Textbook 66
![Page 67: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/67.jpg)
Fractures of Pelvis • Ogen results from direct compression in the form of a heavy blow – Can be caused by direct or indirect forces
• May be accompanied by life-‐threatening loss of blood • Open fractures are quite uncommon. • Suspect a fracture of the pelvis in any pa(ent who has sustained a high-‐velocity injury and complains of discomfort in the lower back or abdomen.
• If Pelvis is unstable or “open book” fracture apply pelvic binder.
67
![Page 68: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/68.jpg)
Pelvic Binder
Source undetermined, Trauma.org 68
![Page 69: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/69.jpg)
Cast Set Up and Nursing Responsibili(es
• Fiberglass • Plaster • Water bucket • Scissors • Towel • Stable pa(ent posi(oning
69
![Page 70: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/70.jpg)
70 Mass Communication Specialist 3rd Class Eduardo Zaragoza, U.S. Navy, Wikimedia Commons
![Page 71: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/71.jpg)
Pa(ent Educa(on on Cast Care
• Unusual odor beneath the cast • Tingling, burning, numbness of toes • Drainage through cast • Swelling or inability to move toes • Toes that are cold, blue or white • Sudden unexplained fever • Pain that is not relieved by comfort
measures • No smoking
71
![Page 72: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/72.jpg)
Splin(ng
• Process of immobilizing and stabilizing painful, swollen, deformed extremi(es
• SOFT or RIGID • Sog: Pillows, Blankets, Dressings, slings • Hard: (very liGle flexibility) • – Plas(c – Wood – Compressed cardboard
72
![Page 73: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/73.jpg)
Why Do We Splint?
• Can reduce pain • Prevent further injury • Limit the damage to sog (ssues • Limit internal & external bleeding • Help relieve pressure against blood vessels • closed fractures from becoming open fractures
• Easier for transport, transfer
73
![Page 74: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/74.jpg)
Splin(ng Principles
• General principles of splin(ng – Remove clothing from the area. – Note and record the pa(ent’s neurovascular status.
– Cover all wounds with a dry, sterile dressing. – Pad all rigid splints. – Maintain manual stabiliza(on. – If you encounter resistance, splint the limb in its deformed posi(on.
74
![Page 75: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/75.jpg)
Assis(ve Walking Devices
• Crutches – Crutch Training to prevent further injury – Weight bearing versus non weight bearing
• Cane • Walker
75
![Page 76: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/76.jpg)
Crutch Walking Instruc(ons
• Crutches should be fiGed such that arms are in comfortable posi(on to support self without res(ng under arms on crutches
• Place approx. 12 inches in front of you • Straighten arms and support self while swinging body through crutches in front of where they were placed.
• Use cau(on when going up/down stairs.
76
![Page 77: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/77.jpg)
Trauma(c Amputa(ons
• Complete-‐ total severing of limb or appendage from rest of body
• Par(al-‐ some sog (ssue remains aGached • arms, ears, feet, fingers, hands, legs, and nose
77
![Page 78: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/78.jpg)
Trauma(c Amputa(on of Hand
Gabriel Mejia, trauma.org 78
![Page 79: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/79.jpg)
• Surgeons can occasionally reaGach amputated parts.
• Make sure to immobilize the part with bulky compression dressings. – Do not sever any par(al amputa(ons.
– Control any bleeding to the stump.
– If bleeding cannot be controlled, apply a tourniquet.
79
![Page 80: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/80.jpg)
• With a complete amputa(on, wrap the severed part in a sterile dressing and place it in a plas(c bag. – Put the bag in a cool container filled with ice. – The goal is to keep the part cool without allowing it to freeze or develop frostbite.
80
![Page 81: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/81.jpg)
Joint Injuries
• Joint Effusions • Costochondri(s • Osteoarthri(s • Sep(c Arthri(s • Rheumatoid Arthri(s
81
![Page 82: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/82.jpg)
Joint Effusion
• Swollen joints happen when there's an increase of fluid in the (ssues that surround the joints. Joint swelling is common with different types of arthri(s, infec(ons, and injuries.
82
![Page 83: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/83.jpg)
Knee Effusion
James Heilman, Wikipedia 83
![Page 84: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/84.jpg)
Costochondri(s • Inflamma(on of junc(on where the ribs join the sternum • Localized chest pain/reproduce by pushing on car(lage in
front of ribcage. • Ogen has no definite cause/resolves without treatment • May be r/t chest infec(ons or minor trauma to chest wall • Ogen in younger popula(on, 12 -‐20 years of age • Diagnosis can be reached ager excluding more serious
causes of chest pain-‐ Differen(al diagnosis for chest pain/angina
• Suppor(ve treatment-‐ an(-‐inflammatory medica(ons, heat applica(on.
84
![Page 85: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/85.jpg)
Costochondri(s
Mikael Haggstrom, Wikimedia Commons 85
![Page 86: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/86.jpg)
Osteoarthri(s (OA)
• Degenera(ve joint disease • Breakdown/erosion of car(lage in joints-‐ decreases shock absorbing
• Ogen related to obesity, injury, overuse syndromes, or hereditary factors
• Most commonly in weight bearing joints – Hips, knees, spine
86
![Page 87: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/87.jpg)
OA Symptoms
• Pain in affected joint ager repe((ve use • Joint pain worse later in the day • Pain and s(ffness ager long periods of inac(vity (sivng)
• Swelling, warmth, crepitus to affected joint • May walk with a limp • Bony enlargement of the joints from spur forma(ons is characteris(c of osteoarthri(s.
87
![Page 88: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/88.jpg)
Heberden's & Bouchard's Nodes
Drahreg01, Wikimedia Commons 88
![Page 89: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/89.jpg)
Bunions
• Enlargement and reposi(oning of joints at the ball of the foot.
• Mostly women • Treatment of bunions includes rest, altera(on of footwear, foot supports, medica(ons, and/or surgery.
Dr. Henri Lelièvre, Wikimedia Commons 89
![Page 90: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/90.jpg)
OA Treatment
• Rehabilita(ve and suppor(ve measures • Adjunc(ve drug therapy • Weight loss, low impact exercise, healthy diet, assis(ve devices
• Non-‐steroidal an(-‐inflammatory medica(ons
90
![Page 91: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/91.jpg)
Sep(c Arthri(s
• inflamma(on of one or more joints as a result of infec(on by bacteria/viruses or less frequently, fungi or parasites.
• Most ogen, the infec(on begins at some other loca(on in the body and travels via the bloodstream to the joint.
• Symptoms ogen include fever, chills, general weakness, and headaches, followed by inflamma(on and painful swelling of one or more joints of the body.
91
![Page 92: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/92.jpg)
Sep(c Arthri(s
• An(cipate x-‐ray of affected joint • Blood cultures • Aspira(on of joint fluid for laboratory studies • An(cipate an(bio(cs, rest, and pain management
92
![Page 93: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/93.jpg)
Sep(c Arthri(s of Right Index Finger
Chris Craig, Wikimedia Commons 93
![Page 94: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/94.jpg)
Rheumatoid Arthri(s (RA) • CHRONIC SYSTEMIC AUTOIMMUNE DISEASE • The inflamma(on in the joints causes pain, s(ffness, swelling, and loss of func(on.
• The inflamma(on ogen affects other organs and systems of the body, including the lungs, heart, and kidneys.
• Women more ogen than men • Usual onset 35-‐50 years of age, but it Can occur in children, teenagers, and elderly people (juvenile rheumatoid arthri(s)
94
![Page 95: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/95.jpg)
Rheumatoid Arthri(s (RA)
• Symmetrical polyarthri(s • RA almost always affects the joints of the hands (such as the knuckle joints), wrists, elbows, knees, ankles, and/or feet.
• Usually at least two or three different joints are involved on both sides of the body, ogen in a symmetrical (mirror image) paGern.
• S(ffness is most no(ceable in the morning and improves later in the day.
95
![Page 96: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/96.jpg)
Rheumatoid Arthri(s (RA)
James Heilman, Wikimedia Commons 96
![Page 97: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/97.jpg)
RA Treatment • Suppor(ve measures:
– nutri(on, rest, physical measures, analgesics
• NSAIDs, Steroids to decrease inflamma(on • Disease-‐Modifying drugs (slow progression of RA)
– e.g. Methotrexate, hydroxychloroquine, leflunomide, sulfasalazine, minocycline
• Immunosuppressants – Azathioprine, cyclosporine
• TNF-‐alpha inhibitors (tumor necrosis factor-‐alpha) reduces pain, s(ffness, swelling in joints
– Etanercept, infliximab, adalimumab,
http://www.mayoclinic.com/health/rheumatoid-arthritis/ds00020/dsection=treatments-and-drugs 97
![Page 98: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/98.jpg)
RA Emergencies
-‐Atlanto-‐axial disloca(on-‐ pain in neck/neuro change -‐Scleromalacia perforans: thinning of sclera in eye, loss of vision -‐ Vasculi(s: obstruc(on of small blood vessels -‐Acute exacerba(on of RA (synovi(s) -‐ Infec(ons
98
![Page 99: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/99.jpg)
Life Threatening Complica(ons Associated with Orthopedic Injuries
• Hypovolemic Shock • Compartment syndrome • Venous Thromboembolism/Fat Embolism • Infec(on-‐ Osteomyeli(s • Acute Tubular Necrosis/Acute Kidney Injury
99
![Page 100: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/100.jpg)
Hemorrhage 2nd to Long Bone FX maximize oxygen delivery -‐ completed by ensuring adequacy of ven(la(on, increasing oxygen satura(on of the blood • control blood loss • fluid resuscita(on.-‐ two large bore IV • lactated Ringer solu(on or normal saline. An ini(al bolus of 1-‐2 L is given in an adult (20 mL/kg in a pediatric pa(ent) and reassess • Possible PRBC transfusion • Prep for surgical interven(on
100
![Page 101: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/101.jpg)
Fat Embolism Syndrome
• A form of ARDS that follows major long bone fractures: 0.5-‐2% pa(ents with mul(ple fx.
• Symptom: hypoxemia, recent long bone/pelvic fracture, possible petechial rash, change in LOC
• embolic marrow fat macroglobules damage small vessel perfusion leading to endothelial damage in pulmonary capillary beds leading to respiratory failure
101
![Page 102: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/102.jpg)
Fat Embolism Syndrome Nursing Management
• Serial ABG’s • CXR-‐ lung infiltrates, may be normal early stages
• EKG • Primarily suppor(ve treatment-‐ oxygen delivery, possible tracheal intuba(on
• Want early fracture fixa(on to decrease incidence
102
![Page 103: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/103.jpg)
Compartment Syndrome • Elevated intra-‐compartmental pressure within a confined myofacial space compromises neurovascular func(on
• Causes: – decreased compartment size (cast) – increased compartment contents
• fractures, crush injuries, burns, s/p surgery, trapped injuries
• Typically develops within 6 to 12 hours ager injury
103
![Page 104: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/104.jpg)
CarrieRocks, Wikimedia Commons 104
![Page 105: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/105.jpg)
Compartment Syndrome signs and symptoms
• Pain-‐ especially with passive flexion • This syndrome is characterized by:
– Pain that is out of propor(on to the injury – Pain on passive stretching of muscles within the compartment
– Pallor – Decreased sensa(on – Decreased power
105
![Page 106: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/106.jpg)
Nursing Management of Compartment Syndrome
• Remove restric(ve dressing, cast, splint etc. • Prep for OR or Surgical decompression: Fasciotomy
• Elevate injured area • No(fy MD STAT*
106
![Page 107: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/107.jpg)
Compartment Pressure Measurement
Intermedichbo, Wikimedia Commons 107
![Page 108: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/108.jpg)
Fasciotomy
Guyprocter, Wikimedia Commons 108
![Page 109: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/109.jpg)
Osteomyeli(s • Acute or chronic bone infec(on
• Risk factors include: Diabetes Hemodialysis Injected drug use Poor blood supply Recent trauma
109
![Page 110: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/110.jpg)
Osteomyeli(s Symptoms
• Bone pain • Fever • General discomfort, ill-‐feeling (malaise) • Local swelling, redness, warmth • Chills • Excessive swea(ng • Low back pain
110
![Page 111: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/111.jpg)
Osteomyeli(s
FB Axelrod et al, Wikimedia Commons Sarindam7, Wikimedia Commons 111
![Page 112: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/112.jpg)
Osteomyeli(s Treatment
• IV access • An(bio(cs IV • Possible surgical interven(on • Debridement • Revasculariza(on • Amputa(on
112
![Page 113: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/113.jpg)
South African Triage Scale
VERY URGENT
• Threatened limb • Disloca(on of larger joint • Fracture with break in skin (open)
URGENT
• Disloca(on of finger or toe • fracture with no break in skin (closed)
113
![Page 114: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/114.jpg)
Geriatric Considera(ons
• Bone fragility, frailness • Decrease in muscular strength and ROM • Chronic disease states-‐Osteoporosis • Loss of height with aging/kyphosis • Co-‐morbidi(es
114
![Page 115: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/115.jpg)
Pediatric Considera(ons
• Infant bones are only 65% ossified • Long bones are porous and less dense and can bend, buckle or break easily (Torus fx)
• Presence of epiphyseal/growth plates, if these are injured, can cause abnormal growth
• Periosteum is thicker and more vascular, healing occurs more quickly
• Vigilance of abuse-‐ injury inconsistent with history
115
![Page 116: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/116.jpg)
PARENT SUPPORT • Parents are trained and become active
participants in the physical therapy treatments and child’s stretching program
• Nurses need to help the parents understand the time commitment involved
• Assess the parents’ ability to monitor the child adequately for complications and confirm they understand the signs and symptoms of the
complications
116
![Page 117: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/117.jpg)
Medical-‐Legal Aspects of Pa(ent with Musculoskeletal Emergencies
• Abuse assessment -‐mul(ple stages of healing -‐injury inconsistent with history
• Informed consent pre surgical • Pa(ent privacy • Occupa(onal Safety • Health Risk Management Programs
117
![Page 118: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/118.jpg)
1. A young male has a musculoskeletal injury and is unresponsive. You will NOT be able to assess:
A. Skin integrity. B. distal pulses. C. capillary refill. D. sensory and motor func(ons.
118
![Page 119: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/119.jpg)
2. The purpose of splin(ng a fracture is to: A. reduce the fracture if possible. B. prevent mo(on of bony fragments.
C. reduce swelling in adjacent sog (ssues. D. force the bony fragments back into anatomic
alignment.
119
![Page 120: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/120.jpg)
3. Which of the following musculoskeletal injuries has the GREATEST risk for shock due to blood loss?
A. pelvic fracture B. posterior hip disloca(on C. unilateral femur fracture
D. proximal humerus fracture
120
![Page 121: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/121.jpg)
4. Tendons aGach a. bone to bone b. muscle to bone c. bone to adipose (ssue d. muscle to joints.
121
![Page 122: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/122.jpg)
• 5. Which medica(on does not effect the integrity of the musculoskeletal system?
a. chemotherapy b. an(-‐epilep(cs c. an(-‐eme(cs d. cor(costeroids
122
![Page 123: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/123.jpg)
• 6. What are the 6 P’s of neurovascular assessment when evalua(ng a musculoskeletal injury?
123
![Page 124: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/124.jpg)
• 7. What are the signs/symptoms of compartment syndrome? Select all that apply. a. Pallor b. Swelling c. Fever d. Pain out of propor(on to injury e. Redness f. Urinary reten(on
124
![Page 125: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/125.jpg)
• 8. Which are diseases/condi(ons that may effect the musculoskeletal system?
a. Rheumatoid arthri(s, Osteomyeli(s, Gout b. RickeGs, Myocardial Infarc(on, Pyelonephri(s c. CVA, Lupus, GERD d. hypertension, high cholesterol, diabetes
125
![Page 126: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/126.jpg)
9. What items do you want to have available and at bedside for a conscious seda(on?
126
![Page 127: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/127.jpg)
10. What does the acronym R.I.C.E. stand for and when would you use it?
127
![Page 128: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/128.jpg)
Further Ques(ons
128
![Page 129: GEMC - Musculoskeletal Emergencies - for Nurses](https://reader034.fdocuments.in/reader034/viewer/2022052504/554aeb25b4c9056a798b5812/html5/thumbnails/129.jpg)
Case Study
129