Transcript Nursing of Adults with Medical & Surgical Conditions
Nursing of Adults with Medical & Surgical Conditions
Fractures & Complications of Fractures
Arthroplasty
Knee Arthroplasty (total knee replacement) – Replacement of the knee joint – Restore motion of the joint, relieve pain, or correct deformity
Arthroplasty
Hip Arthroplasty (total hip replacement) – Replacement of the hip joint
Arthroplasty
Nursing Interventions – Empty and record hemovac – Give oxygen 2-3 l/min – Incentive spirometer q 2hrs – Cough and deep breathe q 2hrs – Record I&O – Bed rest 24-48 hrs – Change dressing as ordered – Diet as ordered – Neurovascular checks q1hr x24, q2hrs x24, then q4hrs – Vital sighs q 4hrs – Maintain position of operative area – Physical therapy will initiate ambulation and prescribe routine – Encourage fluid intake – Antiembolisim stockings – Avoid adduction and hyperflexion of hip
Fracture of the Hip
Etiology/pathophysiology – Most common type of fracture – Women higher risk due to osteoporosis – Types of hip fractures • Intracapsular – inside the joint • Extracapsular – outside the hip joint
Fracture of the Hip
Signs & Symptoms – Severe pain at site – Inability to move the leg voluntarily – Shortening or external rotation of the leg
Fracture of the Hip
Diagnostic Tests – Radiographic examination – Hemoglobin may be decreased because of bleeding
Fracture of the Hip
Treatment – Buck’s or Russell’s traction until surgery – Surgical repair • Internal fixation – Neufeld nail and screws – Kuntscher nail (intramedullary rod) • Prosthetic implants – Austin Moore prosthesis – Bipolar hip replacement (hemiarthroplasty)
Fracture of the Hip
Postoperative interventions – Wound assessment – Vital signs – Assessment of drains • Jackson-Pratt, Hemovac – Incentive spirometer – Turning q 2 hours – Antiembolic stockings – Anticoagulation therapy
Fracture of the Hip
– Maintain leg abduction • abduction pillow – Turn to unoperative side – Limit weight bearing on affected side – Chairs and commode seats should be raised to prevent flexion of hip beyond 60 degrees
Fracture of the Hip
Patient teaching for ORIF – Assess ability to understand – Assist to dangle at bedside – No weight on operative side – Turn every 2 hours, maintain abduction – Assist with ROM – PT will instruct as to ambulation and weight bearing – As pt. progresses, encourage to continue to ambulate only with assistance
Fracture of the Hip
Patient Teaching for Hip Prosthetic Implant – Avoid hip flexion • beyond 60 degrees for approximately 10 days • beyond 90 degrees for 2 to 3 months – Avoid adduction of the affected leg beyond midline for 2 to 3 months – Maintain partial weight bearing for approx. 2 to 3 months – Avoid positioning on the operative side in bed – Maintain abduction of the hip – “DO NOT” list
“DO NOT” List
Other Fractures
Etiology/Pathophysiology – A traumatic injury to a bone in which the continuity of the tissue of the bone is broken.
– Pathological or spontaneous fractures • occur without trauma • osteoporosis, metastatic cancer and bone tumors
Types of Fractures
Open (compound) – Protrusion of the bone through the skin – Require surgical repair – Prone to infection
Closed (simple) – Bone has NOT protruded through the skin – May be realigned by external manipulation
Types of Fractures
Greenstick fracture – Incomplete fracture – Extends only partially through the bone – Common in children because bones are more flexible
Types of Fractures
Complete fracture – Fracture line extends entirely through the bone with the periosteum disrupted on both sides of the bone
Types of Fractures
Comminuted fracture – Bone is splintered into three or more fragments at the site of the break – More than one fracture line
Types of Fractures
Impacted fracture – One bone fragment is forcibly wedged into another bone fragment.
Types of Fractures
Transverse fracture – Break runs directly across the bone.
Types of Fractures
Oblique fracture – Break runs along a slant to the length of the bone.
Types of Fractures
Spiral fracture – Break coils around the bone.
– Usually caused by a twisting force.
Types of Fractures
Colles’ Fracture – Distal portion of the radius within 1 inch of the joint of the wrist – Commonly occurs when a person attempts to break a fall by putting their hands down
Types of Fractures
Pott’s Fracture – Occurs at the distal end of the fibula – A piece of the medial malleolus chips off.
Posterior Left Foot Medial Malleolus
Bone Repair
Fractures
Assessment
Seven P’s of Orthopedic Assessment – Pain • Does it seem out of proportion to the patient’s injury?
• Does it increase with active or passive motion?
– Pallor – Paresthesia or numbness – Paralysis – Polar Temperature • Is it cold compared to opposite extremity?
– Puffiness from edema or hematoma – Pulselessness
Fractures
Signs & Symptoms – Pain – Loss of normal function – Obvious deformity – Change in the curvature or length of bone – Crepitus (grating sound with movement) – Soft tissue edema – Warmth over injured area – Ecchymosis of skin surrounding injured area – Loss of sensation distal to injury – Signs of shock (injury, blood loss, & pain)
Fractures
Diagnostic Tests – Radiographic examination
Fractures
Treatment (Immediate) – Splinting to prevent edema – Body alignment – Elevation of body part – Application of cold packs, first 24 hours – Administration of analgesics – Observation for change in color, sensation, or temperature – Observe for signs of shock
Fractures
Treatment (Secondary Management) – Closed (simple) • closed reduction • traction • open reduction with internal fixation device • immobilization – external fixation device – traction – internal fixation devices; pins, screws, plates
Fractures
Treatment (secondary management) – Open (compound) • Surgical debridement of wound – remove dirt, tissue, etc.
• Administration of tetanus toxoid • Culture of wound • Observation for signs of infection • Closure of wound • Reduction of fracture • Immobilization of fracture • Treatment of complications
Fracture of the Vertebrae
Etiology/pathophysiology – Diving accidents – Blows to the head or body – Osteoporosis – Metastatic cancer – Motorcycle and car accidents – Displaced fracture may place pressure on or sever the spinal cord nerves
Fracture of the Vertebrae
Signs & Symptoms – Pain at site of injury – Partial or complete loss of mobility or sensation below level of injury – Evidence of fracture/ fracture dislocation on x-ray
Fracture of the Vertebrae
Treatment – Stable injuries • pain medication • muscle relaxants • back support, brace or cast – Unstable fractures • Traction – Cranial skeletal traction » Halo brace – Pelvic traction • Open reduction – Harrington rod
Fracture of the Pelvis
Etiology/pathophsiology – Trauma involving great force • falls from extreme heights • automobile accidents • crushing accidents
Fracture of the Pelvis
Signs & Symptoms – Unable to bear weight without discomfort – Pelvic tenderness and edema – Hematuria (bladder trauma) – Signs of shock
Fracture of the Pelvis
Treatment – Bed rest for approx. 3 weeks – Ambulate with crutches for approx. 6 weeks – More severe fractures may require surgery and/or spica or body cast
Complications of Fractures
Compartment Syndrome – Cause • Caused by the progressive development of arterial vessel compression and reduced blood supply to an extremity.
– Signs & Symptoms • Sharp pain with movement, numbness or tingling in the affected extremity, cool & pale or cyanotic, slow capillary refill
Complications of Fractures
– Treatment • Fasciotomy (incision into the fascia) – Complication • Volkmann’s contracture (clawhand)
Complications of Fractures
Shock – Cause – Blood loss, pain, fear – Signs & Symptoms – Altered level of consciousness – Restlessness – Hypotension, tachycardia, & tachypnea – Pale, cool, moist, skin – Treatment – Restore blood volume » IV fluids - LR » Administer blood – Oxygen – Shock trousers
Complications of Fractures
Fat Embolism – Cause • Emoblization of tissue fat with platelets • Most common with multiple fractures and long bone fractures – Signs & Symptoms • Irritability, restlessness,disorientation, stupor, and coma due to hypoxemia • Chest pain and dyspnea – Treatment • IV fluids • Steroids (reduce inflammation) • Digoxin (increase cardiac output) • Oxygen
Complications of Fractures
Gas Gangrene – Cause • Severe infection of the skeletal muscle by Clostridium bacteria – Signs & Symptoms • Pain at site of injury • Gas bubbles under the skin • Signs of infection • Necrotic skin at site • Foul odor from wound drainage – Treatment • Excision of gangrenous tissue • Antibiotics - Penicillin G or Keflin • Strict aseptic technique
Complications of Fractures
Thromboembolus – Cause • Blood vessel is occluded by an embolus – Signs & Symptoms • Area may tingle and become cold, numb, and cyanotic • Embolus in the lungs cause a sharp thoracic or upper abdominal pain, dyspnea, cough, fever, and hemoptysis – Treatment • Anticoagulants – Heparin and/or coumadin
Complications of Fractures
Delayed Fracture Healing – Delayed Union • Fails to heal within the usual time • Healing is impaired but will eventually repair itself – Nonunion • Failure of the ends of the fractured bone to unite • Fails to unite and produce a stable union after 6-9 months • Requires bone grafting, prosthetic implant, internal fixation, external fixation, or a combination of these methods • Electrical stimulation – New method to promote healing – Stimulates bone production
External Fixation Devices
Skeletal Pin External Fixation – Immobilizes fractures by the use of pins inserted through the bone an attached to a rigid external metal frame – Pin Care • Assess every 8 hours for s/s of infection • Remove exudate and clean with hydrogen peroxide using aseptic technique
Skeletal Pin External Fixation
Skeletal Pin External Fixation
Nonsurgical Interventions
Casts – Made of layers of plaster of paris, fiberglass, or plastic roller bandages.
– Stockinette applied, a sheet of wadding, and then casting material – Nursing Assessment • Neurovascular assessment q 15 to 30 min. for first few hours then q 4hours • Assess skin at the cast edges for erythema and irritation.
• Assess for odor or drainage from under cast
Cast Removal – Uses a vibrating saw • Does not cut • Causes fine powder – Wear mask – Skin Care • Gently remove buildup of secretions and dead skin by washing and apply lotion – May take several days – Be careful not to remove rapidly, can cause skin impairment – Muscle Atrophy • Reassure patient that the muscle will regain strength and size with proper exercise
Traction
The process of putting an extremity, bone, or group of muscles under tension by means of weights and pulleys to: – align and stabilize a fracture site – relieve pressure on nerves – maintain correct positioning – prevent deformities – relieve muscle spasms
Types of Traction
Skeletal – Applied directly to a bone – The pin protrudes through the skin on both sides of the extremity and weights are attached to a rope – Used for fractures of the femur, tibia, humerus, and cervical spine
Balanced Suspension Skeletal Traction
Tibial Pin Traction with Steinmann Pin
Types of Traction
Skin Traction – Uses weight that pulls on sponge rubber, moleskin, elastic bandage with adherent, or plastic material attached to the skin below the fracture, with the pull exerted on the limb.
Types of Traction
– Buck’s • Used as a temporary measure to provide support and comfort to a fractured extremity until a more definite treatment is initiated • Traction in in horizontal plane with affected extremity
Types of Traction
– Russell Traction • Similar to Buck’s except that a knee sling is used to provide support to the affected leg.
• Used to treat hip and knee fractures
Types of Traction
– Bryant’s Traction • Both legs are suspended at a 90 degree angle to the trunk of the body and the weight of the lower body pulls the bone fragments of the fractured leg into alignment • Used for small children with fractured femurs
Amputation
Amputation of a portion of or an entire extremity – Malignant tumors – Injuries – Impaired circulation – Congenital deformities – Infections
Amputation
Postoperative Nursing Interventions – Raise foot of bed to elevate extremity • do not elevate on pillow, may cause contracture – Encourage movement from side to side & place in prone position at least 2 times a day to stretch muscles – Teach strengthening exercises – Elastic wraps to shape residual extremity – Assess for respiratory complications, esp in elderly – Phantom-limb pain is normal