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Nursing of Adults with Medical & Surgical Conditions

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Presentation on theme: "Nursing of Adults with Medical & Surgical Conditions"— Presentation transcript:

1 Nursing of Adults with Medical & Surgical Conditions
Fractures & Complications of Fractures

2 Arthroplasty Knee Arthroplasty (total knee replacement)
Replacement of the knee joint Restore motion of the joint, relieve pain, or correct deformity

3 Arthroplasty Hip Arthroplasty (total hip replacement)
Replacement of the hip joint

4 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 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

5 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

6 Fracture of the Hip Signs & Symptoms Severe pain at site
Inability to move the leg voluntarily Shortening or external rotation of the leg

7 Fracture of the Hip Diagnostic Tests Radiographic examination
Hemoglobin may be decreased because of bleeding

8 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)

9 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

10 Fracture of the Hip Maintain leg abduction Turn to unoperative side
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

11 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

12 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

13 “DO NOT” List

14 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

15 Types of Fractures Open (compound)
Protrusion of the bone through the skin Require surgical repair Prone to infection

16 Closed (simple) Bone has NOT protruded through the skin
May be realigned by external manipulation

17 Types of Fractures Greenstick fracture Incomplete fracture
Extends only partially through the bone Common in children because bones are more flexible

18 Types of Fractures Complete fracture
Fracture line extends entirely through the bone with the periosteum disrupted on both sides of the bone

19 Types of Fractures Comminuted fracture
Bone is splintered into three or more fragments at the site of the break More than one fracture line

20 Types of Fractures Impacted fracture
One bone fragment is forcibly wedged into another bone fragment.

21 Types of Fractures Transverse fracture
Break runs directly across the bone.

22 Types of Fractures Oblique fracture
Break runs along a slant to the length of the bone.

23 Types of Fractures Spiral fracture Break coils around the bone.
Usually caused by a twisting force.

24 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

25 Types of Fractures Pott’s Fracture
Occurs at the distal end of the fibula A piece of the medial malleolus chips off. Medial Malleolus Posterior Left Foot

26 Fractures Bone Repair

27 Assessment Seven P’s of Orthopedic Assessment Pain Pallor
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

28 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)

29 Fractures Diagnostic Tests Radiographic examination

30 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

31 Fractures Treatment (Secondary Management) Closed (simple)
closed reduction traction open reduction with internal fixation device immobilization external fixation device internal fixation devices; pins, screws, plates

32 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

33 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

34 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

35 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

36 Fracture of the Pelvis Etiology/pathophsiology
Trauma involving great force falls from extreme heights automobile accidents crushing accidents

37 Fracture of the Pelvis Signs & Symptoms
Unable to bear weight without discomfort Pelvic tenderness and edema Hematuria (bladder trauma) Signs of shock

38 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

39 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

40 Complications of Fractures
Treatment Fasciotomy (incision into the fascia) Complication Volkmann’s contracture (clawhand)

41 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

42 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

43 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

44 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

45 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

46 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

47 Skeletal Pin External Fixation

48 Skeletal Pin External Fixation

49 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

50 Cast Removal Uses a vibrating saw Skin Care Muscle Atrophy
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

51 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

52 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

53 Balanced Suspension Skeletal Traction

54 Tibial Pin Traction with Steinmann Pin

55 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.

56 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

57 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

58 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

59 Amputation Amputation of a portion of or an entire extremity
Malignant tumors Injuries Impaired circulation Congenital deformities Infections

60 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

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