2Managing care of the patient in Cast: A rigid, external immobilizing deviceIs used to:Immobilize a reduced Fracture ( allow the mobilization of the pt)Correct a deformityApply uniform pressure to underlying soft tissueSupport and stabilize weakened Joint
3Types of Casts: Short arm cast 2.Long arm cast Short leg cast Long leg castWalking cast ( long or short) reinforced for strengthBody cast: encircle the trunkShoulder spica cast: a body jacket that enclosed the trunk and the shoulder and elbowHip spica cast: enclose the trunk and lower extremity ( double hip spica cast ( includes both legs
4Casting Materials:Plaster: Rolls of plaster bandage, need 24 to 72 hrs to dry completelyNonplaster: Fiberglass cast ( lighter in wt, stronger, water resistant), has pores so diminish skin problems
9Long-Arm and Short-Leg Cast and Common Pressure Areas
10Teaching Needs of the Patient With a Cast Prior to cast applicationExplain condition necessitating the castExplain purpose and goals of the castDescribe expectations during the casting process: eg, the heat from hardening plasterCast care: keep dry; do not cover with plasticPositioning: elevation of extremity; use of slingsHygieneActivity and mobility
11Cont… Explain exercises Do not scratch or stick anything under the castCushion rough edgesReport the following signs and symptoms: persistent pain or swelling; changes in sensation, movement, skin color, or temperature; and signs of infection or pressure areasRequired follow-up careCast removal
12Nursing Process—Assessment of the Patient With a Cast Prior to castingPerform general health assessmentEvaluate emotional statusDetermine presenting signs and symptoms and condition of the area to be castedKnowledgeMonitor neurovascular status and the potential for complications
13Nursing Process—Diagnosis of the Patient With a Cast Deficient knowledgeAcute painImpaired physical mobilitySelf-care deficitImpaired skin integrityRisk for peripheral neurovascular dysfunction
14Collaborative Problems/Potential Complications Compartment syndromePressure ulcerDisuse syndromeDelayed union or nonunion of fracture(s)
15Interventions Relieve pain Elevate to reduce edemaApply ice or cold intermittentlyImplement position changesAdminister analgesicsUnrelieved pain may indicate compartment syndrome; discomfort due to pressure may require change of castMuscle setting exercises: see Chart 67-3Patient teaching: see Chart 67-4
16Interventions (cont.) Heal skin wounds and maintain skin integrity Treat wounds to skin before the cast is appliedObserve for signs and symptoms of pressure or infectionPad cast and cast edgesPatient may require tetanus boosterMaintain adequate neurovascular statusAssess circulation, sensation, and movementFive “P’s”Notify physician at once of signs of compromiseElevate extremity no higher than the heartEncourage movement of fingers or toes every hour
17Managing patient with an External fixator: Are used to manage open fractures with soft tissue damage. They provide stable support for severe comminuted (crushed or splintered) fractures while permitting active treatment of damage soft tissue.Nursing intervention:Prepare the patient psychologicallyCover sharp points on the fixator or pins to prevent injuriesElevate the extremity to reduce swellingAssess neuromuscular status every 2 hrsAssess pin site for sign of infection and loosening of the pinPin careEncourage isometric and active exercise within the limit of tissue damage. Later the nurse help the patient to mobilize within the prescribed weight bearing limitTeaching patient self care
20Managing the patient in Traction: Is used as short-term intervention until other modalities, such as external or internal fixation are possible.Traction: is the application of a pulling force to a part of the bodyIs used to minimize muscle spasm, to reduce fractures, align and immobilize fractures, to reduce deformity.The effect of traction is evaluated by radioactive studies.
21Traction (cont.)All traction needs to be applied in two directions. The lines of pull are “vectors of force.” The result of the pulling force is between the two lines of the vectors of force.
22Managing the patient in Traction (cont…): Principle of effective traction:Countertraction must be maintained for effective tractionMust be continuous to be effectiveNever interruptedWeight are not removedThe patient must be in in good body alignment in the center of the bedRopes must be unobstructedWeight must hang freely
23Types of tractions: Nursing interventions: I. Skin traction: is used to control muscle spasm and to immobilize an area before surgery. No more than kg of traction should be used, pelvic traction 4.5 to 9 kg depending on the patient weightComplications:Skin breakdown, nerve pressure (drop foot), and circulatory impairment ( DVT)Nursing interventions:Ensuring effective tractionMonitor and managing potential complications
25Types of tractions (cont…): II. Skeletal traction: applied directly to the bone by using metal pin or wires. Most frequently used to treat fracture of long bones and the cervical spine. Is a surgical procedure. Skeletal traction uses 7-12 kg, as the muscle relax the traction weight is reduced to prevent fracture dislocation and to promote healingAfter removing the traction cast or splint are then used to support the healing bone.
27Nursing Interventions: Maintaining effective traction: the nurse should not remove wt from skeletal traction unless life-threatening situation occursMaintaining positioning: such as the foot to prevent footdrop (planter flexion), inward and outward rotation.Preventing skin breakdownMonitoring neuromuscular statusProviding pin site carePromoting exerciseAssess sensation and movementAssess pulses, color capillary refill, and temperature of fingers or toesAssess for indicators of DVTAssess for indicators of infection
28Joint Replacement:Total Hip Replacement: Is the replacement of a severely damaged hip with an artificial jointIndication: arrithritis, femoral neck fracture, failure of previous reconstructive surgeries, and problems resulting from congenital hip diseases.
31Cont… Nursing interventions: 1.Prevent dislocation: positioning the leg in abduction,don’t turn the patient in the affected side,never flex the hip more than 90 degree (don’t elevate the head of the bed more than 60 degreeprotective positioning include maintaining abduction, avoiding internal and external rotation, hyperextension, and a cute flexion
33Total knee replacement: Indication: sever pain and functioning disabilities related to joint surfaces destroyed by arrithritis, bleeding into the jointNursing interventions:Maintain the compressed bandage over the kneeIce may be applied to decrease the swelling and bleedingEncourage active flexion of the foot every hourPrevent complicationsMonitor drainage bagPlace the patient leg in continuous Passive motion device ( promote circulation and movement of the knee joint)Weight bearing limits are prescribed. Patient can get out of the bed the evening of the surgery or the day after surgery
36Management of patient with musculoskeletal disorders (chap 68)Management of patient with musculoskeletal disorders
37Acute low Back pain: Causes: A cut lumbosacral strain, unstable lumbosacral ligaments and weak muscles,osteoarithritis of the spine,spinal stenosis, intervertebral disk problems,and unequal leg length.Other causes include kidney diorders, pelvic problems, retroperitoneal tumors, abdominal aneurysims, obesity and stress.L4-L5 and L5-S1 has the greatest degenrative changes
38Clinical manifestations: A cute or chronic back pain lasting more than 3 months without improvement)FatiquePain radiating down the leg ( radiculopathy; Sciatica)Patient’s gait, spinal mobility, reflexes, leg length, leg motor strength and sensory perception may altered
39Cont… Assessment and diagnostic findings: Focused history and physical examination ( reflexes, sensory impairment, straight leg raising, muscle strengthX-ray of the spine, CT scan, MRIBone scan and blood studyMyelogram and dicogramElectromyogram and nerve conduction studiesMedical management: Analgesia, rest, stress reduction and relaxationReview the Nursing process
43Carpal Tunnel Syndrome Median Neuropathy at the Wrist is a medical condition in which the median nerve is compressed at the wristIrritation of the flexor tendon and median nerveManifestationsNumbness and tinglingThumbIndex fingerLateral ventral surface of the middle finger
44Tinel’s Sign—Assessment of Carpal Tunnel Syndrome
47possible treatments:treating any possible underlying disease or condition, immobilizing braces, physiotherapy, massage therapy, medicationUltimately, carpal tunnel release surgery may be required in which outcomes are generally good
48Metabolic bone disorders: I.Osteoporosis: Is characterized by a reduction in the total bone mass and a changes in bone structure which increases the tendency for fracture.The rate of bone resorption is greater than the rate of bone formation, resulting in a reduced total bone mass.The bones become porous, brittle, and fragileResult in compression fractures of the thoracic and lumber spine, fractures of the neck, intertrochanteic region of the femur, and colle’s fracture of the wristPathophysiology:Loss of bone mass over time due to Aged-related loss: Decreased calcitonin, decreased estrogen ( which prevent bone breakdown), parathyroid hormone increases with age result in increase bone Resorption
50Risk factors: see chart 68-7 Assessment and diagnostic findings:Routine X-ray, and bone sonometerLab. Studies: Serum Ca, Serum Ph, urine calcium excretion, ESRMedical Management:Adequate balanced diet rich in calcium and Vit DRegular weight bearing exercise promotes bone formationPharmacological therapy: Hormonal replacement therapy ( look for side effect of estrogen and progesterone replacement therapy which result in cancers… thus frequent breast examination is recommended )Alendronate alternative to Hormonal replacement therapy: inhibiting osteoclast function and dedcreases bon lossCalcitonin: suppress bone loss
51Progressive Osteoporosis Bone Loss and Compression Fractures
52Osteoporosis Manifestations : Loss of height Progressive curvature of spineLow back painFractures of forearm, spine, hipDevelopment of “dowager’s hump”Dorsal kyphosisCervical lordosis
53Typical Loss of Height Associated With Osteoporosis and Aging
54PreventionFollow a balanced diet high in calcium and vitamin D throughout lifeUse calcium supplements to ensure adequate calcium intake: take in divided doses with vitamin DRegular weight bearing exercises: walkingWeight training stimulates bone mineral density (BMD)See Chart 68-8
55Musculoskeletal Infections: Osteomylitis Is an infection of the bone through three ways ( extension of soft tissue infection, Direct bone contamination from bone surgery, Hematogenous spread (blood born).More difficult to eradicate than soft tissue infectionPathophysiology:Staphylococcus aureus causes 70% to 80% of bone infectionProcess of infection (inflammation, edema, thrombosis of the blood vessels result in ischemia with bone necrosis, which may progress to form bone abscessClinical manifestations: chills, high fever, rapid pulse, pain, swollen area, and tenderness and drainageAssessment and diagnostic Findings:X-ray (shows soft tissue swelling, later bone decalcification and necrosis), MRI, Lab test (leukocytosis, and increased ESR), wound and blood culture
57OsteomyelitisDeep sepsis after arthroplasty may be classified as follows:Stage 1, acute fulminating: occurring during the first 3 months after orthopedic surgery; frequently associated with hematoma,drainage, or superficial infectionStage 2, delayed onset: occurring between 4 and 24 months after surgeryStage 3, late onset: occurring 2 or more years after surgery, usually as a result of hematogenous spread
58Cont…..Prevention: treat all sources of infection, Aseptic surgery, Prophylactic antibiotics, Aseptic postoperative care.Medical management:Pharmacological therapy: Intravenous antibiotic according to the wound cultureSurgical management: expose the bone surgically to remove infected and necrotic materials and irrigating the area with normal saline, direct application of antibiotics surgical (débridement).
59Goutalso called metabolic arthritis) is a disease created by a buildup of uric acid)Characterized by sudden, unexpected, burning pain, as well as swelling, redness, warmness, and stiffness in the affected joint. Low-grade fever may also be present.
61GoutTreat acute attacks before treatment to reduce serum uric acid levelsNSAIDsColchicineCorticosteroidsAnalgesicsUricosuricAllopurinol
62Management of Patients With Musculoskeletal Trauma Chapter 69Management of Patients With Musculoskeletal Trauma
63Injuries of the Musculoskeletal System Contusion: soft tissue injury produced by blunt forcePain,swelling,and discoloration: ecchymosisSkin remains intact
64Strainpulled muscle-injury (stretching) to the musculocutaneous unit (muscle or muscle tendone.Common sites: lower back and cervical.ManifestationsPainLimited motionMuscle spasmsSwellingMuscle weaknessEcchymosis
65Sprain injury to ligaments and supporting muscle fiber around a joint Joint is tendermovement is painful;edema,disability,and pain increase during the first 2 to 3 hoursCommon sites: Ankle and knee
66Management 1. X-ray may be done to rule out fracture. 2. Immobilize in splint, elastic wrap3. Apply ice for first 24 hours.4. AnalgesicsSevere sprains may require surgical repair and/or cast immobilization.Nursing Interventions/Patient Education
67Joint Dislocation articular surfaces of the joint are not in contact A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobilityMost commonShoulderAcromioclavicular jointsSubluxationPartial dislocation
68Fractures:Is a break in the continuity of bone and is defined according to type and extentOccurs when the bone is subjected to stress greater than it can absorb.Can cause by a direct blow, crushing force, sudden twisting motion, and extreme muscle contraction.
69Types of fractures:Complete fracture: break across the entire cross-section of the bone and is frequently displacedIncomplete fracture: (green stick fracture) the break occur through only part of the cross-sectional of the boneA comminuted fracture: fracture has several bone fragmentsClosed fracture: simple fracture does not produce a break in the skinCompound, complex fracture (open fracture): is one in which the skin or mucous membrane wound extends to the fracture bone
70Cont… Grade I: clean wound less than 1 cm Grade II: larger wound without extensive soft tissue damageGrade III: is highly contaminated, has extensive soft tissue damage, and is the most severe
74Manifestations of Fracture PainLoss of functionDeformityShortening of the extremityCrepitusLocal swelling and discolorationDiagnosis by symptoms and x-rayPatient usually reports an injury to the area
75Emergency Management Immobilize the body part Splinting: joints distal and proximal to the suspected fracture site must be supported and immobilizedAssess neurovascular status before and after splintingOpen fracture: cover with sterile dressing to prevent contaminationDo not attempt to reduce the fracture
76Medical Management Reduction ClosedOpenImmobilization: internal or external fixationOpen fractures require treatment to prevent infectionTetanus prophylaxis, antibiotics, and cleaning and debridement of woundClosure of the primary wound may be delayed to permit edema, wound drainage, further assessment, and debridement if needed
77Three Phases of Fracture Healing Inflammatory phaseReparative phase: collagen formation and calcium depositionRemodeling phase:1. Excess callus is removed2. New bone is laid down3. Fracture site calcifies4. Bone is reunited
78Factors enhancing fracture healing: Immobilize of fracture fragmentsMaximum bone fragment contactSufficient blood supplyProper nutritionExercise: wt bearing for long boneHormones: growth hormone, thyroid, calcitonin, Vit. DElectric potential across fracture
79Factors inhibiting fracture healing Extensive local trauma, Bone loss, inadequate immobilizationSpace/tissue between bone fragments, infectionLocal malignancy, Metabolic bone diseaseIrradiated bone (radiation necrosis)Avascular necrosisIntra-articular fractureAgeCorticosteroids (inhibit the repair rate)
80Fracture Complications Early complications:Shock: Hypovolemic or traumatic shockresult from bleeding or from loss of extracellular fluidTreatment:1. Restoring blood volume and circulation2. Releiving patient pain3. Provide adequate splinting.
81Compartment Syndrome 2.develop when tissue perfusion in the muscles less than that required for tissue viability.PhysiologyEntrapment of the blood vessels limits tissue perfusionResults in edema within the compartmentEdema causes further pressureEarly ManifestationsDeep Pain which is not controlled by opioidsNormal or decreased peripheral pulseLater ManifestationsCyanosisParesthesias, paresisSevere pain
82Treatment Interventions to alleviate pressure Removal of the cast Fasciotomy
833. Fat Embolism Syndrome Pathophysiology Bone fracture results in a rise of pressure in the bone marrowFat globules enter the bloodstreamCombine with plateletsTravel throughout the bodyOccluding small blood vesselsCauses tissue ischemia
84Fat Embolism Syndrome Manifestations Confusion Changes in level of consciousnessPulmonary edemaImpaired surfactant productionAtelectasisARDS
85Fat Embolism Syndrome Prevention Early stabilization of long bone fracture.Treatment:Intubation and mechanical ventilationFluid balanceCorticosteroidsVasoactive medication to support the cardiovascular system and prevent hypotension.
864. Deep Vein Thrombosis Manifestations Swelling Leg pain Tenderness CrampingSome are asymptomaticDiagnosisDoppler ultrasound
87Deep Vein Thrombosis Treatment Bed rest Thrombolytic agents Heparin Vena cava filterThrombectomyPrevention is the best treatmentEarly immobilization of fracturesEarly mobilization of the client
885. DIC 6. Infection Delayed complications: Cont…..5. DIC6. InfectionDelayed complications:Delayed Union: Delay healing, which result from infection and distraction of bone fragment, poor nutritionNonunion: failure of the ends of the fractured bone to unite, pt complain of discomfort and abnormal movement at the fracture site. Managed by internal fixation or graftingResult from infection, interposition of tissue between the bone ends, inadequate immobilization, excessive space, and impaired blood supply
89Reaction to internal fixation device Cont….3. Avascular necrosis of the bone: Disruption of the blood supply, dislocation, bone transplantation, prolonged high doses of corticosteroids, chronic renal disease, sickle cell anemia.Reaction to internal fixation device
90Amputation Partial or total removal of a body part May be the result of an acute event or a chronic conditionRisk FactorsPeripheral vascular diseaseHypertensionDiabetesSmokingPeripheral neuropathyHyperlipidemiaTrauma
91Amputation Pathophysiology Interruption of blood flow Circulation impairmentEdema developmentStatus ulcers develop/become infectedDevelopment of gangrene
92Amputation Types of Amputation Above or below the elbow: arm amputationLeg amputationBelow the knee (BKA)Above the knee (AKA)Open amputation (Guillotine)Closed (flap) amputation
93Figure 41–12 Common sites of amputation. A, The upper extremities Figure 41–12 Common sites of amputation. A, The upper extremities. B, The lower extremities. The surgeon determines the level of amputation based on blood supply and tissue condition.
94Figure 41–12 Common sites of amputation. A, The upper extremities Figure 41–12 Common sites of amputation. A, The upper extremities. B, The lower extremities. The surgeon determines the level of amputation based on blood supply and tissue condition.
95Amputation Post Amputation Care Rigid or compression dressing is appliedPrevents infectionMinimize edemaComplicationsInfectionDelayed healingChronic stump painContracture
96Figure 41–13 Stump dressings increase venous return, decrease edema, and help shape the stump for a prosthesis. With an above-knee amputation, a figure-eight bandage is started by bringing the bandage down over the stump and back up around the hips.