VIEWS: 3 PAGES: 60 POSTED ON: 6/13/2014
Nursing of Adults with Medical & Surgical Conditions Fractures & Complications of Fractures Arthroplasty n Knee Arthroplasty (total knee replacement) – Replacement of the knee joint – Restore motion of the joint, relieve pain, or correct deformity Arthroplasty n Hip Arthroplasty (total hip replacement) – Replacement of the hip joint Arthroplasty n 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 n 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 n Signs & Symptoms – Severe pain at site – Inability to move the leg voluntarily – Shortening or external rotation of the leg Fracture of the Hip n Diagnostic Tests – Radiographic examination – Hemoglobin may be decreased because of bleeding Fracture of the Hip n 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 n 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 n 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 n 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 n 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 n Open (compound) – Protrusion of the bone through the skin – Require surgical repair – Prone to infection n Closed (simple) – Bone has NOT protruded through the skin – May be realigned by external manipulation Types of Fractures n Greenstick fracture – Incomplete fracture – Extends only partially through the bone – Common in children because bones are more flexible Types of Fractures n Complete fracture – Fracture line extends entirely through the bone with the periosteum disrupted on both sides of the bone Types of Fractures n Comminuted fracture – Bone is splintered into three or more fragments at the site of the break – More than one fracture line Types of Fractures n Impacted fracture – One bone fragment is forcibly wedged into another bone fragment. Types of Fractures n Transverse fracture – Break runs directly across the bone. Types of Fractures n Oblique fracture – Break runs along a slant to the length of the bone. Types of Fractures n Spiral fracture – Break coils around the bone. – Usually caused by a twisting force. Types of Fractures n 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 n Pott’s Fracture – Occurs at the distal end of the fibula – A piece of the medial malleolus chips off. Medial Malleolus Posterior Left Foot Fractures n Bone Repair Assessment n 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 n 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 n Diagnostic Tests – Radiographic examination Fractures n 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 n 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 n 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 n 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 n 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 n 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 n Etiology/pathophsiology – Trauma involving great force • falls from extreme heights • automobile accidents • crushing accidents Fracture of the Pelvis n Signs & Symptoms – Unable to bear weight without discomfort – Pelvic tenderness and edema – Hematuria (bladder trauma) – Signs of shock Fracture of the Pelvis n 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 n 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 n 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 n 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 n 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 n 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 n 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 n 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 n 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 n 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 n 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 n 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 n 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 n Amputation of a portion of or an entire extremity – Malignant tumors – Injuries – Impaired circulation – Congenital deformities – Infections Amputation n 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
"Nursing of Adults with Medical _ Surgical Conditions"