Chapt69-Mgt Pt's Musculoskeletal Trauma

7/29/2019 Chapt69-Mgt Pt's Musculoskeletal Trauma

1/59

Copyright 2008 Lippincott Williams & Wilkins.

Chapter 69

Management of Patients withMusculoskeletal Trauma


2/59


Injuries of the Musculoskeletal System

Contusion:soft tissue injury produced by bluntforce

Pain, swelling, and discoloration: ecchymosis

Strain: pulled muscle-injury to themusculocutaneous unit

Pain, edema, muscle spasm, ecchymosis, andloss of function are on a continuum graded 1st ,2nd, and 3rd degree


3/59


Injuries of the Musculoskeletal System(cont.)

Sprain: injury to ligaments and supporting musclefiber around a joint

Joint is tender and movement is painful; edema,disability, and pain increase during the first 2 to3 hours

Dislocation: articular surfaces of the joint are not incontact

A traumatic dislocation is an emergency withpain change in contour, axis, and length of the

limb and loss of mobility


4/59


Common Sports-Related Injuries

Contusions, strains, sprains, and dislocations

Tendonitis: inflammation of a tendon by overuse

Meniscal injuries of the knee occur with excessiverotational stress

Traumatic fractures

Stress fractures


5/59


Knee Ligaments, Tendons, and Menisci


6/59


Prevention of Sports-Related Injuries

Use of proper equipment: running shoes for runners,wrist guards for skaters, etc.

Effective training and conditioning specific for the personand the sport

Stretching prior to engaging in a sport or exercise hasbeen recommended but may not prevent injury

Changes in activity and stresses should occur gradually Time to cool down

Tune in to the body; be aware of limits and capabilities

Modify activities to minimize injury and promote healing


7/59Copyright 2008 Lippincott Williams & Wilkins.

Occupational-Related Injuries

Common injuries include strains, sprains, contusions,fractures, back injuries, tendonitis, and amputations

Prevention measures include personnel training,proper use of equipment, availability of safety andother types of equipment (patient lifting equipment,back belts), correct use of body mechanics, andinstitutional policies



Types of Fractures

Complete

Incomplete Closed or simple

Open or compound/complex

Grade I Grade II

Grade III



Types of Fractures (cont.)



Types of Fractures



Manifestations of Fracture

Pain

Loss of function

Deformity

Shortening of the extremity

Crepitus

Local swelling and discoloration

Diagnosis by symptoms and x-ray

Patient usually reports an injury to the area



Emergency Management

Immobilize the body part

Splinting: joints distal and proximal to thesuspected fracture site must be supported andimmobilized

Assess neurovascular status before and after

splinting Open fracture: cover with sterile dressing to

prevent contamination

Do not attempt to reduce the fracture



Medical Management

Reduction

Closed

Open

Immobilization: internal or external fixation

Open fractures require treatment to prevent infection

Tetanus prophylaxis, antibiotics, and cleaning anddebridement of wound

Closure of the primary wound may be delayed topermit edema, wound drainage, furtherassessment, and debridement if needed



Techniques of Internal Fixation



Nursing Management of the PatientWith a Simple Fracture

Assessment: include neurovascular assessment, pain,

activity limitations, patient knowledge, and homeenvironment and support

Goal is to have patient return to usual activities as soonas possible

Patient teaching is a primary intervention as the patientwill usually be cared for in the home setting

See Chart 69-2



Complications of Fractures

Factors that affect fracture healing: see Chart 69-3

Shock

Fat embolism

Compartment syndrome

Delayed union and nonunion

Avascular necrosis Reaction to internal fixation devices

Complex regional pain syndrome (CRPS)

Heterotrophic ossification



Cross Sections of Anatomic Compartments



Wick Catheter Used to MonitorCompartment Pressure



Bone Healing Stimulator



Rehabilitation Related toSpecific Fractures

Clavicle

Use of claviclar strap (figure 8) or sling

Exercises

Limitation of activities

Do not elevate arm above shoulder for approximately

6 weeks

Humeral neck and shaft fractures

Slings and bracing

Activity limitations and pendulum exercises



Fracture of Clavicle andImmobilization Device


23/59


Prescribed Shoulder Exercises(Clavicle Fractures)


24/59


Immobilizers for Proximal HumeralFractures


25/59


Functional Humeral Brace


26/59



Elbow fractures

Monitor regularly for neurovascular compromise andsigns of compartment syndrome

Consider potential for Volkmann's contracture: seeChart 69-4

Encourage active exercises and ROM to preventlimitation of joint movement after immobilizationand healing (4 to 6 weeks for nondisplaced, casted)or after internal fixation (about 1 week)


27/59


Rehabilitation Related to SpecificFractures (cont.)

Colles fracture

Early functional rehabilitation exercises

Active motion exercises of fingers and shoulder

Pelvic fractures

Management depends upon type and extent offracture and associated injuries

Stable fractures are treated with a few days bedrest and symptom management

Early mobilization reduces problems related to

immobility


28/59


Rehabilitation Related to SpecificFractures (cont.)

Hip fracture

Surgery is usually done to reduce and fixatethe fracture

Care is similar to that of a patient undergoingother orthopedic surgery or hip replacementsurgery


29/59


Pelvic Bones


30/59


Stable Pelvic Fractures


31/59


Unstable Pelvic Fractures


32/59


Regions of the Proximal Femur


33/59


Examples of Internal Fixation forHip Fractures


34/59



Femoral shaft fractures

Lower leg, foot, and hip exercises to preservemuscle function and improve circulation

Early ambulation stimulates healing

Physical therapy, ambulation, and weight bearingare prescribed

Active and passive knee exercises are begun assoon as possible to prevent restriction of knee

movement


35/59


Rehabilitation Related toSpecific Fractures (cont.)

Uncomplicated rib fractures

Chest strapping is not used

Encouraged to cough and deep breathe


36/59


Femoral Fractures


37/59


Stretch Spica Wrap


38/59



Thoracolumbar spine fractures

Usually treated conservatively with limited bedrest

Avoid sitting

Progressive ambulation

Emphasize good posture and body mechanics

Implement back strengthening exercises


39/59


Nursing Process

Assessment of thePatient With Fracture of the Hip

Health history and presence of concomitant problems

Pain VS, respiratory status, LOC, and signs and symptoms

of shock

Affected extremity including frequent neurovascular

assessment

Bowel and bladder elimination, bowel sounds, and I&O

Skin condition

Anxiety and coping


40/59


Nursing ProcessDiagnosis of thePatient With Fracture of the Hip

Acute pain

Impaired physical mobility

Impaired skin integrity

Risk for impaired urinary elimination

Risk for ineffective coping

Risk for disturbed thought processes


41/59


Collaborative Problems/PotentialComplications

Hemorrhage

Peripheral neurovascular dysfunction

DVT

Pulmonary complications

Pressure ulcers


42/59


Nursing ProcessPlanning the Care of thePatient With Fracture of the Hip

Major goals include pain relief; achievement of apain-free, functional, and stable hip; healedwound; maintenance of normal urinary eliminationpattern; use of effective coping mechanisms; anoriented patient who participates in decisionmaking; and absence of complications


43/59


Relief of Pain

Administer analgesics as prescribed

Use of Bucks traction as prescribed

Handle extremity gently

Support extremity with pillows and when moving

Position for comfort

Provide frequent position changes

Provide alternative pain relief methods


44/59


Prompting Physical Mobility

Maintain neutral position of hip

Use trochanter rolls

Maintain abduction of hip

Implement isometric, quad-setting, and gluteal-setting exercises

Use trapeze

Use ambulatory aids

Consult with physical therapy


45/59


Interventions Use aseptic technique with dressing changes

Avoid/minimize use of indwelling catheters

Support coping

Provide and reinforce information

Encourage the patient to express concerns

Support coping mechanisms Encourage the patient to participate in decision

making and planning

Consult social services or other supportive services


46/59


Interventions (cont.)

Orient patient to and stabilize the environment

Provide for patient safety

Encourage participation in self-care

Encourage coughing and deep breathing exercises

Ensure adequate hydration

Apply TED hose or SCDs as prescribed

Encourage ankle exercises

Provide patient and family teaching


47/59


Rehabilitation of Patients WithAmputation

Amputation may be congenital, traumatic, or due

to conditions such as progressive peripheralvascular disease, infection, or malignant tumor

Amputation is used to relieve symptoms, improvefunction, and save the person's life

The health care team needs to communicate apositive attitude to facilitate acceptance andparticipation in rehabilitation


48/59


Levels of Amputation


49/59


Rehabilitation Needs

Psychological support

Prosthesis fitting and use

Physical therapy

Vocational/occupational training and counseling

Use a multidisciplinary team approach

Patient teaching: seeChart 69-6


50/59




51/59


Nursing ProcessAssessment of thePatient With an Amputation

Assess neurovascular status and function of

affected extremity or residual limb and ofunaffected extremity

Assess for signs and symptoms of infection

Determine nutritional status

Assess concurrent health problems

Determine psychological status and coping


52/59


Nursing ProcessDiagnosis of thePatient With an Amputation

Acute pain

Risk for disturbed sensory perception

Disturbed body image

Ineffective coping

Risk for anticipatory or dysfunctional grieving

Self-care deficit

Impaired physical mobility


53/59



Postoperative hemorrhage Infection

Skin breakdown


54/59


Nursing ProcessPlanning the Care of thePatient With an Amputation

Major goals include relief of pain, absence ofaltered sensory perceptions, wound healing,acceptance of altered body image, resolution ofgrieving processes, restoration of physicalmobility, and absence of complications


55/59


Interventions Relief of pain

Administer analgesic or other medications asprescribed

Change position

Put a light sandbag on residual limb

Alternative methods of pain relief: distraction; TENSunit

Pain may be an expression of grief and alteredbody image

Promote wound healing

Handle limb gently

Provide residual limb shaping


56/59


Wrapping of Leg After Above-the-KneeAmputation


57/59


Wrapping of Arm After Above-the-ElbowAmputation


58/59


Resolving Grief and EnhancingBody Image

Encourage communication and expression of feelings

Create an accepting, supportive atmosphere Provide support and listen

Encourage the patient to look at, feel, and care forthe residual limb

Help the patient set realistic goals

Help the patient resume self-care and independence

Provide referral to counselors and support groups


59/59

Achieving Physical Mobility

Provide proper positioning of limb; avoidabduction, external rotation, and flexion

Turn the patient frequently; use prone position ifpossible

Use assistive devices

Implement ROM exercises

Implement muscle strengthening exercises

Provide preprosthetic care: proper bandaging,massage, and toughening of the residual limb

Documents

Chapt69-Mgt Pt's Musculoskeletal Trauma