FRACTURES

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Musculoskeletal disordersAssessment A. Health History 1. Elicit a description of the present illness and chief complaint a. Onset b. Course c. Duration d. Location e. Precipitating and alleviating factors f. Cardinal signs and symptoms

Moderate to severe pain Inability to move body part Localized edema Altered sensation to the affected part Contour deformity and asymmetry Contusions

2. Explore the clients history for risk factorsa. Medical conditions (TB, DM, gout, arthritis) or medications that would cause

dizziness, falls or injuriesb. Pediatric illnesses & immunizations (tetanus & polio) c. Environmental or physical conditions or unsafe behavior that would cause

injuries, especially related to job environment & recreation d. History of infrequent exercise and sedentary life


e. Three generation family history of musculoskeletal problems (arthritis &

gout) f. Diet

3. Physical Examination a. Note upright body alignment including posture b. Assess bone discrepancies, including contour, length, alignment and symmetryc. Assess the clients ability to move each joint through its range-of-motion, noting

smoothness, pain, crepitus, and clicks d. Note the clients gait, including coordination, rhythm, stride and balance e. Assess the joint alignment, including symmetry, size, shape, contour, stability, tenderness, heat and swellingf. Hyperthrophy, atrophy, and spasms

B. Nursing diagnoses a. Painb. Ineffective tissue perfusion (specify)

c. Impaired physical mobility d. Risk for infection e. Risk for injuryf. Self-care deficit (specify)

g. Deficient knowledge h. Anxiety

C. Implementation a. Perform neurovascular assessment (six Ps)1. Assess pain

Rate scale (0-10)


Take action: use nonpharmacologic interventions like relaxation technique, massage and guided imagery

2. Assess pulses (pulselessness indicates disruption of arterial blood flow)

Assess various locations, including radial, brachial, pedal, posterior tibial, popliteal, and femoral pulses. Always mark pulses with an X. Document pulse strength using a scale of 0 to 4+: 0, no pulse; 1+, weak; 2+, normal; 3+, strong; 4+, bounding

3. Assess for pallor (disruption of blood flow)

Check capillary refill time should be less than 3 seconds

4. Assess for paresthesia (nerve function may be disrupted by nerve

compression) Determine whether client experiences numbness, tingling Determine whether the client can ascertain dull or sharp touch sensation

5. Assess for paralysis (increasing edema causes nerve compression)

Determine whether the client can move and lift the affected extremity Ascertain whether the client can push the affected extremity against pressure

6. Assess for polar (which indicates disrupted arterial blood flow)

Determine whether the clients extremity feels cool or has a bluish color Note whether the client complains of cold extremity

b. Provide pain relief Elevate the injured extremity above the level of the clients heart for the first 24 hours as ordered


Apply cold packs as ordered for 15-20 minutes intermittently the 1 st 24 hours vasoconstricting effects of cold retard extravasation of blood and lymph (edema) and suppress pain After 24 hours, apply mild heat (15-30 minutes, 4 times daily) to promote absorption

c. Promote mobility

Assist the client with active and passive range-of-motion exercises for unaffected body parts to help maintain function

d. Prevent infection

Monitor clients vital signs Assess for signs or symptoms of infection Monitor WBC count

e. Protect client from injury Instruct the client in and have him demonstrate safe transfer, ambulating and sitting techniques to prevent further injury from the immobilization

f. Promote the clients participation in self-care activities within limitation of the injury and treatment regimen

g. Minimize anxiety

FRACTURES: A traumatic injury interrupting bone continuity


Types:1. Closed, simple, uncomplicated fractures do not cause break in the skin 2. Open, compound, complicated fractures involve trauma to surrounding tissue

and a break in the skin3. Incomplete fractures partial cross-sectional breaks with incomplete bone

disruption4. Complete fractures are complete cross-sectional breaks severing the periosteum

Patterns of Fracture5. Comminuted fractures produce several breaks of the bone, producing splinter

fragments6. Spiral (torsion) fractures involve a fracture twisting around the shaft of the bone 7. Transverse fractures occur straight across the bone 8. Oblique fractures occur at an angle across the bone (less than a transverse)

Fracture types (1)

Etiology: 1. Crushing force or direct blow 2. Sudden twisting motion 3. Extremely forceful muscle contraction

Assessment Findings a. Painb. Edema (due to localization of serous fluid at the fracture site and extravasation of

blood into surrounding tissues) c. Tendernessd. Abnormal movement and crepitus (grating sound heard when fractured limb is

moved)


e. Loss of functionf. Ecchymoses (results from subcuataneous bleeding at the fracture site) g. Visible deformity (caused by muscle spasms leading to limb shortening, a rotational

deformity, or angulation)h. Paresthesia (damage to peripheral nerves)

i. Altered Neurovascular Status Injured muscle, blood vessels, nerves. Compression of structures resulting in ischemia. Findings: o Progressive uncontrollable pain o Pain on passive movement o Altered sensations (paresthesia) o Loss of active motion o Diminished capillary refill response, diminished distal pulse o Pallo

j. Shock Bone is very vascular. Overt hemorrhage through open wound. Covert hemorrhage into soft tissues (especially with femoral fracture) or body cavity, as with pelvic fracture. May be fatal if not detected. Nursing Assessment

Ask patient how the fracture occurred - mechanism of injury important in determining possible associated injuries. Ask patient to describe location, character, and intensity of pain to help determine possible source of discomfort. To aid in evaluation of neurovascular status ask patient to describe sensations in injured extremity. To assess functional mobility observe patient's ability to change position. Note patient's emotional status and behavior - indicators of ability to cope with stress of injury. Assess patient's support system; identify current and potential sources of support, assistance, and caregiving. Review findings on past and present health status to aid in formulating care plan. Conduct physical examination. o Examine skin for lacerations, abrasions, ecchymosis, edema, and temperature. o Auscultate lungs to establish baseline assessment of respiratory function. o Assess pulses and blood pressure; assess peripheral tissue perfusion, especially in injured extremity, to establish circulatory status baseline. o Determine neurologic status (sensations and movement) of extremity distal to injury. o Note length, alignment, and immobilization of injured extremity. o Evaluate behavior and cognitive functioning of patient to determine ability to participate in care planning and patient education activities.

NURSING ALERT


Change in behavior or cerebral functioning may be an early indicator of cerebral anoxia from shock or pulmonary or fat emboli. Nursing Diagnosis

Risk for Deficient Fluid Volume related to hemorrhage and shock Impaired Gas Exchange related to immobility and potential pulmonary emboli or fat emboli Risk for Peripheral Neurovascular Dysfunction Risk for Injury related to thromboembolism Acute or Chronic Pain related to injury Risk for Infection related to open fracture or surgical intervention Bathing or Hygiene Self-Care Deficit related to immobility Impaired Physical Mobility related to injury/treatment modality Risk for Disuse Syndrome related to injury and immobilization Risk for Posttrauma Syndrome related to cause of injury

Nursing Interventions Evaluating for Hemorrhage and Shock

Monitor vital signs as frequently as clinical condition indicates, observing for hypotension, elevated pulse, widening pulse pressure, cold clammy skin, restlessness, pallor. Watch for evidence of hemorrhage on dressings or in drainage containers. Review laboratory data; report abnormal values. Administer prescribed fluids/blood to maintain circulating volume. Monitor intake and output.

Monitoring for Impaired Gas Exchange

Evaluate changes in mental status and restlessness that may indicate hypoxia. Review diagnostic evaluation data - especially ABG values and chest X-ray. Position to enhance respiratory effort. Report any sudden or progressive changes in respiratory status. Encourage coughing and deep breathing to promote lung expansion and diminish pooling of pulmonary secretions. Monitor pulse oximetry. Administer oxygen as prescribed. Maintain cervical spine precautions if spinal injury is suspected.

Preventing Neurovascular Compromise

Monitor neurovascular status for compression of nerve, diminished circulation, development of compartment syndrome. o Pain - progressive, localized, deep throbbing, persistent, unrelieved by immobilization and medications o Pain on passive stretch o Weakness progressing to paralysis o Altered sensation, hypothesia, paresthesia o Poor capillary refill (> 3 seconds)


Skin color - pale, cyanotic Elevated compartment pressure - palpable tightness of muscle compartment Pulselessness - late sign Reduce swelling. o Elevate injured extremity Relieve pressure caused by immobilizing device as prescribed (such as bivalving cast, rewrapping elastic bandage, or splinting device). Relieve pressure on skin to prevent development of pressure sore. o Frequent repositioning. o Skin care - do not massage bony prominences. o Special mattresses.o o o

NURSING ALERT Monitoring the neurovascular integrity of the injured extremity is essential. Development of compartment syndrome (increased tissue pressure causing hypoxemia) leads to permanent loss of function in 6 to 8 hours. This situation must be identified and managed promptly. Preventing Development of Thromboembolism

Encourage active and passive ankle exercises. Use elastic stockings, foot pumps, or sequential compression devices, as prescribed. Elevate legs to prevent stasis, avoiding pressure on blood vessels. Encourage mobility; change position frequently; encourage ambulation. Administer anticoagulants as prescribed. Monitor for development of thrombophlebitis. o Note complaint of pain and tenderness in calf. o Report calf pain. o Report increased size and temperature of calf.

Relieving Pain

Perform a comprehensive pain assessment. o Have patient describe the pain, location, characteristics (dull, sharp, continuous, throbbing, bony, radiating, aching). o Ask patient what causes the pain, makes the pain worse, relieves the pain. Evaluate patient for proper body alignment, pressure from equipment (casts, traction, splints, appliances). Initiate activities to prevent or modify pain. o Assist patient with pain-reduction techniques - cutaneous stimulation, distraction, guided imagery, TENS, biofeedback. o Immobilize injured part. o Position patient in correct alignment. o Support splinted fracture above and below fracture when repositioning or moving patient. o Reposition patient with slow and steady motion; use additional personnel as needed. o Elevate painful extremity to diminish venous congestion. o Apply heat or cold modalities as prescribed. Heat versus cold is controversial. o Modify environment to facilitate rest and relaxation. o Administer prescribed pharmaceuticals as indicated. Encourage use of less potent drugs as severity of discomfort decreases.

Monitoring for Development of Infection


Clean, debride, and irrigate open fracture wound as prescribed as soon as possible to minimize risk of infection. o All open fractures are contaminated. o Begin prescribed antibiotic therapy promptly after wound culture obtained. Use sterile technique during dressing changes to minimize infection of wound, soft tissues, and bone. Evaluate patient for elevation of temperature every 4 hours. Note and report elevated white blood cell (WBC) counts. Report areas of inflammation and swelling around incision or open wound. Report purulent odiferous drainage. Obtain specimens for culture and sensitivity to determine causative organism. Administer antibiotic therapy as prescribed.

Promoting Adequate Hygiene

Encourage participation in care. Arrange patient area and personal items for patient convenience and to promote independence. Modify activities to facilitate maximum independence within prescribed limits. Allow time for patient to accomplish task. Teach safe use of mobility and necessary aids. Assist with ADLs as needed. Teach family how to assist patient while promoting independence in self-care.

Promoting Physical Mobility

Perform active and passive exercises to all nonimmobilized joints. Encourage patient participation in frequent position changes, maintaining support to fracture during position changes. Minimize prolonged periods of physical inactivity, encouraging ambulation when prescribed. Administer prescribed analgesics judiciously to decrease pain associated with movement. Methods o Closed reductiono o o

Bony fragments are brought into apposition (ends in contact) by manipulation and manual traction restoring alignment. May be done under anesthesia for pain relief and muscle relaxation. Cast or splint applied to immobilize extremity and maintain reduction


Traction the act of pulling or drawing which is associated with countertraction o Traction may be used to reduce the fracture or to maintain alignment of bone fragments until healing occurso

Principles:

a. Position should be supine b. Avoid friction c. Allow weights to hang freely apply traction continuously or intermittently d. There should be an adequate countertraction e. The line of pull should be in line with the deformity

Types:

a. Skin traction: weights attached to adhesive, which is applied to the skin

Longitudinal force load: 5-7 lbs

Accomplished by applying a light force that pulls on tape, sponge rubber, or special device (boot, cervical halter, pelvic belt) that is in contact with the skin. The pulling force is transmitted to the musculoskeletal structures. Skin traction is used as a temporary measure in adults to control muscle spasm and pain. Bucks extension exerts a straight pull on the leg when a client fractures a hip

Indication: Fractured femur and hip


Bryants traction both lower limbs extended vertically; used to align

fractured femurs in young children Indication: Femoral fractures, hip injuries (for children below 4 years old)

Russel traction: balanced traction in which the lower leg is supported in a

hammock attached to a rope and pulleys on a Balkan frame Used to treat fractures of the femur

b. Skeletal traction applied to the bone Uses 7-10 lbs. Steinmann pin or Kirschners wire may be inserted through the bone and skin Weights are then attached to a spreader, which is attached to both ends of the pin or wire ( may be used in conjunction with a cast)


Care of Client with Traction: Nursing Assessment

Assess for pain, deformity, swelling, motor and sensory function, and circulatory status of the affected extremity. Assess skin condition of the affected extremity, under skin traction and around skeletal traction, as well as over body prominences throughout the body. Assess traction equipment for safety and effectiveness. o The patient is placed on a firm mattress. o The ropes and the pulleys should be in alignment. o The pull should be in line with the long axis of the bone. o Any factor that might reduce the pull or alter its direction must be eliminated. Weights should hang freely. Ropes should be unobstructed and not in contact with the bed or equipment. Help the patient to pull himself or herself up in bed at frequent intervals. o The amount of weight applied in skin traction must not exceed the tolerance of the skin. The condition of the skin must be inspected frequently. o Cover exposed sharp ends of skeletal pins with cork or other pin covering to protect patient and caregivers from injury. Assess emotional reaction to condition and traction. Assess understanding of the treatment plan.

NURSING ALERT Traction is not accomplished if the knot in the rope or the footplate is touching the pulley or the foot of the bed or if the weights are resting on the floor. Never remove the weights when repositioning the patient who is in skeletal traction because this will interrupt the line of pull and cause the patient considerable pain. Nursing Diagnoses

Impaired Physical Mobility related to traction therapy and underlying pathology Risk for Impaired Skin Integrity related to pressure on soft tissues Risk for Infection related to bacterial invasion at skeletal traction site Ineffective Tissue Perfusion: Peripheral related to injury or traction therapy

Nursing Interventions Minimizing the Effects of Immobility

Encourage active exercise of uninvolved muscles and joints to maintain strength and function. Dorsiflex feet hourly to avoid development of footdrop and aid in venous return. Encourage deep breathing hourly to facilitate expansion of lungs and movement of respiratory secretions. Auscultate lung fields twice per day. Encourage fluid intake of 2,000 to 2,500 mL daily. Provide balanced high-fiber diet rich in protein; avoid excessive calcium intake. Establish bowel routine through use of diet and stool softeners, laxatives, and enemas, as prescribed. Prevent pressure on the calf, and evaluate twice daily for the development of thrombophlebitis.


Check traction apparatus at repeated intervals - the traction must be continuous to be effective, unless prescribed as intermittent, as with pelvic traction.

NURSING ALERT Every complaint of the patient in traction should be investigated immediately to prevent injury. Maintaining Skin Integrity

Examine bony prominences frequently for evidence of pressure or friction irritation. Observe for skin irritation around the traction bandage. Observe for pressure at traction, and skin contact points. Report complaint of burning sensation under traction. Relieve pressure without disrupting traction effectiveness. o Ensure that linens and clothing are wrinkle free. Special care must be given to the back every two hours because the patient maintains a supine position. o Have patient use trapeze to pull self up and relieve back pressure. o Provide backrubs.

Avoiding Infection at Pin Site

Monitor vital signs for fever or tachycardia. Watch for signs of infection, especially around the pin tract. o The pin should be immobile in the bone, and the skin wound should be dry. Small amount of serous oozing from pin site may occur. o If infection is suspected, percuss gently over the tibia; this may elicit pain if infection is developing. o Assess for other signs of infection: heat, redness, fever. If directed, clean the pin tract with sterile applicators and prescribed solution/ointment to clear drainage at the entrance of tract and around the pin, because plugging at this site can predispose to bacterial invasion of the tract and bone.

Promoting Tissue Perfusion

Assess motor and sensory function of specific nerves that might be compromised. o Peroneal nerve - have patient point great toe toward nose; check sensation on dorsum of foot; presence of footdrop. o Radial nerve - have patient extend thumb; check sensation in web between thumb and index finger. Determine adequacy of circulation (eg, color, temperature, motion, capillary refill of peripheral fingers or toes). Report promptly if change in neurovascular status is identified.

Patient Education and Health Maintenance

Teach the patient the purpose of traction therapy. Delineate limitations of activity necessary to maintain effective traction. Teach use of patient aids (eg, trapeze). Instruct the patient not to adjust or modify traction apparatus.


Instruct the patient in activities designed to minimize effects of immobility on body systems. Teach the patient necessity for reporting changes in sensations, pain, movement. c. Open reduction with internal fixation (ORIF) a. Operative intervention to achieve reduction, alignment, and stabilization. Bone fragments are directly visualized. Internal fixation devices (metal pins, wires, screws, plates, nails, rods) used to hold bone fragments in position until solid bone healing occurs (may be removed when bone is healed). After closure of the wound, splints or casts may be used for additional stabilization and support. b. Endoprosthetic replacement Replacement of a fracture fragment with an implanted metal device. Used when fracture disrupts nutrition of the bone or treatment of choice is bony replacement.d. Open Reduction with External fixation device- when fractures accompany

soft tissue injury Stabilization of complex and open fracture with use of a metal frame and pin system. Permits active treatment of injured soft tissue.

CASTS A cast is an immobilizing device made up of layers of plaster or fiberglass (wateractivated polyurethane resin) bandages molded to the body part that it encases. Purposes To immobilize and hold bone fragments in reduction To apply uniform compression of soft tissues To permit early mobilization To correct and prevent deformities To support and stabilize weak joints Types of Casts a. Short-arm Cast Extends from below the elbow to the proximal palmar crease.


b. Gauntlet Cast Extends from below the elbow to the proximal palmar crease, including the thumb (thumb spica).

c. Long-arm Cast Extends from upper level of axillary fold to proximal palmar crease; elbow usually immobilized at right angle.

d. Short-leg Cast Extends from below knee to base of toes.

e. Long-leg Cast Extends from upper thigh to the base of toes; foot is at right angle in a neutral position.

f. Body Cast Encircles the trunk stabilizing the spine.

g. Spica Cast Incorporates the trunk and extremity. Shoulder spica cast - a body jacket that encloses trunk, shoulder, and elbow. Hip spica cast - encloses trunk and a lower extremity.

Single hip spica - extends from nipple line to include pelvis and extends to include pelvis and one thigh.o


Double hip spica - extends from nipple line or upper abdomen to include pelvis and extends to include both thighs and lower legs. o One-and-a-half hip spica - extends from upper abdomen, includes one entire leg, and extends to the knee of the other.o

Complications of Casts

Pressure of cast on neurovascular and bony structures causes necrosis, pressure sores, and nerve palsies. Compartment syndrome - trauma or surgery affecting an extremity will produce swelling (result of hemorrhage from bone and surrounding tissue and of tissue edema). Vascular insufficiency and nerve and muscle compression due to unrelieved swelling can cause irreversible damage to an extremity.

Immobility and confinement in a cast, particularly a body cast, can result in multisystem problems. o Nausea, vomiting, and abdominal distention associated with cast syndrome (superior mesenteric artery syndrome, resulting in diminished blood flow to the bowel), adynamic ileus, and possible intestinal obstruction. o Acute anxiety reaction symptoms (ie, behavioral changes and autonomic responses - increased respiratory and heart rate, elevated blood pressure, diaphoresis) associated with confinement in a space. o Thrombophlebitis and possible pulmonary emboli associated with immobility and ineffective circulation (eg, venous stasis). o Respiratory atelectasis and pneumonia associated with ineffective respiratory effort. o Urinary tract infection (UTI) - renal and bladder calculi associated with urinary stasis, low fluid intake, and calcium excretion associated with immobility. o Anorexia and constipation associated with decreased activity. o Psychological reaction (eg, depression) associated with immobility, dependence, and loss of control.

Nursing Assessment

Assess neurovascular status of the extremity with a cast for signs of compromise. o Pain. o Swelling. o Discoloration - pale or blue. o Cool skin distal to injury. o Tingling or numbness (paresthesia). o Pain on passive extension (muscle stretch). o Slow capillary refill; diminished or absent pulse. o Paralysis. Assess skin integrity of casted extremity. Be alert for: o Severe initial pain over bony prominences; this is a warning symptom of an impending pressure sore. Pain increases when ulceration occurs. o Odor. o Drainage on cast. Carefully assess for positioning and potential pressure sites of the casted extremity Assess cardiovascular, respiratory, and GI systems for possible complications of immobility. Assess psychological reaction to illness, cast, and immobility.


Nursing Interventions Maintaining Adequate Tissue Perfusion

Elevate the extremity on cloth-covered pillow above the level of the heart. Keep the heel off the mattress. Avoid resting cast on hard surfaces or sharp edges that can cause denting or flattening of the cast and consequent pressure sores. Handle moist cast with palms of hands. Turn patient every 2 hours while cast dries. Assess neurovascular status hourly during the first 24 hours, then less frequently as condition warrants and swelling resolves. Observe for signs of circulatory impairment:

change in skin color and temperature wet spots drainage under the cast hot spots areas of the cast feels warmer than the other sections may indicate infection or necrosis numbness or tingling unrelieved pain decrease in pedal pulses prolonged blanching of toes after compression or inability to move toes

If symptoms of neurovascular compromise occur: o Notify health care provider immediately. o Bivalve the cast - split cast on each side over its full length into two halves. If symptoms of pressure area occur, cast may be windowed (hole cut in it) so the skin at the pain point can be examined and treated.

Minimizing the Effects of Immobility

Encourage the patient to move about as normally as possible. Encourage compliance with prescribed exercises to avoid muscle atrophy and loss of strength. o Active ROM for every joint that is not immobilized at regular and frequent intervals. o Isometric exercises for the muscles of the casted extremity. Instruct patient to alternately contract and relax muscles without moving affected part. Reposition and turn patient frequently. Avoid pressure behind knees, which reduces venous return and predisposes to thromboembolism. Use antiembolism stockings as prescribed. Administer prophylactic anticoagulants as prescribed. Encourage deep-breathing exercises and coughing at regular intervals to prevent atelectasis and pneumonia. Observe for symptoms of cast syndrome - nausea, vomiting, abdominal distention, abdominal pain, and decreased bowel sounds.


Encourage patient to drink liberal quantities of fluid - to avoid urinary infection and calculi secondary to immobility.

Preventing Disuse Syndrome

Teach and encourage isometric exercises to diminish muscle atrophy. Encourage use of immobilized extremity within prescribed limits.

NURSING ALERT Cast syndrome (superior mesenteric artery syndrome) is a rare sequela of body cast application, yet it is a potentially fatal complication. It is important to teach patients about this syndrome because this can develop as late as several weeks after cast application Complications Complications Associated with Immobility

Muscle atrophy, loss of muscle strength and endurance Loss of ROM due to joint contracture Pressure sores at bony prominences from immobilizing device pressing on skin Diminished respiratory, cardiovascular, GI function, resulting in possible pooling of respiratory secretions, orthostatic hypotension, ileus, anorexia, and constipation Psychosocial compromise resulting in feelings of isolation and depression.

Other Acute Complications

Venous stasis and thromboembolism Neurovascular compromise Infection especially with open fractures Shock due to significant hemorrhage related to trauma or as a postoperative complication Fat Emboli Syndrome Associated with embolization of marrow or tissue fat or platelets and free fatty acids to the pulmonary capillaries, producing rapid onset of symptoms develops within 24-72 hours after fracture o

common in long bones, pelvis, ribs, sternum, vertebrae, clavicle ARDS results from deposition of embolic fat in the pulmonary circulation Clinical manifestations: o Respiratory distress - tachypnea, hypoxemia, crackles, wheezes, acute pulmonary edema o Mental disturbances - irritability, restlessness, confusion, disorientation, stupor, coma due to systemic embolization, and severe hypoxia o Fever o Petechiae in buccal membranes, hard palate, conjunctival sacs, chest, anterior axillary folds, due to occlusion of capillaries

NURSING ALERT Restlessness, confusion, irritability, and disorientation may be the first signs of fat embolism syndrome. Confirm hypoxia with arterial blood gas (ABG) analysis. Young


adults (ages 20 to 30) and older adults (ages 60 to 70) with multiple fractures or fractures of long bones or pelvis are particularly susceptible to development of fat emboli. Bone Union Problems Delayed union (takes longer to heal than average for type of fracture) Nonunion (fractured bone fails to unite) Malunion (union occurs but is faulty misaligned)

Amputation a. b.c.

Removal of a body part as a result of trauma or surgical intervention Necessitated by: malignant tumor, trauma, arterial insufficiency Types: 1. 2. BKA (below the knee amputation) AKA (above the knee amputation)

Nursing Care: 1. Provide care preoperatively a. Initiation of exercises preoperatively b. Coughing and deep breathing exercises c. Emotional support for anticipated alteration in body image 2. Monitor vital signs and stump dressing for signs of hemorrhage 3. Elevate stump for 12-24 hours to decrease edema; remove pillow after this time for functional alignment and prevent contractures 4. Provide stump care a. Maintain elastic bandage to shrink and shape stump in preparation for prosthesis b. When wound is healed, wash stump daily, avoiding use of oils which might cause macerations c. Apply pressure to the end of the stump with progressively firmer surfaces to toughen stump d. Encourage patient to move the stump e. Place the patient with a lower extremity amputation in a prone position twice daily to stretch the flexor muscles and prevent hip flexion contractures

5. Teach patient about phantom limb sensation Phantom limb: physiologic reaction of the nerves in the stump causing an unpleasant feeling that the limb is still there


Phantom limb pain: when the unpleasant feelings become painful or disagreeable 6. Encourage family to participate in care 7. Allow clients to express emotional reactions

Specific Care for Patient in Spica or Body Cast Positioning

Place a bedboard under the mattress for uniform support of the body. Support the curves of the cast with cloth-covered flexible pillowsprevents cracking and flat spots while cast is drying. o Place three pillows crosswise on bed for body cast. o Place one pillow crosswise at the waist and two pillows lengthwise for affected leg for spica cast. If both legs are involved, use two additional pillows. Encourage the patient to maintain physiologic position by: o Using the overhead trapeze. o Placing good foot flat on bed and pushing down while lifting himself or herself up on the trapeze. o Avoiding twisting motions. o Avoiding positions that produce pressure on groin, back, chest, and abdomen.

Turning

Move the patient to the side of the bed using a steady, even pulling motion. Place pillows along the other side of the bedone for the chest and two (lengthwise) for the legs. Instruct the patient to place arms at side or above head. Turn the patient as a unit. Avoid twisting the patient in the cast. Turn the patient toward the leg not encased in plaster or toward the unoperated side if both legs are in plaster. o One nurse stands at other side of bed to receive the patient's shoulders. o Second nurse supports leg in plaster while the third nurse supports the patient's back as he or she is turned. o Turn the patient in body cast to a prone position twice daily - provides postural drainage of bronchial tree; relieves pressure on back. Keep the cast level by elevating the lumbar sacral area with a small pillow when the head of the bed is elevated.

NURSING ALERT Do not grasp cross bar of spica cast to move the patient. The purpose of the bar is to maintain the integrity of the cast.

Hygienic Care

Provide hygienic care of the patient.


Protect cast from soiling. o Cover perineum with a towel and apply spray (lacquer-type) to perineal area of cast. Tuck 4-inch (10-cm) strips of thin polyethylene sheeting under perineal area of cast and tape to cast exterior. Replace when soiling occurs. o Clean outside of cast with slightly damp or dry, clean cloth. Roll the patient onto fracture bedpan; use small pillow in lumbosacral area for support.

Skin Care

Inspect skin for signs of irritation: o Around cast edge. o Under castpull skin taut and inspect under cast, using a flashlight for illumination. Reach up under cast, and massage accessible skin. Protect the toes from the pressure of the bedding.

Patient Education and Health Maintenance in Patients with Cast Neurovascular Status

Instruct patient to check neurovascular status and to control swelling. o Watch for signs and symptoms of circulatory disturbance, including blueness or paleness of fingernails or toenails accompanied by pain and tightness, numbness, cold or tingling sensation. o Elevate affected extremity, and wiggle fingers/toes. o Apply ice bags as prescribed (one-third to one-half full) to each side of the cast, making sure they do not make indentations in plaster. o Call health care provider promptly if excessive swelling, paresthesia, persistent pain, pain on passive stretch, or paralysis occurs. Instruct patient to alternate ambulation with periods of elevation to the cast when seated. Encourage the patient to lie down several times daily with cast elevated.

Exercise

Instruct patient to actively exercise every joint that is not immobilized and to perform isometric exercises (contract muscles without moving joint) of those immobilized to maintain muscle strength and to prevent atrophy. Tell patient to perform hourly when awake: o Leg cast - Push down on the popliteal (knee) space, hold it, relax, repeat. Move toes back and forth; bend toes down, then pull them back. o Arm cast - Make a fist, hold it, relax, repeat. Move shoulders.

Cast Care

Advise to avoid getting cast wet, especially padding under castcauses skin breakdown as plaster cast becomes soft. Warn against covering a leg cast with plastic or rubber boots because this causes condensation and wetting of the cast. Instruct to avoid weight bearing or stress on plaster cast for 24 hours. Instruct to report to health care provider if the cast cracks or breaks; instruct the patient not to try to fix it. Teach how to clean the cast: o Remove surface soil with slightly damp cloth. o Rub soiled areas with household scouring powder. o Wipe off residual moisture. Therapeutic Intervention


1. Open reduction with plates and screw to hold fracture in alignment a. Internal fixation b. External fixation2. Closed reduction manual traction to move the fragments and restore bone

alignment 3. Application of cast to maintain alignment and immobilize the limb

e. Care of Client with Cast

Observe for signs of circulatory impairment: change in skin color and temperature o wet spots drainage under the casto

hot spots areas of the cast feels warmer than the other sections may indicate infection or necrosis

numbness or tingling unrelieved pain decrease in pedal pulses prolonged blanching of toes after compression or inability to move toes compartment syndrome Protect the cast from damage until dry by elevating it on a pillow; handle with palms of hands only Promote drying of cast by leaving it uncovered; light may be used with care to promote drying Maintain bed rest until the cast is dry and ambulation is permitted Observe for hemorrhage and measure extent of drainage on cast when present Observe for irritation caused by rough cast edges Observe for swelling and notify the physician if necessary Administer analgesics judiciously and report unrelieved pain Observe for signs of infection


4. Application of an external fixation device when fractures accompany soft tissue injury 5. Amputation f. Removal of a body part as a result of trauma or surgical intervention g. Necessitated by: malignant tumor, trauma, arterial insufficiency h. Types: 3. BKA (below the knee amputation) 4. AKA (above the knee amputation) Nursing Care: 8. Provide care preoperatively d. Initiation of exercises preoperatively e. Coughing and deep breathing exercises f. Emotional support for anticipated alteration in body image 9. Monitor vital signs and stump dressing for signs of hemorrhage 10. Elevate stump for 12-24 hours to decrease edema; remove pillow after this time for functional alignment and prevent contractures 11. Provide stump care f. Maintain elastic bandage to shrink and shape stump in preparation for prosthesis g. When wound is healed, wash stump daily, avoiding use of oils which might cause macerations h. Apply pressure to the end of the stump with progressively firmer surfaces to toughen stump i. Encourage patient to move the stumpj.

Place the patient with a lower extremity amputation in a prone position twice daily to stretch the flexor muscles and prevent hip flexion contractures

12. Teach patient about phantom limb sensation Phantom limb: physiologic reaction of the nerves in the stump causing an unpleasant feeling that the limb is still there Phantom limb pain: when the unpleasant feelings become painful or disagreeable 13. Encourage family to participate in care 14. Allow clients to express emotional reactions


CRUTCH INSTRUCTIONS General Information: When using your crutches, beware of ice or snow under your crutch tips. Be careful on wet or waxed floors, smooth cement floors, and small rugs. Take care not to trip over telephone and extension cords, toys, or pets. Avoid crowds. Instructions: 1. 2. 3. 4. Walking: Place both crutches in front of you at the same time. Put them about 1 inch in front and 6 to 8 inches to the side of your toes. Lean on your hands, not your underarms. The top of the crutches should hit about 2 inches below your underarm. Keep your elbows bent as you use the crutches. Keep your injured leg off the floor by bending your knee. Take a step with your crutches. Then, swing your uninjured foot between the crutches landing heel first. Going Up the Stairs: Face the stairs. Put the crutches close to the first step. Push on the crutches with your elbows straight and put your uninjured leg on the first step. Bring both crutches up on the stair at the same time. If using a railing, put both crutches under the other arm. Going Down the Stairs: Stand with the toes of your uninjured leg close to the edge of the step. Bend the knee of your uninjured leg. Slowly lower both crutches onto the next step. Lean on your crutches. Slowly lower your uninjured leg on to the same step. Place both crutches under the other arm when using a railing. Sitting in a Chair:


5.

Turn and back up to the chair until you feel the edge of it against the back of your legs. Keep your injured leg forward. Remove your crutches from under your arms. Sit while bending your uninjured knee. Hold the chair so it doesnt move out from under you. Getting up from a Chair: Sit on the edge of your chair. Put your uninjured foot close to the chair. Push up with your hands using the crutches or arms of the chair. Put your weight on your uninjured foot as you get up. Keep your injured leg bent at the knee and off the floor.

Crutches: A "How-To" Guide Sizing Your Crutches Walking with Crutches Managing Chairs with Crutches Managing Stairs Without Crutches Important Rules for Safety and Comfort It takes some coordination to get around on crutches. To make sure you use your crutches correctly, please read these instructions and follow them carefully. Sizing Your Crutches Even if you've already been fitted for crutches, make sure your crutch pads and handgrips are set at the proper distance, as follows:

Crutch pad distance from armpits. The crutch pads (tops of crutches) should be 1.5" to 2" (about two finger widths) below the armpits, with the shoulders relaxed. Handgrip. Place it so your elbow is flexed about 15 to 30 degreesenough so you can fully extend your elbow when you take a step. Crutch length (top to bottom). The total crutch length should equal the distance from your armpit to about 6" in front of a shoe.

Walking with Crutches (Non-Weight-Bearing) If your foot and ankle surgeon has told you to avoid ALL weight-bearing, it is important to follow these instructions carefully. You will need sufficient upper body strength to support all your weight with just your arms and shoulders.


The Tripod Position The tripod position is the position in which you stand when using crutches. It is also the position in which you begin walking. To get into the tripod position, place the crutch tips about 4" to 6" to the side and front of each foot, then stand on your "good" foot (the one that is weight-bearing). To walk with crutches: 1. Begin in the tripod positionand remember, keep all your weight on your "good" (weight-bearing) foot. 2. Advance both crutches and the affected foot/leg. 3. Move the "good" weight-bearing foot/leg forward (beyond the crutches). 4. Advance both crutches, and then the affected foot/leg.5. Repeat steps #3 and #4.

Managing Chairs with Crutches To get into and out of a chair safely: 1. Make sure the chair is stable and will not roll or slideand it must have arms and back support. 2. Stand with the backs of your legs touching the front of the seat. 3. Place both crutches in one hand, grasping them by the handgrips. 4. Hold on to the crutches (on one side) and the chair arm (on the other side) for balance and stability while lowering yourself to a seated positionor raising yourself from the chair if you're getting up. Managing Stairs Without Crutches The safest way to go up and down stairs is to use your seatnot your crutches. To go up stairs: 1. Seat yourself on a low step. 2. Move your crutches upstairs by one of these methods:

If distance and reach allow, place the crutches at the top of the staircase. If this isn't possible, place crutches as far up the stairs as you canthen move them to


the top as you progress up the stairs. 3. In the seated position, reach behind you with both arms. 4. Use your arms and weight-bearing foot/leg to lift yourself up one step. 5. Repeat this process one step at a time. (Remember to move the crutches to the top of the staircase if you haven't already done so.) To go down stairs: 1. Seat yourself on the top step. 2. Move your crutches downstairs by sliding them to the lowest possible point on the stairwaythen continue to move them down as you progress down the stairs. 3. In the seated position, reach behind you with both arms. 4. Use your arms and weight-bearing foot/leg to lift yourself down one step. 5. Repeat this process one step at a time. (Remember to move the crutches to the bottom of the staircase if you haven't already done so.) Important Rules for Safety and Comfort Don't look down. Look straight ahead as you normally do when you walk. Don't use crutches if you feel dizzy or drowsy. Don't walk on slippery surfaces. Avoid snowy, icy, or rainy conditions. Don't put any weight on your foot if your doctor has so advised. Do make sure your crutches have rubber tips. Do wear well-fitting, low-heel shoes (or shoe). Do position the crutch handgrips correctly (see "Sizing Your Crutches") Do keep the crutch pads 112" to 2" below your armpits. Do call your foot and ankle surgeon if you have any questions or difficulties.

Measurement of crutches:

The top of the crutches should be at least two finger widths deep from the armpit (make sure the shoulders are relaxed). When the arm is hanging straight down, the hand piece should be at the level of the wrist.


Hold the top part of the crutch firmly between the chest and the inside of the upper arm. Do not allow the top of the crutch to push up into the armpit. It is possible to damage nerves and blood vessels with constant pressure. Support the weight with the hands on the hand rests. The hand rests should be padded. When standing still, it will be safer to stand with the crutches slightly ahead and apart. Remember, do not let the top of the crutches push up into the armpit; stand straight.

Walking (non-weight bearing):

Put the crutches forward about one step's length. Push down on the crutches with the hands, hold the "bad" leg up from the floor, and squeeze the top of the crutches between the chest and arm. Swing the "good" leg forward. Be careful not to go too far. Now step on the "good" leg.

Walking (partial-weight bearing):

Put the crutches forward about one step's length. Put the "bad" leg forward; level with the crutch tips. Take most of the weight by pushing down on the handgrips, squeezing the top of the crutches between the chest and arm. Take a step with the "good" leg. Make steps of equal length.

Sit to stand:

Make sure to keep the crutches nearby so they can be reached when needed. Hold the hand grips of both crutches in one hand. Use the crutches with one hand and the side of the chair with the other hand. Make sure the chair is stable. If necessary, have someone stand behind you. Stretch the "bad" leg out straight. Push on chair, crutches, and the "good" leg; stand up. Keep the weight off the "bad" leg. Balance. Place the crutches in place for walking.

Stand to sit:

Walk straight up to the chair. When a step away from the chair, turn until your back is toward the chair using the "good" leg and the crutches. (Move the crutches, then step, crutches, step...a little at a time.) Never pivot. Move backwards until the chair touches the back of the "good" leg. Remove the crutches from under the arms. Hold both crutches in one hand and reach for the chair with the other hand. Stretch the "bad" leg out in front. Sit down slowly.

Stairs:

Use one crutch and the stair rail if present (only if the railing is stable and there is someone to carry the other crutch). Use two crutches if there is no stair rail. It does not matter which side the stair rail is on. If both crutches can be held in one hand safely, you can use both crutches on one side and the railing on the other.

Up stairs:


Walk close to the first stair and hold onto the stair rail. Hold onto the rail with one hand and the crutch with the other hand. Push down on the stair rail and the crutch and step up with the "good" leg. If not allowed to place weight on the "bad" leg, hop up with the "good" leg. Bring the "bad" leg and the crutches up beside the "good" leg. Remember, the "good" leg goes up first and the crutches move with the "bad" leg.

Down stairs:

Walk to the edge of the stairs in the same way. Place the "bad" leg and the crutches down on the step below; support weight by leaning on the crutches and the stair rail. Bring the "good" leg down. Remember the "bad" leg goes down first and the crutches move with the "bad" leg. Use the same rules when going up and down curbs or doorsteps.

Precautions:

Take care on slick or wet surfaces (i.e., the kitchen and bathroom). Be careful of throw rugs; they should be taken up. Never hop around holding on to furniture; it may slide or fall. Keep the crutches near you so they are always in reach. Wear low-heeled shoes that will not slip off (i.e., sneakers). For the first few days, a strong belt may be worn to allow someone to assist you. Be careful of ramps or slopes, as it is a little harder to walk. If falling, throw the crutches out to the side and use your arms to break your fall. To get up, get into a sitting position. Back up to a stool or low chair. Put your hands backwards on to the chair. Bend the "good" leg up. Pull with your hands and push with the "good" leg to get up onto the chair. If not allowed to take weight on the "bad" leg, hop up with the "good" leg. Do not remove any parts from your crutches, including the rubber tips.

Helpful hints:

A bedside toilet may be used. Ask teachers in school to let your child out of class a little early to avoid crowds on the stairs. Keep the "bad" leg up on a stool when sitting. Carry schoolbooks in a backpack to leave both hands free. Avoid leaning on the underarm pieces.


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