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Sprain
Injury to the tendeno ligamentous structure surrounding a joint Usually caused by twisting motion Excessive stretching of muscle and its facial sheath Often involves tendons
Strain
Edema
Decrease in function Contusion
Management Usually self limiting Severe sprains may require suturing of the muscle & Surrounding fascia
Activity limitation
Nursing manageme nt
Analgesia
Dislocation
Severe injury of the ligamentous structure that surround a joint Results in complete displacement and separation of the articular surface of the joint
Dislocation
Dislocation
Clinical Manifestations
Deformity Pain
Tenderness
Loss of function of injured part Swelling in the soft tissue
Relief of pain
Protectio n of injured part
Health Education
Nursing Managemen t
ROM Exercises
Rehabilitatio n
Fractures
Fractures
A fracture is a break in the continuity of the bone caused by trauma, twisting as a result of muscle spasm or indirect loss of leverage, or bone decalcification & disease that results in osteopenia. Assessment findings Pain or tenderness over the involved area. Loss of function. Obvious deformity.
Crepitation
Erythema,edema,ecchymosis Muscle spasm & impaired circulation
Fractures: Causes
Causes
Traumatic
Pathologi c
Hyper-para thyroidism
Cancer
Osteoporos is
Others
Comminuted
Displaced / Involves a displaced fracture fragment that is overriding fracture overriding the other bony fragment Green stick fracture Incomplete fracture with one side splintered and the other side bent. Impacted fracture Comminuted fracture in which more than two fragments are driven into each other Intra articular Fracture extending to the articular surface of fracture the bone Longitudinal An incomplete fracture in which fracture line fracture runs along the longitudinal axis of the bone
Transverse fracture
Pathological fracture
Loss of functio n
Manifestatio n
Muscle spasm
Ecchymosis /contusion
Deformity
Ossification
Consolidation
Remodeling
Fracture Healing
Age
Initial displacem ent
Infections
Pseudo arthrosis Type of non union occurring at the fracture site in which false joint is formed on shaft of long bone. It is a fracture site that has failed to fuse. Each bone end is covered with fibrous scar tissue Refracture Myositis ossificans New fracture occur at original fracture site Deposition of calcium in muscle tissue at the site of significant blunt muscle trauma or repeated muscle injury
Diagnosis
History and physical examination
X-ray CT- scan and MRI
Emergency Management
Etiology BLUNT Motor vehicle collision , Pedestrian event Falls, direct blows, Forced extension / flexion Assessment finding Deformity Edema/ Ecchymosis Muscle spasm Tenderness/ pain Loss of function numbness, tingling, loss of peripheral pulses Grating Open wound, exposure of bone Interventions INITIAL 1. Treat life threatening injuries first 2. Ensure ABC 3. Control bleeding, Splint joints 4. Check neurovascular status before and after splinting 5. Elevate limb if possible 6. Do not attempt to straighten/ manipulate protruding bone/dislocated limb 7. Apply icepack, Get X ray, Administer TT
ONGOING ASSESSMENT 1. Monitor vitals, LOC, SpO2,neurovascular status, pain 2. Assess for compartment syndrome, embolism
Splinting
Collaborative therapy
Fracture reductio n
Manipulation Closed reduction Traction devices Open reduction /internal fixation
Open fractures
Surgical debridement and irrigation TT/DT immunization Prophylactic anti biotic therapy Immobilization
Fracture reduction
Closed reduction
Non- surgical manual realignment of bone
through a surgical incision. Usually involves internal fixation of the fracture by using wires, screws, pins, plates, intramedullary rods or plates Disadvantages: Infection, Complications of anesthesia, Effects of pre-morbid diseases. ORIF Facilitates early ambulation Promotes fracture healing
Traction
Application of a pulling force to any of the
extremity Counter traction pulls in the opposite direction Purposes : prevent or reduce muscle spasm Immobilization Reduce a fracture/ dislocation
Traction cont..
Skin traction
Short term (48-72 hrs)
Skeletal traction
Long term
2.3-4.5 kg
2-20 kg
Pins, wires
Skin traction
Skin traction
Skeletal traction
Casts
Temporary circumferential immobilization device Common treatment following closed reduction Material of cast : PoP, synthetic acrylic, latex free
polymer
Incorporates joint above and below fracture Types :
Single hip spica, Double hip spica, Long leg cast, Short leg cast
External fixation
An external fixator is a metallic device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals. Uses : To apply traction To compress fracture fragments Immobilization Salvage of limb Indications: Extensive soft tissue damage Correction of bony defects Non/ Mal union Limb lengthening
Internal Fixation
Devices (biologically inert metal )
Pins, Plates, intra-medullary rods, metal and bio-
absorbable screws
Devices surgically inserted
Others
Drug therapy Pain management Involuntary reflexes(edema/ nerve injury ) Central/ peripheral muscle relaxants TT/DT Prophylactic antibiotics Nutritional Management Protein : 1 gm /kg BW Vitamins :Especially B,C,D Calcium , Phosphorous, magnesium Fluid intake : 2- 3 liter/ day Small meals for body casts
Nursing Management
Nursing management
NURSING ASSESSMENT SUBJECTIVE DATA Important health information Past health history: traumatic injury , long term repetitive forces, bone/ systemic disease, prolonged immobility, osteoporosis Medications :use of corticosteroids, estrogen replacement therapy Surgery or other treatment :first aid treatment of fracture, previous musculoskeletal surgeries Cognitive perceptual :sudden and severe pain in the affected area, numbness, tingling, loss of sensation ,loss of sensation distal to the injury chronic pain which increases with activity
NURSING ASSESSMENT
OBJECTIVE DATA General :apprehension , guarding of injured site Integumentary : skin lacerations , pallor and cool skin or bluish and warm skin distal to injury , Ecchymosis, hematoma, edema at the site of the injury Cardiovascular :reduced or absent pulses distal to the injury , decreased temperature, delayed capillary refill Neurovascular : parasthesias, absent or decreased sensation , hyper sensation Musculoskeletal :restricted or lost function of the affected part ; local bony defects, abnormal angulations , shortening, rotation or Crepetition of affected part muscle weakness
NURSING DIAGNOSIS
Impaired physical mobility related to loss of integrity of bone structures, movement of bone fragments, soft tissue injury, and prescribed movement restrictions.
Ineffective therapeutic regimen r/t lack of knowledge regarding muscle atrophy, exercise programme, care of cast and external immobilizers
Risk for peripheral neuro vascular dysfunction related to vascular insufficiency and nerve compression Acute pain related to edema , movement of bone fragments, and muscle fragments
Nursing implementation
Health promotion Safety precautions for public
Reduce falls(elderly )
Acute interventions
Preoperative management Pre-op preparation
Skin preparation
Post operative management
Vitals monitoring Neurovascular assessment
w/f bleeding
Post op management
Aseptic technique
Nursing interventions
Other measures: Prevention of complication R/T immobility
Constipation
Renal calculi CV complications
DVT prophylaxis
cast
DO NOT
Get plaster cast wet Remove any padding, Insert any object inside the cast Bear weight on new cast for 48 hrs Cover cast for prolonged periods DOS Elevate extremity for 48 hrs Dry cast thoroughly blow dry Move joints above and below the cast regularly REPORT THE FOLLOWING Increasing pain Swelling with pain and discoloration Pain, burning and tingling under cast Sour and foul odor under cast
Nursing intervention-Rhabilitation
Complications
Compartment syndrome Infection DVT Fat embolism
Compartment Syndrome
Elevated intra-compartmental pressure within a confined myo-fascial compartment.
Compartment Syndrome.
Causes: Restrictive Dressings, Splints, casts, excessive traction, Premature closure of fascia Bleeding Edema Chemical response to snake bite IV infiltration Risk Factors: Trauma Fractures Extensive soft tissue damage Crush injury Reperfusion syndrome Severe burns Knee or Leg surgery
Compartment Syndrome.
Clinical Manifestations 6 Ps 1. Paresthesia: Numbness & Tingling 2. Pain: Distal to injury, not relieved by opioids analgesics & pain on passive stretch of muscle travelling through the compartment 3. Pressure: Increases in the compartment 4. Pallor, coolness, loss of normal color of extremity 5. Paralysis or loss of function 6. Pulselessness or diminished/absent peripheral pulses Myoglobinuria: Dark reddish-brown urine, C/M associated with Acute Renal Failure
Clinical Manifestations
Fever & Pain Erythema in the area surrounding the fracture Tacchycardia Elevated white blood cell count
Interventions
Notify the physician. Prepare to initiate aggressive IV antibiotic therapy.
Precipitating Factors: Inappropriately applied casts or traction Local pressure on a vein Immobility
Clinical Manifestations: Pain and Swelling in the involved extremity Management: Wearing compression stockings Isometric exercises of the fingers, toes and affected exercises ROM Exercises
Fat Embolism
Fat embolism is characterized by the presence of systemic fat globules from fractures that are distributed into the tissues and organs after a traumatic skeletal injury. Occurs within 12-72 hours of injury Risk Factors: Fracture of long bones ribs, tibia, pelvis Total joint replacement surgeries Spinal fusion
Liposuction
Crush injuries Bone marrow transplantation
Fat Embolism.
Clinical Manifestations Signs & Symptoms of ARDS: Chest Pain, Tachypnea, Cyanosis, Dyspnea, Apprehension, Tachycardia, Decreased PaO2 to less than 60 mmHg Memory loss Restlessness & Confusion Petechial Rash over upper chest & neck Elevated temperature and Headache
Investigations:
Fat cells in blood, urine & sputum; ST-segment changes on ECG; Decreased platelet count & hematocrit levels, Prolonged prothrombin time; Pulmonary infiltrates on Chest X-Ray
Fat Embolism.
Management Prevention: Careful immobilization of the long bone fracture Supportive: Fluid resuscitation
Correction of acidosis
Replacement of blood loss Oxygen administration through mask or mechanical ventilation Coughing and Deep breathing
Amputation
Amputation
Surgical removal of all part of a limb Two types of amputation: 1. Closed(flap)-myoplastic: Residual limb is covered by a flap of skin. Flap of skin is sutured posteriorly, common technique in vascular diseases 2. Open(guillotine): Used with infection & who are prone to surgical risks. Wounds heals by granulation or secondary closure in a week.
Amputation
Clinical Indications Circulatory impairment resulting from peripheral vascular disorder Traumatic and Thermal Injuries Malignant tumors Uncontrolled & Widespread infection of the extremity Congenital disorders
Clinical Manifestations Pain Loss of sensation Pallorness Local or systemic manifestations of sepsis
Amputation
Diagnostic History and Physical Examination
Rehabilitation Coordination of prosthesis-fitting and gait training Coordination of muscle-strengthening and physicaltherapy regimens
Joint Surgeries
Joints frequently replaced include the hip, knee, shoulder, elbow, wrist, and ankle and finger joints.
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Non-cemented
implants
implants
We will study
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The total hip arthroplasty or replacement is performed to restore joint motion by replacing arthritic bone with metal components.
The modular prosthetic hip replacement system used today has three components the femoral stem, the femoral head, and the acetabulum. Each component has multiple sizes which allow for a custom fit.
stainless steel and ultra high molecular weight polyethylene. Cementless and cemented prosthesis systems are available.
First performed in 1960. Since then, improvements in joint replacement
surgical techniques and technology have greatly increased the effectiveness of this surgery.
Indications
Osteoarthritis
Indications.
Rheumatoid arthritis Traumatic arthritis
Indications.
Fracture Other s Failure of previous reconstructive surgeries (Failed prosthesis, osteotomy, femoral head replacement) Problems resulting from congenital hip diseases.
Contra-indications
or
long-term
Hip Prosthesis
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Surgical Technique
1. Removing the
femoral head
2. Reaming acetabulum
the
Operation (contd..)
3. Inserting Acetabular Component the 4. Preparing Femoral Canal the
Operation (contd..)
5. Inserting Stem Femoral 6. Attaching Femoral Head the
Operation (contd..)
7. The Completed Replacement Hip
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Fibula
Indications
Osteoarthritis Cartilage defects Ligament tears
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Contra-indications
Clients 65 years of age and older Clients with weight 200 pounds and more Conditions such as diabetes mellitus and peripheral vascular disorders.
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Surgical Technique
1. 2.
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Surgical Technique.
3. 4.
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Surgical Technique.
5. 7.
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Surgical Technique.
8. 9.
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post-op
Discharge
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from
the
hospital in
NURSING MANAGEMENT
ASSESSMENT
Pain localized region in hip Gait pattern Exaggerated gait pattern (limp) Increase in pain when weight-bearing Reduction in the degree of ROM As the degeneration of the joint worsen, individual may be awakened at night with pain
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Muscle atrophy
Active Range Of Motion
Passive ROM
X-ray clear degeneration of the bone
Pain: Hip/Knee
Knowledge deficit
Pre-operative phase
Pain : hip/knee
0 1 2 3 4 5 6 7 8 9 10 no terrible Desired outcomes pain pain Verbalization of reduction of pain. Relaxed facial expression and body positioning. Increased participation in activities. Stable vital signs.
Knowledge deficit
Desired outcomes Verbalize an understanding of usual preoperative and postoperative care and routines.
Demonstrate the ability to
Pain
Potential complication s
Pain : hip/knee
0 1 2 3 4 5 6 7 8 9 10 no terrible Desired outcomes pain pain Verbalization of reduction of pain. Relaxed facial expression and body positioning. Increased participation in activities. Stable vital signs.
Desired outcomes Experience normal healing of the surgical wound Maintain skin integrity as evidenced by absence of redness and irritation and no skin breakdown
during and after the surgery. Tissue necrosis Hematoma formation Desired outcomes Absence of chills and fever. Absence of redness, warmth and swelling around incisions or open wound Usual drainage from the wound. WBC count returning to the normal. Negative cultures of the wound drainage.
fatigue and orthostatic hypotension Weakness and pain in the weight bearing extremity Improper transfer or ambulation techniques.
Desired outcomes
The client will not experience falls.
Potential complications
Shock Neuro-vascular damage Dislocation of prosthesis Fat embolism Thrombo-embolism Contractures
Shock
Asses
for following:
and
report
the
Persistent vomiting
Difficulty
maintaining oral or intravenous intake Significant decline in RBC, Hct, Hb levels, PT and aPTT more than 2 times the control Signs and symptoms of the
Neuro-vascular damage
Assess for and report signs and symptoms Diminished or absent pedal pulses. Capillary refill time in toes greater than 3
seconds. Pallor, blanching, cyanosis or coolness of the extremity. Inability to flex or extend the toes. Numbness or tingling in the foot or toes. Pain in foot during passive motion of the toes or foot. Significant internal or external (10) rotation of the extremity.
Dislocation of prosthesis
Assess and report signs and symptoms Sudden, severe hip/knee pain followed by
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continued pain and muscle spasms during hip movement Palpable bulge over femur head Abnormal rotation of operative leg Inability to move or bear weight on operative leg, Shortening of operative leg Decline in neurovascular status in operative leg.
Fat embolism
Assess for the signs and symptoms : Restlessness Apprehension Confusion Sudden onset of chest pain, tachypnea, pallor with subsequent elevated temperature Pulse, petechiae on buccal conjunctival sac , face, neck (petechiae are late sign) 114 Low PaO2 level.
Thrombo-embolism
Assess for symptoms
Tenderness
signs
and
or
pain
in
extremity Increase in the circumference of calf and thigh Usual warmth or redness of the extremity 115 Positive homans sign.
Contractures
Limitations in range of motion (cannot be assessed for first 2-3 days because of position and movement restrictions)
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HEALTH TEACHING
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DOS
Keep operative leg in proper alignment and avoid rotating hip and knee. Turn only as directed by the physician (many physicians allow turning to un operative side only and instruct client to keep pillows between legs while on side).
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DOS
Elevate operative extremity TKR.
after
Sit in chairs with arms and utilize arms to raise self from chair.
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DOS
Support weight on unoperative leg when raising self from a sitting position.
Reinforce physician instructions about amount of weight bearing on operative extremity
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DOS
Reinforce instructions about correct transfer and ambulation techniques and proper use of walker, quad cane or crutches. Reinforce importance of continuing prescribed exercises for at least a year.
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DONTS
Do not turn the operated leg inward
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DONTS
Do not sit with cross legs. Do not sit for more than 1 hour at a time. Do not reach to the end of the bed to pull covers up. Do not put on shoes or 126 socks without using an
DONTS
Do not sit on low chairs, stools or toilet seats, place a cushion on low chairs, purchase a raised toilet seat for home use and use high toilets for handicapped when in public facilities.
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Preparation of Home
Make modifications to your home prior to surgery that will decrease your risk for falls or injury
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Move electrical and telephone cords away from walkways Use chairs with arm rests Avoid low chairs/sofas surface
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Install grab bars in the bathtub Install skid resistant strips or a rubber mat both in and in front of the bathtub
Recommend raised toilet seat
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Store frequently used items at waist level and less frequently used items in higher cabinets
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