Prepared ByHala Mohamed Abd El Hamed Assistant lecturer of Adult nursing Faculty of Nursing Mansoura University
Fracture• A fracture is a complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent.• Fractures occur when the bone is subjected to stress greater than it can absorb.• Fractures may be caused by direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions.
Medical ManagementReduction:Fracture reduction refers to restoration of thefracture fragments to anatomic alignment andpositioning.Either: closed or open.
Closed Reductionis accomplished by:• Bringing the bone fragments into anatomic alignment through manipulation and manual traction.• The extremity is held in the aligned position while the physician applies a cast, splint, or other device.
Open Reduction• Through a surgical approach, the fracture fragments are anatomically aligned.• Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs.
Nursing ManagementPatients With Closed FracturesThe nurse instructs the patient regarding the propermethods to control edema and pain.elevate extremity to heart level; take analgesics asprescribed.Consume diet to promote bone healing.Use mobility aids and assistive devices safely.Avoid excessive use of injured extremity; observeprescribed weight-bearing limits.State indicators of complications to report promptly tophysician (eg, uncontrolled swelling and pain; cool, palefingers or toes; paresthesia; paralysis; signs of local andsystemic infection; signs of venous thromboembolism;problems with immobilization device).
Fracture of the clavicle. Immobilization is accomplished with atypical displacement in clavicular strap.midclavicular fracture.
Casts• Rigid device that immobilizes the affected body part while allowing other body parts to move• Cast materials—plaster, fiberglass, polyester-cotton• Types of casts for various parts of the body—arm, leg, brace, body
Classification of Traction :• Skin Traction : is maintained by direct application of a pulling force on the client’s skin . It is generally used as a temporary measure. – To reduce muscle spasms – To maintain immobilization before surgery.• Skeletal Traction : is attaches directly to bone , providing a strong steady, continuous pull, and can be used for prolonged periods .
Classification of Traction :• The amount of weight used depends on the injury, pathologic condition, body size, and degree of muscle spasm.• Manual Traction : is applied with hands to temporarily immobilize an injured part. A firm, smooth, steady pull is maintained . Manual Traction is used during casting, reduction of a fracture or dislocated joint.
complications:• potential complications that may develop include the following: – Neurovascular compromise. – Inadequate fracture alignment.. – Skin breakdown . – Soft tissue injury.
complications:potential complications that may develop include the following:– Pin tract infection .– Osteomyelitis can occur with skeletal traction.– In additional, complications from immobility can be encountered , especially with long term traction and in older adult.
• The nurse must be consider the psychological and physiological impact of the musculoskeletal problem, traction device, and immobility.• The nurse must assess and monitor the patient’s anxiety level and psychological responses to traction.
• It is important to evaluate the body part to be placed in traction and its neurovascular status and compare it to the unaffected extremity.• As long as the client is in traction, skin integrity must be assessed and documented, examining especially for redness, bruises, and lacerations.
• Radiological Evaluation while the client is in traction determines the extent of injury, maintenance of bony alignment, and the progress of healing.
• Additional principles to follow when caring for the patient in traction: 1. Traction must be continuous to be effective in reducing and immobilizing fractures. 2. Skeletal traction is never interrupted. 3. weights are not removed unless intermittent traction is prescribed. 4. Any factor that might reduce the effective pull or alter its resultant line of pull must be
4. The factor that might reduce the effective pull or alter its resultant line of pull must be eliminated: 1. The patient must be in good alignment in the center of the bed when traction is applied. 2. Ropes must be unobstructed. 3. Weights must hang free and not rest on the bed or floor . 4. Knots in the rope or the footplate must not touch the pulley or the foot of the bed.
Nursing Management: Alteration in Peripheral Tissue Perfusion: Circulatory Care: tissue perfusion is enhanced by client exercises within the limitations of the traction. Exercises, regular deep breathing and coughing, adequate fluids, and elastic stocking work together to prevent deep venous thrombosis. Teaching the client about anti-coagulant is essential.
Nursing Interventions: High risk for peripheral neurovascular dysfunction: Peripheral sensation management : Accurate assessment of neurovascular status includes evaluating the client’s pain, sensation, active and passive ROM, color, temperature, capillary refill time, and pulses. Neurologic impairment specific to the location of the traction should be assessed. The client must be instructed to report changes in sensation. Taught the client about the appropriate exercises.
• Providing pin site care: The wound at the pin insertion site requires attention . • The goals to avoid infection and development of osteomyelitis.Initially : 1. the site is covered with sterile dressing. 2. the nurse must keep the area clean. 3. Slight serous oozing at the pin site is expected. 4. the nurse assess the pin site and drainage for signs of infection.
Attaining maximum mobility with traction: During traction therapy: 1. The nurse encourage the patient to exercise muscles and joints that are not in traction to guard against their deterioration. During the patient exercises : 1. The nurse ensures that traction forces are maintained and that the patient is properly positioned to prevent complications resulting from poor alignment.
Maintaining the positioning : 1. The nurse must maintain alignment of the patient’s body in traction as prescribed to promote an effective line of pull. 2. The nurse positions the patient’s foot to avoid foot drop , inward rotation, and outward rotation. 3. The patient’s foot may be supported in a neutral position by orthopedics devices.
• Monitoring and managing potential complications:Pressure Ulcers• The nurse examines the patient’s skin frequently for evidence of pressure or friction.• It is helpful to reposition the patient frequently and to use protective devices to relieve pressure.• If the risk of skin breakdown is high, as in a patient with multiple trauma or a debilitated elderly patient, use of a specialized bed is considered to prevent skin breakdown.• If a pressure ulcer develops, the nurse consults with the physician and the wound care nurse specialist.
Monitoring and managing potential complications:Pneumonia• The nurse auscultate the patient’s lungs every 4 to 8 hours to determine respiratory status and teaches the patient deep-breathing and coughing exercises to aid in fully expanding the lungs and moving pulmonary secretions.• If the patient history and baseline assessment indicate that the patient is at high risk for development of respiratory complications, specific therapies may be indicated.• If a respiratory problem develops, prompt institution of prescribed therapy is needed.
Venous Stasis and Deep Vein Thrombosis• Venous stasis occurs with immobility.• The nurse teaches the patient to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT, which may result from venous stasis.• The patient is encouraged to drink fluids to prevent dehydration.• The nurse monitors the patient for signs of DVT, including calf tenderness, warmth, redness, swelling (increased calf circumference).
• You are a staff nurse in the emergency department,and a patient is brought in with an open tibia/fibula fracture.• He is not in respiratory distress, with an SaO2 of 99%, and is communicating appropriately with you, but complains of pain.• What assessments will you gather first, second, and third on this patient? Explain your rationalefor the priority order of your assessments.