2. LEARNING OBJECTIVES
On completion of this chapter , the student will:
1. Identify the signs and symptoms of an acute fracture.
2. Describe common treatment modalities for fractures
3. Discuss the prevention and management of immediate
and delayed complications of fractures.
4. Use the nursing process as a framework for care of the
older adult patient with a fracture of the hip.
5. Apply the nursing process as a framework for care of the
patient with an amputation.
3. Fractures
Fracture :complete or incomplete disruption in the
continuity of bone .
Occur when bone is subjected to stress greater than it can
absorb
Caused by direct blows, crushing forces, sudden twisting
motions, and extreme muscle contractions
When bone is broken, adjacent structures affected ,
resulting in soft tissue edema, hemorrhage into the muscle
and joints , joint dislocations, ruptured tendons, severed
nerves and blood vessels damaged
4. TYPES OF FRACTURES
Complete
Incomplete
Closed or simple
Open or compound/complex
Grade I
Grade II
Grade III
8. 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
9. EMERGENCY MANAGEMENT
Immobilize the body part
Splinting: joints distal and proximal to the suspected
fracture site must be supported and immobilized
Assess neurovascular status before and after splinting
Open fracture: cover with sterile dressing to prevent
contamination
Do not attempt to reduce the fracture
10. MEDICAL MANAGEMENT
Reduction : Closed or Open
Immobilization: internal or external fixation
Open fractures require treatment to prevent infection
Tetanus prophylaxis, antibiotics, cleaning and debridement of
wound
Closure of the primary wound may be delayed to permit
edema, wound drainage, further assessment, and
debridement if needed
12. NURSING MANAGEMENT OF THE PATIENT
WITH A CLOSED FRACTURE
- Instruct for proper methods to control edema and pain ( elevate
extremity to heart level, take analgesics as prescribed)
- Teach exercises to maintain the health of unaffected muscles to
increase the strength of muscles needed for transferring and for
using assistive devices such as crutches, walkers, and special
utensils
- Teach how to use assistive devices safely
- Plans made to help patients modify the home environment as
needed to ensure safety such as removing floor rugs or
obstructing walking paths
- Self care , medication information, monitoring potential
complications
13. NURSING MANAGEMENT OF THE PATIENT
WITH OPENED FRACTURE
- Administer IV antibiotics immediately upon the patient’s
arrival in the hospital along with tetanus toxoid if needed
- Initiate wound irrigation and debridement in operating room .
- Wound is cultured and bone grafting may be performed to fill
areas of bone defects
- Elevate the extremity to minimize edema
- Assess neurovascular status frequently
14. FRACTURE HEALING
Factors that Enhance Fracture Healing
- Immobilization of fracture fragments
- Maximum bone fragment contact
- Sufficient blood supply
- Proper nutrition
- Exercises
- Hormones
- Electric potential across fracture
15. FRACTURE HEALING (CONT.)
Factors that Inhibit Fracture Healing
- Extensive local trauma
- Bone loss
- Weight bearing prior to approval
- Infection
- Inadequate immobilization
- Local malignancy
- Age
- Corticosteroids
16. COMPLICATIONS OF FRACTURES
Shock
Fat embolism
Compartment syndrome
Delayed union and nonunion
Vascular necrosis
Reaction to internal fixation devices
Complex regional pain syndrome (CRPS)
Heterotrophic ossification
17. EARLY COMPLICATIONS
Shock
- Hypovolemic shock resulting from hemorrhage noted in
trauma patients with pelvic fracture in which the femoral
artery is torn by bone fragments
- Treatment consists of stabilizing the fracture to prevent
further hemorrhage, resorting blood volume and
circulation, relieving the patient's pain, providing proper
immobilization and protecting the patient from further
injury and other complication s
18. EARLY COMPLICATIONS (CONT.)
Fat Embolism Syndrome
- May develop after long bone or pelvic bone fracture , or
crush injuries
- Most frequently in adults younger than 40 years of age and
in men
- More common in patients with multiple fracture
- At the time of fracture, fat globules may diffuse from the
marrow into the vascular compartment , which may
occlude the small blood vessels that supply the lungs, brain,
kidneys and other organs
- Onset is rapid, 12-48 hours of injury but may occur up to
10 days after injury
19. EARLY COMPLICATIONS (CONT.)
Fat Embolism Syndrome
Clinical Manifestations
- Hypoxia, tachypnea, tachycardia and pyrexia
- Respiratory distress response includes tachypnea, dyspnea,
crackles , wheezes, precordial chest pain, cough, large
amounts of thick white sputum and tachycardia
- Acute respiratory distress syndrome and heart failure may
develop
- Systemic embolization, patient appears pale, petechiae,
fever greater than 39.5 °C, free fat in urine , acute tubular
necrosis and renal failure may develop
20. EARLY COMPLICATIONS (CONT.)
Fat Embolism Syndrome
Prevention and Management
- Immediate immobilization of fracture including early surgical
fixation, minimal fracture manipulation and adequate support
for fractured bones during turning and positioning .
- maintenance of fluid and electrolyte balance
- Respiratory support is provided with high flow oxygen
- PEEP may be used to prevent or treat pulmonary edema
- Corticosteroids
- Vasopressor medications
- I/O
21. EARLY COMPLICATIONS (CONT.)
Compartment Syndrome
- Compartment syndrome is a limb threatening condition
occurs when perfusion pressure falls below tissue pressure
within a closed anatomic compartment
- Involves sudden and severe decrease in blood flow to tissues
distal to an area of injury that results in ischemic necrosis
- Patient complains of deep, throbbing, unrelenting pain,
which continues to increase despite the administration of
opioids and seems out of proportion to injury
- Pain occurs or intensifies with passive ROM
24. EARLY COMPLICATIONS (CONT.)
Compartment Syndrome
- Assessment and Diagnostic Findings
- 5 Ps: pain, paralysis, paresthesia , pallor, pulselessness
- Doppler ultrasonography
- Palpate muscles
- Surgeon may measure tissue pressure , prolonged pressure of
more than 30 mm Hg can result in compromised
microcirculation
25. EARLY COMPLICATIONS (CONT.)
Compartment Syndrome
- Medical Management
- Notify surgeon immediately
- Fasciotomy ( surgical decompression with excision of fascia ) is
indicated to relieve constrictive muscle fascia
- Wound not sutured , left open to allow muscle tissues to expand,
covered with moist , sterile saline dressings or artificial skin
- Affected part splinted, positon and elevated to heart level ,
passive ROM exercises performed every 4-6 hors
- In 3-5 days , when swelling resolved and tissue perfusion
restored , wound is debrided and closed
27. WICK CATHETER USED TO MONITOR COMPARTMENT
PRESSURE
This link shows how to measure compartment syndrome
https://www.youtube.com/watch?v=XXp0EtKtlF8
28. AMPUTATION
Amputation : removal of a body part
Amputation may be congenital, traumatic, or due to
conditions such as progressive peripheral vascular
disease, infection, or malignant tumor
Amputation is used to relieve symptoms, improve
function, and save the person's life
The health care team needs to communicate a positive
attitude to facilitate acceptance and participation in
rehabilitation
33. REHABILITATION NEEDS
Psychological support
Prosthesis fitting and use
Physical therapy
Vocational/occupational training and counseling
Use a multidisciplinary team approach
Patient teaching: see Chart 69-6
35. MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
Monitor VS and suction drainage for signs of
bleeding
Assess by systems ( respiratory , hematological, GI,
GU, skin) for problems associated with immobility(
atelectasis, pneumonia, DVT, PE)
Administer antibiotics as prescribed
Monitor incision, dressing and drainage for signs of
infection
Assess breakdown of skin
Use of residual limb sock
36.
37. NURSING PROCESS—ASSESSMENT OF THE PATIENT WITH AN
AMPUTATION
Assess neurovascular status and function of
affected extremity or residual limb and of
unaffected extremity
Assess for signs and symptoms of infection
Determine nutritional status
Assess concurrent health problems
Determine psychological status and coping
38. NURSING PROCESS—DIAGNOSIS OF THE PATIENT 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
39. NURSING PROCESS—PLANNING THE CARE OF THE PATIENT
WITH AN AMPUTATION
Major goals include
Relief of pain
Absence of altered sensory perceptions and wound
healing
Acceptance of altered body image
Resolution of grieving processes
Restoration of physical mobility
Absence of complications
40. INTERVENTIONS
Relief of pain
Administer analgesic or other medications as prescribed
Change position
Put a light sandbag on residual limb
Alternative methods of pain relief: distraction; TENS
unit
Pain may be an expression of grief and altered body image
Promote wound healing
Handle limb gently
Aseptic technique
Provide residual limb shaping
41. Resolving Grief and Enhancing Body 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 for the
residual limb
Help the patient set realistic goals
Help the patient resume self-care and independence
Provide referral to counselors and support groups
42. Achieving Physical Mobility
Provide proper positioning of limb; avoid abduction,
external rotation, and flexion
Turn the patient frequently; use prone position if possible
Use assistive devices
Implement ROM exercises
Implement muscle strengthening exercises
Provide “preprosthetic care”: proper bandaging, massage,
and “toughening” of the residual limb