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Medical/Surgical Nursing:
Fractures - Lecture 7
Osteoporosis

· A condition characterized by low bone mass and structural deterioration of bone tissue, leading to increased
bone fragility

·            Major cause of fractures in elderly and post-menopausal women

·            8 times more common in women than men

·            Cannot be detected by x-ray until more than 25%-40% of calcium in the bone is lost

· Cause of primary OA is unknown

·            Secondary OA has a precipitating event

·            Joint cartilage becomes yellow and opaque with rough surfaces and areas of malacia

·            Fragments of cartilage may come loose

·            Inflammation of the synovial membrane secondary to the cartilage breakdown

Clinical Manifestations

· Weight bearing joints are the most affected

·            Joint stiffness occurs after periods of rest

·            Crepitation may be present

·            Usually affected asymmetrically

·            Heberden’s nodes

·            Commonly affects hips, knees and vertebral column

Nursing Diagnoses

· Pain

·            Sleep pattern disturbance

·            Impaired physical mobility

·            Self-care deficit

·            Self-esteem disturbance

·            Altered nutrition: more than body requirements

FRACTURES

· Disruption or break in continuity of the structure of a bone

·            Occurs from trauma (MVA, fall, etc.) or pathologic

·            Classified by types, communication with the environment and location

·            Can also be stable or unstable

Types of fractures

· Complete fractures

·            Incomplete fracture

·            Comminuted fracture

·            Closed fracture

·            Open fracture

CLINICAL MANIFESTATIONS

· Edema and swelling

·            Pain and tenderness

·            Muscle Spasm

·            Deformity

·            Ecchymosis

·            Loss of function

·            Crepitation

COMPLICATIONS

Infection

Compartment syndrome

Fat embolism

Shock

Avascular necrosis

Delayed union and non-union

Reactions to internal fixation devices

Fat Emboli

· Fat embolism: after fracture of long bones or pelvis, multiple fractures or crush injuries, fat emboli may
develop, especially in young adults men, typically 20-30 years old.

Clinical manifestations

· Hypoxia
·            Tachypnea

·            Systemic emboliztion: petechiae are noted in the buccal membrane and conjunctival sac, on the hard
plate or fundus of the eye.

·            Over the chest and anterior axialllry folds.

Prevention

· Quick immobilization of fracture

·            Minimal fracture manipulation

·            Adequate support for fractured bones during turning and positioning.

SHOCK

Delayed union and nonunion

· Delayed union: occurs when healing does not advance at a normal rate for the location and type of fracture.

·      Nonunion: failure of the ends of a fractured bone to unite. (please read medical management on p. 1839)

Avascular necrosis of bone

· Occurs when the bone loses its blood supply and dies.

READ

· P. 1839

·            Reaction to internal fixation device

·            Reflex sympathetic dystrophy syndrome

·            Heterotrophic ossification

Emergency management of fractures

· Immobilize the minute you believe there is a fracture.

·            Splint.

·            If an open fracture cover the wound with a clean sterile dressing to prevent contamination of
deeper tissue

Medical management

· Reduction

·            Immobilization

·            Maintaining restoring function

· READ p. 1840-1841
TRACTION

· SKIN

·        Buck’s

·            Russell’s

·            Bryant’s

·            Pelvic belt

·            Pelvic sling

· CIRCUMFERENTIAL

·            SKELETAL

·            Overhead arm

·            Lateral arm

·            Balanced suspension

HIP FX & REPLACEMENT

· Usually women > men

·            Approximately 75% of falls occur indoors

·            14% - 36% death rate within one year

·            25% can’t walk independently

·            60% do not gain pre-fx ambulation

Intracapsular fracture

· Intracapsular fracture: occurs within the capsule

·            Their name is taken from the specific location (subcapital, transcervical, or basilar neck).

·            These fractures are often associated with osteoporosis and minor trauma.

Extracapsular Fracture

· Occurs below the capsule and are termed intertrochanteric if they occur in a region between the greater and
lesser trochanter.

·            Usually occurs from sever direct trauma or a fall.

Clinical manifestations

· External rotation

·            Muscle spasms

·            Shortening of the affected ext.

·            Severe pain

·            Tenderness to the region of the fracture site

·            Displaced femoral neck fractures cause serious disruption of the blood supply to the femoral head,
which can result in avascular necrosis.

Care

· Surgery repair is the preferred method of managing Intracapsular and Extracapsular.

·            Treatment with traction requires 12-16 weeks of immobilization for healing to occur, even if the
blood supply to the region is intact.

·            Initially the affected area is placed in either a buck's or Russell until surgery.

·            Traction can relieve muscle spasms.

Intracapsular

· are usually repaired with the replacing the head of the femur.

·            Slow to heal because of the disruption in the blood supply

Extracapsular

· is usually pinned.

Nursing management

· Patients surgery may be delayed if the patient has DM, cardiovascular issues. The surgeon might wait till the
patient is stabilized.

·            Analgesics or muscle relaxants (control muscle spasms)

·            Teach patient to use trapeze and show them the exercise prior to surgery.

·            Practice getting in and our of bed.

Post surgery

· Vitals

·            I &O

·            Pain med

·            Check dressing for signs of bleeding and infection

·            Access the toes for neuro-vascualr assessment

·            Ambulaton usually begins on the first day by P/T. Either a walker or crutches are used.

What not to do after hip surgery

· Do not force hip into greater than 90 degrees of flexion

·            Do not force into adduction

·            Do not force hop into internal rotation

·            Do not cross legs

·            Do not put on shoes or stockings until 8 weeks after surgery without adaptive device

·            Do not sit on chairs without arms to aid rising to a standing position.

What you should do after hip surgery

· Use toilet elevator on toilet seats.

·            Place chair inside shower or tub and remain seated while you wash.

·            Use pillow between legs for 8 weeks when lying on the good side or when supine.

·            Keep hip in neutral , straight position when sitting, walking or lying.

·            Notify surgeon of severe pain, deformity or loss of function.

·            Inform dentist of presence of prosthesis before dental work so that antibiotics can be given.

NURSING DIAGNOSES

· Impaired physical mobility related to surgical procedure

·            Pain related to edema from surgery site

·            High risk for infection related to surgical procedure

·            Impaired skin integrity related to immobility and to surgical procedure

CRITICAL THINKING

· You have a 68 yo female patient that presents to your floor from the ER with a Right Hip Fx. She has a foley
in place. Ordered is Buck’s traction with 5 lbs. weight. She is scheduled to have surgery tomorrow.

·            Your pt. comes back after surgery. What will you do to care for her over the next few days?

AMPUTATIONS

· In upper extremities, usually from trauma

·            In lower extremities, usually from vascular problems, except in younger patients

·            In patients with DM, wound care and eye exams should be a priority due to potential complications
of this disease

·            Goal is to preserve extremity length and function while removing all infected, etc. tissue

TYPES

· Syme’s
·            Below the knee (BKA)

·            Above the knee (AKA)

·            Hip disarticulation

·            Guillotine (open)

·            Ray’s

·            Above the elbow (AEA)

Nursing Management

· Inspect the amputation for signs of irritation, especially redness and abrasion.

·            Discontinue use of the prosthesis if an irritation develops.

·            Wash residual limb thoroughly each night with warm water and bacteriostatic soap. Dry gently

·            Do not use any substance such as lotions, alcohol, powders, or oil unless prescribed by doc.

·            Change residual limb sock daily

Post op

· Use pain med

·            Perform ROM to all joints daily.

·            Do not elevate residual limb on pillows

·            Lay prone with hp extension for 30 minutes three to hour times a day.

Phantom pain

· Warn the patient that they might feel this.

·            That they might feel that the limb is still there.

·            itching, tingling, aching.

·            Coldness, shooting, burning or crushing pain.

·            This pain is real……

NURSING DIAGNOSES

· Body image disturbance related to loss of body part

·            Impaired skin integrity related to surgical procedure

·            Pain related to phantom limb sensation

·            Impaired physical mobility related to loss of body part

POST-OP CARE

· Hemorrhage

·            Phantom pain or sensation

·            Sterile dressing changes

·            KEEP TOURNIQUET AT BEDSIDE

·            Watch for flexion contractures

·            Immediate prosthetic vs. delayed prosthetic fitting

·            Grieving process

·            Encourage behaviors other members of health care team have taught

Orthopedic Surgery

Pre-op care

· Focus on hydration

·            Current med history

·            Possible infection

Diagnosis

· Pain related to fracture, orthopedic problems, swelling, or inflammation

·            Risk for peripheral neurovascualr dysfunction related to swelling, constricting devices, impaired
venous return

·            Risk for ineffective management of therapeutic regimen related to insufficient knowledge or
available support and resources.

Nursing Interventions

· Relieving pain

·            Maintaining adequate neuro-vascular function

·            Promoting Health

·            Improved mobility

·            Helping the patient maintain self-esteem.

Assessment of post op

· All systems

·            Please read p.1801-1802

Complications

· Hypovelmic shock

·            Atelectasis pneumonia

·            Urinary retention

·            Infection

·            Venous stasis

Interventions

· Relieve pain

·            Maintain adequate neurovascular

·            Maintain Health

·            improve physical mobility

·            Maintain self-esteem

·            Monitor complications

Diagnosis

· Pain related to the surgical procedure, swelling, and immobilization.

·            Risk for peripheral neurovascular dysfunction related to swelling, constrictive devices, or impaired
circulation.

Osteomyelitis

· An infection of bone by direct or indirect invasion by an organism

·            Most commonly affected is the vertebrae in an adult

·            Direct entry is contamination from open fracture or surgery

·            Indirect is a blood-borne infection from a distant site

· Most common infecting organism is Staphylococcus aureus

·            Are seeing occurrence of MRSA now

·            Acute osteomyelitis refers to the initial infection or an infection of less than 1 month in duration

·            Chronic osteomyelitis refers to a bone infection that persists for longer than 4 weeks or an
infection that has failed to respond to initial tx

Clinical Manifestations

· Fever

·            Night sweats

·            Chills

·            Restlessness

·            Nausea

·            Malaise

·            Severe bone pain

·            Swelling

·            Tenderness

·            Warmth at site

·            Restricted movement

·            Drainage from sinus tracts to the skin and fracture site

·            Chronic – Pus accumulation and scar tissue formation

Diagnostics

· Wound culture determines the causative organism

·            A bone or tissue biopsy is the definitive way to determine the causative agent

·            Elevated WBC, Leukocytes and Sed. Rate

·            On x-ray, will take at least 10 days to show if not weeks

·            Can also do a CT or MRI or gallium scan

Collaborative Care

· Vigorous antibiotic therapy

·            Surgical debridement and decompression

·            Immobilization of affected part

·            Surgical removal of dead bone

·            Constant irrigation

·            Long hospital stay due to need for IV antibiotics

Diagnoses

· Pain

·            Hyperthermia

·            Impaired physical mobility

·            Ineffective management of therapuetic regimen

·            High risk for infection

·            Knowledge deficit

·            Self-care deficit

·            Body image disturbance

·            Impaired skin integrity

Osteoarthritis

· Also known as degenerative joint disease (DJD)

·            Is a slowly progressive disorder of articulating joints and is characterized by degeneration of

articular cartilage

·            Damage is confined to the joints and surrounding tissues

· Cause of primary OA is unknown

·            Secondary OA has a precipitating event

·            Joint cartilage becomes yellow and opaque with rough surfaces and areas of malacia

·            Fragments of cartilage may come loose

·            Inflammation of the synovial membrane secondary to the cartilage breakdown

Clinical Manifestations

· Weight bearing joints are the most affected

·            Joint stiffness occurs after periods of rest

·            Crepitation may be present

·            Usually affected asymmetrically

·            Heberden’s nodes

·            Commonly affects hips, knees and vertebral column

Nursing Diagnoses

· Pain

·            Sleep pattern disturbance

·            Impaired physical mobility

·            Self-care deficit

·            Self-esteem disturbance

·            Altered nutrition: more than body requirements

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