Transcript Nursing of Adults with Medical & Surgical Conditions

Nursing of Adults
with
Medical & Surgical Conditions
Fractures
&
Complications of Fractures
Arthroplasty
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Knee Arthroplasty (total knee replacement)
– Replacement of the knee joint
– Restore motion of the joint, relieve pain, or
correct deformity
Arthroplasty
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Hip Arthroplasty (total hip replacement)
– Replacement of the hip joint
Arthroplasty
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Nursing Interventions
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Empty and record hemovac
Give oxygen 2-3 l/min
Incentive spirometer q 2hrs
Cough and deep breathe q 2hrs
Record I&O
Bed rest 24-48 hrs
Change dressing as ordered
Diet as ordered
Neurovascular checks q1hr x24, q2hrs x24, then q4hrs
Vital sighs q 4hrs
Maintain position of operative area
Physical therapy will initiate ambulation and prescribe routine
Encourage fluid intake
Antiembolisim stockings
Avoid adduction and hyperflexion of hip
Fracture of the Hip
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Etiology/pathophysiology
– Most common type of fracture
– Women higher risk due to osteoporosis
– Types of hip fractures
• Intracapsular
– inside the joint
• Extracapsular
– outside the hip joint
Fracture of the Hip
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Signs & Symptoms
– Severe pain at site
– Inability to move the leg voluntarily
– Shortening or external rotation of the leg
Fracture of the Hip
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Diagnostic Tests
– Radiographic examination
– Hemoglobin may be decreased because of
bleeding
Fracture of the Hip
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Treatment
– Buck’s or Russell’s traction
until surgery
– Surgical repair
• Internal fixation
– Neufeld nail and screws
– Kuntscher nail
(intramedullary rod)
• Prosthetic implants
– Austin Moore prosthesis
– Bipolar hip replacement
(hemiarthroplasty)
Fracture of the Hip
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Postoperative interventions
– Wound assessment
– Vital signs
– Assessment of drains
• Jackson-Pratt, Hemovac
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Incentive spirometer
Turning q 2 hours
Antiembolic stockings
Anticoagulation therapy
Fracture of the Hip
– Maintain leg abduction
• abduction pillow
– Turn to unoperative side
– Limit weight bearing on
affected side
– Chairs and commode
seats should be raised
to prevent flexion of hip
beyond 60 degrees
Fracture of the Hip
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Patient teaching for ORIF
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Assess ability to understand
Assist to dangle at bedside
No weight on operative side
Turn every 2 hours, maintain abduction
Assist with ROM
PT will instruct as to ambulation and weight
bearing
– As pt. progresses, encourage to continue to
ambulate only with assistance
Fracture of the Hip
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Patient Teaching for Hip Prosthetic Implant
– Avoid hip flexion
• beyond 60 degrees for approximately 10 days
• beyond 90 degrees for 2 to 3 months
– Avoid adduction of the affected leg beyond midline for
2 to 3 months
– Maintain partial weight bearing for approx. 2 to 3
months
– Avoid positioning on the operative side in bed
– Maintain abduction of the hip
– “DO NOT” list
“DO NOT” List
Other Fractures
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Etiology/Pathophysiology
– A traumatic injury to a bone in which the
continuity of the tissue of the bone is
broken.
– Pathological or spontaneous fractures
• occur without trauma
• osteoporosis, metastatic cancer and bone
tumors
Types of Fractures
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Open (compound)
– Protrusion of the bone
through the skin
– Require surgical repair
– Prone to infection
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Closed (simple)
– Bone has NOT
protruded through the
skin
– May be realigned by
external manipulation
Types of Fractures
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Greenstick fracture
– Incomplete fracture
– Extends only partially through the bone
– Common in children because bones are
more flexible
Types of Fractures
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Complete fracture
– Fracture line extends entirely through the
bone with the periosteum disrupted on both
sides of the bone
Types of Fractures
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Comminuted fracture
– Bone is splintered into three or more
fragments at the site of the break
– More than one fracture line
Types of Fractures
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Impacted fracture
– One bone fragment is forcibly wedged into
another bone fragment.
Types of Fractures
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Transverse fracture
– Break runs directly across the bone.
Types of Fractures
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Oblique fracture
– Break runs along a slant to the length of
the bone.
Types of Fractures
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Spiral fracture
– Break coils around the bone.
– Usually caused by a twisting force.
Types of Fractures
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Colles’ Fracture
– Distal portion of the radius within 1 inch of
the joint of the wrist
– Commonly occurs when a person attempts
to break a fall by putting their hands down
Types of Fractures
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Pott’s Fracture
– Occurs at the distal end of the fibula
– A piece of the medial malleolus chips off.
Medial Malleolus
Posterior Left Foot
Fractures
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Bone Repair
Assessment
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Seven P’s of Orthopedic Assessment
– Pain
• Does it seem out of proportion to the patient’s injury?
• Does it increase with active or passive motion?
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Pallor
Paresthesia or numbness
Paralysis
Polar Temperature
• Is it cold compared to opposite extremity?
– Puffiness from edema or hematoma
– Pulselessness
Fractures
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Signs & Symptoms
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Pain
Loss of normal function
Obvious deformity
Change in the curvature or length of bone
Crepitus (grating sound with movement)
Soft tissue edema
Warmth over injured area
Ecchymosis of skin surrounding injured area
Loss of sensation distal to injury
Signs of shock (injury, blood loss, & pain)
Fractures
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Diagnostic Tests
– Radiographic
examination
Fractures
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Treatment (Immediate)
– Splinting to prevent edema
– Body alignment
– Elevation of body part
– Application of cold packs, first 24 hours
– Administration of analgesics
– Observation for change in color, sensation,
or temperature
– Observe for signs of shock
Fractures
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Treatment (Secondary Management)
– Closed (simple)
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closed reduction
traction
open reduction with internal fixation device
immobilization
– external fixation device
– traction
– internal fixation devices; pins, screws, plates
Fractures
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Treatment (secondary management)
– Open (compound)
• Surgical debridement of wound
– remove dirt, tissue, etc.
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Administration of tetanus toxoid
Culture of wound
Observation for signs of infection
Closure of wound
Reduction of fracture
Immobilization of fracture
Treatment of complications
Fracture of the Vertebrae
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Etiology/pathophysiology
– Diving accidents
– Blows to the head or body
– Osteoporosis
– Metastatic cancer
– Motorcycle and car accidents
– Displaced fracture may place pressure on
or sever the spinal cord nerves
Fracture of the Vertebrae
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Signs & Symptoms
– Pain at site of injury
– Partial or complete loss of mobility or
sensation below level of injury
– Evidence of fracture/ fracture dislocation
on x-ray
Fracture of the Vertebrae
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Treatment
– Stable injuries
• pain medication
• muscle relaxants
• back support, brace or cast
– Unstable fractures
• Traction
– Cranial skeletal traction
» Halo brace
– Pelvic traction
• Open reduction
– Harrington rod
Fracture of the Pelvis
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Etiology/pathophsiology
– Trauma involving great force
• falls from extreme heights
• automobile accidents
• crushing accidents
Fracture of the Pelvis
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Signs & Symptoms
– Unable to bear weight without discomfort
– Pelvic tenderness and edema
– Hematuria (bladder trauma)
– Signs of shock
Fracture of the Pelvis
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Treatment
– Bed rest for approx. 3 weeks
– Ambulate with crutches for approx. 6
weeks
– More severe fractures may require surgery
and/or spica or body cast
Complications of Fractures
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Compartment Syndrome
– Cause
• Caused by the progressive
development of arterial vessel
compression and reduced
blood supply to an extremity.
– Signs & Symptoms
• Sharp pain with movement,
numbness or tingling in the
affected extremity, cool & pale
or cyanotic, slow capillary
refill
Complications of Fractures
– Treatment
• Fasciotomy (incision
into the fascia)
– Complication
• Volkmann’s contracture
(clawhand)
Complications of Fractures
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Shock
– Cause
– Blood loss, pain, fear
– Signs & Symptoms
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Altered level of consciousness
Restlessness
Hypotension, tachycardia, & tachypnea
Pale, cool, moist, skin
– Treatment
– Restore blood volume
» IV fluids - LR
» Administer blood
– Oxygen
– Shock trousers
Complications of Fractures
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Fat Embolism
– Cause
• Emoblization of tissue fat with platelets
• Most common with multiple fractures and long bone
fractures
– Signs & Symptoms
• Irritability, restlessness,disorientation, stupor, and coma
due to hypoxemia
• Chest pain and dyspnea
– Treatment
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IV fluids
Steroids (reduce inflammation)
Digoxin (increase cardiac output)
Oxygen
Complications of Fractures
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Gas Gangrene
– Cause
• Severe infection of the skeletal muscle by Clostridium
bacteria
– Signs & Symptoms
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Pain at site of injury
Gas bubbles under the skin
Signs of infection
Necrotic skin at site
Foul odor from wound drainage
– Treatment
• Excision of gangrenous tissue
• Antibiotics - Penicillin G or Keflin
• Strict aseptic technique
Complications of Fractures
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Thromboembolus
– Cause
• Blood vessel is occluded by an embolus
– Signs & Symptoms
• Area may tingle and become cold, numb, and
cyanotic
• Embolus in the lungs cause a sharp thoracic or
upper abdominal pain, dyspnea, cough, fever,
and hemoptysis
– Treatment
• Anticoagulants
– Heparin and/or coumadin
Complications of Fractures
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Delayed Fracture Healing
– Delayed Union
• Fails to heal within the usual time
• Healing is impaired but will eventually repair itself
– Nonunion
• Failure of the ends of the fractured bone to unite
• Fails to unite and produce a stable union after 6-9
months
• Requires bone grafting, prosthetic implant, internal
fixation, external fixation, or a combination of these
methods
• Electrical stimulation
– New method to promote healing
– Stimulates bone production
External Fixation Devices
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Skeletal Pin External
Fixation
– Immobilizes fractures by
the use of pins inserted
through the bone an
attached to a rigid
external metal frame
– Pin Care
• Assess every 8 hours for
s/s of infection
• Remove exudate and clean
with hydrogen peroxide
using aseptic technique
Skeletal Pin External Fixation
Skeletal Pin External Fixation
Nonsurgical Interventions
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Casts
– Made of layers of plaster of paris, fiberglass, or
plastic roller bandages.
– Stockinette applied, a sheet of wadding, and then
casting material
– Nursing Assessment
• Neurovascular assessment q 15 to 30 min. for first few
hours then q 4hours
• Assess skin at the cast edges for erythema and irritation.
• Assess for odor or drainage from under cast
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Cast Removal
– Uses a vibrating saw
• Does not cut
• Causes fine powder
– Wear mask
– Skin Care
• Gently remove buildup of secretions and dead skin by
washing and apply lotion
– May take several days
– Be careful not to remove rapidly, can cause skin impairment
– Muscle Atrophy
• Reassure patient that the muscle will regain strength and size
with proper exercise
Traction
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The process of putting an extremity, bone, or
group of muscles under tension by means of
weights and pulleys to:
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align and stabilize a fracture site
relieve pressure on nerves
maintain correct positioning
prevent deformities
relieve muscle spasms
Types of Traction
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Skeletal
– Applied directly to a bone
– The pin protrudes through the skin on both
sides of the extremity and weights are
attached to a rope
– Used for fractures of the femur, tibia,
humerus, and cervical spine
Balanced Suspension
Skeletal Traction
Tibial Pin Traction with
Steinmann Pin
Types of Traction
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Skin Traction
– Uses weight that pulls on sponge rubber,
moleskin, elastic bandage with adherent,
or plastic material attached to the skin
below the fracture, with the pull exerted on
the limb.
Types of Traction
– Buck’s
• Used as a temporary measure to provide
support and comfort to a fractured extremity
until a more definite treatment is initiated
• Traction in in horizontal plane with affected
extremity
Types of Traction
– Russell Traction
• Similar to Buck’s except that a knee sling is
used to provide support to the affected leg.
• Used to treat hip and knee fractures
Types of Traction
– Bryant’s Traction
• Both legs are suspended at a 90 degree angle
to the trunk of the body and the weight of the
lower body pulls the bone fragments of the
fractured leg into alignment
• Used for small children with fractured femurs
Amputation
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Amputation of a portion of or an entire
extremity
– Malignant tumors
– Injuries
– Impaired circulation
– Congenital deformities
– Infections
Amputation
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Postoperative Nursing Interventions
– Raise foot of bed to elevate extremity
• do not elevate on pillow, may cause contracture
– Encourage movement from side to side & place in
prone position at least 2 times a day to stretch
muscles
– Teach strengthening exercises
– Elastic wraps to shape residual extremity
– Assess for respiratory complications, esp in
elderly
– Phantom-limb pain is normal