Transcript Caring for Clients with Musculoskeletal Trauma

Caring for Clients with
Musculoskeletal Trauma
VN 86
BAKERSFIELD COLLEGE
Introduction
 Musculoskeletal Trauma occurs when tissues are subjected to more force than
they are able to absorb.
 Example: A fall, a step off a curb, being tackled, a motor vehicle crash
 Can range from mild to severe:
 1. Soft tissue injury
 2, Fracture
 3. Complete amputation
 May affect surrounding tissues.
 A bone fracture can affect the function of muscles, tendons and ligaments that
attach to it.
MS Trauma
 Older adults are at higher risk for MS trauma due to falls.
 Nurses job to:
 1. Assessment of home for potential hazards- lighting, hand
rails, throw rugs and clutter, bath mats and grab bars in
bathrooms are necessary.
 2. Shoes that will decrease the risk of slipping
Soft Tissue Trauma
 Sprains, strains and soft tissue damage are common injuries.
 The ankle is the most commonly sprained joint.
 The lower back and cervical spine are the most common sites for
muscle strains.
 Contusion- simplest MS injury. Bleeding into the soft tissue from blunt
force.
 Sprain- ligament injury caused by a twisting motion that overstretches
or tears the ligament. Grades 1,2,3 and 4.
 Strain- microscopic tear in the muscle that causes bleeding into the
tissues. The muscle was forced to extend past it’s elasticity.
Interdisciplinary Care Soft tissue trauma
 X-ray to rule out fracture.
 MRI to further evaluate.
 Treatment- Measures to decrease swelling, alleviate pain
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and encourage rest and healing.
Avoid using injured area
May need a splint
Ice first 48 hrs, then heat
Compression dressing
Elevation
NSAID, analgesics including narcotics may be needed.
Health promotion- discussion
Nursing Interventions
 Promote comfort, prevent further injury and allow healing.
 RICE
 Do not attempt to move an injured joint beyond the point of
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comfort.
If fracture is suspected immobilize the joint
Especially important with cervical spine fracture
Palpate for swelling, warmth, tenderness, deformity and
crepitus.
Check capillary refill, pulses, movement and sensation
distal to the injury.
Nursing Process
 Potential Nursing diagnosis:
 1. Impaired tissue integrity rt trauma
 Goal: patient will demonstrate progressive healing of
tissue from 0700-1900 date.
 2. Acute pain rt tissue trauma
 Goal: patient will have pain level of 1-3 on a scale of
1-10 during my shift.
Fractures
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A break of a bone.
Vary in severity depending on location and type of fracture.
Types of Fractures:
See text
The direction of the fracture line is used to classify fractures.
Closed
Open
Comminuted
Compression
Impacted
Depressed
Spiral
Greenstick
Fracture Clinical Manifestations
 Fractures accompanied by soft tissue injuries that involve
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muscles, blood vessels, nerves or skin.
CM- Deformity Complications
Swelling,
Bleeding- hypovolemic shock
Ecchymosis
Infection
Pain
peripheral nerve damage
Tenderness
blood flow disruption
Numbness
necrosis, blood vessel damage
Crepitus
immobility
Muscle spasm
DVT, compartment syndrome, fat emboli
Fracture Healing
 Osteoblasts promote new bone formation
 Osteoclasts migrate to the repair site to remove damaged
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and excess bone in the callus.
Callus- connects bone fragments and splints the fracture,
it’s a stage in fracture
Video on fracture
Healing time varies with the individual.
Uncomplicated fracture of the arm or foot can heal in 6 to 8
weeks. Vertebra- 12weeks, hip- 12-16 weeks.
Interdisciplinary Care Fracture
 Fractures require prompt treatment
 May need to be reduced- Normal alignment of bone is
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restored. Immobilization as soon as possible.
Nursing InterventionsImmobilization, pulses, color movement and sensation
before and after splinting and throughout shift.
Closed Reduction- External manipulation is used to
reposition the bone. Conscious sedation used.
Open Reduction- Completed in the OR. The bone is
exposed and realigned. Screws may be used to maintain
position.
Care of Fractures continued
 Casts- rigid device used to immobilize broken bones and
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promote healing. Plaster or fiberglass.
Muscle spasms can pull bones out of alignment after a
fracture.
Traction- applies a straightening or pulling force to return
or maintain the fractured bones in normal position.
1. Manual Traction- applied by physically pulling on the
extremity. Reduce a fracture or dislocation.
2. Skin Traction- (straight traction)applies the pulling force
through the client’s skin. Non-invasive and is relatively
comfortable for the client. Example: Buck’s traction.
Traction continued
 The Most common type of Skin Traction is Buck’s
Traction- Used to immobilize the leg before surgery to
repair a hip or proximal femur fracture.(NCLEX)
 3. Balanced suspension Traction- Uses more than one force
of pull to raise and support the injured extremity off the
bed and maintain it’s alignment. Increases mobility
while maintaining bone position.
 4. Skeletal Traction- Pulling force is applied directly
through pins inserted into the bone. Risk for infection is
greater than other types.
Surgery and Fractures
 1. External fixation is the simplest form of surgery used to
immobilize a fracture. This uses a external fixator and a
frame connected to pins inserted into the bone. The pins
require care similar to that of skeletal traction pins. The
client is monitored for infection, and frequent
neurovascular assessment is performed.
 2. Internal fixation- surgery called an open reduction and
internal fixation (ORIF). Fracture is directly reduced and a
nail, screws, plates and screws or pins are inserted to hold
the bones in place. Open fractures and hip fractures
are repaired with ORIF.
Nursing Care Fractures
 Priorities for Nursing care:
 Prevent complications
 Managing pain
 Impaired mobility
 Health Promotion- Fractures
 Use safety equipment
 Adequeate daily calcium
 Regular exercise
 Discussion Older Adults and hip fractures!!!!!
Nursing Care Fractures
 Assessment Potential Complications Fractures:
 Increasing pain or pain that is not relieved by analgesia
may indicate a complication such as compartment
syndrome or infection.
 Numbness, tingling, changes in sensation or changes in
movement distal to the fracture may indicate nerve damage
or compartment syndrome.
 Impaired circulation- cool, pale extremity with weak or
absent pulses.
 Edema, warmth and a bluish or purple tinge may indicate
venous venous pooling.
Nursing Diagnosis
 1. Risk for or ineffective peripheral tissue perfusion r/t
altered bone integrity or surgical procedure.
 Goal: Circulation will remain effective.
 2. Acute pain r/t altered bone integrity.
 3. Impaired physical mobility r/t altered bone integrity.
Hip Fracture
 Causes: Decreased bone mass and muscle strength
 Slowed reflexes
 Medications that can affect cognition or balance
 Osteoporosis and loss of bone mass- spontaneous hip
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fracture, minor trauma can lead to hip fracture.
Leads to loss of independence and restricted activity and
death
Break of the femur at the head, neck or trochanteric region.
Most common neck or trochanteric region.
Diagnosed by history and physical and x-ray.
Buck’s traction is applied to reduce muscle spasm until OR.
Hip Fracture
 340,000 people/year, 50% 85 yr and older.
 ORIF or hip replacement is completed
 Femoral head or neck is fractured a prosthesis is inserted to
replace the femoral head= arthroplasty.
 Femoral head and acetabulum replaced= total hip
replacement.
 Video
Hip Fracture Nursing
 1. Maintaining circulation to the injured extremity
 2.Preventing infection
 3. Making pain tolerable
 4. Increasing mobility
 1. Risk for ineffective peripheral tissue perfusion r/t
fracture and swelling
 2.Risk for infection r/t altered bone integrity
 3. Acute pain r/t fracture and muscle spasms
 4. Impaired physical mobility r/t bed rest and fracture
Joint Trauma and Injury
 Joints are the weakest part of the skeleton.
 Can be injured when subject to stretching or twisting.
 Ligaments, tendons and muscles that support the joint may
be stretched or torn, joint cartilage may be damaged, the
joint itself can be dislocated.
 Dislocation- is separation of contact between two bones
of a joint.
 Dislocations are due to sudden force or joint
disease.
 Shoulder and hip dislocation are the most common
Repetitive Use Injuries
 Result from overuse of or repeated stress on a joint without
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adequate recovery time.
Common Types:
Carpal tunnel syndrome, bursitis, and epicondylitis.
Significant disability and lost work time.
Carpal tunnel syndrome-work related injury results
from inflammation and swelling of structures in the wrist
joint. Result is the tunnel narrows, compressing and
irritating the median nerve. Numbness and tingling of the
thumb, index finger and middle finger of the affected hand
develop.
Bursitis
 Inflammation of the bursa, which is a pad sac that prevents
friction between tissues such as ligaments, tendons and
bone. Bursae in the shoulder, hip, leg and elbow may
become inflamed, causing local tenderness and pain with
movement.
 Epicondylitis- also called tennis elbow or golfer’s elbow.
Inflammation of a tendon where it inserts into the bone.
Repeated trauma causes it along with bleeding and
inflammation of the tendon. Point tenderness, pain
radiating down the forearm and history of repetitive use.
Repetitive Use Injury
 Diagnosed by history and physical exam.
 History will reveal an occupational risk or frequent
participation in activities such as tennis, golf, softball, or
baseball.
 Phalen’s test- When Carpal tunnel syndrome is
suspected.
 Initial Treatment- rest and immobilization, splint and
ice for 24-48 hrs. Heat after, NSAID, cortisone into joint.
What about corticosteroids and diabetes?
 Surgery for CTS.
Rotator Cuff and Knee Injury
 Shoulder injuries result from rotator cuff being injured.
 Repetitive use or degenerative changes of involved tissue
 CM- shoulder pain which is worse at night or lying on the
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involved shoulder, motion may be limited
Diagnosed by h&p, x-ray, MRI. Treatment is conservative.
May need surgery.
Knee Injury- ligament tears, meniscal injury, patellar
dislocation seen with sports injury.
CM-acute injury with immediate pain, tearing sensation or
popping. Swelling common. X-ray and MRI complete DX.
Joint rest with RICE, Physical therapy, surgery.
Nursing Care Joint Trauma Repetitive Use
Injury
 Primary focus is education!!!
 Detailed assessment detailed information about known
trauma, circumstances of injury, pain. Examiniation.
 Acute Pain
 Impaired physical mobility
 Psychosocial also.
Amputation
 Partial or total removal of a body part.
 May be completed to treat types of diseases like bone
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cancer, may be the result of a chronic condition such as
peripheral vascular disease or diabetes.
May be due to trauma.
Devestating to the client!
Significant physical and psychosocial effects on the client
and family
Adapting will take time and significant effort.
Pheripheral vascular disease is the major cause of
lower extremity amputation. Peripheral
neuropathy puts clients at risk.
Pathophysiology
 Impaired blood flow along with untreated infection can
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cause tissue death and lead to amputation.
PVD- circulation to the extremites is impaired. This leads to
edema and tissue damage. Healing is impaired (why?)
Thus minor injuries and stasis ulcers can become infected.
Bacteria tend to proliferate.
Peripheral neuropathy- loss of sensation leads to
unrecognized injury and infection.
Level of amputation is determined by the extent of
tissue damage and healthy tissue. Joints try to be
reserved for better function. See textbook.
Amputation
 Complications:
 Infection
 Delayed healing
 Contractures
 Infection- Older, diabetes, PVD higher risk.
 Nursing- assessment, skin care, aseptic technique, turning,
deep breathing and coughing.
 Look for delayed healing in the clients with PVD,
diabetes and who are older along with poor
nutrition and smoking.
Amputation
 Contractures- abnormal flexion and fixation of a joint
caused by muscle atrophy and shortening. Common with
amputations. Measures to prevent: discussion.
 Phantom Limb Pain- Tingling, numbness or itching of
the amputated limb. Cause unknown may be caused by
trauma to the nerves serving the amputated part. Pain
clinic comprehensive pain management program.
 Open and closed amputation
 Prosthetist- prosthetic options.
Nursing Care Amputation
 Potential complications- vitals, urine output, pain not
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relieved by analgesics or change in pain character or
location.
Assessment of wound and dressing- bright red, or
later redness, swelling purulent drainage or
hematoma.
Nursing Diagnosis:
Risk for infection
Acute pain
Impaired physical mobility
Disturbed body image
Amputations
 Video
 Amputation video
 http://www.youtube.com/watch?v=XFb2fXPZi8A