Transcript FRACTURES

Med/Surg I,
Module 4
Part 1 of 4
Orthopedic System
Alteration in Mobility
Integumentary System
1
Chronic Musculoskeletal
Conditions
 Curvature of the Spine
 Osteoporosis
 Osteomyelitis
 Osteoarthritis
2
Curvature of the Spine
Kyphosis (left) and Lordosis (right)
Kyphosis
Source: Image courtesy of Charlie Goldberg, M.D., University of
California, San Diego School of Medicine, San Diego VA Medical Center.
http://medicine.ucsd.edu/clinicalimg/thorax-kyphosis.html
Lordosis
Source: Image courtesy of Charlie Goldberg, M.D., University of
California, San Diego School of Medicine, San Diego VA Medical Center.
http://medicine.ucsd.edu/clinicalimg/thorax-kyphosis.html
3
Scoliosis
Source: Wikimedia Commons, Public Domain
http://commons.wikimedia.org/wiki/Category:Orthosis
4
Osteoporosis
Increased Risk
 Family history
 Female
 Menopause-related low estrogen
females, low testosterone males
 Medications
 Lifestyle
5
Osteoporosis
Prevention
 Diet
 Calcium supplements
 Stop smoking
 Alcohol and caffeine intake
 weight-bearing exercise
 Sunlight
6
Osteoporosis
Diagnosis
 Dual-energy x-ray absorptiometry
(DEXA) scan
 Qualitative ultrasound (QUS) of heel
or calcaneus
7
Osteoporosis
Collaborative Management
 Replace estrogen or testosterone
 Raloxifene (Evista)
 Biphosphonates: Alendronate (Fosamax)
and risedronate (Actonel)
 Teriparatide (Forteo)
 Ibandronate sodium (Boniva)
 Calcitonin (Miacalcin)
 Sodium fluoride
8
Osteoporosis
Nursing Care
 Prevent falls
 Treat pain
 Orthotic devices
 Refer to physical therapy
 Range of motion exercises
9
Osteomyelitis
 Local swelling
 Redness
 Tenderness
 Pain
 Fever
 Bone pain
Source: UCSD Catalog of Clinical Images, Photographs by Charlie Goldberg, M.D.,
UCSD School of Medicine and VA Medical Center, San Diego, California, 92093-0611
http://medicine.ucsd.edu/clinicalimg/extremities-Toe-Osteo.html
http://medicine.ucsd.edu/clinicalimg/extremities-osteomyelitis.html
10
Diagnosis
 Bone scan
 Biopsy
 MRI, CT or ultrasound: fluid
collection, abscess, periosteal
thickening
 Elevated WBC, positive blood cultures
11
Collaborative Care
 Surgical debridement is the primary treatment
 Postoperative care: wound irrigation with strict
sterile technique; monitor site for signs of
infection, monitor temperature and WBC
 Most cases caused by Staphylococcus aureus:
 Parenteral antibiotics based on wound, blood
cultures for 4-6 weeks or
 Oral twice-daily ciprofloxacin if chronic
 Hyperbaric oxygen therapy to promote healing
12
Osteoarthritis
Reprinted with permission: Charles J. Eaton, M.D.
of The Hand Center
http://www.eatonhand.com/
Reprinted with permission: DePuy Orthopaedics,
Inc.
http://www.depuyorthopaedics.com/
13
Clinical Manifestations








Crepitus
Joint stiffness
Pain with movement
Heberden’s nodes (distal joints) and
Bouchard’s nodes (proximal joints)
Knees: Joint effusions
Muscle atrophy
Spine: radiating pain, stiffness, muscle
spasms in extremities
Hips: pain referred to inguinal area,
buttock, thigh or knee; loss of internal
rotation
14
Collaborative Care
 Analgesics
 Rest
 Heat
 Weight control
 TENS
15
Total Joint Arthroplasty
Source: Hughston Foundation
http://www.hughston.com/hha/a.11.2.1.htm
Source: Hughston Foundation
http://www.hughston.com/hha/a.11.2.1.htm
16
Postoperative Care
 Abduction pillow, neutral position
 Prevent embolus
 Prevent infection
 Assess for bleeding
 Neurovascular compromise
 Manage pain
 Promote activity
17
Total Knee Arthroplasty
 Continuous passive motion (CPM)
device
 Ice or hot/ice machine
 Keep knee in neutral, no rotation
inward or outward
 Monitor: thromboembolism,
infection, bleeding, CSM
 Teach: no hyperflexion or kneeling
for 6 weeks
18
Acute Musculoskeletal
conditions: FRACTURES
Source: Wikimedia Commons/Creative Commons Licence
Phote courtesy of “Mexican 2000”/Flickr
http://commons.wikimedia.org/wiki/Image:Clavicle_fracture.jpg
Open or Closed?
Photo source: American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=A00139
20
Compound Fractures
 Grade I
o Small wound
 Grade II
o ~1 cm to 10 cm
o skin & muscle contusions
 Grade III
o Large
o Damaged skin, muscle, nerves, vessels
21
Assessment
 Can he move it?
 Does it hurt?
 Is it deformed?
22
Key Treatments
 Closed reduction
 Immobilization
o Splint
o Cast
 Open reduction
Open reduction; External Fixation
National Institutes of Health Osteoporosis
and Related Bone Diseases National Resource
Center http://jama.ama-assn.org/cgi/reprint/291/17/2160.pdf
23
Cast Care
 Prevent indentations when wet
 Elevate uniformly
 Air dry
 CSM – What am I looking for?
 No scratching implements!
24
Skin Traction
 To decrease muscle spasm
 Weight 5-7 pounds attached w/
adhesive tape
 Used before surgical repair
 Check sling, tape for placement
 Keep pulley, weights in place
Photo Source: www.HealCentral.org, Royal College of Surgeons of Ireland (RCSI), Creative Commons
25
Buck’s Traction
 Hip fracture assessment
 What to do immediately?
 Buck’s traction assessments
 What should be done later?
 What teaching is needed?
Buck’s Traction
Source: DeRoyal Patient Care
http://www.deroyal.com/PDFCatalogs/orthopedicCatalog.aspx
26
Other Skin Traction
 Russell’s
 Cervical
 Thomas splint
 Bryant’s
 Cervical
 Pelvic
27
Skeletal Traction







Weight 25-40 pounds
Are the ropes on the pulleys?
Are the weights hanging free?
Where are the knots?
Monitor CSM
Pin care?
Skin care
28
Balanced Suspension
 Counter-traction by weights
 Check ropes, knots, weights
 Are traction bars tightened?
 Is patient in alignment?
 How do pin sites look?
 When can I remove weights?
29
Spinal Traction
 Where are the knots?
 Are the weights hanging free?
 What do the pin sites look like?
 How do I turn the patient?
 How can I make the patient
comfortable?
30
Complications
 Compartment syndrome
 Fat embolism
 DVT
 Osteomyelitis
 Aseptic necrosis
31
Compartment Syndrome
 Prevention
o Check CSM
o Ice, elevate
o Loosen dressing, open cast
 Emergency care
o Fasciotomy:
32
Fat Embolism
 Long bones, multiple fractures
 Elderly: hip fractures
 Altered mental status
 Respiratory distress
 Petechiae on trunk
 Prevention: early immobilization of
fracture
33
Deep Venous Thrombosis
 Most common complication
 Predisposing factors
 Common sites: leg, pelvic fx
 Pulmonary embolus
prevention
Deep Vein Thrombosis
Source: National Heart & Blood Institute
http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt/DVT_WhatIs.html
34
Osteomyelitis
 Sources: open wounds, implanted
hardware
 Staphylococcus aureus usually
 Rx: IV antibiotics
35
Aseptic Necrosis
 Death of bone tissue
 Hip fractures or bone displacement
 Hardware interferes with circulation
36
Amputation
 Diabetic, smoker, infected foot ulcer
 Trauma
 Grieving loss
 Altered self concept
 Coping
 Family response
37
Surgical Wounds
Web Resource
 http://alfa.saddleback.edu
 Click tab titled, “Med-Surg 1”
 Drop down menu  choose
“Wound Care”
38
Wound Assessment
Measure the wound in centimeters
Assess phase of wound healing
• Reaction
• Regeneration
• Remodeling
Wound location, color of wound bed, condition of
wound margins, integrity of surrounding skin
Signs and symptoms of infection
Drainage: amount, color, consistency, odor
39
Wound Care Dressing
 The ideal dressing
o Keeps wound moist
o Prevents maceration
o Protects from contamination
o Contains wound fluid
o Protects granulation tissue
40
Traditional dry dressings
o Wounds exposed to air are more inflamed,
painful, itchy and have thicker crusts than
moist wounds
o Epithelium migrates into wound bed: if
must burrow between any eschar (crust or
Wet to dry dressing significantly increase
healing time
o Nonocclusive: increased risk of
contamination and infection
41
Moist Wound Healing
• No eschar develops (crust, scab)
• Enhances autolytic debridement: promotes
role of macrophages and leukocytes
• Bacterial barriers: prevent wound
contamination
• Wound fluids kept at site: contain growth
factors and enzymes that promote
autolysis and healing
42
Potential for Infection
Signs of infection
–I-induration
–F-fever
–E-erythema
–E-edema
43
Absorptive powders and pastes
Used in heavily draining wounds:
absorb up to 100x weight in fluid:
may increase wound pH above
physiological levels
May require wrapping in gauze
before inserting into wound bed
Pastes easier to remove from
wound
44
Wound Healing
Normal healing (3R's)
o Reaction: inflammatory process (72
hours)
o Regeneration: proliferation (up to three
weeks)
o Remodeling: (three weeks to two years)
45
Black Wound = Eschar
Cellular debris will escape wound edges as necrotic
tissue begins to separate from granulation tissue
If eschar becomes contaminated:
• becomes excellent medium for infection
• wound remains in reaction or inflammatory
stage
• systemic signs of infection
Eschar delays regeneration phase by interfering with
cell migration and wound closure
Risk of wound infection increases as the amount of
necrotic tissue increases
Needs debridement
46
Yellow Wound
Tissue not damaged enough to form an
eschar so wound covered with thick
yellow fibrous debris or viscous
exudate
o High risk of infection due to excellent medium
for bacterial growth
o Needs continuing debridement
Photo courtesy of Saddleback College, California,
http://www.saddleback.edu/alfa/N170/woundclassification.aspx
47
Red Wound
 Red indicates presence of granulation
tissue.
o Color of granulation tissue affected by
nutritional status and blood supply
• full thickness ulcer: crater with pale pink to beefy red
granulation tissue
• crater slowly fills with granulation tissue from bottom
upward
o Wound contraction and epithelialization
continues. Epithelialization occurs from wound
edges inward.
48
Wound Drainage Devices
 Decrease pressure in the wound by
removing excess exudate thereby
promoting healing from the inside
(secondary healing).
 Examples: Penrose drain, JacksonPratt & Hemovac suction devices
49
Dehiscence/Evisceration
Partial or complete separation of the
outer wound layers. If the internal
organs below the wound protrude out
of it, the wound has eviscerated.
Highest risk is in obese patients,
diabetics or those receiving steroids.
50
Bacterial skin infections
 Folliculitis, furuncles, cellulitis: these
infections are usually caused by
Staphylococcus aureus. Folliculitis involves
the hair follicle. Furuncles (boils) are
deeper.
 Cellulitis is a general infection and involves
deeper connective tissue.
 Topical antibiotics: Neomycin sulfate
(Neosporin)
 Teach: wash area daily with antibacterial
soap, allow skin to dry, prevent cross
contamination
51
Herpes Simplex Virus
 Type 1 causes common cold sore, type
2 causes genital herpes. After first
infection, recurrence is triggered by
stress. Spreads by direct contact.
Patient is contagious for the first 3-5
days.
 Topical acyclovir (Zovirax) shortens
the period of infection
52
Herpes Zoster (Shingles)
 Caused by reactivation of varicella
(chickenpox). Occurs in the dermatome
corresponding to the infected nerve.
Eruptions follow several days after pain in the
area, last several weeks.
 Acyclovir (Zovirax), given topically and/or
orally controls the severity of the lesions and
decreases pain.
53
Acute Burns
54
Superficial Sunburn
o Epidermis pink to red
o Mild edema
o Painful
o Healing time: 3-5 days
o No skin graft
55
Partial Thickness Burn
 Brief contact: scald, flames, grease,
chemicals
 Epidermis and dermis damaged
 Blisters if mild burn, pale, mottled,
waxy white with deeper
 Painful
 Healing time: 2-6 weeks
 No grafting unless healing prolonged
56
Full Thickness Burn
Prolonged contact: scald, flame, tar,
grease, chemical, electricity
Epidermis, dermis & underlying tissues
damaged
Waxy white, dry, leathery, charred
No pain
Healing: Weeks to months
Skin grafts required
57
Percentage of Burn Injury
Source: Burn diagrams courtesy of BioTel Emergency Medical Service (EMS), Texas Department of Health,
http://www.biotel.ws/protocolsHTML/Protocols2004/BurnDiagramBurnFormula.asp
58
Emergency Management
 Excessive leakage of plasma, especially
in the first eight hours post-burn,
causes hypovolemia,
hypoproteinemia,
hemoconcentration, electrolyte
imbalances and acid base
disturbances.
 In the absence of prompt fluid
replacement, burn shock is imminent.
59
Fluid Resuscitation
Initial 24 hours:
Lactated ringer's 2-4 ml/kg/%burn/24
hours - given in the first 8 hours postinjury.
Additional fluid required for inhalation
injury.
Maintain urine output of 30 ml/hr.
5% albumin – keep albumin >2.5 gm/dl
60
Monitoring
 Fluid shift lasts 24 to 72 hours.
 Hematocrit, electrolytes, osmolality,
calcium, glucose, albumin
 Urine output >30 ml/hr
 Myoglobinuria and hemoglobinuria
 Pulse rate and pulse pressure
 Normal sensorium and adequate
peripheral capillary refill
61
Type
Cause
Priority
Thermal
Flame, steam, liquids
Smother flames; Remove
smoldering clothing & metal objects
Chemical
Acids, strong alkalis,
organic compounds
Brush off dry chemicals Remove
clothing;
ascertain type of chemical
Electrical
Direct or alternating
current
Lightning
Separate patient from electrical
current
Smother any flames
Start CPR; Obtain EKG
Radiation
Solar, X-rays
Radioactive agents
Remove from radiation source
Remove clothing if contaminated
using tongs or lead gloves
Send to radiation decontamination
center
62
Skin Care
 Hydrotherapy daily to debride eschar
and cleanse wounds
 Topical enzyme such as collagenase
(Santyl) or Accuzyme will debride
more rapidly
 Silver coated anti-microbial dressing
(Acticoat)
63
Grafting:
 Allograft (skin from a cadaver)
 Synthetic such as Biobrane
 Bioengineered skin substitute
(Transcyte)
64
Prevention of Pressure Ulcers
 Patients at risk
 Inspect skin frequently
 Move at least every 2 hours
 Use life sheet or slide board
 Pad bony prominences
 Remove excess moisture
 Adequate nutrution
 Use protective barriers
65
Braden Scale
1
2
3
4
Sensory
Completely
limited
Very limited
Slightly limited
No impairment
Moisture
Constantly
moist
Very moist
Occasionally
moist
Rarely moist
Activity
Bedfast
Chairfast
Walks
occasionally
Walks
frequently
Mobility
Completely
immobile
Very limited
Slightly limited
No limitations
Nutrition
Very poor
Probably
inadequate
Adequate
Excellent
Friction/
Shear
Problem
Potential
problem
No apparent
problem
66
Pressure Ulcers
Stage I: Redness only
Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures
http://www.saddleback.edu/alfa/
67
Stage 2 Pressure Ulcer
Loss of epidermis and partial loss of dermis
not extending into subcutaneous tissue
Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures
http://www.saddleback.edu/alfa/
68
Stage 3 Pressure Ulcer
Full thickness wound. Includes loss of
epidermis and dermis. Extends into
subcutaneous tissue.
Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures
http://www.saddleback.edu/alfa/
69
Stage 4 Pressure Ulcer
Deep penetrating wound. Includes loss of
epidermis, dermis and subcutaneous tissue.
Extends into muscle and/or bone.
Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures
http://www.saddleback.edu/alfa/
70
Basal Cell Carcinoma
 Malignancy of the basal cell layer of
the epidermis.
 Genetic predisposition, chronic
irritation, and ultra-violet exposure are
risk factors.
Photo Source: Wikimedia Commons
http://commons.wikimedia.org/wiki/Image:Basaliom2.jpg
71
Squamous Cell Carcinoma
 Cancers of the epidermis
 Chronic irritation, skin damage risk
factors
Photo Source: Wikimedia Commons
http://commons.wikimedia.org/wiki/Image:Squamous_Cell_Carc
inoma.jpg
72
Malignant Melanoma
 Pigmented cancers in
the melanin-producing
epidermal cells.
 Risk factors:
predisposition, excess
ultra-violet exposure.
Photo Source: Wikimedia Commons
http://en.wikipedia.org/wiki/Image:Malignant_melanoma.jpg
73
Preventing Skin Cancer
 Avoid sun between 11:00 am and 3:00
pm
 Use sunscreen
 Wear a hat, opaque clothing,
sunglasses in the sun
 Examine body monthly for lesions
74
Seek Medical Attention
 Changes color, especially darkening or spreading
 Changes in size
 Change in shape – sharp border becomes irregular
or flat becomes raised
 Surrounding redness or edema
 Change in sensation, especially itching or
tenderness
 Change in character: oozing, crusting, bleeding,
scaling
75
Photo Acknowledgement:
All unmarked photos and clip art
contained in this module
were obtained from the
2003 Microsoft Office Clip Art Gallery.
76