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XII. ORTHOPEDICS A. Fractures: 1. S/S: a. PAIN and tenderness b. Unnatural MOVEMENT c. Deformity (possible) d.

Shortening of EXTREMITY Caused by muscle spasm e. Crepitus (bones grating together) f. Swelling g. Discoloration h. Worry about COMPARTMENT SYNDROME 2. Tx: a. Immobilize the bone ends plus the adjacent joints. b. Support fracture above and below site. c. Move extremity as little as possible. d. Splints help prevent FAT emboli and MUSCLE spasm. e. What do you do with open fractures? COVER WITH SOMETHING STERILE f. Most important thing NEUROVASCULAR checks g. Neurovascular checks: pulses, color, movement, sensation, capillary refill, temp 160 Hurst Review Services 3. Complications: a. Shock: (hypovolemic) b. Fat embolism: With what type of fractures do you see this? LONG BONE FRACTURE, PELVIC FRACTURE, CRUSHING INJURIES Symptoms depend on what? Petechia or rash over chest, THROMBOCYTOPENIA Conjunctival hemorrhages Snow storm on CXR PATCHY INFILTRATES. Young males First 36 hours c. Compartment syndrome: Increased PRESSURE within a limited space. 1) Pathophysiology: FLUID accumulates in the tissue and impairs tissue perfusion.

The muscle becomes swollen and hard and the client complains of severe PAIN that is not relieved with pain meds. Pain unpredictable PAIN is disproportionate to the injury. If undetected may result in NERVE damage and possible amputation. Common areas? FOREARMS & QUADS 2) Tx: Elevate extremity. Soft cast then rigid cast. Loosen the cast to restore CIRCULATION. Be careful in picking the answer remove cast. Fasciotomy- CUTS DOWN INTO THE TISSUE TO RELIEVE THE PRESSURE. Cast cutters to remove cast Instruct them the cast saw does not touch skin but it does VIBRATES. (So be a nice nurse and warn them) Hurst Review Services 161 d. Healing Concerns: 1) Delayed union: Healing doesnt occur at a normal rate. 2) Non-union: Failure of bone ends to unite; may require bone grafting 3) Mal-union: deformity at the fracture site. S/S: persistent discomfort with MOVEMENT 4. Cast Care: a. Ice packs on the side for first 24 hours because cast is still wet. b. No indentations c. Use PALMS for 1st 24 hours casting material is wet d. Keep uncovered and allow for air DRYING. e. Do not rest cast on hard surface or sharp edge. Rest on soft pillow, no plastic BECAUSE PLASTIC HOLD HEAT.

f. Mark breakthrough bleeding. Circle area, date and time site. g. Cover cast close to GROIN with plastic (once the cast is dry). h. Neurovascular CHECK with the 5 Ps i. What do you do if your client complains of pain? NEUROVASCULAR CHECKS Most pain is relieved by elevation, cold packs and analgesics. (If these things do not relieve the pain think complication). 162 Hurst Review Services 5. Traction: a. Miscellaneous Information: Decreases MUSCLE SPASMS , reduces REEL ON THE BONES, immobilizes Should it be intermittent or continuous? CONTINUOUS. NEVER RELEIVE TRACTION Weights should hang FREELY. Keep client pulled up in bed and centered with a good alignment. Exercise non-immobilized JOINTS. Ropes should move FREELY and knots should be TUCKED. Special air filled or foam mattresses b. Types of Traction: 1) Skin traction: Used short term to relieve MUSCLE spasms and immobilize until SURGERY. This is when tape or some type of material is stuck to the skin and the weights pull against it. Is the skin penetrated? NO Types: Bucks (used most often with hip and femoral fractures) Must do good skin assessments 2) Skeletal traction: This traction is applied directly to the bone with PINS and WIRES.

Used when prolonged TRACTION is needed. Types: Steinman pins, Crutchfield, Gardner-Wells tongs, Halo vest Must monitor the pin sites and do pin care. Sterile tech? YES Remove crusts? YES Is serous drainage okay? YES *TESTING STRATEGY* Never relieve traction (unless youve got a physicians order) Hurst Review Services 163 B. Total Hip Replacement: 1. Prep Op Care: Bucks traction is used frequently pre-op. 2. Post Op Care: a. Nursing Considerations: Neurovascular checks Monitor drains (Dont want fluid to accumulate in tissue). Firm mattress (joints need support) Over-bed trapeze to build upper body strength Positioning: NEUTRAL rotation-toes to the ceiling Limit flexion; want FLEXION of hip Abduction or adduction? ABDUCTION, LEGS APART What exercise can the client do while still confined to bed? ISOMETRICS EXERCISE, SQUEEZE THE QUADS. INCREASE VENOUS RETURN What is the purpose of the trochanter roll? PREVENT EXTERNAL ROTATION Document in nurses notes. No weight-bearing until ordered by physician Avoid crossing legs, bending over. Is it okay to sleep on operated side? NO Is hydrating important with this client? YES PREVENT DVT Stresses to new hip joint should be minimal in the first 3-6 MONTHS.

Is it okay to give pain meds in the operative hip? NO *TESTING STRATEGY* Any time youve got somebody with an orthopedic or a joint problem, they need a firm mattress for support. 164 Hurst Review Services b. Complications: 1) Dislocation circulatory/NERVE damage S/S: shortening of leg, abnormal rotation, cant move extremity, *pain 2) Infection: Prophylactic antibiotics (just like with heart valve replacement) Remove foley and drains as soon as possible. These will serve as a portal for INFECTION 3) Avascular Necrosis: (death of tissue due to poor circulation) 4) Immobility problems c. Client Education/Rehabilitation: Best exercise? WALKING. ROCKING IN ROCKING CHAIRS FOR ELDERLY. Avoid flexion low chairs, traveling long distances, sitting more than 30 minutes, lifting heavy objects, excessive bending or twisting, stair climbing C. Total Knee Replacement (Arthroplasty) 1. CPM: (Continuous Passive Motion) 2. Keeps knee in motion and prevents formation of SCAR TISSUE. 3. PT will set machine to GRADUALLY increase flexion and extension of knee. 4. Never HYPER EXTEND or hyperflex knee. 5. Neurovascular checks. 6. Pain relief. Hurst Review Services 165 D. Amputations: 1. Miscellaneous Information:

Amputations are performed at the most DISTAL point that will heal. The physician tries to preserve the KNEE and ELBOW. 2. Immediate Post Op Care: a. Keep what at the bedside? TOURNIQUET b. Elevation post op is controversial, because of hip contractures, only elevate for a short time to reduce swelling. c. Do not elevate on pillow, elevate foot of bed. d. Prevent hip/knee contractures. How? EXTENTION e. Inspect the residual limb daily to be sure that it lies completely FLAT on the bed. f. Phantom pain What is the first intervention to decrease phantom pain? Diversional ACTIVITY Seen more with AKAs Usually subsides in 3 months. 3. Rehabilitation: a. Why is limb shaping important? PROSTESIS b. How do you want the stump shaped at the end? CONED SHAPE c. What is worn under the prosthesis? LIMB SOCK d. Why is it important to strengthen the upper body? YES e. Is it okay to massage the stump? Promotes CIRCULATION and decreases TENDERNESS f. How do you teach a client to toughen the stump? Press into a SOFT pillow Then a FIRM pillow Then the BED Then a CHAIR NCLEX Tip: Pain: use other things first prior to pill; the definition of pain is what the client says it is; Always assess the clients pain by having them rate their pain on a pain scale (i.e. 010).