Cast Study #4 James Oliver

Recall the Pathophysiology of a fracture from PNB31 y When a bone is broken, the periosteum and blood vessels in the cortex, marrow, and surrounding soft tissues are disrupted y Bleeding occurs from the damaged ends of the bone and from the neighbouring soft tissue y A clot (hematoma) forms within the medullary canal, between the fractured ends of the bone, and beneath the peristeum y Bone tissue immediately adjacent to the fracture dies y Dead tissues (along with debris in the fracture area) stimulates and intense inflammatory response characterized by vasodilation, exudation of plasma and leukocytes, and infiltration by inflammatory leukocytes, growth factors, and mast cells that simultaneously decalcify the fractured bone ends y Within 48 hours after the injury, vascular tissue from surrounding soft tissue and the marrow cavity invades the fracture area, and blood flow to the entire bones is increased y Bine-forming cells in the periosteum, edosteum, and marrows are activated to produce subperiosteal procallus along the outer surface of the shaft and over the broken ends of the bone y Osteoblasts within the procallus synthesize collagen and matrix, which becomes mineralized to form callus y As the repair process continues, remodelling occurs Recall the different types/classifications of fractures Classification of fracture Description/examples Complete-incomplete Complete: Occurs when the bone is broken to form 2 to more separate pieces Incomplete: bone is only partially broken Open-closed Open: compound fracture results when the skin is broken. The bone fragments may be angled and protrude through the skin. There is more damage to soft tissue, including the blood vessels and nerves and there is also a much higher risk of infection Closed: the skin is not broken at the fracture site Type of fracture Description/examples Bowing a bending fracture due to plastic deformation seen almost exclusively in children. This type of fracture typically occurs in the radius or ulna in response to longitudinal stress Butterfly fracture, typically of long bones, in which the centre fragment is triangular. A butterfly fracture of the pelvis is one in which there is an X, the centre of which comprises the symphysis pubis which is detached by four fractures Colles Distal radius at the wrist, commonly occurring when a person attempts to break a fall by extending the arm and open hand. Sometimes the ulna is also damaged Comminuted fracture in which the bone is broken or splintered into pieces. Compression fracture of a vertebra by pressure along the long axis of the vertebral column. Such fractures, which may occur traumatically or as a result of osteoporosis, are marked by loss of bone height. Depressed fracture in which a piece of bone (e.g., the skull, the ribs) is broken and driven inward. Greenstick fracture in which the bone is partially bent and partially broken, as when a green stick breaks. It occurs in children, esp. those with rickets. Impacted fracture in which the bone is broken and one end is wedged into the interior of the other. Linear narrow split in the bone that does not go through to the other side of the bone. Oblique Fracture in which the line of break runs obliquely to the axis of the bone. Pathological fracture of a diseased or weakened bone produced by a force that would not have fractured a healthy bone. The underlying disease may be metastasis from a cancer that originated elsewhere, primary cancer of the bone, or osteoporosis. Pott s Fracture of the lower end of the fibula and medial malleolus of the tibia, with dislocation of the foot outward and backward. Segmental a bone break in which several large bone fragments separate from the main body of a fractured bone. The ends of the fragments may pierce the skin, as in an open fracture, or may be contained within the skin, as in a closed fracture. Simple fracture without rupture of ligaments and skin. Spiral fracture that follows a helical line along and around the course of a long bone. transverse fracture in which the fracture line is at right angles to the long axis of the bone.

Recall the clinical manifestations of a fracture Manifestations Deformity Swelling Pain/tenderness Numbness Guarding Crepitus Hypovolemic shock Muscle spasms Eccymosis Cause Abnormal position of bones secondary to fracture and muscles pulling on fractured bones Edema from localization of serous fluid and bleeding Muscle spasm, direct tissue trauma, nerve pressure, movement of fractured bone Nerve damage or never entrapement pain Grating of bones or entrance of air in an open fracture. Note: do not manipulate that exrremity to elicit crepitus; doing so may cause additional changes Blood loss or associated injuries Muscle contraction near the fracture Extravasation of blood into the subcutaneous tissue

Describe the treatments for fractures: closed reduction, open reduction, internal fixation, external fixation with a cast, external fixator device

What specific assessments would you prioritize and complete when Mr. Oliver arrives on the unit? y Head to toe assessment should be priority once Mr. Oliver arrives y Vital signs including the neurovascular assessment y Medical history should be attained allergies, previous drugs, previous hospital visits, previous surgeries, or drugs y Assessment of surgical sites cast, bruise area y Finally the doctor s orders CBCs, daily PT, INR, bladder scans, etc. Mr. Oliver sustained an open (compound) fracture of the tibia. What complication is he higher at risk for because he sustained an open fracture? What medication hast he doctor prescribed to decrease the risk of this complication? y An open fracture is when the fractured bone has penetrated the skin y With open fractures, the patient is at higher risk for infections since there is access for bacteria to enter the open area y The doctor prescribes Clindamycin 600 mg IV q8h x 2 doses, an antibiotic to decrease the risk for infection of bacteria

What are the classifications, actions, and indications for use, major adverse effects nursing responsibilities and health teaching related to the medications prescribed from Mr. Oliver?

Drug Classification: Stool softeners Drug Name: docusate sodium (Colace) Actions/Effects/Uses y Stool softeners and are used short term to relieve constipation y 1-3 days needed for medication to take into effect

Adverse Effects y Stomach cramps y Nausea y Throat irritation Contraindications: y Allergy y Caution with pregnancy

Nursing Considerations Assessment: Allergy, abdominal assessment, assess BM Administration: Oral, suppository. Take medication with full glass of water Clinical Teaching: y If you experience skin rash, difficulty breathing, fever or vomiting, contact you doctor

Drug Classification: Lincosamide antibiotic Drug Name: clindamycin Actions/Effects/Uses Adverse Effects y Inhibits protein synthesis in y Cardiac arrest susceptible bacteria, causing cell y Pseudomembranous colitis or death severe colitis y Used for penicillin-allergic patients y N/V, diarrhea, abd pain, anorexia or when penicillin is inappropriate y Pain following injection y Hepatic function changes Contraindications: y Allergy to clindamycin y Caution with newborns and infants, and patients with tartrazine sensitivity or hepatic/renal impairment

Nursing Considerations Assessment: Allergy, hx of asthma, hepatic/renal impairment, ulcerative colitis, site of infection, skin color, BP, R, adventitious breath sounds, CBC, renal function tests Administration: Oral, parenteral, topical dermatologic, vaginal preparation. Take with full glass of water or with food Clinical Teaching: y Take full prescribed course of drug, do not stop taking drug without notifying doctor y Mouth care y Report diarrhea, abd pain, rash

Drug Classification: Opioid agonist analgesic Drug Name: oxycodone (Oxycontin) Actions/Effects/Uses Adverse Effects y Acts as agonist at specific opioid y Light-headedness receptors in the CNS to produce y Dizziness analgesia, euphoria, sedation y Sedation, euphoria y The receptors mediating these y Shock, cardiac arrest effects are thought to be the same as y N/V, sweating those mediating the effects of y Resp. depression endogenous opioids y Constipation Contraindications: y Hypersensitivity y Diarrhea, pregnancy y Cautious with abd conditions, CV disease, renal/hepatic impairment

Nursing Considerations Assessment: Hypersensitivity, diarrhea, resp. depression, focus on CNS/Resp. system Administration: Oral Clinical Teaching: y Drug has potential abuse, monitor patient carefully y Take drug as prescribed do not crush/chew y Take with food if nausea, do not drive, use laxative if causes constipation y Report difficulty breathing

Drug Classification: Anti-coagulant Drug Name: heparin Actions/Effects/Uses y Oral/IV anti-coagulant interfere with the hepatic synthesis of vitamin-k dependant clotting factors, resulting in the eventual depletion and prolongation of clotting times; parental anticoagulants interfere with the conversion of prothrombin to thrombin, blocking the final step in clot formation but leaving the circulating levels of clotting factors unaffected.

Adverse Effects y Hemorrhage y Hair loss y Bruising y OP y Suppression of renal function Contraindications: y Hypersensitivity y Severe thrombocytopenia y Uncontrolled bleeding y Caution with pregnancy, elderly at risk for hemorrhage

Nursing Considerations Assessment: skin colour, lesions, orientation, reflexes, affect, P, BP urinalysis, guaiac stools, PT, INR Administration: Parenteral subcut, IV Clinical Teaching: y Frequent blood tests are needed y Be careful to avoid injury risk of bleeding

Drug Classification: Anti-coagulant Drug Name: warfarin sodium (Coumadin) Actions/Effects/Uses Adverse Effects y Oral anti-coagulant interfere with y Alopecia the hepatic synthesis of vitamin-k y Urticaria dependant clotting factors, resulting y Dermatitis in the eventual depletion and y N/V prolongation of clotting times; y Hemorrhage parental anticoagulants interfere y Bruising with the conversion of prothrombin Contraindications: to thrombin, blocking the final step y Allergy in clot formation but leaving the y Hemorrhage disorders circulating levels of clotting factors y TB, hepatic disease, GI ulcers, unaffected. renal disease, indwelling catheters y Caution with HF, diarrhea, fever, depressed patients

Nursing Considerations Assessment: Allergy, hemorrhage disorders, hepatic disease, GI ulcers, orientation, skin colour, P, BP, CBC, PT, renal function test. Evaluate INR for therapeutic range, look for drugs for interaction. Administration: Oral Clinical Teaching: y Do not stop taking without consulting doctor y Avoid injury y Have periodic blood tests

Drug Classification: Opioid agonist analgesic Drug Name: morphine sulfate (MS contin) Actions/Effects/Uses Adverse Effects y Acts as agonist at specific opioid y Light-headedness receptors in the CNS to produce y Dizziness analgesia, euphoria, sedation y Sedation, euphoria y The receptors mediating these y Shock, cardiac arrest effects are thought to be the same as y N/V, sweating those mediating the effects of y Resp. depression endogenous opioids y Constipation Contraindications: y Hypersensitivity y Diarrhea, pregnancy y Cautious with abd conditions, CV disease, renal/hepatic impairment

Nursing Considerations Assessment: Hypersensitivity, diarrhea, resp. depression, focus on CNS/Resp. system Administration: Oral, IV Clinical Teaching: y Drug has potential abuse, monitor patient carefully y Take drug as prescribed do not crush/chew y Take with food if nausea, do not drive, use laxative if causes constipation y Report difficulty breathing

Drug Classification:analgesic (nonopiod), antipyretic Drug Name: Acetaminophen Actions/Effects/Uses Adverse Effects y Reduces fever, minor aches and y Headache, myocardial damage, pains, hepatic toxicity and failure, jaundice y prstaglandins Contraindications: y Allergic to acet y Caution in pregnancy, lactation, impaired hepatic function, chronic alcoholism

Nursing Considerations Assessment: Administration: y Suppositories, PO Clinical Teaching: y Do not take longer then 10 days y Report rash, unusual bleeding or bruising, yellowing of eyes or skin, changes in void patterns y Take drug only for complaints indicated; not anti-flammatory

Drug Classification: Antihistamine, Anticholinergic Drug Name (generic name): Dimenhydrinate Trade Name: Dramamine, Driminate Actions/Effects/Uses Adverse Effects y Anti-motion sickness y Drowsiness, confusion, nervousness, restless, headache, y Depresses hyperstimulated dizziness, vertigo, lassitude, labyrinthine function; may block tingling, heaviness and weakness of synapses in vomiting centre; hands, insomnia, and excitement peripheral anticholingeric effects (especially in children), may contribute to anti-motion hallucinations, seizures, death, sickness blurring of vision, diploma, y Prevention and treatment of nausea, hypotension, palpations, sedated vomiting or vertigo of motion sickness Contraindications: y With allergy to dim. Or lactation y Us cautiously w narrow-angle glaucoma, sensing peptic ulcer, symptomatic prostatic hypertrophy, bronchial asthma, bladder neck obstruction, cardiac arrhymias, pregnancy

Nursing Considerations Assessment: Allergies, pregnancy, asthma Administration: y IV,PO, IM Clinical Teaching: y Avoid activities mental alertness or coordination y Maintain adequate hydration y Don t drink alcohol

Drug Classification: antiemetic, phenothiazine, piperatzine (class) Drug Name: Prochlorperazine Actions/Effects/Uses Adverse Effects -action not fully understood but y Hypotension, diminished sweating, antipsychotics block postsynaptic photosensitivity, constipation, dopamine receptors in brain; dizziness, blurred vision, nasal depresses RAS (wakefulness & congestion emesis) -manages psychotic disorders Contraindications: Control severe nausea and vomiting y Bone marrow depression or Short-term treatment of nonhistory of blood dyscrasias psychotic anxiety y Children under 20 pounds or 2 years y Comatose or greatly depressed states y Hypersensitivity to phenothiazines y Pediatric surgery y Sever hypotension

Nursing Considerations Assessment: Administration: y IM,IV, PO, Clinical Teaching: y Avoid activities mental alertness or coordination y Rise slowly from sitting/lying position y May cause false pregnancy tests y May impair heat regulation y Avoid exercise or anything that will dehydrate y May cause anticholinergic effects (eye dryness, loss of vision) y Report signs of jerky muscle movements, tongue thrusts y IV-maintain hydration before next dose given

y Avoid alcohol y PO-avoid Calcium & Magnesium antacids y Pts taking multiple PO per day, take missed doe if within 1hr of reg. dose time or skip missed dose and continue w reg schedule y Drug Classification: Antiemetic Drug Name: Ondansetron Actions/Effects/Uses y Prevent of chemotherapy induced nausea and vomiting y Block receptors on vagal nerve terminals and chemoreceptor trigger zone

Adverse Effects y Constipation, diarrhea, increased liver, enzymes, headache, fatigue, malaise, chest pain, pruritus, ad pain, urinary retention, hypotension y Cardiac dysrhythmia y Anaphylaxis y bronchospasm Contraindications: y allergy to ondan. y Use cautious w pregnancy, lactation, hepatic impairment

Nursing Considerations Assessment: Drug allergies, et Administration: y PO, IV Clinical Teaching: y Avoid concomitant use of apomorphine due to risk of hypotension y Take oral 1-2 days following chemo or rad to max prevention of nausea and vomit; take every 8 hrs

Drug Classification: antihistamine, anti-motion sickness drug, antiparkinsonian, cough suppressant, sedative-hypnotic Drug Name: Diphenhydramine Actions/Effects/Uses Adverse Effects Nursing Considerations Assessment: y Blocks effects of histamine y Drowsiness, sedation, dizziness, disturbed coordination, fatigue, y Relief symptoms of allergic rhinitis Administration: confusion, restless, excitation, y Nighttime sleep aid nervousness, tremor, headache, y IV,IM, PO blurred vision, diplopia, Clinical Teaching: hypotension, hemolytic anemia, y Admin w food if GI upset hypolastic anemia, y Take s prescribed thrombocytopenia, leukopenia, y Avoid alcohol agranuloctopsis, pancytopenia, y Report diff breathing, hall, thickness of bronchial secretions tremors, loss of coordination, y Anaphylactic shock unusual bleeding or bruising, ire Contraindications: heartbeat Drug Classification: opioid antagonist, diagnostic agent Drug Name: Naloxone (Narcan) Actions/Effects/Uses Adverse Effects y Reverse effects of opiods including y Nausea, vomit, sweating, respiratory depression, sedation, tachycardia, increased bp, hypotension tremulousness, fibrillation, pulmonary edema y Reverse psychotomimetic and Contraindications: dysphoric effects of opioid agonistant such as pentazocine y Allergy to opioid y Diagnosis of acute opioid overdose y Use cautious with opioid addiction, CV disorders, y Improve circulation in refractory pregnancy, lactation shock, reversal of alcoholic coma, dementia of Alz or schizo type

Nursing Considerations Assessment: -monitor after use Administration: y IV, IM, sb Clinical Teaching: y Report sweating, feelings of tremulousness

Identify potential nursing diagnoses for Mr. Oliver and apply the nursing process for providing individualized care for this client. 1. Risk for infection open fracture 2. Risk for immobility cast, fractured tibia 3. Risk for negative self-conception with cast, inability to use his arm, concerned with financial security due to injury When assessing Mr. Oliver s pain, he describes the pain in his lower leg as throbbing and he rates the pain as a 9 out of 10. He describes the pain in his right arm as 3 out of 10. Mr. Oliver has been using his PCA pump frequently. The practical nurse is concerned that his pain is not adequately controlled with his morphine. What are the major adverse effects, nursing responsibilities and health teaching related to the Morphine via PCA? Adverse reactions = sedation, confusion, hypotension, constipation, respiratory distress (Davis 12th ed. pg.884) Nursing responsibilities: y assess the client s level of consciousness and respiration rate y check the IV line for patency, y document the drug dosages administered ( P&P 2nd ed. pg 1312) y assess the patient s pain level to ensure that the PCA is effective Health teachings: y encourage the client to use the morphine as needed without a fear of dependency as it is better, and easier, to relieve pain before it becomes intolerable (P&P 2nd ed. pg. 1685) y teach the client how to use the pump, and explain to them that they can administer a dose at whatever interval the doctor ordered y inform the client how long it should take for the medication to take effect (P&P 2nd ed. pg. 1685) What potential complication are you concerned about? -Compartment syndrome Mr. Oliver is using his pump regularly and he is finding relief for his arm fracture, but not the leg fracture, and severe throbbing pain not relieved by opioids is a sign of compartment syndrome. *Compartment syndrome is on page 2314 of Brunner & Suddarth s Med-Surg What other specific assessment findings would indicate that this complication is developing? What actions would you carry out at this time? -Neurovascular assessment: y assess for any deficit, including paresthesia, unrelenting pain, and hypoesthesia y assess for numbness (both numbness and paresthesia are early signs of nerve involvement) y assess for motion by asking Mr. Oliver to wiggle his toes (weakness is a late sign of nerve ischemia while no movement is a sign of nerve damage) y any deficit in these assessments may indicate compartment syndrome -Peripheral circulation: y assess the colour, temperature, capillary refill time, swelling, and pulse of both legs and compare -Palpation: y if you are able to palpate Mr. Oliver s leg (he has and external fixator that may make this difficult or impossible), a hard and swollen muscle also suggests compartment syndrome -Pressure Measuring: y the actual pressure in the muscle compartment can be measured with a device that is inserted into the muscle compartment, a normal pressure range is 8 mm Hg or less y pressure of 30 mm Hg or more can cause compromised microcirculation *This is more than likely not an RPN skill; however, I did not find anything that states this for a fact, or even if it is a RN skill

You report your findings to the RN in charge and she calls the doctor. The doctor orders include: -increase the Morphine dose via PCA to 2.5mg You encourage Mr. Oliver to continue to use his PCA pump to control his pain, and elevate his right leg on 2 pillows. When you reassess his pain a few hours later, he states his pain is much better and he rates his pain in his right leg as 3 out of 10. Mr. Oliver s right arm with a fiberglass cast is elevated on 2 pillows What are the advantages of a fiberglass cast versus a plaster cast? Fiberglass casts are: y lighter in weight and stronger than plaster y porous, therefore causing less skin problems y unlike plaster casts in that they will not soften when wet (however when the do get wet they need to be dried thoroughly to prevent skin breakdown. The cast can be dried by using a blow drier on low setting.) What are the potential problems for a patient with a cast?  Compartment Syndrome  Pressure ulcers  Disuse syndrome *Cast care information was from Brunner`s Med Surg 2nd ed. pg. 2239-2244

Describe the nursing care and health teaching for a client with a cast: y Describe techniques to promote cast drying (e.g, do not cover, leave expose to circulating air, handle damp plaster cast with palm of hands and do not rest the cast on hard surfaces or sharp edges that can dent soft cast. Describe approaches to controlling swelling and pain (e.g, elevate casted extremity to heart level, apply intermittent ice bag if prescribed, take analgesics as prescribed ) Report any pain uncontrolled by elevating the casted limb and by analgesics may be and indicator of impaired tissue perfusion compartment syndrome or pressure ulcer. Demonstrate ability to transfer (e.g, from a bed to a chair) Use mobility aids safely Avoid excessive use of injured extremity, observe prescribed weight-bearing limits. Manage minor irritations from cast. (e.g. for skin irritation from cast edge, pad rough edges with tape; to relieve itching, blow cool air from hair dryer) Describe care of extremity following cast removal (e.g skin care; gradual resumption of normal activities to protect limb from undue stress management of swelling. Demonstrate exercises to promote circulation and minimize disuse syndrome.

y y y y y y y y

The doctor ordered pin site care bid for the external fixator device on mr. Oliver s right leg. You notice that some pin sites are draiinig a small amout of serous drainage mr s oliver appears anxious ans she comments it looks very heavy and uncomfortable, will my husband be able to move with that on his leg.? The nurse will explain and give psychologically reassurance to the family and to the patient by telling them that even tough the fixator may look clumsy and unwieldy, the patient will be able to mobilize and just have a mild discomfort. Should you be concern about the drainage noted at the pin sites y Some serous drainage on the area should be expected. But Purulent drainage is an indication of infection. y

What is the rationale for performing pin site care y It is important that the nurse perform perform pin site care because by doing this will avoid infection on the site. Describe a procedure for performing pin site care 1. Weekly dry dressing changes. 2. Daily pin-site care with a solution of one half normal saline solution and one half hydrogen peroxide. 3. Chlorhexidine-impregnated disc placed around the pins, with weekly changes of the disc by the surgeon. What complications you assess for related to the pin sites and the external fixator device? Redness, tenderness, infection, increase purulent pin site drainage, infection, uncontrolled swelling and pain, cool and pale finger and toes, paresthesia, loose fixator or clamps. What health teaching advice will you provide Mr. Oliver and his wife regarding the external fixator device y Must teach client what device is and how it works , what the goals are in using this device, how to watch for infections, how to keep clean, and how the patient must be careful maneuvering the limb not to bang the limb

Why did the doctor prescribe Warfarin for Mr. Oliver? What potential complication is Mr. Oliver at high risk for? y Mr. Oliver s blood may have been not thin enough y Warfarin (also known as Coumadin) is an anticoagulant y Mr. Oliver is at very high risk for bleeding Why do you need to check Mr. Oliver s INR results? What does a therapeutic INR mean? Is and INR of 1.7 therapeutic? Will continue to give him his heparin today? y The INR test result is given as a number y There are no units of measurement because the number is a ratio: the ratio of the sample s Prothrombin Time (PT a measure of clotting), to the Prothrombin Time of a normal sample of blood. A result of 1.0, up to 1.5, is therefore normal.

y y y y y

People on warfarin treatment will have different target INR ranges to aim for with warfarin treatment, depending on the reason for anticoagulation (blood-thinning treatment One example is a range of 2.0 to 3.0 for DVT. An INR lower than the desired range means the blood is not thin enough or clots too easily. An INR result higher than the desired range means the blood is too thin . Because 1.7 is not a high enough number (blood is not thin enough ) yes you will continue to administer heparin today Continue to check INR to know what the state of the blood clotting factor is and weather you are in the range you want to be in or not, know whether or not to administer anticoagulants

What is the classification, adverse affects, actions, nursing responsibilities and health teaching related to Warfarin ? y Classification = Anticoagulants y Actions= interferes with synthesis of vitamin K dependant clotting factors , used for prevention of thromboembolic events y Contraindicated = uncontrolled bleeding, open wounds, active Ulcer disease, uncontrolled Hypertension y Adverse reactions= GI- cramps, nausea DERM= dermal necrosis HEMAT= BLEEDING!! y Nursing implications/ teachings = asses for signs of bleeding and hemorrhage (nose bleeds bloody gums, unusual bruising, fall in hemocrit, bloody urine or stools CARE plan for discharge in 5 days Area Where is he going How is he going home Support Teaching Is home ready for him? Will he be able to do daily ADL s in his condition in where he is going back to Teaching about medications and the state in which he is going home (with the external fixation device) Will he have assistance at home (family situation) contact CCAC to see if apply for home care assistance also involve other therapies and supports that may be necessary Set goals / timelines for steps taken at home and what to expect in terms of recovery what needs to happen at home to make goals possible (exercises) Make sure all appointments are made and are understood by client knowing where he needs to be and why Prescriptions are understood and filled and taken properly while at home

Time line Appointments Medications

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