Nursing of Adults with

Medical & Surgical Conditions

Fractures

&

Complications of Fractures

Arthroplasty Knee Arthroplasty (total knee replacement)

– Replacement of the knee joint– Restore motion of the joint, relieve pain, or

correct deformity

Arthroplasty

Hip Arthroplasty (total hip replacement)– Replacement of the hip joint

Arthroplasty Nursing Interventions

– 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

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

Signs & Symptoms– Severe pain at site– Inability to move the leg voluntarily– Shortening or external rotation of the leg

Fracture of the Hip

Diagnostic Tests– Radiographic examination– Hemoglobin may be decreased because of

bleeding

Fracture of the Hip

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

Postoperative interventions– Wound assessment– Vital signs– Assessment of drains

• Jackson-Pratt, Hemovac

– 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 Patient teaching for ORIF

– 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 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

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

Open (compound)– Protrusion of the bone

through the skin– Require surgical repair– Prone to infection

Closed (simple)– Bone has NOT

protruded through the skin

– May be realigned by external manipulation

Types of Fractures

Greenstick fracture– Incomplete fracture – Extends only partially through the bone– Common in children because bones are

more flexible

Types of Fractures

Complete fracture– Fracture line extends entirely through the

bone with the periosteum disrupted on both sides of the bone

Types of Fractures

Comminuted fracture– Bone is splintered into three or more

fragments at the site of the break– More than one fracture line

Types of Fractures

Impacted fracture– One bone fragment is forcibly wedged into

another bone fragment.

Types of Fractures

Transverse fracture– Break runs directly across the bone.

Types of Fractures

Oblique fracture– Break runs along a slant to the length of

the bone.

Types of Fractures

Spiral fracture– Break coils around the bone.– Usually caused by a twisting force.

Types of Fractures 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 Pott’s Fracture

– Occurs at the distal end of the fibula– A piece of the medial malleolus chips off.

Posterior Left Foot

Medial Malleolus

Fractures Bone Repair

Assessment 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?

– Pallor– Paresthesia or numbness– Paralysis– Polar Temperature

• Is it cold compared to opposite extremity?

– Puffiness from edema or hematoma– Pulselessness

Fractures Signs & Symptoms

– 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

Diagnostic Tests– Radiographic

examination

Fractures

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 Treatment (Secondary Management)

– Closed (simple)• closed reduction• traction• open reduction with internal fixation device• immobilization

– external fixation device– traction– internal fixation devices; pins, screws, plates

Fractures

Treatment (secondary management)– Open (compound)

• Surgical debridement of wound– remove dirt, tissue, etc.

• 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

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

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 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

Etiology/pathophsiology– Trauma involving great force

• falls from extreme heights• automobile accidents• crushing accidents

Fracture of the Pelvis

Signs & Symptoms– Unable to bear weight without discomfort– Pelvic tenderness and edema– Hematuria (bladder trauma)– Signs of shock

Fracture of the Pelvis

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 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 Shock

– Cause– Blood loss, pain, fear

– Signs & Symptoms– 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 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• IV fluids • Steroids (reduce inflammation)• Digoxin (increase cardiac output)• Oxygen

Complications of Fractures Gas Gangrene

– Cause• Severe infection of the skeletal muscle by Clostridium

bacteria

– Signs & Symptoms• 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 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

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

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 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

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

The process of putting an extremity, bone, or group of muscles under tension by means of weights and pulleys to:– align and stabilize a fracture site– relieve pressure on nerves – maintain correct positioning– prevent deformities– relieve muscle spasms

Types of Traction

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 SuspensionSkeletal Traction

                                                        

Tibial Pin Traction with Steinmann Pin

Types of Traction 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

Amputation of a portion of or an entire extremity – Malignant tumors– Injuries– Impaired circulation– Congenital deformities– Infections

Amputation 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