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NSG 430 Topic 7 Notes
Adult Health Nursing II (NSG-430)
Grand Canyon University
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Chapter 67 Musculoskeletal Trauma & Orthopedic Surgery Fractures Pathophysiology:
- Disruption or break in continuity of structure of bone
- Open Fracture – break in skin where you see bone
- Closed Fracture – skin intact but bone broken Stages of Healing:
- Fracture Hematoma: 1st 72 hours
- Granulation Tissue: forms basis for new bone substance 3-14 days after
- Callus formation: Minerals deposited in the osteoid a. Can be seen in x-ray
- Ossification: 3wks – 6 months where callus prevents movement
- Consolidation: distance between bone fragments ↓
- Remodeling: excess bone tissue reabsorbed Etiology:
- Majority d/t trauma
- Secondary to disease (cancer, osteoporosis) Types of Fractures:
- Transverse: complete break
- Spiral
- Greenstick: piece breaks off
- Comminuted: bone breaks in several smaller pieces
- Oblique: break is wrapped around bone Category of Fractures:
- Displaced: Comminuted or Oblique
- Nondisplaced: Transverse, spiral, greenstick Clinical Manifestations:
- Edema & Swelling
- Pain and Tenderness
- Muscle Spasm
- Deformity, Contusion
- Loss of function
- Crepitation
- Guarding Complications:
- Angulation: Fracture heals in abnormal position in relation to midline of structure (type of malunion).
- Delayed union: Fracture healing progresses more slowly than expected. Healing eventually occurs.
- Malunion: Fracture heals in expected time but in unsatisfactory position. May cause deformity or dysfunction.
- Myositis ossificans: Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury.
- Nonunion: Fracture does not heal despite treatment. No x-ray evidence of callus formation.
- Pseudoarthrosis: Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site.
- Refracture: New fracture occurs at original fracture site Dx Studies:
- X-ray
- History
- Neurovascular Assessment: Consists of: o Peripheral Vascular Assessment: Color, Temp, Cap refill, peripheral pulses, edema o Peripheral Neurologic Assessment: Sensation, Motor function, pain
Nursing Interventions: Use of Tractions - Purpose: prevent or reduce pain & muscle spasms, immobilize the joint or part of the body, reduce fracture or dislocation, and treat a pathologic joint condition - Nursing Care: Inspect site and monitor pins for infection - Types of traction: o Skin Traction (short term use) – Buck’s Traction (femur fractures), tape, boots, or splints directly applied to skin Weight usually 5-10lbs Proper skin assessment and prevention of breakdown o Skeletal Traction (long term) – Pins and wires inserted to bones Maintain alignment and treat contractures or congenital hip dysplasia Weight usually 5-40lbs Risk for infection, delayed union, and nonunion Complications r/t Immobility o Balanced Suspension Traction (Type of Skeletal Traction) – Uses pt’s own body weight for countertraction using constant traction forces Elevate end of bed Keep weights off the floor Use of Casts - Purpose: temporary after closed reduction – allows pts to perform ADLs - Nursing Considerations: no weight bearing for 36-72 hrs o Leave uncovered to allow air circulation can cause heat burns o Avoid direct pressure use open hands o Once dry rough edges are petaled to prevent skin irritation and then strips of tape over rough areas are placed o Apply ice for 1st 24 hrs o If wet blot dry w/ towel and use hair dryer on low setting o Heart level for 1st 48 hrs Upper Extremity Injury Support Devices - Types of Device: o Sugar Tong Splint: used for wrist injuries o Posterior Splint: used for early swelling in fractured extremity o Short arm cast: used for stable wrist or metacarpal fractures o Long arm Cast: used for stable forearm, elbow, or unstable wrist fractures Vertebral Injury Device - Device used: o Body Jacket Brace: used for immobilization and support of stable spine injuries - Nursing Considerations:
Muscle Relaxants – Carisoprodol (Soma), Cyclobenzaprine (Flexeril), Methocarbamol (Robaxin) - Indication: Manage pain from muscle spasms - NC: Side Effects monitor Prophylactic Vaccines – Tetanus and Diphtheria Toxoid - Indication: Given when immunization status unknown for open fractures Prophylactic Abx – Cephalosporins
- Indication: Given prophylactically preoperative Nutrition Therapy:
- ↑ protein = 1g/kg
- ↑ Vitamins B, C, D intake
- ↑ Ca, Phosphorus, Mg
- ↑ Fluids = 2000-3000mL/day (prevents constipation, renal stones)
- ↑ fiber Those w/ body jacket and hip spica cast = 6 small meals a day Complications of Fractures Infection High rate of infection = Open fractures and soft tissue injuries Measures to prevent infection and osteomyelitis
- Open Fractures: Surgical debridement, Antibiotics at least 3 days Compartment Syndrome “Complication of circulation” Condition in which swelling causes increased pressure w/ limited space
- Since fascia around muscle has limited ability to stretch ↑ swelling causes pressure which compromises blood vessels and nerves Common Causes
- Decreased compartment size d/t restrictive dressings, splints, casts, excessive traction, or premature closure of fracture
- Increased compartment contents d/t bleeding, inflammation, edema, or IV infiltration Clinical manifestations
Ischemia develops within 4-8 hours after onset
6 P’s: Pain, pressure, paresthesia, pallor, paralysis, Pulselessness Interprofessional Care
Prompt Dx is critical perform regular neurovascular assessments on all patients w/ fractures
Assess location, quality, and intensity of pain pain unrelieved by drugs and out of proportion = 1st indication of compartment syndrome Report to HCP o Pain w/ passive movement
Paresthesia (numbness, tingling) another early sign
Reducing traction may help relieve pressure
Pulselessness and paralysis = late sign of compartment syndrome amputation likely Nursing Considerations
For suspected syndrome: do not elevate extremity above heart or apply cold compress d/t vasoconstriction Tx
Surgical decompression (fasciotomy) may be required left open for several days to allow for decompression
Infection may result d/t delayed closure Venous Thromboembolism LE fractures, especially hip fracture, total hip/knee replacement surgery can cause VTE Prevention
- Prophylactic anticoagulants may be given for at least 10-14 days in orthopedic surgical patient
- Common anticoagulants: a. Warfarin (Coumadin) b. LMWH – Enoxaparin c. Aspirin d. Factor Xa Inhibitor – Rivaroxaban, Apixaban
- Have patient dorsiflex and plantar flex ankle of affected extremity and perform ROM on unaffected leg
- May wear compression gradient stockings or use IPCD Anticoagulant Therapy Safety Alert
- Monitor for signs of bleeding (e., nosebleeds, hematuria).
- Teach patient signs of bleeding and what to do if bleeding occurs.
- Teach patient safe self-injection if taking an injectable anticoagulant after discharge.
- Encourage patient to keep appointments for laboratory testing to monitor effects of warfarin (if prescribed). Fat Embolism Syndrome Fat globules enter the circulatory system from fractures
- Often d/t long bones, ribs, tibia, and pelvis fractures
- Collect in areas w/ abundant blood vessels brain, lungs which contributes to mortality from fractures Clinical Manifestations
- Early recognition crucial to prevent death
- Most symptoms appear 24-48 hours after injury presents like Hypoxia
- Chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, hypoxemia d/t poor O2 exchange
- Change of mental status d/t hypoxemia; Petechiae occurs d/t ↓ oxygenation Develops rapidly and acutely skin color changes from pallor to cyanosis, leading to comatose Dx:
- No specific lab tests, but abnormalities may appear: a. Fat cells in blood, urine, sputum b. ↓ PaO2 to less than 60mmHg c. ↓ Platelet count and Hct d. ↑ erythrocyte sedimentation rate
Mandibular Fracture Pathophysiology:
- Trauma to face or jaw Medical Management/Treatment:
- Correct malocclusion
- Surgery = Intermaxillary fixation for 4-6 weeks or bone grafting Nursing Management: Preoperative teaching
- Surgery, facial appearance and changes Postoperative Care
- Patent Airway – observe for obstruction and aspiration by looking for s/s of respiratory distress o Keep HOB elevated
- Have wire cutters taped to head of bead in case of emergency (Cardiac Arrest, Respiratory Distress) o Have tracheostomy kit available
- If Choking or vomiting clear airway w/ suction
- Oral Hygiene important o Warm NS solution, water, or alkaline mouthwashes o Cover sharp wires w/ wax
- Communication: o Dry erase board, texting Drug Therapy:
- Antiemetics if vomiting is present
- Bulk forming laxatives if constipation/gas present Nutrition Therapy:
- Must be liquid
- Low bulk, high carb diet and use of straw = constipation and gas o Ambulation, prune juice, and bulk-forming laxatives help relieve this Patient Education:
- Encourage the patient to share feelings about the changes in appearance.
- Include oral care, diet, how to handle secretions, how and when to use wire cutters or scissors, and when to notify the HCP. Amputation Etiology:
- 2 mil Americans have limb loss
- Young people d/t Trauma Risk Factors:
- Most d/t PVD r/t to DM
Preoperative Care - Positioning, support, residual limb care, compression - Expectations r/t phantom limb sensation Postoperative Care - Prevent complications: - Monitor VS, hemorrhage ifneciton - Sterile dressing change - Immediate prosthesis o Have tourniquet available o Proper bandaging Ensure proper fitting supports soft tissues, reduces edmea, hastens healing, minimizes pain Promotes residual limb shrinkage and maturation Worn continuously except during PT and bathing Appled snugly but not tight - Avoid dangling to ↓ Edeam - Active ROM ASAP - Learn to balance - Prevent flexion contractures o Avoid sitting in chair for more than 1 hr w/ hips flexed or with pillow under surgical extremity o Lie on abdomen for 30 min 3-4 times/day w/ hip extended Patient Teaching - Residual Limb Care - Ambulation - Contracture Prevention - Recognize complications - Follow up care Prosthesis - Not all are candidates o Must have significant strength and energy req. for ambulation Phantom Limb Sensation - Perceived pain in missing part of limb o Worries pts but usually subsides w/ time - Can become chronic shooting, burning, or crushing pain and feelings of coldness, heaviness, and cramping - Tx: o VR Tx o Mirror Therapy – visual info replaces sensory feedback in the brain
Chapter 68 Musculoskeletal Problems Muscular Dystrophy Pathophysiology:
- group of genetic diseases characterized by progressive symmetric wasting of skeletal muscles without neurologic involvement Types of MD:
- Duchenne – most common o X-linked, Mutation of dystrophin gene
- Becker (less severe than Duchenne) o X-linked o Mutation of dystrophin gene Etiology:
- Between 400 and 600 boys are born with MD each year in the United States Risk Factors:
- Duchenne and Becker: usually only affects males Clinical Manifestations: Becker Manifestations
- Onset ages 5–
- Slower course of pelvic and shoulder muscle wasting than Duchenne
- Cardiomyopathy
- Respiratory failure
- May survive into 50s Duchenne Manifestations
- Primarily affects boys
- Onset before age 5
- Progressive weakness of pelvic and shoulder muscles
- Unable to walk by age 12
- Cardiomyopathy
- Respiratory failure in 20s
- Mental impairment Complications:
- Cardiomyopathy Dx Studies:
- Genetic Testing
- Muscle Serum Enzymes (creatinine Kinase)
- Electromyogram
- Muscle Fiber biopsy. Results: o fat and connective tissue deposits o muscle fiber degeneration and necrosis o Deficiency of dystrophin
- ECG – suggest cardiomyopathy Medical Management/Treatment:
- No cure
Drug Therapy: Corticosteroids – Deflazacort (Emflaza) - Therapeutic effect: slow progression for up to 2 years to improve survival Disease Modifying Drug – Eteplirsen (Exondys 51) - 1 st DMD for Duchenne Nursing Management: - Goals: o Preserve mobility o Orthotic jacket to prevent spinal deformity - Monitor cardiac and respiratory function o Cardiomyopathy often occurs and causes HF o Gradual decrease in pulmonary function leads to use of CPAP eventually Trach and MV will be needed - Keep as active as long as possible o Prolonged bedrest = muscle wasting o Limit sedentary periods Nutrition Therapy: - n/a Patient Education: - Encourage ROM, Good nutrition - Signs of disease progression Acute Low Back Pain Pathophysiology: - Lasts 4 weeks or less mostly d/t trauma or an activity that causes stress on lower back Etiology: - Affects 80% of adults Leading cause of job related disability Risk Factors: - Lack of muscle tone, obese - Pregnancy, stress, poor posture - Cigarette smoking, prior fractures, family Hx Clinical Manifestations: - Asymptomatic at time of injury - Usually w/in 24 hrs gradual ↑ in pressure leads to muscle ache, stabbing pain, limited ROM, or inability to stand up Types of Pain - Localized pain = discomfort in specific area - Diffuse pain = larger area, deep tissue - Radicular pain = irritation of nerve root where pain follows nerve distribution (sciatica) - Referred pain = source of pain is another location form where it’s felt Complications: - Missed work Dx Studies: - Straight leg raising test (+ for disc herniation if pain persists) - MRI /CT not done unless trauma or systemic disease is suspected
Clinical Manifestations: - Pain Starts in low back and radiates to buttock and legs o Worse when walking or prolonged standing o Cold, damp weather may worsen pain - Numbness, tingling, weakness, heaviness in legs/buttocks may be present Complications: - n/a Dx Studies: - ↓ pain when bending forward or sitting indicates Spinal Stenosis Medical Management/Treatment: - Epidural Corticosteroid Injections and Implanted devices that deliver pain meds - Surgery for severe cases Drug Therapy: - Mild Analgesics – NSAIDs for pain and stiffness - Antidepressants – Duloxetine Pain and Sleep Problems - Antiseizure Meds – Gabapentin improve walking and relieve leg symptoms Nursing Management: - Weight reduction, rest periods, and exercise/activity throughout the day - PT helps reduce pain and improve body posture - Rest and local heat application Intervertebral Disc Disease Pathophysiology: - Deterioration, herniation, or other problem w/ intervertebral discs (Helps w/ shock absorption) - Results from loss of fluid in the intervertebral discs w/ aging o Discs become thinner as nucleus pulposus dries out progressive destruction and herniated discs that pinch the nerves - Lose elasticity, flexibility, and shock absorption Etiology: - Normal unless pain is also present - Most common in lumbosacral discs (L4-5 and L5-S1) - May be d/t spinal stenosis Clinical Manifestations: - Low back pain = most common symptom o Radiates down butt and below knee along sciatic nerve - Reflexes may be depressed or absent - Paresthesia (numb, tingling) or muscle weakness in legs, feet or toes may occur Complications: - Cauda Equina Syndrome = multiple lumbar nerve root compressions o Severe low back pain, progressive weakness, ↑ pain Dx Studies: - Positive Straight Leg Test = Nerve Root Irritation - X-ray = detect structural defects - Epidural venogram or diskogram if inconclusive
o Bowel/bladder incontinence or retention
Saddle Anesthesia = loss or altered sensation in perineum, butt, inner thighs, and back of legs o Medical Emergency – requires surgical decompression
Cervical Disc Disease = Pain radiates into arms/legs o Handgrip is often weak
EMG of extremities Medical Management/Treatment:
Therapy if Conservative Therapy fails 3 Minimal Invasive Procedures done: o Intradiscal Electrothermoplasty: minimal invasive procedure where needle inserted into disc and heated to destroy small nerve fibers o Radiofrequency Discal Nucleoplasty (coablation Nucleoplasty): minimal invasive procedure where needle generates radiofrequency energy to break molecular bonds o Implantable Devices
Laminotomy w/ Discectomy = most common surgery o Herniated portion of disc removed
Spinal fusion = if spine is unstable Drug Therapy:
NSAIDs, short-term oral corticosteroids, opioid analgesics, muscle relaxants, antiseizure drugs, and antidepressants
Epidural corticosteroid injections may reduce inflammation and relieve acute pain Nursing Management:
Usually managed w/ Conservative therapy o Limit extremes of spinal movement w/ brace, corset, or belt o Local Heat/ice o Ultrasound and massage o Traction o Transcutaneous Electrical Nerve Stimulation
Once symptoms subside back strengthening exercise 2x a day for life Postop Spine Surgery
After Lumbar Fusion: o Pillow under thighs when supine o Pillow between legs when side lying o Have patient logroll
Assess for CSF leakage (Clear, yellow drainage w/ high glucose concentration Supine if suspected
Assess peripheral neurologic status o Q2-4h during 1st 48 hrs post op
Observe for Spinal Cord Edema (Resp. Distress, ↓ neurologic condition of upper extremities) immobilize neck w/ hard or soft collar
Assess bone graft donation site
Used for mild joint pain
Monitor patient on long term NSAID for GI and renal effects Antimalarial agents – Hydroxychloroquine and Chloroquine
Used for fatigue and skin/joint problems
Repress immune system – does not cause immunosuppression
May reduce flares Nursing Considerations
Eye exam every 6-12 months
Retinopathy can develop w/ high doses generally reversed once stopped Antileprosy drug – Dapsone
given if cannot tolerate antimalarial agents Immunosuppressive Drugs - Azathioprine, Cyclophosphamide
Suppress immune system and reduce end-organ damage Nursing Considerations
Monitor closely to ↓ risk for toxicity and SEs
Blood clots are common warfarin or heparin may be prescribed Topical Immunomodulators – Tacrolimus, Pimecrolimus
Used to treat serious skin conditions
Suppress immune activity reduce butterfly rash and discoid lesions Nursing Management:
Major problem is managing active disease while preventing complications of treatment Patient Education:
Help patient understand adherence to Tx plan is not a guarantee against flares
Factors that may happen – best to avoid: o fatigue, sun exposure, emotional stress, infection, drugs, surgery
Energy conservation and pacing techniques
Therapeutic exercise, heat therapy for arthralgia
Relaxation therapy
Avoid physical and emotional stress
Avoid exposure to people with infection
Avoid drying soaps, powders, household chemicals
Use sunscreen protection (at least SPF 15) and protective clothing, with minimal sun exposure from 11:00 AM to 3:00 PM
Need for regular medical and laboratory follow-up Pregnancy should be planned when disease activity is minimal
Stop medication or switch 3 months before pregnancy attempt
Infertility may result from immunosuppressive drugs
Fibromyalgia Pathophysiology:
- Chronic central pain syndrome marked by widespread monoarticular musculoskeletal pain and fatigue w/ multiple tender points
- Involves abnormal central processing of nociceptive pain input in the CNS = widespread neuroinflammation Etiology:
- Common disorder and major cause of disability
- Women 2x likely to get it – aged 20-
- Infection or trauma may trigger in susceptible people Risk Factors:
- Clinical Manifestations:
- Widespread burning pain that fluctuates throughout the day o Cannot determine if pain occurs in muscles, joints, or soft tissues o Head or facial pain d/t stiff/painful neck and shoulder muscles o May have pain from stimulus that usually does not cause pain – Allodynia o Can be accompanied by TMJ dysfunction – 1/3 affected
- IBS w/ constipation and diarrhea, abdominal pain, and bloating common
- Problems swallowing d/t esophageal smooth muscle function
- Increased frequency of urination and urgency
- Women may have difficulty menstruating Dx Studies: Widespread Pain Index (WPI)
- Pain in 11 of 18 tender points on palpation over past week
- Hx of widespread pain for at least 3 months
- Widespread pain occurs on both sides of body and above and below the waist Score on Symptom Severity Index
- WPI score 7 or greater & SSI score 5 or greater or
- SPI score between 3-6 and SSI score of 9 or more w/ fatigue, cognitive symptoms, extensive somatic symptoms Drug Therapy:
- Pregabalin (Lyrica), Duloxetine (Cymbalta), Milnacipran (Savella) – used for chronic widespread pain
- Low dose TCAs, SSRIs, Benzos may be used
- SSRI Depressants (Sertraline, Paroxetine) o only used for patients w/ depression Nursing Management:
- Rest can help w/ pain, aching, and tenderness o OTC analgesics can help o Non opioids – Tramadol (Ultram) may be used o Long-acting opioids not used unless other options weren’t successful
- Relaxation Techniques
NSG 430 Topic 7 Notes
Course: Adult Health Nursing II (NSG-430)
University: Grand Canyon University
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