Orthopedics

XI.

ORTHOPEDICS

A. Fractures: 1. S/S: a. __________ and tenderness b. Unnatural _________________ c. Deformity (possible) d. Shortening of ___________________ 

Caused by muscle spasm

e. Crepitus (bones grating together) f. Swelling g. Discoloration h. Worry about ________________ _________________ 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 ___________ emboli and _____________ spasm. e. What do you do with open fractures? _____________________________ Preferably something ___________________.

f. Most important thing ____________________________ checks g. Neurovascular checks: pulses, color, movement, sensation, capillary refill, temp

151

Orthopedics

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

3. Complications: a. Shock: (Hypovolemic) b. Fat embolism:  With what type of fractures do you see this? The same fractures that can lead to shock: Long bones, (femur) ______________ fractures, and ______________ injuries

 Symptoms depend on what?__________________ Petechiae or rash over chest Conjunctival hemorrhages Snow storm on CXR Young males First 36 hours

c. Compartment syndrome: 

Increased _______________ within a limited space.

1) Pathophysiology: 

______________accumulates in the tissue and impairs tissue perfusion. The muscle becomes swollen and hard and the client complains of severe _________ that is not relieved with pain meds.



Pain unpredictable ______________ is disproportionate to the injury. If undetected may result in _______________ damage and possible amputation. Common areas? _________________ & _______________

2) Treatment and Prevention:

Orthopedics

 Elevate extremity.  Soft cast then rigid cast.

152

Preventive Measures



Loosen the cast to restore _____________.



Be careful in picking the answer “remove cast”.

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.



Cast cutters to remove cast Instruct them the cast saw does not touch skin but it does ___________. (So be a nice nurse  and warn them)



Fasciotomy

4. Cast Care: a. Plaster and Fiberglass Casts 

Ice packs on the side for first 24 hours because cast is still wet.



No indentations



Use _________________ for 1st 24 hours–casting material is wet



Keep uncovered and allow for air _______________.



Do not rest cast on a hard surface or sharp edge. Rest on soft pillow, no plastic.



Mark breakthrough bleeding. Circle area, date and time site.



Cover cast close to ____________________ with plastic (once the cast is dry).



Neurovascular _____________ with the 5 Ps.



What do you do if your client complains of pain? ________________ Most pain is relieved by elevation, cold packs and analgesics. (If these things do not relieve the pain… think complication).

b. Fiberglass Cast 

More common than plaster casts



Advantageous because they are lightweight, waterproof and are ____________________ than plaster casts.



Provides earlier ______________________ than plaster casts.

153

Orthopedics

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

5. Traction: a. Miscellaneous Information: 

Decreases ___________ ______________, reduces, immobilizes



Should it be intermittent or continuous? ___________________



Weights should hang ___________________.



Keep client pulled up in bed and centered with good alignment.



Exercise non-immobilized __________________.



Ropes should move ________________ and knots should be ______________.



Special air filled or foam mattress

b. Types of Traction: 1) Skin traction:

*TESTING STRATEGY* Never relieve traction (unless you’ve got a physician’s order)



Used short term to relieve _______________ spasms and immobilize until _________________.



This is when tape, a boot, splint, or some type of material is stuck to the skin and the weights pull against it.



Is the skin penetrated? ______



Common Type: Buck’s (used with hip and femoral fractures)



Must do good skin assessments

2) Skeletal traction: 

This traction is applied directly to the bone with _____________ and ___________.



Used when prolonged ____________ is needed.



Types: Steinman pins, Crutchfield, Gardner-Wells tongs, Halo vest



Must monitor the pin sites and do pin care.

Orthopedics

Sterile technique? _____________ Remove crusts? __________ Is serous drainage okay? _________ 154

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

B. Total Hip Replacement: 1. Prep-Op Care: 

Buck’s traction is used frequently pre-op.

2. Post-Op Care: a. Nursing Considerations: 

Neurovascular checks



Monitor drains (Don’t want fluid to accumulate in the tissues).



Firm mattress (joints need support)



Over-bed trapeze to build upper body strength



Positioning:

*TESTING STRATEGY* Anytime you’ve got somebody with an orthopedic or joint problem, they need a firm mattress for support.

___________ rotation-toes to the ceiling Limit flexion; want _______________ of hip Abduction or adduction? ________________ 

What exercise can the client do while still confined to bed? _______________



What is the purpose of the trochanter roll? To prevent ___________________ rotation. Document in nurse’s notes.



No weight-bearing until ordered by physician.



Avoid crossing legs, bending over.



Is it okay to sleep on the operated side? _______



Is hydrating important with this client? ________



Stresses to new hip joint should be minimal in the first 3-6 _____________.



Is it okay to give pain meds in the operative hip? __________

155

Orthopedics

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

b. Complications: 1) Dislocation→ circulatory and _________ damage 

S/S: shortening of leg, abnormal rotation, can’t move extremity, pain

2) Infection: 

Prophylactic antibiotics (just like with a heart valve replacement)



Remove Foley and drains as soon as possible. These will serve as a portal for ____________________

3) Avascular Necrosis: (death of tissue due to poor circulation) 4) Immobility problems c. Client Education/Rehabilitation: 

Best exercise? _____________ 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 ____________ ____________. 3. PT will set machine to ____________ increase flexion and extension of knee. 4. Never _________________ or hyperflex knee. 5. Neurovascular checks.

Orthopedics

6. Pain relief.

156

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

D. Amputations: 1. Miscellaneous Information: 

Amputations are performed at the most __________ point that will heal. 

The surgeon tries to preserve the __________ and ____________.

2. Immediate Post-Op Care: a. Keep what at the bedside? ___________ b. Elevation post-op is controversial, because of hip contractures. If ordered, 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? _______________ e. Inspect the residual limb daily to be sure that it lies completely ______on the bed. f. Phantom pain 

What is the first intervention to decrease phantom pain? Diversional ___________________



Seen more with AKA’s



Usually subsides in 3 months.

NCLEX® Tip: Pain: use other things first prior to pill; the definition of pain is what the client says it is. Always assess the client’s pain by having them rate their pain on a pain scale (i.e. 0-10).

3. Rehabilitation: a. Why is limb shaping important? ______________ b. How do you want the stump shaped at the end? ___________ c. What is worn under the prosthesis? _____________________ d. Why is it important to strengthen the upper body? They will be using crutches or a _________________ to ambulate.

e. Is it okay to massage the stump? ___________ promotes circulation and decreases __________________________

f. How do you teach a client to toughen the stump? Press into a ___________ pillow Then a ____________ pillow Then a ________________ Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

157

Orthopedics

Then the ______________

g. Walkers Walk _________ a walker

h. Crutches Crutches should be 1-2 inches below the _____________ to prevent risk of brachial nerve damage. When ambulating stairs with crutches, it’s up with the good leg, and down with the bad leg.

i. Canes

Orthopedics

Used on the strong side of the body

158

Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.