Fractures

67 Fractures




Overview/pathophysiology


A fracture is a break in continuity of a bone. It occurs when stress is placed on the bone that exceeds its biologic loading capacity. Most commonly the stress is the result of trauma. Pathologic fractures can occur when the bone’s decreased loading capacity cannot tolerate even normal stress, as with osteoporosis.



Health care setting


Emergency care, acute care, primary care



Assessment




Physical findings:


Include loss of normal bony or limb contours, edema, ecchymosis, limb shortening, decreased range of motion (ROM) of adjacent joints, and false motion (occurs outside a joint). Patient may describe crepitus, but this should not be elicited by health care provider because of risk of injury to surrounding soft tissues. Complicated or complex fractures can present with signs and symptoms of perforated internal organs, neurovascular dysfunction, joint effusion, or excessive joint laxity. Open fractures involve a break in the skin and will demonstrate a wound in the area of suspected fracture; bone may be exposed in the wound.



Acute indicators:


Fractures cause either insidious and progressive pain or sudden onset of severe pain. They are usually associated with trauma or physical stress, such as jogging, strenuous exercise, or a fall. In the event of pathologic fracture, the patient typically describes signs and symptoms associated with the underlying pathology.



Complications:


Delayed union is failure of bone fragments to unite within the normally accepted time frame for that bone’s healing. Lack of any bony union is known as nonunion, which is demonstrated by nonalignment and lost function secondary to lost bony rigidity. Pseudoarthrosis is a state in which the fracture fails to heal and a false joint develops at the fracture site. Avascular necrosis occurs when the fracture interrupts blood supply to a segment of bone, causing eventual bone death. Myositis ossificans involves heterotrophic bone formation (abnormal, out of the normal area). It occurs most commonly in the arms, thighs, and hips. Complex regional pain syndrome (or reflex sympathetic dystrophy) is an incompletely understood process that results in chronic pain out of proportion to the injury, with reduced function, joint stiffness, and trophic changes in soft tissue and skin following a traumatic event such as a fracture. Other fracture complications include altered sensation, limb length discrepancies, and chronic lymphatic or venous stasis.


Note: Any patient with a suspected fracture should be treated as though a fracture is present until diagnosis is made. Interventions should include immobilization of the affected area and careful monitoring of neurovascular function distal to the injury. Any restrictions to swelling (e.g., rings, wristwatches, bracelets) should be removed before they can contribute to neurovascular dysfunction.



Diagnostic tests


Most fractures are identified easily with standard anteroposterior (AP) and lateral x-ray examination. Occasionally special radiographic views are needed, such as the mortise view with bimalleolar ankle fractures (showing joint spaces between the fibula, tibia, and talus) or x-ray examination through the open mouth to identify fractures of the odontoid process. Magnetic resonance imaging may be useful in evaluating complicated fractures, but its ability to identify different bone densities is limited. Intraarticular fractures may be diagnosed with arthroscopy. Bone scans, computed tomography (CT) scans, tomograms, stereoscopic films, and arthrograms also can be used.





Nursing diagnosis:



Acute pain


related to injury, surgical repair, and/or rehabilitation therapy


Desired Outcomes: Within 1-2 hr of intervention, patient’s subjective perception of pain decreases as indicated by a lower pain intensity rating. Patient demonstrates ability to perform activities of daily living (ADLs) with minimal complaints of discomfort.





































ASSESSMENT/INTERVENTIONS RATIONALES
Assess patient’s pain using a pain intensity rating scale (0 = no pain, 10 = worst pain imaginable). The patient provides a personal baseline report, enabling nurse to more effectively assess subsequent increases and decreases in pain.
If patient-controlled analgesia (PCA) or epidural analgesia is used, assess effectiveness of patient’s pain management while observing for excessive sedation, respiratory depression, and decreased level of consciousness. Keep appropriate reversal agent readily available. Excessive sedation or respiratory depression may necessitate administration of appropriate reversal agent. Most commonly, naloxone is used for opioid-induced side effects, and ephedrine is given for hypotensive crisis associated with epidural administration of anesthetics such as bupivacaine.
If PCA or epidural analgesia is used, verify with another nurse that PCA or epidural pump contains prescribed medication and concentration with prescribed settings for patient dosing, continuous infusion, and/or clinician-activated bolus. Verification of pump settings is critical to the safe delivery of the analgesia.
Assist patient with coordinating time of peak effectiveness of analgesics with periods of exercise or ambulation. Careful timing of analgesics enables patient to achieve optimal pain management before exercise or ambulation. Participation in the exercise regimen contributes to expediency of patient’s recovery.
As prescribed, administer nonsteroidal antiinflammatory drugs (NSAIDs) and assess effectiveness of patient’s pain management, as well as adverse effects. Because of potential for excessive bleeding following NSAID administration, it is important to monitor for hemorrhage at surgical site.
Administer anticoagulants cautiously if patient is receiving epidural analgesia. Epidural analgesia is used commonly in orthopedic surgery and is considered safe to use during epidural analgesia. However, immediate action should be taken if any signs or symptoms suggesting spinal cord compression occur. Diagnosis of epidural hematoma should be considered in the differential diagnosis while using an epidural catheter.
Use nonpharmacologic pain management methods, such as guided imagery, relaxation, massage, distraction, biofeedback, heat or cold therapy, and music therapy. Traditional nursing interventions such as back rubs and repositioning also should be included in pain management plan of care. Nonpharmacologic methods can augment pharmacologic pain management strategies. These methods may be critical for a patient who avoids use of analgesics or experiences minimal pain management with prescribed analgesics.
If appropriate, instruct hospitalized surgical patient in use of PCA or epidural analgesia. Understanding principles of PCA or epidural analgesia will help patient obtain better pain management.
Instruct family/significant other that only the patient may administer a dose of analgesia from the PCA pump. If the family administers medication via the PCA pump, patient may experience negative effects from overmedication (e.g., excessive sedation).
If intraarticular anesthetic or opioid was administered intraoperatively, advise patient that lack of pain in the immediate postoperative period should not be mistaken for ability to move the joint excessively. Patients with minimal postoperative pain may be tempted to increase activity, putting unnecessary stress on the fracture site. Prescribed activity must be carefully followed to avoid additional injury to the affected extremity.




Nursing diagnosis:



Risk for peripheral neurovascular dysfunction


related to interruption of capillary blood flow occurring with increased pressure within the myofascial compartment (compartment syndrome)


Desired Outcomes: Patient has adequate peripheral neurovascular function in the involved extremity as evidenced by normal muscle tone, brisk capillary refill (less than 2 sec or consistent with the contralateral extremity), normal tissue pressures (15 mm Hg or less), minimal edema or tautness, and absence of paresthesia. Patient verbalizes understanding of the importance of reporting symptoms indicative of impaired neurovascular function.


















ASSESSMENT/INTERVENTIONS RATIONALES
Assess patient’s pain at regular intervals, immediately informing physician of increased pain not managed by analgesia. Increased pain, or pain out of proportion to the injury, is the first sign of developing compartment syndrome (pain = first “P”).
Assess tissue pressures in all compartments as prescribed if an intracompartmental pressure device is available. Alert health care provider to pressures higher than 10 mm Hg. Sustained high pressures may indicate developing compartment syndrome; if pressures exceed systolic blood pressure, perfusion to the extremity is threatened. Continued assessment of high-risk patients (e.g., adolescents or young adults with traumatic injury; confused or developmentally disabled patients who cannot accurately report symptoms) should be done to avoid possible complications.
Assess neurovascular status at regular intervals by checking temperature (circulation), movement, and sensation in affected extremity. Paresthesia (second “P”), pallor (third “P”), and poikilothermia (coolness due to diminished blood flow to distal tissues) (fourth “P”) are additional signs of developing compartment syndrome. True paralysis (fifth “P”) is a late sign of compartment syndrome, which indicates significant ischemia/limb impairment. Note: With the exception of pain and paresthesia, the so-called 5 Ps are not reliable for diagnosis, and the presence or absence of them should not affect injury management.

Apply ice and elevate affected extremity when prescribed.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Fractures

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