Grade	Description
0	No pulse
1	Weak and easily obliterated with pressure
2	Difficult to palpate but easy to feel once located
3	Easily palpated and considered normal
4	Strong and bounding

Box 37-3 MUSCLE TONE

Decreased as a result of musculoskeletal, neurologic, metabolic, or infectious disorders and/or fatigue

Increased as a result of spasms, injury, cramps, tremors (associated with electrolyte disorders, neurologic conditions, and infections such as tetanus)

Table 37-2 DEEP TENDON REFLEXES ^*

Grading of Reflexes
Grade	Description
0	No reflex
+1	Less than normal
+2	Average
+3	Stronger than average
+4	Intense (clonus)

* Assess major reflexes: biceps, brachioradialis, triceps, patellar knee jerk, Achilles tendon.

Table 37-3 LABORATORY STUDIES TO AID DIAGNOSIS OF ORTHOPEDIC CONDITIONS

Test	Examples
Alkaline phosphatase level	Increased with healing fractures, metabolic bone disease, osteoporosis, and metastatic tumors of bone
Calcium level	Increased with metastatic bone cancer, dehydration, Paget’s disease Decreased with hypoparathyroidism, advanced osteomalacia, and rickets
Creatine kinase level	Increased in dehydration, hyperthyroidism, renal failure, and rhabdomyolysis
Phosphorus level	Increased in bone metastases and hypoparathyroidism
Alanine aminotransferase (ALT), aspartate aminotransferase (AST)	Increased in myositis
Uric acid level	Increased in gout, multiple myeloma, and acute tissue destruction as a result of starvation or excessive exercise
C-reactive protein	Increased in acute inflammatory changes and rheumatoid arthritis
Antinuclear antibodies	Positive in rheumatoid arthritis, systemic lupus erythematosus, and polymyositis
Serum rheumatoid factor	Positive in rheumatoid arthritis and some chronic inflammatory diseases

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatric

a. Growth or development related

1) Child’s bone structure different from adult’s; children considered skeletally immature

2) Skeleton of infant and young child is largely cartilaginous

a) Bones narrow and flexible

4) Children have open epiphyses (growth plate) until after adolescence; this area is more susceptible to trauma; fractures to the epiphysis constitute one third of all fractures and are described according to Salter-Harris classification system (Fig. 37-1)

5) Child’s ligaments are more resistant than epiphyses to trauma

a) Dislocations rare

b) Fractures often accompany dislocation

c) Sprains (ligamental tears) unusual in young children but do occur in adolescents

b. “Pearls”

1) Fractures result from significant force: history should be appropriate for pattern of injury

2) Warning flags to consider child maltreatment: fracture in infant younger than 1 year, spiral fracture, unwitnessed or unexplained injury, fractures in various healing stages, history of other fractures, fracture that does not fit mechanism of injury stated

3) Approximately 25% of fractures in children younger than 3 years caused by nonaccidental trauma

4) Torus/buckle fractures unique to children

5) Pulling injury to arm can result in “nursemaid’s elbow” (subluxation of the radial head) in child commonly seen between 2 to 3 years of age

6) Limping: uncommon in children; suspect hip disorder if found

7) Unwillingness to bear weight requires further investigation

2. Geriatric

a. Aging related

1) Loss of bone minerals and mass

a) Regeneration prolonged

b) Bones become more brittle

c) Loss of vertebral body height results from compression that occurs with normal aging and leads to kyphosis

2) Muscles lose ability to regenerate new fibers to replace ones lost because of age (atrophy)

a) Decreased muscular strength and endurance, shuffling gait

b) Longer contraction time and tendency to fatigue more easily, which may cause muscle tremors, even at rest

b. “Pearls”

1) Joint stiffness and degenerative changes contribute to decreased mobility

2) Posture affected by age-related changes

3) Gait affected by posture, balance, strength, and flexibility

5) Osteoporosis promotes fractures, especially in vertebral bodies, ribs, proximal femur

6) Osteoarthritis (degeneration of movable joints) affects mostly weight-bearing joints of knees, vertebrae, small joints of hand and feet

7) Rheumatoid arthritis (e.g., systemic disease of connective tissue resulting in joint inflammation) produces swelling, stiffness, ankylosis, redness, warmth of joints

8) Pathologic fracture may be caused by other chronic diseases

9) Paget’s disease

a) Metabolic disease that causes excessive bone resorption and deposits

b) Middle-aged and elderly men primarily affected

c) Affected bones tend to fracture easily

FIGURE 37-1 Salter-Harris classification of pediatric fractures.

(From Simon, R. R., & Koenigsknecht, S. J. [2001]. Emergency orthopedics (4th ed.). New York: McGraw-Hill.)

II. SPECIFIC SOFT TISSUE INJURIES

The soft tissue of the extremities includes the skin, muscles, tendons, ligaments, nerves, and blood vessels. Injuries may occur with or without a bony injury, and in some cases it is difficult to determine the diagnosis. A careful clinical examination, along with radiologic studies to rule out skeletal trauma, is necessary to identify the problem. Certain disorders may result from chronic overuse and may not have an acute history of injury.

A. Contusions/Hematomas

A contusion is a closed wound in which a ruptured blood vessel has hemorrhaged into the surrounding tissues. The blood may form a hematoma if bleeding is sufficient and has been contained. This can result from blunt external forces or exertional stresses. Symptoms may include swelling, discoloration, and tenderness. Populations at risk are those involved in physical activities, sports, or abusive relationships and patients who are taking anticoagulant therapy or who have a history of clotting disorders.

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Direct blow to affected area

b) Object of contact

c) Onset of swelling, discoloration

d) Therapies initiated to relieve symptoms

b. Objective data collection

2) Diagnostic procedures

a) CBC with platelet count to rule out significant blood loss and thrombocytopenia as possible cause of bleeding

b) Coagulation profile (prothrombin time [PT], partial thromboplastin time [PTT], international normalized ratio [INR]) to rule out coagulopathy

c) Radiographs to rule out associated fractures

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute pain

b. Activity intolerance

c. Impaired skin integrity

d. Risk for infection

e. Deficient knowledge

3. Planning and implementation/interventions

a. Prepare for/assist with medical interventions

1) Splint extremity to protect from further injury or iatrogenic injury and for pain reduction

2) Apply pressure dressing to decrease hemorrhage and swelling

b. Administer pharmacologic therapy as ordered

1) Non-narcotic analgesics

2) Narcotics

c. Educate patient and significant others

1) Rest and elevate affected extremity to minimize bleeding and edema formation

2) Apply cold packs to stimulate vasoconstriction

a) Use for 20 minutes at a time, four times per day, for the first 2 to 3 days

b) Wrap cold pack to protect skin from cold and further injury

3) Apply and remove compressive dressing

4) Use physical assistive devices (e.g., cane, crutches, walker)

4. Evaluation and ongoing monitoring (see Appendix B)

a. Pain relief

B. Strains and Sprains

Injuries to the structures around a joint are usually caused by excessive stretch or sudden force. This results in pulling on the structures, which causes tears in muscle and/or tendon. A sprain is the stretching, separation, or tear of a supporting ligament, and a strain is the separation or tear of a musculotendinous unit from a bone. Injury may result in pain, inability to weight bear fully, and swelling of the affected area. Sprains and strains are rare in small children, whose epiphyseal plates are still open and more vulnerable to forces. Athletes and obese patients resuming physical fitness are at risk for these types of injuries. Both strains and sprains are classified based on the amount of damage (Box 37-6).

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Sudden stretching, twisting, or excessive force to joint (e.g., popping sound may be heard or felt)

b) Pain (see Chapter 9): in joint (i.e., ranges from localized to severe and disabling; may be aggravated by movement, muscle tension, weight bearing)

b. Objective data collection

Tags: Emergency Nursing Core Curriculum

Nov 8, 2016 | Posted by admin in NURSING | Comments Off

Nurse Key

Fastest Nurse Insight Engine

Orthopedic Trauma

I. GENERAL STRATEGY

A. Assessment

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

C. Planning and Implementation/Interventions

D. Evaluation and Ongoing Monitoring (see Appendix B)

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

II. SPECIFIC SOFT TISSUE INJURIES

A. Contusions/Hematomas

B. Strains and Sprains

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