Contusion is a soft tissue injury that does not involve a break in the skin. It is produced by blunt force such as blow, kick or fall causing ruptured of the small blood vessels and bleeds into soft tissue, forming black and blue marks beneath the skin (ecchymosis). Blood can build up and form a hematoma in the muscle, initiating an inflammatory response that can result in swelling and additional tissue injury. Contusion can be resolved in 1- 2 weeks. Manifestations seen in the patient is pain, swelling and discoloration in the injured area which can be controlled by application of cold packs and elevation of the extremities above the heart level.
Strain is an injury to muscles or the tendons that attach the muscles to the bones when it is stretched or pulled beyond its capacity. There are three types of strain; the first degree in which there is mild stretching of the muscle or tendon. The patient may have minor and mild symptoms of tenderness and muscle spasm. The second degree strain in which partial tearing of the muscle or tendon occurs. Symptoms include loss of load- bearing strength, muscle spasm, edema and ecchymosis. The third degree strain is severe muscle or tendon stretching with tearing of the tissue accompanied by significant pain, muscle spasm, edema and loss of function.
Sprain is injury to the ligaments surrounding a joint resulting from sudden, unusual movement or stretching about a joint, common with falls and accidental injuries. A hematoma may develop subsequently contributes to the pain because the ass exerts additional pressure on the nerve endings in the area. Sprains are graded into three levels; the first- degree sprain which is a minimum damage in the ligaments resulting in mild edema local tenderness and pain when the joint is moved. Second degree sprain involves partial tearing of the ligament. It results in tenderness, joint instability, and increased edema. The tree- degree sprain occurs when a ligament is completely torn or ruptured accompanied by severe pain, increased edema and abnormal joint movement.
RICE is the acronym for rest, ice, compression and elevation. These are the nursing management in patient with contusion, strain and sprain. Rest is essential to protect the injured muscle, tendon, ligament or other tissue from further injury and patient's body needs to rest so it has the energy it needs to promote healing. Application of cold pack for 20-30 minutes during the first 48 hours after the injury produces vasoconstriction, which decreases bleeding, discomfort and it also limits swelling by reducing blood flow to the injured area. An elastic compression bandage controls bleeding, reduces edema and provides support for the injured tissue. Elevation controls the swelling and it is most effective when the injured area is raised above the level of the heart.
List immediate and delayed complications of fractures.
Hypovolemic shock may result from hemorrhage and it is common for patient with pelvic fractures and femoral fractures.
Fat embolism syndrome occurs in patient with multiple fractures, it may develop immediately after the fracture of the long or pelvic bones.
Compartment syndrome involves sudden and severe decreased in blood flow to the tissues distal to an area of injury that result in ischemic necrosis. The hallmark sign is pain that occurs or intensifies with passive ROM.
Disseminated intravascular coagulation (DIC) may result in widespread hemorrhage and microthrombosis with ischemia. Manifestations include unexpected bleeding after surgery and bleeding from the mucous membrane.
Delayed union occurs when healing does not occur within the expected time frame and may be associated with distraction of bone fragments, systemic or local infection. Nonunion results from failure of the ends of a fractures bone to unite whereas malunion results from failure of the ends of a fractured bone to unite in normal alignment.
Avascular necrosis of bone occurs when the bone losses its blood supply and dies. The patient develops pain and experiences limited movement.
Complex regional pain syndrome is painful sympathetic nervous syndrome problem. Clinical manifestations include severe burning pain, local edema, stiffness, vasomotor skin changes.
Heterotopic ossification is an abnormal growth of bone in response to soft tissue trauma after blunt trauma. The movements are limited due to pain the muscle.
Develop a plan of care for a patient with a simple (closed) fracture.
Impaired physical mobility related to neuromuscular skeletal impairment.
After 8 hours of nursing intervention, the patient will regain or maintain mobility at the highest possible level.
Nursing intervention and rational:
Encourage the patient to participate in diversional or recreational activities to provide release of energy, refocuses attention and enhances self worth.
Instruct the patient in assisting in active or passive ROM of the affected and unaffected extremities to increase blood flow to the muscle and bone, to maintain joint mobility and prevent atrophy or calcium resorption.
Assist the patient in self- care activities to improve muscle strength and circulation and promotes self- directed wellness.
Reposition the patient every 2- 4 hours and encourage deep breathing exercises to prevent respiratory complications.
Encourage to increased intake of fluid up to 2000- 3000 ml/ day to keeps the patient's body well hydrated and decreasing the risk for urinary infection.
After 8 hours of nursing intervention, the goal was met as evidenced by regaining strength of the patient, able to maintain mobility and demonstrate ways to improve health by joining doing active and passive range of motion.
Discuss how the aging process affects healing in the patient with a fractured hip.
Women are more prone to fracture because there are hormonal changes such as estrogen and calcitonin decreases during menopause. The most common fractures in the elderly are the hip and wrist. The rate and effectiveness of bone healing can be altered by the age, general health of the patient. In elderly, alteration in bone structure occurs. The bones become shorter and narrower thus healing process is prolonged. Elderly people have a more delayed course of fracture healing and it may take up to 8 weeks.
Discuss the psychosocial needs of the patient who has had an amputation.
Since loss of extremity is such as shocking experience to a patient, it is naturally for them to feel angry and depressed. Physical disability was found to boost a person's tendency toward anxiety, depression, low self-esteem and less satisfaction with life. The nurse must assess the coping mechanism that the patient is exhibiting such as fear, withdrawal or helplessness. The nurse must create an accepting and supporting atmosphere in which the patient and family are encourage to express and share their feelings and work through the grief process. The support from the family and loved ones promotes the patient's acceptance of the loss. Nothing can compare the love and support that was coming from the patient's family. The nurse also helps the patient to deal with immediate needs and become oriented to realistic rehabilitation goals and future independent functioning. Treatment options include psychotherapy, medication or a combination of the two.
Observe a clinical patient with a comminuted fractured of the tibia. Describe how adjacent structures are affected.
Fractured tibia are often associated with fractured fibula which caused by direct blow, fall with a foot in a flex position or in twisting motion. When the peroneal nerve is assessed and if ever it is damaged, the patient cannot even dorsiflex the great toe and may decrease the sensation in the first web space. In assessing if ever the tibial artery is damage, look for the pulse and evaluate, skin temperature and color and to also consider the capillary refill. Damage of the ligament or hemiarthrosis may occur if the fracture is close to the joint. In general, the patient may be present of pain that increases with plantar flexion and it is not relieved by analgesics, deformity, hematoma, edema, paresthisias and sometimes weak or absent pulse.
What are the types of medical management used for the treatment of fracture.
The basis of the treatment of fracture is reduction and immobilization.
There are two objectives in the treatment of fractures. First id to promote bone healing and restore function and appearance and the second is to return the patient to his activities of daily living in the shortest possible time.
Reduction is the restoration of the fracture fragments to anatomic alignment and positioning. Consent is needed in this procedure and the analgesic and anesthesia is administered to the patients as prescribed.
Closed Reduction is the alignment of fracture fragments through manual manipulation or traction. There are three indications for reduction of fracture. The first is to ensure recovery of limb function, second is to prevent or delay degenerative changes in joints and lastly is to minimize the deforming effects of the injury. The method of closed fracture reduction is to apply traction force to the long axis of the limb and reverse the mechanism that produced the fracture. It may be performed under general or local anesthesia. After the procedure the patent is kept immobilized to relieve pain, to prevent rotation and shearing at the fracture site and to maintain the position of the fracture by preventing displacement until bony union occurs.
Open Reduction is indicated when the reduction cannot be attained by closed methods, for displaced intraarticular fractures, in certain types of epiphyseal fractures and when there are major avulsion fragments when there is disruption of muscles and ligaments. Open reduction is usually followed by internal fixator to stabilize the fracture and allow fracture healing to occur. Advantages of open reduction includes early mobilization, restoration of the anatomic shape of the bone, decreased costs and shorter hospital stays.
What are the needs of patients diagnosed with various types of fractures.
For patient with closed fractures:
The nurse must assess the pain that the patient is experiencing using the pain scale. Instruct the patient regarding the methods to control edema and pain such as elevating the affected extremities to heart level and taking analgesic as prescribed by the physician. Teach the patient passive range of motion to increase strength of the muscles needed for transferring and using assistive device such as crutches and walkers. Teach also the patient on how to use the assistive device. During the health teaching include medication information and monitoring for potential complications. Inform the patient that fracture healing may take for 6- 8 weeks, depending on the quality of the patient's bone tissue.
For patient with open fractures:
The objective of the management are to prevent infection of the wound, soft tissue, and bone to promote healing of the bone and soft tissue. Intravenous antibiotics and tetanus toxoid is administered to the patient to avoid any infection. The fracture is carefully reduced and stabilized by external fixator and the wound is open for 5 to 7 days for irrigation and cleansing. Primary wound closure is usually delayed on open fractures. Instruct the patient to elevate the affected area to minimize edema. Also, assess neurovascular status frequently to assess redness, sensation and swelling. Monitor the temperature of the patient because of risk for hyperthermia. Bone grafting may be necessary in 4- 8 weeks to stimulate bone healing.
For patient with fracture at the clavicle:
The treatment goal of the fractured clavicle is to align the shoulder in its normal position by means of closed reduction and immobilization. A clavicular strap may be use to pull the shoulders back, immobilizing the fracture. The nurse must monitor the circulation and nerve function of the affected arm and compares it with the unaffected arm. Use of sling is needed to support the arm and to relieve pain. Instruct the patient to use the arm for only light activities within the range of comport. The patient needs to know not to elevate the affected arm above the shoulder level until fracture has healed. Encourage the patient to exercise the elbow, wrist and fingers as soon as possible to avoid any complication.
For patient with fracture at the elbow:
Monitor the patient for any changes in neurovascular status and signs and symptoms of compartment syndrome. Encourage immobilizing the affected part with the elbow at 45 to 90 degrees of flexion and placed in a sling. Application of ice is also indicated. Gentle ROM exercise of the injured joint is performed.
For patient with fracture at the wrist:
Close reduction and immobilization with short-arm cast.For fractures with extensive comminition, ORIF, arthroscopic percutaneous pinning or external fixation are used to maintain reduction. Elevate the wrist and forearm for 48 hours after reduction to control swelling. Active motion of fingers and shoulder should begin promptly. Assess the sensory function of the median nerve by pricking the distal aspect of the distal aspect of the index finger. Assess the motor function by the patient's ability to touch the thumb to the little finger.
For patient with fracture at the pelvis:
CT scan must be done to help determine the extent of the injury. Neurovascular assessment of the lower extremity is needed. Palpate the peripheral pulse especially the dorsalis pedis pulses of both lower extremities. Assess for the injuries to the bladder, rectum, intestines, other abdominal organs and pelvic vessels and nerves.
Stable pelvic fracture patients should have a bed rest and symptom management for a few days until discomfort is controlled. Sitz bath may be prescribed to relieve pain and stool softeners may be given for coccyx fracture. Unstable pelvic fracture patients should stabilize the pelvic bone and compress the bleeding vessels with a pelvic girdle.
If major vessels are lacerated, the bleeding may be stopped through embolization using interventional radiology techniques prior to surgery. When the patient is hemodynamically stable, treatment generally involves external fixation or ORIF.
For patient with fracture at the hip:
Buck's extension traction may be applied to reduce muscle spasm, to immobilize extremity and to relieve pain. Open or closed reduction of the fracture and internal fixation may be performed. Replacement of the femoral head with a prosthesis or closed reduction with percutaneous stabilization for an intracapsular fracture are also possible.
Total hip replacement may be used for patients with acetabular defects.
Pain management and prevention of secondary medical problems are some concerns of nurses. Early immobilization of the patient for independent functioning can be restored.
Encourage deep breathing, dorsiflexion as well as plantar flexion exercises for every 1-2 hours. Position the leg in abduction and avoiding internal and external rotation, hyperextension and acute flexion to prevent dislocation of the prosthesis
For patient with fracture at the knee:
CT scan and MRI may be indicated to determine the extent of the injury. Arthrocentesis may be done to provide relief of intra-articular pressure. Anti-inflammatory and analgesic effects of NSAIDs may be prescribed. Nondisplaced fractures may be treated by immobilization and gradual increase in weight-bearing for about 6 months.
Displaced fractures require ORIF surgical procedures.
For patient with fracture at the tibia and fibula:
Closed tibial fractures are treated with close reduction and initial immobilization in a long-leg walking cast or patellar tendon-bearing cast. Elevate leg to control edema. Monitor forsigns and symptoms of compartment syndrome. Partial weight-bearing is usually prescribed after 7-10 days. Comminuted fractures may be treated with skeletal traction, internal fixation with intramedullary nails or plates and screws or external fixation. Hip, foot and knee exercises are encouraged. Open fractures are treated with external fixation. Evaluate neurovascular status.
For patient with fracture at the rib:
Help the patient to cough and take deep breaths by splinting the chest with the nurse's hands. Intercostal nerve blocks administration by the anesthesia care provider to relieve pain and to permit productive cough. Chest strapping to immobilize the rib fracture must not be used.
Discuss factors that affect fracture healing.
Severity of trauma- the amount of trauma in the soft tissue will influence the rate of healing because the cells that differentiate into repair cells for the bone also provides cells to repair soft tissue damage. The hematoma can spread into the surrounding tissue resulting in a dispersion of the efforts of the repair cells. Displaced fractures have a greater amount of cartilage formation and less primary bone formation than a nondisplaced fractures.
Type of bone- cancellous bone is known to unite rapidly where there are points of direct contact between fragments. Cortical bone unites by the repair process of external callus formation if there is wide displacement of the fragments or if immobilization is not rigid.
Immobilization- adequate immobilization of fracture fragments is critical to the healing process. Repeated manipulation or motion of fracture fragments can result in the formation of pseudoarthrosis.
Infection- the presence of infection can slow down or stop the fracture healing process because the cell that would normally involved for the repair will attempt to eliminate infection.
Avascular necrosis- if there is avascular necrosis of one fracture fragment, all healing occurs from one side of the fracture. Although the fracture will heal, it will heal slowly.
Intraarticular fractures- fribronolysin in synovial fluid can disrupt the initial clot and slow the rate of the first stage of fracture healing.
Age- fractures heal more slowly in adults than in children. The younger the age of the individual, the faster the rate of healing.
Hormones- corticosteroids slow the rate of fracture healing. Growth hormone, thyroid hormone, vitamins A and D stimulate the rate of healing.
Discuss early complications of fractures.
Hypovolemic shock is noted in patient with pelvic fracture and open femoral fracture causing hemorrhage because the femoral artery was torn. The nurse must protect the patient from further injury to prevent complications like infection, also relieve the patient's pain by non-pharmacological treatment such as guided imagery and music therapy.
Fat embolism is common in adults younger than 40 years of age and in men and in patients with multiple fracture. The flat globule which was diffused in the vascular compartment occludes in the small blood vessels than supply the lungs, kidneys and other organs. Clinical manifestation includes hypoxia, tachypnea, tachycardia and pyrexia. To reduce incidence of fat emboli, immediate immobilization should be encourage to the patient.
Compartment syndrome occurs when perfusion pressure falls below tissue pressure within a closed anatomic compartment. It involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis. There will be deep, throbbing, unrelenting pain which continues to increase despite the administration of opioids. The hallmark sign is pain that occurs with passive range of motion.
Deep vein thrombosis and pulmonary embolism are associated with reduced skeletal muscle contractions and bed rest. Patients with fractures at the lower extremities are high risk for DVT. The patient encourages deep breathing exercises and coughing exercises to mobilize secretions and passive range of motion of the affected extremities.
Discuss postoperative management of an elderly patient with a hip fracture.
Pain is the common problem of patient after the surgery. In managing the patient's pain: use pain modifying strategies such as guided imagery so that the pain perception diminishes and refocuses his attention. Handle the affected extremity gently, supporting it with hands and pillow to avoid muscles spasm and diminishes soft tissue tension and administer analgesic as prescribed to decrease discomfort.
Since the patient can mobilize without assistance, the nurse must assist in the patient in position changes and transfers to prevent stress in hip fixation; instruct the patient in isometric exercise to strengthen the shoulder and arm muscles; instruct the patient to place pillow between legs when turning to prevent adduction and maintain neutral positioning of the hip to prevent stress at the site of fixation.
The patient is risk for infection; the nurse must assess the wound appearance and characteristic of drainage to detect if there is an infection and administer prophylactic antibiotic if prescribed to reduce the risk for infection.
Due to immobilization, the patient is risk for pulmonary complication and deep vein thrombosis. Encourage the patient in deep breathing and coughing exercise for lung expansion and mobilization of secretions; turn the patient at least every 2 hours to promote optimal ventilation and diminishes pooling of respiratory secretions. To avoid DVT, apply high anti-embolism stockings to prevent stasis; avoid pressure on popliteal blood vessels from pillows to avoid diminish blood flow; and assess skin temperature of legs to detect signs of local inflammation.
Brunner, Suddarths et al. (2008). Medical- Surgical Nursing 12th edition. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins
Mahler, Salmond et al. (2005). Orthopaedic Nursing. Philadelphia, Pennsylvania: W.B Saunders Company
Timby and Smith (2003). Introductory Medical- Surgical Nursing 8th edition. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins
1. Research an article addressing the patient who has undergone an amputation. Explain the patient's rehabilitation and health education needs.
In-hospital rehabilitation, in many ways, is the most critical phase and presents the greatest challenges to the patient, the family, and the amputation team. Initially, the patient is concerned about safety, pain, and disfigurement. Later on, the emphasis shifts to social reintegration and vocational adjustment. The grief response to limb loss is probably universal and time limited. Factors that are noted to facilitate adjustment and rehabilitation in this phase are early prosthetic fitting, acceptance of the amputation and the prosthesis by family and friends, and introduction of a successfully rehabilitated amputee to the recovering patient
At-Home Rehabilitation, by all accounts the amputee's return home can be a particularly taxing period because of loss of the familiar surroundings of the hospital and attenuation of the guidance and support provided by the rehabilitation team. Hence, the attitude of the family becomes a major determinant of the amputee's adaptation. Family members should be involved in all phases of the rehabilitative process.
It is during this phase that the full impact of the loss becomes evident. A number of individuals experience a "second realization," with attendant sadness and grief.Varying degrees of regressive behavior may be evident, such as a reluctance to give up the sick role, a tendency to lean on others beyond what is justified by the disability, and a retreat to "baby talk." Some resent any pressure put upon them to resume normal functioning. Others may go to the other extreme and vehemently reject any suggestion that they might be disabled or require help in any way. An excessive show of sympathy generally fosters the notion that one is to be pitied. In this phase, three areas of concern come to the fore: return to gainful employment, social acceptance, and sexual adjustment. Of immense value in all of these matters is the availability of a relative or a significant other who can provide support without damaging self-es-teem.http://www.oandplibrary.org/assets/images/icon_reference.gif
A subtle but often overlooked issue is the ease with which the disability can be concealed in social settings. One group member, for example, remarked that one advantage of a leg amputation over an upper-limb loss was that it could escape detection in such settings.
Not surprisingly, those amputees able to resume a full and productive life tend to fare best; this is much easier for those with marketable skills who sustain the amputation while still in vigorous health. For elderly amputees who have limited skills, particularly if they have other medical disorders, the probability of a full return to an active life is considerably diminished. This can be partially or fully balanced by a more philosophical acceptance of a new, more leisurely way of living and by reduced responsibility and pressure to produce.