Post on 09-Apr-2018
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Focus onFocus on
FracturesFractures(Relates to Chapter 63,(Relates to Chapter 63,
Nursing Management:Nursing Management:
Musculoskeletal Trauma and Orthopedic Surgery,Musculoskeletal Trauma and Orthopedic Surgery,in the textbook)in the textbook)
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FracturesFractures
Disruption or breakin continuity ofDisruption or breakin continuity of
the structure of bonethe structure of bone Majority of fractures fromMajority of fractures from
traumatic injuriestraumatic injuries
Some fractures secondary to diseaseSome fractures secondary to diseaseprocessprocess
Cancer or osteoporosisCancer or osteoporosis
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ClassificationClassification
Fractures are described andFractures are described and
classified according toclassified according to TypeType
Communication or noncommunicationCommunication or noncommunication
with external environmentwith external environment
Anatomic location of fracture onAnatomic location of fracture on
involved boneinvolved bone
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Types of FracturesTypes of Fractures
Fig. 63-6
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Classification According toClassification According to
External EnvironmentExternal Environment
Fig. 63-7
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Classification According toClassification According to
LocationLocation
Fig. 63-8
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ClassificationClassification
Fractures also described as stable orFractures also described as stable or
unstableunstable Stable fractureStable fracture
Piece of periosteum is intact acrossPiece of periosteum is intact across
fracturefracture Either external or internal fixation hasEither external or internal fixation has
rendered fragments stationaryrendered fragments stationary
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ClassificationClassification
Stable fracture (contd)Stable fracture (contd)
TransverseTransverse SpiralSpiral
GreenstickGreenstick
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ClassificationClassification
Unstable fractureUnstable fracture
Grossly displaced during injuryGrossly displaced during injury Site of poor fixationSite of poor fixation
Usually comminuted or obliqueUsually comminuted or oblique
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ClassificationClassification
Fractures can also be classified asFractures can also be classified as
Closed (simple)Closed (simple) OpenOpen
Compound fractureCompound fracture
Communication of fracture through skinCommunication of fracture through skin
with external environmentwith external environment
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Clinical ManifestationsClinical Manifestations
Mechanism ofinjury associated withMechanism ofinjury associated with
numerous signs and symptomsnumerous signs and symptoms Immediate localized painImmediate localized pain
Decreased functionDecreased function
Inability to bear weight on or useInability to bear weight on or useaffected partaffected part
Patient guards and protects extremityPatient guards and protects extremity
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Clinical ManifestationsClinical Manifestations
Fracture may not be accompaniedFracture may not be accompanied
by obvious bone deformityby obvious bone deformity Immobilize extremityImmobilize extremity if fracture isif fracture is
suspectedsuspected
Unnecessary movementUnnecessary movement Increases soft tissue damageIncreases soft tissue damage
May convert a closed fracture to openMay convert a closed fracture to open
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture HealingBone goes through a remarkableBone goes through a remarkable
reparative process of selfreparative process of self--healinghealing
1.1. Fracture hematomaFracture hematoma
2.2. Granulation tissueGranulation tissue
3.3. Callus formationCallus formation
4.4. OssificationOssification
5.5. ConsolidationConsolidation
6.6. RemodelingRemodeling
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Bone Healing StagesB
one Healing Stages
Fig. 63-9
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing
Fracture hematoma: Initial 72 hoursFracture hematoma: Initial 72 hours
Bleeding creates a hematoma,B
leeding creates a hematoma,surrounding ends of fragmentssurrounding ends of fragments
Hematoma is extravasated blood thatHematoma is extravasated blood that
changes from liquid to semisolid clotchanges from liquid to semisolid clot
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing
Granulation tissue: 3 to 4 daysGranulation tissue: 3 to 4 days
postinjurypostinjury
Active phagocytosis absorbs productsActive phagocytosis absorbs products
of local necrosisof local necrosis
Hematoma converts to granulationHematoma converts to granulation
tissuetissue
Granulation tissue produces basis forGranulation tissue produces basis for
new bone substance (osteoid)new bone substance (osteoid)
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing Callus formation: End of secondCallus formation: End of second
weekweek
Minerals and new bone matrix areMinerals and new bone matrix aredeposited in osteoid; an organizeddeposited in osteoid; an organizednetwork of bone is formed that isnetwork of bone is formed that is
woven around fracture partswoven around fracture parts Callus is primarily composed ofCallus is primarily composed of
cartilage, osteoblasts, calcium, andcartilage, osteoblasts, calcium, andphosphorusphosphorus
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing
ConsolidationConsolidation
As callus continues to develop, distanceAs callus continues to develop, distancebetween bone fragments diminishesbetween bone fragments diminishes
and eventually closesand eventually closes
This stage is known as consolidationThis stage is known as consolidation
Ossification continuesOssification continues
Can be equated with radiologic unionCan be equated with radiologic union
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing Remodeling:Up to a year afterRemodeling:Up to a year afterinjuryinjury
Excess bone tissue is reabsorbedExcess bone tissue is reabsorbed
Union is completeUnion is complete
Gradual return to preinjury structuralGradual return to preinjury structural
strength and shape occursstrength and shape occurs Bone remodels in response to physicalBone remodels in response to physical
loading stressloading stress
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing
Remodeling (contd)Remodeling (contd)
Weight bearing is gradually introducedWeight bearing is gradually introduced New bone is deposited in sitesNew bone is deposited in sites
subjected to stresssubjected to stress
B
oneis resorbed at areas of l
ittle stress
B
oneis resorbed at areas of l
ittle stress
Radiologic union occurs when xRadiologic union occurs when x--rayray
evidence shows complete bony unionevidence shows complete bony union
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing
Factors influencing healingFactors influencing healing
AgeAge Initial displacementInitial displacement
ImmobilizationImmobilization ImplantsImplants
SiteSite InfectionInfection
HormonesHormones Blood supply to areaBlood supply to area
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing
Fracture healing mayFracture healing may
Not occur in the expected timeNot occur in the expected time Delayed unionDelayed union
Not occur at allNot occur at all
NonunionNonunion
Healing time of fractures increasesHealing time of fractures increases
with agewith age
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing
Causes for delayed ossificationCauses for delayed ossification
Inadequate reduction andInadequate reduction andimmobilizationimmobilization
Excessive movementExcessive movement
InfectionInfection
Poor nutritionPoor nutrition
Systemic diseaseSystemic disease
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Clinical ManifestationsClinical Manifestations
Fracture HealingFracture Healing
Electrical stimulation and pulsedElectrical stimulation and pulsed
electromagnetic fields (PEMFs)electromagnetic fields (PEMFs)
Stimulate bone healingStimulate bone healing
Electric currents modify cellElectric currents modify cell
mechanisms, causing bone remodelingmechanisms, causing bone remodeling
Electrodes placed over skin or cast andElectrodes placed over skin or cast and
are used 10 to 12 hours each dayare used 10 to 12 hours each day
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Collaborative CareCollaborative Care
Overall goals of fracture treatmentOverall goals of fracture treatment
Anatomic realignment of boneAnatomic realignment of bonefragmentsfragments
Immobilization to maintainImmobilization to maintain
realignmentrealignment
Restoration of normal or nearRestoration of normal or near--normalnormal
function ofinjured partsfunction ofinjured parts
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Collaborative CareCollaborative Care
Fracture ReductionFracture Reduction Closed reductionClosed reduction
Nonsurgical, manual realignment ofNonsurgical, manual realignment ofbone fragments to previous anatomicbone fragments to previous anatomic
positionposition
Traction and countertraction manuallyTraction and countertraction manually
applied to bone fragments to restoreapplied to bone fragments to restore
position, length, and alignmentposition, length, and alignment
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Collaborative CareCollaborative Care
Fracture ReductionFracture Reduction Closed reduction (contd)Closed reduction (contd)
Performed while patient is under localPerformed while patient is under localor general anesthesiaor general anesthesia
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Collaborative CareCollaborative Care
Fracture ReductionFracture Reduction Open reductionOpen reduction
Correction of bone alignment throughCorrection of bone alignment throughsurgical incisionsurgical incision
Includes internal fixation with use ofIncludes internal fixation with use of
wires, screws, pins, plates,wires, screws, pins, plates,
intramedullary rods, or nailsintramedullary rods, or nails
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Collaborative CareCollaborative Care
Fracture ReductionFracture Reduction Open reduction (contd)Open reduction (contd)
Chief disadvantagesChief disadvantages Possibility ofinfectionsPossibility ofinfections
Complications associated with anesthesiaComplications associated with anesthesia
Effects of premorbid medical conditionsEffects of premorbid medical conditions
Early initiation of ROM of the jointEarly initiation of ROM of the joint
If open reduction with internal fixationIf open reduction with internal fixation
(ORIF) is used for intraarticular fractures(ORIF) is used for intraarticular fractures
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Collaborative CareCollaborative Care
Fracture ReductionFracture Reduction Open reduction (contd)Open reduction (contd)
Machines can provide continuousMachines can provide continuous
passive motion (CPM) to various jointspassive motion (CPM) to various joints Help prevent extraarticular andHelp prevent extraarticular andintraarticular adhesionsintraarticular adhesions
Results in faster reconstruction ofResults in faster reconstruction ofsubchondral bone plate, rapid healing ofsubchondral bone plate, rapid healing ofarticular cartilage,articular cartilage, decreaseddecreasedcomplicationscomplications
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Collaborative CareCollaborative Care
TractionTraction Application of a pulling force to anApplication of a pulling force to an
injured or diseased part of body orinjured or diseased part of body or
extremity while counter tractionextremity while counter traction
pulls in opposite directionpulls in opposite direction
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Collaborative CareCollaborative Care
TractionTraction Purpose of any tractionPurpose of any traction
Prevent orPrevent or muscle spasmmuscle spasm
Immobilize joint or part of bodyImmobilize joint or part of body
a fracture or dislocationa fracture or dislocation
Treat a pathologic joint conditionTreat a pathologic joint condition
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Collaborative CareCollaborative Care
TractionTraction Traction also indicated toTraction also indicated to
Provide immobilization to prevent softProvide immobilization to prevent soft
tissue damagetissue damage
Reduce muscle spasm associated withReduce muscle spasm associated with
low back pain or cervical whiplashlow back pain or cervical whiplash
Expand a joint spaceExpand a joint space
During arthroscopic proceduresDuring arthroscopic procedures
Before major joint reconstructionBefore major joint reconstruction
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Collaborative CareCollaborative Care
TractionTraction Two most common types of tractionTwo most common types of traction
Skin tractionSkin traction
Skeletal tractionSkeletal traction
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Collaborative CareCollaborative Care
TractionTraction Skin tractionSkin traction
Used for shortUsed for short--term treatment untilterm treatment until
skeletal traction or surgery is possibleskeletal traction or surgery is possible
Tape, boots, or splints applied directlyTape, boots, or splints applied directly
to skin to maintain alignment, assist into skin to maintain alignment, assist in
reduction, and help diminish musclereduction, and help diminish muscle
spasms in injured extremityspasms in injured extremity
Traction weights 5 to 10 poundsTraction weights 5 to 10 pounds
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Collaborative CareCollaborative Care
TractionTraction Skeletal tractionSkeletal traction
In place for longer periodsIn place for longer periods
Used to align injured bones and jointsUsed to align injured bones and joints
or to treat joint contractures andor to treat joint contractures and
congenital hip dysplasiacongenital hip dysplasia
Provides a longProvides a long--term pull that keepsterm pull that keeps
injured bones and joints alignedinjured bones and joints aligned
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Collaborative CareCollaborative Care
TractionTraction Skeletal traction (contd)Skeletal traction (contd)
Physician inserts pin or wire into bone,Physician inserts pin or wire into bone,
either partially or completely, to aligneither partially or completely, to align
and immobilize injured body partand immobilize injured body part
Skeletal traction weight ranges: 5 to 45Skeletal traction weight ranges: 5 to 45
poundspounds
Too much weight results in delayed unionToo much weight results in delayed union
or nonunionor nonunion
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Collaborative CareCollaborative Care
TractionTraction Skeletal traction (contd)Skeletal traction (contd)
Major disadvantagesMajor disadvantages
Infection of the area of bone whereInfection of the area of bone where
skeletal pin has been insertedskeletal pin has been inserted
Consequences of prolonged immobilityConsequences of prolonged immobility
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Collaborative CareCollaborative Care
TractionTraction When traction is used, forces areWhen traction is used, forces are
usually exerted on distal fragment tousually exerted on distal fragment to
obtain alignment with proximalobtain alignment with proximal
fragmentfragment
Bucks tractionBucks traction
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Bucks TractionBucks Traction
Fig. 63-10
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Collaborative CareCollaborative Care
TractionTraction Fracture alignment depends onFracture alignment depends on
correct positioning and alignmentcorrect positioning and alignment
while traction forces remainwhile traction forces remain
constantconstant
Forces must be pulling in oppositeForces must be pulling in oppositedirection to prevent patient fromdirection to prevent patient from
sliding to end or side of bedsliding to end or side of bed
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Collaborative CareCollaborative Care
TractionTraction Countertraction commonly suppliedCountertraction commonly supplied
by patients body weight orby patients body weight or
augmented by elevating end of bedaugmented by elevating end of bed
Imperative that nurse maintainsImperative that nurse maintains
traction constantly and does nottraction constantly and does notinterrupt weight applied to tractioninterrupt weight applied to traction
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization CastsCasts
Temporary circumferentialTemporary circumferential
immobilization deviceimmobilization device
Allows patient to perform manyAllows patient to perform many
normal activities of daily livingnormal activities of daily living
Cast materials are natural, syntheticCast materials are natural, synthetic
acrylic, fiberglassacrylic, fiberglass--free, latexfree, latex--freefree
polymer, or a hybrid of materialspolymer, or a hybrid of materials
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Casts (contd)Casts (contd)
After immersion in water, plaster ofAfter immersion in water, plaster of
Paris is wrapped and molded aroundParis is wrapped and molded around
affected part after bony prominencesaffected part after bony prominences
have been paddedhave been padded
Number of layers and techniqueNumber of layers and technique
determines strength of castdetermines strength of cast
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Casts (contd)Casts (contd)
After cast is completely dry, it is strongAfter cast is completely dry, it is strong
and firm and can withstand stressesand firm and can withstand stresses
Plaster sets in 15 minutesPlaster sets in 15 minutes
Not strong enough for weight bearingNot strong enough for weight bearing
until 24 to 72 hoursuntil 24 to 72 hours
Fresh plaster should never be coveredFresh plaster should never be covered
with a blanketwith a blanket
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Casts (contd)Casts (contd)
During drying period, cast should beDuring drying period, cast should be
kept dry and clean, and direct pressurekept dry and clean, and direct pressure
should be avoidedshould be avoided
Once thoroughly dry, edges may needOnce thoroughly dry, edges may need
to be petaled to avoid skin irritationto be petaled to avoid skin irritation
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization
Fig. 63-11
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Casts (contd)Casts (contd)
Synthetic casting materialsSynthetic casting materials
Molded to fit torso or extremity afterMolded to fit torso or extremity after
being activated by submersion in cool orbeing activated by submersion in cool or
tepid watertepid water
Used more often because they areUsed more often because they arelightweight, relatively waterproof, providelightweight, relatively waterproof, provide
immediate immobilizationimmediate immobilization
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Types of castsTypes of casts
SugarSugar--tong splinttong splint
Posterior splintPosterior splint
Short arm castShort arm cast
Long arm castLong arm cast
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Common Types of CastsCommon Types of Casts
Fig. 63-12
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization SugarSugar--tong splinttong splint
Acute wrist injuriesAcute wrist injuries
Injuries that result in significantInjuries that result in significant
swellingswelling
Posterior splintPosterior splint Accommodates swelling in fracturedAccommodates swelling in fractured
extremity postinjuryextremity postinjury
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Short arm castShort arm cast
Treatment of stable wrist orTreatment of stable wrist or
metacarpal fracturesmetacarpal fractures
Circular cast extending from distalCircular cast extending from distal
palmar area to proximal forearmpalmar area to proximal forearm
Provides wrist immobilizationProvides wrist immobilization
Permits unrestricted elbow motionPermits unrestricted elbow motion
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Long arm castLong arm cast
Treatment of stable forearm or elbowTreatment of stable forearm or elbow
fractures and unstable wristfractures and unstable wrist
Similar to short arm cast but extendsSimilar to short arm cast but extends
to proximal humerus, restrictingto proximal humerus, restricting
motion in wrist and elbowmotion in wrist and elbow
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Sling (contd)Sling (contd)
Placement should not put unduePlacement should not put undue
pressure on posterior neckpressure on posterior neck
Encourage patient to move fingers andEncourage patient to move fingers and
nonimmobilized joints of the uppernonimmobilized joints of the upper
extremityextremity
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Body jacket (brace)Body jacket (brace)
Immobilization and support for stableImmobilization and support for stable
spine injuries of thoracic or lumbarspine injuries of thoracic or lumbar
spinespine
After application, nurse assessesAfter application, nurse assesses
patient for cast syndromepatient for cast syndrome
Cast is applied too tightlyCast is applied too tightly
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Body jacket (contd)Body jacket (contd)
Nursing assessment also includesNursing assessment also includes
Observation of respiratory statusObservation of respiratory status
Bowel and bladder functionBowel and bladder function
Areas of pressure over bony prominencesAreas of pressure over bony prominences
During time required for cast to dry,During time required for cast to dry,
nurse should reposition patient everynurse should reposition patient every
2 to 3 hours2 to 3 hours
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Hip spica castHip spica cast
Femoral fracturesFemoral fractures
Immobilize affected extremity andImmobilize affected extremity and
trunk securelytrunk securely
Includes two casts joined togetherIncludes two casts joined together
Body jacket castBody jacket cast
Long leg castLong leg cast
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Collaborative CareCollaborative Care
Fracture ImmobilizationFracture Immobilization Hip spica cast (contd)Hip spica cast (contd)
Assess patient for same problems asAssess patient for same problems as
body jacket castbody jacket cast
Nurse should instruct patient inNurse should instruct patient in
positioning activities required to get onpositioning activities required to get on
and off bedpanand off bedpan
Fracture bedpan may be usedFracture bedpan may be used
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Collaborative CareCollaborative Care
Injuries to Lower ExtremitiesInjuries to Lower Extremities Often immobilized by aOften immobilized by a
Long leg castLong leg cast
Short leg castShort leg cast
Cylinder castCylinder cast
Jones dressingJones dressing Prefabricated splint or immobilizerPrefabricated splint or immobilizer
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Collaborative CareCollaborative Care
Injuries to Lower ExtremitiesInjuries to Lower Extremities Elevate extremity onto pillows aboveElevate extremity onto pillows above
heart level for first 24 hoursheart level for first 24 hours
After initial phase, casted extremityAfter initial phase, casted extremity
should not be placed in a dependentshould not be placed in a dependent
position because of the possibility ofposition because of the possibility of
excessive edemaexcessive edema
Observe for signs of pressureObserve for signs of pressure
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Knee ImmobilizerKnee Immobilizer
Fig. 63-13
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Collaborative CareCollaborative Care
ExternalFixationExternalFixation Metallic deviceMetallic device
Composed of metal pins inserted intoComposed of metal pins inserted into
bone and attached to external rodsbone and attached to external rods
Applies traction or compressesApplies traction or compresses
fracture fragmentsfracture fragments
ImmobilizeImmobilize fragments when cast orfragments when cast or
other traction is not appropriateother traction is not appropriate
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Collaborative CareCollaborative Care
ExternalFixationExternalFixation External device holds fractureExternal device holds fracture
fragments in place similar to afragments in place similar to a
surgically implanted internal devicesurgically implanted internal device
Attached directly to bone byAttached directly to bone by
percutaneous transfixing pins orpercutaneous transfixing pins or
wireswires
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Collaborative CareCollaborative Care
ExternalFixationExternalFixation
Fig. 63-14
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Collaborative CareCollaborative Care
ExternalFixationExternalFixation Indicated inIndicated in
Simple fractures and complexSimple fractures and complex
fractures with extensive soft tissuefractures with extensive soft tissuedamagedamage
Correction of bony defects (congenital)Correction of bony defects (congenital)
PseudoarthrosisPseudoarthrosis Nonunion or malunionNonunion or malunion
Limb lengtheningLimb lengthening
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Collaborative CareCollaborative Care
InternalFixationInternalFixation Surgically inserted at time ofSurgically inserted at time of
realignmentrealignment
Biologically inert metal devices usedBiologically inert metal devices used
Stainless steelStainless steel
VitalliumVitallium TitaniumTitanium
Alignment evaluated by xAlignment evaluated by x--rayray
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QuickTime and aYUV420 codec decompressor
are needed to see this picture.
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Collaborative CareCollaborative Care
Drug TherapyDrug Therapy Patients have varying degrees ofPatients have varying degrees of
pain associated with muscle spasmspain associated with muscle spasms
Involuntary reflexes result fromInvoluntary reflexes result from
edema and nerve injury followingedema and nerve injury following
muscle injurymuscle injury
Central and peripheral muscleCentral and peripheral muscle
relaxants may be prescribedrelaxants may be prescribed
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Collaborative CareCollaborative Care
Drug TherapyDrug Therapy Side effects of muscle relaxantsSide effects of muscle relaxants
DrowsinessDrowsiness
LassitudeLassitude
HeadacheHeadache
Weakness and fatigueWeakness and fatigue
Blurred visionBlurred vision AtaxiaAtaxia
Gastrointestinal upsetGastrointestinal upset
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Collaborative CareCollaborative Care
NutritionalNutritional TherapyTherapy Proper nutrition is essentialProper nutrition is essential
Adequate energy source needed toAdequate energy source needed to
Promote muscle strength and tonePromote muscle strength and tone
Build enduranceBuild endurance
Provide energy for ambulation andProvide energy for ambulation andgaitgait--training skillstraining skills
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Collaborative CareCollaborative Care
NutritionalNutritional TherapyTherapy Patients dietary requirements mustPatients dietary requirements must
includeinclude
Ample protein (1 g/kg of body weight)Ample protein (1 g/kg of body weight)
Vitamins (B, C, D)Vitamins (B, C, D)
CalciumCalcium
PhosphorusPhosphorus
MagnesiumMagnesium
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Collaborative CareCollaborative Care
NutritionalNutritional TherapyTherapy Adequate fluid intakeAdequate fluid intake
2000 to 3000 ml/day2000 to 3000 ml/day
HighHigh--fiber diet with fruits andfiber diet with fruits and
vegetablesvegetables
For body jacket and hip spica castFor body jacket and hip spica castpatients: six small meals a daypatients: six small meals a day
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Nursing ManagementNursing Management
Nursing AssessmentNursing Assessment FindingsFindings
Deformity or unnatural position ofDeformity or unnatural position of
affected limbaffected limb
Edema and ecchymosesEdema and ecchymoses
Muscle spasmMuscle spasm
Tenderness and painTenderness and pain
Loss of functionLoss of function
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Nursing ManagementNursing Management
Nursing AssessmentNursing Assessment Initial treatment (contd)Initial treatment (contd)
Check neurovascular status distal toCheck neurovascular status distal to
injury before and after splintinginjury before and after splinting Elevate injured limb if possibleElevate injured limb if possible
DoDo notnotattempt to straighten fracturedattempt to straighten fractured
or dislocated jointor dislocated joint DoDo notnotmanipulate protruding bonemanipulate protruding bone
endsends
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Nursing ManagementNursing Management
Nursing AssessmentNursing Assessment Subjective dataSubjective data
Past health historyPast health history
Traumatic injuryTraumatic injury
LongLong--term repetitive forces (stressterm repetitive forces (stressfracture)fracture)
Bone or systemic diseasesBone or systemic diseases
Prolonged immobilityProlonged immobility
OsteopeniaOsteopenia
OsteoporosisOsteoporosis
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Nursing ManagementNursing Management
Nursing AssessmentNursing Assessment Subjective data (contd)Subjective data (contd)
MedicationsMedications
Use of corticosteroids (osteoporoticUse of corticosteroids (osteoporotic
fracture)fracture)
AnalgesicsAnalgesics
Surgery or other treatmentsSurgery or other treatments First aid treatment of fractureFirst aid treatment of fracture
Previous musculoskeletal surgeriesPrevious musculoskeletal surgeries
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Nursing ManagementNursing Management
Nursing AssessmentNursing Assessment Subjective data (contd)Subjective data (contd)
CognitiveCognitive--perceptualperceptual
Sudden and severe pain in affected areasSudden and severe pain in affected areas
Numbness, tingling, loss of sensationNumbness, tingling, loss of sensation
Chronic pain that Chronic pain that with activitywith activity
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Nursing ManagementNursing Management
Nursing AssessmentNursing Assessment Objective dataObjective data
Apprehension, guarding ofinjuryApprehension, guarding ofinjury
Skin lacerationsSkin lacerations
Pallor and cool skin or bluish andPallor and cool skin or bluish andwarm distal to injurywarm distal to injury
EcchymosisEcchymosis
HematomaHematoma
Edema at site of fractureEdema at site of fracture
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Nursing ManagementNursing Management
Nursing AssessmentNursing Assessment Objective data (contd)Objective data (contd)
Restricted or lost function of affectedRestricted or lost function of affected
partpart Local bony deformitiesLocal bony deformities
Abnormal angulationAbnormal angulation
Shortening, rotation, or crepitation ofShortening, rotation, or crepitation ofaffected partaffected part
Muscle weaknessMuscle weakness
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Nursing ManagementNursing Management
Nursing AssessmentNursing Assessment Objective data (contd)Objective data (contd)
Localization and extent of fractures onLocalization and extent of fractures on
XX--rayray
Bone scansBone scans
Computed tomography (CT) scanComputed tomography (CT) scan
Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)
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Nursing ManagementNursing Management
Neurovascular AssessmentNeurovascular Assessment Musculoskeletal injuries can causeMusculoskeletal injuries can cause
changes in neurovascular statuschanges in neurovascular status
Causes of nerve or vascular damageCauses of nerve or vascular damage
Application of a cast or constrictiveApplication of a cast or constrictive
dressingdressing
Poor positioningPoor positioning
Physiologic responsesPhysiologic responses
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Nursing ManagementNursing Management
NursingDiagnosesNursingDiagnoses Impaired physical mobilityImpaired physical mobility
Risk for peripheral neurovascularRisk for peripheral neurovascular
dysfunctiondysfunction
Acute painAcute pain
Ineffective therapeutic regimenIneffective therapeutic regimenmanagementmanagement
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Nursing ManagementNursing Management
PlanningPlanning Overall goalsOverall goals
Have physiologic healing with noHave physiologic healing with no
associated complicationsassociated complications
Obtain satisfactory pain reliefObtain satisfactory pain relief
Achieve maximal rehabilitationAchieve maximal rehabilitation
potentialpotential
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Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation Health promotionHealth promotion
Public should be taught to takePublic should be taught to take
appropriate safety precautionsappropriate safety precautions Nurses should advocate for personalNurses should advocate for personal
actions toactions to decrease injuriesdecrease injuries
Encourage moderate exercise to keepEncourage moderate exercise to keepmuscles strong and maintain balancemuscles strong and maintain balance
Calcium and vitamin DintakeCalcium and vitamin Dintake
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Nursing ManagementNursing Management
Preoperative ManagementPreoperative Management Nurse should inform patients ofNurse should inform patients of
ImmobilizationImmobilization
Assistive devices that will be usedAssistive devices that will be used
Expected activity limitations afterExpected activity limitations aftersurgerysurgery
Assure patients their needs will be metAssure patients their needs will be met Assure patients pain medication will beAssure patients pain medication will be
availableavailable
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Nursing ManagementNursing Management
Preoperative ManagementPreoperative Management Skin preparation is very importantSkin preparation is very important
Assist in cleansing skinAssist in cleansing skin
Remove debris and hair to reduceRemove debris and hair to reduce
infectioninfection
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Nursing ManagementNursing Management
Postoperative ManagementPostoperative Management Monitor vitalsMonitor vitals
Apply general principles of nursingApply general principles of nursing
carecare Frequent neurovascular assessmentsFrequent neurovascular assessments
of affected extremityof affected extremity
Minimize pain and discomfortMinimize pain and discomfortthrough proper alignment andthrough proper alignment andpositioningpositioning
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Nursing ManagementNursing Management
Postoperative ManagementPostoperative Management Monitor limitations in movementMonitor limitations in movement
Carefully observe dressings or castsCarefully observe dressings or casts
for bleeding or drainagefor bleeding or drainage
Significant Significant in size of drainage areain size of drainage area
should be reportedshould be reported Measure and assess patency ofMeasure and assess patency of
system and volume of drainagesystem and volume of drainage
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Nursing ManagementNursing Management
Other MeasuresOther Measures Constipation can be prevented byConstipation can be prevented by
Increased activityIncreased activity
High fluid intake (>2500 ml/day)High fluid intake (>2500 ml/day)
Diet high in bulk and roughageDiet high in bulk and roughage
Warm fluids, stool softeners, laxatives,Warm fluids, stool softeners, laxatives,
or suppositories may be necessaryor suppositories may be necessary
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Nursing ManagementNursing Management
Other MeasuresOther Measures Renal calculiRenal calculi
Can develop as a result of boneCan develop as a result of bone
demineralizationdemineralization
Fluid intake of 2500 ml/dayFluid intake of 2500 ml/day
Cranberry juice or ascorbic acidCranberry juice or ascorbic acid
ii
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Nursing ManagementNursing Management
Other MeasuresOther Measures Rapid deconditioning ofRapid deconditioning of
cardiopulmonary systemcardiopulmonary system
Result of prolonged bed restResult of prolonged bed rest
Results inResults in
Orthostatic hypotensionOrthostatic hypotension
Decreased lung capacityDecreased lung capacity
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N i M tN i M t
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Nursing ManagementNursing Management
TractionTraction Persistent skin pressure may impairPersistent skin pressure may impair
blood flow and cause injury toblood flow and cause injury to
peripheral neurovascular structuresperipheral neurovascular structures Observe skeletal traction pins forObserve skeletal traction pins forinfectioninfection
Pin care varies but usually includesPin care varies but usually includesregular removal of exudate, rinsingregular removal of exudate, rinsingpin sites, and drying areapin sites, and drying area
N i M tN i M t
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Nursing ManagementNursing Management
TractionTraction External rotation of hip can occurExternal rotation of hip can occur
when skin traction is used on lowerwhen skin traction is used on lower
extremitiesextremities
Nurse can correct this position byNurse can correct this position by
placing a pillow, sandbag, orplacing a pillow, sandbag, or
rolledrolled--up draw sheet along greaterup draw sheet along greater
trochanteric region of the femurtrochanteric region of the femur
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N i M tN i M t
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Nursing ManagementNursing Management
Ambulatory and Home CareAmbulatory and Home Care Cast careCast care
Dos (contd)Dos (contd)
Move joints above and below castMove joints above and below cast
regularlyregularly
Report signs of possible problems toReport signs of possible problems to
health care providerhealth care provider Keep appointment to have fracture andKeep appointment to have fracture and
cast checkedcast checked
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N i M tN i M t
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Nursing ManagementNursing Management
Ambulatory and Home CareAmbulatory and Home Care Psychosocial problemsPsychosocial problems
ShortShort--term rehabilitative goalsterm rehabilitative goals
Transition from dependence toTransition from dependence toindependence in performing simpleindependence in performing simpleactivities of daily livingactivities of daily living
Preservation or Preservation or strength and endurancestrength and endurance
LongLong--term rehabilitative goalsterm rehabilitative goals Preventing problems associated withPreventing problems associated with
musculoskeletal injurymusculoskeletal injury
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AmbulationAmbulation Degrees of weightDegrees of weight--bearingbearing
ambulationambulation
NonNon--weightweight--bearing ambulationbearing ambulation TouchTouch--down/toedown/toe--touch weighttouch weight--bearingbearing
ambulationambulation
PartialPartial--weightweight--bearing ambulationbearing ambulation WeightWeight--bearing as toleratedbearing as tolerated
FullFull--weightweight--bearing ambulationbearing ambulation
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Assistive DevicesAssistive Devices Common gait patterns with assistiveCommon gait patterns with assistive
devicesdevices
TwoTwo--point gaitpoint gait
FourFour--point gaitpoint gait
SwingSwing--to gaitto gait
SwingSwing--through gaitthrough gait
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Assistive DevicesAssistive Devices Transfer belt should be placedTransfer belt should be placed
around patients waist to providearound patients waist to provide
stability during learning stagesstability during learning stages
Discourage patient from reachingDiscourage patient from reaching
for furniture or relying on anotherfor furniture or relying on another
person for supportperson for support
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Complications of FracturesComplications of Fractures InfectionInfection
High incidence in open fractures andHigh incidence in open fractures and
soft tissue injuriessoft tissue injuries
Massive or blunt soft tissue injuryMassive or blunt soft tissue injury
often has more serious consequencesoften has more serious consequences
than fracturesthan fractures Devitalized and contaminated tissue isDevitalized and contaminated tissue is
an ideal medium for pathogensan ideal medium for pathogens
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Complications of FracturesComplications of Fractures
InfectionInfection
Treatment is costly in terms ofTreatment is costly in terms of
Extended nursing and medical careExtended nursing and medical care
Time for treatmentTime for treatment
Loss of patient incomeLoss of patient income
Osteomyelitis may become chronicOsteomyelitis may become chronic
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Compartment SyndromeCompartment Syndrome
Two basic types of compartmentTwo basic types of compartmentsyndromesyndrome
Compartment sizeCompartment size Resulting from restrictive dressing,Resulting from restrictive dressing,
splints, casts, excessive traction, orsplints, casts, excessive traction, orpremature closure of fasciapremature closure of fascia
Compartment sizeCompartment size Related to bleeding, edema, chemicalRelated to bleeding, edema, chemical
response to snakebite, or IV filtrationresponse to snakebite, or IV filtration
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Compartment SyndromeCompartment Syndrome
Expected range ofExpected range of
intracompartmental pressureintracompartmental pressure
readings is 0 to 15 mm Hgreadings is 0 to 15 mm Hg Depends on patients age and bodyDepends on patients age and body
mass indexmass index
Readings of 30 to 50 mm Hg indicateReadings of 30 to 50 mm Hg indicatecompartment syndromecompartment syndrome
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Compartment SyndromeCompartment Syndrome
Fig 63Fig 63--1515
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Compartment SyndromeCompartment Syndrome
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Compartment SyndromeCompartment Syndrome
Clinical ManifestationsClinical Manifestations Six Ps are characteristic ofSix Ps are characteristic of
impending compartment syndromeimpending compartment syndrome
ParesthesiaParesthesia: Numbness and tingling: Numbness and tingling
PainPain: Distal to injury that is not: Distal to injury that is not
relieved by opioid analgesics and painrelieved by opioid analgesics and pain
on passive stretch of muscle travelingon passive stretch of muscle travelingthrough compartmentthrough compartment
Compartment SyndromeCompartment Syndrome
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Compartment SyndromeCompartment Syndrome
Clinical ManifestationsClinical Manifestations 6 Ps (contd)6 Ps (contd)
PressurePressure:: in compartmentin compartment
PallorPallor: Coolness, and loss of normal: Coolness, and loss of normal
color of extremitycolor of extremity
ParalysisParalysis: Loss of function: Loss of function
PulselessnessPulselessness: Diminished/absent: Diminished/absent
peripheral pulsesperipheral pulses
Compartment SyndromeCompartment Syndrome
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Compartment SyndromeCompartment Syndrome
Clinical ManifestationsClinical Manifestations Urine output must be assessedUrine output must be assessed
because there is a possibility ofbecause there is a possibility of
muscle damagemuscle damage
Myoglobin released from damagedMyoglobin released from damaged
muscle cells precipitates as a gelmuscle cells precipitates as a gel--likelike
substancesubstance
Causes obstruction in renal tubulesCauses obstruction in renal tubules
Compartment SyndromeCompartment Syndrome
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Compartment SyndromeCompartment Syndrome
Clinical ManifestationsClinical Manifestations Large amounts of myoglobinemiaLarge amounts of myoglobinemia
may result in acute tubular necrosismay result in acute tubular necrosis
Acute tubular necrosis causes acuteAcute tubular necrosis causes acuterenal failurerenal failure
Common signs of myoglobinuriaCommon signs of myoglobinuria
Dark reddish brown urineDark reddish brown urine Clinical manifestations associated withClinical manifestations associated with
acute renal failureacute renal failure
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V Th b iV Th b i
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Venous ThrombosisVenous Thrombosis
Veins of lower extremities and pelvisVeins of lower extremities and pelvis
are highly susceptible to thrombosisare highly susceptible to thrombosis
formationformation
Precipitating factorsPrecipitating factors
Incorrectly applied casts or tractionIncorrectly applied casts or traction
Local pressure on a veinLocal pressure on a vein
ImmobilityImmobility
V Th b iV Th b i
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Venous ThrombosisVenous Thrombosis
Aggravated by inactivity of musclesAggravated by inactivity of musclesthat normally assist in pumpingthat normally assist in pumping
action of venous bloodaction of venous blood Instruct patient toInstruct patient to
Wear compression gradient stockingsWear compression gradient stockings
Move fingers or toes of affectedMove fingers or toes of affectedextremity against resistance andextremity against resistance andperform ROM exercisesperform ROM exercises
V Th b iV Th b i
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Venous ThrombosisVenous Thrombosis
Prophylactic anticoagulant drugsProphylactic anticoagulant drugs
may be orderedmay be ordered
LowLow--molecularmolecular--weight heparinweight heparin
frequently usedfrequently used
Newer class of antithrombotic drugsNewer class of antithrombotic drugs
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F t E b li (FES)F t E b li (FES)
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Fat Embolism (FES)Fat Embolism (FES)
Two theories related to originTwo theories related to origin
Mechanical theory (contd)Mechanical theory (contd)
Fat droplets transverse capillary bed toFat droplets transverse capillary bed toenter systemic circulation, where theyenter systemic circulation, where theythen embolize to other organsthen embolize to other organs
Biochemical theoryBiochemical theory
Catecholamines released at time ofCatecholamines released at time oftrauma mobilize free fatty acids fromtrauma mobilize free fatty acids fromadipose tissueadipose tissue
F t E b li (FES)F t E b li (FES)
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Fat Embolism (FES)Fat Embolism (FES)
Two theories related to originTwo theories related to origin
BiochemicalBiochemical theory (contd)theory (contd)
Causes loss of chylomicron emulsionCauses loss of chylomicron emulsionstabilitystability
Chylomicrons form large fat globules thatChylomicrons form large fat globules thateventually lodge in the lungseventually lodge in the lungs
Biochemical change sets up anBiochemical change sets up aninflammatory response secondary toinflammatory response secondary todestabilization of free fatty acidsdestabilization of free fatty acids
F t E b li (FES)F t E b li (FES)
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Fat Embolism (FES)Fat Embolism (FES)
Two theories related to originTwo theories related to origin
BiochemicalBiochemical theory (contd)theory (contd)
Injury to lung parenchymaInjury to lung parenchyma Tissues most often affectedTissues most often affected
LungsLungs
BrainBrain
HeartHeart
KidneysKidneys
SkinSkin
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Fat Embolism (FES)Fat Embolism (FES)
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Copyright 2007, 2004, 2000, Mosby, Inc., an affi liate of Elsevier Inc. All Rights Reserved.
( )( )
Clinical ManifestationsClinical Manifestations Signs and symptoms of acuteSigns and symptoms of acute
respiratory distress syndromerespiratory distress syndrome
(ARDS)(ARDS) Chest pain, tachypnea, cyanosis,Chest pain, tachypnea, cyanosis,
dyspnea, apprehension, tachycardia,dyspnea, apprehension, tachycardia,
decreased partial pressure of arterialdecreased partial pressure of arterialoxygenoxygen
Fat Embolism (FES)Fat Embolism (FES)
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Copyright 2007, 2004, 2000, Mosby, Inc., an affi liate of Elsevier Inc. All Rights Reserved.
( )( )
Clinical ManifestationsClinical Manifestations Clinical course of fat embolus mayClinical course of fat embolus may
be rapid and acutebe rapid and acute
Patient frequently expresses a feelingPatient frequently expresses a feelingofimpending disasterofimpending disaster
In a short time skin color changesIn a short time skin color changes
from pallor to cyanosisfrom pallor to cyanosis
Patient may become comatosePatient may become comatose
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Fat Embolism (FES)Fat Embolism (FES)
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Copyright 2007, 2004, 2000, Mosby, Inc., an affi liate of Elsevier Inc. All Rights Reserved.
( )( )
Clinical ManifestationsClinical Manifestations Chest xChest x--ray may reveal areas ofray may reveal areas of
pulmonary infiltrate or multiplepulmonary infiltrate or multiple
areas of consolidationareas of consolidation WhiteWhite--out effectout effect
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