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By JillSandy

Added: September 26, 2011 14:02:30

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1 Disruption or break in the continuity of the tibia and fibula at the distal end of the bones. Open fractures involve communication of the fracture through the skin with external environment.
1.1 TREATMENT GOAL Anatomic realignment of bone fragments (reduction), immobilization to maintain realignment, and restoration of normal or near-normal function of the injured part
1.1.1 FRACTURE IMMOBILIZATION Casts, splints Potential Complication: Compartment Syndrome
1.1.2 FRACTION REDUCTION OPEN REDUCTION Correction of bone alignment through a surgical incision; usually includes use of wires, screws, pins, plates, intramedullary rods, or nails OPEN REDUCTION INTERNAL FIXATION (ORIF) Open reduction with all wires, screws, etc. inside the body/not visible when skin disruptions are closed. Potential Complications Patient Teaching Infection Compartment Syndrome Nursing Care Activity BSC? wt bearing? etc. Frequent assessments CMS checks q2 OPEN REDUCTION EXTERNAL FIXATION (OREF) A metallic device composed of metal pins inserted into the bone and attached to external rods to stabilize the fracture while it heals TRACTION Application of pulling force to an injured or diseased part of the body or an extremity while counter traction pulls in the opposite direction GOALS 1. Prevent or reduce muscle spasm 2. Immobilize a joint or part of body (to prevent soft tissue damage and complications) 3. Reduce a fracture of dislocation
1.1.4 DRUG THERAPY CENTRAL & PERIPHERAL MUSCLE RELAXANTS carisoprodol (Soma), cyclobenzaprine (Flexeril), or methocarbamol (Robaxin) for pain relief associated with muscle spasms Tetanus and diphtheria toxoid or tetanus immunoglobulin BONE-PENETRATING ANTIBIOTICS cephalosporin - cefazolin (Kefzol, Ancef)
1.1.5 NUTRIONAL THERAPY Ample Protein Vitamins Ca2+, Phosphorus, Mg2+ High-fiber, adequate fluids
1.2 Potential Complications
1.2.1 FAT EMBOLISM SYNDROME presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury CLINICAL MANIFESTATIONS (may be rapid and acute) Chest pain, petechiae/purpura around neck, chest wall, axilla, buccal membrane or conjunctiva of eye, tachypnea, cyanosis, dyspnea, appreshension, tachycardia, decreased PaO2, memory loss, restlessness, confusion, elevated temperature, headache, continued change in LOC TREATMENT Symptom related and supportive •O2 with possible intubation or intermittent positive pressure ventilation •Fluid resuscitation •TCDB PREVENTION Careful immobilization
1.2.2 INFECTION An invasion of the body by a pathogen and the resulting signs and symptoms that develop in response to invasion OSTEOMYELITIS severe infection of the bone, bone marrow, and surrounding soft tissue CLINICAL MANIFESTATIONS Systemic: fever, night sweats, chills, restlessness, nausea, malaise Local: constant bone pain unrelieved by rest and worsens with activity; swelling, tenderness, warmth at infection site; restricted movement Later: drainage from sinus tracts TREATMENT •Vigorous and prolonged IV antibiotic therapy •Surgical debridement and decompression •Treat symptoms (swelling, pain, etc.) PREVENTION Prophylactic antibiotic use Keep dressings CDI Handle wound and surrounding area only with clean/sterile gloves
1.2.3 COMPARTMENT SYNDROME Elevated intracompartmental presure within a confined myofascial compartment com promises the neurovascular function of tissues within that space. ETIOLOGY 1. Decreased compartment size resulting from restrictive dressings, splints, casts, excesive traction or premature closure of fascia 2. Increased compartment content related to bleeding, edema, chemical response to snakebite or IV infiltration. CLINICAL MANIFESTATIONS (may be one or all) 1. Paresthesia 2. Pain distal to injury not relieved by opiod analgesics 3. Pressure increases in compartment 4. Pallor, coolness and loss of normal color of extremity 5. Paralysis or loss of function 6. Pulselessness of diminished/absent peripheral pulses TREATMENT • Relief of pressure (i.e. removal of cast/splint, decrease in traction, not elevating effected limb) • Surgical decompression (Fasciotomy) • Possible amputation
1.3 CAUSES Motor vehicle accidents, skiing accidents, and high-energy falls are most common
1.4 SIGNS/SYMPTOMS •Immediate and local pain •Edema and swelling •Muscle spasms •Ecchymosis/Contusion •Crepitation •Broken skin on/around shin or ankle •Decreased function •Guarding and protecting •Obvious bone deformity •Visible bone •Inability to bear weight on effected leg
1.4.1 DIAGNOSIS •Positive X-ray •Visible bone disruption
2 Nursing Diagnoses
2.1 Risk for infection: osteomyelitis, r/t potential bacterial infiltration of bone, s/t compound fracture AEB •Open tib-fib fracture •Subsequent ORIF •Prophylactic IV antibiotic orders (Ancef)
2.1.1 INTERVENTIONS Medications Administer antibiotics as ordered •Ancef 1000 mg IVPB q8h Administer analgesics as ordered •Norco 10-325 1-2 tab PO q4h PRN pain 1 tab 9/20 @ 1945, 1 tab 9/21 @ 0120, 1 tab 9/21 @ 0430, 1 tab 9/21 @ 1017, 2 tab 9/21 @ 1328 •Morphine 6 mg IVP q2h PRN pain 4 mg 9/21 @ 0812, 4 mg 9/21 @ 1205 Assessments 3. Observe for signs and symptoms of infection regularly Fever erythema ↑ pain edema purulent drainage foul odor wound/blood cultures, etc. Patient Teaching 4. Self-assessment and report: i.e. when pain present, assigning value S/S infection
2.2 Impaired skin integrity r/t open fracture: high-energy trauma to leg from vehicle (from without to within), bone breaking and penetrating through skin (from within to without), surgical wound from ORIF s/t Tibia-Fibular Fracture AEB •Open Tib-fib fracture •Subsequent ORIF •Ped vs Auto accident
2.2.1 INTERVENTIONS Assessments 1. Assess for signs of delayed healing (poor approximation of suture line, wound does not decrease in size) 2. Assess dressing for color, odor, presence of drainage (and amount), intactness Wound care 3. Treat wound as ordered by wound therapy or physician (keep clean, reinforce dressing as needed, etc.)
2.3 Risk for injury: compartment syndrome, Fat Embolism Syndrome, DVT r/t broken bone that potentiates release of fat globules that may travel to other body organs and triggers inflammatory process thus increasing intracompartmental pressure,potential for increased intracompartmental pressure, extended periods of immobility s/t tib-fib fracture AEB •Open Tib-fib fracture •Subsequent ORIF •Bulky dressing on LLE with splint •LLE elevated above heart (higher risk for FES) •Lovenox 40 mg SubQ qday
2.3.1 INTERVENTIONS Assessments 1. Assess for S/S FES and DVT 2. Assess for S/S Compartment Syndrome Activity 3. Keep LLE immobilized as ordered
3 •74 y/o Hispanic Female •Presented @ ER via EMS post ped vs auto accident • A&O x4 •Trauma to LLE
3.1 SOCIAL HISTORY •Widowed, lives alone •Denies tobacco and alcohol use •7 grown children
3.2 SIGNIFICANT MEDICAL HISTORY •Hypothyroidism •Hard of hearing, bilaterally •Full-code •NKDA
3.2.1 HOME MEDICATIONS •Levothyroxine 100 mg PO (supplemental thyroid hormone for hypothyroidism)
3.3 Diagnostic Evaluation 9/20/2011 (No post-op labs)
3.3.1 LAB 1. CBC w/ Diff WNL 2. Chemistry Panel WNL, except 3. Glucose 146 ↑ (70-110 mg/dL) 4. Blood type: O+
3.3.2 CXR 5. Negative; Normal lungs and surrounding structures
3.3.3 Pelvic X-Ray 6. Negative; Normal pelvis and surrounding structures
3.3.4 Ankle X-Ray 7. Pre-operative: Fracure of distal fibula and distal tibia. The foot is dislocated withe th talus located medially and posteriorly. There is also a fx of proximal 5th metatarsal. Fracture of calcaneous noted as well. TX 8. Intra-operative: Multiple views demonstrate side plate and screw fixation of the medial malleolar fracture and screw fixation of the calcaneal fracture. there is near anatomic alignment, without gross hardware failure.
4 Pt Teaching
4.1 Assess level of knowledge
4.1.1 S/S infection
4.1.2 Discharge Instruction ACTIVITY •Non-weight bearing on LLE until physician says otherwise •Use crutches or walker for ambulation assistance DIET •High protien •Vitamins B, C, D •Calcium, Phosphorus, Magnesium •High-fiber and adequate fluid intake FOLLOW-UP follow up with physician as ordered upon discharge MEDICATIONS •Ancef PO (for infection prevention) •Levothyroxine (for hypothyroidism) •Narcotic analgesic PO (for pain control) WHEN TO CALL DR infection increasing pain