354 Test 3 objectives
Chapter 10
The student will:
1. Explain regulatory mechanisms for fluid balance
Kidney - A well-hydrated person excretes 1 to 2 L urine per day (1 mL/kg/h).
HEALTHY kidney works to correct for changes in blood pH that occur when the
respiratory system either is overwhelmed or is not healthy
Skin – insensible - Perspiration is visible water and electrolyte loss through the skin
(sweating). The chief solutes in sweat are sodium, chloride, and potassium
Lung – insensible - The lungs normally eliminate water vapor, also referred to as
insensible water loss, at a rate of approximately 300 mL daily
GI tract - Loss of fluid from the gastrointestinal (GI) tract is about 100 to 200 mL daily.
Pituitary – ADH -- ADH is secreted by the pituitary gland in reaction to dehydration or
blood loss and acts at the nephrons. At the collecting duct of the nephron, ADH causes
increased reabsorption of water from the tubules into the bloodstream
Adrenal: aldosterone= NA+ retention - water retention) and potassium loss. Conversely,
decreased secretion of aldosterone causes sodium and water loss and potassium retention
Others include
• Baroreceptors – left atrium
•
RAAS – Kidney makes and store Renin, Renin makes Angiotensin I. ACE
convert Angio 1 to 2
•
ADH and thirst - ADH made in hypothalamus – Thirsty controlled in
hypothalamus
•
Osmoreceptors – Stimulate ADH, Sense change in NA+
•
Natriuretic Peptides – ANP, BNP, Oppose RAAS
2. Explain how fluid shifts within the body
Osmosis: water move from high to low through semi-permeable membrane
Diffusion: Movement of PARTICLES (things, solutes) from high concentration to low
Filtration: Movement of both water and particles from high to low
Sodium-potassium pump (ATP) = Require ATP to move fluid
Osmolality and osmolarity are terms that describe the concentration of solutes or
dissolved particles in a solution
3. Fluid Spacing
Second Spacing - Abnormal accumulation of interstitial fluid (edema)
Third Spacing - areas that normally do not have fluid or only a small amount:
peritoneal cavity and pleural space -. Examples of third-spaced fluid include ascites, pleural
effusion, pericardial effusion, and angioedema, ascites (belly), pulmonary edema (lungs),
buns
4. Identify and interpret lab values relating to fluid volume
NA+
135 – 145mEq/L
K+
3.5 – 5.0mEq/L
Ca++
8.6 – 10.5mg/dL
Mg++
PO4Cl-
1.3 – 2.6mg/dL
2.5 – 4.5mg/dL
97 - 107mEq/L
Identify and interpret signs and symptom of a fluid volume imbalance
Hypovolemia: Fluid volume deficit
Causes - Losing fluid and/or not taking in fluid, Vomiting, Diarrhea, Suctioning, 3rd spacing,
Fever, burns’ S/S – Weight loss, decreased skin turgor, Oliguria, Decreased bp, Flat neck veins,
Weakness, thirst Increased HR, Sunken eyes, Cool, clammy skin, confusion,
Hypervolemia: Fluid volume excess
Causes: Decreased functioning of heart, kidneys, liver, retention of water and sodium
S/S – Edema, JVD, Crackles, increased -weight, BP, HR, urine. peripheral edema and ascites,
Identify appropriate treatments for fluid volume imbalances
Hypovolemia - Assess
I & O, Daily weights, VS, Skin/tongue turgor, Mental function, Give fluids, Oral preferred, then
isotonic IV
Hypervolemia – Diuretics -Loops, Thiazides, K+ sparing, Dialysis in critical situations
Fluid and sodium restriction, Daily weights. Assess: Breath sounds, Edema, I&O, supp 02,
Identify abnormal electrolyte values, associated signs and symptoms, and possible causes
Hyponatremia <135
Causes
Elec imbalan
Causes
S/S
Treatment
Loss na+, excess water,
Poor turgor, Dry
Replace Na PO, IV.
Hyponatremia
SSRI, Diuret
mucosa, N&V,
Res H2O, isotonic
<135
Reg by ADH
Orthostatic
fluid, effect of medThirst, RAAS
hypotension
(diuretics, lithium,
Neuro changes: AMS AVP receptor
Seizures, Coma
anta[Vaprisol])
PT @ risk – Lithium,
seizure.
Less water, much salt, diarr, Thirst, Dry swollen
hypotonic electrolyte
Hypernatremia
>145. Potatoes,
burns, near drow
tongue
solution (0.3% NS),
avocados, bananas,
Neuro:Restlessness
more water, I/O,
broccoli high in
Irritability, Seizures
watch OTC med, add
potassium
Twitching, NV, inc Tp h2o wt enteral feed
Diuretics,
Meds
EKG: flat T waves
inc K+: PO IV *No
Hypokalemia
<3.5 Reg by
Vomiting/diarrhea/suctioning Fatigue, anorexia, NV, pushing allowed
Ren 80%, GI-20
Poor diet. Taking
Decrea bowel motility, Check daily, ID
Spinach, Baked potato, Diur/steroid, hypoados
wk pause, Arrhythmias patients at risk for:
Baked cod
/ dysrhyth, hypoac refl Diuretics. Watch
digitalis ( tak digitalis
are at increased risk
for Digitalis toxicity
when their K+ is low)
Monitor: ECG,
arrhythmias, ABGs,
shallow / ineffective
respirations,
diminished breath
sounds, patients
receiving digitalis for
toxicity, I&O
Hyperkalemia
>5.0
Hypocalcemia
Rare, usually in renal failure
Rapid administration of K+
Meds, Crush injuries/lysis
Dysrhythmias, Muscle
weakness
Hyper-reflexes
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•
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Hypercalcemia
EKG: tall, tented T
waves, muscle
weakness, Irritability,
anxiety, Death row
drug, musc wk, burn,
trauma, parathesis,
admo cram
Hypoparathyroidism
• Chvostek and
Trousseau
Thyroid surgery
Pancreatitis
• Hyperactive
reflexes
Renal failure
• Seizures
Inadequate vitamin D
Low magnesium/high Tetany (spasms)
Positive Trousseau
phosphorus
sign (BP cuff)
Low albumin
Meds, malabsorption
Tumors
Hyperparathyroidism
Immobility
Multiple fractures
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Hypomagnesemia
>1.3
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•
•
Often goes with low
K+ and low Ca++
Loss through GI tract
Chronic ETOH abuse
•
•
Emergency: calcium
gluconate, insulin and
glucose, dialysis, loop
diuretics, I&O
ID risky patients
Watch salt substitutes
Dialysis if severe,
hyperton
Calcium gluconate,
calcium chloride
• Vitamin D
• Dietary
increase
• Monitor
closely:
laryngeal
stridor
•
•
Weak muscles
Hypoactive
reflexes
A, N, V
Bone pain
Pathological
fractures
Watch digitalis
Treat cause
Dilute with
fluids
• Restrict Ca++
intake
• IV phosphate
• Calcitonin
• Corticosteroids
• Meds
Increase mobility
• Watch digitalis
Neuromuscular
irritability
A, N, V
Diet
PO meds
IV: **no pushing
allowed
•
•
•
Hypermagnesemia
2.3
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•
•
•
•
Hypophosphatemia
2.5
Milk, poultry, liver
Enteral /parenteral
feeds
Meds (diaure,
diagosin, Alcohol,
V/D
Watch digitalis
Very rare
Renal failure
Overzealous
correction of
hypomagnesemia
Overuse of magbased antacids
Excessive soft tissue
injury
Malnourished patients
Related to K+ shifts
Diarrhea
Crohn’s disease
ETOH abuse
Malabsorption, alcoholic
Aloh, mg antacid.
Hyperphosphatemia Renal failure
TPN
4.5
Too much Vit D
Hypochloremia
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•
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•
•
Gastric suctioning
Gastric surgery
Vomiting
Diarrhea
Low Na+ intake
Diuretics
Increased
tendon reflexes
Positive Chvostek and
Trousseau signs, HTN,
hypoactive
bowl,
tremor
ECG
• CNS
depression:
• Muscle
weakness
• Drowsiness
• Depressed
respers
• Cardiac arrest
• Coma, dec
BPR
Magnesium sulfate
IV administered with
an infusion pump
Monitor vital signs
and urine output
Fall prec
Low ATP,
Parasthesias
Muscle weakness
Hypoxia: CP, resp
failure, Reciprocal
relationship with
Ca++:
Low phos= high
calcium
Tetany
Look at low Ca++
A, N, V
Hyperactive reflexes
Soft-tissue
calcifications
Symptoms occur due
to associated
hypocalcemia
• Agitation
• Irritability
• Tremors
• Seizures
• Hyperactive
reflexes
• Tetany
Prevention first
Add to TPN
IV phosphate when GI
tract not functioning
No aggressive calorie
replacement: gradual
increase, Supplements
Food high K
•
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•
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Prevent it first
Vent support
Calcium
gluconate
Dialysis
Loops
Mon seizeur,
avoid
magnessium
Treat
underlying
disorder
Calcitrol
Diuresis
Dialysis
Volume
replacement
Normal saline
IV or 0.45%
D/C diuretic
High chloride
foods (think:
high sodium
foods)
Hyperchloremia
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•
•
•
•
Usually iatrogenic
(caused by a medical
treatment)
Excessive NaCl
infusion
Head trauma
Excess ACTH
Decreased GFR
Tachypnea
Lethargy / weakness
Rapid, deep
respirations
Hypertension
Cognitive changes
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Related to
hypernatremia
Correct cause
Restore acidbase balance
IV sodium
bicarb (inverse
relationship)
Diuretics
Maintain
adequate
hydration
Identify appropriate treatments for electrolyte imbalances
See treatment in the table above
Interpret arterial blood gas values: uncompensated and partially compensated
PH = 7.35 – 7.45
PaCO2 = 45 – 35
HCO3 = 22 – 26
Identify appropriate treatments for abnormal arterial blood gas levels
Values
Causes
Metabolic Acidosis
PH<7.35
Loss of bicarb:
HCO3<22
Diarrhea, Diuretics
PCO2<35
H+ gain = aspirin,
(Compensati)
lactic, DKA, uremia
PH>7.45,
Vomiting
Metabolic Alkalosis
Treatment
Fix cause
Give bicarb
Dialysis if needed
Fix cause
HCO3>26
PaCO2>45 (Comp)
Respiratory Acidosis
Respiratory Alkalosis
PH<7.35
PCO2>45
HCO3>26 (comp)
PH>7.45
PCO2<35,
HCO3<22(compens)
Hyperventilation
Excess gastric
suctioning
Loss of K+
Excess Tums
ingestion
Pulmonary edema
• Aspiration of
foreign object
• Sleep apnea
• Sedative OD
• PNA
• COPD
Extreme anxiety
Aspirin overdose
(early phase),
hypoxemia
Inappropriate
ventilator settings
Monitor I&O
Restore fluid volume
Replace K+
Improve ventilation
Bronchodilators
Abx for infections
Supplemental O2
Mechanical ventilation
if needed
Raise HOB
Hydration/secretions
• Paper bag
• Benzodiazepine
• Fix underlying
problem
● Metabolic acidosis
o A low arterial pH due to reduced bicarbonate concentration
▪ Occurs when acid accumulates, or bicarbonate is lost in body fluids
● Low pH <7.35
● Low bicarbonate (HCO3) <22 in blood serum *cardinal feature*
● Hyperkalemia (very common)
o When H+ ions move into cells, K+ ions move out of the
cell
o Causes
▪ Increased production or intake of metabolic acid
● Aspirin overdose
● Alcoholic ketoacidosis
● Diabetic ketoacidosis
● Lactic acidosis (d/t tissue trauma or excessive exercise)
● Starvation
● Thyroid storm
▪ Decreased bicarbonate production
● Dehydration
● Liver failure
▪ Decrease in the excretion of metabolic acid:
● Oliguria (unable to void) from any cause
● Renal failure
▪ Bicarbonate loss:
● Diarrhea that is prolonged
o
o
o
o
o
● Intestinal drainage
Anion gap – calculated to determine cause of metabolic acidosis
▪ Anion gap: The difference between the sum of cations and anions in the
blood calculated from a venous blood sample
▪ Normal range: 10 – 14
● >14 High anion gap acidosis
Signs and symptoms
▪ Headache
▪ Confusions
▪ Drowsiness
▪ Increased respiratory rate and depth
▪ N/V
▪ Peripheral vasodilation
▪ Decreased CO (occurs when pH drops to < 7.0)
▪ Decreased BP
▪ Flushed, cold, clammy skin
▪ Dysrhythmias (in cases of shock)
Manifestations – based on cause
▪ Renal: Polyuria and increased acid in the urine
▪ Respiratory: Kussmaul Respirations (deep, rapid)
▪ Gastrointestinal: Anorexia, nausea, vomiting, diarrhea, fruity breath (if
DKA)
▪ Neurological: Headache, lethargy, drowsiness, loss of consciousness,
coma, death
▪ Cardiovascular: EKG changes (due to hyperkalemia), bradycardia,
hypotension (vasodilation)
Nursing considerations
▪ Assess cardiovascular system
▪ EKG, telemetry monitoring
▪ Electrolyte imbalances must be corrected before treating acidosis
Treatment
▪ Correct underlying problem
▪ Correct electrolyte imbalance (hyperkalemia)
▪ Bicarbonate may be administered
● Metabolic alkalosis
o A high arterial pH with increased bicarbonate concentration
▪ High pH >7.45
▪ High bicarbonate >26
▪ Hypokalemia (common)
o Causes
▪ Base Excess (Bicarbonate):
● Diuretic therapy
● Excessive intake of bicarbonate, acetate, or citrate (antacids
containing bicarbonate)
▪ Excessive loss of metabolic acid:
● Vomiting for long periods of time (losing stomach acid)
● Prolonged NG suctioning without adequate electrolyte replacement
(losing stomach acid)
● Excess intake of mineralocorticoid
o Manifestations (usually related to low levels of calcium)
▪ Neurological: Fidgeting and twitching tremors related to decrease in
ionized Ca
▪ Respiratory: Slow, shallow respirations in an attempt to retain CO2
▪ Cardiac: Atrial tachycardia and depressed / flat T waves related to
hypokalemia
▪ Gastrointestinal: Nausea, vomiting, and diarrhea, causing loss of
hydrochloric acid (if GI losses cause)
o Treatment
▪ Correct underlying disorder
▪ Supply chloride (to allow excretion of excess bicarbonate, and restore
fluid volume)
▪ Provide antiemetic if needed (for GI losses)
▪ Carbonic anhydrase inhibitors (Diamox) If fluid bolus contraindicated
(renal failure, CHF, fluid-volume overload)
●
o
o
o
o
Respiratory acidosis (too much carbonic acid)
Low arterial pH due to increased PCO2
▪ Low pH <7.35
▪ PaCO2 >45
▪ Hyperkalemia
*Always due to respiratory problem with inadequate excretion of CO2
(hypoventilation)*
Causes
▪ Conditions that affect pulmonary function: COPD, pneumonia, atelectasis
▪ Depression of respiratory system: Opioid overdose, head injuries
▪ Post-op pain: Splinting (pain makes us breathe shallowly – fractured ribs)
▪ Conditions that alter chest wall excursion: Mechanical hypoventilation,
diseases affecting innervation of thoracic muscle (polio, Guillain-Barre),
thoracic trauma (flail chest)
Symptoms
▪ Increased pulse
▪ Increased respiratory rate (but will be shallow)
▪ Decreased BP
▪ Mental status changes
▪ Feeling of fullness in head
▪ Hypotension (due to vasodilation)
o Assessment
▪ Breath sounds
▪ VS
▪ SaO2
▪ Mucus membrane color
▪ LOC
▪ K levels (hyperkalemia)
▪ EKG
o Treatment – aimed at improving ventilation
▪ Reposition
▪ Turn cough/deep breathe
▪ Encourage incentive spirometer per protocol
▪ Bronchodilators
▪ Suction if secretions a problem
▪ Mechanical ventilation
● Respiratory alkalosis (too little carbonic acid)
o High arterial pH due to reduced CO2
▪ High pH >7.45
▪ PaCO2 <35
▪ Hypokalemia
o *Always due to hyperventilation*
▪ Primary stimulation of the CNS: Apprehension, anxiety, fear, encephalitis
(infection of the CNS), salicylate acid (aspirin) overdose/poisoning
▪ Stimulation of CNS (reflex): Hypoxia that stimulates hyperventilation
(CHF, respiratory infection), elevated temperature
▪ Mechanical hyperventilation: Breathing over a ventilator
o Manifestations
▪ Lightheadedness
▪ Inability to concentrate
▪ Numbness and tingling
▪ Sometimes LOC
Identify hypo, hyper, and isotonic fluids
Isotonic – 1. NS (0.9% NACl(water, sodium, chloride) – Given wt blood, Replace large Na+
losses
2. Lactated Ringer’s (Ca++, K+, Na+, Cl-, water) – Correct dehydration, GI loses.
3. D5W, 5% dextrose in water (water and sugar) (Calories) - Monitor for hyperglycemia
Hypotonic - Half strength NS (0.45% NS)
• Replace cellular fluid
•
Provide free water
•
Treat hypernatremia
Hypertonic - Add two isotonic together: NS plus D5W
3% sodium chloride
Identify IV complications and appropriate treatments
Iv Complication
Meaning or
S/S
Causes
Fluid overload
excessive IV
moist crackles on lung,
fluids, increased
cough, restlessness,
blood pressure and distended neck veins,
central venous
edema, weight gain,
pressure, hepatic,
dyspnea, and rapid,
cardiac, or renal
shallow respirations
disease.
Air embolism
Air entering into
palpitations, dyspnea,
central veins gets
continued coughing,
to the right
jugular venous
ventricle, where it distention, wheezing,
lodges against the and cyanosis;
pulmonary valve
hypotension; weak,
and blocks the
rapid pulse; altered
flow of blood
mental status; and chest,
shoulder, and low back
pain
Infiltration &
extravasation
unintentional
administration of a
nonvesicant
solution or
medication into
surrounding tissue
edema around the
insertion site, leakage of
IV fluid from the
insertion site,
discomfort and coolness
in the area of
infiltration, and a
significant decrease in
the flow rate.
Treatment
decreasing the IV
rate, monitoring vital
signs frequently,
assessing breath
sounds, and placing
the patient in a high
Fowler position.
calls for immediately
clamping the cannula
and replacing a
leaking or open
infusion system,
placing the patient on
the left side in the
Trendelenburg
position, assessing
vital signs and breath
sounds, and
administering
oxygen.
warm compresses to
sites. cold
compresses to sites of
extravasation from
alkylating and
antibiotic vesicants.
Thrombophlebitis
presence of a clot
plus inflammation
in the vein
localized pain, redness,
warmth, and swelling
around the insertion site
Phlebitis
poor venipuncture
technique, catheter
in place for a
prolonged period,
and failure to
adequately secure
the catheter
Redness, warm, pain or
tenderness at the site or
along the vein, and
swelling
Hematoma
results when blood
leaks into tissues
surrounding the IV
insertion site
ecchymosis, immediate
swelling at the site, and
leakage of blood at the
insertion site.
Clotting &
obstruction
Blood clots may
form in the IV line
as a result of
kinked IV tubing,
a very slow
infusion rate, an
empty IV bag, or
failure to flush the
IV line after
intermittent
medication or
decreased flow rate and
blood backflow into the
IV tubing
discontinuing the IV
infusion; applying a
cold compress first to
decrease the flow of
blood, followed by a
warm compress;
elevating the
extremity; and
restarting the line in
the opposite
extremity
prevented by using
aseptic technique
during insertion,
using the appropriatesize cannula or
needle for the vein,
considering the
composition of fluids
and medications
when selecting a site
removing the needle
or cannula and
applying light
pressure with a
sterile, dry dressing;
applying ice for 24
hours to the site to
avoid extension of
the hematoma;
elevating the
extremity to
maximize venous
return
Clotting of the needle
or cannula may be
prevented by not
allowing the IV
solution bag to run
dry. Maintaining an
adequate flow rate,
and flushing the line
after intermittent
medication or other
solution
administration
solution
administrations
Infection
temperature elevation,
backache, headache,
increased pulse and
respiratory rate, nausea
and vomiting, diarrhea,
chills and shaking, and
general malaise
Measures to prevent
infection are essential
at the time the IV line
is inserted and
throughout the entire
infusion. Clean/wipe
Chapter 35
The student will:
Describe the basic structure and function of the musculoskeletal system including bone
anatomy and make-up (pathophysiology)
Functions:
- Protection of vital organs
- Framework to support body structures, mobility
- Movement: produce heat and maintain body temperature
- Facilitate return of blood to the heart
- Reservoir for immature blood cells
- Reservoir for vital minerals
Structure:
- 206 bones in the body
- Long bones
- Short bones
- Flat bones
- Irregular bones
Discuss Bone types (Long bones, Short bones, Flat bones, Irregular bones) and location in
the body
- Long bones: e.g. femur; humerus - epiphyseal plate nurtures and facilitates
longitudinal growth
- Short bones: bones located in the ankles and hands – metacarpals
- Flat bones: protects vital organs, important for hematopoiesis, e.g. sternum, skull
- Irregular bones: cannot be categorized, e.g. vertebrae and jaw bones
- Joints & muscles
Discuss assessment of the musculoskeletal system
History:
Includes data related to function ability
- ADLs: feeding, bathing, personal hygiene, etc.
- IADLs: finances, transportation
- Ability to perform various activities: exercise patterns
-
Note any problems related to mobility
Family hx
General health maintenance; occupation
Learning needs; socio-economic factors
Medications (including over the counter)
Physical Assessment:
- Pain, tenderness, altered sensation
- Posture and gait
- Bone integrity
- Joint function
- Muscle strength and size
- Skin
- Neurovascular status
Bone pain: dull
Muscular pain: soreness, “muscle cramps”
Fracture pain: sharp and piercing
Define kyphosis, scoliosis, and lordosis
3 Spine Abnormalities:
1. Kyphosis: forward curvature of the thoracic spine (humpback or slouching posture).
Can occur in degenerative diseases of the spine such as arthritis, disc degeneration, or
fractures related to osteoporosis and injury to the spine. convex curvature
2. Lordosis: “swayback”, exaggerated curvature of the lumbar spine. Pregnancy is a
common cause as well as tight low back muscles, and excessive visceral fat.
3. Scoliosis: lateral curving deviation of the spine. May be congenital or idiopathic (no
cause identified), or the result of damage to paraspinal muscles (muscular dystrophy).
Determine appropriate diagnostics tests for musculoskeletal conditions (x-ray, CT, MRI,
bone densitometry, electromyography) and provide patient education and preparation for
the tests
X-Ray Studies:
- Determine bone density, texture, erosion; widening and narrowing, signs of
irregularity, fluid, spur formation; multiple x-rays w/ multiple views are needed (anterior,
posterior, lateral) for full assessment. May be used to determine status of healing process.
Computed Tomography (CT) Scans:
- May be used with or without oral or intravenous contrast. May be used to visualize
and assess tumors; injury to soft tissue, ligaments, or tendons; severe trauma to chest,
abdomen, pelvis, head or spinal cord. Used to identify location and extent of fractures
in areas that are difficult to evaluate (acetabulum) and not visible on x-ray.
Magnetic Resonance Imaging (MRI):
-
-
-
Non-invasive imaging technique; used to visualize and assess torn muscles, ligaments,
and cartilage; herniated discs; and a variety of hip or pelvic conditions. No pain
during procedure; MRI is noisy and patient’s with most metal implants (cochlear
implants) or clips are not candidates for MRI.
Helps to enhance visualization, IV contrast may be used, claustrophobic patient’s may
not be able to tolerate; open system may be used but it has lower-intensity magnetic
fields and lower-quality images.
Advantages of open MRI: increased patient comfort, reduced problems w/ claustrophobic
patient’s and reduced noise.
Bone Densitometry:
- Used to evaluate Bone Mineral Density (BMD)
- Can be performed using x-ray or ultrasound
- Most common: DXA (most common for BMD testing) or DEXA, QCT, QUS
- DXA measures BMD and predicts fracture risk through accurate monitoring of bone
density changes in patients with osteoporosis who are undergoing treatment.
- pDXA (Peripheral dual-energy x-ray absorptiometry may be an alternative test to
measure BMD of the forearm, finger, or heel.
Electromyography (EMG):
- provides information on electrical potential of muscles and nerves leading to them.
- Evaluated muscle weakness, pain, and disability
- Differentiates muscle and nerve problems
- Identifies extent of damage if nerve function doesn’t return within 4 months of injury
- Needle electrodes are inserted into selected muscles and responses to electrical stimuli
recorded.
Identify labs that coincide with musculoskeletal disorders including: Serum Calcium,
Serum Phosphorus, Acid Phosphatase, Alkaline Phosphatase (ALP), Calcitonin, PTH,
Vitamin D, Serum Osteocalcin, Urine Calcium
Serum Calcium: Altered in patients with osteomalacia, PTH dysfunction, Paget’s disease,
metastatic bone tumors, prolonged immobilization.
Serum Phosphorus: inversely related to calcium levels and are diminished in osteomalacia
associated with malabsorption syndrome.
Acid Phosphatase: Elevated in Paget’s disease and metastatic cancer.
Alkaline Phosphatase (ALP): Elevated during early fracture healing and in diseases with
increased osteoblastic activity (metastatic bone tumors).
Serum Osteocalcin: indicates the rate of bone turnover
Urine Calcium: levels increase with bone destruction (PTH dysfunction, metastatic bone
tumors, multiple myeloma)
Bone metabolism may be evaluated through thyroid studies and determination of Calcitonin,
PTH, and Vitamin D levels.
Chapter 36
1. Discuss Care of the patient with low back pain
 Because low back pain is self-limited and will resolve on its own within 4-6
weeks, patient is given analgesics and told to rest and avoid strain
 As a result, management of patient with low back pain focuses on discomfort
relief activity modification and patient education
a. Pain management
b. Exercise
 Alter activity patterns to avoid pain
 Change position frequently do not stay in the same position for a long
period of time (BED REST IS NOT RECOMMENDED)
 Low stress aerobic exercise such as walking, or swimming is
recommended
 Walk daily and gradually increase the distance and pace of walking
 Avoid high strain activities such as horseback riding and weightlifting
c. Body mechanics
 Do not twist, bend, lift and reach as it stresses the lower back
 Practice good posture





Push objects rather than pull them
Keep load close to the body when lifting and not far away (avoid forward
flexion position)
Squat while keeping the back straight when picking something off the
floor
Bend knees and tighten abdominal muscles when lifting
Use wide base of support
d. Work modifications









Adjust height of chair using a footstool to position knees higher than hips
•Adjust height of work area to avoid stress on back
Avoid bending, twisting, and lifting heavy objects
Avoid prolonged standing and repetitive tasks
Avoid work involving continuous vibrations
Use lumbar support in straight back chair with arm rests
When standing for any length of time, rest one foot on a small stool or box to
relieve lumbar lordosis
Wear low heels with good arch support and avoid wearing high heals
Patients standing for a long time should rest one foot on a low stool to decrease
lumbar lordosis. Stand on a foot cushion made of foam or rubber
e. Stress reduction
Stress and anxiety evoke muscle spasms (increases back pain), assess
environmental variables such as work life, home life with family and relationships
f. Health promotion: activities to promote a healthy back
 Knees and hips should be flexed with knees in level with the hips
 Feet should be flat on the floor or supported on a raised surface
 Do not sit on stools or chairs that don’t provide back support
 Do not lift weights that are more than 1/3rd of your weight to prevent
injury
g. Dietary plan and encouragement of weight reduction
 Obesity overworks the back muscles
 Weight reduction is needed through diet modification to reduce back pain
2. Assess for cauda equina syndrome, radiculopathy, and sciatica
 Cauda Equina Syndrome:
o
o
o
Cause of low back pain that occurs due to compression of the cauda equina spinal
nerves present in the lower portion of the spinal cord
Nerve compression causes severe/ progressive neurologic deficit, bowel and bladder
dysfunction (INCONTINENCE), saddle anesthesia
 Saddle anesthesia is loss of sensation (anesthesia) restricted to the area of the
butt, perineum, and inner surfaces of the thighs
Cauda Equina is a medical emergency and patient must receive immediate treatment to
prevent permanent nerve damage
o

Treatment includes surgical removal of vertebral fragments and decompression of the
tumor mass that is causing compression of the cauda equina
Radiculopathy vs Sciatica
Radiculopathy:
o Pain radiating down the leg as a result of a diseased spinal nerve root
o Occurs with lower region of the spine and is associated with sciatica pain
Sciatica:
o Pain radiating from an inflamed sciatic nerve
Radiculopathy describes symptoms produced by the pinching of a nerve root in
the spinal column.
Sciatica is one of the most common types of radiculopathies and refers to pain
that originates in your lower back and travels through your buttocks and down the
sciatic nerve – the largest single nerve in the body.
3. Discuss assessment and S&S of a patient with Carpal tunnel syndrome

What is it?
o Carpal tunnel syndrome is an entrapment neuropathy (nerve becomes
compressed by something) that occurs when the median nerve at the
wrist is compressed by edema, or a soft tissue mass
o Commonly caused by repetitive hand and wrist movements
o Associated with diabetes, RA, hairdressers, construction workers, assembly
line workers (repetitive flexing of the wrist)

Assessment:
o
o

S&S:
Perform a TINEL test on a patient at risk for carpel tunnel
Positive Tinel sign helps to identify patients who require interventions
o
Numbness, tingling, burning, and pain

o
Especially in the thumb and the index, middle, and ring fingers
Shock-like sensations that radiate to the thumb and index, middle, and ring
fingers
o
Pain and tingling (PARESTHESIA) that extends to the whole hand or up to the
wrist and forearm toward the shoulder
o
Hand weakness and clumsiness

o
This may cause difficulty with fine movements such as buttoning clothes
Dropping things

This may be due to weakness, numbness, or a loss of awareness of where
the hand is in space (proprioception)
4. Discuss Post-operative assessment, care, and complications for musculoskeletal
surgery (hands, fractures, hip, knee, foot)
 Hands
o
Hourly neurovascular assessment for the first 24 hours following surgery is
needed to monitor nerve function and perfusion
 Compare affected hand to the unaffected hand and compare the post op
status of both hands to the pre-op status
 Ask patient to describe what kind (if any) of sensation present
 Have patient demonstrate mobility of the hand while still enforcing
prescribed mobility limitations
 If pins were used to hold bones together, educate patient about aseptic
wound and pin care as pins serve for potential infection sites
o Dressings must be nonconstrictive to allow for blood flow
o Intermittent use of ice packs to the surgical area during the first 24-48
hours (prevents and controls edema)
o Active (prescribed) extension and flexion of the fingers must be done
(unless contraindicated) to allow for circulation
o If patient has edema in the area, instruct patient to elevate hand to heart
level with pillows reduces swelling and reduces pain in the hands
o If patient is ambulatory, provide conventional sling with hand elevated at
heart level reduces swelling and reduces pain in the hands
o Encourage patient to use the involved surgical hand within few days postsurgery, unless contraindicated, within the limits of discomfort.
o Keep dressing dry by covering it with a secured plastic bag when bathing
o Educate patient on how to monitor neurovascular status and to report
complications such as paresthesia, paralysis , uncontrolled pain, coolness of
fingers, extreme swelling and excessive bleeding, purulent drainage, foul odor
and fever to the surgeon
5. Discuss Post-Op hip arthroplasty care including prevention of complications and
mobility
- Post-op goals include the absence of complications
- Major goals before and after surgery may include relief of pain, achieving pain-free,
functional, stable hip joint
- Assess for bleeding and fluid accumulation
- Risks and complications: bleeding, dislocation of hip prothesis, VTE, Infection, Heel
pressure injury
Prevent infection:
- Remove drain within 24-48 hrs
- Strict hygiene practices
- At risk for up to 24 months
- Prophylactic antibiotic may be given
Prevention of DVT:
- Appropriate prophylaxis
- Instituting preventative measures
- Monitoring the patient closely for clinical signs of the development of DVT and PE
Patient education and rehabilitation
6. Define and discuss joint arthroplasty
- Used for patient’s with OA; severe joint pain or loss of function; joint degeneration due
to RA, trauma, congenital deformity, certain fractures.
7. Identify common foot deformities (hammer toe, clawfoot, hallux valgus, flatfoot)
 Hammer Toe
o Abnormal bend in the middle joint (INTERPHALANGEAL JOINT) of
a toe or multiple toes

Clawfoot
o Abnormally high arch of the foot and deformity of the forefoot

Hallus Vagus
o AKA bunion is a deformity where the great toe deviates laterally

Flatfoot
o Longitudinal arch of the foot is completely diminished
8. Discuss patho and S&S of osteoarthritis and management
Pathophysiology
 Occurs when cartilage that cushions the ends of bones in the joints gradually
deteriorates (WEAR & TEAR)
o Articular cartilage, is a lubricated smooth tissue that protects our bones
from damage
o With osteoarthritis, the articular cartilage breaks down and causes
progressive damage to the underlying bone that it covers
o This eventually leads to the formation of lumps (osteophytes) that
protrudes into joint space
o Osteophytes are bony spurs or lumps that grow on the bones
around the joints
o Joint space allows for bone movement within joints
o Joint space becomes narrowed due to osteophyte formation
o Leads to deceased movement and more damage
o Older age, female gender, obesity are all contributors of OA
o OBESITY the most prominent modifiable risk factor of OA
o Obesity increases the load placed on joints which hastens the
breakdown of articular cartilage
o Usually occurs in the hands, hips and knees
o Decreases quality of life and quantity of life
o Program of diet and exercise is advised to help minimize symptoms
especially in obese patients
Signs and Symptoms
o Pain
o Morning stiffness is usually brief lasting less than 30 minutes
o Functional impairment
o Joint pain aggravation by movement or exercise and relieved by rest
o Affected joint is enlarged with decreased ROM
o Crepitus may be palpated
Management
o Decrease pain and stiffness and maintain joint mobility.
o Exercise
o Cardiovascular aerobic exercises and lower extremity strength
training prevents OA progression and its symptoms
o Weight-loss
o Decreases excess load on the joint
o Occupational and physical therapy can help the patient adopt selfmanagement strategies
o Orthotic devices (e.g., splints, braces)
o Walking aids (e.g., canes) can improve pain and function by
decreasing force on the affected joint.
o Pharmacologic management directed toward symptom management
and pain control
o Initial analgesic therapy is acetaminophen
o Some patients respond to the nonselective NSAIDs and COX-2
enzyme blockers; however, COX-2 enzyme blockers must be used
with caution because of the associated risk of cardiovascular
disease and little to no decrease in GI upset.
o Used in conjunction with nonpharmacologic strategies
9. Identify Causes, Risks, S&S, and treatment of Osteoporosis
 Most prevalent bone disease in the world; more than 1.5 million osteoporotic
fractures occur each year
 Normal homeostatic bone turnover is altered, and the rate of bone resorption is
greater than the rate of bone formation, resulting in loss of total bone mass
 Bone becomes porous, brittle, and fragile and breaks easily under stress
 Frequently results in compression fractures of the spine, fractures of the neck or
intertrochanteric region of the femur, and fractures of the wrist
 Risk factors, refer to Chart 36-11
Causes
o Primary osteoporosis occurs in women after menopause (usually by age 51
o Not solely due to age
o Due to failure to develop optimal peak bone mass and low vitamin D
levels contributing to the development of osteopenia without
associated bone loss
o Secondary osteoporosis is the result of medications or diseases that affect
bone metabolism.
o Men are more likely than women to have secondary causes of
osteoporosis, including the use of corticosteroids (especially if they
receive doses in excess of 5 mg of prednisone daily for more than 3
months) and excessive alcohol intake.
o Small-framed women are at greatest risk for osteoporosis.
o Ethnicity
o Asian and Caucasian women are at highest risk.
o African American women tend to have higher mineral mass when
younger but are still at risk due to the prevalence of sickle cell and
autoimmune diseases in this population. In addition, many African
American women also have poor calcium intake due to lactose
intolerance
Prevention
Treatment
10. Identify Causes, S&S, and treatment of Osteomalacia
 A metabolic bone disease characterized by inadequate bone mineralization
 Softening and weakening of the long bones causes pain, tenderness, and
deformities caused by the bowing of bones and pathologic fractures
 Deficiency of activated vitamin D causes lack of bone mineralization and low
extracellular calcium and phosphate
 Causes include gastrointestinal disorders, severe renal insufficiency,
hyperparathyroidism (causes excretion of phosphate), anticonvulsant medication,
dietary deficiency where VITAMIN D is not added to food
Signs & symptoms
 Softening and weakening of the long bones causes pain, tenderness, and
deformities caused by the bowing of bones and pathologic fractures
Treatment
 Physical, psychological, and pharmaceutical measures to reduce discomfort and
pain
 Correct underlying cause
 Kidney disease: supplement calcitriol
 Malabsorption: Increased doses of vitamin D and calcium are usually
recommended
 Exposure to sunlight may be recommended; ultraviolet radiation transforms a
cholesterol substance (7-dehydrocholesterol) present in the skin into vitamin D
11. Identify Prevention, causes, S&S, and treatment of Osteomyelitis
 Infection of the bone

Occurs because of
o Extension of soft tissue infection
o Direct bone contamination
o Bloodborne spread from another site of infection
o This typically occurs in an area of bone that has been traumatized
or has lowered resistance
 Causative organisms
o Methicillin-resistant Staphylococcus aureus
o Other: Proteus and Pseudomonas spp., Escherichia coli
Treatment
 May need strict bed rest to prevent spread of bacteria
 Pain management
 Antibiotics IV
 Wound care with aseptic technique
 Hyperbaric oxygen therapy
 Nutrition: Increase protein, increase calories, vitamin C
12. Identify Prevention, causes, S&S, and treatment of Septic arthritis
 High risk: older adults >80, and those with comorbid conditions such as diabetes,
RA, skin infections
 Most commonly single knee and hip joints
 Presents with a warm, painful, swollen joint with decreased range of motion.
Systemic chills, fever, and leukocytosis are sometimes present
 Prompt recognition and treatment are key
 Treatment includes aspiration of joint to remove fluid, exudate, and debris;
immobilization of joint; pain relief; and antibiotics
13. Identify S&S and general treatment for bone cancer
Medical Management:
- Primary: surgical excision, radiation therapy, chemotherapy
- Secondary: palliative
Nursing Management:
- Monitoring and managing potential complications
- Delayed wound healing
- Infection
- Hypercalcemia
Patient and family education regarding diagnosis, disease process, and treatment
S/Sx: muscular weakness, incoordination, anorexia, nausea, vomiting, constipation,
electrocardiographic changes (shortened QT interval and ST segment, bradycardia, heart
blocks), altered mental states (confusion, lethargy, psychotic behavior).
Treatment:
- Hydration with IV administration of normal saline solution, diuresis, mobilization,
and medications such as IV bisphosphonates (zoledronic acid).
- Inactivity leads to additional loss of bone mass and increased calcium in the blood,
the nurse assists the patient to increase activity and ambulation.
- Denosumab may be prescribed if the calcium levels are not responsive to the IV
bisphosphonates.
Chapter 37
Discuss Pin care and infection prevention with external fixation
 The nurse assesses each pin site at least every 8 to 12 hours for
redness, swelling, pain around the pin sites, warmth, and purulent
drainage, because these are the most common indicators of pin
site infections.
● For the first 48 hours after insertion, the site is covered with a
sterile absorbent nonstick dressing and a rolled gauze or Ace-type
bandage
o After this time, a loose cover dressing or no dressing is
recommended
● EBP recommendations:
o Pins located in areas with soft tissue are at greatest risk for
infection
o After the first 48 – 72 hours following skeletal pin
placement, pin site care should be performed daily or
weekly
o Chlorhexidine 2 mg/mL solution is the most effective
cleansing solution; if chlorhexidine is contraindicated (due
to known sensitivity or skin reaction), saline solution
should be used for cleansing
o Strict handwashing before and after skeletal pin site care
● The nurse must inspect the pin sites every 8 hours for reaction and
infection
Discuss nursing role with skeletal traction (maintaining effective traction)
Maintaining effective skeletal traction:
● Check apparatus to see that ropes are in wheel grooves of the
pulleys, ropes are not frayed, weights hang freely, and the knots of
the rope are tied securely
● Evaluate patient position, because slipping down in bed results in
ineffective traction
● Evaluate traction apparatus and patient position
● Maintain alignment of body
● Report pain promptly
● Trapeze to help with movement
● Assess pressure points in skin at least every 8 hours
● Regular shifting of position
● Special mattresses or other pressure reduction devices
● Perform active foot exercises and leg exercises every hour
● Anti-embolism stockings, compression devices, or anticoagulant
therapy may be prescribed
● Pin care
● Exercises to maintain muscle tone and strength
Describe Post-Op Amputation skin care and infection prevention (patient education for
discharge)
 Administer analgesic or other medications as prescribed
 Changing position
 Putting a light sandbag on residual limb
 Alternative methods of pain relief: distraction, TENS unit
 Promoting wound healing
o Handle limb gently
o Residual limb shaping
 Resolving grief and enhancing body image
o Encourage expression of feelings
o Create an accepting, supportive atmosphere
o Provide support and listen
o Encourage patient to look at, feel, and care for the residual limb
o Help patient set realistic goals
o Help patient resume self-care and independence
o Referral to counselors and support groups
 Promoting independent self-care
o Encourage active participation in care
o Continue support in rehabilitation facility or at home
o Focus on safety and mobility
Discuss Cast care and patient education
o Cast care:
▪ Cast care first 24 hours, elevate with ice over fracture site; allow cast to
dry
● Can use a fan or a hair dryer (on COOL setting) to facilitate drying
or to relieve itching
▪ Always report increased pain, changes in color, coolness of extremity,
numbness or tingling in distal extremities
▪ Stay dry: Protect plaster casts from moisture at all times (plastic cover
during bathing); for fiberglass casts dry thoroughly after getting wet
▪ Teach patient how to perform self-care and use assistive devices for
mobility during recovery
● Teach patient to resist the urge to scratch under the cast (can give
antihistamines to help with itchiness) DO NOT stick foreign
objects into the cast
● Diet: Increase fiber and fluids due to immobility to prevent
constipation (unless contraindicated by fluid restriction [chronic
kidney disease and congestive heart failure]), increase vitamins
and minerals (protein, vitamin C)
Discuss Cast application and types
A cast is a rigid external immobilizing device that is molded to the contours of the body. The
cast must fit the shape of the injured limb correctly to provide the best support possible
The most common casting materials consist of fiberglass or plaster of Paris
Generally, casts can be divided into three main groups: arm casts, leg casts, and body or spica
casts:
Plaster Casts
Fiberglass Casts
Less costly
More expensive
Can take 24 – 72 hours to dry post-application
Reach full rigidity within 30 minutes of application
Heavy
Lighter in weight
Not water-resistant
More water-resistant
Achieve a better mold, easier to mold
Are more difficult to contour and mold more
commonly used for simple fractures of upper /
lower extremities
* Wet plaster casts should be handled only by the
palms of the hands – NOT the fingertips – to
prevent indentations in the cast (indentations can
result in areas of pressure on the skin which could
lead to pressure injuries)
*Composed of polyurethane resins
*A wet plaster cast feels damp, appears dull and
gray, sounds dull on percussion, smells musty �
considered fully dry when it appears hard and firm,
has a white / shiny appearance, is resonant to
percussion, and is odorless
*Stronger and more durable than plaster
*May have rough edges that can crumble and cause
irritation smoothing the edges resolves this
problem
*To prevent skin breakdown, moleskin can be used
over any area that may rub the patient’s skin
*Facilitate radiographic imaging better than plaster
The application of a cast is a specialized skill, typically performed by orthopedic technologists.
The skillset needed to apply and remove casts requires education, training, practice, and constant
review of provider competence to ensure patients receive safe, high-quality care.
Discuss Fracture assessment (5P’s)
Pain - When a patient complains of hurting, how long does it come and go, describe, scale pain
rating etc
Pallor - Skin look as white as a sheet
Pulselessness – palpate Dorsalis Pedis & Posterior Tibialis
Paresthesia - an abnormal sensation of tingling or numbness or burning - Checking for Feeling
in the large Great toe or foot test
Paralysis - When a patient cannot move a toe or foot
Discuss General musculoskeletal care for sprain, strain, and simple fracture
A strain is an injury to a muscle or tendon from overuse, overstretching, or excessive stress;(Muscle pull)
A first-degree strain is mild stretching of the muscle or tendon with no loss of ROM Ex - tenderness and mild
muscle spasm
A second-degree strain involves moderate stretching and/or partial tearing of the muscle or tendon Ex - pain with
passive ROM (PROM), edema, significant muscle spasm
A third-degree strain is severe muscle or tendon stretching with rupturing and complete tearing of the involved
tissue Ex - tearing, snapping, or burning, muscle spasm,
A sprain is an injury to the ligaments and tendons that surround a joint. It is caused by a twisting motion or
hyperextension
A Grade I sprain is stretching or slight tearing in some fibers of the ligament and mild, localized hematoma
formation. Manifestations include mild pain, edema, and local tenderness.
A Grade II sprain is more severe and involves partial tearing of the ligament. Manifestations include increased pain
with motion, edema, tenderness, joint instability, ecchymosis
A Grade III sprain is a complete tear or rupture of the ligament. A Grade III sprain may also cause an avulsion of the
bone. Symptoms include severe pain, edema, tenderness, ecchymosis, and abnormal joint motion
Protection from further injury is accomplished through support of the affected area (e.g., sling,
brace) and/or splinting, taping, or compression bandages. To control pain, bleeding, and
inflammation, most contusions, strains, and sprains are managed with the RICE method
o RICE – soft tissue injury treatment
▪ Rest
▪ Ice - no longer than 20 minutes
▪ Compression - An elastic compression bandage controls bleeding, reduces
edema
▪ Elevation - Elevation at or just above the level of the heart controls the
swelling
▪ *Immobilize for third degree strain / sprain
▪ Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed for
pain management
Define Fracture types (avulsion, greenstick, simple, compound, comminuted, compression,
epiphyseal, spiral, stress, pathological)
A closed fracture (simple fracture) is one that does not cause a break in the skin
An open fracture (compound, or complex, u) is one in which the skin or mucous membrane
wound extends to the fractured bone
A compound fracture involves damage to the skin or mucous membranes and is also called an
open fracture.
A compression fracture involves compression of bone and is seen in vertebral fractures.
An impacted fracture occurs when a bone fragment is driven into another bone fragment.
A transverse fracture occurs straight across the bone shaft.
Discuss complications of fractures including assessment, S&S, and treatment of shock, fat
embolism, compartment syndrome, VTE, and PE
o Shock
▪ Hypovolemic related to hemorrhage, especially in a trauma patient with
pelvic fractures and with displaced or open femoral fracture involving the
femoral artery
▪ Treatment:
● Stabilize fracture
● Restoring blood volume and circulation (give blood and fluids)
● Relieving the patient’s pain
● Provide proper immobilization
● Protecting patient from future injury
o Compartment syndrome
▪ Elevation of pressure within an anatomic compartment that leads to
impaired tissue perfusion, cell death / necrosis / permanent dysfunction
▪ Arises from an increase in compartment volume (edema or bleeding), a
decrease compartment size (restrictive cast) or both
▪ May take up to 48 hours for symptoms to present but develops quickly
within 6 to 8 hours after initial injury or after fracture repair
▪ S&S: Deep, throbbing, unrelenting pain, unrelieved by medications, pain
seem disproportional to injury and intensifies with passive ROM
▪ Management:
● Assess NV frequently after a fracture and focus on the 5 P’s:
o Pain, pallor, pulselessness, paresthesia, and paralysis
● Evaluate motion:
o Ask the patient to flex and extend the wrist or plantar /
dorsi flex the foot
o No movement indicates nerve damage
● Assess peripheral circulation:
o Color, temp, capillary refill, edema, and pulses
o Pulselessness is a very late sign of compartment syndrome
● Pain assessment:
o Most crucial in early recognition
o Palpation of the muscle reveals it to be swollen and hard w/
skin taut and shiny
▪ Treatment:
● Notify the surgeon immediately if suspected
● Delay in treatment can lead to permanent nerve and muscle
damage, necrosis, infection, rhabdomyolysis (breakdown of
muscle tissue that releases damaging protein into the blood,
causing damage to kidneys) with acute kidney injury and
amputation
● Conservative measures:
o First open cast and elevate to heart level (no higher)
o If ineffective fasciotomy
▪ Surgical decompression with excision of the fascia
to relieve the constrictive muscle fascia
▪ Wound is left open to allow the muscle tissues to
expand it is covered with a moist sterile saline
dressing or with artificial skin or a wound vac
▪ Affected limb is splinted in a functional position
and elevated to heart level and prescribed
intermittent PROM
In 2 to 3 days when swelling has gone down, and tissue perfusion restored the wound is debrided
and closed
o Fat embolism syndrome
▪ When fat emboli enter circulation, they occlude the small blood vessels
that supply the lungs, brain, kidneys and other organs
▪ Rapid onset – 12-72 hours after injury
▪ S&S: Classic triad hypoxemia, neurologic compromise (confusion,
restlessness, agitation, seizures), and a petechial rash (2 to 3 days after
onset)
▪ Prevention/Management:
● Immediate immobilization
● Early surgical fixation
● Minimal fracture manipulation
● Adequate support for bones with turning and positioning
● Maintenance of fluid and electrolyte balance
▪ Treatment: Is supportive
● Vasopressors
● Mechanical vent
Sometime corticosteroids
● pulmonary embolism (PE): a blood clot or thrombus within a pulmonary artery that
blocks or obstructs blood flow to the lungs
● venous thromboembolism (VTE): a blood clot that forms in the venous vasculature that
may manifest as a DVT or a PE
● VTE, including DVT and PE, are associated with reduced skeletal muscle contractions
and bed rest. Patients with fractures of the lower extremities and pelvis are at high risk
for VTE. PE may cause death several days to weeks after injury. See Chapter 26 for a
discussion of VTE, PE, and DVT.
● S&S and complications of fractures (i.e., nonunion)
o Failure of fractured bones to heal together
o Most common in the tibial fractures
o Patient complains of persistent discomfort and abnormal movement at the fracture
sites
o Management:
▪ Ultrasound stimulation and electrical bone stimulation daily, electrical
stimulation promotes the functioning of osteoblasts
▪ Surgical:
● Bone grafts, internal / external fixators
▪ Bone graft:
● Reconstructive process that results in a gradual replacement of the
graft with new bone
● Can be autograph (tissue from iliac crest, harvested from patient)
or allograft (harvested from a donor) or a bone graft substitute
● Promoting bone growth afterward immobilization and nonweightbearing exercises are required while bone graft is
incorporated, and healing occurs can take 6-12 months or longer
● Complications:
o Infection
o Fracture of graft
o Nonunion
o Partial acceptance
o Graft rejection
o Transmission of disease with allograft
o Nursing:
▪ Emotional support, pain management, monitoring for complications,
patient education