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NCLEX Exam bone fracture Study guide
What is a bone fracture? It’s a break or crack in a bone. Causes of Bone Fractures: happens because the bone can NOT withstand the force
- Trauma (fall, car accident etc.)
- Twisting (sports injury, abuse etc.)
- Diseases (bone cancer or osteoporosis) Children tend to heal faster than adults from bone fractures because the periosteum (the dense fibrous membrane covering the bones) is stronger, more flexible, and thicker than an adults. It can take anywhere from 3 to 12 weeks to heal from a bone fracture, depending on the person’s age and health status. Complications of a bone fracture include:
- Infection (osteomyelitis)
- Compartment syndrome
- Fat embolism Signs and Symptoms of a Bone Fracture “BROKEN” B ruising over the site (discolored with swelling) and pain R educed movement of extremity or muscle O dd appearance (looks abnormal) K rackling sounds due to bone fragments rubbing together (crepitus) E dema and erythema at the site N eurovascular impairment…6 P’s (ischemia: pain, pallor, paralysis, paresthesia, pulselessness (late sign), poikilothermia) **Types of Bones Fractures: Remember these types!!
- Did it break through the skin? Open or closed Open Fracture (“Compound”) : a fractured bone that breaks through the skin Closed Fracture (“Simple”): a fractured bone that does NOT penetrate through the skin (skin remains intact)
- Is the bone completely broken or part of it? Complete or incomplete Complete Fracture: the fracture completely separates the bone in two
Incomplete Fracture: the fracture does NOT break the bone all the way through
- What is the pattern or details or the fracture? Straight across, up and down, at an angle, crushed in fragments Greenstick: one side of the bone is bent while the other is broken… incomplete type of fracture ( most common in pediatric patients because their bones are more flexible than an adults) Comminuted: the bone is broken into many fragments (3 or more) Transverse : the fracture is straight across the bone shaft Oblique : the fracture is slanted across the bone shaft
Compartment syndrome occurs when too much pressure is exerted within the muscle compartments found within t he fascia. This can occur when there is hemorrhaging (bleeding) or swelling present after an injury, like with a bone fracture (or with external factors like a cast being too tight or traction). All this can increase the pressure within the compartments. As the pressure builds, this will cut off the blood supply and nerve function to this muscle. If not corrected within 6 hours, the damage is permanent. Remember from anatomy and physiology that in the leg and arm there are individual compartments grouped together (but separated from one another) that contain bone, muscle, nerves, and vessels. Each compartment usually has it own muscle, nerve, and vessel supply. Fascia is what keeps all these structures in place and separated. The important thing to remember about fascia when talking about compartment syndrome is that is does NOT expand when pressure increases within a compartment (so there will be no relief within the compartment from the fascia). Instead the pressure stays within the compartment and causes blood vessel and nerve function to become compromised (diminished). So, ischemia is going to occur to the muscle and distal extremity to the fracture. Assess the 6 P’s :
- P ain (early sign)
- P aresthesia (can be an early sign too)
- P allor
- P aralysis
- P oikilothermia
- P ulselessness (late sign) P ain: worst with passive touch or movement, elevating the limb, or any pressure, stretching increases the pain. Pain medication is not relieving it. P aresthesia: patient may report it feels like the extremity distal to the fracture feels like it is falling asleep or a “pin and needle” sensation. Can they feel you touch their extremity? ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE! P allor: Extremity should be pink and have normal capillary refill less than 2 seconds. In CS, it may appear pale or dusky and have a capillary refill greater than 2 seconds. ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE! P aralysis: can the patient move the distal extremity from the fracture or has the movement decreased…this is a bad sign! ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE! P oikilothermia: This occurs when the affected extremity distal from the fracture feels cooler to the touch compared to the
unaffected extremity. The extremity can NOT regulate its temperature. P ulselessness: Always mark the pulses with a black marker and have a Doppler available to monitor the sound of the pulse. (this is a late sign in compartment syndrome) Nursing interventions for Compartment Syndrome:
- keep the extremity AT HEART level (NOT below….remember you want to maintain arterial pressure and elevating it above heart level will cause more ischemia)
- loosen and remove restrictive items
- notify the physician
- perform neurovascular checks (6 P’s)
- prepare the patient for possible bivalvement of the cast, reduction of weight in the traction, or in severe cases fasciotomy. Various treatments for a Bone Fracture: Bone reduction: putting the fractured bone back in its original state. Closed reduction : done manually….nonsurgical with general anesthesia
- Cast (plaster or fiberglass) placed to keep broken bone in place to allow it to heal Things to remember about casts:
- Monitor for compartment syndrome: 6 P’s
- Monitor for infection: hotspots in the cast, severe pain, fever
- Keep the cast and extremity elevated above the heart level (decreases swelling)
- Apply ice packs to the cast for the first 2 days to decrease swelling
- Even drying for new cast by turning every 2 hours
- Use palms of hand to handle (not fingertips) with a new wet plaster cast. o WHY? Prevents dent formation in the cast by handling with the palms of hand, which can cause skin breakdown overtime.
- Maintain skin integrity: petal the cast….. use soft tape called moleskin around the edge to prevent skin breakdown
- Keep cast dry and never stick anything inside to scratch an itch Open reduction : done surgically to put fractured bone back in its original state and a fixation device used:
- Internal: attached to the bone inside the skin (pins, rods, plates, screws or external)
- External: fixture attached to the outside of the skin that helps with bone healing (can be adjusted…metal braces, screws) Traction: aligns the bone with a constant steady pulling action.
- Make sure the weights are hanging freely and not on floor
- Never remove weights with a MD order
- Pin care and monitor for infection (odorous draining, redness, pain)
- Neurovascular status: 6 P’s
- Overhead trapeze bar to move around in bed Video and quiz:
when pressure increases within a compartment (so there will be no relief within the compartment from the fascia). Instead the pressure stays within the compartment and causes blood vessel and nerve function to become compromised (diminished). So, ischemia is going to occur to the muscle and distal extremity to the fracture. Therefore, what are you going to do for a patient experiencing compartment syndrome? Nursing Interventions Include:
- perform neurovascular checks (6 P’s)
- keep the extremity AT HEART level (NOT below….remember you want to maintain arterial pressure and elevating it above heart level will cause more ischemia)
- loosen and remove restrictive items
- notify the physician (of course do this while you are simultaneously doing everything else) o prepare the patient for possible bivalvement of the cast or reduction of weight in the traction per MD order, and in severe cases a fasciotomy. o May monitor compartment with needle manometry to measure pressure within the affected compartment (>20 mmHg) Assessing the 6 P’s:
- P ain (early sign)
- P aresthesia (can be an early sign too)
- P allor
- P aralysis
- P oikilothermia
- P ulselessness (late sign) P ain: worst with passive touch or movement, elevating the limb, or any pressure, stretching increases the pain. Pain medication is not relieving it. P aresthesia: patient may report it feels like the extremity distal to the fracture feels like it is falling asleep or a “pin and needle” sensation. Can they feel you touch their extremity? ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE! P allor: Extremity should be pink and have normal capillary refill less than 2 seconds. In CS, it may appear pale or dusky and have a capillary refill greater than 2 seconds. ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE! P aralysis: can the patient move the distal extremity from the fracture or has the movement decreased…this is a bad sign! ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE! P oikilothermia: This occurs when the affected extremity distal from the fracture feels cooler to the touch compared to the unaffected extremity. The extremity can NOT regulate its temperature. P ulselessness: Always mark the pulses with a black marker and have a Doppler available to monitor the sound of the pulse. (this is a late sign in compartment syndrome) Now let’s eliminate options…remember this is a select all that apply (so there will be more than one answer): A. Reassure the patient that this is normal after a bone fracture, and reposition the cast. ELIMINATED! This is not normal and should be investigated/reported to the physician along with performing some nursing interventions. B. Re-adjust the cast to ensure it fits snugly against the fracture. ELIMINATED! We definitely don’t want to do
this because this will increase the muscle’s compartment pressure even more. We want to decrease pressure and re- adjusting the cast to fit more snugly will cause more problems. C. Perform neurovascular checks. CORRECT! As discussed above in detail, we want to check the 6 P’s….pain (early sign), paresthesia, pallor, paralyisis, poikilothermia, pulselessness (late sign). D. Elevate the leg above heart level. ELIMINATED! We want to keep the leg AT HEART LEVEL, not above it. Keep the extremity at heart level helps maintain arterial pressure, which is very important because the muscle compartment is experiencing ischemia. E. Loosen and remove restrictive items. CORRECT! Yes, we most definitely want to do this to help alleviate any extra pressure on the compartment! F. Notify the physician. CORRECT! Of course, we will be doing this while simultaneously doing all the other things. The MD may order bivalvement of the cast (cutting it in half) or performing a fasciotomy in severe cases. Answers: C, E, and F Cast care questions: ******look over cellulitis so you know the difference between that and infection *putting this because pressure ulcers are mentioned in the chapter Pressure Injuries (Ulcers) NCLEX Review Pressure Injuries: formerly called pressure ulcers and have been previously called decubitus ulcers and bedsores as well. What is a pressure injury? It is the breakdown of skin integrity due to unrelieved pressure of some type. Unrelieved pressure can be from a bony area on the body that comes into contact with a hard surface or a medical device that causes unrelieved pressure (nasal cannula, bed pan, ortho device…splints etc.). In addition, this can happen due to friction and shearing of the skin. This is where the skin and bone are pulled in opposite directions causing injury to the capillary bed that perfuses the skin. How do pressure injuries happen? Example: Let’s say a patient is sitting in a bedside chair for a long time and can’t shift their own weight without assistance. What bony prominence is a great site for a pressure injury to develop in this position? Coccyx bone! The exerted pressure from a bony prominence and in this case it is the coccyx bone, and the external surface (hence the chair’s seat) leads to a decrease in the blood supply to the epidermis and dermis. HOW? As the bone pushes down and the external surface pushes up it pinches the blood supply shut. This leads to a decrease in blood flow to the skin layers and the potential development of a pressure injury. Risk Factors for Pressure Injury Development Risk Factors: think of any patient population that has issues with alleviating pressure on a bony prominence (can’t verbalized it to you or move themselves) or will have issues with skin integrity
- Poor Nutrition….decreases skin integrity
- Immobile….can’t alleviate pressure
- Neuro Issues: unaware of the need to shift weight….spinal cord injuries or altered mental status….can’t alleviate pressure
Stage 1: Skin is completely intact! The area will be very red but it does NOT blanch (hence turn white when pressed on). Stage 2: Skin is visibly damaged and NOT intact with PARTIAL loss of the dermis. No subq (fatty tissue) will be visible. Wound may be opened with superficial red/pink opened ulcer or may have the formation of an opened or closed blister.
Stage 3: Skin is visibly damaged and NOT intact with FULL loss of the skin tissue. May see the subq (fatty tissue). Wound edges may be “rolled” away…..epibole. Bone, tendon and muscle NOT visible. Stage 4: Skin is visibly damaged with FULL loss of the skin tissue that will expose bone, muscle, tendon, and ligaments. Unstageable: Slough (yellowish or tan) or eschar (brownish black) is covering a full thickness ulcer. You can’t assess the actual depth of the wound because of the slough or eschar covering the ulcer.
team or for a wound culture if an opened wound is present…..may contain MRSA or other antibiotic resistant bacteria etc. Assess for potential patients who are at most risk for pressure injuries using the Braden scale every shift: It has 6 categories:
- sensory, moisture, activity, mobility, nutrition, and friction and shear
- 9 or less: Very high risk of developing a pressure injuries
- 19-23: No risk Keep skin dry and clean on patients with incontinent issues (barrier creams to protect skin) or who are sweaty. Make sure the patient has clean linens and is always wearing a clean gown….try to use articles that are wrinkle free. Turn every 2 hours…the minimum of how often a patient should be turned. Watch for friction and shear activities….be careful moving up in the bed.
- When patient is sitting up, position the bed so they can’t easily slide down. HOW? Slightly elevate the foot of the bed. Also, take special care when moving the patient up in bed. Use a transfer pad and lift the patient up….don’t scoot them up. Be aware there are special air beds for patients at major risk for pressure injuries. In addition, there are heel boots, elbow pads, and gel cushions (especially if the patient uses the wheelchair often or sits in the beside chair a lot)…these are just a few items available to help prevent pressure injuries. Routinely assess the skin integrity that comes into contact with medical devices. Recommend a nutrition consult: this can help improve the patient’s diet to promote wound healing. Wound care per wound care nurse recommendations: the wound care nurse will assess the wound and write out a plan of care for the nurse to follow. This usually includes specific types of dressing changes based on the severity of the injury (products to be used) and how often to change the dressing. There are various methods for treating a pressure injury and it depends on the severity and stage of the injury: wound vac, debridement of the wound, dressing changes, hyperbaric oxygen therapy (high amounts of oxygen delivered to the wound to promote healing) etc. READ CH. 42 Ch. 62 Burns NCLEX Review What are burns? It is damage to the skin’s integrity from some type of energy source, such as: - Heat (thermal): this can be hot liquid, steam, fire etc. that comes into contact with the skin… most common type
- Electrical : an electric current passes through the body and damages tissues o It’s hard to determine the extent of damaged from this type of burn because the damage can extend under the skin. This is known as the “ iceberg effect ”. o Watch for heart dysrhythmias and if the current is strong enough this can lead to bone fractures (watch for cervical spine injuries). o Watch for renal failure: WHY? if the electrical current is strong enough this can cause the muscles to release myoglobin and cells to release hemoglobin. These substances block the tubules in the kidneys, which leads to acute tubular necrosis. This can happen with full-thickness burns as well
because the muscle layer can be involved in this severe burn.
- Chemical: toxic substances come into contact with the skin (powders, gases, or certain foods…no heat needed). Remember alkali burns are harder to treat because these type of burns are NOT neutralized by the skin when compared to acidic burns.
- Cold: coldness comes into contact with the skin too long….example: frostbite
- Radiation: sun, treatments for cancer
- Friction: force abrasion to the skin….car accident…road rash, rope burn Burn severity depends on:
- depth of damage to the skin
- percentage of the total surface of the skin affected (check out my video on rule of nines)
- patient’s age (children at most risk due to small size and elderly slower healing….usually have extensive medical history…skin is thin),
- medical history (diabetic already has issues with circulation already) - where the burn is located (front and back of trunk, face and neck…. THINK respiratory issues or is it a circumferential burn….a burn that “circles” or surrounds an extremity or the torso?
- did the patient experience an inhalation injury? Therefore, if a patient has a large amount of total body surface area affected by a burn and the burns extends deep past the epidermis and dermis the patient is at risk for many problems…because severe burns affect all the systems of the body (immune system, renal, fluid/electrolytes, respiratory, GI etc. ) So, first let’s talk about: Degrees of Burns (depth of burn damage) There are first, second, third, and fourth degree burns….based on the depth of the burn… partial-thickness to full- thickness. However, to understand the various depth of burns let’s review the skin layers. Skin Layers Epidermis : top layer….it’s very thin compared to the dermis…keeps us protected for the environmental hazards… preventing infection. Below that is the dermis , which is thicker than the epidermis….it contain the blood vessels along with the nerve endings, sweat/oil glands and the cells that help create new skin cells (thiswhy patients who have burns that involve deep into the dermis will need skin grafts because the body CAN’T remake the skin cells). Below the dermis is the subcutaneous tissue (also called hypodermis) : which contains fatty tissue, veins and arteries, nerves and helps insulate the muscles, bones, organs and REGULATES our body temperature. Patients who have burns that extend down into this layer will have problems regulating their body temperature. Then below this are muscles, bones, and ligaments. 1 st^ Degree (superficial): affects the top layer of the skin “epidermis”
- least severe of all the types
- heals usually within 7 days
- skin is very red or pink, painful, warm to touch, no blisters or usually no scar left behind
- brisk capillary refill (the faster the capillary refill, the more superficial the burn is) 2nd degree (partial-thickness) can be superficial or deep partial-thickness affecting various areas of the dermis
- Appears black, charred with eschar
months to heal and needs skin grafting ********for full-thickness burns watch for ATN (acute tubular necrosis) because myoglobin and hemoglobin can be released into circulation…goes to kidneys and blocks perfusion, which leads to AKI (acute kidney injury). Rule of Nines for Burns in an Adult
So what are the rule of nines? It’s a calculation used to calculate the total body surface area burned for burns partial-thickness or greater. The percentage will determine treatment like fluid replacement and if the patient meets the criteria for a burn unit. The body is broken down in areas and nines are assigned to each area: Start at the top and work downward (Remember THE FRONT AND THE BACK OF EACH AREA and there are two arm and two legs ): Adult: Head and Neck: 9% (4.5% anterior and posterior) Right Arm: 9% (4.5% anterior and posterior) Left Arm: 9% (4.5% anterior and posterior) Trunk: 36% (18% anterior and posterior) Perineum: 1% Right Leg: 18% (9% anterior and posterior) Left Leg: 18% (9% anterior and posterior) Practice problem:
The upper and lower airways can be affected with an inhalation injury. The upper airway tends to be affected the most because the lower airway is usually protected by the glottis and vocal cord structures. When would you suspect an inhalation injury in a patient? Remember these signs and symptoms!
- Burned in an enclosed structure
- Burn located on the face (especially mouth and nose)
- Carbonaceous sputum ….spit has soot in it…(smoke)
- Hair singeing on the head and nose hairs
- Soot in the mouth and nose (smoke)
- Skin bright red (CO poisoning)
- Trouble talking…voice is hoarse
- Confusion, anxiety
- Increased heart rate Now let’s shift gears and talk about phases of burn management and the physiology of burns and mesh it will nursing interventions so you can easily understand the reason WHY you will be doing this specific nursing intervention. Phases of Burn Management: Remember “ EAR ” Emergent : onset of the burn injury to restoration of capillary permeability (lasts 24-48 hours)
- Risk for: hypovolemic shock, respiratory distress, compartment syndrome Acute: capillary permeability stabilized (diuresis) to wound close (starts 48-72 hours until wound heals)
- Focus: preventing infection, alieving pain, ensuring proper nutrition, wound care Rehabilitative : burn healed to patient able to function again (mental and physical)
- Focus: psychosocial, ADLs, PT, OT, cosmetic correction Physiology of Burns and Nursing Interventions for Burns For this physiology discussion we are talking about a patient who has experienced partial to full-thickness severe burns on
15% or more on total body surface area. Simple burns don’t experience this type of physiological change in the body. During the emergent phase , which is the first 24 hours, there is a huge change in the capillary permeability. This happens really fast….like 25 to 30 minutes fast! Remember our patient focus is fluid status! What happens? Fluid (we’re talking about plasma) moves from the intravascular space into the interstitial tissue because the capillary bed is more permeable. Due to this SODIUM leaves with this plasma and this drops sodium levels in the blood….so you will see HYPOnatremia. In addition, albumin levels will drop because it leaves as well. What does albumin do? It regular oncotic pressure….in other words it regulates water…..so there will more spacing of fluid (swelling). What will happen to the composition of the blood left in the intravascular space? Remember the fluid (plasma) that suspends the components of blood has left….so the blood will become very thick!! This will cause an INCREASE in the hematocrit level (it will actually decrease once fluids are replaced). The thickness of the blood will cause problems with micro-circulation. Cells are damaged from the injury: HYPERkalemia (damaged cell release potassium into the blood), WBC and immunoglobulins that help fight infection are damaged: AT RISK for INFECTION. Problems for nurses to focus on: Fluid volume deficient (hypovolemic shock), electrolyte imbalances, potential renal failure and GI problems (due to fluid volume deficient, compartment syndrome (circumferential burns)
Hypovolemic shock : fluid left the intravascular system and there is a limited amount of fluid (hence blood) the heart can pump to the organs….will see an increased heart rate, decreased blood pressure, and decrease cardiac output NEEDS FLUIDS!!!! Fluid treatment is essential for major burns….the Parkland’s Burn Formula may be used to calculate the amount of fluids needed over the next 24 hours. The formula calculates the amount of fluid (lactated ringers…LR) needed 24 hours after a burn (this is the time the patient received the burn….not arrived to you). It is used for patients who have partial-thickness (2nd^ degree burns) or higher. Intravenous fluid resuscitation is needed for adults when a total body surface area of least 15% or more is burned for adults, and in 10% in children. (Diver, 2008) To calculate the amount of LR needed 24 hours after a burn using the Parkland’s Burn Formula:…. Volume of Fluid needed (LR) = 4 mL x percentage of BSA x patient weight kilograms How to give the fluids : 1/2 during the first 8 hours and then other 1/2 over the next 16 hours to equal 24 hours Practice Problem: A 46 year old male patient has partial thickness burns on:
- Anterior head and neck
- Front and back of left arm
- Front of right arm
- Posterior Trunk
- Front and back of right leg
- Back of left leg: The patient weighs 180 lbs. Using the Parkland’s Burn Formula to calculate fluid replacement, calculate the hourly fluid rate (mL/hr) for this patient over the next 24 hours? Answer: 1 st^8 hours: 1,433 mL…..next 16 hours: 717 mL/hr Rationale: 63% BSA burned 180 lb….divide by 2.2= 81.8….82 kg 4 mL x 63 x 82 = 20,664 mL of LR total 1 st^8 hours: 22,932 divide by 2 = 11,466 mL…hourly rate (divide by 8): 1433.25…..1,433 mL/hr Next 16 hours: 11,466 mL….hourly rate (divide by 16): 716.625……717 mL/hr Nursing interventions: Monitor urinary output every hour!! UOP is the best way to determine if the patient is being hydrated properly. The patient will have a Foley catheter. You want to make sure the patient’s UOP is at least 30 cc/hr. If it is NOT contact the MD! In addition, albumin may be ordered to help shift fluid back into the intravascular system. What systems will experience changes due to the fluid shift? Renal system: patient will be oliguric at first because of the shifting of blood, but then after about 24-72 hours diuresis will occur due to the stabilizing of the capillary system. Therefore, watch renal function and urinary output closely.
