The patient's history indicates an injury often associated with immediate localized pain, decreased function, and inability to use the affected part. The patient guards and protects the part against movement. The fracture may not be accompanied by obvious bone deformity.
Manifestations include edema and swelling, pain and tenderness, muscle spasm, deformity, ecchymosis, loss of function, and crepitation.
Fractures are also described as stable or unstable. A stable fracture occurs when some of the periosteum is intact across the fracture and either external or internal fixation has rendered the fragments stationary. Stable fractures are usually transverse, spiral, or greenstick. An unstable fracture is grossly displaced during injury and is a site of poor fixation. Unstable fractures are usually comminuted or oblique.
A fracture is a disruption or break in the continuity of the structure of a bone. Traumatic injuries account for the majority of fractures, although some fractures are secondary to a disease process (pathologic fractures). Fractures are described and classified according to (1) type, (2) communication or noncommunication with the external environment, and (3) location.
The majority of fractures heal without complications. If death occurs after a fracture, it is usually the result of damage to underlying organs and soft tissue or of certain complications of the fracture.
The ossification process is arrested by causes such as inadequate immobilization and reduction, excess movement, infection, and poor nutrition.
Direct complications of fractures include problems with bone union, avascular necrosis, and bone infection. Indirect complications are associated with blood vessel and nerve damage resulting in conditions such as compartment syndrome, venous thrombosis, fat embolism, and traumatic or hypovolemic shock.
Although most musculoskeletal injuries are not life-threatening, open fractures or fractures accompanied by severe blood loss and fractures that damage vital organs are medical emergencies requiring immediate attention.
An x-ray examination is used to determine the presence of a fracture.
Therapeutic Management of Fractures
The goals of fracture treatment are (1) anatomic realignment of bone fragments, (2) immobilization to maintain realignment, and (3) restoration of function of the part.
The patient with a fracture will have no associated complications, obtain satisfactory pain relief, and achieve maximal rehabilitation potential.
The patient with a fracture may be treated in an emergency department or physician's office and released to home care, or the patient may require hospitalization. Specific nursing measures depend on the type of treatment used and the setting in which the patient is placed.
Preoperative management. If surgical intervention is required to treat the fracture, the patient will need preoperative preparation. In addition to the usual preoperative nursing measures, the nurse should inform the patient of the type of immobilization device to be used and expected activity limitations.
Proper skin preparation is an important part of preoperative preparation. The aim of skin preparation is to clean the skin and remove debris and hair to reduce the possibility of infection.
The patient must be assured that all needs will be met by the nursing staff until the patient can again meet his/her own needs Assurance that pain medication will be available if needed is often beneficial.
Postoperative management. Frequent neurovascular assessments of the affected extremity are necessary to detect subtle changes. Any limitations of movement or activity related to turning, positioning, and extremity support should be monitored closely
Pain and discomfort can be minimized through proper alignment and positioning.
Dressings or casts should be carefully observed for any covert signs of bleeding or drainage. Increased bleeding can be monitored by drawing a circle on the cast around an area of drainage and by noting the date and time. A significant increase in the size of the drainage area should be reported.
If a wound-drainage system is in place, patency of the system and volume of drainage should be assessed at least once each shift. Whenever the contents of a drainage system are measured or emptied, the nurse should use sterile technique to avoid contamination.
If the patient is immobilized as a result of the fracture, the nurse must plan care to prevent constipation and renal calculi.
Constipation can be prevented by maintenance of a high fluid intake and a diet high in bulk and roughage. If these measures are not effective in maintaining the patient's normal bowel pattern, stool softeners, laxatives, or suppositories may be necessary. Maintaining a regular time for elimination despite bed rest is effective in promoting regularity.
Renal calculi can develop as a result of bone demineralization caused by immobilization. Unless contraindicated, a fluid intake of 2100 to 2800 ml/day is recommended. Cranberry juice is often recommended to acidify the urine and discourage development of stones.
Rapid deconditioning of the circulatory system can occur as a result of bed rest. These effects can be diminished by permitting the patient to sit on the side of the bed, allowing the lower limbs to dangle over the bedside, and performing standing transfers (unless these measures are contraindicated).
When the patient is allowed to increase activity, careful evaluation should be made to assess for orthostatic hypotension.
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