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MSK/Burns/Abuse Lecture 11/09/2009

Paper: 10 pages doesn’t include cover page, copy of procedure &

references etc. 10 pages Max but can be fewer. Can turn into Moodle or

bring in a paper copy on Monday 10/23.

Case Study: What are we going to assess for this patient in addition to

what we have?

• CMS assess

• Pain level

• Risk Factors for this fall: Osteoporosis, Age, Thin & Frail, Nutritional

status, Hx previous fx

• What else is worrisome for this geriatric pt with a fx?

○ Prolonged immobility leading to loss of function

• How do we prevent osteoporosis

○ Eliminate carbonated beverages, walking 30 mins 5-6x/week,

calcium supplements

Types of Fx (See slide for illustration)

• Long Bone fx

• Small Bone fx

• Spine fx
○ Spinous processes

○ Vertebral body

Types of Traction

• Buck’s: non-invasive, 5-10 lbs, prevents pain b/c decreases muscle

spasm. Maintains alignment of the bone.

• Skeletal traction: pins into bone & contraption that attaches the

weight

• Concerns for a pt in traction?

○ Pressure ulcers – can prevent by turning as long as traction

stays aligned, usually need 2 ppl – one to hold pt traction in

place & one to turn

○ CMS – assess the distal extremity

○ Infection (for skeletal traction)

Priority Assessment

• CMST: Circulation (cap refill, pulse), Motion, Sensation,

Temperature

• Other assessments: circumference of extremity & the quality of pin

sites – s/b w/o signs of infxn
Case Study 8 hours later

• Priority concern now: sensation to L hand extremity – pale, cool,

decrease in sensation, pain w/passive movement

Compartment Syndrome

• Limb-threatening occurrence: high priority for us

• If concerned about this would measure circumference regularly to

ensure it’s not getting bigger

• Surgeon can insert a needle into compartment to get a pressure

reading on it.

• Fasciotomy done if d/t compartment itself, Bivalve cast (clamshell

cast) if d/t tightness of the cast

• Prevention of compartment syndrome: Elevate the limb! And don’t

overload with fluid resuscitation.

Question: what to do when pt has cool/pale distal extremity to injury

in a cast

• Reinforce Dressing

• Remove pillow & lay the leg flat
• Warm the foot w/heating pad & assess pulse w/doppler (don’t do

this b/c heating pad will make the extremity more edematous!)

• Elevate the leg higher & apply ice

Case Study: 24 hours later

• Priority assess when she starts to become restless? – Check

oxygenation status since restlessness is the first indicator of  O2.

• What are your priority actions?

○  O2 via NC (already getting 2L)

○ Notify the physician because… Fat Embolism! Altered mental

status is one of the first signs of this!

Fat Embolism

• Assessment

○ Altered mental status

○ Respiratory distress (tachypneic,  O2 sat)

○ Truncal Petechiae – b/c fat globules block the microcirculation

• Nursing Care

○ O2

○ Monitor circulation
○ Hydration

• 1-3% of pt with single long bone fx get these

• Trunchal petechiae is 20-50% (???)

• Prevent by early immobilization of the fx & operative fixation to

repair the break

What other complications are orthopedic patients at risk for?

• DVT – most common complication of ortho surg & LE fx

• Infection – osteomyelitis especially

• Pneumonia

Types of Fixation – See Slide

• ORIF - Open reduction internal fixation

• IMN – Intramedullary nail

• External fixation – Ex Fix

• Fusion (spine) – seen very rarely in other extremities

• Joint replacement

Case Study – 3 days later
• Hip Precautions for this patient – can’t flex more than 90 degrees,

keep hips abducted & avoid crossing legs. These pts given

“elevators” to go over the toilet so they are not bending down so

deep to go to the bathroom. These precautions done for 6-8 weeks

(see slide for pictures)

• Other d/c issues

○ Meds: pain meds, ongoing DVT prophylaxis

○ Outpatient PT/OT & other f/up appointments

○ They know the signs of infxn

○ Types of weight-bearing permitted: NWB or TDWB

Return to Case Study

• Priority Assessments

○ LOC, Pain, Fluid Status ( AEB low BP &  LOC), Breathing

Approach to care of the burn patient

• Identify degree of burn & calculate percentage burns

• Calculate fluid requirements

• Maintain ABCs

• Initiate & continue wound care
• This pt would go to the ICU – discussion of which pts go to ICU &

which would go to Med Surg unit

• Rule of 9s: circumferential scald burns from mid abdomen to toes

bilaterally

• For our patient – calculates out to 65%

Degrees of Burn Injury

• Superficial (1st degree)

○ Epidermis Only

○ Heal 3-6 days

• Partial Thickness (Dermal)

○ Epidermis + Dermis

○ Superficial: heal 10-21 days, Uniformly pink, moist & painful,

scarring minimal if at all & function intact

○ Deep: heal 3-8 weeks, Dry & white, not painful d/t nerves

burned away, person will be severely scarred & lose fxn

• Full Thickness

○ Epidermis + entire dermis, sometimes into fat

○ Cannot heal on own

○ Needs grafting to heal
Capillary Leak

• Total Burn < 20% BSA = localized

• Total Burn > 20% BSA = systemic – Ineffective Perfusion, Fluid

Volume Decrease, Ineffective Cardiac Output

• Leak seals in 12-24 hours, fluid re-mobilization (migration from

interstitium back into vasculature) starts at about 24 hours, then 2-

3 days after, you enter the diuretic stage where the fluid is being

expelled.

• Initially hyponatremic & hyperkalemic, later on hyponatremic &

hypokalemic

Fluid Resuscitation

• Parkland formula: 3-4 ml/kg/% TBSA burned

○ ½ total volume in first 8 hours

○ ½ total volume over next 16 hours

○ Lactated Ringer’s – has a little extra water & don’t need to

give a maintenance fluid on top of that for ongoing hydration

needs.

• Ongoing fluid resuscitation w/goal of urine output > 30 ml/hr
• Persistent massive fluid needs -> plasmapheresis being used to

modulate the inflammatory response

Calculating Fluid Administration (KNOW THIS!!! Per Kyla)

• For Ms G: 50 kg; 65% burns; 3 ml/kg/% TBSA

○ 3 ml/kg = 150 ml/%

○ 150 x 65 = 9,750 ml

○ 1st 8 hours = ½ of total = 4875 @ 610 ml/hr

○ Next 16 hours = 4875 @ 305 ml/hr

• 8 hours starts from the time of the burn – if pt got 2L fluid with

paramedics, for example, we don’t count this in our equation.

Whether they got fluid or not, just do our calculation &

administration anyway

Systemic Effects r/t Capillary Leak (will cover in further detail when we

talk about sepsis & shock) – see slide with list of symptoms
ABCs – Escharotomy sometimes needed since circumferential aschar

on trunk can compress lungs, inhibit ventilation. Also happens on

extremities & compresses circulation (note that escharotomy is not done

through fascia)

Burn Dressings

• Goal: keep clean, moist, prevent infection

• Note: cold water on burn only helps in 1st degree type burns at

home, can contribute to hypothermia for more serious burns.

• Wound coverings

○ Antimicrobial creams (silver sulfadiazene – silver has

antimicrobial properties & also keeps moist)

○ Light wraping of gauze to keep cream in place

○ Wet dsg when wound is healing & not infected

○ We don’t use wet-to-dry b/c v painful with these pts & that

level of debridement not usually needed

• Wound treatments – usually once or twice a day & this pt is at a

specialty center for burns

• Nursing Concerns for these patients with big burn dressings

○ Pain – pre-medicate, sometimes even with propofol
○ Infection – odor, purulence, exudate, edges of burn start to

look inflamed & red, graft will slough off if infectious process

is happening

Burns on her R arm from hot water – best tx for this burn?

• Cool the burn w/moist sterile compress then cover w/dry sterile

dressing & administer tetanus

Skin Grafting

• Graft care

○ Ensure Adherence

○ May need wound vac

○ Can be homo or hetero graft – some are human some are

pigs, or an auto graft – self donation of skin graft – pt can

keep donating from self, skin put through a “mesher” creating

honeycomb appearance.

○ Must be immobilized in that area until skin graft has “taken”

• Acticoat – helps skin heal (LOOKUP)

Nursing Care of the Burn Pt
• Alteration in comfort

○ RTC & PRN meds

○ Premedicate for wound care or other treatments

• Risk for impaired wound healing r/t edema

○ Elevate

○ Soft wraps may be used to decrease swelling

• Risk for altered nutrition

○ Start PO diet or tube feeds on admission – as stress ulcer

prophy and high metabolic needs d/t injury. (Unless there is

some type of major indication)

○ Would monitor blood glucose as well & would keep glucose

out of fluids for 1st 24 hrs.

• Risk for infection

○ Dressings as ordered

• Environment

○ Massive burns may require “tropicana room”

• Occupational/Physical Therapy from the very beginning, unless a

skin graft needs to adhere or some other contra-indication.

○ Maintain mobility & fxn

○ Prevent contractures
• Significant Psychosocial needs

• Reflect on case studies

○ 78 y.o. female, dependent on caregivers, history of fractures,

recent severe burn

○ What is another RN priority given these? -> report known or

suspected abuse

Elder Abuse Laws – see slide

• Financial – identity theft/embezzlement

• Physical – includes hitting, spitting, and biting

• Neglect – failure to provide adequate daily necessities such as

personal hygeine, medical care, food

• Most abuse goes undetected or unreported by health care

professionals

Take Home Points Slide!!
11/09/2009
11/09/2009