Upload
simonedarling
View
220
Download
0
Embed Size (px)
Citation preview
8/14/2019 N144 MSK Burns Abuse Lecture
1/15
MSK/Burns/Abuse Lecture 11/09/2009
Paper: 10 pages doesnt 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
8/14/2019 N144 MSK Burns Abuse Lecture
2/15
Spinous processes
Vertebral body
Types of Traction
Bucks: 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
8/14/2019 N144 MSK Burns Abuse Lecture
3/15
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 its 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 dont
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
8/14/2019 N144 MSK Burns Abuse Lecture
4/15
Warm the foot w/heating pad & assess pulse w/doppler (dont 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
8/14/2019 N144 MSK Burns Abuse Lecture
5/15
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
8/14/2019 N144 MSK Burns Abuse Lecture
6/15
Hip Precautions for this patient cant 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
8/14/2019 N144 MSK Burns Abuse Lecture
7/15
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
8/14/2019 N144 MSK Burns Abuse Lecture
8/15
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
total volume in first 8 hours
total volume over next 16 hours
Lactated Ringers has a little extra water & dont 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
8/14/2019 N144 MSK Burns Abuse Lecture
9/15
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 = 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 dont 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
8/14/2019 N144 MSK Burns Abuse Lecture
10/15
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 dont 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
8/14/2019 N144 MSK Burns Abuse Lecture
11/15
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
8/14/2019 N144 MSK Burns Abuse Lecture
12/15
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
8/14/2019 N144 MSK Burns Abuse Lecture
13/15
8/14/2019 N144 MSK Burns Abuse Lecture
14/15
11/09/2009
8/14/2019 N144 MSK Burns Abuse Lecture
15/15
11/09/2009