NSG210 Hinkle Ch. 37: Management of Patients With Musculoskeletal Trauma

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 37, pp. 1152-1202 (textbooks/HINKLE_MS_CH37.pdf, also in textbooks/exam03/). Week 08 reading (Peripheral Vascular Diseases lecture, amputation slides 29-34; also activity and rest); on Exam 3. Numbering note: the course outline cites “Chapter 38 (Amputations),” which is older-edition numbering; amputation is in Ch. 37 of the 15th edition. Lecture emphasis for amputation is in nsg210-week-08-peripheral-vascular-diseases-lecture.

Learning Outcomes

1. Differentiate contusions, strains, sprains, dislocations, and subluxations.
2. Identify manifestations, treatment, complications, and rehabilitation for common fractures.
3. Describe nursing management and teaching for a cast, splint, brace, or traction.
4. Use the nursing process for the older adult with a hip fracture.
5. Recognize sports- and occupation-related musculoskeletal disorders.
6. Apply the nursing process for the patient with an amputation.

I. Soft Tissue Injuries

• Contusion: blunt force bleeding into soft tissue (bruise, hematoma); resolves 1-2 weeks
• Strain (“muscle pull”): muscle or tendon overstretch
  • 1st degree: mild stretch, no ROM loss, tenderness, mild spasm
  • 2nd degree: partial tear; pain with passive ROM, edema, spasm, bruising
  • 3rd degree: complete rupture; tearing/snapping pain, loss of function; x-ray to rule out avulsion fracture
• Sprain: ligament injury from twisting or hyperextension (ankles, knees, wrists)
  • Grade I: stretch or slight tear; Grade II: partial tear with instability; Grade III: complete tear, abnormal joint motion, possible avulsion
• Tendons attach muscle to bone; ligaments attach bone to bone
• Treatment: RICE - Rest, Ice (intermittent for first 24-72 hours, no more than 20 minutes at a time), Compression (elastic bandage), Elevation (at or just above heart level); NSAIDs; splint, brace, or cast for severe injuries
• Neurovascular checks every 15 minutes for 1-2 hours, then every 30 minutes until stable; report decreasing sensation or motion and rising pain (compartment syndrome)

II. Dislocations

• Dislocation: joint surfaces completely out of alignment; subluxation: partial
• Orthopedic EMERGENCY - nerves and vessels may be compressed; delayed reduction risks avascular necrosis (AVN)
• Signs: acute pain, abnormal joint position, decreased ROM, asymmetry
• Immobilize at the scene; consent; prompt closed reduction with analgesia, muscle relaxants, or anesthesia; immobilize; neurovascular checks at least every 15 minutes until stable; then gentle progressive ROM

III. Tendon, Ligament, and Meniscus Injuries

• Rotator cuff tear: aching pain worse with use, trouble sleeping on that side, decreased ROM and strength; conservative (PT, NSAIDs, steroid injection) or surgery; sling 4-6 weeks; rehab 3-6 months
• Epicondylitis: lateral (tennis elbow, 7 times more common) and medial (golfer’s elbow); rest, ice, NSAIDs, splint, PT; steroid injections reserved (tendon degeneration)
• Collateral ligament (MCL, LCL) injury: foot planted, knee struck from the side; RICE, hinged brace, crutches; MCL heals 8-12 weeks; severe LCL often needs surgery
• Cruciate ligament (ACL, PCL): foot planted, forward or backward force; “pop,” swelling within 2 hours; RICE, crutches; arthroscopic reconstruction with graft for active patients; post-op neurovascular checks, cryotherapy, ankle pumps, quad and hamstring sets
• Meniscal tear: twisting or squatting; knee “gives way,” clicks, or “locks” (bucket-handle tear); effusion; ice 15 minutes every 4-6 hours, crutches, PT; arthroscopic meniscectomy or repair
• Achilles tendon rupture: “pop,” cannot plantar flex or bear full weight; cast or boot with heel lift, or surgery for young athletes

IV. Fractures

A. Types (Figure 37-2)

• Closed (simple): skin intact; open (compound): wound extends to bone
• Open fracture grades (Gustilo-Anderson): I clean wound under 1 cm; II larger wound, minimal soft tissue damage; III severe contamination, extensive soft tissue damage, vascular injury, or traumatic amputation
• Comminuted (several fragments), greenstick (one side broken, other bent), transverse, oblique, spiral (twisting), compression (vertebrae), depressed (skull), impacted, avulsion (fragment pulled off by tendon), pathologic (diseased bone - osteoporosis, tumor, metastasis), stress (repeated loading), epiphyseal, intra-articular (into joint; leads to early arthritis)

B. Clinical manifestations

• Pain (continuous, worse until immobilized; spasms begin within minutes to 30 minutes), loss of function, deformity, shortening (spasm overlaps fragments), crepitus (grating), localized edema and ecchymosis

C. Emergency management

• Immobilize BEFORE moving; splint joints above and below; leg can be bandaged to the other leg; arm to chest or sling
• Check neurovascular status distal to injury before and after splinting
• Open fracture: cover with sterile dressing; do NOT try to reduce, even if bone protrudes
• In ED: remove clothes from uninjured side first; cut away if needed; move injured part as little as possible

D. Medical management

• Reduction as soon as possible (harder as healing begins): closed (manipulation, manual traction, cast or splint; x-ray to confirm) or open reduction internal fixation (ORIF: pins, wires, screws, plates, nails, rods)
• Immobilization: casts, splints, traction, external fixators, internal fixation
• Restore function: elevate, ice, neurovascular checks, pain control, isometric and muscle-setting exercises, ADLs
• Closed fracture healing: about 6-8 weeks

E. Open fractures

• Risk of osteomyelitis, tetanus, gas gangrene
• IV antibiotics on arrival plus tetanus toxoid IM as indicated
• Irrigation and debridement in OR ASAP; wound culture; external fixation; wound usually left open (delayed closure, wound VAC); repeat debridement; bone graft as needed
• Elevate; frequent neurovascular checks; monitor temperature

F. Fracture healing

• Faster: flat bones (pelvis, sternum, scapula), ends of long bones (cancellous, vascular), younger patients
• Slower (Chart 37-3): age over 40, AVN, bone loss, smoking, diabetes, RA, corticosteroids and NSAIDs, extensive trauma, poor immobilization, infection, malignancy, malalignment, early weight bearing

V. Early Complications

A. Shock

• Hypovolemic from hemorrhage, especially pelvic and femoral fractures (femur can lose 1-2.5 L into tissues)
• Stabilize fracture, restore volume, relieve pain, immobilize

B. Fat embolism syndrome (FES)

• Fat globules from marrow enter circulation after long bone (femur) and pelvic fractures; more common in CLOSED fractures; males 10-40
• Onset 24-72 hours (up to a week)
• Classic triad: hypoxemia, neurologic changes, petechial rash
  • Respiratory first: hypoxia, tachypnea, dyspnea, tachycardia, chest pain, low-grade fever, crackles; may progress to ARDS
  • Neuro: restlessness, agitation, confusion, seizures
  • Petechiae 2-3 days later on chest, mucous membranes (nondependent areas)
• Safety alert: subtle personality change, restlessness, irritability, or confusion after a fracture means get ABGs immediately
• Prevention: immediate immobilization, early surgical fixation, minimal manipulation, support during turning, fluid balance; treatment is supportive (oxygen, fluids, ventilation, sometimes steroids)

C. Acute compartment syndrome - surgical emergency

• Pressure in a closed compartment exceeds perfusion pressure (swelling or bleeding inside; tight cast or dressing outside); tibial fractures highest risk; young adults; develops over hours (up to 48)
• Five Ps: pain, pallor, pulselessness, paresthesia, paralysis
  • CARDINAL sign: pain out of proportion to the injury, deep and burning, NOT relieved by analgesics, worse with PASSIVE STRETCH
  • Then decreased sensation, numbness, weakness; paralysis and pulselessness are LATE
• Muscle swollen and hard, skin taut and shiny; compartment pressure normal 8 mm Hg or less; over 30 mm Hg sustained causes irreversible damage
• Nursing action: notify surgeon immediately; REMOVE constriction (bivalve or open cast, loosen splint and dressings); keep extremity at HEART LEVEL - NOT above (elevation lowers arterial perfusion); opioids; watch urine for rhabdomyolysis
• Fasciotomy: wound left open with moist saline dressing or wound VAC; limb splinted in functional position at heart level; closed in 2-3 days
• Delay leads to permanent nerve/muscle damage, infection, rhabdomyolysis with kidney injury, amputation
• Missed compartment syndrome in the arm causes Volkmann ischemic contracture (clawlike hand)

D. Other early complications

• VTE (DVT, PE): highest risk with lower extremity and pelvic fractures; PE can occur days to weeks later
• DIC: bleeding from mucous membranes, IV sites, GI and urinary tracts
• Infection: all open fractures are contaminated - irrigation, debridement, tetanus, IV antibiotics

VI. Delayed Complications

• Delayed union (heals slower than expected), nonunion (fails to unite; most common in tibia), malunion (heals deformed; most common in hand) - persistent discomfort and abnormal movement at site
  • Treatment: electrical bone growth stimulators, low-intensity ultrasound, bone grafts (autograft - often iliac crest; allograft - donor), internal or external fixation; non-weight bearing; healing 6-12 months
• Avascular necrosis (AVN): bone loses blood supply and dies; hip most common; after femoral neck fractures, dislocations, high-dose steroids, radiation, sickle cell, alcohol, smoking; pain with movement then at rest
• Complex regional pain syndrome (CRPS): disproportionate burning pain, edema, hyperesthesia, stiffness, color and temperature changes, shiny skin; women, average age 40; treatment early pain control (NSAIDs, gabapentin, amitriptyline, nerve blocks) and early rehab; do NOT use the affected limb for BP or venipuncture
• Heterotopic ossification: bone forming in soft tissue after injury; pain, stiffness, decreased ROM

VII. Casts, Splints, and Braces

A. Casts

• Immobilize joints above and below the fracture
• Types: short arm (below elbow to palmar crease), long arm (axilla to palm, elbow at 90 degrees), short leg (below knee to toes, foot at right angle), long leg (upper thigh to toes), walking boot, body cast, shoulder spica, hip spica
• Fiberglass: light, strong, water resistant, rigid in 30 minutes; gives off heat while setting (warn patient); waterproof lining allows showering (blot, drain, dry with cool or warm hair dryer about 1 hour)
• Plaster: cheaper, better mold, heavy, takes 24-72 hours to dry; heat can burn (especially older adults); do NOT cover while drying; handle with PALMS only (fingertips dent and create pressure points); support on pillow (cloth, not plastic) or smooth firm surface; dry cast is white, shiny, hard, resonant, odorless; wet cast is gray, dull, damp, musty
• Petal rough edges; moleskin over rough areas

B. Splints and braces

• Splints: faster, noncircumferential (allow swelling), easy to remove for inspection; preferred initial immobilization; overwrap with elastic bandage in spiral
• Braces (orthoses): custom fit, longer-term support

C. Nursing management

• Before application: assess skin, neurovascular status; clean and treat wounds; tetanus booster if dirty wound and last dose over 5 years; explain heat sensation
• Neurovascular checks at least every hour for 24 hours, then every 1-4 hours: pulses, capillary refill (under 3 seconds), color, temperature, edema, movement, sensation; compare with other limb
• Elevate above heart for first 24-48 hours (EXCEPT if compartment syndrome is suspected - then heart level); ice on sides of cast without denting or wetting
• NEVER ignore pain in a casted patient - unrelieved pain and rising analgesic needs must be reported immediately (compartment syndrome, pressure injury, impaired perfusion)
• Pressure injury signs: painful “hot spot,” tightness, warmth on cast, drainage stain, odor; cast may be windowed or bivalved (replace window piece to prevent window edema)
  • Lower extremity pressure points: heel, malleoli, dorsum of foot, fibular head, patella; upper: medial epicondyle, ulnar styloid
• Infection: foul odor, purulent drainage staining cast, fever
• Disuse syndrome: isometric exercises (make a fist, push knee down) and quadriceps and gluteal setting (hold 5-10 seconds, 10 times every hour awake); move fingers and toes hourly
• Teaching (Chart 37-5): elevate, ice as prescribed, report uncontrolled pain, cool pale digits, numbness, inability to move; for itching use a hair dryer on cool - never insert objects; pad edges; keep dry
• Cast removal: explain saw vibrates but does not cut skin; support limb; soak skin in warm water, emollient, do not scrub or scratch; elevate (not above heart) for swelling; gradual activity

D. Upper extremity immobilization

• Elevate arm above heart on pillow, each joint higher than the one before (hand above elbow above shoulder)
• Sling should distribute weight over shoulders and trunk, not back of neck; remove often
• Watch for Volkmann contracture: unable to extend fingers, pain with passive stretch, poor circulation

E. Lower extremity immobilization

• Support leg on pillows to heart level; ice 1-2 days; recumbent with leg up several times a day; toe and ankle exercises
• Peroneal nerve compression at fibular head: numbness, tingling, burning on top of foot, weak dorsiflexion - leads to FOOTDROP
• Teach crutch or walker use; cast shoe for weight bearing

F. Body and spica casts

• Superior mesenteric artery (cast) syndrome: duodenum compressed; anxiety reaction, abdominal distention and discomfort, nausea, bilious vomiting; check bowel sounds every 4-8 hours; NG decompression; window or bivalve cast

VIII. External Fixators

• Pins through skin into bone attached to an external frame; for open fractures with soft tissue damage, comminuted fractures, nonunion, limb lengthening
• Advantages: immediate stability, less blood loss, wound access, early mobility
• Prepare patient for appearance (body image); cover sharp pin ends with caps
• Elevate to heart level; neurovascular checks every 2-4 hours
• Pin sites inspected every 8-12 hours: redness, swelling, pain, warmth, purulent drainage; serous drainage, warmth, mild redness normal for first 48-72 hours
• Pin care: clean each pin with separate swab; chlorhexidine 2 mg/mL (watch for allergy); leave uninfected crusts in place
• NEVER adjust the clamps - provider’s job
• Ilizarov fixator: circular frame with wires; patient adjusts telescoping rods daily to lengthen limb or correct deformity

IX. Traction

• Pulling force to align fractures, reduce spasm and pain; usually short-term until surgery
• Principles: countertraction needed (patient’s body weight, bed position); continuous; SKELETAL traction is NEVER interrupted; weights not removed unless intermittent traction ordered; weights hang FREELY (not on bed or floor); ropes unobstructed in pulley grooves; knots away from pulleys; patient centered and aligned in bed
• Skin traction (Buck’s extension): temporary for hip fractures (limited evidence of benefit); 5-8 lb (2.25-3.5 kg) on a leg, max about 8 lb; foam boot or traction tape; avoid pressure on malleoli and fibular head
  • Remove boot to inspect skin at least twice daily (second person supports leg); check circulation 15-30 minutes after application, then every 1-2 hours; peroneal nerve checks (dorsiflexion); foot exercises hourly
• Skeletal traction: pin or wire through bone (proximal tibia, distal femur) or skull tongs; 25-40 lb; balanced suspension with Thomas splint and Pearson attachment
  • NEVER remove weights unless life-threatening emergency
  • Footdrop prevention, neutral foot position
  • Trapeze to move (do not push with elbows or heel); off-load heels; skin checks every 8 hours
  • Neurovascular checks every hour for 24 hours, then every 4 hours; calf pumps 10 times an hour
  • Pin sites: sterile dressing first 48 hours, then loose or none; care daily or weekly with chlorhexidine; inspect every 12 hours
• Immobility complications: atelectasis and pneumonia (auscultate every 4-8 hours, cough and deep breathe, incentive spirometer), constipation (fiber, fluids, softeners), urinary stasis and UTI (void every 3-4 hours, fluids), VTE (ankle exercises every 1-2 hours, fluids, stockings, anticoagulants), pressure injuries, anxiety and confusion

X. Fractures of Specific Sites

• Clavicle: fall or blow to shoulder; patient slumps shoulders; clavicular strap (figure-eight) or sling; heals 6-12 weeks; do not raise arm above shoulder until healed; exercise elbow, wrist, fingers; complications: brachial plexus or subclavian vessel injury, pneumothorax
• Humeral neck: fall on outstretched hand; older women; arm hangs limp; sling and swathe; PENDULUM exercises early to prevent frozen shoulder; heals 6-10 weeks
• Humeral shaft: watch RADIAL NERVE; sugar-tong (coaptation) splint, then functional brace with collar-and-cuff sling for about 8 weeks; pendulum exercises
• Elbow (distal humerus): risk of brachial artery and median nerve injury; Volkmann ischemic contracture is most serious complication; monitor five Ps
• Proximal radius: fall on outstretched hand; aspirate hemarthrosis; sling; early motion
• Radius and ulna shafts: long arm cast, elbow 90 degrees; finger exercises; heals 12-16 weeks; avoid lifting and twisting
• Wrist (Colles fracture, distal radius): fall on outstretched hand; older adults with osteoporosis; sugar-tong splint then short arm cast in 2-3 weeks; move fingers and shoulder (finger flexion and extension 10 times every hour); check median nerve (sensation at tip of index finger; touch thumb to little finger)
• Hand: boxer’s fracture (5th metacarpal); buddy taping for phalanx 3-4 weeks; elevate
• Pelvis: high mortality (hemorrhage); signs - ecchymosis, tenderness at pubis, iliac spines, sacrum; numbness of groin/thighs; severe back pain (retroperitoneal bleed); check dorsalis pedis pulses (absent may mean iliac artery tear); handle gently
  • Stable: bed rest, analgesics, progressive mobility, fiber, stockings, logrolling; sacral fracture - watch for paralytic ileus; coccyx - donut cushion, sitz baths, stool softeners
  • Unstable (“open book,” vertical shear): pelvic binder, embolization, external fixation or ORIF; deaths from hemorrhage and head injury in first 24 hours, later from MODS and sepsis
• Acetabulum: knees into dashboard; traction or ORIF; complications AVN, nerve damage, arthritis
• Femoral shaft: young adults, high energy; large blood loss (1-2.5 L, shock); skeletal traction or splint then intramedullary nail ASAP; complications FES, compartment syndrome, knee stiffness
• Tibia and fibula: check PERONEAL nerve (cannot dorsiflex great toe, numb first web space) and tibial artery; cast or brace; heals 10-14 weeks; high risk of compartment syndrome
• Ribs: pain causes splinting and shallow breathing leading to atelectasis and pneumonia; pain control (scheduled acetaminophen plus NSAID, lidocaine patch, nerve block), splint chest with pillow to cough, incentive spirometer; NO chest binders; heals in 6 weeks; older adults with multiple rib fractures should be admitted
• Thoracolumbar spine: T12-L2 most common; osteoporosis causes 50-70% (compression fractures); immobilize until cord injury ruled out; stable - brief bed rest and brace (TLSO); unstable - surgical fusion within 24 hours

XI. Hip Fracture (Older Adult)

• Over 300,000 a year in adults 65+; 95% from falls; women; risk: osteoporosis, weak quadriceps, poor vision and balance, cognitive impairment, orthostasis from medications (antihypertensives, diuretics, sedatives, antipsychotics, antidepressants, benzodiazepines, opioids - Beers Criteria)
• Intracapsular (femoral head and neck): high risk of AVN and nonunion (blood supply disrupted)
• Extracapsular (intertrochanteric, subtrochanteric)
• Manifestations: groin or outer thigh pain; affected leg SHORTENED, ADDUCTED, and EXTERNALLY ROTATED (more shortening and rotation with extracapsular); impacted fractures may still bear weight
• Older adult risks: delirium, atelectasis, pneumonia, VTE, pressure injuries, dehydration and malnutrition (may lie on floor for a day before found); monitor chronic conditions and medications
• Treatment: surgery ASAP (displaced femoral neck within 24 hours) - ORIF with pins, screws, compression hip screw and plate; hemiarthroplasty (femoral head only) or total hip arthroplasty for intracapsular fractures; Buck’s traction only temporary
• Post-op nursing:
  • Pain control (preemptive before PT)
  • Neurovascular checks; DVT prevention (stockings or SCDs off 20 minutes twice a day for skin care, anticoagulants, ankle exercises every 1-2 hours, fluids)
  • Turn to the UNINJURED side with a pillow between the legs (keep abducted); trochanter roll prevents external rotation
  • Trapeze to strengthen arms; out of bed to chair day 1; weight bearing as prescribed; hip precautions only after arthroplasty
  • Cough, deep breathe, incentive spirometer
  • Remove urinary catheter within 24 hours; bladder scan if no void in 6 hours
  • Skin: pressure redistribution mattress, off-load heels, vertical elastic tape to avoid blisters
  • Delirium prevention: orientation, glasses and hearing aids, consistent staff, lights at night, call bell
  • Hemorrhage: monitor VS, drainage, H&H
  • Late: infection (constant hip pain, high ESR), nonunion, AVN
• Discharge: usually to rehab; home safety (raised toilet seat, grab bars, remove throw rugs, lighting); osteoporosis screening (DEXA), calcium and vitamin D, weight-bearing exercise

XII. Sports and Occupational Injuries

• Sports injuries (Table 37-1): clavicle, shoulder dislocation (anterior arm looks longer, empty socket), elbow dislocation, wrist fracture, knee sprain and strain, meniscal tear (McMurray sign click), ankle sprain, strain, fracture, metatarsal stress fracture; return to play when pain free with good ROM; prevent with equipment, conditioning, stretching, hydration
• Occupational: sprains, strains, tears cause most lost workdays; nurses are in the top 10 occupations for injuries - use safe patient handling equipment

XIII. Amputation

• Most from vascular disease (PVD, diabetes); trauma second; African Americans at higher risk; about 2 million Americans living with limb loss
• Goals: control pain or disease, improve function, save or improve quality of life
• Level: most distal point that will heal (circulation, tissue viability, infection, prosthetic use); preserve knee and elbow
  • Syme (ankle disarticulation), below-knee (BKA - preferred, less energy to walk), knee disarticulation, above-knee (AKA), hip disarticulation (usually wheelchair)
  • Staged (guillotine) amputation for infection/gangrene: open amputation, antibiotics, definitive closure days later
• Complications: hemorrhage, infection, skin breakdown, phantom limb pain, joint contracture, neuroma

A. Assessment

• Neurovascular and functional status of both limbs; infection signs (nodes, fever, purulent drainage) and culture
• Nutrition: adequate protein and vitamins; extra calories for prosthesis use and transfers
• Comorbidities (diabetes, anemia, cardiac, respiratory); medications (steroids, anticoagulants)
• Psychological status, grief

B. Pain and phantom limb pain

• Incisional pain: opioids; reposition; light sandbag on residual limb for spasm
• Phantom limb pain in 60-80%: missing limb feels crushed, cramped, twisted, burning, electric; ACKNOWLEDGE it as real; usually decreases over time (may last 2 years)
• Preemptive epidural analgesia may reduce it; acetaminophen, NSAIDs, gabapentin, opioids, ketamine, beta-blockers (dull burning), anticonvulsants (stabbing, cramping), tricyclic antidepressants; mirror therapy, massage, TENS, biofeedback, acupuncture, guided imagery

C. Wound healing and residual limb care

• Dressings: rigid removable (less edema, faster to prosthesis) or soft compression dressings (if drainage or poor skin); drain; staples out about 3 weeks
• Inspect incision daily; measure residual limb every 8-12 hours for edema; neurovascular checks
• If rigid or soft dressing comes off: IMMEDIATELY wrap with elastic compression bandage and notify surgeon (edema develops fast and delays rehab)
• Compression at ALL times; figure-eight wrap with more pressure DISTALLY to shape a cone for the prosthesis; elastic bandage, shrinker sock, or air splint
• After healing: wash with mild soap and water and dry at least twice daily; NO oils, lotions, creams; inspect with mirror; residual limb sock changed daily, no wrinkles; prosthetic socket washed with mild detergent and dried completely
• Toughening: push limb into soft pillow, then firmer pillow, then hard surface; massage after healing; desensitization
• Do not wear prosthesis if redness, blisters, or breakdown

D. Positioning and mobility (lower limb) - high yield

• Elevate residual limb on a pillow for the FIRST 24 HOURS ONLY (edema)
• After 24 hours: NO pillow under the residual limb (causes hip flexion contracture); avoid elevation, abduction, external rotation, and flexion
• Do not sit for long periods (hip flexion contracture) or let the limb dangle (edema)
• PRONE position 20-30 minutes several times a day to stretch hip flexors
• Keep legs together (prevent abduction deformity)
• Early ROM: hip and knee for BKA; hip for AKA
• Strengthen arms (trapeze, weights, seated push-ups for triceps), trunk, and abdominal muscles for crutch walking
• Center of gravity changes - practice balance; transfer belt; nonskid shoe
• Parallel bars with temporary prosthesis, then crutches; do not hold residual limb flexed while walking
• Non-prosthesis candidates: amputee wheelchair (rear axle set back about 2 inches to prevent tipping backward)

E. Upper limb amputation

• Exercise both shoulders (both used to operate prosthesis); postural exercises; one-handed ADLs early; temporary prosthesis early; cotton T-shirt under harness

F. Body image, grief, self-care

• Encourage patient to look at, touch, and care for the residual limb; be present when patient first views self in a mirror
• Accept grief behaviors (crying, anger, withdrawal); counseling, pastoral care, support groups, peer visitors
• Encourage independence in self-care; do not rush; OT and PT

G. Complications

• Hemorrhage: monitor VS and drains; keep a LARGE TOURNIQUET at the bedside; apply for severe bleeding and notify surgeon immediately
• Infection: prophylactic antibiotics; monitor drainage color, odor, consistency, increasing pain, fever, WBC with bands over 10%
• Skin breakdown from prosthesis or immobility
• Immobility complications: atelectasis, pneumonia, DVT/PE, constipation, urinary stasis, pressure injuries

H. Rehabilitation and discharge

• Multidisciplinary team (nurse, provider, PT, OT, prosthetist, social worker, psychologist, vocational rehab)
• Prosthetic socket adjusted over first 6-12 months as limb shrinks
• Home assessment, inpatient rehab improves outcomes, transportation, support groups, health screening
• Veterans: VA/DoD amputation care guidelines and registry

High-Yield Numbers

• Ice no more than 20 minutes at a time, first 24-72 hours
• Neurovascular checks after injury: every 15 minutes for 1-2 hours; after cast: every hour for 24 hours
• Capillary refill under 3 seconds
• FES onset 24-72 hours; petechiae 2-3 days
• Compartment pressure normal 8 or less; over 30 mm Hg irreversible damage
• Closed fracture heals 6-8 weeks; clavicle 6-12; humeral neck 6-10; radius/ulna 12-16; tibia 10-14; ribs 6 weeks
• Fiberglass cast rigid in 30 minutes; plaster dries 24-72 hours
• Elevate casted limb above heart for 24-48 hours (unless compartment syndrome suspected)
• Buck’s traction 5-8 lb; skeletal traction 25-40 lb
• Skeletal traction neuro checks every hour for 24 hours then every 4 hours
• Pin site normal serous drainage first 48-72 hours
• Muscle setting: hold 5-10 seconds, 10 times an hour
• Femur can lose 1-2.5 L of blood
• Hip fracture: shortened, adducted, externally rotated; displaced femoral neck surgery within 24 hours; catheter out within 24 hours
• Phantom limb pain 60-80%
• Residual limb on pillow first 24 hours only; prone 20-30 minutes several times a day
• Staples out about 3 weeks after amputation

Priority Nursing Actions and Red Flags

• Pain out of proportion, unrelieved by opioids, worse with passive stretch: compartment syndrome - notify surgeon, loosen or bivalve cast, keep limb at HEART level
• Confusion, restlessness, dyspnea, petechiae 1-3 days after femur or pelvic fracture: fat embolism - oxygen, ABGs, notify
• Open fracture: sterile dressing, do not reduce, IV antibiotics, tetanus
• Dislocation: emergency reduction to prevent AVN and nerve/vessel damage
• Splint before moving; check pulses before and after
• Pelvic fracture with absent pedal pulses or hypotension: hemorrhage
• Numbness on top of foot, weak dorsiflexion: peroneal nerve compression (footdrop)
• Foul odor or drainage through cast: infection
• Never remove skeletal traction weights; never adjust external fixator clamps
• Body cast with vomiting and distention: superior mesenteric artery syndrome
• Rib fractures: pain control so the patient can deep breathe; no binder
• Hip fracture older adult: watch for delirium, turn to uninjured side with pillow between legs
• Amputation: tourniquet at bedside; if dressing falls off wrap immediately; no pillow under residual limb after 24 hours; prone positioning; acknowledge phantom pain

Medications

Related

• nsg210-hinkle-ch26-vascular-disorders - PAD as the main cause of amputation (same lecture)
• nsg210-week-08-peripheral-vascular-diseases-lecture - lecture amputation slides
• nsg210-hinkle-ch36-musculoskeletal-disorders - osteoporosis, osteomyelitis, arthroplasty
• nsg210-hinkle-ch19-chest-lower-respiratory-disorders - flail chest, chest trauma
• INDEX - NSG210 chapter index
• nsg210-textbook-chapter-crosswalk