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(Massey, 2020)

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Treat patient's pain, using non-pharmacologic (Electrical bone stimulation, social interaction, distraction or RICE: rest, ice, compression, and elevation) pharmacologic(Opioids or patient-controlled analgesics), or a combination of approaches.

Assess neurovascular status; check for pain, pallor, pulses, and paresthesias in the affected extremity.

Monitor for signs of shock(rapid pulse, decreased blood pressure and pallor)

Encourage adequate fluid intake to avoid urinary stasis and constipation.

Monitor vital signs

Assess for signs and symptoms of fat emboli, such as, restlessness, confusion and irritability or pulmonary embolism, tachypnea, hypotension and weak, rapid pulse.

Perform dressing changes, as needed, if open wounds are present. Assess wounds for redness, irritation, and drainage.

Assess lung sounds for changes; administer supplemental oxygen based on pulse oximetry levels, as ordered. Encourage coughing and diaphragmatic breathing exercises and the use of incentive spirometry if the patient requires prolonged bed rest for immobilization.

Encourage the patient to participate in care to promote feelings of control.

Inspect the skin, pin insertion sites, and wounds for signs and symptoms of infection. Obtain cultures of any drainage.

Assist the patient with mobility as soon as possible. Help the patient walk, and demonstrate how to use crutches or other assistive devices, reinforcing any teaching performed by the physical therapist.

(Wolters Kluwer [Lippincott Advisor], 2019)

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Age; history of chronic illnesses that may increase risk for complications; medications (especially anticoagulants); history of musculoskeletal injuries; normal activity levels; and etiology of current fracture(Pearson, 2015) .

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Assessment of distal pulses in the injured extremity; pain; edema; swelling; color of skin; temperature of skin; malformation of extremity; range of motion of extremity; and sensation(Pearson, 2015) .

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Pain- Assess patients pain on a 0-10 scale, pain with movement, location, quality and etiology of pain.
Pulses- Compare distal pulses between the affected extremity and unaffected extremity. Compartment syndrome or arterial compromise may be indicate if there is a lack of distal pulse.
Pallor- Compare skin color of affected extremity, unaffected extremity, and skin in general. Pallor may indicate severe loss of blood. Pallor with coolness  of affected extremity may indicate decreased arterial supply. Cyanosis and warmth may indicate venous stasis.                  Paresthesia- Ask the patient for any changes in sensation such as burning, tingling, or numbness. Paresthesia may indicate neural damage or involvement.  Paralysis/paresis- Assess the patient's ability to  move body parts distal to the fracture (fingers and toes). If the patient is not able to achieve this, this may indicate paralysis; muscle weakness may indicate paresis. Paralysis or paresis may indicate nerve or tendon damage(Pearson, 2015) .

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Bone Fractures Types Nursing Interventions, Treatment, Signs and Symptoms NCLEX

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SpongeBob SquarePants - Glass Bones and Paper Skin

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Imaging:

Anteroposterior, oblique, and lateral X-rays of the suspected fracture as well as X-rays of the joints above and below the fracture confirm the diagnosis.

Magnetic resonance imaging or computed tomography scanning (bone) may confirm the diagnosis if not conclusive on X-ray.

(Wolters Kluwer [Lippincott Advisor], 2019)

Blood Test:

Blood chemistry studies

Complete blood count

Coagulation studies

(Pearson, 2015)

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If fracture requires immobilization with traction:

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If fracture requires immobilization with traction:

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Ensure proper weight use for traction.

Reposition the patient frequently to increase comfort and prevent pressure injury.

Assist with ROM exercises to prevent muscle atrophy.

Encourage coughing and diaphragmatic breathing exercises to prevent hypostatic pneumonia.

Perform pin site care if skeletal traction or an external fixation device is used.

(Wolters Kluwer [Lippincott Advisor], 2019)

Pictures: (Pearson, 2018, pg 863)

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Observe for skin irritation near cast edges, and check for foul odors and discharge.

Support the cast with non-plastic-covered pillows.

Perform frequent neurovascular checks.

(Wolters Kluwer [Lippincott Advisor], 2019)

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Osteomyelitis- infection of the bone begins as inflammation within the bone caused by an infectious organism gaining access following the trauma (open fracture) or surgical repair of fracture. Treatment can take up to 3 months on oral and IV abx and surgical debridement. If treatment is unsuccessful amputation might occur.

Avascular necrosis- bone tissue necrosis that occurs after circulation is compromised. When blood flow to the fracture site is disrupted, ischemia leads to tissue (bone) necrosis. Most common in hip fractures or fractures where bone is displaced. Treatment can be bone grafts or prosthetic replacement.

Failure to heal- fracture that is not healed within 6 months. Can include malunion (fracture heals incorrectly) or nonunion (fracture that never heals) and both can cause immobilizing deformity of the bone.

Hemorrhage- bleeding is a risk following fracture due to bones being highly vascularized and can lead to hypovolemic shock (most likely with fractured femur).

Muscle contractures, peripheral nerve damage, soft tissue damage/infection

(Holman et al., 2019)

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DVT/pulmonary embolism- common complication following trauma, surgery, and/or immobility

Fat embolism- fat globules from bone marrow are released into vasculature and can travel to small blood vessels including those in the lungs which can result in acute respiratory insufficiency and impaired organ function. Can occur within 12-48 hours following long bone fracture, within 72 hr following pelvic fracture/surgery, most common following hip fracture.

Compartment syndrome- usually affects extremities, can be caused by internal sources (accumulation of blood or fluid in muscle compartment) or external sources (tight cast, constrictive bulky dressing. Neuromuscular damage occurs in 4-6 hours, if untreated tissue necrosis can result

Renal calculi from decalcification (prolonged immobility)

Fractured ribs can result in respiratory impairment. This usually results from limitation of expansion of the chest wall.

Fracture in the spinal column can cause damage to the spinal cord. This can result in loss of motor function, sensory function, reflexes, and some organ function (elimination, respiration, GI tract).

Skull fractures can lead to different issues depending on the type of trauma (refer to intracranial regulation).

Skin breakdown can result from casts or bandages being too tight, becoming wet, or from friction (too loose) or from immobility.

(Holman et al., 2019)

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Transverse - break in the bone that is a straight line across the bone.

Linear - Break inside the bone that does not displace the bone.

Oblique (non-displaced)  - the bone cracks either part or all of the way through, but the bone does move and maintains its proper alignment.

Oblique (displaced) - Diagonal break across the bone where the bone snaps into two or more parts and moves so that the two ends are not lined up straight.

Spiral - The break spirals around the bone; common in a twisting injury.

Greenstick - Incomplete fracture where the broken bone is not completely separated.

Comminuted - the bone is broken in three or more pieces with fragments of the bone present at the fracture site.

Segmental - The same bone is fractured in two places, so there is a "floating" segment of bone.

Compression - The bone is crushed, causing the broken bone to be wider or flatter in appearance.

(Pearson, 2015)

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Physical activity
Falls
Car Accidents
Weak bone tissue
Osteoporosis
(Teamortho, 2015)

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The physician when presented with a possible bone fracture can usually diagnose with a physical exam but  will commonly order an x-ray to confirm. However some patients will require a MRI scan ( for stress fractures), CT scan or bone scan.

(pearson, 2015)

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Skin breakdown from a splint that was wrapped too tight and remained wet.

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Massey, M. (2020). Mobility ppt narrated [34]. Retrieved July 17, 2020, from https://wc.instructure.com/courses/14097/files/1467282?module_item_id=688015.

Teamortho January 30, 2. (2015, January 31). 5 Most Common Bone Fractures for Kids. Retrieved July 20, 2020, from https://www.sportsandspineortho.com/most-common-bone-fractures-kids/

Pearson Education. (2015). Nursing: A concept-based approach to learning. (2nd ed., Vol. 1). Upper Saddle River, NJ: Pearson.

Pearson Education. (2015). Nursing: A concept-based approach to learning. (2nd ed., Vol. 2). Upper Saddle River, NJ: Pearson.

Wolters Kluwer. (2019). Diseases and conditions. Retrieved from Lippincott Advisor for Education: http://advisor-edu.lww.com/lna/home.do

Holman, H. C., Williams, D., Sommer, S., Johnson, J., Ball, B. S., Wheless, L., Leehy, P., Lemon, T. (2019). RN Adult Medical Surgical Nursing (11th ed.). (eBook) https://www.atitesting.com

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Depending on the patients type of bone fracture treatment can include immobilizing the bone with a plaster cast or through the use of a boot or brace. It is important to not take this off before your doctor allows you to. In most cases this will only need to stay on for a few weeks. Some more complicated fractures will require surgery, surgical traction or metal rods or plates to hold bone together.

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Keep cast dry-It is important that the patient does not get the cast wet.

Do not put weight on bone fractures that are ordered to be kept weight free.

Monitor  circulation ( color, capillary refill)

If itching persist, the patient may use a hair dryer on cool setting to blow cool air into cast to help alleviate itching.

do NOT place items into cast

if sling is used, make sure that it distributes weight equally

When the cast is removed am oscillating cast remover is used. A guard will prevent the cast remover from penetrating past the depth of the cast so it will not cut the patient but the machine can be loud and the patient will feel some vibration.

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The RICE method can be used to help alleviate swelling and or pain ( Ice only when able, do not apply ice onto casts)

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Fall prevention-

begin a regular excerise program

remove any items in pathways

remove small throw rugs

place items that are used frequently at easy reach to avoid having to use a step stool.

install grab bars near toilet

use non slip mats in bathroom

improve lighing

wear shoes with good support and non slip soles

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CEC – Falls Prevention - Safe use of Mobility Aids – Forearm Support Frame (May 2016)

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The top of the crutches should be appx. 1.5 - 2 inches below your armpit when standing up.

The hand grips should be even with the top of your hips.

You should have a slight bend in your elbow when gripping the hand grips.

Move both crutches forward at the same time.

put weight onto your hand using the hand grips and move the uninjured limb forward.

Next move the injured limb forward between the crutches.

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Foot and Ankle Associates of North Texas

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Crutches, Canes, and Walkers Nursing NCLEX Assistive Devices Review

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The doctor after removing the cast may prescribe  the patient to rehab or physical therapy.
Follow the doctors instructions on activities; resuming intense physical activity too soon can increase the chance of re-injury.

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Eat a healthy balanced diet to promote bone health-

Calcium- cheese, milk, yogurt, seeds, dark green leafy greens, soybeans.

Vitamin D - fortified mil, cereal, eggs ( yolk) and salmon

protein- lean meats and fish, tofu

Vitamin C , Iron and potassium- assorted fresh fruits and vegetables

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Bone Healthy Foods | Best of Everything with Barbara Hannah Grufferman

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Report increasing pain, worsening symptoms, swelling, heat or foul odor to your doctor immediately.

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Healthy and safe exercise is a great way to help prevent bone fractures from occurring as they naturally strengthen bone density.

Weight bearing- walking, jogging, hiking

Resistance exercises- lifting weights

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Nursing Cast Care NCLEX Practice Question for Fractures