Orthopedic Nursing 36f6f

Historical Background of Orthopedic Nursing The word ‘orthopedics’ was derived from the Greek words; orthos meaning straight or free of deformity and pais meaning child.

History of the Philippine Orthopedic Center POC started in February 9, 1945 by PCAU General Hospital. The US Army established the hospital in Mandaluyong, Rizal. It was then called as Mandaluyong Emergency Hospital. Its main purpose is to help take care of the civilian casualties of war. But its function was not only as emergency basis seeing not only victims of wars but also all cases.

Orthopedics also called orthopedic surgery medical specialty concerned with the preservation and restoration of function of the skeletal system and its associated structures, i.e., spinal and other bones, ts, and muscles. Nicolas Andry, a professor of medicine at the University of Paris published a textbook in Orthopedics in 1741 concerning the following; 1. Maintaining a straight child 2. Straightening a deformed child 3. Finding new ways to straighten deformed child

In May 1945, the hospital was turned over to the Phil. Government. In August 1945, the Bureau of Health took over and only fracture cases and bone t condition remained. The hospital kept functioning during those difficult years and it is attributed to the skill, ingenuity, dedication and foresight of the staff lead by Dr. Jose V. delos Santos.

In 1728-1793, John Hunter contributed to the advancement of understanding fractures and other musculo-skeletal injuries.

The hospital finally transferred to its present site in Quezon City.

Orthopedics began in the 18th century with the pioneering efforts of Jean André Venet, who established an institute in Switzerland for the treatment of crippled children's skeletal deformities.

Review of Structure and Function of the Musculo-skeletal System I The Bones A.

In 1834-1891, Hugh Owen Thomas, an Englishman specialized in the treatment of chronic t disease, fractures and dislocations. In 1867-1948, Agnes Hunt, referred to as the Florence of Nightingale of Orthopedic Center in Great Britain.

The human skeleton consist of two main division: 1. Axial – body upright structure a) Skull b) vertebral column c) ribs 2. Appendicular – the body appendages a) Arms b) hips c) legs

B. Four major bone type 1. Long bones - length exceeds breadth and thickness 2. Short bones - equal in main dimensions 3. Flat bones – primary made up of cancellous bone tissue 4. Irregular bones

The efforts of Sir Robert Jones and the massive casualties of World War I led to the founding of many orthopedic training centers in the early 20th century. In 1840, William Little established the Royal Orthopedic Infirmary in Great Britain. In 1857, Anthonius Methyson of Holland described the plaster bandage. In 1866, the New York Orthopedic Dispensary was formed.

C. Long Bones: 1. Structure a) Diaphysis – shaft provides strength resist bending b) Metaphysis – flared portion between diaphysis and epiphysis c) Epiphysis – end Primary cancellous bone Assist with bone development d) Epiphyseal plate/line – between metaphysis and epiphysis - Cartilage growth in length of diaphysis and metaphysis e) Periosteum – connective tissue covering bone continues at the end of bone with t capsule but does not cover articular cartilage 2. Blood supply

A vastly increased knowledge of muscular functions and of the growth and development of bone was gained in the 19th century. Significant advances at this time were the new operation of tenotomy (the cutting of tendons, which made correcting deformities easier), the surgical correction of clubfoot, the invention of the Thomas splint (which provided better for fractures of long bones in the limbs), and the introduction of quick-setting plaster of Paris for use in orthopedic bandages. Modern orthopedics has extended beyond the treatment of fractures, broken bones, strained muscles, torn ligaments and tendons, and other traumatic injuries to deal with a wide range of acquired and congenital skeletal deformities and with the effects of degenerative diseases such as osteoarthritis. A specialty that originally depended on the use of heavy braces and splints, orthopedics now utilizes bone grafts and artificial plastic ts for the hip and other bones damaged by disease, as well artificial limbs special footwear, and braces to return mobility to disabled patients. Orthopedics uses the techniques of physical medicine and rehabilitation and occupational therapy in addition to those of traditional medicine and surgery.

a) Nutrient artery – tunnel in the diaphysis of long bone b) Periosteal vessels – supply compmact bones with nutrients

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c)

Metaphyseal and epiphyseal vessels – supply the spongy bone and narrow of the epiphysis

V ts 3 Basic t Types

D. Functions 1. Provides framework for the body 2. Serves as lever for skeletal muscles 3. Protects vital organs such as the brain, heart and lungs 4. Stores calcium and release it to the blood stream according to the body requirement 5. Manufactures new blood cells in the red bone marrow

1.

2 types a) sutures – permits no movement

II Cartilage

b) syndesmosis – permits minimal movement between bones

1) Fibrocartilage – greatest tensile strength occurs in the intervertebral dics and in the symphysis pubis 2) Elastic cartilage – possesses firmness and elasticity occurs in the external air and in the Eustachian tube 3) Hyaline cartilage – cushions most of the ts to help soften any impact firm yet flexible occurs also in the part of the nasal system, larynx, trachea and in the bronchial ring

3.

Synovial ts, the most common t type, have the most complex structure and permit maximum mobility. These ts include the following

c)

articular cartilage

d) synovial cavity FRACTURES A. Fracture is a break in the continuity of the bone. In adults this break is usually complete in that the periosteum and the cortical tissue on both sides are completely severed.

IV Skeletal muscle

c.

Cartilagenous ts connect two bones with cartilage, allowing only slight movement.

b) synovial membrane

Tendons – firm cords of fibrous tissue that extend from the muscle to the periosteum - connects muscle to each other to other tissue

b.

2.

a) t capsule

III Ligaments and Tendons Ligaments – strong cords of fibrous tissue - t capsule provides the primary connection between the bones, but ligament bind the ts more firmly

a.

Fibrous – composed of fibrous tissue, tightly, connecting the articular surfaces of two bones

In pathology, a break in a bone, caused by stress. Certain normal and pathological conditions may predispose bones to fracture. Children have relatively weak bones because of incomplete calcification, and older adults, especially women past menopause, develop osteoporosis, a weakening of bone concomitant with aging. Pathological conditions involving the skeleton, most commonly the spread of cancer to bones, may also cause weak bones. In such cases very minor stresses may produce a fracture. Other factors, such as general health, nutrition, and heredity, also have effects on the liability of bones to fracture and their ability to heal.

Muscles can be long and tapered, short and blunt, triangular, quadrilateral or irregular. Muscle fiber arrangement varies 1. In some muscles, the fiber runs parallel to the muscles long axis 2. In others, the fibers are oblique and bipennate like the feather of a quill pin 3. Fibers curve cut from a narrow attachment at the muscles and to form a triangle Main functions 1. Prime mover – directly brings about a desired motion 2. Antagonist – muscles that directly opposes the movement under consideration 3. Fixation – generally stabilizes a t or its part thereby maintaining position while prime mover acts

An incomplete break or greenstick fracture is mere common in children. Bone broken is bent but securely hinged at one side. A complete fracture occurs when periosteum and cortical tissue completely severed on both sides of bone.

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B. Fracture bone fragments are labeled according to relationship to the cortex of the body. 1.

distal – away from

2.

proximal – here to

The most important phase in obtaining the union of fracture fragments. a. Cast b. Traction c. Brace d. Fixation devices a. Internal fixation devices b. External fixation devices

C. Causes of fracture 1.

CARE OF PATIENT IN CAST

In normal bones, fracture occurs when more stress is placed upon a bone that is able to absorb such as:

Plaster Cast – is temporary immobilization device, which is made of gypsum sulfate, rendered anhydrous by calcification when mixed with water swells and forms into hard cement.

a) Direct blow or crushing form b) Twisting force (torsion a severe twisting of a broken bone at a side different from where the force was actually applied. c)

FUNCTIONS 1. 2. 3. 4.

Powerful contractions – highly developed muscles contract so violently that muscles tear from bone sometimes pulling a small piece of bone with it.

Bones weakened by a disease or tumors and subject to pathological fractures

Classification of fractures

*Complications of cast 1. Neurovascular compromise 2. Incorrect fracture alignment 3. Cast syndrome, superior mesenteric artery a. Occurs with body cast b. Traction on superior mesenteric artery causes decrease in blood supply to bowel c. Signs and symptoms, abdominal pain, nausea and vomiting 4. Compartment syndrome – is a condition in which increases pressure within limited space, compromises circulation and function of the tissue within that space.

Broad classification 1.

Open fracture

2.

Closed fracture

Principles of Fracture Treatment A. Reduction or realignment of bone fragments B. Maintenance or realignment by immobilization C. Restoration of function

Principle in application of plaster cast 1.

A. Reduction 1. Closed reduction – is accompanied by application of plaster cast after the fracture4 have been aligned with or without the use of anesthesia, to include the t above and below the fracture line. 2.

immobilize prevent or correct deformity , maintain and protect realigned bone promote healing and early weight bearing

* Cast can be applied to the extremities, to the trunk and to the extremity and trunk as in spicas. It can be applied to encase the whole area where it should be applied or it can be applied as a splint or mold.

d) Fatigue and stress bone breaks after repeated stress 2.

To To To To

2. 3. 4.

Open reduction – immobilization is done by nails, screws, pins, wires or rods which are inserted with or without plates. Such devices stay in the patient indefinitely unless they produce symptoms after healing takes place.

A cast is applied with padding first Padding materials include the following – wadding sheet, roll cotton, stockinet felt. It can be applied as a combination like stockinet and wadding sheet. Apply it to the t above and t below the injured part. Apply it in circular motion and mold it as you do the procedure by the palm. it with the palm

Contraindications of plaster cast application 1. Pregnancy 2. Skin diseases

B. Immobilization

For Circular Cast Application

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1. 2.

Check for doctor’s orders Inform and prepare the patient for the procedure. Explain to the patient and his relatives the need for placing the affected part of the body cast. Show an illustration of the type of cast to be applied to help them visualize HOW IT IS and WHAT IT IS. They are also made aware of the approximate duration for the body to remain in cast, the limitation and the discomfort arising from immobilization less boredom and frustrating. If possible, a good cleaning bath and shampoo be given to the patient. The affected part be cleansed thoroughly with soap and water or with detergent and dried. If there is a wound dress it accordingly. 3. Ready all things needed for the application. 4. Position the extremity (by the doctor) 5. Apply padding including the ts above and below the fracture line with thicker pads on the bony prominences 6. Soak the plaster cast into a bucket with water; leave it undisturbed until bubble ceases, one after the other. 7. Grasp both ends, when bubbles cease, towards the center without squeezing it. 8. Free the end of the cast and hand it to operator. 9. Apply cast in CIRCULAR MOTION until the whole area is covered and mold it during the process of application by the palm. 10. the cast while applying. 11. Handle the cast with care.

Care of the Patient in Cast The duration of keeping the body or part of it in cast is at least 1 month. Though, it varies among patients. Factors that influence the duration are 1. Age of the patient 2. Part of the e body affected 3. The degree of injury the affection of the part *During the entire period that the patient is in cast, the nurse responsibility is focused on the following: a. Neurovascular check b. Preservation of the efficiency of the cast c. Maintenance and promotion of the integrity of the system of the body d. Maintenance of the cleanliness of the cast A. Neurovascular checks In all casted patient, COLOR, MOTION, TEMPERATURE AND SENSATION OF TOES/FINGERS should be observed every 30minutes for several hours. After cast application, longer if there is edema, and then regularly every 3 hours. Circulatory impairment results in symptoms of coldness, edema, cyanosis, pain and finally numbness in the toes or fingers. The blanching sign will indicate whether or not there is an adequate circulation. When the nail of the thumb or great toes is compressed and immediately released, the color should go from white to pink with the same speed/. If not, the circulation is slow and the toes or fingers need closer observation. Patients in arm or leg casts should be able to move and feel each toe or finger, because the same nerve does not innervate each other. All toes and fingers should be checked.

Moving patients or transferring with wet cast must be avoided as much as possible. If this is necessary, care must be taken to maintain the integrity of the cast. The excess plaster cast is trimmed by means of a trimming knife. Cast spilled on the skin is easily removed by wiping it with a damp cloth.

Nerve Function Test

To hasten drying of the cast, several ways can be used 1. Exposure to open air or electric fan 2. Exposure to heat lamp 3. Placing the patient in a warm room Care should be taken in protecting the patient form rapid drying of the cast, as this will result to a dry outer layer while the inner layer remains wet. Complaints of discomfort should be investigated and appropriate measures be given to bring comfort.

Nerve

Action by the nurse - Test for Sensory Function

Radial

Prick web part between thumb and index finger

Median Prick distal surface of index finger

Action by the patient - Test for Motor Function Hyperextend the thumb Oppose thumb and little finger flex wrist

Ulna

Prick distal end of the small finger

Abduct all fingers

Peroneal

Prick lateral surface of the great toes toe

Dorsiflex ankle extend toes

Edges that are extremely rough should be trimmed and smoothened very slightly with a knife.

Tibial

Prick medial and lateral surface of sole of foot

Rough edges can be covered with adhesive petals, especially if there is no stockinet underneath the plaster and wadding sheet.

Psychological Implications and Going Home In Cast

Patients in body cast or spica cast is turned every 4-6 hours to promote even drying of the cast. Finishing touches on the dried cast.

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second

Plantar flex ankle and flex toes

To relieve patients’ apprehension and anxieties that crowd their minds with their cast on, the nurse can help the [patient make a start toward resolving some of the problems by helping them become to remain as independent as possible. Instruction regarding cast care need to be received and patient can be reminded that frequent rest periods for the entire body are necessary. Discussing plans with the patient before discharge will make the transition from the hospital to another facility much smoother and add to her peace of mind.

3.

c. d. e. Infections, tissue a. b. c. d.

feeling of deep pressure paresthesia motor weakness or paralysis necrosis due to skin breakdown drainage through casts sudden, unexplained rise in temperature hot spot felt on cast over the lesion pressure on the groins, knee, ankle and metatarsals

What to observe/remarks Spica Casts 1. Signs of respiratory distress 2. Signs of cast syndrome a. Prolonged nausea b. Repeated vomiting c. Distention d. Vague abdominal pain e. Absence of bowel sounds 3. Pressure on the jaws, ears, face, clavicle area, anterior superior iliac crest, groin, buttocks, and above the knee. 4. Urinary and bowel disturbances 5. Signs of plaster cast a. itchiness/burning sensation b. severe pain c. rise in the body temperature d. disturb sleep e. night cries among babies f. restlessness 6. Signs of infections and tissue necrosis

Cast of the upper extremities 1. Signs of impaired circulation/circulation of fingers such as a. cyanosis of the skin b. coldness of the skin c. loss of function d. numbness e. pulselessness of the extremity f. severe pain g. marked swelling 2. Nerve damage due to pressure on the nerve as it es over bony prominences a. pain increasing in persistence b. anesthesia c. feeling of deep pressure d. paresthesia e. motor weakness and paralysis 3. Infections, tissue necrosis due to skin breakdown a. musty, unpleasant odor over the cast or edges of the cast b. drainage through cast or windows c. sudden unexplained rise in temperature d. hot spot felt on cast over lesion 4. Pressure on the elbows, axilla, wrists, metacarpals and iliac crest

Turning Patient In Cast Turning casted trunk and lower extremities must be done carefully. The Patient must be lifted and not rolled or dumped. should be provided to the encased part and the whole body.

Remarks 1. Avoid insertions of foreign bodies in cast 2. Avoid soiling of the cast 3. Report signs of cracks and weakness of the cast 4. Maintain proper alignment of casted extremity 5. Proper of the cast

The first changing of the patients’ position is dependent on the condition of the cast and the body area involved. The first turning usually is to dry the posterior surface of the cast as well as to provide comfort and protect against respiratory complications.

Cast of the Lower Extremities 1. Observe for impaired circulation as manifested by a. Cyanosis or bluish discoloration of the skin b. coldness of sensation c. loss of function of the affected extremity d. numbness e. absence of pulse f. marked swelling 2. Nerve damage due to pressure on the nerve as it es over bony prominences a. increasing persistent localized pain b. numbness in the extremity

There should be no attempt to turn the patient alone if one estimates that one is physically unable without the patient’s assistance. Turning Patient in Hip Spica 1 - 1 ½ A. Supine to lateral With 2-3 working together the patient is gently pulled toward the unaffected side. Member remains on this side to give the patient the sense of security while the other member moves to the opposite side of the bed where the affected leg is to arrange the pillow along the entire length of the casted leg and back.

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B. Supine to prone

For traction to be effective, there must be also a pull in the OPPOSITE DIRECTION (COUNTER TRACTION) by using the body or by elevating part of the bed toward the traction.

One member places his hands on the patient shoulder and hips, while the other the thighs and extremities. The member of the opposite side pulls the shoulder and thighs as the patient is gently teased on his front. After the patient has been turned, observe the following points: a. Toes should not dips against the mattress b. Body section of the cast plaster should not press the back, chest and abdomen c. Heels should be maintained in correct angulations and should be allowed to extend beyond the mattress

PRINCIPLES OF TRACTION 1. MAINTAIN THE ESTABLISHED LINE OF PULL Weights should hang freely, not hitting the bed or resting on the floor. The position of the weights should be rechecked if the level of the bed is altered. AVOID 1. Bumping against the weights when walking near the bed. 2. Allowing the weights to sway. Both movements can cause pain for the patient in traction. It is preferred that the weights should not hang over the patient, if necessary, the nurse should tape the weights so they will not fall on the patient.

Placing Patient in Bedpan In bowel or bladder elimination, the buttocks should be lower than the head and toward the breast. This can be achieved by: a.

Elevating the head part slightly and placing a small pillow under the back of the patient.

b.

Placing a folded cloth on the posterior aspect of the bedpan. This will absorb moisture and this prevents spoiling the cast. Adult patients are usually placed in their good side first. The bedpan is placed so that the buttocks are on the posterior section of the bedpan. Pillows, blankets are then arranged to the legs and back so that there will no be back flow. If patient can himself by lifting with the aid of the overhead trapeze, the bedpan is slipped under the buttocks. Bladder and bowel elimination in children with hip spica if placed in headboard frame is not difficult if the bedpan is kept constantly in the spica under the buttocks.

2. PREVENT FRICTION Traction rope should rest in the groove of the pulley and move easily. The rope should not be frayed. The nurse should TIE securely knots in the traction rope and tape the rope ends. The rope knots should not lodge against the pulley because this will interfere with the line of pull. For the same reason, the nurse should ensure that the pulley, spreader bar and footplate do not rest against the foot of the bed. 3. MAINTAIN COUNTER TRACTION To provide traction, the nurse must ensure that counter traction is maintained. If the weight of the patient body is to provide the counter traction, HIS BODY should not interfere with the DIRECTION OF PULL. For instance, the feet of the patient in BUCK traction should not touch the foot of the bed, or if the patient is in cervical traction, his head should not touch the head of the bed. 4. MAINTAIN CORRECT BODY ALIGNMENT The patient should have correct BODY alignment while lying centered in the bed. The nurse must ensure that the patient does not angle his body or lean off the side of the bed because the line of traction pull would then be changed or interrupted.

Instrument for Cast Removal 1. Cast cutter (manual electric) 2. Spreader 3. Trimming knife 4. Bandage scissors 5. Plaster sears

Types of Traction 1. SKIN TRACTION Skin traction is accomplished by weights that pull on tape, sponge rubber or plastic materials attached to the skin. TRACTION on the SKIN, TRANSMITS traction to the musculoskeletal structures. Forms 1. Buck Extension A form of skin traction in which the pull is exerted in one plane when partial or temporary immobilization is desirable. In Buck’s extension, strips of adhesive, moleskin or perforated flex foam are applied smoothly to each side of the affected extremity and attached to a spreader block at the foot. The extremity is wrapped with elastic bandage to improve adherence of the tape to the skin and prevent slipping. A traction rope is attached to the

Points to 1. After the cast is removed, the part with pillow maintaining the same position that existed in the cast. 2. Move the extremity gently. 3. Observe the skin for any abrasions and plaster sore. 4. Wash skin with mild soap followed by application of oil or lanolin. TRACTION Traction is the application of a pulling force to a part of the body. It is used to align and immobilize fractured bones, to relieve muscle spasms and to correct flexion contractures, deformities and dislocations.

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spreader block then over the pulley, thence to a weight hung over the side of the bed. 2. Russell’s Traction Russell traction when properly applied in good mechanical working efficiency is a comfortable device for the patient. The equipment required is not elaborated. A single section of common Balkan frame can be attached to the bed with overhead bar directly above the injured limb. Four pulleys are used. These pulleys are arranged so that one is on the overhead bar at a level directly above the tubercle of the tibia of the fractured leg, another is attached to the footplate and two are attached to a crossbar at the foot of the bed and are placed at about the level of the mattress. A hammock which is used from the knee sling and traction tapes form the BASIS OF TRACTION.

fractures of the femur. It may be used with skin traction and other balanced suspension apparatus. Because upward traction is required for these fractures, the patient is placed on a fracture bed. Inasmuch as fracture occurs under varying circumstances and involves individuals of different ages, weights and body builds, NO TWO FRACTURES ARE ALIKE and every fractured patient require individual treatment. By same token, traction may be modified in many ways to meet a variety of special requirements, as exemplified by so called “BALANCED SUSPENSION TRACTION” and the “RUNNING TRACTION”. 3. MANUAL TRACTION Means the application of traction to a part of the body by the hands of the operator. When assisting with the application of traction or a cast, the nurse may be asked to apply a manual traction. This calls a firm smooth grip on the extremity and the avoidance of sudden jerking movements.

Important points in the nursing care of patient in Russell Traction BALANCED SUSPENSION Balanced suspension traction is used primarily for femoral fractures in adults by means of the Thomas splint with a Pearson attachment. Balanced suspension provides counter traction by its own system of weights and pulleys. Therefore when the patient lifts, the splint should also lift so that traction is maintained. The Thomas splint has a sling that s the thigh. The nurse should check for irritation from the ring to the groin, inner thigh and ischium. The Pearson attachment is connected to the splint by the knee and s the calf in a position parallel to and above the bed. A Steimann pin or Kirschner wire is inserted through the distal end of the femur or through the proximal or distal end of the tibia. The nurse teaches the patient and family that the traction’s main purpose is to provide sling, this allows the leg to rest comfortably and provides freedom to move without disrupting traction pull or alignment. By using the overhead trapeze, the patient can lift the shoulders and upper body. This movement allows for change of linen from the top to the bottom of the bed. Similarly, the nurse can apply lotion to the patient’s back because the individual is not allowed to turn for back care.

1.

The knee sling should be smooth and its edges must not cause pressure on the soft tissue over the peroneal nerve. 2. The heel of the foot in traction should just clear the bed. Firm pillows should the thigh and the calf along the entire length, leaving the heel free of the bed. 3. The popliteal space must be watched for ridging and skin denudation. Elevation of the backrest is permitted and few difficulties are encountered in giving nursing care because the fractured leg is not at the mercy of the gravity and will not be altered in position. 4. Encourage active dorsiflexion and plantar flexion of the feet. Important features 1. 2. 3.

A piece of felt should be inserted between the sling and the patient’s skin to prevent wrinkling of the sling under the popliteal area. This will assist in eliminating pressure sores that sometimes form at this point. The heel should clear the bed. The ideal position for the heels of the patient in Russell traction is that of a person standing with his heels four inches apart. Abduction is to be avoided. Two pillows are usually placed under the limb in traction. One under the thigh to maintain the desired angle and the other under the calf down and including the Achilles tendon.

UPPER EXTREMITY TRACTION Skin/Skeletal Sidearm traction is used to immobilized fracture of the humerus and may be applied either a skin or skeletal traction. There is outward pull on the upper arm and an upward pull on the forearm. For this reason, two separate set-ups of adhesive strips and elastic bone wraps are needed. In addition, if skeletal traction is used, a Kirschnerwire is usually inserted trough the olecranon. If the traction equipment is attached to the bed frame under the mattress, elevating the head of the bed will not disrupt the traction pull. However, if the frame is attached so that it moves when the bed position changes, the nurse should keep the head of the bed flat. Placing a folded blanket under the mattress near the traction frame can provide COUNTER TRACTION.

2. SKELETAL TRACTION Method of traction used most frequently in the treatment of fracture of the femur, humerus and the tibia. The traction is applied directly to the bones by use of a metal pin or wire (Kirschnerwire, Steimann pin), inserted into and through a bone distal to the fracture. Usually the skin is made under local anesthesia. The pin or wire is sterilized with all the aseptic precaution of an operation. Following insertion of pins, the wound is covered with a small gauze squares. If the wire or pin extends back to the caliper, a cork placed over the end of the pin prevents the tearing of lines and other more serious accidents. Skeletal traction is applied by weights and pulleys as described for skin traction. The Thomas Splint with the Pearson attachment is usually used with skeletal traction in

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Skeletal Overhead 90-90 traction, there is an upward pull on the upper arm, which is at a 90degree to the body. The elbow is flexed at a 90degree that the forearm is suspended in a sling and rest above and across the body. Weight is attached to the sling and to the Kirschner wire that is usually inserted through the olecranon. Because the arm is elevated, the patient should have less edema. This will be the case as long as the nurse ensures the patient keeps the involved hand ed in the sling and does not allow it to hang freely.

position relieves pressure from the lower back by decreasing the lumbar curve. It also provides counter traction. If traction increases pain to the back or legs, the nurse should report this to the physician. 2. Pelvic sling It is used continuously to stabilize and immobilize fractures of the pelvis. A large canvas sling attached to weights suspends the patient’s buttocks just off the bed. The pelvic sling may also be used to compress the entire pelvis (by applying pressure along each side), if there is a pelvic ring separation. Compression is achieved when the physician repositions the rods from the attachment edges of the sling to grooves that are closer together toward the patient’s midline. Strict immobilization is required to maintain the traction force. The nurse should give back care every 4 hours by sliding her hands between the sling and the patient’s back. However, it is difficult to reach the buttocks for skin care and bathing and the patient may generally uncomfortable. For these reasons an external fixator may be inserted into each iliac crest to stabilize unstable fractures of the pelvis. External fixation can reduce the patient’s pain, allow for his early ambulation and facilitate nursing care.

CERVICAL TRACTION Skin Cervical Halter Skin traction is frequently used for patients with sprains or strains to the cervical spine and ruptured cervical discs. It is applied to the cervical spine by a halter with straps that go under the chin and around the head of the base of the skull. After the halter is placed, the spreader bar and attached weights are connected. The patient may have small pillow under his head and should rest the back against the bed. Because cervical traction is usually ordered intermittently for a specified period, the nurse should teach the patient how to remove and reapply it. This information is especially important for the patient because there may be the need to remove the halter if vomiting or choking occurs. Any severe headache or pain in the area of the traction should be reported.

NURSING PRIORITIES FOR PATIENTS IN TRACTION 1. Frequently inspection of the fracture dressing in the first 24hours after application. A bandage that appears loose when applied may in a very few hours cause constriction which if not relieved may lead to gangrene of the extremity. 2. Dressing is applied in such a way as to leave the tips of the fingers and toes exposed. Any cyanosis, loss of temperature, tingling sensation in these parts should warn the nurse that the dressings are too tight. If the condition is caused by a single turn of the bandage, the turn may be divided with scissors, but it is usually advisable to notify the surgeon. 3. After the first 24 hours, the fracture dressing should be inspected at least 3-4 times daily. Evidences of constriction should be noted and pressure points checked – heel on the bedclothes resting on toes. 4. It is also important to ask the patient if there are any painful areas. 5. If traction is in used, the apparatus should be checked to see the ropes are in the wheel of the groove of the pulleys that the ing apparatus is free of the pulleys, that the weights hang freely and that the patient has not slipped down in the bed. 6. The foot must be in natural position; rotation outward or inward should be reported. FOOT DROP is to be avoided and the patient’s foot must be maintained in the neutral position ed by appropriate orthopedic devices. The rope sometimes frays; therefore, it too must be inspected at least daily. 7. Weights are necessary to provide constant force and may be ordinary metal traction weights or bags of water, hot or cold. It is especially important that the knots on the traction rope be tied securely. Enough weight is applied at first to overcome shortening tendency of the injured limb, but is gradually lessened as the fracture becomes more fixed. Weights should never be removed from a patient with fracture unless a life-threatening situation arises. Weight and pulley is applied to secure constant corrective extension. 8. WHEN THERE IS PULL IN ONE DIRECTION, THERE MUST BE AN EQUAL PULL IN THE OPPOSITE DIRECTION. Counter traction is supplied by either the patient’s body and

Skeletal Cervical Tong Skeletal traction to the cervical spine is used to immobilize and reduce fractures of the cervical spine that may injure the spinal cord. This type of traction is always continuous and is applied by Gardner, Vinki or crutchfield tongs inserted into the skull. There should be little bleeding after the first 24hours should be reported. If the tongs loosened or slip out, emergency measures include immobilizing the patient’s head with sandbags and notifying the physician immediately. With the skeletal traction to the cervical spine, there is a straight line of pull and the head of the bed may be elevated 6 inches to provide counter traction. An overhead trapeze must not be used with either skin or skeletal traction because it is use could strain the individual’s neck. The physician determines the degree of stability of the spine and writes specific orders for the patient to turn. If turning is allowed, the nurse should use the “LOGROLLING”. Technique that is, the patient is rolled as a unit so that the spine stays aligned and is not twisted. PELVIC TRACTION Types 1. Pelvic belt is primarily for relief of lower back pain to the lumbar spine whereas the pelvic sling is used to treat a pelvic fracture. Pelvic belt traction is applied to the lumbar spine by a pelvic belt with straps attached to weights. It is used to reduce muscle spasms and in the conservative management of low back pain and herniated lumbar disc. This traction may be ordered for intermittent periods. However, patient’s cooperation is crucial to success. The nurse should place the patient in William’s position, in which both the hips and knees are flexed at a 30degree angle and the head of the bed is slightly elevated. This

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friction against the bed (fracture of the upper extremity) or by elevating the foot of the bed (fracture of the lower extremity). 9.

When traction frames are used, a trapeze may be suspended overhead within easy reach of the patient. This apparatus is of great help in assisting the patient to move in bed and on and off the bedpans. NURSING CARE OF PATIENT IN TRACTION Nursing principles and implications The purposes of traction regardless how it is achieved are 1. To reduce and to immobilize a fracture 2. To lessen or to eliminate muscle spasms 3. To prevent fracture deformity

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