Primary Nursing Diagnosis

Pain (acute or chronic) related to inflammation and swelling of the tendon

OUTCOMES. Comfort level; Pain control behavior; Pain: Disruptive effects; Pain level

INTERVENTIONS. Pain management; Analgesic administration; Positioning; Teaching: Prescribed activity/exercise; Teaching: Procedure/treatment; Teaching: Prescribed medication

644 Musculoskeletal Trauma

^ PLANNING AND IMPLEMENTATION Collaborative

In the emergency situation, planning and implementation are related to the priorities of airway, breathing, circulation, and neurological status. Unless the musculoskeletal injury is threatening the patient's circulation because of bleeding, management of musculoskeletal injuries usually occurs after the patient is stabilized. When a musculoskeletal injury interrupts a bone or joint, the trauma causes severe muscle spasms that lead to pain, angulation (abnormal formation of angles by the bones), and overriding of the ends of the bones. These complications need to be managed immediately to prevent increased soft tissue injury, decreased venous and lymphatic return, and edema. If the patient has any exposed soft tissue or bone, cover the area with a wet, sterile saline dressing. Prevent reentry of a contaminated bone into the wound if possible.

Early immobilization of the extremity at the trauma scene—which is actually the first step in trauma rehabilitation—preserves the function and prevents further injury. Immobilization limits muscle spasm, decreases angulation and injury from the overriding bone ends, and prevents closed fractures from becoming open fractures. Traction may also be applied to align bone ends in a close-to-normal position. This procedure restores circulatory, nerve, and lymphatic function and limits tissue injury and swelling. Generally, immobilization devices that are applied before the patient is admitted to the hospital are left in place until x-rays are performed.

When the fracture is confirmed by diagnostic testing, the bone is reduced by restoring displaced bone segments to their normal position. When the physician restores the bone to normal alignment, venous and lymphatic return improves, as does soft tissue swelling. The orthopedist may perform a closed reduction in which she or he manually manipulates the bones to restore alignment. When closed reduction is not possible, a surgical (open) reduction is performed. The method of reduction depends on the grade, type, and location of the fracture.

External fixation devices are now being used frequently for many fractures that would until recently have been treated with traction. External fixation, such as the Hoffmann device, is a metal system of rods that is designed to maintain alignment of fracture fragments. The patient requires less immobilization and therefore usually suffers fewer of the hazards of immobility. Use the device itself to position limbs, unless it is being used to stabilize a pelvic fracture. External fixation devices may also cause complications, however. Some patients react to them with local irritation, and a few develop infections. Monitor the area every 8 hours while the patient is hospitalized and clean it according to hospital protocol. The most common method is with half-strength hydrogen peroxide. Use of povidone-iodine (Betadine) or Neosporin ointment around the pins after cleansing may also be indicated to prevent infection.

Pharmacologic Highlights

Medication or

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