Fractures - Emergency Nursing

FRACTURES

Immediate management of a fracture may determine the patient’s outcome and may mean the difference between recovery and dis-ability. When the patient is being examined for fracture, the body part is handled gently and as little as possible. Clothing is cut off to visualize the body. 

Assessment is conducted for pain over or near a bone, swelling (from blood, lymph, and exudate infiltrat-ing the tissue), and circulatory disturbance. The patient is assessed for ecchymosis, tenderness, and crepitation. The nurse must re-member that the patient may have multiple fractures accompanied by head, chest, spine, or abdominal injuries.

Management

Immediate attention is given to the patient’s general condition. Assessment of airway, breathing, and circulation (which includes pulses in the extremities) is conducted. The patient is also evalu-ated for neurologic or abdominal injuries before the extremity is treated, unless a pulseless extremity is detected.

If a pulseless extremity is identified, repositioning of the ex-tremity to proper alignment is required. If the pulseless extrem-ity involves a fractured hip or femur, Hare traction (a portable in-line traction device) may be applied to assist with alignment. If repositioning is ineffective in restoring the pulse, a rapid total-body assessment should be completed, followed by transfer of the patient to the operating room for arteriography and possible arterial repair.

After the initial evaluation has been completed, all injuries identified are evaluated and treated. The fractured body part is inspected. Using a systematic head-to-toe approach, the clinician inspects the entire body, observing for lacerations, swelling, and deformities, including angulation (bending), shortening, rota-tion, and asymmetry. All peripheral pulses, especially those distal to the fractured extremity, are palpated. The extremity is also as-sessed for coolness, blanching, and decreased sensation and motor function, which are indicative of injury to the extremity’s neuro-vascular supply.

A splint is applied before the patient is moved. Splinting im-mobilizes the joint above and below the fracture, relieves pain, restores or improves circulation, prevents further tissue injury, and prevents a closed fracture from becoming an open one. To splint an extremity, one hand is placed distal to the fracture and some traction is applied while the other hand is placed beneath the fracture for support. The splints should extend beyond the joints adjacent to the fracture. Upper extremities must be splinted in a functional position. If the fracture is open, a moist, sterile dress-ing is applied.

After splinting, the vascular status of the extremity is checked by assessing color, temperature, pulse, and blanching of the nail bed. If there is evidence of neurovascular compromise, the splint is removed and reapplied. In addition, any complaints of pain or pressure are investigated.