Violence, Environments, Musculoskeletal

• Ask....
• Have you been kicked, hit, punched or hurt by someone in the past year?
• Do you feel safe in your current relationship?
• Is there a partner from a previous relationship who makes you feel unsafe now?

• immediate care of the injury
• reassure
• determine immediate threat
• treat medical problems
• document

• isolate them from the abuser
• develop an alternate destination
• provide referral phone number/agencies
• respect difficulty to leave the partner

• they will be withdrawn
• they will have multiple bruises all with different stages of healing

talk to charge nurse and fill out a abuse report, which is anonymous and inform social worker/CPS

• felt in large muscles
• occurs after exercise or heavy labor
• pain is brief, but intense
• nausea
• tachy
• pallor
• weak
• diaphoresis

occurs when an individual engages in a strenuous activity in hot, humid weather or in sedentary individuals

• fatigue
• lightheaded
• n/v/d
• feelings of impending doom
• tachycardia/tachypnea
• hypotension
• elevated body temp
• dilated pupils
• mild confusion
• profuse diaphoresis

most serious, and as a medical emergency.  Results from failure of hypothalamic thermoregulatory processes

• increased sweating
• vasodilation
• increased RR
• depletion of F&E
• Temp >104
• altered mentation
• ABSENCE of perspiration
• circulatory collapse

• hot
• dry
• ashen

• Manage/maintain ABC's
• High flow O2 with non rebreather or BVM
• IV access and fluids
• Cool patient
• ECG
• Obtain blood for electrolytes and CBC
• Insert urinary catheter
• Elevate feet

• Monitor ABC's
• VS
• LOC
• cardiac rhythm
• O2 sats
• Electrolytes
• UO

Myoglobinuria....urine sample (rhabdomylisis)

DIC....clotting studies (PT,PTT)

• Initiate rapid cooling measures
• remove patients clothes
• place wet sheets over patient and place fan in front of patient
• immerse in ice water bath
• administer cool IV fluids or lavage with cool fluids

administer Thorazine

tea colored urine

• working out too hard causing extreme fatigue
• hypotension
• increased CPK
• renal failure
• lactic acid

insert foley and start aggressive fluid resuscitation

• decreased temp
• shivering
• hypoventilation
• hypotension
• altered LOC
• areflexia
• pale, cyanotic skin
• blue, white frozen extremities
• dysrhythmias
• fixed dilated pupils

• mild 93.2-96.8
• moderate 86-93.1
• profound <86

• brady
• a fib
• v fib
• asystole

• ABC's
• High flow O2
• Anticipate intubation
• Rewarm patient
• Anticipate need for hemodialysis or cardiopulmonary bypass
• Establish IV access w/ 2 large bore catheters
• Keep patients head covered with warm, dry towels or stocking cap to limit loss of heat
• Treat patient gently to avoid increased cardiac irritability

warm central trunk first when they have profound hypothermia to limit rewarming shock

• 95 degrees
• warming places the patient at risk for after drop, a further drop in the core temperature. 

This can induce hypotension and cardiac dysrhythmias

• ABC
• assume cervical spine injury/stabilize
• provide 100% O2 via non rebreather mask or BVM
• Anticipate need for intubation
• Establish IV access w/ 2 lg bore catheters for fluid resuscitation/warming
• assess for other injuries
• remove wet clothes and cover w/ warm blankets
• obtain temp and rewarm as needed
• obtain c spine and chest x rays
• insert gastric tube

• ABC
• Temp
• s/s of acute respiratory failure
• monitor for neurologic changes

vascular supply....no blood

injury which occurs when a joint exceeds its normal limit...ankle, knee or shoulder

produces slight pain and swelling

RICE

pain, tenderness, swelling, and inability to use the limb for more than a short time

RICE with weight bearing crutches

tearing of the ligaments resulting in pain, tenderness, swelling, discoloration and inability to use the limb

RICE with NON weight bearing crutches

Rest, Ice, Compression, Elevation

20 min/day...4x/week

weakening or overstretching of a muscle where it attaches to the tendon

mild-local pain with tenderness and light muscle spasm

moderate-local pain with tenderness, swelling, discoloration and inability to use the limb for long prolonged periods

severe-local pain with tenderness, swelling, discoloration and may offer hx of "snapping noise" at time of incident

RICE with same rules with crutches for each

occurs when joint exceeds its ROM and the joint surfaces are no longer articulating....will have severe swelling and possible vein/artery damage

• weak distal pulses and sensations
• skin color changes and increased moisture
• increased capillary refill

• splint in the position found or a position of comfort
• apply cold compress
• pre and post relocation x ray
• stabilization for 6 weeks

• cast
• sling

need surgery immediately....it's an emergency

• they are caused by force, check for other injuries
• immobilize joints inferior/superior to area of injury
• dislocations are very painful...give analgesia
• keep patient NPO for possible surgery
• fx may occur in conjunction with dislocations...get x rays

splint first....cause prevents compartment syndrome

disruption or break in the integrity of the bone

• simple-bone is broken but skin is in tact
• compound-bone is protruding, has punctured the skin and returned beneath the surface, or a foreign body has penetrated the skin and bone causing fx

occurs when a bone bends and cracks, instead of breaking completely in to separate pieces

bone is twisted apart....

aka torsion fx

• edema/swelling
• pain/tenderness
• muscle spasm
• deformity....or not
• ecchymosis
• loss of fxn
• crepitation

• anatomic realignment of bone fragments (reduction)
• Immobilization with splint then cast
• Restoration to normal or near normal fxn

• pain
• pointed tenderness
• pulses distal to injury
• paresthesias-tingly
• paralysis

cuz bones have a blood supply and the patient can become shocky from a fx

spinal compression fx

paralytic ileus

kidney injury

lung/spleen,liver injuries

genitourinary/gastrointestinal injury

fx of dislocated hip or femur

• decreased distal pulses
• decreased distal skin temp
• cyanosis
• decreased distal sensation
• shock

• elevate the injury above the level of the heart
• cold compresses
• analgesia as needed

• shock
• infection
• fat embolism
• compartment syndrome
• venous thrombosis

CSM

• neurovascular compromise is a serious emergency
• all injuries are fx until proven otherwise
• baseline VS are important...you never know
• all clothing is removed to do a complete assessment
• keep pt NPO cuz possible surgery

• immobilization
• cold compress
• elevation

reassess patient for other problems

• prevent further damage to soft tissues
• prevent damage to nerves, arteries and veins
• decrease pain

both proximal and distal areas to the suspected fx

motor and sensory status before the splint was applied

complete immobilization of the injury and surrounding distal and proximal areas

• keep it dry
• keep the injured limb elevated above the level of the heart for 24-48 hours
• wiggle fingers 1x/hr
• return immediately if foreign body is dropped in to cast

• cold/hot fingers
• pale/dusky fingers
• absence of feeling in fingers
• foul odor from cast
• unresolved pain

• measure with shoe they will be wearing
• shoes should be tie/buckle with a 1"heel

NO SLIP ON SHOES

• arm piece is 2" from axilla
• grips should be 6-8 inches to the side and from of the foot
• elbow at 30 degree angle
• *don't lean on armpits

• cane is held next to the foot and the elbow should be at a 30degree angle
• used for balance only...minimal support

need to have a tetanus shot if they haven't had one in the last 5-7 years (?)

scraping of epithelia layer exposing dermal layer

tx-scrub and irrigate, apply topical ointment and non adherent dressing

full thickness skin loss in which a section of the skin is pulled away....deep, goes down to the dermis

tx-scrub, irrigate and debride the wound, dress with bulky dressing

bruise in which the vessels are damaged, but the skin isn't disrupted

tx-cold compress and analgesia....NO dressing

escape of blood into subcutaneous space

tx-depends on location

penetration of the skin by a pointed or sharp object....may appear innocent, but may have damaged underlying structures

tx-soak in surgical soap solution BID for 2-4 days, antibiotics if infected and tetanus shot

localized collection of pus in subcutaneous skin

tx-antibiotics, needle drainage, or I&D.  Will need daily wound care and packing if had I&D

an open wound or cut through the dermal layer...can be minor or major

• tx-thorough cleaning with betadine, H2O or NS
• Closure with steristrips, staples, sutures, dermabond
• Dry sterile dressing
• Tetanus shot

• keep it clean and dry
• may clean with water daily
• assess for infection

• 3-5 days for face
• 7-10 days for all others

sharp penetrating object causing a wound

tx-don't remove, stabilize object if necessary

• compartment syndrome
• fat emboli
• thromboembolitic complications
• infection
• avascular necrosis
• delayed non-union
• rhabdomyelisis

5P's

associated with long bone fx 24-48 hours after injury

• respiratory distress
• tachy

tx-support ABC's

• wound healing is delayed due to age and impaired nutrition
• have chronic medical problems that can cause increased risk for complications
• teach about poly pharmacy and side effects
• mobility is a problem and increases risks for complications
• vision may b impaired....making it hard to id complications and read instructions
• $$ may make it hard to seek care promptly

Neglect is more common

• frequent flyers are usually women
• many are drug seekers
• 1/3 of all OD patients/suicide attempts are trying to escape abusive relationships