Bones

With a possible cervical spine injury, the nurse opens the airway by placing fingers behind both angles of the mandible and lifting the jaw forward, without tilting the head. Lifting the jaw pulls the tongue off the back of the throat while the neck stays still.

A broken mandible or maxilla bleeds into the mouth, swells, and can let the tongue or loose bone fall backward. The nurse sits the patient up if the spine allows, suctions blood, and watches for stridor, drooling, and a voice change. Nothing goes through the nose (no nasogastric tube, no nasal airway) when the midface is broken, because the fracture may open into the skull base.

After a jaw is wired shut, the nurse keeps wire cutters (or scissors for elastic bands) and suction at the bedside and gives antiemetics on time. If the patient vomits, the nurse turns them onto their side and suctions first; the wires are cut only if the airway cannot be cleared. The patient goes home with cutters and is taught the same rule.

After a blow to the back of the head, the nurse checks level of consciousness and pupils and looks for bruising behind the ear or around the eyes and clear drainage from the nose or ear, testing the drainage with a halo on gauze or a glucose check. Drainage is never packed or plugged, and no nasogastric tube, nasal suctioning, or nose-blowing is allowed, because a tube can pass through a fractured skull base into the brain and leaking fluid means an open path for infection. Any drop in level of consciousness, new pupil change, or worsening headache and vomiting is reported at once as a sign of bleeding or rising pressure inside the skull.

Bruising over the mastoid (Battle sign), bruising around both eyes (raccoon eyes), or clear fluid from the nose or ear point to a fracture through the skull base. The bruising may not appear for a day or more, so its absence soon after the injury does not rule out a fracture. A halo ring on gauze or drainage that tests positive for glucose suggests spinal fluid, and the nurse reports it promptly. Nothing goes through the nose: no nasogastric tube, no nasal suction, no nasopharyngeal airway, and the patient is told not to blow the nose.

Because the closed skull cannot expand, a change in level of consciousness is the earliest sign of rising pressure, and the nurse reports it without waiting for vital signs to change. Rising systolic pressure with a widening pulse pressure, a slow heart rate, and irregular breathing (Cushing triad) are late signs. The nurse keeps the head of the bed raised about 30 degrees with the head and neck midline, and avoids straining, coughing, and sharp hip or neck flexion.

Leaking spinal fluid is allowed to drain onto a loose sterile dressing that is changed as it gets wet. Packing the nose or ear traps fluid at an open path to the brain and raises the risk of meningitis, so the nurse never plugs the leak and watches for fever, stiff neck, and worsening headache.

The needle for a subclavian line passes close to the top of the lung, so pneumothorax is a known risk of this site. The nurse infuses nothing through the new line until a chest X-ray confirms the tip position and shows no pneumothorax, because fluid run into a misplaced catheter can go into the chest. After insertion the nurse watches for sudden shortness of breath, chest pain, diminished breath sounds on that side, or a falling oxygen saturation and reports them at once.

Two or more adjacent ribs broken in two or more places leave a loose segment that sinks in on inspiration and bulges out on expiration, opposite to the rest of the chest. The nurse gives oxygen, watches for falling oxygen saturation and signs of a bruised lung or pneumothorax, and prepares for intubation and mechanical ventilation if breathing fails.

Absent breath sounds on one side, a trachea pushed toward the other side, distended neck veins, and a falling blood pressure mean trapped air is compressing the lung and heart. The nurse calls the provider at once, gives high-flow oxygen, and prepares for needle decompression at the second intercostal space in the midclavicular line or a lateral site per protocol, followed by a chest tube. The nurse does not wait for a chest x-ray, because the patient can go into cardiac arrest in that time.

For an adult, the nurse places the heel of one hand on the lower half of the sternum, the other hand on top, and pushes straight down at least 2 inches but no more than 2.4 inches at 100 to 120 per minute, letting the chest fully recoil each time. Hands stay above the xiphoid, because pressure there can injure the liver beneath.

Before inserting a nasogastric tube, the nurse measures from the tip of the nose to the earlobe and then down to the xiphoid process, and marks that length on the tube. This length only estimates the distance to the stomach, so placement is confirmed by x-ray before the first feeding or medication. The nurse documents the external length at the nostril and checks it before each use per facility policy, because a tube that has moved can deliver feeding or medication into the esophagus or airway.

When the baby's shoulder catches behind the symphysis pubis, the nurse calls for help, flexes the mother's thighs back toward her abdomen, and applies firm pressure just above the symphysis as the provider directs. Never push on the fundus, because that wedges the shoulder tighter against the pubic bone and raises the risk of injury to the baby.

A pelvic fracture can tear the urethra and can bleed heavily. Blood at the urethral meatus, bruising of the perineum or scrotum, or inability to void means the nurse does not insert a urinary catheter and notifies the provider so the urethra can be checked first. The nurse also watches for falling blood pressure and a rising pulse, because a large amount of blood can collect inside the pelvis unseen.

The nurse watches for a rising heart rate, narrowing pulse pressure, falling blood pressure, cool pale skin, and spreading flank, perineal, or scrotal bruising, starts two large-bore IVs, and applies a pelvic binder or folded sheet centered at the greater trochanters as ordered to close the ring and slow the bleeding. The nurse does not rock or press on the pelvis to check it and moves the patient as little as possible, because movement can dislodge clot and restart bleeding.

Blood at the urethral meatus, blood in the urine, inability to void, or perineal or scrotal bruising mean the urethra or bladder may be torn. The nurse does not insert a urinary catheter and reports the finding, because a catheter can turn a partial urethral tear into a complete one; the provider rules out urethral injury first, usually with a retrograde urethrogram.

When the baby's head delivers and pulls back tight against the perineum, the front shoulder is stuck behind the symphysis. The nurse calls for help, notes the time, helps pull the mother's thighs back toward her belly (McRoberts), and gives firm pressure with the heel of the hand just above the symphysis as the provider directs. The nurse never pushes on the fundus, because that drives the shoulder harder against the bone.

After a crash or fall, pelvic pain, perineal bruising, or blood at the urethral opening can mean a broken pelvic ring, which can bleed heavily inside the pelvis. The nurse keeps the patient still, does not rock the pelvis to test it, and watches for shock: a climbing heart rate and falling blood pressure. With blood at the meatus the nurse does not insert a urinary catheter and reports it, because a catheter can worsen a torn urethra.

Until imaging and exam clear the spine, the head and neck stay in line with the body: a rigid collar, a jaw thrust instead of a head tilt to open the airway, and a log roll with one person holding the head and calling the count. The nurse never lifts the patient by the shoulders or turns the trunk without the head, because movement at an unstable level can injure the cord or make an existing injury worse.

The phrenic nerve leaves the cord at C3 to C5 (see Spinal cord), and swelling after a neck injury can spread upward over the first few days, so a patient who breathes well on admission can tire later. The nurse trends respiratory rate, cough strength, and vital capacity as ordered, keeps suction and intubation equipment ready, and reports a rising rate or weakening cough right away. Oxygen saturation can stay normal until breathing is already failing, so it is not the sign to wait for.

Before the tap, the nurse reports signs of raised intracranial pressure, such as headache with vomiting, a falling level of consciousness, or pupil changes, because draining fluid from below can shift the brain down and herniate the brainstem. The nurse positions the patient side-lying with knees drawn up and chin tucked, or sitting and leaning over a table. Afterward the patient lies flat as ordered, and the nurse checks the site for leaking or bleeding and asks about headache and leg numbness or weakness.

An epidural goes into the same low lumbar spaces, and its most common side effect is a drop in maternal blood pressure, which reduces blood flow to the placenta and can slow the fetal heart rate. The nurse gives the ordered IV fluid bolus before placement, then checks blood pressure and fetal heart rate often per facility policy. If pressure falls, the nurse turns the patient to her side, increases IV fluids as ordered, and notifies the anesthesia provider right away.

After a fall from a height or a car crash, the nurse keeps the head, neck, and trunk in line and turns the patient only by log-rolling with enough staff until the spine is cleared by the provider. Twisting an unstable fracture can injure the spinal cord. The nurse checks movement and sensation in the legs before and after each turn and reports any change at once.

Swelling under a rigid splint can cut off blood flow and press on nerves in the hand. The nurse checks the fingers for color, warmth, capillary refill, sensation, and movement, compares them with the other hand, and reports numbness, tingling, pale or cold fingers, or pain out of proportion to the injury right away. Before discharge the nurse teaches the client to elevate the hand above the heart, move the fingers often, and return at once for those same signs.

The nurse checks each fingertip for color, warmth, capillary refill (normally back within about 2 seconds), sensation on both sides, and the ability to bend and straighten, and compares with the other hand. A pale, cool fingertip or refill that has slowed since the last check means poor blood flow: the nurse loosens a tight outer wrap per facility policy and notifies the provider at once. New numbness, tingling, weakness, or pain that keeps rising or is not relieved by the ordered pain medicine is also reported promptly, because the splint or swelling may be pressing on nerves and blood vessels.

A child who falls on an outstretched arm can break the humerus just above the elbow, where the brachial artery lies against the bone, so the nurse checks the radial pulse, capillary refill, color, warmth, sensation, and finger movement, and repeats the check after every splint, cast, or position change. A pale, cold hand or a fading pulse means the artery is pinched or injured; pain that keeps climbing despite ordered pain medicine and worsens when the fingers are passively stretched is the early sign of compartment syndrome, where a lost pulse is a late sign the nurse never waits for. For any of these findings the nurse loosens any tight dressing, keeps the arm at heart level rather than raised, and calls the provider at once, because delay can cost the forearm muscle.

Each check compares the casted hand with the other hand: capillary refill under about 3 seconds, color, warmth, swelling, numbness, and finger movement. Pain out of proportion to the injury that worsens when the nurse passively stretches the fingers is the earliest sign of compartment syndrome, so the nurse reports it right away, because rising pressure can kill muscle and nerve within hours and a lost pulse is a late sign. While waiting for the provider, the nurse keeps the arm at heart level, not above it, since elevation lowers blood flow into a compartment that is already starved.

The nurse feels behind and below the medial malleolus for the posterior tibial pulse and compares both feet; when a cast covers the ankle, this pulse cannot be felt, so the nurse checks the toes' color, warmth, capillary refill, feeling, and movement instead. Pain out of proportion to the injury, pain when the toes are moved passively, numbness, a cool pale foot, or a pulse that was present and is now gone means the nurse keeps the leg at heart level, loosens any tight dressing, and notifies the provider immediately. Pain comes before pulse loss, and lost blood flow or compartment syndrome can permanently damage nerve and muscle within hours.

Landing on the feet from a height can break one or both heels and, in about 1 in 10 patients, the thoracolumbar spine too, so assess for back pain, check leg sensation and movement, and keep the spine immobilized until it is cleared. Watch the injured foot for compartment syndrome: pain out of proportion to the injury or with passive toe movement, tense swelling, and numbness or tingling. If these appear, keep the foot at heart level instead of raised, remove ice, loosen any tight dressing or splint, and notify the provider immediately, because the trapped pressure cuts off blood flow and fasciotomy is time-critical.

In the first 24 to 72 hours after a femur fracture, fat from the marrow can travel to the lungs and brain. The nurse watches for sudden shortness of breath, a falling oxygen saturation, new confusion or restlessness, and tiny red-purple spots on the chest, armpits, or neck. The nurse raises the head of the bed, gives oxygen, and calls the provider or rapid response team at once.

The nurse checks both feet and compares them after a leg cast or surgery, after a procedure through the groin artery, and in peripheral artery disease, and marks a hard-to-find pulse with a pen. The artery is absent or hard to feel in some healthy people, so a pulse never found is checked with the posterior tibial pulse behind the inner ankle bone and a Doppler. A pulse that was present and then disappears means blood flow may be blocked: the nurse checks the other foot and the groin site for bleeding or swelling, and notifies the provider at once.

The nurse checks the toes for color, warmth, capillary refill under about 3 seconds, sensation, and movement, and compares with the other foot. Early warnings are pain out of proportion to the injury, pain not relieved by the ordered pain medicine, pain that gets worse when the toes are passively stretched, and numbness or tingling. Pale, cool, or pulseless toes, or toes the patient cannot move, are late signs. The nurse keeps the limb at heart level rather than elevated, does not apply ice, loosens any tight dressing, notifies the provider immediately, and prepares for the cast to be split or for a fasciotomy.

The nurse checks the knee jerk (normal is 2+) every hour or per protocol, along with respiratory rate and urine output, because magnesium dampens nerves in order: reflexes fade before breathing slows, and the kidneys are the only way it leaves the body. If the reflex is absent, respirations fall below 12, or urine output drops below 30 mL/hr, the nurse stops the infusion, notifies the provider, and has calcium gluconate, the antidote, ready. With an epidural in place the knee jerk may be blunted, so the nurse tests the biceps or brachioradialis reflex instead.

A brisk 3+ or 4+ knee jerk, especially with ankle clonus (rhythmic beats of the foot after a quick upward flex), means the brain is irritable and an eclamptic seizure may be near. The nurse reports it right away with the blood pressure, headache, visual changes, and upper abdominal pain, and starts seizure precautions per facility policy, with suction and oxygen ready and a quiet, dim room. Magnesium sulfate is given to prevent the seizure, not to lower the blood pressure.

After a tibial fracture, crush injury, or tight cast, pain out of proportion to the injury, pain that gets worse when the nurse gently stretches the toes, pain opioids do not relieve, and new numbness or tingling mean pressure in a muscle compartment is choking off blood flow; a lost pulse is a late sign, and the nurse does not wait for it. The nurse keeps the leg at heart level, not raised, because elevation lowers the blood pressure feeding the compartment, loosens tight dressings or wraps, and notifies the provider at once. A cast is split or bivalved on the provider's order, and the definitive treatment is surgical fasciotomy.

The tibia lies just under the skin, so its fractures often break through it and let bacteria reach the bone. The nurse controls bleeding with direct pressure, covers the wound with a sterile dressing, does not push bone ends back in or try to straighten the leg, splints it as found, and checks pulses, color, warmth, sensation, and movement below the injury before and after splinting. The nurse keeps the patient NPO for surgery and expects IV antibiotics and a tetanus status check.