Turning a pt with an unstable femoral fracture

Nurses General Nursing

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This was not a real patient-- I had her in sim lab (I'm a student obviously). The lab focus was more on communication between the nurses than on the care of the fracture. It was discovered that the patient had been sent up from ER with a pillow supporting her fractured leg which the instructors pointed out was very bad. I was hesitant to move the leg at all, for fear of doing more damage in the process, causing the muscle to contract, etc. Would there be some liability issue there if I caused more harm? OTOH I can't just leave it sitting like that. Wouldn't it have been put into traction until the surgery?

In addition the patient had been sitting there for a few hours and was now complaining of back pain. Her peri and sacral areas needed to be checked and she needed to be turned. And she was complaining of being SOB and her HOB was not elevated enough.

How in the world should I do all this with an unstable leg fracture? I wish I had asked the teacher but we were running out of time and like I said, the focus was on communication skills.

Also, for any patient who needs their HOB elevated, but also needs to be turned every 2 hours, how do you have someone lie on their side with the HOB raised and still be comfortable??

So much to learn still!!

Specializes in Med-Surg, , Home health, Education.

Most of the time they are placed into Buck's traction. You could still have them rotate their shoulders and upper back and place a small pillow behind them. You could elevate the HOB a little. I'd just get an order for O2 for the SOB. You wouldn't want to elevate the bed too much. Most likely to have pain and spasms regardless. Usually they put them on a muscle med (valium etc) and pain meds.

Thanks! That makes more sense! :)

I was thinking they should be in a traction but my classmate said not until after the surgery. So my instincts were correct on a lot of things, I just didn't have the confidence to act on them. It didn't help that the instructors were watching from behind a glass window and we were being filmed!

Specializes in Public Health, TB.

Unfortunately, our ED seldom initiates Bucks traction, so we do it ASAP once the patient gets to the floor. They don't have it post-op because they usually have an ORIF. And yes you can elevate the HOB, especially once the traction has been applied.

Regarding the shortness of breath--this could be a sign of a fat embolism--look for petechiae and notify the MD.

Specializes in Med-Surg, , Home health, Education.
Thanks! That makes more sense! :)

I was thinking they should be in a traction but my classmate said not until after the surgery. So my instincts were correct on a lot of things, I just didn't have the confidence to act on them. It didn't help that the instructors were watching from behind a glass window and we were being filmed!

If they are in traction it's before surgery not after. And lots of time it isn't initiated in the ED- they come to the floor and the med-surg nurses apply it with whatever weight is ordered. It helps reduce the spasms.

Specializes in Med/Surg.

We are an ortho floor and see a lot of this, some doctors like their patients in traction prior to surgery some don't. Most do not feel much pain until they are moved, so turning them every two hours is essential. A lot of times especially if the patient is obese or elderly it is important to get several people to help and turn as much as possible so you can properly assess the skin on these patients. For turning you hope you have a large draw sheet, place a pillow or two between the legs (I like to lay one lengthwise between the thighs and then one or two (depending on the size of the patient) vertically between the knees to turn them. Then using the draw sheet you as much as you can logroll them to one side, pull the draw sheet down while a co-worker supports them, assess, have them turn to the other side and repeat. Whether they are in bucks or not, it is important to keep the leg as anatomically aligned as possible and don't underestimate the ability some people have to try to walk on a fractured leg. I've never seen Buck's after surgery. I've also never seen an order for an elevated HOB. I'd definitely try to disuade the doctor from this as it will increase the risk of skin breakdown from shearing and would be very uncomfortable for these patients with limited mobility as it is. Definitely would want to rule out a fat embolism first from the fracture causing the dyspnea, but I'd slap on some oxygen and given morphine and ativan if ordered in the mean time. Just my :twocents:

Traction is not absolutley necessary pre-op and I can't think of any reason to have traction after surgery. Just log roll them carefully with a pillow between their legs (lengthwise works best). Keep the leg positioned properly while doing so. R/O fatty embolism b/c of the SOB. Adequate analgesia is a must.

Thanks for sharing! It's great to hear from those who have experience with this! I will have to seek out a patient similar to this next time I'm in clinicals and help with the turning.

Specializes in ER, progressive care.
Regarding the shortness of breath--this could be a sign of a fat embolism--look for petechiae and notify the MD.

This. Remember there is a risk of fat embolism especially with long bone fractures!

Petechiae generally appear along the chest & axillae. Tachycardia, although vague, may also be present, along with SOB.

And on a side note, petechiae also occur when a patient's platelet count is low.

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