Fracture Nursing Care Plans

A fracture is a broken bone. It happens when the force on the bone exceeds what the bone can take, most often from car accidents, falls, or sports injuries. Low bone density and osteoporosis weaken bone and lower that threshold. You will see it charted as Fx or #.

The categories you need to recognize at the bedside:

• Incomplete: Only part of the cross-section breaks. One side breaks, the other bends (greenstick).
• Complete: The fracture line crosses the entire bone, and fragments are usually displaced.
• Closed: The break does not extend through the skin.
• Open: Bone fragments push through muscle and skin. Treat it as contaminated.
• Pathological: The break occurs in diseased bone (cancer, osteoporosis) with little or no trauma.

Nursing Care Plans & Management

Your priorities for a client with a fracture are pain control, stable alignment and immobilization, infection prevention, early mobilization, nutrition for bone healing, and teaching the client and family how to manage care and rehab. Address the anxiety, fear, and frustration that come with sudden loss of function too.

Nursing Assessment

Assess for the following subjective and objective data:

• Visible deformity or swelling at the fracture site
• Pain or tenderness that worsens with movement or pressure
• Loss of function or decreased range of motion
• Numbness or tingling in the affected limb
• Open wound or exposed bone
• Edema around the site
• Ecchymosis or hematoma
• Crepitus or abnormal movement at the fracture site
• Decreased sensation, diminished pulses, or cyanosis

In emergency trauma care, start with triage and the basics: airway, breathing, circulation, cervical spine protection, and level of consciousness. Then build the care plan around preventing complications during healing, with regular neurovascular checks to catch trouble early.

Nursing Interventions and Actions

1. Maintaining Alignment, Cast, and Traction

Immobilization is what protects the reduction, but it is also what puts the client at risk. A tight cast strangles circulation, traction that slips loses the pull, and pressure points break down skin. Stay ahead of all three.

Assess pulses, edema, coolness, ability to move digits, paleness or cyanosis, and numbness distal to a new cast every 2 hours. Swelling tightens the cast and impairs circulation; a bivalved cast manages severe swelling before it damages tissue. Recheck neurovascular status and pulses every 2 to 4 hours in traction, watching for paleness, numbness, changes in movement, and weakness or contractures of uninvolved muscles and joints.

Know the traction you are managing. Traction realigns bone ends, immobilizes the part, corrects deformity, decreases muscle spasm, and rests the extremity. It may be manual, skin (pull attached with bandages or straps), or skeletal (pull attached to a pin, wire, or tongs inserted into bone distal to the fracture). Skeletal traction takes more weight than skin can tolerate. Check that the weight amount is correct and hanging free, ropes ride in the track with secure knots, pulleys turn, and frames and splints sit where they belong. Lubricate pulleys, check ropes for fraying, wrap knots with adhesive tape, and confirm all clamps are functional. Never lift or release the weights. Free movement of weights during repositioning prevents sudden pull, pain, and spasm.

Position the client so the pull stays on the long axis of the bone. This promotes alignment and lowers the risk of delayed healing and nonunion. Place lifts under the bed wheels if ordered for counterbalance, and raise the head or foot of the bed to provide the pull and counter-traction prescribed. Respect the restrictions tied to each setup: no bending at the waist or sitting up with Buck traction, no turning below the waist with Russell traction. With an external fixator (Hoffman), check the integrity of the device. It gives rigid support without ropes or weights and allows more mobility and easier wound care, but loose or overtightened clamps change the compression and cause misalignment.

Maintain bed rest or limb rest as indicated, and support the joints above and below the fracture when moving or turning. Place a bed board under the mattress or use an orthopedic bed; a sagging mattress deforms a wet cast, cracks a dry one, or fights the traction pull. Support the site with pillows or folded blankets and hold a neutral position with sandbags, splints, a trochanter roll, and a footboard. Use enough staff when turning, and do not use the abduction bar to turn a client in a spica cast, because hip, body, and multiple casts are heavy and the cast can break. As edema subsides in a splinted extremity, the splint may need readjustment or conversion to a cast to keep the fracture aligned.

Review followup and serial X-rays for alignment and early callus formation; they guide activity level and any change in therapy. Give bisphosphonates as ordered (see Pharmacologic Management), and start or maintain electrical stimulation if it is being used to promote bone growth in delayed healing or nonunion.

Cast care. Dry a wet plaster cast completely: turn the client every 2 hours, support on pillows, expose as much of the cast to air as possible, and handle it with the palms of your hands to avoid indentations that create pressure areas. Let it dry from the inside out, half an hour or more depending on the material. Do not use a heated fan or dryer, which dries the surface while the inside stays wet and can burn the skin underneath. Elevate the cast on a pillow until dry to promote venous return and reduce swelling. Clean a plaster cast with vinegar and water; wash fiberglass with mild soap and water. Petal rough edges, and check the skin near cast edges for redness or abrasion. Outline any drainage on the cast with the date and time to track whether it is increasing. Keep food and small objects out of the cast, since anything trapped against broken skin invites pressure injury and infection.

Pediatric considerations. Teach parents and child to keep the limb elevated, support it with a sling when standing, and avoid letting it hang down or standing for long periods. Tell them to report pain, swelling, a musty odor, tightness or looseness, or any neurovascular change, which signals infection or compromise that may need a cast change. Have parents massage skin at the cast edges, skip lotions and powder there, and pad edges as needed. Keep restrictions per the physician, and keep coat hangers and other scratching tools out of the cast. Maintain body alignment in the hips, legs, arms, and shoulders, and realign the child after position changes. With skin traction, keep nonadhesive straps in place and do not remove or change them unless permitted and someone holds the traction; note any tightness or looseness that makes the traction ineffective. Encourage range of motion to unaffected joints and use a footplate to prevent foot drop. Cleanse and dress skeletal pin sites daily with antiseptic ointment as ordered, watch for infection, and check the clamp screws for accurate attachment; do not remove the traction. Encourage muscle and joint exercise, isometrics, and ROM of unaffected parts to prepare for crutch walking and keep joints mobile. Provide quiet play, diversional activities, and visits from friends, and let the child do as much self-care as age and immobilization allow. Teach the purpose and expected duration of traction so the child can adjust, and reassure that it is part of healing.

2. Promoting Pain Relief and Pain Management

Fracture pain comes from tissue damage, inflammation, and the movement bone fragments need to heal, plus the pressure and weight on the limb. Get ahead of it, because pain that goes uncontrolled limits everything else.

Assess and document pain using a rating scale (Wong-Baker FACES, visual analog, or FLACC: face, legs, activity, crying, consolability). Note relieving and aggravating factors and nonverbal cues such as vital sign, emotional, and behavioral changes. Anxiety amplifies the perception of pain, so let the client talk through the injury; reliving the event helps relieve anxiety.

Keep the part immobilized with bed rest, cast, splint, or traction, which relieves pain and prevents further tissue injury. Elevate and support the injured extremity to promote venous return and reduce edema. Avoid plastic sheets and pillows under a drying cast, which trap heat, and elevate the bed covers off the toes for warmth without pressure. Explain procedures before you start, and medicate before care activities. Tell the client to ask for medication before the pain becomes severe.

Perform active and passive ROM on unaffected muscles to keep strength and resolve inflammation, and add comfort measures such as massage, back rubs, and position changes to improve circulation and reduce muscle fatigue. Offer stress management (progressive relaxation, deep breathing, visualization, guided imagery) and diversional activities matched to the client's age and abilities; both refocus attention and improve coping with an injury whose pain may persist. Investigate any unusual, sudden, or deep, progressive, poorly localized pain unrelieved by analgesics, which may signal infection, tissue ischemia, or compartment syndrome.

Apply cold or an ice pack for the first 24-72 hr and as needed to reduce edema, hematoma, and pain; protect the skin and adjust duration to the client's comfort. Give analgesics around the clock for 3-5 days. Ketorolac (Toradol) relieves bone pain with longer action and fewer side effects than narcotics. Common medications:

• Narcotic and nonnarcotic analgesics: morphine, meperidine (Demerol), hydrocodone (Vicodin)
• NSAIDs (injectable and oral): ketorolac (Toradol), ibuprofen (Motrin)
• Muscle relaxants: cyclobenzaprine (Flexeril), carisoprodol (Soma), diazepam (Valium)

Maintain IV patient-controlled analgesia (PCA) by peripheral, epidural, or intrathecal route, keeping the infusion and equipment safe and effective. Steady analgesia prevents the swings in pain that bring back muscle tension and spasm.

3. Monitoring and Preventing Neurovascular Complications

A fracture can compress the nerves and vessels around it, and the window to save the limb is short. Your neurovascular checks are what stand between a recoverable injury and a permanent one. Compartment syndrome is the emergency you are watching for.

Assess capillary return, skin color, and warmth distal to the fracture. Return of color should be rapid (3-5 sec). White, cool skin means arterial impairment; cyanosis means venous impairment. Be aware that pulses, capillary refill, color, and sensation can stay normal in compartment syndrome because superficial circulation is usually intact. Measure the injured extremity along its full length and compare with the uninjured side, noting any hematoma; a rising circumference may mean tissue swelling or hemorrhage. A 1-inch increase in an adult thigh can equal about 1 unit of sequestered blood.

Check the peripheral pulse distal to the injury by palpation or Doppler and compare with the other limb. A decreased or absent pulse may mean vascular injury and needs immediate evaluation, though a pulse can sometimes be felt past a soft clot, and flow through larger arteries can continue after rising compartment pressure has collapsed the smaller vessels in the muscle. Investigate sudden limb ischemia (cooler skin, pallor, increased pain), since joint fracture-dislocations, especially the knee, can damage adjacent arteries. Watch for tenderness, swelling, and pain on dorsiflexion (positive Homans' sign) for thrombophlebitis and pulmonary emboli, remembering a negative sign is unreliable in older adults with reduced pain sensation. Monitor vital signs and note pallor, cyanosis, cool skin, and changes in mentation, which reflect inadequate circulating volume.

Perform neurovascular assessments noting motor and sensory changes, and have the client localize pain. Numbness, tingling, and increased or diffuse pain occur when circulation to the nerves is inadequate or the nerves are damaged. Report at once any pain out of proportion to the injury, increasing pain on passive movement, paresthesia, muscle tension or tenderness with erythema, or a change in pulse quality distal to the injury, and do not elevate the extremity. Bleeding and edema inside tight fascia cause ischemic myositis or compartment syndrome, which needs emergency decompression. Test the peroneal nerve by pinch or pinprick in the dorsal web between the first and second toe and check the ability to dorsiflex; leg fracture, edema, compartment syndrome, or traction malposition all threaten this nerve. Inspect tissue at the cast edges for pressure points and investigate any reported burning under the cast, which signals pressure or ischemia. Watch where the supporting ring of a splint or sling sits, since pressure in the axilla or groin can cause ischemia and permanent nerve damage.

Remove jewelry from the affected limb before edema traps it. Elevate the injured extremity to promote venous drainage and reduce edema, but stop elevation and ice once compartment syndrome is suspected, because raising an already ischemic limb impedes arterial flow. Encourage the client to exercise digits and joints distal to the injury and to ambulate as soon as possible. Apply ice bags intermittently for short periods over 24-72 hours. Test stools and gastric aspirate for occult blood and watch for bleeding at trauma or injection sites and oozing from mucous membranes, since gastric bleeding accompanies trauma and can reflect a clotting disorder. Monitor hemoglobin, hematocrit, and coagulation studies such as PT to estimate blood loss and catch coagulation deficits from major trauma, fat emboli, or anticoagulants. Review EMG and nerve conduction velocity studies to separate true nerve dysfunction from muscle weakness (see Diagnostic Procedures and Laboratory Studies).

Give IV fluids and blood products as needed to maintain circulating volume. Split or bivalve the cast to relieve compression. Measure intra-compartmental pressures when appropriate; a reading of 30 mm Hg or more signals the need for prompt intervention. Prepare for surgery (fibulectomy, fasciotomy) when indicated. Failure to relieve compartment syndrome within 4-6 hr of onset can cause severe contractures, loss of function, disfigurement, or amputation.

4. Promoting Effective Gas Exchange

After a fracture, shallow breathing from pain and immobility lowers lung expansion and oxygenation, and long-bone and pelvic fractures bring the added threat of fat emboli. Watch the chest as closely as the limb.

Monitor respiratory rate and effort, noting stridor, accessory muscle use, retractions, and central cyanosis. Tachypnea, dyspnea, and changes in mentation are early signs of respiratory insufficiency and may be the only clue to early pulmonary emboli. Auscultate for unequal, hyperresonant sounds, crackles, rhonchi, wheezes, and inspiratory crowing; adventitious sounds point to atelectasis, pneumonia, emboli, or ARDS, and inspiratory crowing suggests fat emboli. Note increasing restlessness, confusion, lethargy, and stupor, which signal deteriorating consciousness as hypoxemia or acidosis develops. Inspect for petechiae above the nipple line, in the axilla spreading to the abdomen or trunk, on the buccal mucosa and hard palate, and in the conjunctival sacs and retina; this is the most characteristic sign of fat emboli and may appear within 2-3 days of injury. Watch sputum for blood, since hemoptysis occurs with pulmonary emboli.

Monitor serial arterial blood gases, hemoglobin, calcium, ESR, serum lipase, fat screen, and platelets. Anemia, hypocalcemia, elevated ESR and lipase, fat globules in blood, urine, and sputum, and thrombocytopenia accompany fat emboli. Handle injured tissue and bone gently during the first several days to prevent fat emboli, which usually appear within 12-72 hr. Coach deep breathing and coughing, reposition frequently to drain secretions, and assist with incentive spirometry. Give supplemental oxygen if indicated; a falling PaO2 and rising PaCO2 mean impaired gas exchange or developing failure. Give low-molecular-weight heparin and corticosteroids as indicated (see Pharmacologic Management).

5. Enhancing Physical Mobility

Pain, immobility, and the cast or crutches all cut into mobility, and bed rest is its own source of complications. Move the client safely and early to protect both the fracture and everything bed rest threatens.

Assess the degree of immobility and the client's perception of it, since self-perception can exceed the actual limits and needs correcting. Check health literacy and cultural practices so teaching fits. Auscultate bowel sounds, monitor elimination, and set up a regular bowel routine with a bedside commode or fracture pan and privacy; bed rest, analgesics, and diet changes slow peristalsis. Monitor blood pressure as activity resumes and note dizziness, because postural hypotension is common after prolonged bed rest and may need a tilt table with gradual upright positioning.

Keep the client engaged with diversional and recreational activities and a stimulating environment to support a sense of control and reduce isolation. Teach or assist with active and passive ROM of affected and unaffected extremities to improve muscle tone, preserve joint mobility, and prevent contractures, atrophy, and disuse calcium resorption. Use isometric exercises starting with the unaffected limb to maintain strength without moving joints; hold them while acute bleeding and edema are present. Provide a footboard, wrist splints, and trochanter or hand rolls to keep a functional position and prevent foot drop and contractures. When traction stabilizes a lower-limb fracture, place the client supine periodically to prevent hip flexion contracture, and teach use of the trapeze and the "post position" (uninjured foot flat, knee bent, lifting the body off the bed) to ease hygiene and linen changes.

Assist with self-care such as bathing and shaving to build strength and control. Provide and teach mobility aids (wheelchairs, walkers, crutches, canes); early mobility reduces phlebitis and other bed-rest complications, and correct technique keeps the client safe. Reposition and encourage coughing and deep breathing to prevent skin and respiratory complications. Teach the client and family external fixator care, prescribed exercises in the fixator, and the signs of complications.

Push fluids to 2000-3000 mL per day within cardiac tolerance, including acid-ash juices, to lower the risk of urinary infection, stones, and constipation. Provide a diet high in protein, carbohydrate, vitamins, and minerals, but limit protein until the first bowel movement. Healing depletes nutrients fast, and skeletal traction can cost as much as 20 to 30 lb (9 to 13 kg), which hits muscle mass, tone, and strength hard; protein increases small-bowel contents and gas, so restore GI function before increasing it. Add roughage and fiber and limit gas-forming foods to prevent constipation and distension, and start a bowel program (stool softeners, enemas, laxatives) as needed. Teach the client and family analgesic use and nonpharmacologic pain control such as imagery, relaxation, and distraction, since controlled pain means better participation in activity. Consult physical, occupational, or rehabilitation therapy for an individualized program, and refer to a psychiatric clinical nurse specialist when the client or family needs more support coping with prolonged immobility and loss of control.

6. Maintaining Skin Integrity

Immobility, casts, and traction devices all press on skin and restrict circulation, and a pressure injury under a cast can go unnoticed until it is deep. Inspect, offload, and pad before breakdown starts.

Examine the skin for open wounds, foreign bodies, rashes, bleeding, discoloration, duskiness, and blanching, all of which reveal circulation or device problems that may need intervention. Check where the splint ring of the traction device sits, since poor positioning injures skin. Massage skin and bony prominences, keep linens dry and wrinkle-free, and pad elbows and heels with water pads. Reposition frequently and use a trapeze to lift pressure off the same areas and reduce abrasions.

Plaster cast application and skin care. Cleanse the skin with soap and water for a dry, clean field, since excess powder cakes with water and perspiration. Rub gently with alcohol or dust lightly with zinc stearate powder to pad bony prominences and protect skin. Cut a length of stockinette to cover the area and extend several inches past the cast to prevent indentations over bony prominences and weight-bearing areas. Use the palm of your hand to apply, hold, and move the cast, and support it on pillows; uneven plaster abrades skin. Trim excess plaster from the edges as soon as casting is done, promote drying by removing bed linen and exposing the cast to air, and watch the pressure areas at and under the cast or splint, which may be painless when nerve damage is present. Pad (petal) the edges with waterproof tape as a barrier to flaking and moisture, and clean excess plaster off the skin while it is still wet before it flakes into the cast.

Perineal cast protection. Provide frequent perineal care to prevent breakdown and fecal contamination. Tell the client and family not to insert objects into the cast. Massage the skin around the cast edges with alcohol to toughen it; skip creams and lotions, whose oils seal the cast and stop it breathing, and skip powders, which accumulate inside. Turn frequently to include the uninvolved side, back, and prone positions as tolerated, with the feet over the end of the mattress to offload them and the cast edges.

Skin traction application and skin care. Cleanse with warm, soapy water to lower contaminants, then apply tincture of benzoin to toughen the skin. Apply commercial traction tapes (or strips of moleskin or adhesive tape) lengthwise on opposite sides of the limb, never encircling it, which would compromise circulation. Extend the tapes beyond the limb and mark where they extend so you can spot slippage. Pad under the leg and over bony prominences, then wrap the limb, tapes, and padding with elastic bandages snugly but not tightly for traction pull without compromising circulation. Palpate the taped tissue daily and document tenderness; tenderness means skin irritation, so prepare to remove the system. Remove skin traction every 24 hr per protocol to inspect and give skin care.

Skeletal traction and fixation skin care. Bend or cap wire and pin ends with rubber, cork, or needle caps to prevent injury to other body parts. Pad slings and frames with sheepskin or foam, and provide foam, sheepskin, flotation, or air mattresses, since immobilized bony prominences away from the injury also lose circulation. Monovalve, bivalve, or window the cast per protocol to release pressure and access wounds.

7. Preventing Infection

Open fractures, surgical hardware, and pin sites all give bacteria a way in, and an untreated bone infection becomes osteomyelitis. Watch the wounds and pins, and keep your technique sterile.

Inspect the skin for irritation or breaks before pins or wires go in; never place them through infected, broken, or abraded skin, which seeds bone infection. Assess pin sites and skin for increased pain, burning, edema, erythema, foul odor, or drainage, which signal local infection or necrosis leading to osteomyelitis, and investigate any abrupt onset of pain and limited movement with localized edema and erythema. Assess muscle tone, reflexes, and the ability to speak; rigidity, tonic jaw spasm, and dysphagia mean tetanus. Watch wounds for bullae, crepitation, bronze discoloration, and frothy or fruity-smelling drainage, which suggest gas gangrene. Line perineal cast edges with plastic wrap, since damp, soiled casts grow bacteria, and tell the client not to touch insertion sites. Monitor vital signs and note chills, fever, malaise, and changes in mentation; hypotension and confusion appear with gas gangrene, while tachycardia, chills, and fever reflect sepsis.

Monitor labs and diagnostics: CBC (anemia with osteomyelitis, leukocytosis with infection), ESR (elevated in osteomyelitis), wound, serum, and bone cultures and sensitivity to identify the organism and the right antimicrobial, and radioisotope scans, where hot spots mark the increased vascularity of osteomyelitis. Provide sterile pin or wound care per protocol with meticulous handwashing, and institute prescribed isolation when there is purulent drainage. Give IV and topical antibiotics and tetanus toxoid as indicated (see Pharmacologic Management). Irrigate wounds or bone and apply warm, moist soaks as ordered to reduce organisms; a continuous antimicrobial drip into bone may be needed for osteomyelitis when blood supply is compromised. Assist with incision and drainage, drain placement, and hyperbaric oxygen, and prepare for sequestrectomy (removal of necrotic bone) to allow healing and stop the spread.

8. Assisting With Self-Care

Reduced mobility, assistive devices, and pain all make daily tasks harder. Find out what the client can and cannot do, then build the independence back rather than doing everything for them.

Assess the client's self-care limitations so you can match the right methods. Make sure prescribed pain management is in place, because uncontrolled pain restricts movement and self-care. Start an exercise regimen that builds the endurance and strength of the muscle groups tied to the client's specific deficit. Refer to occupational therapy and use assistive and dressing aids, including adaptive clothing, to strengthen dressing, bathing, and hygiene. Teach the family how to assist during self-care, which reduces the need for skilled home services and reinforces your teaching. Refer to care management or social services for clients who need financial help for equipment or home assistance, or community agencies that loan equipment.

9. Patient Education and Health Teaching

Most clients leave with a cast and a long recovery they do not fully understand. What you teach about wound care, mobility, diet, and warning signs is what keeps them out of trouble after discharge.

Review the pathology, prognosis, and what to expect; internal fixation can weaken the bone over time, and nails, rods, or plates may be removed later. Teach a low-fat diet with adequate quality protein and rich in calcium for healing. Discuss the drug regimen: proper use of analgesics and antiplatelet agents lowers complications, and long-term alendronate (Fosamax) may reduce stress fractures. Take Fosamax on an empty stomach with plain water, since food, antacids, and calcium alter absorption.

Reinforce the mobility and ambulation methods the physical therapist taught, because improper use of ambulatory devices causes further damage and delays healing. Suggest a backpack to carry articles and free the hands for crutches, especially with an arm cast. List which activities the client can do independently and which need help, and identify community services (rehab teams, home nursing, homemaker services). Encourage continued active exercise of the joints above and below the fracture to prevent stiffness, contractures, and muscle wasting. Stress clinical and therapy followup; healing can take up to a year, and PT or OT, sometimes with low-intensity ultrasound for lower forearm or lower leg fractures, maintains strength and function. Review pin and wound care and regular cleaning of the external fixator to reduce infection risk, and teach the client and family never to adjust the clamps and nuts of a fixator, which alters compression and alignment.

Teach the signs that need medical evaluation: severe pain, fever, chills, foul odors, changes in sensation, swelling, burning, numbness, tingling, skin discoloration, paralysis, white or cool toes or fingertips, warm spots, soft areas, and cracks in the cast. Some darkening (vascular congestion) is normal when walking on a casted leg or using a casted arm and should resolve with rest and elevation. Teach care of a green or wet cast: let it cure properly, and keep it off rubber or plastic pillows, which trap heat and slow drying. A blow-dryer on cool can dry small damp areas. Cover the cast with a plastic bag in wet weather or while bathing, and clean a soiled cast with a slightly damp cloth and scouring powder, since moisture softens plaster; fiberglass resists moisture and is lighter. Recommend adaptive clothing and covering exposed toes with a stockinette or soft socks for warmth and protection, and tell the client to continue permitted exercises.

After cast removal, warn the client that the skin is commonly mottled and covered with scales or crusts of dead skin, which can take several weeks to normalize. Wash gently with soap, povidone-iodine (Betadine), or pHisoDerm and water, then lubricate with a protective emollient, since the new skin is tender. Tell the client the muscles may look flabby and atrophied, and recommend supporting the joint above and below the part and using mobility aids while strength returns. Elevate the extremity as needed, because swelling tends to follow cast removal.

10. Managing Constipation

Decreased activity, opioids, and immobility all slow the gut, so constipation is nearly built in. Get ahead of it with fluids, fiber, mobility, and a bowel program rather than waiting for impaction.

Assess the client's usual bowel pattern and auscultate the abdomen for bowel sounds. Increase fluids unless contraindicated to soften stool, and add balanced fiber and bulk to improve consistency and passage. Teach pain strategies that lean less on opioids (drug combinations, visualization, relaxation), since nonopioids in combination cut opioid need and the constipation that follows. Encourage mobility to the limit of prescribed activity, because movement drives peristalsis; do not leave the client in bed if more activity is tolerated. Teach what worsens elimination (opioids, low intake, immobility), and give stool softeners, enemas, and laxatives as prescribed, moving to a suppository or enema if softeners or laxatives fail.

11. Pharmacologic Management

Medications start with pain control, then move to preventing infection, spasm, and clots and supporting bone healing.

• NSAIDs (injectable and oral): ketorolac (Toradol), ibuprofen (Motrin). Used for mild to moderate pain, like ibuprofen or naproxen sodium.
• Narcotic and nonnarcotic analgesics: morphine, meperidine (Demerol), hydrocodone (Vicodin). Opioids bind CNS receptors to manage severe pain; NSAIDs cover mild to moderate pain and inflammation with less dependence risk.
• Muscle relaxants: cyclobenzaprine (Flexeril), carisoprodol (Soma), diazepam (Valium). Relieve spasm and improve pain control and mobility.
• Bisphosphonates: alendronate (Fosamax), risedronate (Actonel). Inhibit osteoclast-mediated bone resorption, letting bone formation gain, which promotes healing and slows turnover in osteoporosis.
• Low-molecular-weight heparin or heparinoids: enoxaparin (Lovenox), dalteparin (Fragmin), ardeparin (Normiflo). Prevent thromboembolism, including DVT and pulmonary emboli.
• Corticosteroids: used with some success to prevent or treat fat embolus.
• IV and topical antibiotics: wide-spectrum, prophylactic or organism-specific.
• Tetanus toxoid: given prophylactically, since tetanus is possible with any open wound. Risk rises with field-condition wounds (outdoor, rural, work environments).
• Stool softeners: docusate sodium (Colace), docusate calcium (Surfak).
• Osmotic laxatives: polyethylene glycol (Miralax), lactulose. Draw water into the bowel to soften stool.
• Bulk-forming laxatives: psyllium (Metamucil), methylcellulose (Citrucel). Add bulk for regular movements.
• Stimulant laxatives: bisacodyl (Dulcolax), senna (Senokot). Stimulate intestinal muscle to move stool.

12. Diagnostic Procedures and Laboratory Studies

• X-rays: visualize the presence, location, and extent of the fracture and guide treatment.
• Complete blood count (CBC): evaluates for infection, anemia, and other blood issues.
• ESR and C-reactive protein (CRP): inflammatory markers that flag underlying infection or inflammation.
• Coagulation studies (PT, aPTT, INR): guide anticoagulant use, surgery, and preventive measures to limit clotting or bleeding during healing.
• Electromyography (EMG): assesses nerve and muscle function and the extent of nerve involvement.
• Nerve conduction velocity (NCV): measures the speed and strength of impulses along nerves.
• Radioisotope scans: assess bone metabolism and detect abnormalities such as stress fractures or bone infection using tracers that gather where bone activity is increased.