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Pulmonary embolism after repair of a traumatic Achilles tendon rupture
OCTOBER 1996, VOL 64,NO 4 CAS
E
C0
M M EN TA R
Y
Pulmonary embolism after repair of a traumatic Achilles tendon rupture
P
ulmonary embolism is defined as a mechanical obstruction of the blood flow to a branch of the pulmonary artery from the lodgment of a thromboembolus.1 Pulmonary emboli can be caused by air, fat, bone, amniotic fluid, neoplasms, thrombi, or foreign bodies2 The thromboembolus usually comes from the venous system of the legs and results in D decreased cardiac output, pulmonary vasospasm, hypertension, impaired blood oxygenation, and D bronchospasm.3 Pulmonary embolism is one of the most frequent causes of sudden death in hospitalized patients and is seen most commonly after trauma injuries, surgical procedures, and pelvic or femoral shaft fractures: Ninety percent of hospital deaths occur within two hours after the onset of the initial symptoms (eg, sudden apprehension, dyspnea, tachycardia, rales, urgency in voiding caused by dilated hemorrhoidal veins).’ The mortality rate from pulmonary embolism is approximately 40%, and one half of the patients die within 30 minutes of the onset of symptoms.hClassic signs of pulmonary embolism (ie, hemoptysis, pleural friction rub, cardiac gallop, cyanosis, chest splinting) are present in only 24% of patients.’ Signs and symptoms of pulmonary embolism range from none to fever and severe cardiopulmonary dysfunction and
often are confused with those of myocardial infarctions, pneumothoraces, rib fractures, or other conditions associated with chest p a h X Diagnosis of pulmonary embolism is based on the results of several diagnostic tests (eg, chest x-rays, 12-lead electrocardiograms [ECGs], arterial blood gases, blood enzyme levels, ventilation/perfusion scans). Medical treatment of pulmonary embolism includes supportive measures to maintain circulatory function and the administration of heparin sodium for systemic anticoagulation.’ Thrombolytic therapy with streptokinase, urokinase, or tissue plasminogen activator may be used for acute, life-threatening pulmonary embolism when cardiopulmonary function is severely compromised (eg, cardiogenic shock, profound hypoxemia, elevated pulmonary arterial pressure).10Long-term anticoagulation may be achieved by administering oral warfarin sodium or subcutaneous heparin sodium. Surgical treatment includes pulmonary embolectomy , venous interruption by vein ligation to prevent the thromboembolus from traveling to the pulmonary artery, and vena cava plication to allow blood flow but to trap emboli.Il Pulmonary embolism develops in 10%to 40% of patients with deep venous thrombosis (DVT) CAROLYN VOLPICELLO, RN, MA, CNOR, is a senior staff nurse at SI Vincent’s Hospital and Medical Center of New York. 599 AORN JOURNAL
after trauma injuries and surgical procedures.I2It may develop as a result of vessel wall injury, local venous stasis, and the release of factors that cause hypercoagulation.I3Pulmonary embolus formation can be prevented through early diagnosis and the prevention of DVT associated with trauma injuries and surgical procedures. The following case study discusses the postoperative complication of pulmonary embolism that resulted from the development of DVT after an Achilles tendon repair. CASE STUDY Mr B was a 4.5-year-old male who ruptured his right Achilles tendon while playing racquetball. The indirect injury to Mr B’s Achilles tendon resulted from a forced dorsiflexion of his right ankle as he pushed off the floor during his return shot. Mr B was unable to continue playing racquetball and had to be carried off the court. Mr B’s playing partner brought him to the local hospital’s emergency department (ED) for treatment of his traumatic injury. An ED triage physician examined Mr B and referred him to an orthopedic surgeon for surgical intervention. Diagnosis. The orthopedic surgeon performed a physical examination of Mr B that revealed swelling, ecchymosis, and a palpable gap at the site of the Achilles tendon injury. The surgeon noted that the gap was located approximately two inches above the musculotendinous junction (ie, the
OCTOBER 1996, VOL 64,NO 4
insertion point of the Achilles tendon on the calcaneus). Active ankle plantar flexion was weak on the Mr B's right side, and Mr B complained of localized pain to his right posterior ankle. Mr B reported a sudden, knife-like pain in his lower right leg and the inability to stand on his feet after the indirect injury to his Achilles tendon. The surgeon conducted the Thompson teal4 by having Mr B lay prone on the examination table and dangle his feet off the end of the table. The surgeon squeezed Mr B's right calf musculature and noted the right ankle did not plantar flex when he applied pressure to the gastrocnemius and soleus muscles and the Achilles tendon. Based on these findings, the surgeon diagnosed Mr B's indirect injury as a complete Achilles tendon rupture. The surgeon discussed surgical repair of the Achilles tendon with Mr B and obtained an informed, signed surgical consent from him. Treatment. The surgeon placed a splint on Mr B's right lower leg and sent Mr B home on crutches, advising him to rest, ice, and elevate his right limb. He also gave Mr B a prescription for pain medication and scheduled him for surgery the following week. A few days before his scheduled surgery, Mr B went to the hospital for preadmission testing, which included laboratory tests, a 12-lead ECG, a chest x-ray, and a preoperative anesthesia assessment. Mr B's test results were normal except for a slightly elevated creatine phosphokinase, which is indicative of muscle trauma. Day of surgery. On the moming of his surgery, Mr B arrived at the admitting area of the surgical suite where the preoperative nurse interviewed him and prepared him
for surgery. Mr B informed the nurse that he had hay fever but was not asthmatic; otherwise, his medical history showed Mr B to be in good health. Mr B had been NPO since midnight and had not taken any medications. Patient prepamtion. The circulating nurse and the scrub person prepared the OR for a soft tissue repair of Mr B's right Achilles tendon. The circulating nurse transported Mr B to the OR by wheelchair and helped him onto the OR bed. The anesthesia care provider inserted a peripheral IV line into Mr B's left wrist; applied a pulse oximeter, ECG leads, and a blood pressure cuff; and administered oxygen to Mr B via nasal cannula. After the anesthesia care provider administered a spinal anesthetic, the surgeon applied a tourniquet to Mr B's right upper thigh over cotton cast padding. An appropriate number of surgical team members then placed Mr B in a prone position on the OR bed. The anesthesia care provider administered a prophylactic antibiotic (ie, 1 g cefazolin sodium) through Mr B's IV line before the surgical procedure. Surgical procedure. The circulating nurse prepped Mr B's right leg up to the knee. The scrub person and the surgeon draped Mr B's right leg with orthopedic drapes and a sterile stockinet that covered the surgical leg. The surgeon elevated Mr B's right leg and applied an Esmarch bandage to exsanguinate it before the circulating nurse inflated the pneumatic tourniquet to 300 mm Hg. The surgeon made the incision and performed a soft tissue dissection. He located the ends of the ruptured tendon, reapproximated the proximal and distal portions of the tendon, and repaired them with 600 AORN JOURNAL
#2 polyester sutures. After repairing the tendon, the surgeon closed the wound with a running absorbable suture. The surgeon applied sterile dressings, cast padding, and a short-leg cast with Mr B's right foot in a plantar flexed 20" position. Surgical team members placed Mr B in a supine position, then lifted him onto a stretcher and transferred him to the postanesthesia care unit (PACU). Mr B remained in the PACU until he was ready to be transferred to the postsurgical unit. Postopemtlve compllcatlons. On postoperative day one, Mr B complained of discomfort at the surgical site and dizziness, and he was unable to ambulate with crutches. Mr B's symptoms were treated with pain medication, and he was allowed to remain on bed rest. On postoperative day two, Mr B reported less pain at the surgical site but still complained of dizziness. He was unable to walk with crutches, and he had a body temperature between 38.3" and 38.8" C (101" and 102" F). Mr B was able to ambulate with crutches on postoperative day three; however, he complained of shortness of breath during ambulation. The postsurgical nurses alerted the house physician to Mr B's symptoms. The house physician ordered posteroanterior and lateral chest xrays, a 12-lead ECG, arterial blood gases, blood enzyme levels, and a ventilationjperfusion scan. Test resulk. Mr B's chest x-rays showed an elevated diaphragm and dilated pulmonary arteries. His 12-lead ECG results demonstrated inverted T waves, transient right bundle branch block, right ventricular hypertrophy, and tall P waves. Mr B's arterial blood gas results indicated arterial hypoxemia (ie, low partial oxygen) and
OCTOBER 1996, VOL 64, NO 4
hypocapnia (ie, low partial carbon dioxide), which were ominous signs of a massive embolus. Mr B’s blood enzyme levels showed an elevation in his blood lactic dehydrogenase and bilirubin levels from increased pressure and blood volume in the great veins caused by right ventricular strain. His ventilation/perfusion scan indicated a severe obstruction of blood flow to the pulmonary artery. After reviewing Mr B’s test results, the house physician diagnosed pulmonary embolism caused by the postoperative complication of DVT formation. Medical treatment. The house physician began treating Mr B’s pulmonary embolism by ordering the immediate administration of oxygen at a high flow rate via nasal cannula, analgesia (ie, meperidine hydrochloride), and anticoagulation therapy with IV heparin sodium. The house physician ordered an initial bolus of 10,OOO U of IV heparin sodium to halt the thrombotic process and to stabilize the platelets in the embolus to prevent the release of vasoactive and bronchoactive substances. He then ordered the postsurgical nurses to administer a continuous IV drip of 10,OOO U
of heparin sodium every hour. The house physician monitored Mr B’s partial thromboplastin time (P’lT) by drawing blood samples and using the Lee-White clotting time method to adjust the dosage of heparin sodium to one and one half to two times the PIT control time.Is Mr B remained on IV heparin sodium for seven days and was placed on oral warfarin sodium before discharge for six months of anticoagulation therapy. Mr B’s discharge plan included patient teaching about anticoagulant therapy and the need for routine PTT studies and scheduled visits to his internist. The nurses also discussed the need for a postoperative follow-up visit to the orthopedic surgeon at three weeks for suture removal and a cast change to place the right ankle in a neutral position. Mr B was informed that his right leg would remain in a short-leg cast for at least eight to 10 weeks and that he would be required to crutch walk until the surgeon determined when to discontinue external immobilization. Mr B did not experience any further postoperative complications and returned to his normal activity level six months after his right
NOTES 1. B E Jarrell, R A Carabasi, Surgery, thud ed (Baltimore: Williams & Wilkins, 1996) 149-151. 2. J Luckman, K C Sorensen, Medical-Surgical Nursing: A Psychophysiologic Approach, fourth ed (Philadelphia: W B Saunders Co, 1993) 1 1 19-1 120. 3. Jarrell, Carabasi, Surgery. third ed, 149-151. 4. Ibid. 5. B Gregory, Orthopedic Surgeiy (St Louis: Mosby-
Year Book, Inc, 1994)45. 6. Luckman, Sorensen, Medical-Surgical Nursing: A Psychophysiologic Approach, fourth ed, 11 19-1120. 7. Jarrell, Carabasi, Surgery, thud ed, 149-151. 8. S A Budassi, J M Barber, Emergency Nursing: Principles und Practice, second ed (St Louis: MosbyYear Book, Inc, 1992)456-457.
Achilles tendon repair.
COMMENTARY Pulmonary embolism formation can be prevented through the early diagnosis and prevention of DVT. Perioperative nurses can intervene by encouraging patients to ambulate early during the postoperative period. If patients are confined to bed rest, nurses should apply elastic wraps or pneumatic stockings to patients’ lower extremities to avoid the pooling of blood in the calf muscles and the development of DVT. Range-ofmotion exercises also should be performed several times a day.16 Nurses’ fm emotional support can allay patients’ fears and apprehension and serve as a stabilizing factor during treatment for pulmonary embolism.17Patients’ frustrations and the general discomfort associated with immobility from prolonged bed rest can be managed with relaxation techniques, diversional activities (eg, music), guided imagery, and back rubs.18 Providing consistent patient care, encouragement, and hope to patients experiencing pulmonary embolism can augment medical treatments and facilitate optimal recovery. A
9. Jarrell, Carabasi, Surgery, third ed, 149-151. 10. Ibid. 1 1. Luckman, Sorensen, Medical-Surgical Nursing: A Psychophysiologic Approach, fourth ed, 11191120. 12. Jarrell, Carabasi, Surgery, third ed, 149-151. 13. Gregory, Orthopedic Surgery, 45. 14. S J Gates, P A Mooar, Orthopaedics and Sports Medicinefor Nurses: Common Problems in Management (Baltimore: Williams & Wilkins, 1989) 220. 15. Jarrell, Carabasi, Surgery, thud ed, 151. 16. Budassi, Barber, Emergency Nursing: Principles and Practice, second ed, 457. 17. Luckman, Sorensen, Medical-Surgical Nursing: A Psychophysiologic Approach, fourth ed, 1 120. 18. Ibid. 601
AORN JOURNAL
E
C0
M M EN TA R
Y
Pulmonary embolism after repair of a traumatic Achilles tendon rupture
P
ulmonary embolism is defined as a mechanical obstruction of the blood flow to a branch of the pulmonary artery from the lodgment of a thromboembolus.1 Pulmonary emboli can be caused by air, fat, bone, amniotic fluid, neoplasms, thrombi, or foreign bodies2 The thromboembolus usually comes from the venous system of the legs and results in D decreased cardiac output, pulmonary vasospasm, hypertension, impaired blood oxygenation, and D bronchospasm.3 Pulmonary embolism is one of the most frequent causes of sudden death in hospitalized patients and is seen most commonly after trauma injuries, surgical procedures, and pelvic or femoral shaft fractures: Ninety percent of hospital deaths occur within two hours after the onset of the initial symptoms (eg, sudden apprehension, dyspnea, tachycardia, rales, urgency in voiding caused by dilated hemorrhoidal veins).’ The mortality rate from pulmonary embolism is approximately 40%, and one half of the patients die within 30 minutes of the onset of symptoms.hClassic signs of pulmonary embolism (ie, hemoptysis, pleural friction rub, cardiac gallop, cyanosis, chest splinting) are present in only 24% of patients.’ Signs and symptoms of pulmonary embolism range from none to fever and severe cardiopulmonary dysfunction and
often are confused with those of myocardial infarctions, pneumothoraces, rib fractures, or other conditions associated with chest p a h X Diagnosis of pulmonary embolism is based on the results of several diagnostic tests (eg, chest x-rays, 12-lead electrocardiograms [ECGs], arterial blood gases, blood enzyme levels, ventilation/perfusion scans). Medical treatment of pulmonary embolism includes supportive measures to maintain circulatory function and the administration of heparin sodium for systemic anticoagulation.’ Thrombolytic therapy with streptokinase, urokinase, or tissue plasminogen activator may be used for acute, life-threatening pulmonary embolism when cardiopulmonary function is severely compromised (eg, cardiogenic shock, profound hypoxemia, elevated pulmonary arterial pressure).10Long-term anticoagulation may be achieved by administering oral warfarin sodium or subcutaneous heparin sodium. Surgical treatment includes pulmonary embolectomy , venous interruption by vein ligation to prevent the thromboembolus from traveling to the pulmonary artery, and vena cava plication to allow blood flow but to trap emboli.Il Pulmonary embolism develops in 10%to 40% of patients with deep venous thrombosis (DVT) CAROLYN VOLPICELLO, RN, MA, CNOR, is a senior staff nurse at SI Vincent’s Hospital and Medical Center of New York. 599 AORN JOURNAL
after trauma injuries and surgical procedures.I2It may develop as a result of vessel wall injury, local venous stasis, and the release of factors that cause hypercoagulation.I3Pulmonary embolus formation can be prevented through early diagnosis and the prevention of DVT associated with trauma injuries and surgical procedures. The following case study discusses the postoperative complication of pulmonary embolism that resulted from the development of DVT after an Achilles tendon repair. CASE STUDY Mr B was a 4.5-year-old male who ruptured his right Achilles tendon while playing racquetball. The indirect injury to Mr B’s Achilles tendon resulted from a forced dorsiflexion of his right ankle as he pushed off the floor during his return shot. Mr B was unable to continue playing racquetball and had to be carried off the court. Mr B’s playing partner brought him to the local hospital’s emergency department (ED) for treatment of his traumatic injury. An ED triage physician examined Mr B and referred him to an orthopedic surgeon for surgical intervention. Diagnosis. The orthopedic surgeon performed a physical examination of Mr B that revealed swelling, ecchymosis, and a palpable gap at the site of the Achilles tendon injury. The surgeon noted that the gap was located approximately two inches above the musculotendinous junction (ie, the
OCTOBER 1996, VOL 64,NO 4
insertion point of the Achilles tendon on the calcaneus). Active ankle plantar flexion was weak on the Mr B's right side, and Mr B complained of localized pain to his right posterior ankle. Mr B reported a sudden, knife-like pain in his lower right leg and the inability to stand on his feet after the indirect injury to his Achilles tendon. The surgeon conducted the Thompson teal4 by having Mr B lay prone on the examination table and dangle his feet off the end of the table. The surgeon squeezed Mr B's right calf musculature and noted the right ankle did not plantar flex when he applied pressure to the gastrocnemius and soleus muscles and the Achilles tendon. Based on these findings, the surgeon diagnosed Mr B's indirect injury as a complete Achilles tendon rupture. The surgeon discussed surgical repair of the Achilles tendon with Mr B and obtained an informed, signed surgical consent from him. Treatment. The surgeon placed a splint on Mr B's right lower leg and sent Mr B home on crutches, advising him to rest, ice, and elevate his right limb. He also gave Mr B a prescription for pain medication and scheduled him for surgery the following week. A few days before his scheduled surgery, Mr B went to the hospital for preadmission testing, which included laboratory tests, a 12-lead ECG, a chest x-ray, and a preoperative anesthesia assessment. Mr B's test results were normal except for a slightly elevated creatine phosphokinase, which is indicative of muscle trauma. Day of surgery. On the moming of his surgery, Mr B arrived at the admitting area of the surgical suite where the preoperative nurse interviewed him and prepared him
for surgery. Mr B informed the nurse that he had hay fever but was not asthmatic; otherwise, his medical history showed Mr B to be in good health. Mr B had been NPO since midnight and had not taken any medications. Patient prepamtion. The circulating nurse and the scrub person prepared the OR for a soft tissue repair of Mr B's right Achilles tendon. The circulating nurse transported Mr B to the OR by wheelchair and helped him onto the OR bed. The anesthesia care provider inserted a peripheral IV line into Mr B's left wrist; applied a pulse oximeter, ECG leads, and a blood pressure cuff; and administered oxygen to Mr B via nasal cannula. After the anesthesia care provider administered a spinal anesthetic, the surgeon applied a tourniquet to Mr B's right upper thigh over cotton cast padding. An appropriate number of surgical team members then placed Mr B in a prone position on the OR bed. The anesthesia care provider administered a prophylactic antibiotic (ie, 1 g cefazolin sodium) through Mr B's IV line before the surgical procedure. Surgical procedure. The circulating nurse prepped Mr B's right leg up to the knee. The scrub person and the surgeon draped Mr B's right leg with orthopedic drapes and a sterile stockinet that covered the surgical leg. The surgeon elevated Mr B's right leg and applied an Esmarch bandage to exsanguinate it before the circulating nurse inflated the pneumatic tourniquet to 300 mm Hg. The surgeon made the incision and performed a soft tissue dissection. He located the ends of the ruptured tendon, reapproximated the proximal and distal portions of the tendon, and repaired them with 600 AORN JOURNAL
#2 polyester sutures. After repairing the tendon, the surgeon closed the wound with a running absorbable suture. The surgeon applied sterile dressings, cast padding, and a short-leg cast with Mr B's right foot in a plantar flexed 20" position. Surgical team members placed Mr B in a supine position, then lifted him onto a stretcher and transferred him to the postanesthesia care unit (PACU). Mr B remained in the PACU until he was ready to be transferred to the postsurgical unit. Postopemtlve compllcatlons. On postoperative day one, Mr B complained of discomfort at the surgical site and dizziness, and he was unable to ambulate with crutches. Mr B's symptoms were treated with pain medication, and he was allowed to remain on bed rest. On postoperative day two, Mr B reported less pain at the surgical site but still complained of dizziness. He was unable to walk with crutches, and he had a body temperature between 38.3" and 38.8" C (101" and 102" F). Mr B was able to ambulate with crutches on postoperative day three; however, he complained of shortness of breath during ambulation. The postsurgical nurses alerted the house physician to Mr B's symptoms. The house physician ordered posteroanterior and lateral chest xrays, a 12-lead ECG, arterial blood gases, blood enzyme levels, and a ventilationjperfusion scan. Test resulk. Mr B's chest x-rays showed an elevated diaphragm and dilated pulmonary arteries. His 12-lead ECG results demonstrated inverted T waves, transient right bundle branch block, right ventricular hypertrophy, and tall P waves. Mr B's arterial blood gas results indicated arterial hypoxemia (ie, low partial oxygen) and
OCTOBER 1996, VOL 64, NO 4
hypocapnia (ie, low partial carbon dioxide), which were ominous signs of a massive embolus. Mr B’s blood enzyme levels showed an elevation in his blood lactic dehydrogenase and bilirubin levels from increased pressure and blood volume in the great veins caused by right ventricular strain. His ventilation/perfusion scan indicated a severe obstruction of blood flow to the pulmonary artery. After reviewing Mr B’s test results, the house physician diagnosed pulmonary embolism caused by the postoperative complication of DVT formation. Medical treatment. The house physician began treating Mr B’s pulmonary embolism by ordering the immediate administration of oxygen at a high flow rate via nasal cannula, analgesia (ie, meperidine hydrochloride), and anticoagulation therapy with IV heparin sodium. The house physician ordered an initial bolus of 10,OOO U of IV heparin sodium to halt the thrombotic process and to stabilize the platelets in the embolus to prevent the release of vasoactive and bronchoactive substances. He then ordered the postsurgical nurses to administer a continuous IV drip of 10,OOO U
of heparin sodium every hour. The house physician monitored Mr B’s partial thromboplastin time (P’lT) by drawing blood samples and using the Lee-White clotting time method to adjust the dosage of heparin sodium to one and one half to two times the PIT control time.Is Mr B remained on IV heparin sodium for seven days and was placed on oral warfarin sodium before discharge for six months of anticoagulation therapy. Mr B’s discharge plan included patient teaching about anticoagulant therapy and the need for routine PTT studies and scheduled visits to his internist. The nurses also discussed the need for a postoperative follow-up visit to the orthopedic surgeon at three weeks for suture removal and a cast change to place the right ankle in a neutral position. Mr B was informed that his right leg would remain in a short-leg cast for at least eight to 10 weeks and that he would be required to crutch walk until the surgeon determined when to discontinue external immobilization. Mr B did not experience any further postoperative complications and returned to his normal activity level six months after his right
NOTES 1. B E Jarrell, R A Carabasi, Surgery, thud ed (Baltimore: Williams & Wilkins, 1996) 149-151. 2. J Luckman, K C Sorensen, Medical-Surgical Nursing: A Psychophysiologic Approach, fourth ed (Philadelphia: W B Saunders Co, 1993) 1 1 19-1 120. 3. Jarrell, Carabasi, Surgery. third ed, 149-151. 4. Ibid. 5. B Gregory, Orthopedic Surgeiy (St Louis: Mosby-
Year Book, Inc, 1994)45. 6. Luckman, Sorensen, Medical-Surgical Nursing: A Psychophysiologic Approach, fourth ed, 11 19-1120. 7. Jarrell, Carabasi, Surgery, thud ed, 149-151. 8. S A Budassi, J M Barber, Emergency Nursing: Principles und Practice, second ed (St Louis: MosbyYear Book, Inc, 1992)456-457.
Achilles tendon repair.
COMMENTARY Pulmonary embolism formation can be prevented through the early diagnosis and prevention of DVT. Perioperative nurses can intervene by encouraging patients to ambulate early during the postoperative period. If patients are confined to bed rest, nurses should apply elastic wraps or pneumatic stockings to patients’ lower extremities to avoid the pooling of blood in the calf muscles and the development of DVT. Range-ofmotion exercises also should be performed several times a day.16 Nurses’ fm emotional support can allay patients’ fears and apprehension and serve as a stabilizing factor during treatment for pulmonary embolism.17Patients’ frustrations and the general discomfort associated with immobility from prolonged bed rest can be managed with relaxation techniques, diversional activities (eg, music), guided imagery, and back rubs.18 Providing consistent patient care, encouragement, and hope to patients experiencing pulmonary embolism can augment medical treatments and facilitate optimal recovery. A
9. Jarrell, Carabasi, Surgery, third ed, 149-151. 10. Ibid. 1 1. Luckman, Sorensen, Medical-Surgical Nursing: A Psychophysiologic Approach, fourth ed, 11191120. 12. Jarrell, Carabasi, Surgery, third ed, 149-151. 13. Gregory, Orthopedic Surgery, 45. 14. S J Gates, P A Mooar, Orthopaedics and Sports Medicinefor Nurses: Common Problems in Management (Baltimore: Williams & Wilkins, 1989) 220. 15. Jarrell, Carabasi, Surgery, thud ed, 151. 16. Budassi, Barber, Emergency Nursing: Principles and Practice, second ed, 457. 17. Luckman, Sorensen, Medical-Surgical Nursing: A Psychophysiologic Approach, fourth ed, 1 120. 18. Ibid. 601
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