142 – Unit II Musculoskeletal System The supporting framework of the body it consists of your bones, joints cartilage, tendons, muscle and ligaments. Purpose - Provides protection to vital organs (heart, lungs, brain etc..) Provides sturdy framework to support body structures and voluntary movement Stores minerals (Ca, Mg, Ph, Fl) Hematopoiec tissue-allows for blood cell formation Bones (206 bones) Long – femur, humorous, radius Short – carpals and metatarsal on both hands and feet Flat – sternum, ribs, skull, scapula Irregular – vertebral column, mandible, patella,sacrum Bone cells Osteoblasts – bone-forming cells Osteocytes – mature bone cells Osteoclasts – bone reabsorbing cells The process of bone formation is called osteogenesis Joints The junction where two or more bones that are articulated (close to each other) and provide motion and flexibility in several directions. Types of Joints Synarthrosis – immovable (skull sutures, sacrum) Amphiarthrosis – limited movement (vertebral joints, symphysis pubis) Diarthrosis – freely movable Ball & socket – full freedom of movement (hip, shoulder) Hinge – bending in one direction (elbow, knee) Saddle – movement in two planes at right angles (base of the thumb) Pivot – rotation turning a door knob (articulation between radius & ulna) Gliding – limited movement in all directions (wrist) Cartilage 1
Transcript
142 – Unit II
Musculoskeletal SystemThe supporting framework of the body it consists of your bones, joints cartilage, tendons, muscle and ligaments.
Purpose - Provides protection to vital organs (heart, lungs, brain etc..)Provides sturdy framework to support body structures and voluntary movementStores minerals (Ca, Mg, Ph, Fl)Hematopoiec tissue-allows for blood cell formation
Bones (206 bones)Long – femur, humorous, radiusShort – carpals and metatarsal on both hands and feetFlat – sternum, ribs, skull, scapulaIrregular – vertebral column, mandible, patella,sacrum
Bone cells Osteoblasts – bone-forming cellsOsteocytes – mature bone cellsOsteoclasts – bone reabsorbing cells
The process of bone formation is called osteogenesis
JointsThe junction where two or more bones that are articulated (close to each other) and provide motion and flexibility in several directions.
Types of JointsSynarthrosis – immovable (skull sutures, sacrum)Amphiarthrosis – limited movement (vertebral joints, symphysis pubis)Diarthrosis – freely movable
Ball & socket – full freedom of movement (hip, shoulder)Hinge – bending in one direction (elbow, knee)Saddle – movement in two planes at right angles (base of the thumb)Pivot – rotation turning a door knob (articulation between radius & ulna)Gliding – limited movement in all directions (wrist)
CartilageConnective tissue that provides support to soft tissueFound in between articulated surfacesAvascular (no blood supply) – fed by synovial fluid
MuscleUsed for body movement, posture and heat production
Skeletal- More than 55% of muscle in bodySmooth- Inside of arteries, inside of bladder, inside lining of GI tractCardiac- Found in heart
Causes spontaneous contractions and relaxations in the heartWhen muscle contracts it brings two points of attachment closer together
1
Ligaments and TendonsLigaments- attach bone to boneTendons – attach muscle to bone
Both are made up of connective tissueBoth have poor blood supply (avascular) so nutrition is gained from synovial fluid
FasciaThink of an envelopeFibrous connective tissue that encapsulates musclesSmooth tissue that allows gliding of muscle over muscle
2
Musculoskeletal AssessmentPatient History Past medical history- specifically:
Description of health problemsFamily history of M.S. problemsMedication history (otc drugs, rx drugs, nutritional supplements)Hx of bone infection (osteomylitis)Assess for muscle spasms. What do they use to treat?Surgical hx r/t m.s problemsWas patient ever immobilized for long periods of time (risk of renal calculi and osteoporosis)ADL assessment- independent, needs assistance Are they able to move joints independently without restriction?Elimination- can they get to the bathroom on time? Use of assistive devicesNutritional intake (24 hr recall, supplements, weight loss or gain.)
PainAssess for:
intensity - pain scale 1-10quality - sharp, dull, throbbing, burningonset – when did it starttiming – when is pain worse (morning, evening.)aggravating factors – what seems to make it worseassociation – is it linked to anything else
If unrelenting pain to an area after medication, it may indicate compartment syndrome. This means device being used (traction, casts, splints etc.) will need to be removed immediately. Neurovascular compromise is occurring.
Physical exam InspectionDid patient walk in independently, or via wheelchair, assistive devices usedObserve posture and gait:Looking for abnormal walking pattern and spinal abnormalitiesKyphosis – hunchback, forward curvature, roundness of thoracic spineLordosis – swayback, exaggerated curve (inward) of lumbar spineScoliosis – lateral curvature of the spine
PalpationStart at head downwardCompare sides to assess for symmetry.Assess skin temp, tenderness, swelling or crepitation
Range of MotionActive ROM – pt does independently w/o assistancePassive ROM – pt able to perform with assistanceAssessment of:
Flexion – bending at a jointExtension – straightening at a joint (ie-stretching)Abduction – moving away form midlineAdduction – moving toward the midlinePronation – turning palm downwardSupination – turning palm upwardInversion – turning inward
3
Eversion – turning outwardCircumduction – Moving extremity full circumference
Muscle strength scale0 – no muscle contraction detected1 – Barely detectable flicker or trace of contraction2 – Active movement with no gravity3 – Active movement against gravity4 – Active movement against gravity and some resistance5 – Active, against full resistance w/o evident of fatigue
This is normal muscle strength
Abnormal Findings -Crepitus (grating, crackling sound or sensation)A lot of times heard in pt’s with fractures, or osteoarthritis
Kyphosis- “dowagers hump”. Convex shape to the thoracic region.Abnormal muscle movement
Paralysis - loss of voluntary sensation or movementHemiplegia – paralysis of one side of the bodyParaplegia – paralysis of the of the lower half extremitiesQuadriplegia – paralysis of all 4 extremities
Contractures- shortening of muscles or ligaments and as a result there will be tightness, and alignment will be incorrect. Extremities will eventually become immobilized
Additional Assessments to assess for neurological compromise: 6– P’sPain- ask patient to use pain scale to rate pain( See “pain” above)Pressure –test to be sure fingers can fit underPallor – color (pale,cyanotic) , may feel cool or cold. Check cap refillPulselessness – an emergency. Pulses are strong or bounding, diminished, absent or audible via doppler
Always check unaffected extremity first then check affected legParasthesias – numbness, tingling, burning sensation (indicating circulation problems, intermittent claudication)Paralysis – loss of sensation or movement. Assesss by having pt exercise area above or below injury (ie wiggle toes, move fingers)
Diagnostic evaluation of M.S. system X-ray – Used to detect fractures can detect bone density, identify calcifications and tumorsCT scan - x-ray picture of internal M.S. structures can use contrast for definition
With contrast check for allergies! Pt has to lay still 20 – 60 min. MRI - Visualize Soft tissue, such as cartilage
Visualization of cartilage tears, ligaments, tumors, and herniated diskNon-invasive with or w/o contrastNo pacemakers, no metal clips or implantsTakes 1-2 hours, claustrophobia is a problem
Arthroscopy -scope inserted to examine joint disordersScope is used to insert air or fluid into joint, take film of joint, take biopsySterile (done in OR under strict asepsis) invasive procedureSterile dressing
4
Elevate 24 hours post, limited action for few days postBone densitometry – osteoporosis check for bone densityArthrocentesis- joint aspiration – Needle will be put into joint to extract synovial fluid
Usually clear or straw colored and transparent, abnormal would be blood, pus, cloudy or uric acid crystals Usually used to remove excessive fluid from an area, relive pain Invasive – risk for infection, impaired skin integrityCompression dressing post/op
Electromyography – EMG – painful, measures and records muscle activity with electricalStimulation
Lab TestsCBC – WBC (infection), H&H (anemia)Electrolyte imbalance – Ca (immobile pt, calcium leaves bone and enters blood), Phosphorous, uric acid (gout) Alkaline phosphatase – elevated during initial bone healingSedimentation rate – ESR elevated during inflammation
5
Soft Tissue Injuries
Hot and cold therapy treatment for soft tissue injuries:
Cold TherapyWhen – between the first 24-48 hours to prevent swelling, pain, and muscle spasms by promoting, vasoconstrictionHow –
Use ice bags, cold packs – 20 minutes on 20 minutes offCompress with compression bandageElevate above level of heart b/c of swelling and excessive fluid to the area, elevation increases venous return
RICE = R-rest, I-ice, C-compress, E-elevate , Hot Therapy
About 48 hours after injuryPromote circulation, analgesic, reduce muscle spasm, enhances flexibilityHow – light/radiation, hot pack, heat padsUse intermittent 15-30 minutes on and offNot over 100 degreesCare in elderly, young, diabetics or spinal injury patients due to loss of sensation in extremities.NI -
Protect skin from irritationSubjective info from pt to monitor response
ContusionsA soft tissue injury produced by blunt force trauma such as a blow, kick or fallNo damage to bones of the M.S. system
Bleeding from rupture of small blood vessels resulting in ecchymosis (bruise)Or a hematoma when bleeding under the skin is excessive
Clinical manifestationsPainSwellingSkin discolorationLimited ROMNo loss of joint function
RICE – Rest. Ice, Compress, Elevate
*****WITH BOTH SPRAINS AND STRAINS THERE ARE THREE CLASSIC SYMPTOMS, PAIN, TENDERNESS AND SWELLING.
StrainsAn excessive stretching of the muscles and its facia sheathMay also involve tendonsCaused by overuse, over-stretching, twisting and excessive stress.Tiny microscopic tears occur with some bleeding into the soft tissueHeals in 2-6 weeks
6
S/S:Sudden pain with out muscle movementMuscle soreness and tendernessPain Swelling,Bruising and rednessMuscle spasms and decreased movement Initially will not be able to bear weight on that extremity
Sprains An injury to the ligament structures surrounding a jointCaused by wrenching or twisting motionMay take weeks or months to healJoint is stretched beyond normal ROM tearing ligaments, capsule or synovium of jointBlood vessel rupture and edema occursAn avulsion may occur (bone fragment is pulled away by a ligament or tendon)Common areas for sprains:
Ankles and wristsCommon in people who are in to sportsS/S:
Swelling Joint tendernessLimited joint mobilitySevere Pain with sprain b/c of amount of nerve endings where it occurs.
Diagnosis and treatment of Sprains and Strains:
Diagnosis:HistoryPhysical examX-ray to r/o fracture and to see if there is a widening of the joint area itself.
Treatment:RICE technique in acute phaseMedications:
Mild analgesics (NSAID’s)Heat in post-acute phaseProtected exercisesSurgical repair if necessaryImmobilize if necessary
ACL Injury– Anterior cruciate ligamentA common sports injury in which the stabilizing ligaments of the knee are lost or compromisedS/S:
Snapping sound, pain, swellingUnable to bear weight on that leg.
7
Management:Surgical repair and use of full leg immobilization device
Torn meniscusTear in the fibro-cartilaginous semicircular structure of the knee jointS/S:
Popping sound, tearing sensation, swelling, inability to extend kneeManagement:
Surgery - total Menisectomy
8
Joint Dislocations and Subluxations
Full Joint Dislocation A condition in which the articular surfaces of your bones forming the joints are no longer in anatomical contact. (Bones completely separate)Severe injury of the ligament structures that surround a joint
Orthopedic emergency to have dislocated joint because the following factors becomes distorted and severely stressed:
o Blood supply to the area o nerves running through that area o soft tissue
If it goes untreated run the risk for developing avascular necrosis can occurDue to insufficient or no blood supply going to area
There is also risk of developing nerve palsy r/t pressure resting against nerve, and if continued for long period of time extremity may become paralyzed, have weakness, numbness and tingling. Once nerve palsy develops it is very difficult to trea
SubluxationPartial joint dislocation
Etiology 3 categories Congenital : Children or babies that are born with hip displasia Spontaneous: Actual disease osteoporosis, pagets disease, bone tumor or cyst Somatic : Sports injuries
Once dislocation occurs: Blood supply to area is compromised Nerves in area compromised Damage to surrounding ligaments
Signs & Symptoms of a dislocation: Severe pain to area Tenderness Swelling of soft tissue Limited ROM Numbness especially if there is nerve damage Asymmetry of MS contour (ie shortening of extremity) Loss of function to extremity Impaired neurovascular function Area distal to the joint may become cool, weak pulse, poor capillary refill Ecchymosis
Diagnosis: Patient hx Incident of what happened Physical exam X-ray to visualize how much structures have shifted
Treatment:Orthopedic EmergencyGoal is to re-align dislocated portion and relieve pain
Analgesics Muscle relaxants RICE Immobilize area to protect injured joint in acute phase
o Once joint is stabilized, gentle ROM exercises can be performed
9
Open –vs- Closed Reduction Closed reduction is accomplished by using hands to put the joint back into place manually
o Very painful procedureo Medication or sedation (local or general) is required before the procedure b/c of the intensity of the pain.
Open reductions means the joint is surgically repaired.o Surgical realignment of jointo Immobilization of area post-op (casts or splints) until fully healed.
Why do you think you want to reduce it immediately? To ensure circulation to that area especially if patient is complaining of numbness and tingling to the extremity With reduction many times you may have to provide splint, cast or traction for patient to help speed recovery.
Nursing Dx Acute Pain:
o Pt will be medicated Be sure extremity is elevated because of swelling you want to decrease edema, If patient is using an immobilizer make sure patient uses it correctly
Impaired mobility Altered health maintenance
o Teach and demonstrate and have patient demonstrate back how to use an immobilizer
10
Fracture
It is a break in the continuity if bone and it is defined according to the type and extent.
Occurs from trauma or a blow to a direct area
Crushing sports injury and sudden
Pathophysiology
4 categories
Closed fractures : bone is broken on the inside and there is no external injury, bone is broken
but skin is intact.
Open fractures : There is a break in the skin causes by fractured bone protruding out.
Stable fractures : break occurs, but bone is not completely broken off
Unstable fractures : bones are grossly misplaced. Another name for this is an open fracture.
Ie -Compound fracture
What Causes Fractures
Trauma such as a direct blow
Pathological bone diseases like osteoporosis where there is bone demineralization, bone tumors
Taking meds that have S/E of depletion of bone or bone demineralization
Long term steroid use makes your bones very porous and brittle which means more prone to breakage
Different types of fractures
Memorize picture in book( pg 2081) several questions on test
Stable fractures:
Greenstick fracture : a fracture in which one side of a bone is broken and the other side is still stable
(not broken); seen in long bones
Transverse fracture: a fracture that is straight across the bone; seen in long bones.
Spiral fracture: a fracture that twists around the shaft of the bone; climbs or decends in a wrap around
fashion.
Unstable Fractures:
Compound Fracture: Bone is broken off altogether and is protruding out of the skin.
Comminuted fracture : a fracture in which bone has splintered into several fragments. Most likely to
hear crepitus with this type of fracture.
Depressed fracture : a fracture in which fragments are driven inward; skull and facial bones.
Oblique fracture: a fracture occurring at a slant across the shaft of the bone
Impacted fracture : a fracture in which a bone fragment is driven into another bone fragment; one bone
driven into another
Can be stable or unstable:
Compression fracture: a fracture in which bone has been compressed; seen in vertebral fractures; seen
in osteoporosis.
11
Pathologic fractures : a fracture that occurs through an area of diseased bone, can occur without trauma
Can occur with osteoporosis, Paget’s disease, bone tumors, osteosarcoma, osteomalacia, bone cyst.
Which fracture is the worst one, the one you are prone to infection and takes a longer time to heal?
Compound fractures cause the bone to protrude out
Clinical Manifestations
Pain
Tenderness
Muscle spasms
Loss of function/immobilization of area
Deformities where the extremity is just hanging
Distal pulses may or may not be palpable
Bone protrusion may be visible
Crepitus: rubbing / grading sound, heard esp. with comminuted fractures
Swelling w/numbness possible r/t nerve damage
Ecchymosis
Breaks in the skin especially if it is an open / compound fracture
May or may not have damage to body organs
***ALWAYS ASSESS AREAS DISTAL TO BREAK FOR SIX P’S****************
If you fracture your ribs you will be compromising your lungs, heart, and spleen
Diagnosis of a fracture:
X-ray
Patient hx
Physical exam
MRI
Ct-scan depending on the location and extent of the fracture
***before doing anything with a fracture you MUST take an X-ray***
***once fracture is corrected then another X-ray must be taken to confirm placement********
How to manage a fracture:
Do not realign a bone
If it is an open fracture and you see bone sticking out = cover it w/sterile gauze or clean lint free material to
decrease risk of contamination
Immobilize that part of the body and if you are moving that person you are going to support above and below the
area that is affected.
Closed reduction: Non-surgical
12
o X-ray is taken , then fracture is manually put back together by hand, and then another x-ray is taken to
confirm placement. Bone is then immobilized with cast, splint or brace until area heals.
Open reduction : ORIF (Open Reduction Internal Fixation) done in OR under general anesthesia,
o Patient is given pain meds, incision is made, bones are realigned, then insertion of pins, rods, nails, or
screws are used to put that bone back together into anatomical position
o Higher risk than closed reduction b/c of risk for infection, and riskd from anesthesia especially in young
and elderly.
Traction
The application of a pulling force on a fractured extremity to maintain alignment
Once area has been fixed and back in place the patient may have to wear a cast, splint and they may have to
have internal or external fixation devices.
SplintsImmobilization device that supports one or both sides of a part of the body and is secured with tape or ace bandage plastic, thermoplastic
Purpose –In an emergency or for non rigid immobilizationTo stabilize fracture during anticipated swelling and edemaProvide functional support & positioning before cast application
Nursing interventionsWell padded to prevent pressure and prevent skin abrasions & skin breakdownAssess NV status frequently and 6 p’sWrap splint with elastic bandageTeach patient to apply braceTeach patient to protect skinTeach patient to assess for 6p’s
Casts
Cast – rigid external immobilizing device molded to contours of the body
Purpose – immobilize part of body, support weakened joints, and treat deformities
Examples:
Short arm cast for fractures of the wrist area
Long arm cast for unstable wrist fracture or forearm fracture
Body jacket for fractures of thoracic or lumbar area to stabilize vertebral column
Hip/biker cast for pt’s that have suffered hip fractures
Types –
Plaster –
Does not have full strength until dry
Takes time to harden
Can be dented during hardening
New – white, shiny, odorless
Wet – grey, dull, musty
Fiberglass –
Better of the two choices
Light weight
Stronger, h2o resistant and durable
Hardens within minutes
Cast application
15
Skin assessment –
Clean and dry
Unusual swelling, bruising or edema
Body part in proper alignment
Marked area around bony prominences
Layer of stockingette to pt skin- make sure no wrinkles or creases
Thin layer of padding added especially over boney prominences
Apply cast material
Nursing interventions
Initially ice will be applied to areas above and below the cast to reduce swelling
Elevate cast limb on plastic covered pillow to encourage venous return to reduce edema
ROM exercises for joints above and below cast
Do skin assessment to assess for problems (ie discoloration of the toes, unusual pain, burning and tingling under cast, foul
odor coming from cast)****see complications below****
Check for stain on casts- if present , circle it, time ,date and initial it. When re-checked later be sure stain has not spread
The best place to assess for bleeding w/in a cast is to lift the cast up, and check underneath.
Nursing Diagnosis
Risk for peripheral neurovascular dysfunction R/T cast too tight
Patient teaching
Itching under cast – do not stick sharp object, use cool blow drier
This is because you can’t see under cast, and an object can cut you and you wouldn’t know. May lead to
Osteomylitis
Do not get cast wet-only cover when showering b/c of risk of moisture build-up
If cast does get wet use hairdryer on cool setting to dry
Do not remove any padding either above or below the cast.
Do not put powder in cast
Do not cover with plastic for long, only for showering.
Do not bear weight on it for first 48 hours.
Exercise unaffected limb to avoid disuse syndrome
Complications of cast wear:
16
Perineal nerve palsy-
Will most ofter be seen in arm or leg where perineal nerve is
Caused by:
Cast too tight
Cast put on prematurely (area is still swelling and edematous)
Your tissue will eventually press against perineal nerve
Once nerve palsy sets in there will be
Pain
Numbness and tingling to lower extremity.
Cast will have to be removed immediately.
Compartment syndrome –
Increase in tissue pressure within a limited space that compromises circulation and function of tissue within a confined area
Caused by cast that is too tight
Remove cast, considered a medical emergency
Symptoms – unrelenting pain not relieved by meds
Tissue necrosis / infection
Caused by avascular necrosis (sluggish or no blood supply to part of body, which causes cell and tissue death)
Warm musty odor coming from cast
Skin assessment – 1x per shift
Look down cast with flashlight, pull skin taught
Assess cast for staining on cast on top, sides and especially under the cast
If you do find drainage, circle it, date and time and initial, then check again later to be sure area hasn’t spread.
*******Do not cover cast with plastic or rubber except to take shower
Cast syndrome
Only with a body cast
Restricted chest expansion, compression of mesenteric artery causes decrease of GI motility
S/S:
Anorexia, accumulation of gas, N.V., abdominal discomfort
Risk of gangrene of intestines due to lack of blood supply to GI tract
Do thorough abdominal assessment every shift, best right lower quadrant at the ileocecal valve
Listen 3-5 minutes
Foot drop –
17
Caused by perineal nerve damage
Immobility problems r/t cast wear:
Deep Vein Thrombosis – DVT
Pressure ulcers
Pneumonia (elderly),
Constipation,
UTI
Bone demineralization
Internal FixationUsed for stable fractures Put the fracture back together internally with the use of pins, rods and screws attached permanently to boneProducts are mostly made out of stainless steel and titanium
Post-op:X-ray to be sure has been correctly alignedF/U X-rays over next few weeks or months to be sure alignment is maintained
External Fixation Device************Look at pictures*****************
Used to realign crushing injuries, where the bone has been fragmented into pieces, and there is a lot of edemaand long bone injuries.Surgical incision is made and rods pins and screws are used to realign fracture but area will not be closed completely.
Incisions are made coming out through the skin and an external metal frame attachedThis holds the bone together on the inside of the extremity
Metal pins maintain position of the bone through attachment to a portable external frameUsually applied in operating room
Sterile procedure, Patient is sedated; a nerve block will be given to extremityStays in place approx. 6-8 weeks
IndicationsFor stabile support of severe fractures, crushed or splintered bone while permitting active treatment of damaged tissueProvides access to open wounds for debridement, irrigation & skin graftsProvides limb lengthening (telescoping rods, turned by pt)Reduce, align & immobilize fracture by a series of pins inserted into bonePosition is maintained by attachment to external frame
ContraindicationsPatients with diabetesElderly (esp. those that are confused)Immunocompromised r/t high risk of infection.
Nursing assessmentPin site assessment 1x/shift (redness, drainage, tenderness, pain & loosening of the pins)
Nurses do not tighten pins or clean device , patients are taught how to do thisIf pins were to become loose, and patient is unsure of how to tigten, call Orthopedics, who will show themWhen Patient cleans device it will be with sterile water, and sterile cotton swabs
Extremity elevated to reduce swelling
18
Cover sharp points on External Fixator to reduce device induced injury to patient or othersAssess 6-P’sNeurovascular status check q2-4 hoursIsometric and active exercise within limits of tissue damageEncourage patient to adhere to weight bearing order from MD to avoid pin looseningDo not pull on rods- lift extremity to move patients.
ComplicationsAnestesia (esp in older patients)May prolong periods of immobilityPt will not have a lot of use of this extremity- probably will only be able to move toes or fingersRisk for infection (watch for purulent drainage( serous normal)
Administer antibiotics
Complications with fractures:
19
InfectionEspecially if it is an open (compound) fracture. If area is contaminated surgical debridement will be necessary.
Patient will be on antibiotics. When area is irrigated topical antibiotics will be used also.
Hypovolemic Shock Shock from hemorrhage loss and from loss of extra-cellular fluid into damaged tissue. May occur from fracture to extremities, thorax, pelvis or spine
Assessment Decreased BP, increase HR & Resp, cool and clammy, restlessness and decreased LOC
Management Replace fluid loss, keep warm, monitor V.S. & O2 status, restore blood volume and circulation, and monitor labs especially hct, hmb
Fat EmbolismFat globules in blood stream that results from a fracture of the long bones in the body (Tibia, Femur)Fat globules lodge in the capillary bed of the lungs, and also may make it to the brainUsually seen within 24-48 hours of fracture long bonesSeen frequently in young adults (20-30)
Chest painDifficulty breathing /wheezingUse of accessory muscles while breathing HypoxicHeadacheChange in mental status (memory loss, irritable, confused, agitated, sense of impending doom)Increased HR (tachycardia) & Respirations (tachynpea)Petechiea
Management – coughingDeep breathing and coughing exercises (mainstream treatment)Anti-coagulants (ie – lovenox)Aspirin Administer O2Bed restChest X-ray to visualize areas that have consolidated w/in the lungIntubation if none of the previous interventions work.
Compartment Syndrome Tissue perfusion in the muscles is less than that required for tissue viabilityRise in inter-compartmental pressure within the muscle itself that results in tissue damage. Usually associated with
IV infiltration into tissues instead of veinsCast or splint too tight.
Tissue death within 4 hoursNormal pressure 8 mm of mercury, above 8mm tissue perfusion will be impaired.
Manifestations-Unrelenting deep throbbing pain not relived by medsSwelling, numbness, tinglingNail beds cyanotic, poor cap refill, loss of distal pulseParalysis
Management Notify MD STAT- Medical emergency
20
Remove constricting dressing or castMeasure pressure
Surgical Fasciotomy (surgical decompression)Fascia and muscles are cut open to allow for swelling. This is left open for several days.Prophlaxis antibiotics will be ordered ,and area will have to be debrided because of high risk for infection. Once swelling is over, patient will go through another surgery to close the area.
Cover limb with moist dressingElevate limbIf not treated immediately, pt may end up with contractures, limited ROM, or loss of use of extremity
Deep Vein Thrombosis – DVTRelated to bed rest, decreased mobility (immobility)& skeletal contracturePrevention:
ROM (esp dorsiflex and plantar flex-which can not be done in a cast but can be done with external fixator.Prophalactic anticoagulants (Lovenox)Anti-embolism stockings
Assess Redness, tenderness, heat, pain and positive Homans sign
ManagementAnticoagulant therapy
Avascular Necrosis Caused by blood supply to bone being sluggish or lost, and as a result bone loses its blood supplyOccurs mostly at femoral head, talus bone of the ankle or lunate bone of the wristOccurs with steroid use, chronic renal failure, prior bone transplant, sickle cell disease
Assessment:Pain numbness and tingling in extremity,Limb unstableDecreasing ROM
DX: X-ray, bone scan, CT scan
Management:No weight bearing to bone Removal of bone or bone graft or prosthesisJoint fusion, replacement or amputation
Delayed Union Healing does not occur at a normal rate for the type and location of fracture
Non-Union Failure of the ends of the fractured bone to unite
Wrist Fracture (Colles Fracture)Fracture of the distal radius
21
Seen in elderly with osteoporotic changes in the boneUsually seen in someone who breaks fall with the hand and wrist ( esp elderly and people who play sports)
ManifestationPainful fracture (localized pain to wrist)Swelling to surrounding areaDorsal displacement of the distal fragment (X-ray shows dinner fork deformity)Loss of sensation due to pressure on median nerve
ComplicationsVascular insufficiency
ManagementClosed reduction (manipulation)- no surgery involvedImmobilized with splint or castPain meds before reduction and prn.Follow up with X-ray to be sure bones have been reduced to normal anatomic alignmentElevate first 48 hours Exercise immediately fingers and hands
Nursing DxAltered peripheral tissue perfusionRisk for impaired skin integritySelf care deficit
Hip Fractures Most common fracture in older adults
Different types –Intracapsular –Occurs in hip join itself-( ie- head of femur,acetabulum area)
Harder fracture to heal b/c it it difficult for the blood supply to get to the intracapsular area of the hip joint Occult – Fracture, little trauma, minor discomfortImpacted & Non-displaced – moderate pain, no deformitiesDisplaced – lot of groin pain, externally rotated leg, ORIF to fix
Causes:Osteoporosis
Extracapsular – Occurs outside of joint capsule itself
TrochantericSubtrochanteric
Causes:Falls (esp on snow or ice)Direct trauma to hip (ie-car accidents
Manifestations External rotation of legLots of muscle spasmsShortening of the affected leg Excruciating pain (Localized) and tenderness at site of injuryDisruption of blood supply to area
Diagnosis:X-ray- definitve testCT scan
22
MRIPatient History and physical exam- will note shortening of the affected leg, swelling
Medical Management : Prior to surgery temporary skin traction (Bucks Traction- no more than 5-10 lbs, wrap is applied directly to skin.) to relieve pain and spasms
Not left on for more than 48 hours.Sand bags for alignment and prevention of rotationAnalgesics Muscle relaxants r/t muscle spasmsSurgical repairPre-op-
Administer pain meds for pain managementMuscle relaxantsTeach use of overhead trapeze to maintain correct realignment achieved with traction
Post Surgery –Monitor VSMonitor I&O with foleyLung assessment r/t risk of pneumonia- teach pt to cough and deep breathe, use of incentive spirometerContinue to administer pain medsAddress dressing area for unusual drainage, bleeding or bulging
Neurovascular assessment- color, temp, cap refill, distal pulse (always assess good leg first to get a feel for what the pulse should be and use that as a reference point to compare) edema, lack of sensation or unusual sensation
Post-op teaching:DO NOTS: ****Look at pictures in book****Do not force into more than 90* of flexion
Can sit in an upright 90* angle, but no bending over more than 90*Force hip into internal rotation (do not turn leg inward when lying down)Force hip into adduction- leg must remain slightly abducted.
****All are achieved by use of an abductor pillow****Never cross legsSit on chairs without arm rests
Arm rests are used for pt to push themselves out of chair.DO:Wear shoes, but adaptive devices are needed to put shoes on b/c no bending overElevated toilet seatsAbductor pillow b/t legs (while in bed ) for first 8 weeks s/p surgery***look at picture***Keep hip in neutral positionNotify MD if severe pain, deformity or loss of function in leg (difficulty moving)
Complications of hip fractures:Avascular necrosis (esp with intracapsular fractures where blood supply has been cut off)Dislocation-
Patient will hear a popping soundWill manifest as pain to buttocks areaPt will have to be re-xrayed and f/u surgery may have to be done.
Leg shortening (pt. may end up with a deformity)May need lift for shoe
Non-union Failure of bones to heal and fuse and align appropriately
Bone infection (osteomylitis)Osteomylitis is dangerous b/c bone is hard and dense and it is difficult for antibiotics to reach abscess (casing around infection
Blood vessel and nerve damage as a result of avascular necrosis
Interventions
23
Post-op careMedication, IV antibioticsDeep breathing – strength exercisesFoot exercises, flexion, extensionAnti-embolic stockings to compress and increase circulationNutrition, urinary output, Abductor pillow in proper alignmentMonitor for DVT, skin assessment, NV complicationsBreath sounds every shiftPatient teaching prior to and post surgery
Nursing Dx-PainImpaired Skin IntegrityR/F InfectionSelf care deficit
Nursing Diagnosis for FracturesImpaired skin integrityRisk for impaired Skin IntegrityAcute Pain
24
Risk for infectionImpaired physical mobilityRisk for impaired peripheral vascular dysfunction
Positive aspects that influence bone healing: If you immobilize the area in a timely fashion and bones are connected back together in a timely fashion that
will contribute to faster bone healing. Apply ice to area Ensure sufficient blood supply by inspecting :Note if it is pink, pale, blue, check distal pulse, capillary refill,
touch it to see if it feels warm or cool to touch Nutrition: make sure patient is receiving adequate amount of protein, Vit C, Calcium, Vit D. Weight bearing exercises: especially if it is a fracture to the long bone. Hormones: Calcitonin, thyroid, estrogen, growth hormones.
Negative aspects that inhibit bone healing:Extensive trauma to an area and it took a really long time to correct or make those bones come into contact with each other that can negatively impact on bone healing Infection that went to the bone and patient developed osetomyelitisDecreased circulation to the areaProne to certain bone diseases such as Paget’s disease, or if they already have osteoporosisNot eating what they should be eatingAge- the older you are the harder it is for fractures to heal Immunocompromised Long term steroid use Asthmatic
Nursing intervention for patient with fractures
Closed fractures You want to show your patient how to use assistive devices correctly. Return to ADL’s as ASAP Exercise affected and unaffected extremities
Open / Compound fractures Prevent infection Give patient prophylaxis direction Culture area to make sure there are no harmful organisms growing in there Elevate extremity: you want to eliminate edema to that area Neuro assessment a q4hrs Monitor v/s especially temp( first sign of a brewing infection an increase in temp)
Assistive Devices
CanesHelp pt walk with greater balance and support and relieves pressure from weight bearing joints by redistributing the weight.
25
Types – single legged, tripod (three feet), quad (best stability)
Measurement –Patient standing uprightSlightly flex elbow at 30* angleHandle of cane at same level as greater trochanterTip of cane 6” to the right or left of the base of the 5th toe
Must have non skid rubber tip at basePt must wear good shoesHold cane in hand of good side (opposite side of affected extremity)Advance cane at same time as affected leg to relieve pressure
Cane up and down stairs – “good to heaven, bad to hell”When going up, lead with good legWhen going down lead with bad leg
WalkerA four point assistive device that provides a much broader base of supportWith and w/o wheels
Measurement –Standing upright20 – 30* flex at elbowTop of walker is level with thumb joints, and there should be NO flexion of thumb joints
Wear sturdy shoesUse walker to assist in getting up with good leg assist
Push off bed/chair to stand- never pull walker towards themLook up as you walk- towards the horizon, not down.
Crutches (see library packet)For partial weight bearing or non weight bearing ambulationTo be a candidate for crutch use:
Pt must have adequate upper body strength and good arm controlSufficient balance and erect postureMust have adequate cardio reserve
Measurement –Should be standing can be lying (standing is preferred)Stand against wall with feet slightly apart and shoes ON.Measure from axilla to base of feet (in bed axilla to base of feet + 2”-don’t need shoes on in bedHand piece adjusted to allow 20-30* angle at elbowMust have foam rubber upper arm piece to avoid crutch palsy (radial nerve pressure)
S/S: numbness, paralysis tingling to extermityPatients arm should be at 20-30* angleWeight of body carried on hands- not on arm pieceHold crutches in tripod position 8-10” in front of body
Crutch Walking – tripod position-****Look at pictures in book***2 pt gait –
Used for patients who are PWB on both legs, probably from injuryResembles normal walkingCrutch is advanced then opposite leg Crutch is used in place of swinging of arms
3 pt gait –For no weight bearing on one legThink of patient with cast on.There are three points on the floor (two crutches and one leg)
4pt gait –PWB on both legs
26
Slow version of 2 pt for supportReserved for pt’s with poor balanceFour points on floor at all times (two crutches and two feet)Advance left foot, right crutch, then right foot, left crutch (one foot then crutch)
Swing through/Swing To –Variation of three point gait for pt’s who are NWB to one legSwing To-
Usually used in the beginning, when pt’s are adjusting to crutchesSwing good extremity to the level of the crutch (tripod)
Swing Through-Usually reserved for when pt can go faster, and it more sure of themselves on crutchesSwing good extremity through the crutches so it ends up in front of them.
Crutch up and down stairs same as cane (good to heaven, bad to hell)******Look at pictures****Up good leg 1st, then advance crutches Down bad leg 1st with crutches
Complications R/T ImmobilityOrthostatic hypotension – sudden drop of BP from supine to upright position
AmputationsRemoval of body part, usually and extremity (arm or leg)Indications depend on underlying disease or cause
May be traumatic or therapeuticWhat is left? – StumpBKA / AKA – below knee amputation, above knee amputationAEA/BEA- above/below elbow amputation
27
Goal of Amputation:Removal of as little of the extremity as possible to preserve function, but at the same time removal of dead, infected or ischemic tissueRelieve symptoms such as pain and compromised circulation, improves quality of life
Causes of amputations:Traumatic accident, crushing injury, frostbite, gangrene
Manifestations of patients who will require amputationsExcruciating pain (although this in itself is not always an indicator)Numbness, tingling, loss of sensation to an area is indicative of impaired circulation.Doppler study indicating decreased blood flow to areaArea may be dark or pale in colorArea may be cold or cool to touchWill probably exhibit local or systemic signs of infection.
Types of amputationsClosed – remove bone, suture skin and put muscle flap over areaOpen – remove everything bone, muscle soft tissue than corterise Disarticulation – removal of an actual joint itself
DiagnosisPatient history and physical exam
Physical appearance of soft tissueSkin TemperatureSensory function (using cold or hot, sharp or dull, tuning fork to see if vibration felt)Presence of peripheral pulses ( if distal pulse can not be felt f/u with Doppler study)*****assess good leg first to get baseline and if deviation is noted in bad leg
Arteriography for circulatory statusDoppler Recording for info r/t blood flow to extremity
Pre-op Assessment and PreparationCirculation of affected part via Doppler studyBaseline NV status pre and post to compareAssess physical and emotional status
Stress importance of getting well post-surgery (usauuly therapist involved b/c many pt’s become depressed)
Allow grieving and open communicationDiscuss options re: prostheticsExplain Phantom limb pain
Pain , cramping, burning sensation to area that is no longer there. This is normal for patient to feelWill subside, but may last up to a year.
Medical management post-op“Phantom limb pain”
Monitor pain and administer medsMonitor respiratory statusNeuro-vascular monitoring (will now assess for a proximal pulse b/c not able to assess for distal. Ie- with a BKA you would assess for the popliteal pulse, With AKA assess for femoral pulse)
28
Baseline VS (to assess for S/S of shock r/t hemorrhaging)Assure proper healingPrevent dependant edema to stump area
Care following amputationsDaily inspection for irritation, redness, abrasion to areaPost- surgery goal is to get pt in an upright position so they can dangle extremitiesWhen starting ambulation, only ambulate for 5 minutes to prevent dependant edema to areaStump care –
Wash dailyNo lotions powders or oils- can cause skin breakdown
Phantom pain and pain medsProper use of prosthetics-
Correct fittingProsthesis should be put on before pt gets out of bed
Use of compression stockings to prevent edema to that area.ROM everyday utilizing overhead trapeze to build upper body strength so pt will be able to use crutchesProne position for 30-40 min x 3-4 times a day to prevent flexion contractures.
ComplicationsHemorrhage – major complicationInfection- may infect bone (osteomylitis)Delayed healing – especially in pts with circulatory problemsFlexion contracture–Especially to hip area
We want patient to get OOB, and sit in chair, but for no longer than 1 hour b/c longer than an hour forces hip into contracted state. Place patient on stomach (prone position) for 20-30 minutes a day x 3-4 times a day. The rationale behind this is to keep leg in extensionNo elevation of stump
Skin irritations r/t prosthesisPhantom limb pain – very real especially if traumatic injury
Pre-op – explain phantom painEdema
Compression dressing, NO elevation of stump
Nursing DxPainAlteration in sensory perceptionImpaired skin integrityBody image disturbanceDysfunctional grievingRisk for infectionImpaired mobilityRisk for depression
Common Joint Surgical Procedures******Look at pictures*********
Arthroplasty (Joint Replacement)Can be full or partial replacementSurgical removable of deformed or diseased joint surface with replacement by smooth artificial surfaces made of metal or plastic (usually hips and knees)
29
Provides relief of pain, improve or maintain ROM and normal function, and correct deformitiesCommonly replaced joints:
HipsKneesFingers Shoulders
Indications:Osteoarthritis r/t excessive weight bearing on joints- seen in people who play sports- most common causeAvascular necrosisRheumatoid arthritisFailed prior reconstructive surgeriesCongenital hip diseaseFractures
Nursing interventionPreop baseline assessment to compare to postopPrevent infection, aseptic technique, antibiotic therapy, C&SPromote ambulation ASAP per MD ordersPrevent dislocation:
Sit patient in high seatsFracture pan for voidingNo drivingNo adductionNo crossing legsBed elevation less than 60*No hip bending more than 90*
Safe transfer OOB – get out of bed on either side with assist of 2 S/S of dislocation :
Shortening of legLeg not alignedAbnormal rotationPain, pop heard by patient
ComplicationsInfection-considered most serious complication of joint surgery
If infection occurs in area joint was replaced, further surgeries will need to be done, and the following surgery will be more intenseIf area becomes infected it will almost always lead to pain, loosening of prosthetic device and dislocation
Bleeding - hip 200- 500cc drainage within first 24 hoursWithin 48 hours down to less than 30ccKnee 200-400cc first 24 hoursWithin 48 hours down to 30cc
Injury to nervesExcess wound drainageLoosening of prostheticShortening or misalignment of extremityHeterotrophic ossification-development of new bone in space of device
Avascular necrosisDVT
Pt’s will be on Lovenox post surgery to prevent DVT, and sent home on low dose aspirinImportant to note:
If patient returns home and starts running fever of unknown origin, increased pain locally to replaced joint area, unusual drainage at incision site, these are all indications that there is an infection. Notify MD ASAP.
Nursing Diagnosis:Pain
30
-medsImpaired physical mobility
-maintain alignment, assistive devicesSelf care deficitImpaired tissue integrityRisk for infectionRisk for ineffective neurovascular dysfunctionAnxiety
-diversion therapyInfection
Osteomylitis
A severe Infection of the bone, bone marrow and soft tissue surrounding bone
2 modes of bone infectionDirect bone contamination –
Open Fracture, bullet or stab wounds
31
Organism enters BS, makes its way to bone and multiplies. Abscessed area w/in bone in formedS/S- Bone pain (dull,aching constant pain that is there all the time even at rest. Pain increases w/ activity. Type of pain you can live with, annoying pain) and increased pressure b/c bone can not expand
Indirect bone contamination-Extension of soft tissue infection ( pressure ulcer, incision infections)Blood borne spread ( boil, infected tooth that spreads, URI,UTI that spreads to BS)
EtiologyBacterial – S.aureus(most common w/ direct contamination) S. pyogenesViralForeign material
Dx tests*** MRI and CT scan (early definitive test)- Identifies area of infection in bone and soft tissueBlood or wound cultures- to Id organism
Will show elevated WBC, ESR (Indicates infection in body, but not where)X-ray irregular – decalcification of bone site will be seenRadionuclide bone scan- Used to ID area within bone that is infectedUltra sound – to visualize fluid abscessBone or soft tissue biopsy- to ID organism causing osteomylitis
32
TreatmentTreat aggressively with IV antibiotics for 6 weeks-3 months
Harsh antibiotics- aminoglycosides- (end in –ycin) which cause ototoxicityAlso preventing spread with prophylactic antibiotics
Surgical debridementHyperbaric O2 therapy
100% O2 administered directly to area that has osteomylitisBelieved to stimulate circulation and heal infected tissue
Bone Grafting****If none of the above procedures work pt may be candidate for amputation.Needle aspiration for sample for C&SPharmacology –
Ototoxicity, photosensitivity, GI Upset, colitis, Candida overgrowth (yeast infections, oral infections)Use Probiotics, acidophillus ,yogurt to reintroduce yeast back into the body wile on antibiotics
R/t patient has an illness that they are going to be treated for long term. Will include a lot of patient teaching re: medications, diet
Osteoporosis
A chronic, insidious progressive metabolic systemic bone disease characterized by low bone mass and structural deterioration of bone tissue leading to bone fragility, and in turn fractures
Demineralization of bones resulting in porous, brittle, fragile bones
Also called “Silent Thief “ or “Silent” disease
33
Disease happens w/out you even knowing
A reduction of bone density and a change in bone structure both of which increase susceptibility to fractures
Not a disease of the elderly, can happen to anyone at any time
Risk factorsPregnancy and lactationIncreased age increases riskFemales Increased risk (but males can get too, but they get a much higher intake and lower output of ca+)Having a thin,small, frameFamily History of osteoporosisDiet Low in CALCIUM
Lactointolerant, vegetariansRace – White, Asian more susceptibleEndocrine – menopause r/t sharp decline in estrogen (rapid bone loss occurs at same time)Neurological disease- Parkinson’s,
Medications –Long term use of corticosteroids, anti-seizure meds, aluminum containing antacids, thyroid hormones
Secondary osteoporosis caused by external forces like meds, and diseases like Parkinson’s
Osteoblast and osteoclast imbalance causes osteoporosis
Modifiable factors – not genetic, only changeable factorsHormones (see below)Cigarette smokingCaffeine excessLow body weight ETOH intake excessSedentary life styleSafety strategies to prevent falls
Diagnosis**Based on patient history and PEBone mineral density test (BMD)
– Measures how tightly packed bone is on the X-ray
–Will only show after 30% of bone destroyedQuantitative computer tomography (QCT)
– Good for spine*** Dual energy x-ray absorptionmetry (DEXA)
-Reserved for patients who are on meds for osteoporosis to see if improvement in condition is occurring,Lab studies
Serum calcium, phosphorous, alkaline phosphotate,These all work together for ca+ absorption. calcitonin, vit.d ****look up levels****
Bone Biopsy
Medical ManagementBiphosphonates – Fosomax, inhibits bone reabsorption to prevent osteoporosis, helps to build bone
Can be given daily or weekly POGive 30 min before meals on empty stomachSitting in an upright position to lessen the change of esophageal irritation Can be standing and moving around, just not lying or recliningS/E- Anorexia, weight loss, gastritis, esophageal irritation
Calcitonin –Replacement hormone to increase bone massHRT - estrogenEvista – SERM - selective estrogen receptor modulator, works like estrogenExercise – weight bearing (walking) and resistance training Nutrition – calcium, vit D, milk, cheese, fish oil, supplements, green leafy veg.Cut down/out drinking and smoking
Nursing Diagnosis:PainRisk for injuryKnowledge deficit
Rheumatoid Arthritis ****Look at pictures****A chronic systemic inflammatory disorder that’s characterized by: Inflammation of connective tissue w/in jointsPain Changes in joint structure Pathophysiology
Cause unknownGenetic predisposition
35
May be autoimmuneMost widely accepted theory
Body produces antibodies Rheumatoid ((RF) factor which combines with IgG and deposit on Synovial membranes and cartilage of joints, as a result of this erosion of articular cartilage occurs , and synovial lining thickens.
Immune system mistakes your tissue for foreign tissue and as a result of that, it tries to neutralize it and get rid of it.
Inflammation of synovium- edematous, with a lot of excessive growth of inflamed membraneAs time goes by there is fusing and immobility of the joints
Incidence – Seen more in femalesSymptoms appear usually between 30-50 years old
Incidence increases with agePeriods of exacerbations and remissions – some good and some bad times with pain
Patient history*** Generalized stiffness in morning lasts from an hour to several hours for more than 6 weeks*** Symptoms bilateral and symmetrical
Joint pain w/warmth and tenderness to the touchSwelling of 3 or more joints for more than 6 weeksNodules over joints as disease progresses
*** Acute- comes on quickly in starts in small joints of hand, wrist and feetManifestations
SystemicSymptoms occur symmetricallyOnset is insidiousSystemic-
Patient Hx and PE*** Blood test – rheumatoid factor, ESR, WBC, C-reative protein will be elevated
Normal ESR isElevated ESR indicates that there is an active inflammation somewhere , but not where.
Normal RH Factor is less than 60- anything over seven may indicate RAIn over 80% of patients with RA blood test for RF will come back positive indicating autoimmune response, probably RA
Normal WBC is 5,000-10,000 mm3 in pt’s w/ RA WBC will be over 10,000C - reactive protein elevated- Normal is <1.0 mg/dl or 10 mg/L (SI units)
*** Athrocentesis ( joint aspiration ) with synovial fluid analysisWBC”S may be seen in Synovial fluid
Bone Scan- will be able to pick up changes early on in the diseaseX-ray- will see joint space narrowing
Ie- Methotrexate, gold therapyGoal of these drugs is to slow down or prevent progression of disease
Immunosuppressive therapy (corticosteroids)IM injections into joints that should provide pain relief for several months
OT / PT therapyPT- helps patient to maintain joint motion and muscle strengthOT-help patient to develop upper body strength to gain strength for the use of possible assistive devices
Apheresis –Filtering of blood to remove antibodies (ie Rheumatoid factor). Remaining blood is reinfused back to patient.Done once a week for about 12 weeksSimilar to plasmaphoresis
Surgery
Patient teaching:Rest- esp. during flare ups and in between activities such as ADL’sJoint protection- esp about use of assistive devices to protect joints during periods of exacerbationsHeat and cold therapy- max 15-30 min
Heat seems to bring RA patients most relief (Warm shower in AM, hot packs to neck and shouldersExercise-
No aggressive exercise. Stationary bike, walking, gardening, swimmingNon-pharmacological techniques
Yoga, massage. Guided imagery Nursing DX
Pain r/t chronic state of inflammation, joint overuseImpaired physical mobility r/t pain, stiffnessBody image disturbance r/t nodulesSelf care deficit r/t joint immobility, contractures, progression of disease
Osteoarthritis (aka Degenerative Joint disease)****Look at pictures***Slowly progressiveA degenerative Non-Inflammatory joint disease characterized by:Usually unilateral (but can be bilateral) degeneration of jointsCartilage disruption-Loss of articular cartilage of weight bearing joints
Mostly affects adults usually in the 3 decade peaks around the 5th 6th decadeIncidence increases with age
Mechanical stress to joint caused by repetitive motion (ie sports players)Joint trauma such as dislocations, fractures, reductions or surgeries where avascular necrosis developsInflammation r/t release of enzymes locally at that site that causes further disruption of articular cartlidgeJoint instability esp. with damage to structures surrounding joint capsule itselfSkeletal deformities esp. congenital in nature
PathophysiologyCartilage damage triggers a metabolic responseSmooth white translucent articular cartilage becomes yellow, dull, and granular
Cartilage b/c soft, less elastic, and less able to resist wear on the jointsErosion of cartilage
Cartilage becomes thin, less able to stand pressure. Bony outgrowths on the corners of the bone itself (osteophites or spurs) later in diseaseCysts may develop in boneEventually you will lose most of cartilage in joint
Signs and symptoms*** Gradual and insidious
Discomfort to joint- can be mild to severs depending on the stage of diseaseJoint discomfort/stiffness usually in morning less than 15- 30 minutes- decreases with movement
*** Usually asymmetrical painDecreased ROMLoss of function to extremityJoint limitationsCrepitus (grating rubbing sound) r/t cartlidge in joints rubbing against each otherBoney out growths- nodules (HEBURDENS NODULES) under skin .Joints cool to touch
*** No real test to diagnose
Assessment and Dx findingsPatient history and Physical exam
Compare to contralateral joint if not affectedEnlarged joints
CT ScanX-ray images of thin slices of soft tissue and bone
MRIMagnetic and radio waves to produce actual images of bone and soft tissue
Bone scan-Nuclear scanning test that is used to ID new areas of bone growth or breakdownEvaluation of damage to bonesIdentifies sites of infection or trauma
X-ray – Loss of joint cartilage- cartilage breakdownJoint space narrowing b/t jointsErosionsLater in disease bony outgrowths (osteophites)
Arthrocentesis with synovial fluid analysisTo differentiate b/t Osteo and RA (Pt’s with RA will have WBC’s in synovial fluid, and pt’s w/OA fluid will usually be normal- clear, yellow, no WBC’s)
38
***********No blood test useful*********
ManagementRest and joint protection esp. during acute episodes of exacerbationHeat and cold therapy
Heat is more effective for stiffness 20-30 minutes on then off for both
Nutritional therapy/ exerciseLimit weight bearing on jointIsometric exercises (NWB exercises are best- ie swimming)
Complementary and alternative therapyAcupuncture has been shown to be very effective for chronic painYoga, massage, guided imageryGlucosamine
It is believed that Glucosamine works by preventing breakdown of cartilageTake with foodUse cautiously in pt’s who are diabetic b/c if they are taking oral hypoglycemics together w/ glucosamine some reports have shown that it lowers blood sugar to a much lower level
Meds –, NSAIDS ie Motrin or ibuprophenThree A’s- anti-inflammatory, anti-pyretic, analagesicS/E GI Bleeding and erosion
Look for melena (dark tarry stool)Corticosteroids- Given as an IM injection into the joint itself.
Usually lasts for several monthsReduces inflammation and relieves pain in patient
Topical analgesicsSurgery –
ArthroscopyOsteomoty (incision in bone to realign joint)Joint replacement
Patient TeachingLose or maintain weight to put less weight on jointsUse of assistive devices esp. during acute flare up (ie-braces, splints, canes)Avoid forceful repetitious movementUse good posture and body mechanics
To pick up something from the floor do not bend at the waist, bend at the knees and use leg musclesPace activities and routine tasks to lace less stress on joints
Periods of rest
Nursing diagnosisPain (acute or chronic) r/t inflammationDisturbed sleep pattern r/t painImpaired physical mobility r/t weakness or stiffness of jointSelf care deficit r/t joint deformity and pain.
***Note differences in osteoarthritis and Rheumatoid arthritis**************
Lab Values to Know for this unit*****Normal values******
ESR- o Males up to 15mm/hro Females up to 20 mm/hr
Calcitonin o Males –less than or equal to 19 pg/mlo Females- less than or equal to 14 pg/ml
Chapter 11
ADL’s – Activities of Daily Living
Assistive technology – item or piece of equipment used to improve the functional capability of individuals with disabilities
40
Disability – restriction or lack of ability to perform an activity in a normal manner
Habilitation – making able – learning new skills and abilities to meet maximum potential
Impairment – loss or abnormality of psychological, physiologic or anatomic structure or function at the organ level
Instrumental activities of daily living (IADLs) – complex aspects of independence including meal preparation; grocery shopping, household management, finances and transportation
Rehabilitation – making able again – relearning.
Autonomic Hyperreflexia – a neurological disorder characterized by a discharge of sympathetic nervous system impulses as a result of stimulation of the bladder, large intestine or other visceral organs. It occurs in persons with certain spinal cord injuries. Symptoms may include bradycardia, profuse sweating, headache and severe hypertension
Hardiness – a personality characteristic that is a buffer in the stress and depression dynamic and increases a person’s capability of having a positive psychological reaction to a stressor
Different Scales/Scores Health-Related hardiness Scale (HRHS) – high score – hardiness Zung Self-Rating Depression Scale (ZSDS) – measured depression – high level – indicates
depression Clinical Response Scale (CRS) – physical health status is measured – high measured worsened
health status Barthel Activities of Daily Living Index (BADL)– measured disability - a high score indicated
independence and a low sore indicated disability. FIM – measures level of independence PULSES – measures physical condition
Range of Motion TerminologyAbduction – away from bodyAdduction – towards bodyFlexion – bending of a joint to that the angle diminishesExtension – the joint angle is increasedRotation – turning of a part around its axis (neck)Internal – turning inwardExternal – turning outwardDorsiflexion – movement that flexes or bends the hand back toward the body or foot toward the legPalmar flexion – movement that flexes or bends the hands in the direction of the palmPlantar flexion – movement that flexes or bends the foot in the direction of the solePronation – hand/palm is downSupination – hand/palm is upOpposition – touching the thumb to each fingertip on same handInversion – movement that turns the sole of the foot inwardEversion – movement that turns the sole of the foot outwardActive – performed by patient under supervisionActive - Assisted – performed by patient with the nurse helpingPassive – performed by the nurse
41
A joint should be moved through its ROM three times – twice a day. The joint should be supported, the bones above the joint stabilized and body part distal to the joins is moved through the range of motion of the joint.
Weight bearing exercises may slow the bone loss that occurs with disability. There are 5 types:1. Passive – carried out by therapist without assistance from patient2. Active-Assisted – both therapist and patient do together3. Active – patient does it themselves4. Resistive – carried out by the patient working against resistance produced by either manual or
mechanical means5. Isometric – contracting and relaxing a muscle while keeping the part in a fixed position.
Performed by patient.
Orthostatic Hypotension may develop when the patient assumes a vertical position. Because of inadequate vasomotor reflexes, blood pools in the splanchnic (visceral) area and in the legs, resulting in inadequate cerebral circulation. Symptoms include: diaphoresis (sweating), nausea, tachycardia, dizziness, drop in blood pressure & pallor).
Crutches & Canes
CrutchMeasuring laying down – from the anterior fold of the axilla to the sole of the foot and then 2 inches is
added. The hand piece should be adjusted to allow 20 t 30 degrees of flexion at the elbow. The wrist should be extended and the hand dorsiflexed. A foam rubber crutch r pad on the underarm piece is used to relieve pressure of the on the upper arm and thoracic cage.
Place patient against the wall with feet slightly apart and away from wall. A distance of 2 inches is marked on the floor, to the side from the tip of the toe. 6 inches is measured straight ahead from the first mark. Next 2 inches is measured below the axilla to the second mark for the approximate crutch length.
Crutch Gaits
4 point gaitPWB on both feetMaximal support providedRequires constant shift of weightRight foot, left crutch, left foot, right crutch
2 point gait – like walking with arms swinging with crutchPWB on both feetLess supportFaster than a 4 point gaitRight foot & left crutch togetherLeft foot and right crutch together
42
3 point gaitNWBNeed good balanceNeed good arm strengthFaster gaitCan use with walkerRight footLeft foot (NWB) and both crutches
Swing ToWB both feetStabilityNeed arm strengthBoth CrutchesBoth Feet next to crutches
Swing throughWBNeed arm strengthNeed coordination/balanceMost advanced gaitBoth crutchesSwing both feet ahead of crutches
Stairs:Up with the good, down with the badWhen going up the stairs, put the good foot up first or the crutches and follow with the badWhen going down the stairs, put the bad foot first and then down with the good.
CaneTo fit the patient with a cane, the patient is instructed to flex the elbow at a 30 degree angle, hold the
handle of the cane about level with the greater trochanter, and place the tip of the cane 6 inches lateral to the base of the fifth toe.
Hold the cane in the hand opposite the affected extremity to widen the base of support and to reduce the stress on the involved extremity. Advance the cane at the same time that the affected leg is moved.
Orthosis is an external appliance to provides support, prevents or corrects deformities and improves function. They include braces, splints, collars, corsets or supports that are fitted an orthotist or prosthetist.
Static orthoses (no moving parts) are used to stabilize joints and prevent contractures Dynamic Orthoses are flexible and are used to improve function by assisting weak muscles. prosthesis is an artificial body part; it may be internal or external
Nutritional Requirements to Promote healing of WoundsProteinCaloriesWaterMultivitaminVitamin C – promote collagen synthesisZinc sulfate
43
Vitamin A – cautious amounts
44
Chapter 54
Arthritis – inflammation of a joint
Monoarticular – affects a single joint
Polyarticular – affects multiple joints Ankylosis – immobility of a joint
Antibody – protein substance developed by the body in response to and interacting with a specific antigen
Antigen – a substance that induces production of antibodies
Arthroplasty – replacement of a joint
Complement – a plasma protein associated with immunologic reactions
Cytokines – non-antibody proteins that act as intercellular mediators
Diarthrodial – a joint with two freely moving parts
Hemarthrosis – bleeding into the joints
Joint Effusion – the escape of fluid from the blood vessels or lymphatics into the joint space
Matrix – non-cellular components of tissue
Osteophyte – a bony outgrowth or protuberance; spur
Pannus – newly formed synovial tissue infiltrated with inflammatory cells
Prostaglandins – lipid-soluble molecules that mediate the inflammatory process
Subchondral bone – bony plate that supports the articular cartilage
Synovial – pertaining to the joint-lubricating fluid
Tophi – accumulation of crystalline deposit in articular surface, bones, soft tissue and cartilage
Rheumatic disease include common disorders such as osteoarthritis, systemic lupus erythematosus or scleroderma. It affects skeletal muscles, bones, cartilage, ligaments, tendons and joints
Disarthrodial or synovial joints function is movement in normal joints – it is smooth, nearly friction-free, resilient surface for the movement is
provided by articular cartilage which covers the bone end of the joint. Lining the inner surface of the fibrous capsule is the synovial membrane, which secretes fluid
into the space between the bone ends. The synovial fluid functions as a shock absorber and a lubricant, allowing the joint to move freely
The joint is the area most commonly affected by the inflammation and degeneration seen in rheumatic disease. They all involve some degree of inflammation and degeneration.
Inflammation is manifested in the joints as synovitis.
45
In RD – the primary process is inflammation as a result of the immune response. Degeneration occurs as a secondary process, resulting from the effect of pannus (proliferation of newly formed synovial tissue infiltrated with inflammatory cells. The inflammation is a result of altered immune function.
Degenerative RD – inflammation occurs as a secondary process. This synovitis is usually milder, more likely to be seen in advanced disease and is a reactive process.
Degeneration Mechanical Stress – wear and tear Altered lubrication – lessened lubrication of the joint Immobility – loss of pumping action because of immobility – encourage slow range of motion
to remobilize joint
Diagnostic Findings for RD
Arthrocentesis – needle aspiration of synovial fluid to test and to relieve pain. Patient is observed for infection and hemathrosis (bleeding into the joint).o Fluid is clear, viscous, straw-colored and scanty when it is healthyo Milky, dark yellow complement – usually is inflammatoryo Arthrocentesis of small joints is difficult. Mostly done in knee & shoulder
X-ray Arthrography - a radiopaque substance or air is injected into the joint cavity to outline the
contour of the joint. The joint is then put through passive ROM while several x-rays are taken. Joint scan – most sensitive study, allows determination of joint damage through the body. Not
used often because of cost. Tissue Biopsies – done in surgery Muscle biopsy – to diagnosis myositis Skin biopsy – to confirm inflammatory tissues diseases such as lupus or scleroderma Blood Tests
o Creatine – may indicate renal damage in SLE, scleroderma and polyarteritiso Erythrocyte Sedimentation Rate (ESR) – increase may indicate inflammatory connective
tissue diseaseo Hematocrit decrease can be seen in chronic inflammationo RBC – decrease can be seen in RA & SLEo WBC – decrease can be seen in SLE
Gout or infectious arthritis – the presence of crystals or bacteria in the synovial fluids
NIHeat application are helpful in relieving pain, stiffness & muscle spasmMaximum benefit is achieved in 20 minutesIf acute – cold applications may be triedUse one pillow under head to reduce dorsal kyphosisPillow should NOT be placed under knees because it will promote flexion contracture
Rheumatoid Arthritis Seen in women The prototype for inflammatory arthritis Types
o Early stage RA – 46
o Moderate, Erosive RAo Persistent, Erosive RAo Advanced, unremitting RA
Systemic Lupus Erythematosus (SLE) Autoimmune systemic disease that can affect any body system. Involvement of the
musculoskeletal system is a common presenting feature Involved joint swelling, tenderness, pain and skin changes CNS involvement
Scleroderma Called Systemic Sclerosis Starts with Reynaud’s phenomenon and swelling in the hands Known as the “hard Skin” disease and is a rare disease
Polymyositis Shows first as muscle weakness Idiopathic Rare
Polymyalgia Rheumatica Severe proximal muscle discomfort with mild joint swelling. Severe aching the neck, shoulder & pelvic muscles. Mostly in people over 50
Osteoarthritis Known as degenerative joint disease or osteoarthrosis - without inflammation Most common and frequently disabling of the joint disorders Over diagnosed and trivialized Peaks in the 5th & 6TH decade of life Affects the articular cartilage, subchondral bone (the bony plate that supports the articular
cartilage) and synovium A combination of cartilage degradation, bone stiffening and reactive inflammation of the
synovium occurs Risks: age, obesity, previous joint damage, genetic susceptibility s/s are pain, stiffness & functional impairment Occurs in WB joints but also proximal and distal finger joints are involved Bony nodes may be present and are usually painless, unless inflamed Characterized by progressive loss of joint cartilage, which appears on an x-ray as a narrowing
of joint space. Osteotomy (to alter the force distribution in the joint) & arthroplasty (joint replacement) are
used to ease pain Viscosupplementation - the reconstitution of synovial fluid viscosity Hyaluronic acid is used in the procedure Tidal irrigation – intro and then removal of large volume of saline into the joint.
Spondyloarthropathies – another category of systemic inflammatory disorders Medical Management is treating pain and maintaining mobility by suppressing inflammation. Ankylosing Spondylitis – affects the cartilaginous joints of the spine and surrounding tissues
o Usually diagnosed in 20 – 30’s
47
o Not as severe in femaleso Back pain is a featureo Can lead to respiratory compromise and complicationso Good body position is important in case ankylosis (fixation) occurs
Reactive arthritis (Reiter’s syndrome)o Arthritis occurs following an infection.o Affects young adult males and is characterized by urethritis, arthritis and conjunctivitiso Dermatitis of the mouth & penis may be present
Psoriatic arthritiso Characterized by Synovitis, polyarthritis & spondylitis.o Psoriasis and arthritis are common conditions
Metabolic and Endocrine Diseases with RD Amyloidosis, scurvy, diabetes, HIV infection, AIDS Gout is the most common – crystal in the joints
o Hyperuricemia may be due to severe dieting or starvation, excessive intake of foods that are high in purines (shellfish, organ meats)
o Over secretion of uric acids or a renal defect resulting in secretion of uric acid occurso Seen in the great toe, hands and ear. Kidney stones deposits
Fibromyalgia – involves chronic fatigue, generalized muscle aching and stiffness
Other types of arthritisTenosynovitisBursitisBacterial
Neisseria gonorrheaNongonococcal bacteriumStaphylococcus aureas – most commonThe results of the cultures are used to determine the appropriate antibiotic therapy. Immobilization of joint and repeated joint aspiration may be necessary along with IV antibiotics
Neoplasms & Neurovascular, Bone and Extra-Articular Disorders Lipoma, hemangioma and fibroma such as ganglion, bursitis & synovial cyst Neurovascular disorders include
Synovium – membrane in joint that secretes lubricating fluid
Tendon – connects muscle to bone
Tone – normal tension in resting muscle
Hematopoeiesis – red bone marrow located w/in the bone cavities produces red and white blood cells
Joints - hold the bones together and allow the body to move
Muscles attached to the skeleton contract, moving bones and producing heat, which helps maintain body temp.
Skeletal System – 206 bones in the human body Long bones (femur) Short bones (metacarpals) Flat bones (sternum) Irregular Bones (vertebrae)
Bones are made of cancellous (trabecular) or cortical (compact) bone tissue.
Flat bones – provide organ protection and are am important site for hematopoiesis. They are made up of cancellous bone layered between compact bone.
51
Important regulating factors in bone include: Stress Vitamin D Calcium Calcitonin Parathyroid hormone Blood supply
Weight bearing is important. Without it, the bones loses calcium (resorption) and become osteopenic and weak which may fracture easy
Parathyroid hormone and Calcitonin are the major hormonal regulators of calcium homeostasis. Parathyroid hormone regulates the concentration of calcium in the blood, in part by promoting movement of calcium from the bone.
Calcitonin, secreted by the thyroid gland in response to elevate blood calcium levels, inhibits bone resorption and increase the deposit of calcium in bone
Blood supply to the bone also affects bone formation. With diminished blood supply or hyperemia (congestion), Osteogenesis and bone density decrease. Bone necrosis occurs when the bone is deprived of blood.
Bone Healing1. Hematoma and inflammation – last several days2. Angiogenesis and cartilage formation – blood vessels and cartilage overlie the fracture3. cartilage calcification - 4. cartilage removal – calcified cartilage is removed by Osteoclast and replaced by woven bone5. bone formation – ossification6. remodeling – may take months or years
Bone mass peaks at about 35 years of age, after which there is a universal gradual loss of bone
Pain:Bone Pain – dull, deep ache – that is boring in natureMuscular Pain – soreness or aching – muscle crampsFracture Pain – sharp and piercing and relieved by immobilizationBone infection with muscle spasm or pressure on sensory nerve may be sharpPain that increases with activity may indicate joint sprain or muscle strainSteadily increasing pain points to progression of an infection, a malignant tumor or neurovascular complicationRadiating Pain – when pressure is exerted on a nerve root.
o Ball & Socket – hip and shouldero Hinge – bending in one direction – elbows & kneeo Saddle joint – movement in 2 planes at right angles to each other – thumbo Pivot joint – permit rotation – ex turning a doorknob – wristo Gliding joint – limited movement in all directions – carpal bones of the wrist
Muscle Actions Synergists – muscles assisting the prime mover Antagonists – muscles causing movement opposite that of the prime mover – when biceps are
contracted – triceps is the antagonist
Gait – assessed by having the patient walk away from the examiner for a short distance. It is examined for smoothness and rhythm. Any unsteadiness or irregular movements are considered abnormal.
Joint Deformity:Contracture – shortening of surrounding joint structureDislocation – complete separation of joint surfacesSubluxation – partial separation of articular surfaces
RA – subcutaneous nodules are soft and occur within and along tendonsGout – nodules are hard and lie within and adjacent to joint capsuleOsteoarthritic nodules are hard and painless and represent bony overgrowth from destruction of cartilaginous surface of bone within the joint capsule.
Fasciculations – involuntary twitching of muscle fiber groups
Neurovascular status Compartment syndrome – pressure within a muscle that increases to such an extent that
microcirculation diminishes, lead nerve damage and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. CMS is an assessment – Circulation, Motion, Sensation
Diagnostic Procedures X-ray CT – can reveal tumors of the soft tissue or injuries to ligaments or tendons MRI – uses magnetic fields, radio waves to show, tumors or narrowing of tissue pathways
through bone & soft tissue
53
Arthrography – radiopaque substance or air is injected into a joint cavity to outline the soft tissue structures and the contour of the joint. The joint is put through ROM to distribute the contract agent while a series of x-rays are obtained. If a tear is present the agent leaks out of the jointo Joint is rested for 12 hour after procedure and an compression bandages is applied. Normal
to hear clicking up to 2 days Bone Densitometer – used to estimate bone mineral density (BMD). Done using X-rays or
ultrasound Bone Scan – detects metastasis and primary bone tumors, osteomyelitis, certain fractures and
aseptic necrosis. A bone-seeking radioisotope is injected intravenously. The scan is performed 2 to 3 hours after the injection. An increased uptake of isotope is seen in primary skeletal disease (osteosarcoma), metastatic bone disease, inflammatory skeletal disease (osteomyelitis) and fractureso Need to check if patient is allergic to radioisotope. Patient needs to drink plenty of fluid to
help distribute and eliminate the isotope Arthroscopy – camera to look at the joint. Done in the operating room. Injection of a local
anesthetic into the joint or general anesthesia is used. A large bore needle is inserted and the joint is distended with saline. Complications are infection, Hemarthrosis, neurovascular compromise, etc..
Arthrocentesis (joint aspiration) – obtain synovial fluid for examination or to relieve pain due to effusion. Helps to diagnose septic arthritis. Reveals Hemarthrosis (bleeding into the joint cavity). Normal fluid is scanty, clear, pale or straw-colored
EMG (Electromyography) provides information about the electrical potentional of the muscles and the nerves leading to them
Biopsy – determines the structure and composition of bone marrow, muscle or synovium to help diagnose disease
Blood/Urine – can provide info about primary skeletal disease (Paget’s), a developing complication (infection, baseline for therapy (anticoagulant) or response to therapy
54
Chapter 67
Definitions
Abduction – away from body
Adduction – toward body
Arthrodesis – surgical fusion of joint
Arthroplasty – surgical repair of joint; joint replacement
Avascular necrosis – death of tissue due to insufficient blood supply
Cast syndrome – psychological and physiologic response to confinement in body cast
CPS device – Continuous Passive Motion – promotes ROM –
Edema – soft tissue swelling due to fluid accumulation
External fixator – external metal frame attached to and stabilizing bone fragments – used to manage open fractures with soft tissue damage. Used for severe comminuted (crushed or splintered) fractures. Fractures of the humerus, forearm, femur, tibia and pelvis are managed by external fixator
Monitoring of neurovascular status of the extremity is every 2-4 hours and assessment of pin sites for infection and loosening.
Nurse NEVER adjusts the clamps on the external fixator Encourage isometric and active exercise Ilizarov EF used to correct angulations and rotational defects to treat nonunion fracture and to
lengthen limbs
Fasciotomy – surgical procedure to release constricting muscle fascia to relieve muscle tissue pressure
Fracture – break in the continuity of the bone
Heterotrophic ossification – misplaced formation of bone
Hemiarthroplasty – replacement of one of the articular surfaces – not all
Joint Arthroplasty or replacement – replacement of joint surfaces with metal or synthetic materials
Meniscectomy – excision of a damaged joint fibro cartilage
Bone graft – placement of bone tissue to promote healing, to stability or replace diseased boned
Tendon Transfer – movements of tendon insertion to improve function
PMMA – bone –bonding agent that has properties similar to bone. Loosening of the prosthesis due to cement-bone interface failure is a common reason for prosthesis failure
Neurovascular status – neurological and circulatory function of body part
ORIF – Open reductions with internal fixator – surgery to repair and stabilize a fracture
55
Osteomyelitis – infection of bone
Osetotomy – surgical cutting of bone
Traction – application of pulling force to a part of the body
Cast – a rigid immobilizing device that is molded to the contours of the body. The purpose is to immobilize a body part in a specific position and to apply uniform pressure on encased soft tissue.
Cracking or denting of the cast is prevented by supporting the patient on a firm mattress and with flexible, waterproof pillows until the cast dries. The nurse turns the patient to a prone position, twice daily, to provide postural drainage of the bronchial tree and to relive pressure on the back.
Traction – application of a pulling force to a part of the body. Used to minimize muscle spasms To reduce, align and immobilize fractures To reduce deformity To increase space between opposing surfaces Vectors of Force – the lines of pull in traction Short-term – helps to reduce disuse syndrome Counter traction is the force acting in the opposite direction and must be maintained for
effective traction Weigh are never removed unless intermittent traction is prescribed
o Buck’s Traction – straight or running. Skin Traction – directly to skin No more than 4.5 to 8 lbs can used on extremity Pelvic traction is 10-20 lbs Buck’s traction, cervical head halter & pelvic belt Unilateral or bilateral is skin traction to the lower leg. The pull is exerted in one
plane when partial or temporary immobilization is desired. Used after fractures of the proximal femur before surgical fixation
Skin breakdown, nerve pressure and circulatory impairment are complication Foot drop may occur because of pressure on the peripheral nerves DVT is another complication Patient should not turn from side to side Check skin three times a day – remove boot Assess nerves and sensation Check circulation, including DVT assessment, every 1-2 hours
o Balanced suspension – skeletal traction – supports the extremity off the bed Skeletal Traction that is applied directly to the bone Used to treat fractures of the femur, tibia and cervical spine Doctor applies using surgical asepsis Uses 15-25 lbs Supports the affected extremity, allows patient movement Thomas splint with a Pearson attachment is frequently used for fractures of the
femur. Nurse must never removed weights from skeletal traction unless a life-threatening
situation occurs. May result in injury to patient. Check for skin breakdown on elbows as well as nerve damage, heals Check pin site to avoid infection and development of osteomyelitis every 8 hours
Complications of Traction56
Pneumonia – ausculate lungs every 4 to 8 hours to determine respiratory status and teach patient deep breathing and coughing exercise to fully expand lung and moving pulmonary secretions
Constipation and Anorexia – reduced gastrointestinal motility results in constipation and anorexia – a diet high in fiber may help gastric motility
Urinary Stasis and Infection – lots of liquid and urinate every 3 to 4 hours Venous Stasis & DVT – check every 1 to 2 hours
Brace – Orthoses – for long-term use
Hip Precautions Never cross legs Never bend at hip more than 90 degrees Do not elevate head of bed more than 60 degrees Keep legs abducted (apart) When sitting patient’s hips should be higher than knees Avoid internal and external rotation, hyperextension and acute flexion Needed for 4 months following surgery Dislocation can occur
o Increased pain at surgical siteo Acute groin pain in affected hipo Shortening of the lego Abnormal external or internal rotationo Restricted ability or inability to move lego “popping” sensation in hipo If it happens, hip must be stabilized to legs does not sustain circulatory and nerve damage.o After closed reduction, limb may be stabilized with bucks traction or brace to prevent
recurrent dislocation.
DVT – Deep Vein Thrombosis Occurs 5 to 7 days after surgery 45% to 70% chance 20% of those that develop DVT also develop pulmonary emboli Signs include, calf pain, swelling and tenderness and negative Homan’s signs Encourage patient to consume adequate amounts of fluid, perform ankle and foot exercises
hourly Low dose heparin or Lovenox (enoxaparin) is prescribed prophylaxis after hip surgery Patients who have diabetes, RA, infections or large hematomas are high risk Acute infections may occur 3 months after surgery
Knee Replacement Post-op – knee is in a compression bandage Ice may be applied to control edema and bleeding Assess neurovascular status of leg Encourage active flexion of foot every hour when patient is awake Wound drainage is 200-400 ml first 24 hours and then 25ml by 48 hours CPM device -10 degrees of extension and 50 degrees of flexion are prescribed initially,
increasing to 90 degrees of flexion with full extension by discharge Pre-op – ask patient about occurrence of colds, dental problems, UTI and other infections 2
weeks before surgery. Osteomyelitis could develop through hematologous spread57
Post Op Concerns with Orthopedic surgery Hypovolemic shock because of blood loss
o Pulse rate increase, respiratory rate decreases, BP low, pallor, urine output less than 30 ml per hour, restlessness, decreased hemoglobin and hematocrit
Atelectasis (collapsed lung) and pneumonia may be related to preexisting pulmonary disease, deep anesthesia, decreased activity, , underlying musculoskeletal disorder. Monitor breath sounds and encourage the accumulation of secretions. Insensitive spirometer is encouraged. coughing exercises. Full expansion of the lungs prevent
Fat Embolus may occur with orthopedic surgery. Be alert to changes in respiration, behavior and LOC
DVT’s - Infection Urinary Retention – encourage patient to void every 3 to 4 hours Well-balanced diet is important for wound healing. Large amts of milk should not be given
because this adds to calcium pool in the body and requires that the kidneys excrete more calcium, which increases the risk for urinary calculi
58
Chapter 68
Definitions
Bursitis – inflammation of a fluid-filled sac in a joint
Contracture – abnormal shortening of muscle or fibers of joint structures
Involucrum – new bone growth around sequestrum
Radiculopathy – disease of a nerve root
Sciatica – sciatic nerve pain; pain travels down back of thigh into foot
Sequestrum – dead bone in abscess cavity
Tendonitis – inflammation of muscle tendons.
Osteoporosis Reduction in bone density and bone structure Bone resorption is greater than the rate of bone formation Bones become porous, brittle and fragile Results frequently in compression fractures Higher in caucasion & Asian, small framed, older women Sometimes develops Kyphosis – dowager’s hump Loss of height Protruding abdomen Reduce caffeine, cigarettes and alcohol early Some diseases bring on osteoporosis – celiac disease and hypogonadism and medications
(corticosteroids and anti-seizure) Calcitonin, which inhibits bone resorption is decreased in the elderly Estrogen, which inhibits bone breakdown, decreases with age PTH –parathyroid hormone – increases with aging, increasing bone turnover and resorption. Need to exercise with WB exercise Co-morbidity – anorexia, hyperthyroidism, malabsorption syndrome, renal failure Relieve pain High fiber diet to reduce constipation Reduce risk of falls
Osteomyelitis Bone infection Three modes:
o Extension of soft tissue infectiono Direct bone contamination from bone surgery, open fracture of traumatic injuryo Hematogenous – blood born spread from other sites and infections
Stage I – acute, occurring during first 3 months State II – delayed onset – occurring between 4 and 24 months State III – late onset – occurring 2 or more years after surgery – usually as a result of
Hematogenous spread Staphylococcus auerus causes 70-80% S/s of osteomyelitis
59
o Inflammationo Edemao Thrombosis of the blood vessels occurs in the area, resulting in ischemia with bone necrosiso Bone abscess can form if not treatedo Onset is sudden when it is blood borne
Chills, high fever, rapid pulse, general malaiseo patient may complain of a constant, pulsating pain that intensifies with movement as a
result of the pressure of the collecting pus. If patient does not respond to therapy, infected bone is surgically exposed, and purulent and
necrotic material is removed and area is irrigate with sterile saline solution. IV Therapy can be done at home.
60
Chapter 69
Definitions
Allograft – tissue harvested from a donor for use in another person
Amputation – removal of a body part, usually a limb or part of a limb
Arthroscope – surgical instrument used to examine internal joint structures
Autograft – tissue harvested from one are of the body and used for transplantation to another are of the body
Contusion – a soft tissue injury produced by blunt force. Small blood vessels rupture and bleed into soft tissues.
Debridement – surgical removal of a contaminated and devitalized tissues an foreign material
Dislocation – separation of joint surfaces
Fracture – a break in the continuity of a bone
Fracture reduction – restoration of fracture fragments into anatomic alignment and rotation
Melana – dark stool with upper GI blood from Ibuprofen
Malunion – healing of a fractured bone in a misaligned position
Meniscus – crescent shaped fibrocartilage found in certain joints, such as the knee joint
Nonunion –failure of fragments of fractured bone to heal together
Phantom limb pain – pain perceived as being in the amputate limb
RICE – Rest, Ice, Compression, Elevation24- 48 hours Cold applied for 20 to 30 min during first 24 – 48 hours to produce vasoconstriction Elevation controls the swelling After 48 hours – heat can be applied for 15 to 30 min to relive muscle spasms and to promote
vasodilatation, absorption and repair
Rotator Cuff – shoulder muscles and their tendons
Sprain – an injury to ligaments and other soft tissues at a joint Treat with RICE
Strain – a muscle pull or tear Treat with RICE Muscle tears with some bleeding into the tissue. Sore and sudden pain with local tenderness on muscle use and isometric contraction Caused by overuse, overstretching or excessive stress
Subluxation – partial separation or dislocation of joint surfaces
Tendonitis – inflammation of a tendon
61
Types of FracturesGreenstick – where one side of the bone is broken and the other side is bent.Transverse – fracture is straight across bone – mostly seen in long bonesOblique – Fx line slants on an angle across shaft of boneSpiral – like oblique but wraps around and climbsComminuted – bone splinters – not goodDepressed – skull – bone fragments are inward (facial & cranial)Compression – vertebral – fragments are pushed togetherPathologic – disease – Paget’s, Osteomylitis – bone infectionImpacted – one bone fragment is impacted to anotherCompound – worst – breaks through the skin
Signs & symptoms Pain Loss of Function Deformity Crepitus – grinding – rubbing Swelling Ecchymosis – bruise Break in skin Damage to organs
DX of fractureHistory of incidentAssessmentCT or X-ray
Manage Emergency Care Cover open wounds with sterile, lint-free materials to prevent infection. DO NOT REALIGN Closed reduction – done manually and bone set in place. X-ray first – closed reduction – x-ray
again Open reduction – Surgery – ORIF FX immobilization – casts Exercises – isometric exercises of affected and unaffected Help patient – with ADL’s
Hypovolemic Shock – resulting from hemorrhage and from loss of extra-cellular fluid into damaged tissues
Assessment/Signs & Symptoms of Shock Decreased BP Tachycardia Tachypnea – fast breathing Skin Color Restlessness Decreased LOC
Nursing Interventions for Shock Keep patient warm Monitor VS and O2 status Restore blood volume and circulation Monitor labs
Fat embolism Fat globule in blood stream Seen within 24-72 hours with fracture of long bones Seen frequently in young adults (20 – 30 years old)
Assessment/Signs & Symptoms of Fat Embolism Hypoxia – inadequate oxygen Headache/Pyrexia Irritability, confusion & agitation Feelings of Doom Tachycardia Tachypnea Wheezing Petechia – red spots on skin Use of accessory muscle/ARDS
NI for Fat Embolism
63
Teach to cough, deep breath Heparin Aspirin O2 Bed rest Corticosteroid I & O Prevent metabolic acidosis
Compartment Syndrome Tissue perfusion in the muscle is less than required for tissue viability Rise in the intra-compartmental pressure with tissue damage (30 min) and death (4 hours) Average 8 or less 30 bad
Signs & Symptoms of Compartment Syndrome unrelenting deep throbbing pain swelling, numbness & tingling cyanotic nail beds paralysis above heart level
NI for Compartment Syndrome Notify MD Remove any constrictions Measure pressure Surgical fasciology – to remove pressure Decompress with excision of the fibrous membrane that covers and separates muscles
DVT ((Deep Vein Thrombosis) related to bed rest and reduction in skeletal contraction redness, tender, heat, pain and negative Homan’s signs
Vascular Necrosis Bones loses its bloods supply Bones cells die Frequently seen in femoral head, talus bone of ankle and lunate? bone of the wrist Steroid Therapy – Tape
Assessment/Signs & Symptoms for Vascular Necrosis Pain, ______ unstable and decreasing function
DX for Vascular Necrosis X-ray, bone scan & CT Scan
NI for Vascular Necrosis Non-weight bearing Removal of bone (tape)
Delayed union – healing does not occur at a normal rate
Occult – groin pain & weight bearing Impacted and non-displaced moderate discomfort, groin & knee pain – non visible Displaces leg externally, rotated, painful
Extra capsular Trochanteric Subtrochanteric
Signs & Symptoms of Hip Fracture Muscle spasms Shortened leg with adduction and external rotation Pain Tenderness at site
NI for Hip Fx Temporary Skin Traction (Bucks) Sandbags Surgical repair
Post Op Care for Hip Fx:RepositioningStrengthening ExercisesMonitor for:
DVTSkin AssessmentPulmonary Complications
Neurovascular complicationsDislocation
Wrist FX Fx of distal radius (Polle’s Fx) and Ulnar
Signs & Symptoms of Wrist Fx
65
Dinner fork deformity/deformed wrist Proximal depression and fullness to distal aspect of wrist Loss of sensation and feelings to fingers due to (tape)
NI for Wrist Fx. RICE Closed reduction Immobility – cast Fixation device Pain meds Elevate Exercise
Nursing Dx for Wrist Fx Altered peripheral tissue perfusion:
o Risk for impaired skin integrityo Risk for infectiono Self care deficit
Amputations Closed – bone area is removed and muscle flap Open – all is removed – cauterize stump Disarticulation – removal of a body part through a jointPerformed at most distal site – determined by circulation
Chronic systemic inflammatory disorder characterized by swelling/pain and includes Symptoms are acute Autoimmune Seen mostly in females Symptoms appear between 30 & 50 Exhabesence
MuscoskeletalBilateral, Symmetrical, swelling, joint pain, hot
Signs & Symptoms of RA Joint pain Joint stiffness
OASwimming is best
67
Independent Study
Acute Lower Back Pain – Causes:
Musculoskeletal Problems: Other Problems:Acute lumbro-sacral strain Bone metastasisUnstable lumber-sacral ligaments and joints Kidney disordersOsteoarthritis of spine Pelvic problemsSpinal stenosis Retroperineal tumorsDisc problems (ie-degeneration or herniation) Abdominal aneurysmsUnequal leg length Psychosomatic problems (ie stress & depreOsteporotic verterbral fx Obesity
If r/t MS disorders, Pain will increase with activity If r/t other causes pain will not increase with activity Patients with chronic (more than 3 months) may develop dependence on ETOH or drugs to
cope with pain. Disk degeneration (esp L4-L5 and L5-S1) have greatest degenerative changes, and most often
contribute to low back pain.Manifestations:
Acute or chronic (longer than three months) low back pain Pt may c/o sciatica (pain down leg) which suggests nerve root involvement Pt’s gait, spinal mobility, reflexes, leg strength and length and sensory perception may be
altered Paravertebral muscle spasm (greatly increased muscle tone in the back muscles) is common
Medical Management: Most back pan is self limiting and resolves within 4 weeks with analgesics, rest, stress
reduction, and relaxation Twisting, bending lifting and reaching should be avoided Management focuses on pain relief, activity modification, and patient education. Patient taught to change positions frequently- sitting should be limited to 20-50 minutes based
on level of comfort With severe pain bed rest may be recommended for up to four days max. (usually 1-2) Avoid prone position
Proper Body Mechanics: Use low heeled shoes If you have to stand for long periods, shift weight frequently, and rest one foot on a stool Proper posture is chest up, and abdomen tucked in Do not lock knees when standing Keep feet flat on the floor while sitting, with back supported Pt should sleep on their side with hip and knees flexed Lifting should be done with quadriceps muscles of thighs, not back muscles, with feet apart for
a wide base of support.
Disc Herniation
68
Most back problems are r/t disc problemsPathophysiology:
In herniation of the disc (ruptured disc) the nucleus of the disc protrudes and causes nerve compression.
Propulsion or rupture is usually associated with degenerative changes that occur w/ agingo Loss of proteino Development of radial cracks in annulus
Also , after falls, and repeated trauma, such as lifting cartlidge may be injuredo For most pt’s the immediate s/s of trauma are short lived, and injuries to the disc are not
apparent for months or years. When the disc starts to degenerate later on it may herniate or rupture and compress spinal nerves
A ruptured or herniated disc produces pain due to pressure on nerve endings (Radiculopathy) Continued pressure may produce degenerative changes in the involved nerve, such as changes in
sensation and deep tendon reflexes.
Manifestations:o A herniated disc with accompanying pain may occur in any portion of the spine
o Spondylosis- degenerative changes occurring in disc and vertebrae which lead to herniationo Cervical disc herniation usually occurs at the C5-6 and C6-7 spaces.
Pain and stiffness may occur in the neck, shoulders, and scapula area Sometimes pts mistake this for heart trouble or bursitis Pain may also occur in the upper extremities and head accompanied by paresthesia and
numbness of UE Cervical MRI confirms dx Cervical spine may be immobilized by use of cervical collar, brace or traction Bed rest is important (1-2 days) b/c it eliminates the stress of gravity of the head on the
cervical spineo Thoracic herniation is rareo Lumbar disc herniation usually occurs at the L4-5or L5-S1 spaces
Herniated lumber disc produces low back pain, and varying degrees of sensory and motor impairment
Low back pain may be accompanied by radiation of the pain into one hip and down the leg (sciatica)
Pain is aggravated by actions that increase intraspinal fluid pressure (lifting, bending, sneezing and coughing and straining)
Pain is usually relived by bed rest There is usually some sort of postural deformity associated w/ lumbar herniation r/t pain
Assessment and diagnostic findings: MRI tool of choice to locate even small herniations Neuro exam carried out to see if there is deficit from root compression
Medical management: Usually managed conservatively w/ bed rest and medication If this does not work, there are several surgeries available to correct disc herniation Surgical excision of a herniated disc is performed when there is evidence of a progressive neuro deficit
(muscle weakness and atrophy, loss of sensory and motor fxn, loss of spinchter control), or continuing pain and sciatica that does not respond to conservative treatment.
The goal of surgical tx is to reduce pressure on the nerve root, relive pain and reverse neuro deficits. Types of surgical interventions:
69
o Discectomy- Removal of herniated fragments of disc w/ fusion- bone graft is used to fuse the vertebral spinous process
the object of spinal fusion is to bridge over the defective disc to stabilize the spine and reduce the rate of reoccurance
Laminectomy-Removal of part of vertebral bone in order to expose neural elements of spinal canal
HemilaminectomyRemoval of a smaller part of the vertebrae
Partial laminectomy-Creation of a hole in the vertebrae
Foraminotomy-Removal of vertebral foramen to increase space for exit of the spinal nerve
Results in reduced pain, compression and edema.
Carpal Tunnel Syndrome – An entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath or soft tissue mass.
Patient experiences pain, numbness, paratesia,along median nerve. Thumb and first two fingers are most affected
Repetitive work causes it for the most part (ie typing) Can also be caused by arthritis, hypothyroidism or pregnancy Tinels sign used to identify it Night pain is common
Sports Injuries Contusions, sprains, strains Tendonitis – inflammation of a tendon caused by overuse
o Tennis Elbow and Achilles tendonitis in runners and gymnasts and intrapatellar tendonitis in basketball players
Meniscal injuries of the knee occur with excessive rotational stress Fractures such as colles fx in skaters and bikers, metatarsal fx in ballet and track and field, stress fx
with repeated bone trauma from activities such as jogging, gymnastics, basketball or aerobics. Tibia, fibula and metatarsals are most likely to be fx’d
Gout Gouty arthritis – the presence of crystals in the synovial fluids r/t hyperuricemia (high uric
acid) Hyperuricemia may be r/t starvation, excessive intake of foods high in purines (shellfish, organ
meat) or geneticManifestations:
High uric acid in blood First sign is usually acute arthritis in the big toe Acute attack may be triggered by trauma, ETOH ingestion, dieting, medications and illness Pt may also have renal calculi
NI for Gout Heat application are helpful in relieving pain, stiffness & muscle spasm
70
Maximum benefit is achieved in 20 minutes If acute – cold applications may be tried Use one pillow under head to reduce dorsal kyphosis Pillow should NOT be placed under knees because it will promote flexion contracture Crystals in synovial fluid are sodium urate crystals (Tophi) Tx w/ allpurinol, but cautiously b/c of s/e.
Paget’s Disease – (osteitis deforman) Disorder of localized rapid bone turnover, mostly commonly affecting the skull, femur, tibia,
pelvic bones and vertebrae. Primary proliferation of osteoclasts, they eat the bone Followed by osteoblastic activity that replaces the bone. As bone turner occurs, a disorganized pattern of bone develops Pathologic fractures occur Bowing of the legs causes misalignment of the hip, knee and ankle joints
o Misalignment causes development of arthritis, back and joint pain Occurs in people over 50 and men more often Cause not known but it is hereditary Insidious- patient may never know they have it until pathological fx occurs S/S :
o Bowing of femur and tibiao Enlargement of skull
Patient may report that hat no longer fits, face has a small triangular appearanceo Deformity of pelvic bones o Thorax is compressed and immobile w/ respirationso Cortical thickening of long boneso May have cranial nerve compression that can affect hearingo Waddling gait noticed because of femur and tibia bowingo Trunk looks shortened and arms look long (ape-like)o Pain, tenderness and warmth over bones may be noticed
Pain increases with weigh bearing, esp. with LE involvement Temperature increases over affected bones b/c of increased vascularity
o Pt’s w/ large vascular lesions may develop high output cardiac failure Diagnosis
Treatment:o Administration of NSAIDS, walking aids, shoe lifts and PTo Administration of Calcitonin subq or nasal inhalation.
S/E- flushing of face, nauseao Fosamax & Didronel also used for rapid reduction in bone turnover. o Mithracin – a cytotox antibiotic maybe be used to control the disease – IVo Adequate calcium – 1500 mg and vit D (400-600 IU)
Osteomalacia
71
Metabolic bone disease characterized by mineralization of bone. Because of faulty mineralization, there is a softening and weakening of the skeleton, causing pain and tenderness to touch, bowing of the bones and pathologic fractures.
Pathophysiology:o Deficiency of activated Vitamin D (calcitrol) which promotes calcium absorptiono May result from failed calcium absorption and from excessive loss of calciumo GI disorders (celiac disease, chronic biliary tract obstruction, chronic pancreatitis, small bowel
resection) in which fats are not absorbed are likely to produce ostomalaciao Also liver and kidney disease can produce a lack of vitamin D because these are the organs that
convert Vitamin D to its active formo Hyperparathyroids leads to skeletal decalcification and then to osteomalacia by increasing
phosphate excretion in the urineo Prolonged use of anti-seizure meds increases risk
S/So Spinal Kyphosis and bowed legso X-rays show generalized demineralization of boneo Decrease in serum CA+ and phosphorus levels, and mildly elevated alkaline phos.
Nursing Interventions:
o Spend time in the sun to promote Vitamin Do Increase Vitamin D and calcium.o Eat eggs, chicken livers, milk and cereals high in Vitamin Do Monitor serum calcium levels to reduce risk of hypercalcemia when vit d intake is increasedo Can be helped with diet control
Bone Tumors ****Primary complaint: Pain for all bone tumors
Metastatic bone tumors are more common than primary bone tumors Benign bone tumors
o More common and not a cause of deatho Some benign tumors have the potential to become malignanto Osterochondroma is the most common bone tumor
Seen as a large project of bone at the end of a long bone (knee or shoulder)o Enchodroma – common tumor of the hyaline cartilage that develops in the hand, femur, tibia
or humerus. Usual symptom is mild ache
o Bone cysts are expanding lesions within the bone. Seen in young adults who present with a painful, palpable mass of the long bones,
vertebral or flat bone Unicameral bone cysts occur in children and cause mild discomfort and possible
pathologic fractures of the upper humerus and femuro Osteoid Osteoma – painful tumor that occurs in children and young adults. Neoplastic tissue
is surrounded by reactive bone formationo Osteoclastomas are giant cell tumors that are benign for long periods but may invade local
tissue and cause destruction. Occurs in young adults and are soft and hemorrhage May undergo malignant transformation and metastasize
72
Malignant Bone Tumorso Primary tumors that cause bone destruction, weakening of bones and fractureso Rare that arise from sarcomas or bone marrow elements
Osteogenic sarcoma (osteocarcome) is the most common and most fatal primary malignant bone tumor.
Prognosis depends on whether it has metastasized to the lungs Appears in males between 10 & 25 years old, in older people with Paget’s
disease and a result of radiation exposure. S/s – weight loss, pain, swelling, limited motion, Increased alk. Phos.. Most common sites are distal femur, proximal tibia and proximal humerus Bony mass may be palpable, tender and fixed w/ venous distention
Chondrosarcomas Tumor of the hyaline cartilage Common primarily malignant bone tumor Large, bulky, slow-growing tumors that affect adults Includes pelvis, femur, humerus, spine, scapula and tibia Large bloc excision or amputation of the affected extremity results in increased
survival rate
Metastatic Bone Diseaseo Secondary Bone Tumoro More common than primaryo Most common primary sites of tumors that metastasize to bone are:
Kidney Prostate Lung Breast Ovary Thyroid
o Most frequently attack the skull, spine, pelvis, femur and humerus and involve more than one bone (polyostotic)
Secondary Tumors cause bone destruction, which weakens the bones, resulting in bone fractures Places pressure on adjacent bone tissue Treatment of metastatic bone disease is pallatiative. It is to help reduce pain to help with the
quality of life Hypercalcemia results from breakdown of bone. Treatment includes hydration with IV Hematopoieis is interrupted by treatments for the cancer. Pt’s w/ metastatic bone disease are at a much hight risk for pulmonary congestion, hypoxemia,
DVT’s and hemorrhage than others post-op.
Hypercalcemia is a dangerous complication of Bone cancerS/S- muscle weakness, incoordination, anorexia, N/V, constipation, ECG changes, and altered mental state.
