Background of Anatomy and Physiology. Human skeleton made up of 206 bones 1.Axial skeleton includes a.Bones of skull b.Ribs and sternum c.Vertebral column 2.Appendicular skeleton includes a.Bones of limbs b.Shoulder girdles c.Pelvic girdle. Classification of bones by shape. - PowerPoint PPT Presentation
Background of Anatomy and Physiology Human skeleton made up of 206 bones Human skeleton made up of 206 bones 1. 1. Axial skeleton includes Axial skeleton includes a. a. Bones of skull Bones of skull b. b. Ribs and sternum Ribs and sternum c. c. Vertebral column Vertebral column 2. 2. Appendicular skeleton includes Appendicular skeleton includes a. a. Bones of limbs Bones of limbs b. b. Shoulder girdles Shoulder girdles c. c. Pelvic girdle Pelvic girdle
Transcript
Background of Anatomy and Physiology
Human skeleton made up of 206 bonesHuman skeleton made up of 206 bones1.1. Axial skeleton includesAxial skeleton includes a.a. Bones of skullBones of skull b.b. Ribs and sternumRibs and sternum c.c. Vertebral columnVertebral column
2.2. Appendicular skeleton includesAppendicular skeleton includes a.a. Bones of limbsBones of limbs b.b. Shoulder girdlesShoulder girdles c.c. Pelvic girdlePelvic girdle
Classification of bones by shape
Functions of bones 1. Form structure and provide support for
soft tissues 2. Protect vital organs from injury 3. Serve to move body parts by providing
points of attachment for muscles 4. Store minerals 5. Serve as site for hematopoiesis
Bone cells include 1. Osteoblasts: cells that form bone 2. Osteocytes: cells that maintain bone
matrix 3. Osteoclasts: cells that resorb bone
Clients with Musculoskeletal Disorders
Background 1. Normal bone remodeling process involves
sequence of bone reabsorption and formation
2. Adults replace about 25% of trabecular bone (the porous type of bone found in the spine and all articulating joints) every 4 months through reabsorption of old bone by osteoclasts and formation of new bone by osteoblasts
Client with osteoporosisDefinition a. Disorder characterized by loss of bone
mass, increased bone fragility, increased risk for fractures
b. Imbalance of processes that influence bone growth and maintenance; associated with aging, but may result from endocrine disorder or malignancy
c. Significant health threat for Americans: estimated 28 million persons; more common in aging women: half of women over 50 experience osteoporosis-related fracture in lifetime (hip, wrist, vertebrae)
Client with osteoporosis
Risk Factors Unmodifiable risk factors
1. Aging:
2. Gender:
3. European Americans and Asians have less bone density than African Americans
Client with osteoporosisNursing Care a. Emphasis is prevention and education of clients under age
of 35 b. Prevention of complications in those with osteoporosis
Health Promotiona. Calcium intake1. Maintain daily intake of calcium at recommended levels, in divided
doses a. Age 19 – 50: 1000mg b. Age 51-64: 1200 mg c. Age 65 and >: 1500 mg)2. Optimal intake before age 30 – 35 increases peak bone mass3. Foods high in calcium include milk, milk products, salmon,
sardines, clams, oysters, dark green leafy vegetables4. Supplementation: calcium carbonate (Tums); calcium combined
with Vitamin D for older adults
Client with osteoporosis
Exercise 1. Physical activity that is weight-bearing 2. Walking 20 minutes, 4 or > times per week
Health-related behaviors 1. Include not smoking 2. Avoid excessive alcohol 3. Limit caffeine to 2 – 3 cups of coffee daily 4. Limit diet soda
Client with osteoporosis
Nursing Diagnoses a. Health Seeking Behaviors b. Risk for Injury c. Imbalanced Nutrition: Less than
body requirements d. Acute PainHome Care: Focus is on education
including safety and fall prevention inside and outside the home
Client with Paget’s Disease (osteitis deformans)Description a. Progressive skeletal disorder with
excessive metabolic bone activity leading to affected bones becoming larger and softer
b. Affects femur, pelvis, vertebrae, sacrum, sternum, skull
c. Relatively rare d. Occurs more often in whites e. Slightly more common in males f. Familial tendency
Client with Paget’s Disease (osteitis deformans)Pathophysiology
a.Bones are initially soft and bowing occurs; then become hard and brittle leading to fractures
b.Slow progression with 2-stage process 1. Excessive osteoclastic bone resorption 2. Excessive osteoblasticbone formation
Client with Paget’s Disease (osteitis deformans)Manifestations a. Most are asymptomatic b. Localized pain of long bones, spine,
pelvis, cranium; pain is mild to moderate deep ache which is aggravated by pressure and weight-bearing noticed at night and when resting
c. Flushing and warmth over areas of bone involvement
Client with Paget’s Disease (osteitis deformans)Complications a. Degenerative osteoarthritis b. Pathological fractures c. Nerve palsy syndromes from
involvement of upper extremities d. Compression of spinal cord causing
tetraplegia e. Mental deterioration from skull
involvement and brain compression
Client with Paget’s Disease (osteitis deformans)Collaborative Care a. Pain relief b. Suppression of bone cell activity c. Complication prevention
Diagnostic Test a. Xray (often incidental) b. Bone scan:
Client with Paget’s Disease (osteitis deformans) c. CT scans and MRI: d. Serum alkaline phosphatase: e. Urinary collagen pyridinoline testing:
indicator of rate of bone resorption
Client with Paget’s Disease (osteitis deformans)Medications a. Mild symptoms relieved by aspirin or
NSAIDs b. Bone resorption retarded by 1. Biphosphonates: calcium supplements are
prescribed in addition a. Alendronate (Fosamax) b. Pamidronate (Aredia) c. Tiludronate (Skelid)2. Calcitonic: works as analgesic for bone pain a. Salmon calcitonin (Calcimar) b. Human calcitonin (Cibacalcin)
Client with Paget’s Disease (osteitis deformans)Surgery a. Total hip or knee replacement is usually required
when client with Paget’s disease develops degenerative arthritis of hip or knee
b. May require surgery for spinal stenosis, nerve root compression
Nursing Diagnoses a. Chronic Pain 1. May involve wearing a back brace for relief of back
pain 2. Heat therapy and massage b. Impaired Physical MobilityHome Care: manifestations often relieved by treatment
Client with osteomalacia (adult rickets)
Metabolic bone disorder characterized by inadequate or delayed mineralization of bone matrix leading to marked deformities of weight bearing bone and pathologic fractures
Pathophysiology a. Primary causes are vitamin D deficiency and hypophosphatemia 1. Vitamin D deficiencya. Present in 1. Older adults 2. Very-low-birth weight infants 3. Strict vegetariansb. Caused by 1. Diet low in vitamin D 2. Impaired intestinal absorption of fats 3. Inadequate sun exposure 4. Some types of renal failure 2. Hypophosphatemia: most commonly caused by alcohol abuse
Process of vitamin D metabolism in the body
Client with osteomalacia (adult rickets)Other causes 1. Insufficient calcium absorption in intestines, due
to lack of calcium or resistance to action of Vitamin D
2. Increase loss of phosphorus through urineManifestations a. Bone pain and tenderness b. Common fractures are distal radius and
Client with osteomalacia (adult rickets)Diagnostic Tests a. X-ray demonstrates generalized bone
demineralization b. Serum calcium levels are normal or low c. Serum parathyroid hormone is frequently
elevated as compensatory response d. Alkaline phosphatase level usually
elevated
Client with osteomalacia (adult rickets)Medications a. Treatment of underlying condition b. Vitamin D therapy with calcium and
phosphate supplements c. Radiologic evidence of healing
apparent within weeks of therapy
Client with osteomalacia (adult rickets)Nursing Care a. Assessment of dietary intake of Vitamin D, calcium,
phosphorus, exposure to ultraviolet light b. Management of client responses to bone pain and
tenderness, fractures, muscle weakness c. Vitamin D sources include dairy products fortified
with Vitamin D and cod liver oil d. If client takes supplements, must be aware of
potential for toxicity with fat soluble vitamins e. Fall prevention
Client with osteomyelitis1. Infection of the bone, may occur as acute, subacute, or chronic2. Consequence of bacteremia, invasion from contiguous focus of
infection, skin breakdown; more prevalent in adults over age of 503. Pathophysiologya. Usually bacterial in nature: most commonly Staphylococcus
aureusb. Sources of infection 1. Direct contamination of bone from open wounds (trauma) 2. Complication of surgery 3. Extension of chronic ulcers including venous, arterial,
diabeticc. Infection develops in bone, which may interfere with vascular
supply to bone, and necrosis occurs; difficult for antibiotics to reach the bacteria within the bone
Osteomyellitis
Osteomyellitis
Client with osteomyelitis
Collaborative Care a. Pain relief b. Infection elimination or prevention c. Early diagnosis to prevent bone
necrosis by early antibiotic therapy d. Often requires bone debridement and
long course of antibiotics
Client with osteomyelitis
Diagnostic Tests a. MRI and CT scans: b. Radionucleotides bone scans: c. CBC and ESR: WBC and ESR are elevated d. Blood and tissue cultures: identify
infectious organism and determine appropriate antibiotic therapy
Client with osteomyelitis
Medications a. Antibiotics mandatory to prevent acute
case from becoming chronic osteomyelitis b. Initially treated as staph infection until
results of culture are obtained c. Definitive antibiotics prescribed according
to culture results d. Continued at least 4 – 6 weeks with
intravenous or oral antibiotics
Client with osteomyelitis
Surgery a. Needle aspiration or percutaneous needle
biopsy performed to obtain specimen; specimen may also be obtained during debridement procedure
b. Surgical debridement is primary treatment for chronic cases: wound is opened, irrigated; drainage tubes may be inserted for irrigation, suction, and antibiotic instillation
Client with osteomyelitis
Nursing Care a. Persons with chronic osteomyelitis face
frequent and lengthy treatments b. Client needs to be aware of manifestations
of recurrent infection (inflammation in area, temperature elevation)
c. Prognosis is uncertain and client must be maintained under care to prevent amputation or functional deficits
Client with osteomyelitis
Nursing Diagnoses a. Risk for Infection b. Hyperthermia: interventions include maintenance of
adequate fluid intake c. Acute Pain: splinting or use of immobilizer may limit
swelling and improve pain d. AnxietyHome Care a. Often vital part of treatment of osteomyelitis b. Referral to home care agency for support with wound
1. Tumors may be malignant or benign a. Benign tumors grow slowly and do not
invade surrounding tissues b. Malignant tumors grow rapidly and
metastasize
2. Tumors can be primary (rare) or metastatic lesions originating from primary tumors of prostate, breast, kidney, thyroid, lung
Neoplastic Disorders: Bone TumorsPathophysiology 1. Cause unknown, but connection
exists between bone activity and development of primary bone tumors
2. Primary tumors cause osteolysis, bone breakdown, which weakens bone and leads to bone fractures
3. Malignant bone tumors invade and destroy adjacent bone tissue
Neoplastic Disorders: Bone TumorsManifestations: often history of fall or blow to
extremity brings mass to attention 1. Pain 2. Mass 3. Impaired function
Neoplastic Disorders: Bone TumorsDiagnostic Tests 1. Xray: shows location of tumors and extent of bone
involvement a. Benign tumors show sharp margins separating from
normal bones b. Metastatic bone destruction: characteristic “moth-
eaten” pattern 2. CT scan: evaluation of extent of tumor invasion into
bone, soft tissues, neurovascular structures 3. MRI: determine extent of tumor invasion, response of
bone tumors to radiation and chemotherapy, recurrent disease 4. Needle biopsy to determine exact type of bone tumor 5. Serum alkaline phosphatase: elevated with malignant
bone tumors 6. RBC count elevation 7. Serum calcium: elevated with massive bone destruction
Neoplastic Disorders: Bone TumorsTreatments 1. Chemotherapy a. Used to shrink tumor before surgery b. Control reoccurrence c. Treat metastasis 2. Radiation a. Often combined with chemotherapy b. Used for pain control with metastatic carcinomas c. Eliminate tumor remains after surgery 3. Surgery a. Eliminate primary bone tumors to eliminate tumors
completely; may involve excise tumor or amputate affected limb b. With some surgeries, cadaver allografts or metal
prostheses used to replace missing bone to avoid amputation
Neoplastic Disorders: Bone TumorsNursing Diagnoses 1. Risk for Injury (pathologic fractures) 2. Acute and Chronic Pain 3. Impaired Physical Mobility 4. Decisional Conflict: assist client in gaining
information for informed decisions regarding treatment options
Home Care 1. Client education regarding treatment plan, wound
care, activity and weight bearing restrictions 2. Support with referral to prosthetic specialist or
hospice as case indicates
Client with a Fracture
Fracture: any break in continuity of bone1.Occurs when bone is subjected to more
kinetic energy than the bone can absorb2.Mechanisms producing fracture a. Direct: energy applied at or near site
of fracture b. Indirect: transmitted from point of
impact to site where bone is weaker
Client with a Fracture
Classifications of fracturesA. Simple (closed) skin intact over fracture or compound
(open) where skin is interrupted over injury and there is increased risk for infection
B. Fracture line may be 1. Oblique: 2. Spiral: 3. Avulsed: 4. Comminuted: 5. Compressed: 6. Impacted: 7. Depressed:
Common types of fractures
Open fracture
Closed fracture
Client with a Fracture
c. Complete fracture involves entire width of bone; incomplete fracture does not involve the entire width of bone
d. Stable (nondisplaced) fracture is fracture in which bones maintain their anatomic alignment; unstable (displaced) fracture: fracture in which bones move out of correct anatomic alignment
e. Description according to point of reference i.e. midshaft, intrarticular
Client with a Fracture
Manifestations a. May be accompanied by soft tissue
b. May be alteration in circulation, sensation, swelling, pain
c. May be obvious deformity or fracture d. May have felt the breakage of bone
during the injury event
Client with a Fracture
Fracture healinga. Phases include1. Inflammatory phase a. Bleeding and inflammation develop at site of fracture b. Hematoma forms around the bone surface c. Necrosis of osteocytes leads to vasodilation and
edema d. Collagen forms and allows calcium to be deposited2. Reparative phase a. Callus begins to form b. Osteoblasts promote formation of new bone c. Osteoclasts destroy dead bone and assist in
synthesis of new bone
Client with a Fracture
Remodeling phase a. Excess callus is removed b. New bone is laid down along the fracture line c. Eventually fracture site is calcified and bone is
reunitedb. Healing of fracture influenced by 1. Age and physical condition of client 2. Type of fracturec. Time 1. Uncomplicated fracture of arm or foot heals in 6 – 8
weeks 2. Fractured hip heals in 12 – 16 weeks
The stages of bone healing
Client with a Fracture
Emergency care involvesa. Immobilization of fracture 1. Immobilize above and below the deformity 2. Splint to maintain normal anatomical alignment and
prevent further dislocation or damage 3. Use air splint or splint to bodyb. Maintenance of tissue perfusion 1. Control obvious bleeding with pressure dressing 2. Assessment of pulses, movement, sensation; any
alteration requires prompt medical evaluation c. Prevention of infection: Cover open wounds with
sterile dressing
Client with a Fracture
Diagnostic Tests a. History of incident and initial assessment b. X-ray of bones involved in fracture c. Additional tests as indicated: CBC, blood chemistries,
coagulation studies to assess for blood loss, renal function, muscle breakdown, excessive bleeding or clotting
8. Medications a. Pain relief according to degree of injury and client’s
assessment of pain (may require narcotics) b. NSAIDs for anti-inflammatory affect as well as analgesia c. Medications to guard against ulcers d. Stool softeners to prevent constipation e. Antibiotics especially with open fractures f. Anticoagulants, if client considered at risk for deep vein
thrombosis
Client with a Fracture
Treatmentsa.Surgery1.Indications a. Requires direct visualization and
repair b. Fracture associated with long-term
complications c. Severely comminuted fracture, which
threatens vascular supply
Client with a Fracture
Types a. External fixation:
b. Internal fixation:
External fixation of a fracture
Internal fixation hardware
Internal fixation hardware
Client with a Fracture
Traction: application of straightening or pulling force to maintain or return fractured bones in normal alignment; prevent muscle spasms
1. Weights are used to maintain necessary force2. Types of traction a. Manual: by hand b. Straight: pulling force in straight line; Buck’s traction:
straight skin traction often used with fractured hip c. Balanced suspension: involves more than one force of
pull d. Skeletal: application of pulling force through
placement of pins into the bone; allows use of more weight to maintain alignment; increased risk of infection
Figure 38.5C Skeletal traction
Client with a Fracture
Casting: rigid device applied to immobilize bones and promote healing
1. Extends above and below the fractured bone which must be relatively stable
2. Types include a. Plaster: 48 hours needed to dry b. Fiberglass: dries within one hour d. Electrical bone stimulation: application of electrical
current at the fracture site; used to treat fractures that are not healing properly 1.Increases migration of osteoblasts and osteoclasts to fracture site 2.May be accomplished invasively or noninvasively 3.Contraindicated in presence of infection
Client with a Fracture
Complicationsa. Compartment syndrome: excess pressure in limited space,
constricting structures within and reducing circulation to muscles and nerves; normal pressure is 10 – 20 mm Hg
1. Results from hemorrhage and edema following a fracture or crush injury or external compression of limb, if cast is too tight
2. May result in cyclic ischemia and edema increasing risk for loss of limb or sepsis
3. Usually develops within first 48 hours of injury 4. Manifestations include progressive pain often distal
to injury not responsive to analgesia, decreased sensation, loss of movement; pulses may remain normal
Client with a Fracture
Fat Embolism Syndrome (FES) 1. Fat globules lodge in pulmonary vascular bed or
peripheral circulation: occurs with long bone fracture, pressure within bone marrow rises, exceeds capillary pressure and fat globules leave bone marrow and enter circulation
2. Manifestations: characterized by neurologic dysfunction, pulmonary insufficiency, petechial rash on chest, axilla, and upper arms within few hours or week after injury
3. May result in pulmonary edema, atelectasis, ARDS 4. Prevention: early stabilization of long-bone fractures
Client with a Fracture
Deep vein thrombosis (DVT): blood clot forms in lining of large vein; can lead to pulmonary embolism
1. Prevention: early immobilization of fracture and early ambulation
2. Prophylactic anticoagulation, antiembolism stocking and compression boots
3. Prompt diagnosis of DVT and adequate treatment
Infection: any complication decreasing blood supply increases risk; may result from contamination at time of injury or during surgery
1. Organisms include Pseudomonas, Staphylococcus or Clostridium
2. May lead to osteomyelitis, infection within the bone
Client with a Fracture
Delayed union: prolonged healing of bones beyond usual time period
1. Risk Factors include a. Poor nutrition b. Inadequate immobilization c. Prolonged reduction time d. Infection, necrosis, age e. Immunosuppression f. Severe bone trauma2. Detected by serial x-rays (x-ray findings lag 1 – 2
weeks behind the healing process)
Client with a Fracture
Nonunion 1. Persistent pain and movement at fracture site 2. Treatments a. Surgery: internal fixation, bone grafting b. Debridement if infection present c. Electrical stimulation
swelling, changes in skin color, texture, temperature, and decreased motion
3. Treatment includes sympathetic nerve block
Client with a Fracture
Nursing Care involved with fractures includes management of 1. Pain 2. Impaired physical mobility 3. Impaired tissue perfusion 4. Neurovascular compromise 5. Assessment of client’s response to traumaHealth Promotion 1. Emphasis is trauma prevention 2. Maintain good bone health including weight-bearing
Nursing Diagnoses 1. Acute Pain 2. Risk for Peripheral Neurovascular Dysfunction 3. Risk for Infection 4. Impaired Physical Mobility 5. Risk for Disturbed Sensory Perception: Tactile
Home Care: Client and family teaching focuses on individualized needs
1. Cast care 2. Following physician’s directions regarding weight
bearing 3. Home physical therapy referral 4. Obtaining needed equipment
Client with an Amputation
Partial or total removal of body part resulting from traumatic event or chronic condition
B. Causes of amputation 1. PVD is major cause 2. Trauma is major cause of upper extremity
amputation 3. Other traumatic events resulting in
amputation include frostbite, burns, electrocution
C. Underlying cause of amputation is interruption in blood flow either acute or chronic
Client with an Amputation
Levels of amputation1. Determined by local (ischemia and gangrene) and system
factors (cardiovascular status, renal function, severity of diabetes mellitus)
2. Goals a. Alleviate symptoms b. Maintain health tissue c. Increase functional outcome: joints are preserved
whenever possible to allow for greater function
Types of amputation 1. Open (guillotine): performed when infection is
present and remains open to drain 2. Closed (flap): wound is closed with flap of skin
sutured in place over stump
Common sites of amputation
Client with an Amputation
Amputation site healing 1. Immediate post-operative: assess
circulation to stump 2. Rigid or compression dressing is applied
to prevent infection and minimize edema 3. Stump is wrapped in Ace bandage to allow
a conical shape to form and prevent edema applied from distal to the proximal extremity
Client with an Amputation
Complications1. Infection: a. Local 1. Drainage or odor 2. Redness 3. Positive wound culture 4. Increased discomfort at suture lineb. System 1. Fever, chills 2. Increased heart rate or decreased blood pressure 3. Positive wound or blood cultures
Client with an AmputationDelayed healinga. Slower rate of healing than normal b. Factors include 1. Poor or inadequate nutrition 2. Poor blood flow, possibly related to smoking 3. Decreased cardiac output limits circulationChronic stump paina. Results from neuroma formation causing severe burning
Phantom limb pain/ phantom limb sensation a. Majority of amputees have sensations
such as tingling, numbness, cramping or itching in the phantom foot or hand, often self-limited
b. Phantom limb pain is pain often difficult to treat; may be referred to pain clinic for comprehensive pain management
Phantom Limb Pain
Phantom limb pain is a frequent complication of amputation.
Client complains of pain at the site of the removed body part, most often shortly after surgery.
Pain is intense burning feeling, crushing sensation or cramping.
Some clients feel that the removed body part is in a distorted position.
Management of Pain
Phantom limb pain must be distinguished from stump pain because they are managed differently.
Recognize that this pain is real and interferes with the amputee’s activities of daily living.
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Management of Pain
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Some studies have shown that opioids are not as effective for phantom limb pain as they are for residual limb pain.
Other drugs include intravenous infusion calcitonin, beta blockers, anticonvulsants, and antispasmodics.
Client with an Amputation
Contracture
a. Abnormal flexion and fixation of joint caused by muscle atrophy and shortening
b. Common complication associated with above the knee amputation
c. Interventions include 1. Lying prone for periods throughout day 2. Active and passive range of motion 3. Avoid prolonged sitting
Client with an Amputation
Prosthesis a. Type depends on level of amputation,
client’s occupation and life style b. Client with lower extremity amputation
often fitted with early walking aids: pneumatic device that fits over stump and allows early ambulation, decreased postoperative swelling
Client with an Amputation
Nursing Diagnoses a. Acute Pain b. Risk for Infection c. Impaired Skin Integrity d. Risk for Dysfunctional Grieving e. Disturbed Body Image f. Impaired Physical MobilityHome Care: Education and information for client
and family regarding stump care, prosthesis fitting and care, assistive devices, exercises, rehabilitation, safety issues
