Unit 2 CH. 40
Interventions for traction
-Interventions to prevent skin breakdown, nerve pressure, and circulatory impairment -Measures to reduce anxiety (providing and reinforcing info, encourage patient participation in decision making & in care, frequent visits, diversional activities) -Use of assistive devices -Consultation with referral for physical therapy -Prevention of atelectasis & pneumonia -high-fiber diet -encourage fluids -identify and include food preferences
Planning of a patient with osteoporosis
-Knowledge about osteoporosis & treatment regimen -Relief of pain -Improved bowel elimination -Absence of additional fractures
Planning of a patient with bone tumors
-Knowledge of disease process and treatment -Control of pain -Absence of pathological fractures -Effective coping patterns -Improved self esteem -Absence of complications
Patient and family education for a patient with osteomyelitis
-Long-term antibiotic therapy and management of home I.V. administrations -Mobility limitations -safety and prevention of injury -Post-op and follow up care
Manifestations of Osteoporosis
-Loss of Height -Progressive Curvature of Spine -Lower Back Pain -Fracture of forearm, spine, or hip -Vertebral Collapse -Pain
Modifiable Risk Factors
-Low-estrogen levels in women (Amenorrhea, Menopause) -Low testosterone levels in men -Dietary; low lifetime calcium intake, vitamin D deficiency -Medication use (Corticosteroids, Anticonvulsants) -Lifestyle (inactivity, smoking, alcohol)
Planning process of a patient with knee/hip replacement surgery
-Major goals before & after surgery may include the relief of pain, adequate neurovascular function, health promotion, improved mobility, and positive self-esteem -Post-op goals include the absence of complications
Referred Pain
-May originate from abdominal or pelvic viscera -This type of pain is generally not affected by posture or movement
Dual-Energy X-Ray Absorptionometry (DEXA)
-Measures bone density in the lumbar spine or hip
Gout
-Metabolic disorder characterized by an episodic acute inflammatory arthritis triggered by crystallization of urate within the joints
Post-op assessment of a patient with bone tumors
-Monitor VS, LOC, neurovascular status, pain -Signs & symptoms of complications -Monitor lab results (WBC and serum calcium level) -Signs & symptoms of hypercalcemia
o Duchenne Muscular Dystrophy (DMD)
-Most Common -Inherited as a recessive single-gene defect on the X chromosome (a sex-linked recessive disorder), and is transmitted from the mother to male children
Osteoporosis
-Most prevalent bone disease in the world -Normal homeostatic bone turnover is altered, and the rate of bone resorption is greater than the rate of bone formation, resulting in loss of total bone mass -Bone becomes porous, brittle, and fragile and breaks easily under stress
Compartment syndrome
-Most serious complication of casting and splinting -Occurs when increased pressure within a confined space compromises blood flow and tissue perfusion -Ischemia and potentially irreversible damage to the soft tissues may occur within a few hrs if action isn't taken -Diagnoses of this is the 6 P's and ICP -notify physician right away
Interventions of a patient with knee/hip replacement surgery
-Muscle setting; ankle and calf-pumping exercises -Measures to ensure adequate nutrition & hydration (large amounts of milk shouldn't be given to orthopedic patients on bed rest) -Skin care measures -Follow physical therapy and rehab programs -Encourage patient to set realistic goals & perform self-care within limits of the therapeutic regimen
Muscular Dystrophy
-Muscular dystrophy is a group of inherited muscle diseases that cause progressive muscle degeneration and wasting
What medications are effective in relieving acute low back pain?
-NSAID (Tylenol) -muscle relaxants (cyclobenzaprine [Flexeril])
Pharm management of Paget's Disease
-NSAIDs for pain -Calcitonin -Bisphonates (Didronel) -Mithracin: a cytotoxic antibiotic may be used for severe disease resistant to other therapy
Interventions of the patient undergoing foot surgery
-Neurovascular assessment is vital -Relieving pain -Improving mobility -Measures to prevent infection -Patient education
Assessment for traction
-Neurovascular checks -Mobility -Pain and discomfort -Emotional and behavioral responses -Coping -Thought process -Knowledge
Assessment of a patient with osteoporosis
-Occurance of osteopenia and osteoporosis -Family history -Previous fractures -Dietary consumption of calcium -Exercise patterns -Onset of menopause -Use of corticosteroids as well as alcohol, smoking, and caffeine intake -DXA -Serology & radiography studies
Non-Modifiable Risk Factors for Osteoporosis
-Older age -Family history of osteoporosis -History of fracture in a first-degree relative -Female Caucasian Asian -Thin and/or having a small frame
Assessment of a patient with bone tumors
-Onset and course of symptoms -Knowledge of disease and treatment -Pain -Patient coping -Family support and coping -Physical exam of area, including neurovascular status and ROM -Mobility and ADL abilities
What are the "6 P's"?
-Pain -Poikilothermia (unable to maintain core temp) -Pallor -Pulselessness -Paresthesia -Paralysis
Assessment post-op of a patient with knee/hip replacement surgery
-Pain -Vital signs -LOC -Neurovascular checks -Signs & symptoms of bleeding : wound drainage -Mobility & understanding of restrictions -Bowel sounds and elimination -Urinary output -Signs & symptoms of complications: DVT or infection
Pain of Spinal Origin
-Pain associated with pathology of the spine such as disk disease or arthritis, may be referred to other structures such as the buttocks, groin, or legs
Interventions of a patient with low back pain
-Pain management -Exercise -Body mechanics -Work modifications -Stress reduction -Health promotion; activities to promote a healthy back -Dietary plan & encouragement of weight reduction
Mobility and ambulation of a patient with knee/hip replacement surgery
-Patients usually begin ambulation within 1 day after surgery using walker or crutches -Weight bearing as prescribed by the physician
Total Knee Replacement
-Performed if the patient has intractable pain and x-ray films show evidence of arthritis of the knee
Ankulosing Spondylitis Treatment
-Physical Therapy -NSAIDs
Preventing a VTE of a patient with knee/hip replacement surgery post-op
-Physical signs include: pain, tenderness at or below the area of the clot, swelling or tightness of the affected leg, possibly with pitting edema, with either warmth or cooling, and skin discoloration -PE symptoms may include: acute onset of dyspnea, tachycardia, confusion, and pleuritic chest pain -Intermittent compression devices should be applied either intraoperatively or immediately post-op (must remain on legs at all times) -Dorsi and plantar flex the ankles and toes 10-20 times Q 1/2 hr while awake
How does the nurse provide pin site care for skeletal traction?
-Pins located in areas with soft tissue are at greatest risk for infection -After the first 48 - 72 hrs following pin placement, pin care should be performed daily or weekly -Chlorhexidine 2 mg/mL solution is the most effective cleansing solution -Strict hand washing before & after care should always take place -Inspect pin sites every 8 hrs for reaction
Hip prosthesis
-Positioning of the leg in abduction to prevent dislocation of the prostheses -Don't flex hip more than 90 degress -Avoid internal rotation -Protective positioning -Hip precautions
Planning of a patient with osteomyelitis
-Prevention is the goal -Relief of pain -Improved physical mobility -Control & eradication of infection -Knowledge of therapeutic regimen
Interventions of a patient with osteoporosis
-Promoting understanding of osteoporosis & treatment -Relieving pain -Improving bowel elimination -Preventing injury
How do we prevent/manage constipation and anorexia in a traction patient?
-Reduced gastrointestinal motility results in constipation and anorexia -High fiber diet and fluids -If constipation develops, may need to use stool softeners or laxatives, suppositories, and enemas
Planning of a patient with low back pain
-Relief of pain -Improved physical mobility -Use of back conservation techniques & proper body mechanics -Improved self-esteem -Weight reduction
Total Elbow Replacement
-Replacement of the humeral and ulnar surfaces of the elbow joint with a metal and polyethylene prosthesis
Assessment of a patient with osteomyelitis
-Risk factors -Signs & symptoms of infection localized pain, edema, erythema, fever, drainage -With chronic osteomyelitis, fever may be low grade -Signs & symptoms of adverse reactions & complications of antibiotic therapy -Ability to adhere to prescribed therapeutic regimen-antibiotic therapy
Diagnoses of the patient undergoing foot surgery
-Risk for ineffective peripheral tissue perfusion -Acute pain -Impaired physical mobility -Risk for infection
Assessment pre-op of a patient with knee/hip replacement surgery
-Routine pre-op assessment -Hydration status -Medication history -Possible infection(ask specifically about colds, dental problems, urinary tract infections within 2 weeks) -Knowledge -Support and coping
Radicular Back Pain
-Sharp, radiating from the back to the leg along a nerve root -This pain may be aggravated by movements such as coughing, sneezing, or sitting
Manifestation of Paget's Diseases
-Skeletal deformities, mild - moderate aching pain, and tenderness with warmth over bone
Nursing care of patient undergoing surgery of the hand/wrist
-Surgery is usually an outpatient procedure -Patient education -Neurovascular assessment; Q hour for the first 24 hrs -Pain control measures: medication, elevation, intermitten ice or cold -Prevention of infection -Assistance w/ ADLs & measures to promote independence
Assessment of the patient undergoing foot surgery
-Surgery is usually performed as an outpatient procedure -Routine outpatient preoperative assessment -Patient knowledge -Neurovascular assessment of foot -Ambulation & balance -Explore need for home assistance
What medications are effective for chronic low back pain?
-TCA (amitriptyline [Elavil]) -SNRI (duloxetine [Cymbalta]) -atypical seizure medications (gabapentin [Neurontin])--- prescribed for radiculopathy---
Total Hip Replacement
-The articular surfaces of the acetabulum and femoral head are replaced
Joint Arthroplasty
-The reconstruction or replacement of a joint -Usually indicated when the patient has severely restricted joint mobility and pain at rest
Planning in traction
-Understanding of the treatment regimen -Reduced anxiety -Maximum comfort -Max level of self-care within therapeutic limits of the traction -Absence of complications
Tophi
-Urate deposits in subcutaneous tissues cause the formation of small white nodules called
Joint replacements
-Used to treat severe joint pain & disability and for repair and management of joint fractures or joint necrosis -Frequently replaces joints include the hip, knee, and fingers -Joints include the shoulder, elbow, risk, and ankle
Complementary and Alternative Therapies
-Vitamin E and selenium -Amino acids -Dark reddish-blue berries (cherries and blackberries -Acupuncture
What is the pathophysiology of Paget's disease?
-primary proliferation of osteoclast which induces bone resorption (breakdown) followed by a compensatory increase in osteoblastic activity that replaces bone
What are the clinical manifestations of septic arthritis?
-warm, painful, swollen joint w/decreased ROM -systemic chills -fever -leukocytosis (increase in WBC)
What are strategies to prevent acute low back pain?
-weight reduction as needed, modify diet to achieve ideal body weight -avoid high heels -walk daily and gradually increase the distance and pace -avoid jumping and jarring activities -stretch to enhance flexibility, do strengthening exercises
The residual limb may be placed in an extended position. The residual limb should not be placed on a pillow because a flexion contracture of the hip may result.
After an amputation to part of the leg, how should the residual limb be placed after surgery?
Plantar fasciitis
An inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced with the first steps in the morning
Braces
Are used to provide support, control movement, and prevent additional injury. They are custom fitted to various parts of the body
Generally, casts can be divided into 3 man groups:
Arm casts, leg casts, and body or spica casts
Drain use post-op of a patient with knee/hip replacement surgery
Assess for bleeding and fluid accumulation
How often are assessments done on a patient who has just had a cast put on?
At least every hr for the first 24 hrs and every 1 - 4 hrs thereafter to prevent neurovascular compromise related to edema and/or the device
Someone should ask another person for help lifting an object more than one third of a person's weight.
At what weight should a person get help lifting an object, instead of attempting to lift it themselves?
To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan?
Increase fiber intake.
Osteomyelitis
Infection of the bone
RICE
Rest Ice Compression Elevation other interventions: immobilize, anti-inflammatory medication (NSAIDs)
What is the most common cause of joint infections in all age groups?
S. aureus, followed by gram positive bacteria including streptococci
20-50 minutes at a time.
Sitting should be limited to how long?
Healthy Behaviors of Osteoporosis
Smoking cessation Avoid alcohol Limit caffeine 2-3 cups/day
Which device is designed specifically to support and immobilize a body part in a desired position?
Splint
Symptoms of Paget's Disease
May be insidious & may be attributed to old age or arthritis; most patients don't have symptoms
Abduction
Movement away from the center or median line of the body
Adduction
Movement toward the midline of the body
Muscular Dystrophy Manifestations
Muscles weakness Difficulty with ambulation (eventually wheelchair bound, to finally bed bound) Cardiac abnormalities Endocrine abnormalities Mental retardation
Gout Medications
NSAIDs Colchicine Corticosteroids Xanthine Oxidase Inhibitors Uricosuric Drugs Allopurinol (Zyloprim) Febuxostat (Uloric)
Kyphosis: increased forward curvature of the thoracic spine that causes a bowing or rounding of the back, leading to a hunchback or slouching posture.
Name this spinal deformity
Lordosis: Or swayback, an exaggerated curvature of the lumbar spine.
Name this spinal deformity
Scoliosis: a lateral curving deviation of the spine
Name this spinal deformity
Cerebral disturbances (due to hypoxia and the lodging of fat emboli in the brain) and manifest as mental status changes varying from headache and mild agitation to delirium and coma.
Neurologic manifestations of FES typically include:
What are the major hormonal regulators of calcium homeostasis?
PTH and calcitonin
radiculopathy.
Pain that radiates down the leg is known as ______________________?
While assessing sensation, the nurse monitors for:
Paresthesia or absence of feeling in the affected extremity, which could indicate nerve damage
Age 20
Peak bone mass is reached usually by what age?
Bone tumors
Primary - Benign and malignant Metastatic bone tumors - more common than primary tumors
Which action by the nurse would be inappropriate for the client following casting?
Protect the cast by covering with a sheet.
Cast syndrome
Psychological or physiologic responses to confinement in body cast
Clawfoot: pes cavus
Refers to a foot with an abnormally high arch and a fixed equines deformity of the forefoot
physical activity; dietary intake of certain nutrients, especially calcium; and several hormones, including calcitriol, parathyroid hormone, calcitonin, thyroid hormone, cortisol, growth hormone, and the sex hormones estrogen and testosterone.
The balance between bone resorption and formation is influenced by what factors?
hypoxemia, neurologic compromise, and a petechial rash
The classic triad of clinical manifestations of FES include:
Atrophy
The decrease in the size of a muscle is called _________________.
hypertrophy
The enlargement of a muscle, which results from an increase in the size of individual muscle fibers is called ___________________.
Loss of height, Postural changes, Kyphosis, Loss of flexibility, Flexion of hips and knees, Back pain, Osteoporosis, and Fracture
What age related findings might you see involving the bones?
Diminished range of motion, Stiffness, Loss of height
What age related findings might you see involving the joints?
Joint pain on motion; resolves with rest, Crepitus, Joint swelling/enlargement, Osteoarthritis (degenerative joint disease)
What age related findings might you see involving the ligaments?
Loss of strength, Diminished agility, Decreased endurance, Prolonged response time (diminished reaction time), Diminished tone, Broad base of support, History of falls
What age related findings might you see involving the muscles?
Unexpected bleeding after surgery and bleeding from the mucous membranes, venipuncture sites, and gastrointestinal and urinary tracts.
What are early manifestations of Disseminated intravascular coagulation (DIC)?
bandages, casts, splints, continuous traction, and external fixators.
What are methods of external fixation?
Cognitivebehavioral therapy (e.g., biofeedback), exercise regimens, spinal manipulation, physical therapy, acupuncture, massage, and yoga.
What are some effective non pharmacologic interventions for treating chronic low back pain?
Flat bones are located where extensive protection of underlying structures is needed: skull bones, sternum and ribs, and bones of the pelvis.
What are some examples of flat bones?
Irregular bones cannot be categorized in any other group: vertebrae and bones of the jaw.
What are some examples of irregular bones?
The bones of the upper and lower extremities: tibia, fibula, femur, humerus, radius, and ulna.
What are some examples of long bones?
The articulation between the radius and ulna, which permits such activities as turning a doorknob and joint between the atlas and the axis (first and second cervical vertebrae) which allows rotation of the head. allows one bone to move around a central axis without displacement.
What are some examples of pivot joints?
irregularly shaped bones located in the ankle and hand: carpals and tarsals.
What are some examples of short bones?
low-fat milk, yogurt, and cheese. Foods with added calcium such as orange juice, cereals, and bread are also beneficial.
What are some good sources of calcium?
vitamin D-fortified milk and cereals, egg yolks, saltwater fish, and liver.
What are some good sources of dietary vitamin D?
Structural: Gradual, progressive loss of bone mass after age 30 y, and Vertebral collapse. Functional: Bones fragile and prone to fracture—vertebrae, hip, wrist.
What are the age related structural and functional changes in bone?
Structural: Cartilage—progressive deterioration, Thinning of intervertebral disks Functional: Stiffness, reduced flexibility, and pain interfere with activities of daily living
What are the age related structural and functional changes involving the joints?
Structural: Lax ligaments (less-than-normal strength; weakness) Functional: Postural joint abnormality, Weakness
What are the age related structural and functional changes involving the ligaments?
Structural: Increase in collagen and resultant fibrosis, Muscles diminish in size (atrophy); wasting, Tendons less elastic. Functional: Loss of strength and flexibility, Weakness, Fatigue, Stumbling, Falls
What are the age related structural and functional changes involving the muscles?
Long, short, flat, and irregular.
What are the four categories of bone, classified by shape?
Atelectasis and pneumonia
What are the pulmonary threats to older people after a hip fracture?
1. Synarthrosis joints, also referred to as fibrous joints, are immovable because of fibrous tissue banding: the skull sutures. 2. Amphiarthrosis joints, also referred to as cartilaginous joints, allow limited motion: the vertebral joints and the symphysis pubis. 3. Diarthrosis joints, also referred to as synovial joints, are freely movable joints.
What are the three basic types of joints?
Hematogenous osteomyelitis- Blood borne spread of infection Contiguous-focus osteomyelitis- contamination from outside: surgery, gunshot etc. Osteomyelitis with vascular insufficiency- reduced blood supply, as seen in diabetes
What are the three classifications of Osteomyelitis?
Osteoblasts
What bone cell functions in bone formation?
The leg is shortened, adducted, and externally rotated. The patient reports pain in the hip and groin or in the medial side of the knee.
What clinical manifestations might you see with a fracture of the femoral neck?
Hemorrhage, infection, skin breakdown, phantom limb pain, and joint contracture.
What complications might occur after an amputation?
An infection of the bone that results in inflammation, necrosis, and formation of new bone.
What is Osteomyelitis?
Infection, and bleeding.
What is a complication of an arthrocentesis?
A hallmark sign is pain that occurs or intensifies with passive ROM.
What is a hallmark sign of compartment syndrome?
The joints of the carpal bones in the wrist; allow for limited movement in all directions
What is an example of a gliding joint?
The joint of the thumb; allows movement in two planes at right angles to each other.
What is an example of a saddle joint?
Presence of infected dead bone, a sequestrum, that has separated from the living bone. A sheath of new bone, called the involucrum, forms around the dead bone.
What is the hallmark feature of chronic osteomyelitis?
Staphylococcus aureus
What is the most common cause of Osteomyelitis?
Intracapsular fracture
What is the name for a fracture at the neck of the Femur?
Extracapsular fractures
What is the name for a fracture of the trochanteric region (between the base of the neck and the lesser trochanter of the femur) and of the subtrochanteric region?
A complete fracture
What is the name for a fracture that crosses the entire cross section of the bone and is frequently displaced?
closed fracture (simple fracture)
What is the name for a fracture that does not cause a break in the skin?
An incomplete fracture (e.g., greenstick fracture)
What is the name for a fracture that involves a break through only part of the cross-section of the bone, and commonly occurs in children?
comminuted fracture
What is the name for a fracture that produces several bone fragments?
To prevent the hip and leg from rolling outward.
What is the purpose of a trochanter roll?
Young adults need a daily vitamin D intake of 600 IU, whereas adults 50 years and older require a daily intake of 800 to 1,000 IU to ensure good bone health.
What is the recommended daily intake of Vitamin D?
used to evaluate spinal nerve root disorders (radiculopathies)
What might Electromyogram (EMG) and nerve conduction studies be used to detect in patients with low back pain?
useful in identifying underlying problems, such as obscure soft tissue lesions adjacent to the vertebral column and problems of vertebral disks
What might a CT scan be used to detect in a patient with low back pain?
may disclose infections, tumors, and bone marrow abnormalities
What might a bone scan and blood studies be used to detect in a patient with low back pain?
permits visualization of the nature and location of spinal pathology
What might an MRI be used to detect in a patient with low back pain?
may demonstrate a fracture, dislocation, infection, osteoarthritis, or scoliosis
What might an X-ray be used to detect in a patient with low back pain?
useful in detecting tears in ligaments, muscles, tendons, and soft tissues in the back
What might an ultrasound be used to detect in a patient with low back pain?
MRI or arthroscopy will identify the fracture and confirm the diagnosis. if the fracture is nondisplaced, x-rays will not always reveal the fracture because cartilage is nonradiopaque.
What might be done to verify a intra-articular fracture?
Oral or vaginal candidiasis, loose or foulsmelling stools.
What might be signs of a superinfection?
the nurse inquires if the patient is taking any anticoagulant medications and assesses for any active skin infection. An EMG is usually contraindicated in persons receiving anticoagulant therapy (e.g., warfarin) because the needle electrodes may cause bleeding within the muscle.
What must the nurse check for before a patient undergoes an electromyography (EMG)?
More than 98%.
What percent of total body calcium is present in bone?
crackles, wheezes, precordial chest pain, cough, large amounts of thick white sputum, and tachycardia.
What pulmonary symptoms might you see in a patient with FES?
1 cm
When taking measurements of an extremity, variations in size greater than ____________ are considered significant.
Osteoclasts
Which bone cells are involved in dissolving and resorbing bone?
Osteocytes
Which bone cells are mature bone cells involved in bone maintenance?
The hip and shoulder; permit full freedom of movement.
Which joints are ball and socket joints?
The elbow and knee (also joints in fingers and toes); permit bending in only one direction, either flexion or extension.
Which joints are hinge joints?
A prone position should be avoided because it accentuates lordosis.
Which sleeping position should be avoided for a patient with back pain?
Have the patient lay down on their back and lift each leg upward, with knee extended. back and leg pain suggest nerve root involvement.
While doing a physical assessment how can the nurse check to see if nerve root involvement might be the cause of the back pain?
Complete fracture
a break across the entire cross section of the bone, can be displaced
When do patients post THA began ambulation?
a day after surgery with assistance of a walker or crutches
What is the major defect in osteomalacia?
a deficiency of activated vitamin D which promotes calcium absorption from the GI tract and facilitates mineralization of bone
What protects skeletal demineralization?
a diet rich in calcium and vitamin D throughout life, with an increased calcium intake during adolescence and the middle years -includes 3 glasses of skim vitamin D milk, cheese, steamed broccoli, canned salmon w/bones, calcium fortified orange juice -weight bearing exercises (20-30 mins of aerobic exercising, NOT swimming) *weight training/walking*
What is bone?
a dynamic tissue in a constant state of turnover
What is a hammer toe?
a flexion deformity of the interphalangeal joint which may involve several toes
What can precise measurement of ROM be measured with?
a goniometer (a protractor designed for evaluating joint motion)
What may happen if the patient with low back pain experiences secondary gains such as "workers compensation, easier lifestyle or workload, increased emotional support"?
a low back neurosis may develop, antidepressants and counseling may be needed to assist the patient in resuming a full, productive life
What is carpal tunnel syndrome?
a numbness and tingling in the hands and arms caused by a pinched nerve in the wrist -frequently occurs in women b/t 30-60 yrs. of age -commonly caused by repetitive hand and wrist movements, associated w/RA, diabetes, acromegaly, hyperthyroidism, or trauma
What helps identify patients needing intervention for carpal tunnel syndrome?
a positive tinel's sign
What is arthroscopy?
a procedure that allows direct visualization of a joint through the use of fiberoptic endoscope, it is a useful adjunct to diagnosing joint disorders
What is bone remodeling?
a process that occurs throughout the lifespan in which old bone is removed (resorption) and new bone is added to the skeleton (formation)
What does the procedure for arthrography consist of?
a radiopaque agent or air is injected into the joint cavity to visualize the joint structures such as the ligaments, cartilage, tendons, and joint capsule, the joint is put through its ROM to distribute the contrast agent while a series of x-rays are obtained, if a tear is present the contrast agent leaks out of the joint and is evident on the x-ray
What is a cast?
a rigid external immobilizing device that is molded to the contours of the body, generally permit mobilization of the patient while restricting movement of the affected body part
What is bursae?
a sac filled with synovial fluid that cushions the movement of tendons, ligaments, and bones over bones or other joint structures
What is dupuytrens disease?
a slowly progressive contracture of the palmar fascia that causes flexion of the fourth, fifth, and sometimes middle finger rendering these finders more or less useless *it is linked to an inherited autosomal dominant trait and occurs most frequently in men of Scandinavian or Celtic heritage who are older than 50 years* -also associated with arthritis, diabetes, gout, cigarette smoking, and alcoholism
What is a callus?
a thickened area of skin that has been exposed to persistent pressure or friction -faulty foot mechanics usually precede formation of a callus
What may be suspended overhead within easy reach for the patient who requires movement during traction without use of elbows of heels?
a trapeze, helps patient move about in bed, on and off the bedpan
Dislocation
articular surfaces of the joint are not incontact *traumatic dislocation* = EMERGENCY *manifestations*: pain, change in contour of the limb, loss of mobility
How may dupuytrens disease start?
as a nodule, it may or may not progress, producing a contracture of the fingers and palmar skin changes
What is the main nursing concern following the application of an immobilization device?
assessment and prevention of neurovascular dysfunction or compromise of the affected extremity
How often does the nurse assess the pin sites of external fixators?
at least every 8-12 hrs for redness, swelling, pain, warmth, purulent drainage
What are potential complications associated with THA?
dislocation of the hip prosthesis, excessive wound drainage, VTE, infection, heel pressure ulcer, heterotopic ossification (formation of bone in the periprosthetic space), avascular necrosis, loosening of the prosthesis
What is fat embolism?
disruption to blood supply caused by fat globules in a blood vessel *symptoms typically occur 24-72 hours after trauma*
What demonstrates function of the peroneal nerve?
dorsiflexion of the foot
What is bone pain typically described as?
dull, deep ache that is "boring" in nature, not typically related to movement and may interfere with sleep
When is energy used?
during muscle contraction and relaxation
What is a major goal following surgery in the older adult patient population?
early mobilization, begun within 48hrs of surgery
What is the joint examined for if it is compromised or the joint is painful?
effusion (excessive fluid within the capsule), swelling, and increased temperature that may reflect active inflammation
What type of surgery are most orthopedic surgeries?
elective, therefore most patients donate their own blood during the weeks preceding (autologous)
What do muscle cells contract in response to?
electrical stimulation delivered by an effector nerve cell at the motor end plate
Nursing Interventions: Closed fracture
elevate extremity proper nutrition (protein, calcium, vitamin D) mobility aids (lower extremity fracture -- crutches, walker, etc.) activity restriction/resumption
How should the extremity of the patient with an immobilized upper extremity be when lying down?
elevated so that each joint is positioned higher than the preceding proximal joint (elbow higher than the shoulder, hand higher than the elbow)
How is lumbar flexion increased?
elevating the head and thorax 30 degrees by using pillows or a foam wedge and slightly flexing the knees supported on a pillow
How may pain due to edema that is associated with trauma, surgery, or bleeding into tissues be controlled?
elevation, and if prescribed intermittent application of ice or cold packs
What does treatment of a callus consist of?
eliminating the underlying causes and having a painful callus treated by a podiatrist -a keratolytic ointment may be applied and a thin plastic cup worn over the heel if the callus is on the area -felt padding with an adhesive backing is also used to prevent and relieve pressure
Resolving Grief && Enhancing Body Image
encourage communication && expression of feelings create an accepting, supportive atmosphere provide support && listen encourage patient to look at/feel/care for the residual limb help patient resume self-care && independence help patient set *realistic goals* referral to counselors && support groups *psychosocial component!!!*
What is hypertrophy?
enlargement, increase in the size of the muscle
What may be prescribed preop of joint replacement to increase hemoglobin?
epoeitin alfa
How often does complete skeletal turnover occur?
every 10 years
How often does the nurse inspect the traction pin site for infection and inflammation?
every 8hrs
How often are neurovascular assessments done after application of an immobilization device?
every hour for the first 24hrs, every 1-4hrs thereafter to prevent neurovascular compromise r/t edema or the device
What advantages do splints offer over cast?
faster, easier to apply, noncircumferential and thus do not compromise circulation when the natural swelling during the inflammatory phase of injury occurs, easily removed facilitating inspection of the injury site
What is joint pain described as?
felt around or in the joint and typically worsens with movement
What do the most common casting materials consist of?
fiberglass or plaster
What is a muscle that is limp and without tone described as?
flaccid
What is pes planus?
flat foot, a disorder in which the longitudinal arch of the foot is diminished -may be congenital, bone or ligament injury, excessive weight, muscle fatigue, poorly fitting shoes, arthritis
When may contoured splints of plaster or pliable thermoplastic materials be used for?
for conditions that do not require rigid immobilization, for those in which swelling may be anticipated, for those that require special skin care
What do frequent surgical procedures include?
for fractures: open reduction with internal fixation (ORIF) closed reduction with internal fixation (fracture fragments are not surgically exposed), arthroplasty, meniscectomy, and joint replacement for joint conditions, amputation for severe extremity conditions (gangrene, massive trauma), bone graft for joint stabilization, defect filling, or stimulating of bone healing and tendon transfer for improving motion
What doe sources of vitamin D include?
fortified milk and cereals, egg yolks, saltwater fish, and liver
What are complications of Paget's disease?
fractures, arthritis, and hearing loss
What are good hip exercises?
frequent walks, swimming and use of a high rocking chair
Brace/Splint/Cast - Assessment (BEFORE application)
general health assessment, emotional status, presenting s/s and condition of the area monitoring neurovascular status (neurovascular changes: "6 P's") && for potential complications treat lacerations && abrasions BEFORE cast/brace/splint provide info about the purpose of treatment prepare patient for application by explaining procedure
What do the nursing interventions for arthrocentesis consist of?
hair removal from the site may be needed, pain may be a concern: tell the patient that analgesics may be admin. to alleviate discomfort during the procedure, Ice may be prescribed for the first 24-48hrs post procedure to diminish edema formation and pain, signs and symptoms of complications explained
What may be used to minimize hip joint flexion after a THA?
high seat (orthopedic) chairs, semireclining wheelchairs, and raised toilet seats
What should all older adult patients post THA be placed on?
higher specification, foam pressure relieving mattresses rather than standard hospital mattresses
How often should isometric exercises be performed?
hourly while the patient is awake, holding for 5-10 seconds, 10 times each (quadriceps & gluteal)
What is an effusion suspected?
if the joint is swollen and the normal body landmarks are obscured. most common site is the knee
When may the patient require a tetanus booster?
if the wound is dirty and if the last known booster was administered 5 years ago
What does the musculoskeletal system serve as a reservoir for?
immature blood cells and essential minerals, including calcium, phosphorus, magnesium, and fluoride
What are the benefits of external fixation as opposed to other modes of treatment?
immediate fracture stabilization, minimization of blood loss, increased patient comfort, improved wound care, promotion of early mobilization and weight bearing on the affected limb, and active exercise of adjacent uninvolved joints
What do the goals of orthopedic surgery include?
improving function by restoring motion and stability and relieving pain and disability
Where does cortical bone exist?
in areas where support is needed EX: long bones which are designed for weight bearing and movement
How may traction need to applied at times to achieve the desired line of pull?
in more than one direction, lines of pull known as vectors of force (pull in opposite directions)
Where can bursae be found?
in the joints of the elbow, shoulder, hip and knee
When do those experiencing pain with rheumatic disorders experience the worse pain?
in the morning, upon waking
Where do bursitis and tendonitis frequently occur?
in the shoulder
What is the function of calcitriol?
increase the amount of calcium in the blood by promoting absorption of calcium from the GI tract
What is the disadvantage of use of external fixators?
increased risk for pin site infections
What is pain experienced by patients who undergo foot surgery related to?
inflammation and edema, formation of a hematoma *to control edema the foot should be elevated on several pillows when sitting or lying -support of entire limb under knee is preferable -ice packs applied intermittently during the first 24-48hrs to control edema -as activity increases patient may find that dependent positioning of the foot is uncomfortable
What is the action of calcitonin?
inhibit bone resorption and promote bone formation
What is the action of estrogen?
inhibits bone breakdown, and decreases with aging
Sprain
injury to ligaments around a joint *manifestations*: joint is tender, movement is painful, edema; disability & pain increases during first 2-3 hours
What does the nurse explain to the patient about a bone scan?
it can assist in the identification of bone disease before it can be detected on an x-ray Encourage patient to drink plenty of fluids to help distribute and eliminate the isotope Beforehand the nurse can ask the patient to empty the bladder, because a full bladder interferes with accurate scanning of the pelvic bones
Why must weights never be removed during traction unless a life threatening situation occurs?
it defeats the purpose and may result in injury to the patient
What is the action of PTH?
it increases with age, thus increasing bone turnover and resorption
What may causes scoliosis?
it may be congenital, idiopathic, or the result of damage to the paraspinal muscles (muscular dystrophy)
What is the junction of two or more bones called?
joint or articulation
What may pain that increases with activity indicate?
joint sprain, muscle strain, or compartment syndrome
What are the most common sites of tumors that metastasize to bone?
kidney, lung, prostate, breast, ovary, and thyroid
What are common deformities of the spine?
kyphosis: hunchback lordosis: swayback (middle back goes inward), an exaggerated curvature of the lumbar spine scoliosis: lateral curving deviation of the spine
What is acute back pain?
lasting fewer than 3 months
What may the physical exam of a patient with osteoporosis disclose?
localized pain, kyphosis or the thoracic spine, shortened stature, problems in mobility and breathing may exist as a result of changes in posture and weakened muscles
What four categories are the 206 bones of the body classified into?
long, short, flat, and irregular
What is osteopenia?
low bone mineral density, which is the precursor to osteoporosis
What are good sources of calcium?
low fat milk, yogurt, cheese, orange juice, cereals, and bread
What does the nurse educate the patient post THA about related to protective positioning?
maintain abduction and avoiding internal and external rotation, hyperextension, and acute flexion, at no time should patient cross his/her legs or bend at the waist (put on shoes or socks)
What is done if satisfactory knee flexion is not achieved?
manipulation of the knee joint under general anesthesia may be necessary about 2 weeks after surgery
Rehabilitation of Patients w/ Amputation
may be congenital or traumatic, or caused by conditions i.e. progressive peripheral vascular disorder, infection, or malignant tumor amputation used to relieve symptoms, improve function, && improve quality of life
What is cast syndrome?
may be psychological or physiological psychological component is similar to claustrophobic reaction, patient exhibits an acute anxiety reaction (increased RR, diaphoresis, dilated pupils, increased HR, elevated BP) *admin of pain and antianxiety medication prior to procedure may help reduce this reaction
What are loose bodies "joint mice"?
may occur in a joint space as a result of articular cartilage wear and bone erosion -can interfere with joint movement "locking the joint" -removed by arthroscopic surgery if they cause pain or mobility issues
What metabolic changes contribute to osteoporosis in older adults?
menopausal withdrawal of estrogen and decreased activity
What do most joint replacements consist of?
metal (cobalt-chromium, titanium) and high density polyethylene components
Rehabilitation: Pelvic Fractures
mgmt depends on type && extent of fracture and associated injuries stable fractures are treated with few days best rest && symptom mgmt early mobilization reduces problems r/t immobility
How long may the remodeling phase take?
months to years depending on the extent of bone modification needed, the function of the bones, and the functional stresses on the bone
How much of total body calcium is present in the bone?
more than 98%
What are synergists?
muscles assisting the prime mover
What are the leading cause of disability in the US?
musculoskeletal disorders and injuries
What are priority nursing interventions for patients in traction?
neurovascular assessments
How does the nurse monitor a patient in a large body cast for potential physiologic cast syndrome?
noting bowel sounds every 4-8 hrs and reports abdominal discomfort and distention, nausea, vomiting to the pcp
What are the nursing interventions for electromyography (EMG)?
nurse inquires if the patient is taking anticoagulants and assess for skin infection, instruct patient not to use any lotions or creams on the day of the test
Osteoarthritis Risk Factors
o Aging (primary risk factor) o Genetics o Excessive or Increasing Body Weight o Inactivity o Repetitive Joint Use: o Textile Mill Workers o Sports Participants
Limb-Girdle Progression
o Extremely variable o Usually slow
The Difference in the types of Muscular Dystrophy relate to:
o Genetic pattern of transmission o The age at onset o The gender affected o The muscles involved o The rate at which the disease progresses
Osteoarthritis
o Labeled as a degenerative joint disease o The most common occurring of all forms of arthritis o Leading cause of pain and disability in older adults
Gout Risk Factors
o Male Gender o Aging o Hypertension o Obesity o Metabolic Syndrome o Type 2 Diabetes Mellitus o Chronic Kidney Disease o Medications: Diuretics Aspirin
Muscular Dystrophy Treatment
o No Cure or Specific Treatment o Care Focuses on Preserving and Promoting Mobility
Osteoarthritis Effects
o Pain/Stiffness in Joints o Sciatic Nerve Pain o Decreased ROM o Paresthesias o Grating or Crepitus o Joint Enlargement o Flexion Contractures
Osteoarthritis Treatment
o Range of Motion exercises, muscle- strengthening exercises, aerobic exercises, walking, quadriceps - strengthening exercises, yoga, tai chi, and water aerobics o Heat and ice o A balance between exercise and rest o Use of cane, crutches, or a walker as needed o Weight loss
Duchenne Muscular Dystrophy Progression
o Rapid o Patient usually confined to wheelchair by age 15 o Death occurs by age 20
Myotonic Progression
o Slow o Death usually occurs in early 50s
Facioscapulohumeral Progression
o Slow o Normal life span
Becker Progression
o Slow o Patient usually confined to wheelchair at 25 years after onset o Life span into 30s and 50s
Advanced Gout
o Tophi evident on joints, bursae, tendon sheaths, pressure points, helix of ear o Joint stiffness, limited ROM, and deformity o Ulceration of tophi with chalky discharge
Acute Gouty Arthritis Effects
o Usually monoarticular, affecting: Metatarsophalangeal joint of great toe Instep Ankle Knee Wrist Elbow o Acute pain o Red, hot, swollen, and tender joint o Fever, chills, malaise o Elevated WBC and sedimentation rate
Osteomalacia Causes
o Vitamin D Deficiency o Phosphate Depletion o Systemic Acidosis o Bone Mineralization Inhibitors o Chronic Kidney Disease o Calcium Malabsorption
Myotonic Manifestations
o Weakness and atrophy of facial muscles o Muscle weakness of distal extremities o Cardiac abnormalities o Endocrine abnormalities o Mental retardation (common)
Facioscapulohumeral Manifestations
o Weakness of face and shoulder girdles o Eventual involvement of abdominal, feet, and pelvic muscles
Becker Manifestations
o Weakness of pelvic and shoulder girdles o Cardiac involvement, possible heart failure
Limb-Girdle Manifestations
o Weakness of shoulder and pelvic girdles
When may the external fixator be removed?
once the soft tissue heals and there are no signs of infection, the fracture may require additional stabilization by a cast, molded orthosis, or internal fixation while healing
What conditions contribute to joint degeneration?
osteoarthritis, rheumatoid arthritis, trauma, and congenital deformity
Which cells function in bone formation by secreting bone matrix?
osteoblasts
What are the cells of the bones?
osteoblasts, osteocytes, and osteoclasts
What is the most common benign bone tumor?
osteochondroma
What are the multinuclear cells involved in dissolving and resorbing bone?
osteoclasts located in shallow Howships lacunae (small pits in bone)
What are the mature bone cells involved in bone maintenance?
osteocytes located in lacunae (bone matrix units)
What is the most prevalent bone disease in the world?
osteoporosis
What causes a loss of height in older adults?
osteoporosis (abnormal excessive bone loss) kyphosis (hunching of back) thinned intervertebral disks compressed vertebral bodies flexion of the knees and hips
What is the most common and most fatal primary malignant bone tumor?
osteosarcoma -prognosis depends on whether the tumor has metastasized to the lungs at the time the patient seeks health care -appears most frequently in children, adolescents, and young adults, in older ppl w/Paget's disease, and ppl w/a history of radiation exposure
What is a hallmark sign of compartment syndrome?
pain that occurs or intensifies with passive ROM
What are the five "P's" indicative of neurovascular compromise?
pain, pallor, pulselessness, paresthesia, and paralysis
What is the treatment of advanced metastatic bone cancer?
palliative, the therapeutic goal is to relieve the patient's pain and discomfort while promoting quality of life
What are the muscles of the body composed of?
parallel groups of muscle cells (fasciculi) encased in fibrous tissue called fascia (epimysium)
What signs need to be reported to the surgeon after surgery of the wrist or hand?
paresthesia, paralysis, uncontrolled pain, coolness of fingers, extreme swelling, excessive bleeding, purulent drainage, foul odor, fever
What is done to avoid flexion contractures?
patient instructed to limit positions of flexion of the knee and to avoid a knee Gatch position and pillows behind the knee
What does a nurse assess prior to a client having a cast, splint, or brace put on?
patient's general health, presenting signs and symptoms, emotional status, understanding of the need for the device, condition of the body part to be immobilized (must include skin assess & neurovascular status)
What patients may develop cast syndrome?
patients immobilized in large cast
What patients may benefit from additional Mg supplements?
patients who have had GI diseases (celiac disease, alcoholism)
Who is a total knee arthroplasty (TKA) considered for?
patients whose joints cannot be managed by nonsurgical treatment and who have severe pain and functional disability r/t destruction of joint surfaces by osteoarthritis, rheumatoid arthritis, or posttraumatic (osteonecrotic) arthritis
How may back pain resulting from compression fracture be relieved?
short periods of resting in bed in a supine position or side lying position , supportive mattress, knee flexion which relaxes back muscles, intermittent local heat and backrubs, move trunk as a unit and avoid twisting
What is isotonic contraction?
shortening of the muscle without an increase in tension within the muscle EX: flexing the forearm
What are splints often used for?
simple and stable fractures, sprains, tendon injuries, other soft tissue injuries
Closed fracture
simple, no break in the skin
Who are at the greatest risk for osteoporosis?
small framed Asian and Caucasian women
Contusion
soft tissue injury produced by blunt force *manifestations*: pain, swelling, discoloration (ecchymosis)
What is muscular pain described as?
soreness or aching and is referred to as muscle cramps
What is a muscle with greater than normal tone described as?
spastic
A client reports swelling and severe pain in the right wrist. After examination and radiographs negate a fracture, what would the physician likely prescribe as treatment?
splint
What is more commonly used in outpatient settings for acute and definitive management of orthopedic injuries?
splinting
What does estrogen do?
stimulates osteoblasts and inhibits osteoclasts therefore bone formation is enhanced and resorption is inhibited
What are the types of diarthrosis joints?
ball and socket: hip and shoulder, permit full freedom and movement Hinge joints: elbow and knee, permit bending in only one direction (extension/flexion) Saddle joints Pivot joints: allow one bone to move around in a central axis without displacement (radius and ulna); turning door knob Gliding joints: allow for limited movement in all directions (carpal bones of the wrist)
Why does the nurse caution the patient in severe pain not to remain on bed rest?
because extended periods of inactivity are not effective and result in deconditioning
Why is EMG usually contraindicated in people taking anticoagulants?
because the needles electrodes may cause bleeding within the muscle
When should orthopedic surgery be performed?
before surrounding muscles become contracted and atrophied and serious structural abnormalities occur
What does the reactive phase consist of?
bleeding into the injured tissue and local vasoconstriction occur, and a hematoma forms at the site of the fracture. Cytokines are released, initiating the fracture healing process by causing replicating cells (fibroblasts) to proliferate which in turn causes angiogenesis (growth of new blood vessels) to occur. Granulation tissue begins to form within the clot and becomes dense.
What may be done to relieve itching when wearing a cast?
blow cool air from hair dryer, do not insert foreign objects inside
What is osteogenesis and when does it begin?
bone formation and before birth
What is the consequence of osteoporosis?
bone fracture
What does a deficiency of vitamin D result in?
bone mineralization deficit, deformity, and fracture
What do the tendons attach muscles to?
bones, connective tissue, other muscles, soft tissue, and skin
What does the musculoskeletal (MS) system consist of?
bones, joints, tendons, ligaments, and bursae of the body
Incomplete fracture
break through only a part of the cross section
What is hallux valgus?
bunion, can be caused hereditarily, ill fitting shoes, osteoarthritis, and gradual lengthening and widening of the foot associated with age *wearing a shoe molded to the shape of the foot may be the only treatment needed* -corticosteroid injections control acute inflammation -in advanced cases surgical removal
What are signs and symptoms associated with flat foot?
burning sensation, fatigue, clumsy gait, edema, pain -exercises to strengthen the muscles and to improve posture and walking habits are helpful
How is osteoporosis diagnosed?
by DEXA (dual energy x-ray absorptiometry), baseline DEXA recommended for all women over 65yrs, postmenopausal women older than 50yrs w/osteoporosis risk factors
How are corns treated?
by a podiatrists by soaking and scraping off the horny later, by application of a protective shield or pad, or by surgical modification of the underlying offending osseous structure
When is peak bone mass reached?
by age 20
How may large amounts of fluid present in the joint spaces beneath the patella be identified?
by assessing for the balloon sign and for ballottement of the knee
When should patients post op for TKA mobilize and ambulate?
by first postop day
How is the patients gait assessed?
by having the patient walk away from the examiner for a short distance
How may Tinel's sign be elicited in patients with carpal tunnel syndrome?
by percussing lightly over the median nerve located on the inner aspect of the wrist *if the patient reports numbness, tingling, or pain the test is positive*
Medical management of fractures
*Fracture reduction* - restoration of the fracture fragments to anatomic alignment && positioning *Closed reduction* - uses manipulation && manual traction (*traction may be used (skin or skeletal)) *Open reduction* - fixation devices hold bone fragment in position (metallic pins, wires, screws, plates) *Immobilization* - external (casts, splints) or internal fixation
Assessment of fractures
*Pain*: continuous, increase in severity until mobilized, muscle spasms *Loss of function*: unable to function properly, abnormal movement *Deformity*: displacement (can still see deformity in closed if fracture is significant enough) *Shortening*: long bones, extremity appears shortened compared to other extremity *Crepitus* *Localized edema && ecchymosis (bruising)*
Rehabilitation: Femoral Shaft Fractures
*ROM exercises!!!!!* lower leg, foot, && hip exercises to preserve muscle function && improve circulation early ambulation stimulates healing physical therapy, ambulation, && weight bearing are prescribed active && passive knee exercises are begun as soon as possible to prevent restriction of knee mvmt
Rehabilitation: Radial/Ulnar/Wrist/Hand Fractures
*a LOT of physical therapy* early functional rehabilitation exercises active motion exercises of fingers && shoulder
How is the nurse going to assess the neurovascular status post-op of a patient who underwent foot surgery
-Assess swelling and neurovascular status Q 1 - 2 for the first 24 hrs -Instruct patient in signs & symptoms to assess and report
Muscle Spasm Pain
-Associated with many spine disorders, although its origin maybe unclear -This type of back pain is dull and may be accompanied by abnormal posture and taut spinal muscles
How do we prevent/manage atelectasis and pneumonia in a traction patient?
-Auscultate lungs Q 4 - 8 hrs -Deep breathing and coughing exercises
Prevention of osteoporosis
-Balanced diet high calcium & vitamin D throughout life -Use of calcium supplements to ensure adequate calcium intake: take in divided doses w/ vitamin C -Regular weight-bearing exercises: walking -Weight training stimulates bone mineral density
How do we prevent/manage urinary stasis and infection in a traction patient?
-Incomplete emptying of bladder while laying in bed may lead to stasis and infection -Monitor fluid intake and output, and character of urine -Adequate hydration is important, patient needs to void Q 3 - 4 hrs
Total Shoulder Replacement
-Indicated for unremitting pain and marked limitation of ROM because of arthritic involvement of both the humeral and glenoid joint surfaces of the shoulder
Prevention of infection of a patient with knee/hip replacement surgery
-Infection may occur in the immediate post-op period (within 3 months, as a delayed infection (4-24 months), or because of spread from another site (more than 2 yrs) -Scrubbing of the surgical site the night before or morning of surgery helps decrease chances of infection
Osteomyelitis
-Infection of the bone
Osteomyelitis
-Inflammation of the bone and bone marrow -Occurs because of :extension of soft tissue infection, direct bone contamination, blood borne spread from another site of infection -Causative organisms: Staph aureus, e-coli
Lyme Disease
-Inflammatory disorder caused by the spirochete Borrelia bugloferi, which is transmitted by ticks
How is the nurse going to help improve mobility post-op of a patient who underwent foot surgery
-Instruction in weight-bearing restrictions as prescribed -Use of assistive devices -Measures to ensure patient safety
External fixator
External metal frame attached to bone fragments to stabilize them
Injury to the peroneal nerve as a result of pressure is a cause of _____. Consequently, the patient drags the foot when ambulating
Footdrop
6-8 weeks
Fracture healing and restoration of strength and mobility may take an average maximum of __________________________________, depending on the quality of the patient's bone tissue.
Complications of Osteoporosis
Fractures -Hip (increases After Age 70, Doubles Every 5 Years) -Pelvis
What are the side effects of bisphosphonates?
GI (dyspepsia, nausea, flatulence, diarrhea, constipation) -patients may develop esophageal or gastric ulcers
Prick the top of the index finger, and ask the patient to touch the thumb to the little finger.
How can the nurse assess for Median nerve function?
Prick the skin midway between the great and second toe, and ask the patient to dosiflex the ankle and extend the toes.
How can the nurse assess for Peroneal nerve function?
Prick the medial and lateral surface of the sole, and ask the paitient to plantar flex the toes and ankle.
How can the nurse assess for Tibial nerve function?
Prick the small finger, and ask the patient to abduct all fingers.
How can the nurse assess for Ulnar nerve function?
Prick the skin midway between the thumb and second finger, and ask the patient to stretch the thumb, wrist, and fingers.
How can the nurse assess for radial nerve function?
Elevating the injured extremity and applying ice as prescribed.
How is edema controlled after a fracture?
6-12 months or longer
How long does a grafted bone take to heal?
206
How many bones are in the human body?
approximately 1,000 to 1,200 mg a day.
How much daily intake of calcium is essential to maintaining adult bone mass?
To heart level, but not above.
If compartment syndrome is suspected, at what level should the extremity be elevated?
Why is an electromyography test done?
to evaluate muscle weakness, pain, and disability
What is a cast used specifically for?
to immobilize a reduced fracture, to correct or prevent a deformity (club foot, hip displacement), to apply pressure to underlying soft tissue, or to support and stabilize weakened joints
Why are body cast used?
to immobilize the spine
What are external fixator used for?
to manage complex open fractures with soft tissue damage, treat defects, correct nonunion (bone lacks stability), lengthen limbs
Why may an arthrocentesis be carried out?
to obtain synovial fluid for purposes of examination or to relieve pain due to effusion
Why may a continuous passive motion (CPM) device be prescribed?
to promote range of motion, circulation, and healing and to prevent scar tissue from forming in the knee, which could decrease mobility and increase postop pain -patient leg placed in this device immediately after surgery -degree of flexion, extension of joint, and cycle rate prescribed by surgeon -responsibility of nurse to maintain device and monitor patients response to therapy
What are braces used for?
to provide support, control movement, and prevent additional injury, custom fitted to various parts of the body, tend to be indicated for longer term use than splints
What do the nurse and physical therapist educate the patient about after cast removal?
to resume activities gradually within the prescribed therapeutic regimen, instruct patient to control swelling by elevating the formerly immobilized body part no higher than the heart, until normal muscle tone and use are reestablished
What are the two most common surgical management options for carpal tunnel syndrome?
traditional open nerve release or endoscopic laser surgery -both done under local anesthesia and involve making incisions into the affected wrist and cutting carpal ligament so that the carpal tunnel is widened -smaller incisions are made during the endoscopic laser procedure *following either the patient wears a hand splint and limits hand use during healing* -full recovery may take several weeks or months
What may be applied to bony prominences during traction to decrease friction?
transparent film, hydrocolloid dressings, or skin sealants
What can prevent an ingrown toe nail?
trimming the nails properly and filling the corners consistent with the contour of the toe -active treatment consist of: washing the foot twice a day and relieving the pain by decreasing the pressure of the nail plate on the surrounding soft tissue -warm wet soaks help drain an infection
Balanced Suspension *Thomas Leg Splint*
two sets of weights, patient can move vertically with trapeze
What influences the rate of fracture healing?
type of bone fractured adequacy of blood supply condition of the fracture fragments immobility of the fracture site age and general health of the person
What manifestations of DVT should be looked for during traction?
unilateral calf tenderness, warmth, redness, and swelling
What are the characteristics of systemic infection when a patient is wearing a cast?
unpleasant odor, purulent drainage staining the cast
What conditions may be corrected by surgery?
unstabilized fracture, deformity, joint disease, necrotic or infected tissue, and tumors
How long may osteoporosis be undetectable on the x-ray?
until there has been 25-40% demineralization, resulting in radiolucency of the bones
Rehabilitation: Clavicle Fracture
use a clavicular strap/sling exercises for elbow, wrist, fingers *asap* do not elevate arm above shoulder for approx. 6 weeks
What does the pin site care consist of?
use aseptic technique, cleanse each pin separately to avoid cross-contamination with nonshedding material (gauze, cotton tip swabs) by using a chlorhexidine 2mg/mL solution, pin sites should be cleaned and dressed as prescribed unless there is copious drainage, dressing becomes wet, or infection is suspected in which case cleaning and dressing may be more frequent *nurse notifies pcp if infection or pins or clamps seem loose*
What is arthrography?
used to identify the cause of any unexplained joint pain and progression of joint disease
Joint Replacements
used to treat severe joint pain && disability and for repair && mgmt of joint fractures or joint necrosis frequently replaced joints: *hip*, *knee*, fingers shoulder, elbow, wrist, && ankle may also be replaced
Traction
uses a *pulling force* to *promote* and *maintain alignment* to an injured part of the body
What does traction do?
uses a pulling force to promote and maintain alignment to an injured part of the body, used as a short term intervention until other modalities such as external or internal fixation are possible
What does the procedure for arthrocentesis consist of?
using aseptic technique, the physician inserts a needle into the joint and aspirates fluid, anti-inflammatory meds may be injected into the joint, a sterile dressing is applied afterwards, there is a risk of infection afterwards.
What do the irregular bones include?
vertebrae and bones of the jaw
What does the patient typically report if pressure necrosis occurs?
very painful "hot spot" and tightness under the cast
What plays a major role in calcium absorption and bone health?
vitamin D
What does treatment of hammer toe consist of?
wearing open toed sandals or shoes that conform to the shape of the foot, carrying out manipulative exercises and protecting the protruding joints with pads -surgery (osteotomy) may be used to correct a resulting deformity
When is skeletal traction used?
when continuous traction is desired to immobilize, position, and align a fracture of the femur, tibia, and cervical spine, used when skin traction is not possible, a greater weight is used (11-18kg, 25-40llbs)
How does compartment syndrome occur?
when increased pressure within a confined space (cast, muscle compartment) compromises blood flow and low tissue perfusion occurs, ischemia and potentially irreversible neuromuscular damage can occur within a few hours if action is not taken *(associated with tight casts or constrictive splints)
What is septic (infectious) arthritis?
when the joints become infected through spread of pathogens from other body parts (hematogenous spread) or directly through trauma or surgical instrumentation
What is isometric contraction?
when the length of the muscles remains constant but the force generated by the muscles is increased EX: pushing against an immovable wall
Where are the flat bones located?
where extensive protection of underlying structure is needed (the sternum or skull)
Where is cancellous bone found?
where hematopoiesis and bone formation occur EX: flats bones which are important sites of hematopoiesis and frequently protect vital organs
How should the patient post THA sit?
with hips higher than the knees, the affected leg should not be elevated when sitting and patient may flex the knees
How are the effects of traction evaluated?
with x-ray and adjustments made if needed
How often does the nurse assess circulation of the foot after skin traction is applied?
within 15-30 minutes, then every 1-2hrs
Who loses more bone mass women or men?
women
What are the nursing interventions after an arthroscopy?
wrap the joint with a compression dressing to control the swelling, ice may be applied to control edema and enhance comfort, joint kept extended and elevated frequently, prn analgesics, patient is instructed to avoid strenuous activities of the joint and exercises must be approved by the pcp, patient and family instructed to monitor for complications (fever, excess bleeding, numbness, swelling, cool skin)
Osteomyelitis Manifestations
• Acute/Chronic Bone Pain • Low Back Pain • Drainage/Ulceration • Swelling/Tenderness • Fever, Chills, Malaise • Tachycardia • Nausea, Vomiting, Anorexia
Ankylosing Spondylitis Systemic Manifestations
• Anorexia/Weight Loss • Fever/Fatigue • Uveitis (Inflammation of Eye) • Inflammatory Bowel Disease • Psoriasis • Pulmonary/Cardiac Dysfunction
Osteoporosis Medications
• Bisphosphonates (Drug of Choice) • Calcitonin • Estrogen Replacement Therapy • Selective Estrogen Receptor Modulators (SERMS) • Teriparatide (Forteo)
Osteomalacia Effects
• Bone pain • Muscle weakness • Difficulty changing from lying to sitting position and sitting to standing position • Waddling gait • Dorsal kyphosis • Pathologic fractures
Osteomalacia Medications
• Calcium • Phosphate • Vitamin D Supplements
Lyme Disease Complications
• Chronic Recurrent Arthritis o Primarily affecting large joints (especially the knee • Meningitis • Encephalitis • Neuropathies • Myocarditis/Heart Block
Lyme Disease Manifestations
• Flu-like Symptoms o Fatigue o Malaise o Fever o Chills o Myalgias o Headache o Stiff neck • Rash • Neurologic Symptoms o Facial nerve palsy o Meningitis o Flat or slightly raised red lesion at the site of the tick bite
Complications of Gout
• Kidney disease • Kidney stones • Acute renal failure
Ankylosing Spondylitis Manifestations
• Persistent/Intermittent Low Back Pain (Worsens at Night) • Limited Back Motion • Lumbar Curve is Lost, Thoracic Curvature Accentuated • Possible Fusion of Entire Spine
Duchenne Muscular Dystrophy Manifestations
•Weakness of pelvic and shoulder girdles o Waddling gait o Toe walking o Lordosis o Cardiac abnormalities o Low IQ in 50% of cases
Needs of Patient with Knee Replacement Surgery
*Continuous Passive Motion* - promote *ROM*, *circulation*, *healing* - prevent scar tissue in knee - placed in device immediately *Physical Therapy* - strength && ROM - assistive devices - *ambulate post op day 1* *Acute Rehab* - 1-2 weeks - total recovery: 6 weeks
What Bisphosphonates increase bone mass and decrease bone loss by preventing osteoclast function?
*daily or weekly oral preparations of:* -alendronate (Fosamax) -risedronate (Actonel) *monthly oral preps of:* -ibandronate (Boniva) *yearly IV infusion of:* zoledronic acid (Reclast) *only Alendronate & Risedronate are approved by FDA for use in men* *administer on arising in the morning with a full glass of water on an empty stomach, and patient must stay upright for 30-60minutes, do not take Ca and Vitamin D supplements same day as bisphosphonates*
Hip/Pelvic Fractures
*maintain neutral position of hip && leg (to heal right — do NOT put stress on joints)!!!* use *trochanter rolls* (or roll up a towel — cushion against hips to keep alignment) maintain abduction of the hip isometric, quad-setting, && gluteal-setting exercises use of trapeze use of ambulatory aids consultation w/ physical therapist
Rehabilitation: Elbow Fractures
*monitor regularly* for *neurovascular compromise* && signs of *compartment syndrome* (more common compartment syndrome b/c more prominences) active exercises && ROM encouraged to prevent limitation of joint mvmt after immobilization && healing
Traction Rules
*must be continuous* to be effective Skeletal traction is *NEVER interrupted* weights are not removed unless intermittent traction ordered (rare) patient must be in *good body alignment* in *center of bed* ropes must be unobstructed weights must hang freely && not rest on the bed knots in the rope or footplate must not touch the pulley or foot of the bed
*Rehabilitation: Hip Fractures*
*surgery* usually done to reduce && fixate the fracture
What are additional principles to follow when caring for the patient in traction?
*traction must be continuous to be effective in reducing and immobilizing fractures* *Skeletal traction is never interrupted* *weights are not removed unless intermittent traction is prescribed* -any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated -the patient must be in good body alignment in the center of the bed when traction is applied -ropes must be unobstructed *weights (usually 5-8lbs) must hang freely and not rest on the bed or floor* -knots in the rope or the footplate must not touch the pulley or the foot of the head of the bed
Osteoporosis
-"porous bones" -A metabolic bone disorder characterized by: Loss of bone mass Increased bone fragility Increased risk of fractures
Patient education of a cast
-(before application) explanation of condition necessitating the cast, purpose and goals of cast, expectations during the casting process -cast care: keep dry, do not cover with plastic -positioning: elevation of extremity, use of slings -hygiene -activity and mobility -don't scratch/stick anything in cast -cushion rough edges -report pain, swelling, changes in sensation, movement, skin color or temp, signs of infection or pressure areas
Risk Factors for Osteoporosis
-A - Alcohol -C - Corticosteroid -C - Calcium (Low) -E - Estrogen (Low) -S - Smoking -S - Sedentary Lifestyle
Ankylosing Spondylitis
-A chronic inflammatory arthritis that primarily affects the axil skeleton, leading to pain and progressive stiffening and fusion of the spine
Osteomalacia
-A metabolic bone disease characterized by inadequate bone mineralization -Softening & weakening -Deficiency of activated vitamin D causes lack of bone mineralization & low extracellular gastrointestinal disorders, severe renal insufficiency, hyperparathyroidism, and dietary deficiency
Osteomalacia
-A metabolic bone disorder characterized by inadequate or delayed mineralization of bone matrix in mature compact and spongy bone, resulting in softening of bones
Arthroscopy
-A surgical procedure in which an arthroscope (a thin tube that is lighted and has a camera in one end) is inserted into a joint
How is the nurse going to improve physical mobility for a patient with osteomyelitis
-Activity is restricted -Gentle ROM to joints above and below the affected part -Participation in ADLs within limitations
Diagnoses of a patient with osteomyelitis
-Acute pain -Impaired physical mobility -Risk for extension of infection: bone abscess formation -Deficient knowledge
Diagnoses of a patient with low back pain
-Acute pain -Impaired physical mobility -Risk for situational low self-esteem -Imbalanced nutrition
Diagnoses of a patient with knee/hip replacement surgery
-Acute pain -Risk for peripheral neurovascular dysfunction -Risk for ineffective therapeutic regimen management -Impaired physical mobility -Risk for situational low self-esteem and disturbed body image
Planning of the patient undergoing foot surgery
-Adequate tissue perfusion -Relief of pain -Improved mobility -Absence of complications
How are we going to relieve the pain of a patient with knee/hip replacement surgery post-op?
-Administration of medications (patient-controlled analgesia, other meds, medicate BEFORE planned activity and ambulation) -Use alternative methods of pain relief (repositioning, distraction, guided imagery) -Specific individualized strategies (use of ice or cold, elevation, immobilization)
Postmenopausal osteoporosis
-Affects bones such as vertebral bodies
Risk factors for osteoporosis
-Alcohol intake of 3 or more drinks daily -Current use of tobacco products -Family history -History of bone fracture during adulthood -Inactive or sedentary lifestyle -Inadequate calcium and vitamin D intake -Low BMI -Malabsorption disorders (e.g., eating disorder, celiac disease, bariatric surgery) -Men older than 60 years of age -Women who are postmenopausal -Prescribed corticosteroids (e.g., prednisone) for longer than 3 months
Paget's disease
-Also known as osteitis deformans -Disorder of localized bone turnover -Incidence: 2% - 3% of population over 50 -More common in men, risk increases with age -Excessive bone resorption by osteoclasts is followed by increased osteoblasts activity; bone structure disorganized, weak, and highly vascular
Osteotomy
-An incision into or transection of the bone, may be performed to realign an affected joint, particularly when significant bony overgrowth or osteophyte formation has occurred
What does the pharmacologic therapy for Paget's disease consist of?
-Bisphosphonates: they stabilize the rapid bone turnover, their use reduces serum ALP & urinary hydroxyproline levels [etidronate Didronel] -Plicamycin (Mithracin): a cytotoxic antibiotic is reserved for severely affected patients with neurologic compromise and for those whose disease is resistant to other therapy [administered by IV infusion, liver, kidney, and bone marrow function must be monitored during therapy]
Bouchard's nodes
-Bony enlargement of proximal interphalangeal joints
Heberden's nodes
-Bony enlargements of distal interphalangeal joints
Common conditions of the upper extremities
-Bursitis & tendonitis -Loose bodies -Impingement syndrome -Carpal tunnel syndrome -Ganglion -Supuytren's contracture
Pharm therapy of osteoporosis
-Calcium & vitamin D - primary -Bisphosohonates - first line after primary (Fosamax, Actonel, Boniva, Reclast) -Cacitonin -Selective estrogen modulators :evista -Teriparatide -RANK ligand - last resort
Interventions of a patient with bone tumors
-Care is similar to that of patients who have undergone orthopedic surgery -Patient & family education -Prevention of fractures (support extremities at all times, external supports or fixation devices, restrict weight bearing and activity as prescribed, use of assistive devices)
Pressure ulcers
-Casts or splints can put pressure on soft tissues -Lower extremity sites most susceptible: heal, malleoli, dorsum of foot, head of fibula, anterior surface of patella -Upper extremity sites: medial epicondyle of humerus, ulnar styloid
Local Pain
-Caused by compression or irritation of sensory nerves -Fractures, strains, and sprains are common causes of local pain
Treatment of osteomalacia
-Correct underlying cause -Increased doses of vitamin D & calcium are usually recommended -Handle patient gently; patient is at high risk for fractures -Address Pain & discomfort
Diagnoses of a patient with bone tumors
-Deficient knowledge -Acute and chronic pain -Risk for injury - Ineffective coping -Risk for situational low self-esteem
Diagnoses of patient w/ a brace, splint, or cast
-Deficient knowledge -Acute pain -Impaired physical mobility -Self-care deficit -Impaired skin integrity -Risk for peripheral neuromuscular dysfunction
Diagnoses of a patient with osteoporosis
-Deficient knowledge -Acute pain -Risk for constipation -Risk for injury
Diagnoses for traction
-Deficient knowledge -Anxiety -Acute pain -Self-care deficit -Impaired physical mobility
Collaborative problems & potential complications with bone tumor surgery
-Delayed wound healing -Nutritional deficiency -Infection -Hypercalcemia
Assessment of a patient with low back pain
-Detailed description of pain including OLDCARTS -Work and recreational activities - -Effect of pain & movement limitation on lifestyle & ADLs -Assess posture, position changes, and gait -Physical exam: spinal curvature, back & limb symmetry, movement ability, DTRs, sensation, and muscle strength
Monitoring wound damage of a patient with knee/hip replacement surgery post-op
-Drainage of 200 - 500 ml in the first 24 hrs is expected; by 48 hrs postop the total daring in 8 hrs usually decreases to 30 mL or less and the suction device is removed -Drains that remain in place for longer than 24 hrs are at an increased for risk of infection
How we we prevent/manage DVT in a traction patient?
-Educate patient how to perform ankle and foot exercises Q 1 - 2 hrs while awake -Include family members -Also exercise unaffected limb
What is the nursing management for septic arthritis?
-Educate the patient and family about the process -Explain the importance of supporting the affected joint, adhering to antibiotic regimen, inspecting skin under splints, observing weight bearing and activity restrictions -Educated patient about recurrence of infection
How is the nurse going to help in relieving pain post-op of a patient who underwent foot surgery
-Elevate foot -Use of intermittent ice -Medications oral analgesics
Knee prostheses
-Encourage active flexion exercises -Use of continuous motion device
What are the risk factors for osteoporosis?
-Genetics: Caucasian/Asian, female, family history, small frame *predispose to low bone mass* -Age: post menopause (50-55), advanced age, low testosterone in men, decreased calcitonin *hormones (estrogen, calcitonin, testosterone) inhibit bone loss* -Nutrition: low Ca intake, low vitamin D, high phosphate intake (carbonated beverages), inadequate calories *reduces nutrients needed for bone remodeling* -Physical exercise: sedentary, lack of weight bearing exercise, low weight and body mass index *bones need stress for bone maintenance* -Lifestyle choices: caffeine, alcohol, smoking, lack of exposure to sunlight *reduces osteogenesis in bone remodeling* Medications: corticosteroids, antiseizure medications, heparin, thyroid hormone Comorbidities: anorexia, hyperthyroidism, malabsorption syndrome, kidney failure *affects calcium absorption and metabolism* -obesity (immobility contributes to osteoporosis)
Biologic Disease-modifying Antirheumatic Drugs (DMARD) TNF
-Given to patient who fail to respond to treatment with NSAIDs
Septic (infectious) arthritis
-High risk: older adults & those with comorbid conditions -Most commonly knee and hip joints -Prompt recognition w/ culture of synovial fluid -Diagnosed with culture of synovial fluid -Treatment includes immobilization of joint, pain relief, and antibiotics
Potential complications/problems of a patient with knee/hip replacement surgery post-op
-Hypovolemic shock -Atelectasis -Pneumonia -Urinary retention -Infection -DVT or PE -Constipation or fecal impaction
How is the nurse going to relieve pain for a patient with osteomyelitis
-Immobilization -Elevation -Handle with great care and gentleness -Administer prescribed analgesic
What is a cast used for?
-Immobilize a reduced fracture -correct a deformity -apply uniform pressure to soft tissues -support to stabilize a joint
Principles of effective traction
-Whenever traction is applied, a counterforce must be applied. Frequently, the patients body weight and positioning in bed supply the counterforce -Traction must be continuous -Skeletal traction is never interrupted -Weights aren't removed unless intermittent traction is prescribed -Any factor that reduces pull must be eliminated -Ropes must be unobstructed, and weights must hang freely -Knots or the footplate must not touch the foot of bed
What measures will the nurse take to prevent infection post-op of a patient who underwent foot surgery
-Wound or pin care -Keep dressing clean and dry -Signs and symptoms of infections
What is osteomalacia?
-a metabolic bone disease characterized by inadequate mineralization of bone *the skeleton softens and weakens, thus causing pain, tenderness to touch, bowing of the bones, and pathologic fractures* -on physical exam: spinal kyphosis, bowed legs
What is osteomyelitis?
-an infection of the bone that results in inflammation, necrosis, and formation of new bone -those at risk are: older adults, poorly nourished, or obese, impaired immune system, chronic illness (diabetes, RA), long-term corticosteroid therapy, immunosuppressive agents, or IV drug users *causative organisms: MRSA, E. coli, Proteus, Pseudomonas*
What does the nursing management for patients with bone tumors consist of?
-ask about the onset and course of symptoms -assess the pts understanding of the disease process, how the family and pt have been coping, how pt has been managing pain -Nurse limits palpation of the mass to decrease any potential seeding process -Mass size and associated soft tissue swelling, pain and tenderness are noted -Assessment of neurovascular status & ROM
What does the nursing assessment of low back pain consist of?
-ask patient to describe the discomfort (location, severity, duration, characteristics, radiation, weakness in the legs) -descriptions of how pain occurred (Ex: opening a garage door) -how the patient has dealt with the pain (suggest areas for interventions & patient education) -if back pain is recurring info about previous successful pain control helps planning current management -assess environmental variables, work situations, family relationships -assess effect of chronic pain on the emotional well being of the patient
What do the diagnostic studies for septic arthritis include?
-aspiration, examination and culture of synovial fluid -CT & MRI may reveal damage to the joint lining -Radioisotope scanning may be useful in localizing the infections process *there may not be an external wound or reported recent trauma*
What medications are recommended as prophylaxis for VTE after THA?
-aspirin -LMWH (enoxaparin [Lovenox], dalteparin [Fragmin]) -synthetic pentasaccharides (fondaparinux [Arixtra]) *should continue for at least 6 weeks following surgery*
What are the nursing interventions in relation to atelectasis and pneumonia?
-auscultate the lungs every 4-8hrs to assess resp. status -educate pt about performing deep breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions -use of incentive spirometer if needed
What should patients do to avoid aggravating low back pain?
-avoid twisting, bending, lifting, reaching -change position frequently -limit sitting to 20-50 mins. based on level of comfort *absolute bed rest is no longer recommended* -ADL's should be resumed asap -low stress aerobic exercises recommended -conditioning exercises for back and trunk begun after about 2 weeks to help prevent recurrence of pain
What must be done to ensure effective skin traction?
-avoid wrinkling and slipping of the traction bandage and to maintain countertraction -proper positioning must be maintained to keep the leg in a neutral position -patient should avoid turning side to side, but with assistance can slightly shift positions
What is the nursing management for the patient undergoing foot surgery?
-before surgery nurse assesses the patients gait and balance, neurovascular status of the foot, availability of assistance at home and structural characteristics of the home -after surgery neurovascular assessment of the exposed toes (every 1-2hrs for the first 24 hrs) is essential -Educate patient &family how to assess for edema & neurovascular status (circulation, motion, sensation) -after surgery the patient will have a bulky dressing on foot protected by a light cast or boot -some patients are allowed to walk on the heel and progress to weight bearing as tolerated -Patient instructions about aseptic wound care and pin care may be needed -surgery is usually performed as outpatient procedure
What does the nursing management of the patient undergoing surgery of the hand or wrist consist of?
-before surgery, nurse assesses the patients level and type of discomfort, limitations in function *following surgery hourly neurovascular assessment of the exposed fingers for the first 24hrs is essential for monitoring nerves and perfusion* -nurse compares affected extremity w/unaffected extremity and postop status w/ the preop documented status -ask patient to describe sensations in fingers -nonconstrictive dressings -intermittent use of ice packs to surgical area during first 24-48hrs to control edema -unless contraindicated active extension &flexion of the fingers to promote circulation are encouraged -oral analgesics for pain -Pt. education about risk for falls & impaired cognition -To control swelling nurse ask patient to elevate the hand to the level of the heart with pillows -During first few days patient needs assistance with ADL's after a few days patient develops skills in one handed ADLs -Instruct patient during bathing to keep dressing dry by covering it with a secured plastic bag *generally wound is not redressed until patients follow up*
How can the proper posture be verified?
-by looking in a mirror to see whether the chest is up, the abdomen is tucked, and the shoulders are down and relaxed
What are the nursing interventions in relation to constipation and anorexia?
-caused by reduced GI motility -a diet high in fiber and fluids may help stimulate gastric motility -stool softeners, laxatives, suppositories, and enemas -include patients food preferences to improve appetite
Fiberglass casts
-composed of polyurethane resins -lighter in weight, stronger, water resistant, and more durable than plaster -more commonly used for simple fractures of the upper & lower extremities
What does neurovascular assessment consist of when it comes to the casted extremity?
-peripheral circulation -motion -sensation of the affected extremity - assessing the fingers or toes and comparing them to the opposite extremity
What are the nursing interventions post TKA?
-dress knee with a compression bandage -ice/cold packs applied to control edema and bleeding -neurovascular status (movement, sensation, color, pulse) of affected leg assessed q2hrs -q4hrs -encourage active flexion of the foot every hour while patient is awake -is drain is used, it is usually left in place only for 24 hrs to reduce risk of infection -antibiotics given prophylactically and continued for 24hrs -if extensive bleeding is anticipated an auto transfusion drainage system is used during immediate postop period -knee protected with a knee immobilizer and elevated when patient sits in a chair
What are the clinical manifestations of dupuytrens disease?
-dull and aching discomfort -morning numbness and stiffness in the affected fingers -condition starts in one hand but eventually both are affected *finger stretching exercises or intra-nodular injections of corticosteroids may prevent contractures*
What are the clinical manifestations of compartment syndrome?
-dusky, pale appearance of the exposed extremity -cool skin temperature -delayed cap refill -paresthesia *unrelenting pain not relieved by position changes, ice or analgesia -patient may complain that the cast, splint, or brace is too tight *PCP must be notified immediately
What are the nursing interventions in relation to VTE?
-educate patient about how to perform ankle and foot exercises within the limits of traction every 1-2hrs when awake to prevent DVT -involving family can increase adherence -drink fluids to prevent dehydration
What are the requirements for discharge home following a TKA?
-evidence of wound stability (no erythema, discharge, or redness) -appropriate anticoagulation status (INR b/t 1.5 and 2) -progress toward physical therapy (appropriate use of walker) -satisfactory pain control with oral meds
What should be done after the external fixator is applied?
-extremity is elevated to the level of the heart to prevent swelling -any sharp points on the fixator or pins are covered with caps to prevent device induced injuries *the nurse must be alert for potential problems caused by pressure from the device on the skin, nerves, or blood vessels and for the development of compartment syndrome -nurse monitors neurovascular status of the extremity every 2-4hrs -Bc the pin sites are inserted externally, particular attention is focused on the pin sites for inflammation and infection *The end goal is to avoid osteomyelitis (infection of the bone)*
What does the health history r/t to osteoporosis focus on?
-family history -previous fractures -dietary consumption of calcium -exercise patterns -onset of menopause -use of certain medications (corticosteroids) -alcohol use, smoking, caffeine intake -any symptoms the patient is experiencing (back pain, constipation, altered body image) are explored
What is the pharmacologic therapy for osteoporosis?
-first line medications: calcium, vitamin D supplements, and bisphosphonates -to ensure adequate Ca intake a Ca supplement (Caltrate, Citracal) w/vitamin D may be prescribed & taken w/a beverage high in vitamin C to help absorption -recommended daily dose should be split and not taken single
What are the proper body mechanics to prevent low back pain?
-good posture -avoid twisting, lifting above waist level, and reaching up for any length of time -push objects rather than pull them -keep load close to your body when lifting -life with the large leg muscles, not the back muscles -squat while keeping the back straight when necessary to pick something off the floor -avoid overreaching or a forward flexion position -use a wide base of support
What is osteomyelitis classified as?
-hematogenous: due to bloodborne spread of infection -contiguous focus: from contamination from bone surgery, open fracture, traumatic injury (gun shot wound) -osteomyelitis w/vascular insufficiency: seen in those w/diabetes, mostly affecting the feet
What may the exercise program made by the physical therapist for patients with low back pain include?
-hyperextension exercises to strengthen the paravertebral muscles -flexion exercises to increase back movement and strength -isometric flexion exercises to strengthen trunk muscles *each 30 min. daily exercise period begins and ends with relaxation*
What is an ingrown toenail caused by?
-improper self treatment -external pressure (tight shoes or stockings) -internal pressure (deformed toes, growth under the nail) -trauma or infection
What are signs of dislocation of the hip prosthesis?
-increased pain at the surgical site, swelling, immobilization -acute groin pain in the affected hip/increased discomfort -shortening of the affected extremity -abnormal external or internal rotation of the affected extremity -restricted ability or inability to move the leg reported "popping" sensation in the hip *nurse/patient must immediately notify surgeon bc the hip must be reduced and stabilized promptly so leg does not sustain circulatory and nerve damage*
Hematogenous Osteomyelitis
-infections are caused by pathogens that are carried in the blood from sites of infection elsewhere in the body
What is the pathophysiology of osteomyelitis?
-initial response is inflammation, increased vascularity, edema -after 2-3 days thrombosis of local blood vessels occurs resulting in ischemia with bone necrosis -unless treated promptly an abscess forms -resulting abscess cavity contains sequestrum (dead bone tissue) which doesn't easily liquefy and drain, therefore cavity cannot collapse and heal as it does in soft tissue abscesses -New bone growth (involucrum) forms and surrounds the sequestrum *although healing seems to take place a chronically infected sequestrum remains and produces recurring abscesses throughout the patients life: chronic osteomyelitis*
What are the clinical manifestations of Paget's disease?
-insidious, some patients don't experience symptoms but only have skeletal deformity -most frequently identified by x-ray studies performed for another problem -sclerotic changes and cortical thickening of long bone occur -skull may thicken and patient reports that a hat no longer fits -cranium may enlarge giving face a triangular shape -impaired hearing from cranial nerve compression & dysfunction -femurs and tibiae tend to bow -spine bent forward and rigid -chin rests on the chest -immobile thorax during respiration -mild to moderate aching pain, and tenderness and warmth over bones may be noted -pain and discomfort are often wrongly attributed by the patient to old age or arthritis -normal blood Ca levels -x-ray shows local areas of demineralization and bone overgrowth in characteristic mosaic patterns
What should the nurse discuss with the patient post THA about homecare?
-keep incision clean and dry -medication therapy (NSAID, opioids) -cleanse incision daily with soap and water and change dressing -signs of wound infection (pain, increased redness, swelling, purulent drainage, fever) *explain that sutures/staples will be removed 10-14 days after surgery* -avoid acute flexion and crossing legs -avoid low seated chairs -sleep with pillow between legs to avoid adduction -avoid sitting for longer than 45 minutes -Can resume driving 4-6 weeks after -avoid tub baths, jogging, heavy lifting, excessive bending, twisting *Pcp should give patient a card indicating he/she had a hip joint replacement to alert security personnel who use screening devices at airports/malls*
What are methods for avoiding displacement of the hip following a THA?
-keep knees apart at all times -put a pillow between the legs when sleeping -never cross the legs when seated -avoid bending forward when sitting -avoid bending forward to pick up objects on floor -use a high seated chair and a raised toilet seat -do not flex the hip to put on clothing such as pants, stockings, socks, or shoes
Major goals of a cast
-knowledge of the treatment regimen -improved physical mobility -achievement of max level of self-care -healing of any trauma associated lacerations and abrasions -maintenance of adequate neurovascular function -absence of complications
What do the clinical manifestations of osteosarcoma include?
-localized bone pain -tender, palpable soft tissue mass -primary lesion at distal femur, proximal tibia, and proximal humerus
What do lab studies of patients with osteomalacia show?
-low serum calcium -low phosphorus levels -elevated ALP -urine excretion of calcium -low creatinine
What are the clinical manifestations of metastatic bone disease?
-may be symptom free/ have pain that ranges from mild and occasional to constant and severe, various degrees of disability, and at times obvious bone growth -weight loss, malaise, and fever -tumor may be diagnosed only after pathologic fractures
What is the pathophysiology of osteomalacia?
-may result from failed Ca absorption or from excessive Ca loss from the body (kidney failure) -GI disorders (celiac disease, chronic biliary tract obstruction, chronic pancreatitis, small bowel resection) produce osteomalacia -liver and kidney disease bc these are the organs that convert vitamin D into to its active form -HPT leads to osteomalacia by increasing phosphate excretion in the urine
What are the nursing interventions in relation to urinary stasis and infection?
-monitor fluid intake and character of urine -adequate hydration -instruct patient to consume adequate amounts of fluid and void every 3-4 hrs -notify pcp of signs of UTI
Nursing management of an external fixator
-monitor neurovascular status of the extremity Q 2 - 4 hrs & promptly report changes to primary provider -pay attention to any signs of infection at pin sites -aseptic technique during pin insertion is advised
What is mestatic bone disease (secondary bone tumor)?
-more common than primary bone tumors -tumors arising from tissues elsewhere in the body may invade the bone and produce localized bone destruction (lytic lesions) or bone overgrowth (blastic lesions) -most frequently attack the skull, spine, pelvis, femur, and humerus and often involve more than one bone (polyostotic)
What are symptoms of hypercalcemia?
-muscle weakness, incoordination, anorexia, nausea & vomiting, constipation -electrocardiographic changes (shortened QT and ST, bradycardia, heart blocks) -altered mental status (confusion, lethargy, psychotic behavior) -treatment includes hydration w/ IV admin. of NS, diuresis, mobilization, medications such as bisphosphonates -Nurse assists the pt to increase activity and ambulation
What does the nurse do during the interview of a patient with low back pain?
-observe the patients posture, position changes, and gait *often the patients movements are guarded with the back kept as still as possible* -patient should be directed to a chair of standard height with arms for support
What people are at the greatest risk for septic arthritis?
-older than 80yrs. old -people with diabetes, RA, skin infection -alcoholism -people w/a history of joint replacement surgery -IV drug users
What medications are used to treat early impringement syndrome?
-oral NSAIDs -intra-articular injections of corticosteroids
What does evidence based treatment for carpal tunnel syndrome consist of?
-oral/oral intra-articular injections of corticosteroids (methylprednisolone [Depo-Medrol]) -application of wrist splints to prevent hyperextension and prolonged flexion of the wrist
What is Paget's disease?
-osteitis deformans -disorder of localized rapid bone turn over, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae -incidence slightly greater in aging men than in women -family history has been noted w/siblings developing -cause is unknown
What is the medical management for Paget's disease?
-pain usually responds to NSAID's -physical therapy, walking aids, shoe lifts for gait problems (bowing of legs) -weight is controlled to reduce stress on weakened bones and misaligned joints
What are the clinical manifestations of carpal tunnel syndrome?
-pain, numbness, paresthesia, and possibly weakness along the median nerve distribution (thumb, index, and middle finger) *night pain and/or fist clenching upon awakening is common*
What should the nursing management for individuals with external fixators include?
-patient is at risk for an altered body image r/t the overwhelming size and bulk of the apparatus -to promote acceptance of the device, patients should be given comprehensive info about the frame, reassurance that discomfort is minimal, and that early mobility is anticipated (clothing/other materials may need to be altered or used to cover the device)
Nursing management of the patient w/ an immobilized lower extremity
-patients leg must be supported on pillows to the level of the heart to control the swelling -cold therapy or ice packs should be applied as prescribed over the fracture site for 1 - 2 days -gentle toe and ankle exercises
What may disorders of the foot be caused by?
-poorly fitting shoes -fungal infections, plantar warts -diabetes -peripheral vascular disease, arteriosclerosis -RA -obesity
What is the medical management for septic arthritis?
-prompt treatment -Broad spectrum IV antibiotics started promptly then changed to organism specific antibiotics after culture results -IV antibiotics are continued until symptoms resolve -Synovial fluid is aspirated and analyzed periodically for sterility and decrease in WBC's -Primary Provider may aspirate the joint to remove excessive joint fluid, exudate, and debris which may provide comfort -Arthrotomy & arthroscopy used occasionally -Joint is supported & immobilized by a splint -Analgesics given to relieve pain -Nutrition and fluid status monitored -ROM exercises prescribed as soon as pt can begin movement w/o exacerbating symptoms of acute pain -Patient is assessed periodically over next year for recurrence
Preventive nursing care for traction
-proper alignment and maintenance of traction -monitor for complications of skin breakdown, nerve pressure, and circulatory impairment (inspect skin at least 3X day, palate traction tapes to assess tenderness, assess sensation & movement, assess pulses, color, capillary refill, and temp of fingers or toes, assess for indicators of DVT, infection)
What are the clinical manifestations of a patient with low back pain?
-radiculopathy -sciatica -affected gait, spinal mobility, reflexes, leg length, leg motor strength, sensory perception -paravertebral muscle spasm (greatly increased muscle tone of the back postural muscles) -loss of normal lumbar curve and spinal deformity
What is the pathophysiology of osteoporosis?
-reduced bone mass, deterioration of bone matrix, and diminished architectural strength -normal homeostatic bone turnover is altered -the rate of bone resorption (break down) is greater than bone formation resulting in a reduced total bone mass -bone becomes progressively porous, brittle, and fragile; they fracture easily under stresses that would not break the normal bone -fractures may be the first clinical sign of osteoporosis -development of kyphosis causes an associated loss of height, may increase risk of falls due to pulmonary insufficiency -not painful until bone is fractured
What does the nurse do during traction to monitor and prevent skin breakdown?
-remove the foam boots to inspect the skin, the ankle, tendon at least 3 times daily (a second person is needed to support the person during inspection) -palpates the area of the traction tape daily to detect tenderness -provides frequent repositioning to alleviate pressure and discomfort, bc the patient must remain in a supine position is at increased risk for pressure ulcers -use higher specification foam mattresses rather than standard hospital foam mattresses
Preventative interventions for traction
-report any alteration in sensation or circulation -frequent back care and skin care -regular shifting of position -special mattresses or other pressure reduction devices -perform active foot & leg exercises Q hr -pin care -exercises to maintain muscle tone and strength
What does treatment of bursitis and tendonitis consist of?
-rest of the extremity -intermittent ice and heat to the joint -NSAIDS to control inflammation and pain *arthroscopic synovectomy may be considered if shoulder pain and weakness persist* -Corticosteroid injections
What are measures to promote healing of impringement syndrome?
-rest the joint in a position that minimizes stress on the joint -support the affected arm on pillows while sleeping to keep from turning onto the shoulder -gradually resume motion and use of the joint, assistance with dressing and other ADL's may be needed -avoid working and lifting above shoulder level or pushing an object against a locked shoulder -perform the prescribed daily ROM and strength exercises
Types of traction
-skin (Buck's extension traction, cervical head alter, pelvic traction) -skeletal
What are the characteristics of benign bone tumors?
-slow growing, well circumscribed, and encapsulated -few symptoms, and are not a cause of death
What does the nurse assess on physical exam of the patient with low back pain?
-spinal curve, any leg length discrepancy, pelvic crest and shoulder symmetry -nurse palpates the paraspinal muscles and notes spasm and tenderness *when the patient is in a prone position the paraspinal muscles relax and any deformity caused by spasm can subside* -nurse ask patient to lean forward and then laterally, noting any discomfort or limitations -assess nerve involvement by assessing deep tendon reflexes, sensations (paresthesia), muscle strength *back and leg pain on straight leg raising (w/patient supine, legs lifted upwards with knee extended) suggest nerve root involvement*
What does management for plantar fasciitis include?
-stretching exercises -wearing shoes with support and cushioning to relieve pain -orthotic devices (heel cups, arch supports, night splints) -corticosteroid injections
Traction
-the application of pulling forces to a part of the body -purposes: reduce muscle spasms, reduce, align, and immobilize fractures, reduce deformity, and increase space between opposing forces -used as a short-term interventions until other modalities are possible
What are effective nonpharmacologic interventions for low back pain?
-thermal applications (hot/cold) -spinal manipulation (chiropractic therapy) *lumbar support belts are not effective in treating acute low back pain but may be effective devices for preventing low back pain in occupational health settings* -Cognitive behavioral therapy (biofeedback) -exercise regimens -acupuncture, massage, yoga for chronic low back pain
Nursing management of the patient w/ an immobilized upper extremity
-to control swelling, arm is elevated above heart level with a pillow -a sling may be used when patient is ambulating -circulatory disturbances: cyanosis, swelling, inability to move fingers
What is the proper technique for lifting?
-use strong quadriceps muscles of the thighs with minimal use of weak back muscles -with feet placed hip-width apart to provide a wide base of support the patient should bend the knees -then tighten the abdominal muscles, and lift the object close to the body with smooth motion, avoiding twisting and jarring motions *to prevent recurrence of acute low back pain, the patient should avoid lifting more than one third of his or her weight without help*
External fixation devices
-used to manage open fractures with soft tissue damage -temporary until pt has surgery -provide support for complicated or comminuted fractures -patient requires reassurance because of appearance of device -discomfort is usually minimal, and early mobility may be anticipated -elevate to reduce edema -monitor for signs & symptoms of complications, including infection -pin care -patient education
What are the clinical manifestations of osteomyelitis?
-when it is bloodborne the onset is sudden, occurring often with clinical manifestations of sepsis (chills, high fever, rapid pulse, general malaise) -patient may describe constant pulsating pain that intensifies with movement as a result of the pressure of the collecting purulent material -when it occurs from adjacent infection or from direct contamination there are no manifestations of sepsis, the area is swollen, warm, painful, and tender to touch -the patient with chronic osteomyelitis presents with a nonhealing ulcer that overlies the infected bone with a connecting sinus that sill intermittently drain pus, fever may be low grade and occur in afternoon/evening *w/longterm antibiotic use the nurse monitors the patient for signs of superinfection (oral/vaginal candidiasis, loose or foul smelling stools)*
What are ineffective treatments for carpal tunnel syndrome?
-yoga -laser therapy, ultrasound therapy -NSAIDs -diuretics, vitamin B6
What should the daily intake of calcium be to maintain adult bone mass?
1,000- 1, 2000 mg
What is the recommended adequate intake of calcium for adults?
1,000-1,300 mg/daily
How much calcium do postmenopausal and older adults need to consume?
1,200 mg daily, quantities larger than this may place patients at heightened risk of renal calculi (kidney stones) or CVD
How much blood loss during orthopedic surgery may be anticipated?
1,500mL, several units of typed and cross matched blood should be available
When do preop skin preps such as showers with antiseptic soap begin for orthopedic surgery?
1-2 days before the surgery
What amount of drainage after a THA is expected in the first 24 hrs?
200-500mL, by 48hrs the total drainage in 8hrs usually decreases to 30mL or less and suction device is removed *nurse promptly notifies the surgeon of excessive or foul smelling drainage*
To augment the flow of fluid, the nurse elevates the extremity so that it's above the level of the heart during first _______ hours post application
24-48
When can patient resume ADL's following THA?
3 months later
What is chronic back pain?
3 months or longer without improvement
How long should the patient not cross the legs or flex the hips more than 90 degrees after THA?
4 months
How long should hip precautions be enforced post THA?
4 months or longer
When is serous drainage and mild redness at the pin sites of external fixators expected?
48-72 hrs post insertion
Assessing for neurovascular changes: *6 P's*
6 P's: Pain Poikilothermia (takes on ambient temperature) Pallor Pulselessness Paresthesia (pins && needles feeling)
How long does total recovery take following a TKA?
6 weeks or longer
What should the daily intake of vitamin D for young adults be to ensure good bone health
600IU
How soon can DVT form following surgery without prophylaxis?
7-14 days and lead to PE, which can be fatal
When is the risk of dislocation greatest following a THA?
8-12 weeks, therefore stresses to the hip should be avoided especially during this time
What is the recommended vitamin D intake for adults 50 years and older?
800-1,000U
What should the daily intake of vitamin D for adults 50 years and older be to ensure good bone health
800-1000IU
chronic pain is considered to last 3 months or longer without improvement.
A patient comes back to the clinic with a continued complaint of back pain. What time frame does the nurse understand constitutes "chronic pain"?
Intravenous (IV) antibiotics are administered immediately upon the patient's arrival in the hospital along with tetanus toxoid if needed.
A patient shows up to the ER with an open fracture, what would you prepare to administer immediately?
What is a cast?
A rigid, external immobilizing device
Osteomalacia is also referred to as:
Adult Rickets
What type of traction is used to immobilize fractures of the proximal femur and hip before surgical fixation?
Buck extension
What are the types of skin traction used for adults?
Buck's extension (applied to lower leg), chin halter strap (occasionally used to treat chronic neck pain), and the pelvic belt (sometimes used to treat lower back pain)
What are common causes of claw foot?
Charcot Marie tooth disease, diabetes, and tertiary syphilis
When assessing peripheral circulation, the the nurse must:
Check peripheral pulses as well as capillary refill response (within 3 seconds), edema, and the color and temp of the skin
The nurse never adjusts the __________. It is the primary care providers responsibility
Clamps on the external fixator frame
The nurse is assisting with the application of a cast. Which of the following would the nurse expect to be done first?
Cleaning the skin surface.
Needs of Patient w/ Hip Replacement Surgery
Come back to this!!!
Disuse syndrome
Immobilization in a cast, splint, or brace can cause muscle atrophy and loss of strength -deterioration of body systems as a result of prescribed or unavoidable activity
Using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles. With feet placed hip-width apart to provide a wide base of support, the patient should bend the knees, tighten the abdominal muscles, and lift the object close to the body with a smooth motion, avoiding twisting and jarring motions.
Describe the correct way to lift an object?
While assessing motion, the nurse should note any:
Weakness or paralysis of the injured body part
A client with a fractured distal left radius reports discomfort at the cast site, with pain specifically in the upper forearm. What would the nurse expect the physician to do?
Cut a cast window.
pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours.
Describe compartment syndrome.
The client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which of the following complications?
Dislocation of the hip
epiphyseal plate, or growth plate. The epiphyseal plate nurtures and facilitates longitudinal growth and is calcified in adults.
During childhood and adolescence, there is a layer of cartilage known as the __________________________, or ____________________, that separates the epiphysis (ends of bone) from the diaphysis (shafts of bone).
excessive fluid within the capsule of a joint.
Effusion is:
Reactive phase. When a fracture occurs, the body's response is similar to that after injury elsewhere in the body. Bleeding into the injured tissue and local vasoconstriction occur, and a hematoma forms at the site of the fracture. Cytokines are released, initiating the fracture healing processes by causing replicating cells known as fibroblasts to proliferate, which in turn causes angiogenesis to occur (i.e., the growth of new blood vessels). Granulation tissue begins to form within the clot and becomes dense. This phase of the healing process is typically the most painful for the patient
Explain Phase 1 of fracture healing.
Reparative phase. During this phase, the granulation tissue is initially replaced with a callus precursor, called procallus. Fibroblasts invade the procallus and produce a denser type of callus that is composed mostly of fibrocartilage. This fibrocartilaginous callus is replaced with denser bony callus within approximately 3 to 4 weeks postinjury. Lamellar bone then forms as the bony callus calcifies months postinjury.
Explain Phase 2 of fracture healing.
Remodeling phase. The final phase of fracture healing results in remodeling the new bone into its former structural arrangement. Necrotic bone is removed by the osteoclasts. Although the final structure of the remodeled bone resembles the original unbroken bone, a thickened area on the surface of the bone may remain after healing. Remodeling may take months to years, depending on the extent of bone modification needed, the function of the bone, and the functional stresses on the bone.
Explain Phase 3 of fracture healing.
clean wound less than 1 cm long.
Explain a Grade 1 open fracture.
larger wound without extensive soft tissue damage or avulsions.
Explain a Grade 2 open fracture.
highly contaminated and has extensive soft tissue damage. It may be accompanied by traumatic amputation and is the most severe.
Explain a Grade 3 open fracture.
Which intervention should the nurse implement with the client who has undergone a hip replacement?
Instruct the client to avoid internal rotation of the leg.
Flatfoot: pes planus
Is a common disorder in which the longitudinal arch of the foot is diminished
Ingrown toenail
Is a condition in which the free edge of a nail plate penetrates the surrounding skin
Hallux valgus
Is a deformity in which the great toe deviates laterally -Marked prominence of the medial aspect of the first metatarsophalangeal joint
Hammer toe
Is a flex ion deformity of the interphalangeal joint -Toes are usually pulled upward, forcing the metatarsal joints downward
Morton's neuroma
Is a swelling of the third branch of the median plantar nerve
Callus
Is a thickened area of the skin that has been exposed to persistent pressure or friction
Corn
Is an area of hyperkeratosis produced by internal pressure or external pressure -The fifth toe is most frequently involved, but any toe may be involved
What should patients who have no contraindications (history of bleeding disorders) receive for DVT prophylaxis for THA surgery?
LWMH
This is Normal. It is normal to experience clicking or crackling in the joint for 24 to 48 hours after the procedure until the contrast agent or air is absorbed.
The patient just had an arthrography study done on his knee 12 hours ago. He is complaining that every time he moves his knee he hears a crackling sound. What should the nurse tell the patient?
T or F All traction needs to be applied in two directions. The lines of pull are "vectors of force". The result of the pulling forces is between the 2 lines of the vectors of force
True
A client is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm?
Use of isometric exercises
What is one serious effect of impaired circulation in the arm?
Volkmann contracture, which is a specific type of compartment syndrome, contracture of the fingers and wrist occurs as the result of obstructed arterial blood flow to the forearm and hand
What may result in postponement of surgery?
any infection presenting 2-4 weeks before planned surgery
What is the chief cause of musculoskeletal related disabilities in the US?
arthritis
What are common side effects of calcium supplements?
abdominal distention and constipation, Ca from foods is better absorbed but Ca supplements may be needed for those who are lactose intolerant
What may the nurse encourage the patient to do to decrease venous stasis?
active flexion-extension ankle exercises and isometric contraction of the calf muscles (calf pumping exercises) 10 times/hr while awake -in addition to anti embolism stockings, compression devices, and anticoagulant therapy to prevent thrombus formation
Rehabilitation: Humeral Neck && Shaft Fracture
activity limitations until adequate period of immobilization slings && bracing: immobilize bone that is messed up (still can move other extremities)
What do PE signs consist of?
acute onset of dyspnea, tachycardia, and pleuritic chest pain (right/left side of chest, esp. when inhale/exhale)
What is the main source of energy for muscle cells?
adenosine triphosphate (ATP)
What are work modifications to prevent low back pain?
adjust height of work area to avoid stress on back -adjust height of chair using a footstool to position knees higher than hips -use lumbar support in straight back chair with arm rests -avoid prolonged standing and repetitive tasks -avoid bending, twisting, and lifting heavy objects -when standing for any length of time, rest one foot on a small stool or box to relieve lumbar lordosis -avoid work involving continuous vibrations
Buck's traction
aligned by foam boot && traction applied by free hanging weight
Nursing Interventions: Open fracture
all closed fracture interventions cover with sterile dressing to prevent contamination immobilize
Who does fat embolism mostly occur in?
all patients with long bone fractures
What are synarthrosis joints?
also referred to as fibrous joints, are immovable because of fibrous tissue banding (the skull sutures)
What joints are referred to as cartilaginous joints?
amphiarthrosis, allow limited motion (the vertebral joints and the symphis pubis)
What does the withdrawal of estrogens at menopause or with oophorectomy cause?
an accelerated bone resorption (break down) within the first 5 years after cessation of menses *it is believed that testosterone and estrogen are important in maintaining bone mass in men*
What is a "corn" described as?
an area of hyperkeratosis (overgrowth of a horny layer of epidermis) produced by internal pressure (arthritis) or external pressure (ill fitting shoes) *fifth toe is most frequently involved but any toe can be*
What is plantar fasciitis?
an inflammation of a thick band of tissue that connects the heel bone to the toes -presents as an acute onset of heel pain experienced with the first steps in the morning -pain diminishes with gentle stretching of the foot and Achilles tendon
What is onychochryptosis?
an ingrown toenail in which the free edge of a nail plate penetrate the surrounding skin -a secondary infection or granulation tissue may develop
What is stomatitis controlled with?
anesthetic or antifungal mouthwash
When is the peak adult bone mass achieved?
b/t 18 and 25 yrs. of age
What are bones composed of?
cells, protein matrix, and mineral deposits
What are the second most common malignant tumors?
chondrosarcomas, tumors of the hyaline cartilage
What is pes cavus?
claw foot, foot with an abnormally high arch and a fixed equines deformity of the forefoot
What is the normal color of synovial fluid?
clear, pale, straw colored, and scanty in volume
What contributes to loss of muscle strength in older adults?
collagen structures are less able to absorb energy increased inactivity, diminished neuron stimulation, and nutritional deficiencies
What is the most serious complication of casting and splinting?
compartment syndrome
What potential complications from casts, splints, or braces should the nurse assess for?
compartment syndrome, pressure ulcer formation, and disuse syndrome
Fracture
complete or incomplete disruption in the continuity of bone structure
What types of fractures are managed with external skeletal fixators?
complicated fractures of the humerus, forearm, femur, tibia, and pelvis
Open fracture
compound, complex; skin or mucous membranes compromised
Skeletal Traction
continuous traction, passing a metal pin/wire thru the bone, ropes && weights are attached to the end of the pin greater weights used (11 - 18 kg)
Splints && Braces
contoured *splints* of plaster or pliable thermoplastic materials may be used for: - conditions that do *NOT* require *rigid immobilization* - for those in which *swelling may be anticipated* - for those who require *special skin care* *braces* (i.e. *orthoses*) are *custom-fitted* to various parts of the body && are used to: - provide support - control movement - prevent additional injury
What are sarcomeres?
contractile units of skeletal muscle that contain thick myosin and thin actin filaments
What is the normal curvature of the spine described as?
convex through the thoracic portion and concave through the cervical and lumbar portions
What are tendons?
cords of fibrous tissue that connect (muscle to bone)
What does open reduction consist of?
correction and alignment of the fracture after surgical dissection and exposure of the fracture
What must be done whenever traction is applied to achieve effective results?
countertraction (the force acting in the opposite direction)
What is a common cause of back pain?
disk degeneration, L4-5 & L5-S1 are subject to the greatest mechanical stress and greatest degenerative changes
Early Complications of Fractures
shock fat embolism *compartment syndrome* - caused by excess edema cutting off nerve pathways (pressure needs to be relieved) VTE, PE (pulmonary embolism = has traveled to the lungs)
What is atrophy?
decrease in the size of the muscle caused by bed rest and immobility
What are the goals of traction?
decreasing muscle spasms and pain, realignment of bone fractures, and correcting or preventing deformities
What may causes kyphosis?
degenerative diseases of the spine; arthritis or disk degeneration, fractures related to osteoporosis, and injury or trauma
Delayed Complications of Fractures
delayed union, malunion, nonunion *avascular necrosis of bone* - bone death d/t lack of blood flow to the bone complex regional pain syndrome (CRPS) heterotrophic ossification (bone has grown somewhere it should not be) compartment syndrome
What is muscle fatigue thought to be caused by?
depletion of glycogen and accumulation of lactic acid
Brace/Splint/Cast - Monitoring && Treating Pain
describe exact site, character, && intensity of pain treat w/ elevation, ice packs, && analgesics
What is impringement syndrome?
describes impaired movement of the rotator cuff of the shoulder -characterized by edema from hemorrhage, pain, shoulder tenderness, limited movement, muscle spasm, eventual disuse atrophy -may progress to a partial or complete rotator cuff tear
How does the nurse prepare the patient for the application of the splint, brace, or cast?
describing anticipated sights, sounds, and sensations (heat from the hardening reaction of the fiberglass or plaster)
What is the goal of primary bone tumor treatment?
destroy or remove the tumor rapidly
What are the freely movable joints?
diarthrosis, also referred to as synovial joints
What is radiculopathy?
disease of a nerve root that may result in pain that radiates down the leg (seen in patients with back pain)
What does the neurovascular assessment include?
peripheral circulation, motion, and sensation of the affected extremity, assessing the fingers and toes of the affected extremity, and comparing them with the opposite extremity When assessing peripheral circulation: check peripheral pulses, cap refill, edema, color and temperature of skin When assessing motion: note any weakness or paralysis of the injured body part When assessing sensation: monitor for parathesias or absence of feeling in the affected extremity would could indicate nerve damage The nurse should encourage the patient to move all fingers or toes when awake to stimulate circulation
What factors influence the balance between bone resorption and formation?
physical activity dietary intake of certain nutrients especially calcium hormones: calcitriol (activated vitamin D), parathyroid hormone (PTH), calcitonin, thyroid hormone, cortisol, growth hormone, sex hormones (estrogen and testosterone)
OREF (Open Reduction External Fixation)
pins in bone, fixation on outside (pins attached to compression device) -- higher risk for infection *nursing interventions*: protect from infection: clean, *PIN CARE* assess for signs of infection (excess swelling, excess redness, yellow/white/green drainage)
What demonstrates function of the tibial nerve?
plantar flexion
ORIF (Open Reduction Internal Fixation)
plates && screws under the skin, can't be seen *nursing interventions*: make sure dressings are clean && dry prophylaxis for developing DVT surgical + fracture/musculoskeletal interventions
What may weakness of a group of muscles indicate?
polyneuropathy, electrolyte disturbances (particularly K+ and Mg), myasthenia gravis, poliomyelitis, and muscular dystrophy
What is deficiency in vitamin D often associated with?
poor intake of calcium
What do immobility related complications include?
pressure ulcers, atelectasis, pneumonia, constipation, loss of appetite, urinary stasis, UTI, VTE
What does the procedure for arthroscopy consist of?
procedure takes place in the OR under sterile conditions with either injection of a local anesthetic into the joint or general anesthesia, a large bore needle is inserted and the joint is distended with NS, the scope is introduced and joint structures are visualized, after the procedure puncture wound is closed with adhesive strips or sutures and covered with a sterile dressing
What poses a risk for osteomalacia?
prolonged use of [Dilantin] phenobarbital, insufficient vitamin D
What may be administered for 24-48hrs post insertion to prevent infection?
prophylactic broad spectrum IV antibiotics
How are bones strengthened?
prophylactic internal fixation, arthroplasty, PMMA (bone cement) reconstruction
Strain
pulled muscle *manifestations*: pain, edema, muscle spasm, ecchymosis (bruising), loss of function
Skin Traction
pulling force applied by weights that are attached to the client using Velcro / tape / straps / boots / cuffs 2 - 3.5 kg on extremities 4.5 - 9 kg on pelvic
What phase of fracture healing is typically most painful for the patient?
reactive
What are the phases of fracture healing?
reactive phase, reparative phase, remodeling phase
What are the major nursing goals for the patient with low back pain?
relief of pain, improved physical mobility, use of back conserving techniques of body mechanics, improved self esteem, weight reduction -use of a medium to firm nonsagging mattress (bed board may be used) -avoid prone (stomach) position because it accentuates lordosis -instruct patient to get out of bed by rolling on to one side and placing the legs down while pushing the torso up, keeping the back straight -low stress aerobic exercises (walking/swimming)
What type of exercises are most beneficial in developing and maintaining bone mass?
resistance and impact
What are signs of fat embolism following orthopedic surgery?
respiratory distress, onset of delirium, any acute changes in level of consciousness and development of unusual skin rashes, especially a papular rash on the upper torso
Cast
rigid, external immobilizing device uses: immobilize a reduced fracture correct a deformity apply uniform pressure to soft tissues support && stabilize weakened joints
What are long bones shaped like?
rods or shafts (diaphysis) with rounded ends (EX: femur)
What are ligaments?
ropelike bundles of collagen fibers that bind the articulating bones together (bone to bone)
What is sciatica?
sciatic nerve pain, pain travels down back of thigh into the foot (seen in back pain)
What is most back pain?
self limiting and resolves within 4 weeks with analgesics, rest and avoidance of strain
What is examination of synovial fluid helpful in the diagnosis of?
septic arthritis and other inflammatory arthropathies and reveals the presence of hemathrosis (bleeding into joint)
Comminuted fracture
severe bone fragments; shattered the bone
What is fracture pain described as?
sharp and piercing and is relieved by immobilization
What is the proper patient positioning following a THA?
supine position with his/her head slightly elevated and the affected leg in a neutral position, use of an abduction splint, a wedge pillow, or two/three pillows b/t the legs prevent adduction beyond the midline of the body, cradle boot may be used to prevent leg rotation and to support the heel off the bed *when the nurse turns the patient in bed to the unaffected side it is important to keep the operative hip in abduction, patient should not be turned to the operative side which could cause dislocation* *Patients hip should not be flexed more than 90 degrees*
What are the major functions of the MS system?
support and protect the body and foster movement of the extremities
What is balanced suspension traction?
supports the affected extremity off the bed and allows for some patient movement without disruption of the line of pull, countertraction is produced by slings, or splints
What is joint arthroplasty?
surgical removal of an unhealthy joint and replacement of joint surfaces with metal or synthetic materials
What are red flags that trigger prescribing diagnostic procedures for low back pain?
suspected spinal infection, severe neurologic weakness, urinary or fecal incontinence, and a new onset of back pain in a patient with cancer
What are the three basic kinds of joints?
synarthrosis, amphiarthrosis, and diarthrosis
What medications are considered not effective in relieving low back pain?
systemic corticosteroids
What does the nurse instruct the patient to do to prevent disuse syndrome?
tense or contract muscles (isometric muscle contraction) without moving the underlying bone EX: push down the knee or make a fist
What should the nurse educate the patient with a cast that is ready for removal about?
that the cast saw uses an oscillating blade that vibrates but does not spin, it does not penetrate deeply enough to injure the patients skin, padding is cut with scissors, the formerly immobilized body part will be weak from disuse, stiff, and may appear atrophied (as the cast is removed the affected body part should be supported), skin (which is usually dry and scaly) is vulnerable to injury from scratching, skin needs to be washed gently and lubricated with an emollient lotion, *patient should be instructed to avoid rubbing and scratching the skin bc doing so can damage newly exposed skin
What muscles are important in lifting activities?
the abdominal and thoracic muscles
What is disuse syndrome?
the deterioration of body systems as a result of prescribed or unavoidable musculoskeletal inactivity
What makes patients who have had bariatric surgery at risk for osteoporosis?
the duodenum is bypassed which is the primary site for absorption of calcium
What are frequently replaced joints?
the hip, knee, and finger
What are the short bones?
the irregularly shaped bones located in the ankle and hand (metacarpals)
What is the prime mover?
the muscle that causes a particular motion
Whose responsibility is it to adjust the clamps on the external fixator?
the physician *the nurse never adjusts them*
What is superior mesenteric artery syndrome?
the physiologic manifestation associated with immobilization from a body cast (decreased physical activity, GI motility decreases, intestinal gases accumulate, intestinal pressure increases, and an ileus may occur)
What is ossification?
the process by which the bone matrix is formed and hard mineral crystals composed of calcium and phosphorus are bound to collagen fibers
What is a total hip arthroplasty (THA)?
the replacement of a severely damaged hip with an artificial joint
What may happen if compartment syndrome is due to a cast or tight splint?
the splint may be loosened or removed and the cast bivalved (cut in half longitudinally) to release constriction and allow for inspection of the skin
What does external fixation involve?
the surgical insertion of pins through the skin and soft tissues into and through the bone
What is required to improve outcomes of impringement syndrome?
therapeutic exercise regimen
What should the nurse inform the patient about the procedure for arthrography?
they may feel some discomfort or tingling during the procedure after the procedure, a compression elastic bandage may be applied if prescribed, and the joint is usually rested for 12hrs. Strenuous activity should be avoided until approved by pcp. Nurse provides additional comfort measures (analgesia, ice packs) Explains that it is normal for patient to experience clicking or crackling in the joint for 24-48hrs after the procedure until the contrast agent or air is absorbed
How do most fractures heal?
through a combo of intramembranous and endochondral ossification processes
What are common causes of lordosis?
tight low back muscles, excessive visceral fat, pregnancy as the woman adjusts her posture in response to changes in her center of gravity
Why do muscles contract?
to bring the two points of attachment closer together, resulting in movement
What is the purpose of electromyography?
to determine any abnormality of function and differentiate muscle and nerve problems
Why does the nurse adjust the extremity so that it is above the level of the heart for the first 24-48hrs post application of an immobilizing device?
to enhance arterial perfusion and control edema
