Musculoskeletal system Jane Lou E. Gargaritano, R.N.
I. PHYSIOLOGY OF MUSCULOSKELETAL SYSTEM 1. Provide protection for vital organs. 2. Supports body structures by providing a strong and sturdy framework. 3. Locomotion/movements. 4. Mineral storage 5. Hematopoiesis 6. Heat production
ANATOMY OF THE SKELETAL SYSTEM a. Axial Skeleton There are 80 axial skeletons -skull -vertebras -ribs b. Appendicular Skeleton There are 126 appendicular skeletons -limbs -shoulders -hips APPENDICULAR SKELETON AXIAL SKELETON
Structural Types of Bones Cortical (compact) bone With a dense outer layer — the cortex.
This structure resists bending.
2. CANCELLOUS (SPONGY OR TRABECULAR) BONE
Present in the interior ofmature bones. This structure resists compression
TYPES OF BONES 1. LONG BONES a. Have greater length than width. b. Consists of Central Shaft (diaphysis), two Ends (epiphysis)and the Epiphyseal Plate c. Somewhat curved to support the body. PURPOSE: Weight Bearing e.g. femur, tibia, fibula, humerus, ulna, radius, phalanges
2. SHORT BONES a. Cubed-shaped, they are nearly equal in length and width. b. Cancellous bone covered by a thin layer of compact bone. e.g. carpals, tarsals, ankle
3. FLAT BONES a. Thin bones composed of two compact bones enclosing a layer of bone tissue. b. Important site for hematopoiesis. c. Frequently provide vital organ protection. e.g. Sternum, Scapulae, Skull, Ribs 2 TYPES OF BONE MARROW Red Bone Marrow- In the flat bones
Produces RBC, Platelets & some WBC
b. Yellow Bone Marrow- Made up of adipose tissues & usually located in the medullary cavity of long bones.
storehouse of fats
BONE MARROW ALL BONE MARROWS ARE RED FROM BIRTH UNTIL THE CHILD IS 7 YRS. OLD
4. IRREGULAR BONES a. Complex shapes and sizes. e.g. Vertebrae, ear ossicles, facial bone, pelvis
THREE BASIC CELL TYPES: 1. OSTEOBLASTS 2. OSTEOCYTES 3. OSTEOCLASTS
1. OSTEOBLASTS -Bone-building cells -Secretes Collagen Fibers & ground substances (glycoproteins & proteoglycans) for the formation of the matrix -Initiates CALCIFICATION in response to estrogen MATRIX – PROVIDES A FRAMEWORK IN WHICH INORGANIC MINERAL SALTS ARE DEPOSITED OSSIFICATION
MAIN cells in bone tissue
help maintain bone tissue's daily metabolism by exchange of nutrients and waste with the blood
3. OSTEOCLASTS Bone-crusher Huge cells that releases powerful lysosomal enzymes & acids that digest the bone matrix. Resorption
BONE MAINTENANCE:Regulating factors that determine the balance between bone formation & bone resorption. LOCAL STRESS 2. VITAMIN D (CALCITRIOL) 3. HORMONAL CONTROL –
CALCITONIN & PARATHYROID HORMONE
4. BLOOD SUPPLY 5. VITAMIN C *Promotes synthesis of COLLAGEN 6. CALCIUM and PHOSPHORUS *gives the bone its Compressional strength
JOINTS (ARTICULATION)– the junction of two or more bones Characteristics: 1. Joints allow the movement between bones. 2. Joint surfaces are covered with cartilage. -Prevent direct contact between two ends of the bone. -Allow gliding or sliding motion. -Absorbs shock. 3. Joints are enclosed in a capsule. 4. Joints contain a cavity filled with synovial fluid. 5.LIGAMENTS 6.TENDONS
LIGAMENTS HOLDS TWO BONES TOGETHER TENDONS HOLDS BONES AND MUSCLES TOGETHER
Classifications 1. SYNARTHROSIS – immovable joints (ex. SKULL) 2. AMPHIARTHROSIS – partially movable joint (ex. TRACHEA) 3. DIARTHROSIS – freely movable joints; the MOST COMMON TYPE OF JOINTS
TYPES OF DIARTHROSIS JOINTS a. Ball and Socket joints Movement in almost all directionermit full freedom of movement. b. Hinge joints – unidirectional ; allows flexion extension of an appendage - permit unidirectional bend c. Pivot joints – allows twisting around each otherermits rotation. d. Gliding joints – allows bone to slide past each other e. Saddle joint – allows all movement except full rotation
II. ANATOMY OF MUSCULAR SYSTEM
II. ANATOMY OF MUSCULAR SYSTEM Characteristics: 1. Muscles are made up of bundles of muscle fibers. 2. Muscles provide the force to move bone. 3. Muscles assist in maintaining posture. 4. Assists with heat production.
MUSCLES ARE MADE UP OF FIBERS --- FORMED FROM THE FUSION OF MYOBLASTS FIBERS --- ARE COMPOSED OF FILAMENTS --- MYOSIN & ACTIN --- SARCOMERES (BASIC FUNCTIONAL UNIT OF THE MUSCLE) MUSCLE CONTRACTION – INTERACTION BETWEEN MYOSIN AND ACTIN
*Muscles are covered by connective tissues known asfascia. SKELETAL MUSCLE CONTRACTION
Effector nerve cell
Myosin + Actin
SMOOTH SKELETAL CARDIAC
Types of Muscle Contraction 1. ISOMETRIC CONTRACTION -Muscles contract but does not shorten. There is no joint movement. e.g. Quadriceps and Gluteal Setting Exercises, Kegel’s Exercise, Valsalvamaneuver. 2. ISOTONIC CONTRACTION -Involves change in muscle length and no change in tension. e.g. Flexion of forearm, Sit-ups
Description Type The patient moves own body part or limbs. a. ACTIVE The nurse moves the patient’s body part without any assistance from the patient. b. PASSIVE RANGE OF MOTION EXERCISES
Description Type The patient moves a weak body part as far as possible using his stronger arm or leg. c. ACTIVE – ASSISTIVE Contraction of muscle against an opposing force. d. ACTIVE – RESISTIVE RANGE OF MOTION EXERCISES cont’d
TYPES OF MOTION: 1.FLEXION -Bending at a joint; decreasing the angle between the joints. 2. EXTENSION -Straightening at a joint; increasing the angle between the joints. 3. ABDUCTION -Movement of a body part away from the midline. 4. ADDUCTION -Movement of a body part toward the midline.
5. ROTATION -Turning around a specific axis. *Internal – moving limb inward *External – Moving limb outward 6. CIRCUMDUCTION -The circular movement of a limb such that the distal end of the limb delineates an arc. 7. SUPINATION -Turning upward of palm 8. PRONATION -Turning downward of palm 9. INVERSION -Sole is pointed inward 10. EVERSION -Sole is pointed outward
11. PROTRACTION -Pushing forward 12. RETRACTION -Pulling backward 13. PLANTAR FLEXION -Pointing toes downward away from the body 14. DORSIFLEXION -Pointing toes upward toward the body
III. TRAUMATIC INJURIES STRAIN SPRAIN CARPAL TUNNEL SYNDROME FRACTURES HIP FRACTURE
1. STRAIN: aka PULLED MUSCLES – EXCESSIVE STRETCHING OF A MUSCLE OR TENDON.
2. SPRAIN – INJURY TO THE LIGAMENTS SURROUNDING A JOINT
Sudden TWISTING or WRENCHING motion
Painful joint movement
Nursing Management for Strain and Sprain:
GOAL: To control inflammation a. RICE R – Rest WHY? To prevent further damage.
I – Ice or Cold Application WHY? To prevent edema. WHEN? Best applied for the first 24 – 48 hours. *Apply only for 20 – 30 minutes. Why not more than 30 min.? 1. To prevent further damage that can lead to tissue ischemia. 2. To prevent reflex vasodilation. *Followed by HEAT Application (15-30 mins, 4x/day)
-Measures electrical potential associated with skeletal muscle contractions. Informed consent Instruct the client that needle insertion is uncomfortable. Instruct the client not to take any stimulants or sedatives for 24 hours before the procedure. Inform the client that slight bruising may occur at the needle insertion sites.
NURSING MANAGEMENT GOAL no. 1: To prevent further compression of the nerves. 1. REST HANDS. 2. Avoid excessive use of involved hand. 3. Instruct patient not to sleep over the involved hand. 4. Administer medication as ordered. GOAL no. 2: To prevent injury. 1. Instruct pt to wear gloves.
MEDICAL MANAGEMENT 1. Analgesics and Antiinflammatory Agents ASA (acetylsalicylic acid/Aspirin) NSAIDs 2. Corticosteroids SURGICAL MANAGEMENT Carpal Tunnel Release -cutting and releasing of the transverse ligament.
You are educating a group of student nurses about bones. You asked them to give an example of a short bone. The student nurses are correct if they answered which of the following? The ankle The bones of the arms and legs The breast bone The shoulder blade
The bone marrow has two types. The difference between the red bone marrow and yellow bone marrow is that: The yellow bone marrow is for fat storage and can be found in the intramedullary cavity of the sternum and scapula while the red bone marrow is for blood production and can be found inside the femur. The red bone marrow contains hematopoietic tissues that can be found in thin compact bones like the breastbone while the yellow bone marrow is for lipid storage and can be found in lengthy bones. During infancy, only yellow bone marrows are present . Only after 7 years do red bone marrows form. Red bone marrows and yellow bone marrows only differ in color. Function-wise, they’re the same.
In human anatomy, osteoblasts are immature osteocytes that: Maintains the bone tissue’s daily metabolism requirement. Are the main cells found inside the bones and are in charge of bone formation. Destroy the bone matrix and are key tools for bone remodeling Are immature osteocytes that are responsible for starting calcification by producing and releasing collagen fibers.
Doodaw said that he just injured his ligament. As a nurse, you know that ligaments are: Tough bands of slightly elastic connective tissues that connects two bones. Bands of connective tissues that connects a bone to a muscle Bands of connective tissue that connects two muscles Flexible connective tissues that encapsulates a bone.
What is known as the functional unit of the muscle? Myosin Actin Sarcomere Z-band
Mr. Alejandro suffered from stroke 6 months ago and is unable to move the left part of his body. The doctor order for passive ROM exercises to strengthen the weak part of Mr. Alejandro’s body. As a nurse, you are aware that in passive ROM exercises, you are going to: Let the patient lift weights on both arms to avoid atrophy of the muscles. Instruct the patient to move and rotate his left shoulder using his right shoulder to exercise the affected extremity. Circumduct his arms around the shoulder joint Ask the patient to attempt pushing on a wall or a hard surface.
Pronation is to: Turn the palm upward Turn the palm downward To move forward the jaw To move the jaw backward
Papa P, a popular matinee idol, came to the ER one day with a sprain of the left foot. You remember that sprain is an injury in the: Bones Ligaments Tendons Fascia
Papa P. insisted that he had to go back to the set of his movie to finish his scene. Using your knowledge in managing sprains, you should advise Papa P. that: He needs to remain in hospital premises for cast application He is advised to rest his injured foot to avoid further damaging the area Illegal detention is strictly avoided in the hospital so he is free to go whenever he wants Sprain is just a simple injury and he can return to finish his movie provided he drinks his analgesic as ordered.
Diether, another popular movie heartthrob, came to your ER one day and complained of numbing of the fingers. He was diagnosed with Carpal Tunnel syndrome of the right hand 6 months ago. What statement made by Diether indicates that he was further aggravating his condition? I have stopped gardening eversince I had this condition. I feel better everytime I sleep over my right hand. To avoid burning myself, I use mittens everytime I cook. I know that any type of compression can cause me more injury.
6. FRACTURES -is a break in the continuity of a bone. - occurs when the bone is subjected to stress greater than it can absorb. - Mechanical overload to the bone.
Types of Fracture a. Complete -The entire circumference of the bone is impaired. b. Incomplete -Only partial circumference of the bone is impaired. c. Transverse -The line of break is across the bone. d. Oblique -The line of break goes diagonal along the bone. e. Spiral -The line of break goes around the bone.
f. Greenstick -One side of the bone is impaired, the other side is bent. g. Comminuted -Bone parts are splintered into two or more small pieces. h. Impacted -One bone end enters the intramedullary space of another bone end. i. Closed or Simple -There is no break in the skin. j. Open or Compound -Bone fracture caused a break in the skin.
OPEN FRACTURES GRADE I – clean wound less than 1 cm long GRADE II – larger wound WITHOUT extensive soft tissue damage GRADE III – highly CONTAMINATED
Cause: Traumatic direct blows crushing forces sudden twisting motions
S/Sx: Pain – acts as SPLINT Tenderness Loss of motion – loss of bone integrity Edema Crepitus – rubbing of bone fragments Ecchymosis Shortening of the limb – r/t contraction of muscles attached above and below the site of fx (1-2 inches) Obvious deformity - r/t swelling
DIAGNOSTIC TESTS: Radiography /X-RAY - Most widely used noninvasive musculoskeletal diagnostic procedure. 2. CT SCAN - Multiple X-rays create a three-dimensional view of a cross-section of a body.
Emergency Management: GOAL: 1. Assess injury. Never attempt to reduce the fracture if bone is protruding. 2. Apply direct pressure. 3. Keep client warm. 4. Immobilize the fracture. 5. Cover open Fx with a sterile dressing. 6. Assess NVS IMMOBILIZE
ASSESS NEUROVASCULAR STATUS 6P’s P P P P P P Pain Pallor Pulse Paresthesia Paralysis Polar / Poikilothermia
Nursing Interventions: 1. Maintain alignment & immobilization of the affected extremity. 2. Elevate the Fx site above the heart level. 3. NVS assessment. 4. Consume appropriate diet for bone healing. CHON Vit C Vit D Ca
5. Fluids to prevent constipation, renal calculi, UTI, & DVT. 6. Give analgesics as prescribed. 7. Report uncontrolled pain. 8. Observe for S/Sx of Fat Embolism Syndrome. 9. Teach about cast care, traction, and crutch walking if needed. 10.Give tetanus prophylaxis as ordered for open fractures.
OPEN Fx Irrigation and Debridement -devitalized bone fragments are removed to prevent occurrence of osteomyelitis and gangrene. -wound tissue is cultured for any infxn -primary wound closure is delayed until determined that infxn is not present. (5-7 days) -monitor V/S
Medical Management: A. REDUCTION- restoration of fracture fragments to anatomical alignment. Closed reduction –through manual manipulation and external manual traction followed by application of cast. *X-ray after procedure Open reduction –surgical approach to reduce fracture fragments with fixation.
OPEN REDUCTION WITH INTERNAL FIXATION (ORIF) OPEN REDUCTION WITH EXTERNAL FIXATION (OREF)
Care for Patients with External Fixators Cover pins. Provide Pin site care. Monitor for signs of complications.
COMPLICATION of EXFIX Infection Nursing Management Assess for redness, tenderness, pain, swelling and loosening of pins. Prevent crust formation. Notify the physician for signs of infection.
OSTEOMYELITIS -Most common form of bone infection. CA: Staphylococcus aureus Signs & Symptoms:
Swelling at the site
OSTEOMYELITIS THREE MODES OF INFECTION EXTENSION OF SOFT TISSUE INFECTION DIRECT BONE CONTAMINATION FROM BONE SURGERY, OPEN FX HEMATOGENOUS SPREAD
Diagnostic Tests: X ray MRI
Management: 1. IV Antibiotics for 3-6 wks. (Penicillin) 2. Immobilize affected part of the patient by casting or splinting 3. Wound debridement. 4. Sequestrectomy
B. CAST -rigid external immobilizing device that is molded to the contours of the body. Plaster Cast -traditional cast calcined gypsum to calcium sulfate -initially emits heat -cools in 15 minutes -dries in 24-72 hours - maybe softened by warm water
Proper handling of a damp cast includes of the following except: A CAST MUST NEVER REST ON ANY HARD SURFACE OR SHARP EDGES THE PALMS OF THE HANDS MUST BE USED IN HANDLING A DAMP CAST HANDLING IT WITH THE BALLS OF THE FINGERS TO AVOID ACCIDENTAL DROPPING
You are a nurse caring for a patient applied with a cast. In order to dry the cast, you are going to: COVER THE CAST WITH STERILE CLOTHING TO FACILITATE FAST DRYING EXPOSE THE CAST IN CIRCULATING AIR LET THE PATIENT STAY IN A HOT ROOM TO FACILITATE EVAPORATION OF WATER DROPLETS IN THE CAST
DRY WET Appearance Percussion Odor Texture DRY CAST VS. WET CAST Gray White & Shiny Dull Resonant Musty Odorless Firm, hard & rough Damp to touch
Fiberglass -synthetic cast - lighter in weight, stronger and water resistant. -it has small pores to allow air to enter -water resistant - DOES NOT soften when wet -dries 20-30 minutes - dried by HAIR DRIER – cool setting
Purpose 1. Immobilize a reduced Fx. 2. To maintain body alignment. prevent deformities.
TYPES OF CASTS 1. short arm cast -Extends from below the elbow to the palmar crease, secured around the base of the thumb 2. Long Arm Cast - Extends from the upper level of the axillary fold to the proximal palmar crease. 3. short leg cast - Extends from below the knee to the base of the toes.
4. Long Leg Cast -Extends from the junction of the upper and middle third of the thigh to the base of the toes. 5. Walking Cast - A short or long leg cast reinforced for strength. 6. Body Cast -Encircles the trunk.
7. Spica Cast Shoulder Spica Cast - A body jacket that encloses the trunk and the shoulder and the elbow. Hip Spica Cast -Encloses the trunk and a lower extremity.
Nursing Management 1. Carry with the palms of the hand when WET. 2. Elevate with pillow. 3. Expose to dry environment. 4. Observe HOT SPOTS and musty odor. 5. Maintain skin integrity by petalling the edges. 6. Perform NVS meticulously and regularly. 7. Do not scratch the skin under the cast by inserting objects inside the cast. 8. Keep clean and dry. Regularly inspect the cast.
Nursing Management Check neurovascular status. Assess the client’s toes or fingers for: Change in color Coolness Swelling Movement
Nursing Management Post Removal of Cast Assess and check neurovascular status Instruct patient to expect slight discomfort or stiffness of the extremity Using gentle strokes or motion, clean the extremity by scrubbing. Elevate the leg to prevent swelling Full ROM exercises must be done as often as tolerated to regain muscle strength.
1. A young girl has a closed reduction of a fractured ulna and has a synthetic cast. She asks if she can take a shower. The nurse should respond: It may take a long time for the cast padding to dry. It is unsafe for you to travel alone It can lead to serious infection Warm water could soften the cast
An xray film of a client’s arm reveals a comminuted fracture of the left radial bone. The nurse understands that with a comminuted fracture: There is a break in the skin and the bone is protruding Splintering has occurred on one side and bending on the other The bone has broken into several fragments but the skin is intact The bone is broken into two parts, and the skin, may or may not be broken.
A client with osteomyelitis of the leg is to have a debridement of the infected bone. When planning post op care, the nurse knows that: Frequent ROM exercises will be needed Septicemia is a common post op complication The client’s leg will be immobilized in a cast or splint The client will be out of bed after the first day.
At the scene of an accident, the nurse can minimize the immediate life threatening systemic complication of injury to the long bones of the injured person by: Elevating the affected limb Immobilizing the affected extremity Handling and transporting gently Encouraging deep breathing
A cast placed on a client’s leg has dried. If the drying process were completed, the nurse would observe the cast to be: Dull and gray in appearance Shiny and white in appearance Cool to the touch and gray in appearance Warm to touch and white in appearance
A young male client has had a cast placed on his right leg. While caring for the client, the nurse identifies a “hot spot” or area in the cast that feels warm. The nurse reports the findings to the physician because the data indicates possible: Poor circulation Pressure from the cast Uneven cast drying Infection
After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirmed that his leg is fractured. Following an application of a leg cast, the nurse will check first the clients toes for: Increase in temperature Change in color Edema Movement
C. TRACTION Purpose: 1. Muscle spasm control 2. Immobilize Fx’s 3. Pain relief 4. Correct deformities
TRACTION --- THE FORCE THAT PULLS A BODY PART COUNTERTRACTION --- FORCE ACTING IN THE OPPOSITE DIRECTION Body weight Usually, the patient’s and supply the needed countertraction. Bed position adjustments
Types 1. Skin Traction -pulling force is applied directly to the skin and indirectly to the bones to maintain alignment. -Generally 5-10 lbs (2 to 4kg)of weight is used for the pulling force. *Pelvic Traction = 10-20lbs *Cervical Traction = 15 lbs
BUCK’S EXTENSION TRACTION Indication: - Simplest form of traction. Counter Traction: Shock block at the foot of the bed; slightly elevate foot of the bed COMMON site of PU Femur fracture Heel
APPLICATION OF BUCK’S EXTENSION TRACTION
Before the traction is applied, the nurse will make sure that the SKIN is:
--- free from ABRASIONS AND CIRCULATORY DISTURBANCES
--- clean and dry before the traction tape is applied.
To apply, one nurse elevates and supports the extremity UNDER THE HEEL while another nurse places the foam boot.
APPLICATION OF BUCK’S EXTENSION TRACTION
Next, the nurse secures the velcro straps around the leg.
The nurse passes the rope over a pulley then attaches the weight.
Post application, the nurse assesses circulation and sensation especially of the region distal to the fracture within 15 – 30 minutes.
BUCK’S EXTENSION TRACTION
SKIN TRACTION COMPLICATIONS SKIN BREAKDOWN --- results from IRRITATION Greatest risk? OLDER ADULTS Manage by: Massaging the patient’s back and buttocks frequently (q2h) NERVE PRESSURE --- pressure on the peroneal nerves. Possible result? FOOT DROP Manage by: Placing a footplate on the affected side CIRCULATORY IMPAIRMENT
b. RUSSEL’S TRACTION Indication: - Knee is suspended in a KNEE SLING. - Hip is flexed to 20° from the mattress. -COMMON site of PU Femur/ Hip joint fracture Popliteal
c. BRYANT’S TRACTION Indication: -children w/ CONGENITAL HIP DISLOCATION -for children BELOW 2-3 years -for children weighing LESS THAN 30-40 lbs N/R: -Buttocks should not touch the mattress. -both legs raised @ 90º angle -assess neurovascular status Pressure Ulcer: HEEL
d. CERVICAL TRACTION Indication: Example: Cervical Head Halter, Counter Traction: COMMON site of PU : Cervical Spine Fracture Elevate HOB 30-40° Chin and Ears
e. PELVIC TRACTION Indication: Pelvic bone fracture - make use of a pelvic halter. P.U.: Hips/ Upper end of femur POSITION: Supine
2. SKELETAL TRACTION -Weights are attached directly to the bone DISTAL to the FRACTURE -Make use of pins, screws, wires or tongs -Weight limit: 15 – 30 lbs
a. Balanced Suspension Traction - Makes use of Thomas Splint with Pearson Attachment. -Hips are flexed 30° from the matress. PIN SITE: DISTAL END OF THE FEMUR -Pearson Attachment: -Thomas Splint: Main Advantage: Allows patient movement without disturbing the line of traction. CALF THIGHS
NURSING MANAGEMENT: PRINCIPLES OF EFFECTIVE TRACTION
Must be continuous to be effective
Weights are NOT removed
Observe good body alignment
Ropes must be unobstructed
Weights must hang freely
Assess neurovascular status and checking toenails for circulatory disturbances
Knots should not touch the pulley Never tighten any loose screws or pins Don’t massage painful calf Increase FIBER in the diet Heparin is given to prevent thrombophlebitis Social Interaction
COMPLICATIONS OF FRACTURE 1. Fat Embolism Syndrome Occurs most frequently in young adults (20-30 years of age and elderly adults. ONSET --- 24 – 72 HOURS AFTER INJURY
PATHOPHYSIOLOGY 1. Fat Embolism Syndrome
FRACTURE - STRESS -- RELEASE OF CATECHOLAMINES - MOBILIZE FATTY ACIDS - DEVELOPMENT OF FATTY GLOBULES IN THE BLOODSTREAM.
FRACTURE FRAGMENTS OF BONE MARROW CAN ESCAPE MEDULLARY CAVITY – TRAVEL TO BLOODSTREAM
COMPLICATIONS OF FRACTURE 1. Fat Embolism Syndrome Signs & Symptoms:
Respiratory: ARDS r/t pulmonary congestion
S/Sx: TACHYPNEA, DYSPNEA, CHEST PAIN, HYPOXIA
Cerebral Disturbances: r/t cerebral occlusion
S/Sx: MENTAL STATUS CHANGES (HEADACHE, MILD AGITATION, CONFUSION TO DELIRIUM, COMA
S/Sx: PETECHIAE IN THE BUCCAL MEMBRANES , CONJUNCTIVAL SAC OR OVER THE CHEST
Adequate support of fractured bones during positioning and turning
Support respiratory function
(place in Fowler’s position) Oxygen administration (High concentration) Corticosteroid therapy Report to the physician
2. COMPARTMENT SYMDROME IS A COMPLICATION THAT DEVELOPS WHEN TISSUE PERFUSION IS LESS THAN THAT REQUIRED FOR TISSUE VIABILITY.
Nursing Interventions: Notify the physician immediately Elevation of the extremity Release constrictive devices Fasciotomy - surgical decompression with excision of the fascia that covers and separates muscles
left open for 3-5 days
ROM exercises q 4-6 hours
closed when tissue perfusion is restored and swelling has resolved
A client in skeletal traction complains of unrelieved pain at rest and paresthesia in the affected extremity. The assessment by the nurse reveals diminished pulse, pallor, and increased pain on passive motion. What must the nurse do first? A. Administer oxygen B. Encourage deep-breathing and coughing exercises C. Administer pain medication as ordered D. Notify the physician immediately
A 7-year-old boy is in the ER with a greenstick fracture of the ulna. How will the nurse explain the fracture to the parents? The bone is broken across the growth plate. There is a splintering of the bone on one side. There is a separation of the bone at the fracture site. The bone is broken into several fragments.
A client has a fractured hip and is currently in Buck’s extension traction before surgery. How is the counter traction in Buck’s extension traction achieved? Applying a 10-pound counterweight at the knee. B. Placing shock blocks under the head of the bed. C. Elevating the knee gatch and elevating the head of the bed about 30. D. Elevating the foot of the bed frame and allowing the weights to hang freely.
A client in traction slides down in the bed so that the feet touch the foot of the bed. What should the nurse do to ensure that the pull of traction remains uninterrupted? A. Release the weights, pull the client up in bed, and then reapply weights. B. Ask the physician for a change in the amount of weight ordered. C. Move the client up in bed without releasing the pull of traction on the extremity. D. Elevate the client's feet on a pillow.
The nurse is caring for a client with skeletal traction. It is most important that the nurse monitor which of the following? A. The pin site for unusual redness, swelling, purulent drainage, and foul odor. B. The distance between the client's hip and the traction. C. The number of times the client exercises the affected limb. D. How the client is coping with immobilization.
A client is being treated with Buck’s extension traction. What is an important nursing intervention for this client? Remove the traction boot every 6 hours to provide skin care. Check and clean the pin sites at least three times daily. Check the area around the hip where the traction is applied. Verify that the weight is of the correct amount as ordered and are hanging freely.
A client is confined to bed with a fracture of the left femur. He begins receiving subcutaneous heparin injections. What is the purpose of this medication? A. Prevent thrombophlebitis and pulmonary emboli associated with immobility. B. Promote vascular perfusion by preventing formation of microemboli in the left leg. C. Prevent venous stasis that promotes vascular complications associated with immobility. D. Decrease the incidence of fat emboli associated with long bone fractures.
What is important assessment information to obtain from a client who is being admitted with a tentative diagnosis of a fractured hip? Circulation and sensation distal to the fracture. Amount of swelling around the fracture site. Status of the range of motion in the extremity. Amount of pain that the fracture is causing.
The nursing care plan for a 2-month-old infant in a left hip spica cast includes what nursing measures?
Palpate the left brachial artery and compare it with the right. Check cast for tightness by inserting fingers between skin and cast. Blanch the skin of areas proximal to the casted left leg. Maintain constant traction on the affected left leg.
Nursing care for the client in Russell traction includes what measures? Maintaining client in semi-Fowler’s position to promote deep breathing. Checking the distal circulation of the affected leg. Turning the client every 2 hours to the unaffected side. Allowing the client to sit in a chair at the bedside.
A client is admitted with a fractured right femur. The nurse understands that an initial danger to the client because of this type of fracture is: Fat embolus Septicemia Vascular damage Compartmental syndrome
The nurse understands the following about teaching proper technique of isometric exercise. Isometrics is exercising both my arms and legs simultaneously. Isometrics is running in place for 5 minutes, then taking a pulse check. Isometrics is applying pressure with arms and legs to create resistance against stable objects. Isometrics is moving arms and legs through full range of motion.
A client is in Buck's extension traction. The client asks the nurse to help reposition him toward the head of the bed. The nurse should remember that while repositioning the client, she should:
Place the weights on the corners of the bed to allow the nurse to move the client. Add weight to the hanging weight to keep the client's position in balance. Release the traction tension and weight while moving the client. Use a draw sheet with one other person and carefully slide the client up the bed.
7. HIP FRACTURE Most common cause of traumatic death among elderly. Risk Factors: -Age -Chronic medical condition -Sex -Heredity -Nutrition -Smoking -Alcohol -Medications
types of hip fracture 1. INTRACAPSULAR Most common type: FEMORAL NECK FRACTURE -Treated as emergency situation
2. EXTRACAPSULAR Most common type: INTERTROCHANTERIC FX Trochanteric regions have excellent blood supply and heal readily, however, soft tissue damage can still occur.
SIGNS & SYMPTOMS 1.Affected leg is adducted, externally rotated and the limb is shortened. 2. Complaints of pain in the GROIN or in the HIP. 3. Inability to move affected leg. 4. Stiffness, bruising and swelling in and around your hip area.
SURGICAL MANAGEMENT: 1. ORIF – Most Common 2. HIP REPLACEMENT
Partial Hip Replacement
Total Hip Replacement
NURSING MANAGEMENT GOAL of NSG Measure: Prevention of Hip Dislocation Positioning: -Maintain hip abduction -NO HIP FLEXION beyond 90° -Elevate HOB 30°- 45° Turning: - Turn patient to the UNAFFECTED SIDE
Guidelines 24Hours Post Hip Replacement a. Keep the knees apart at all times. b. Put a pillow between the legs. c. Keep extended and abducted. d. Never cross the leg when seated. e. Avoid bending forward. f. Use a raised toilet seat. g. Do not flex the hip to put on clothing. h. Flat on bed except on eating. i. Advise patient to report “POPPING” sensation in the hip. j. Dorsiflexion and extension of the foot to prevent thrombosis k. Trochanter rolls to prevent external rotation. l. Avoid prolong sitting and standing position.
m. Monitor the wound for infection & hemorrhage. n. Monitor circulation & sensation of the affected side. o. Maintain the use of anti-embolism stockings. p. Maintain the Hemovac or Jackson-Pratt drain if in place. Monitor & record output of drainage: *expected drainage 48 H post-op: 30 mL/8H
WHEN TO AMBULATE ??? FIRST Post Op DAY: - patient should be ABLE to TRANSFER from bed to the bed side chair. SECOND Post Op DAY: - ambulation at a FUNCTIONAL DISTANCE. - NOTE: Pt can exert PARTIAL WEIGHT BEARINGon affected leg for 2 MONTHS.
THIRD Post Op DAY:
- patient may be discharged.
The nurse is preparing a client who sustained a hip fracture. The nurse should teach the client to avoid which of the following groups of activities to prevent dislocation of the hip? A. Crossing legs, bending at hips, and sitting on low toilet seats B. Taking leisurely walks, low chair seats, and bending at hips C. Using reachers for applying shoes and socks, and sitting in chairs with arms D. All exercises, bedrest, and using raised toilet seats
Which of the following statements by the client who has recently had a total hip replacement indicates that he does not understand the mobility limitations?
“I should not bend down to put on shoes or socks.” “It is OK to cross my legs if I am sitting in a chair.” ”I should put a pillow between my legs when lying on my side.” “I should not sit in low chairs or on toilet seats that are low.”
PURPOSES: 1. To relieve symptoms. 2. To improve function. 3. To save or improve the patient’s quality of life.
TYPES OF AMPUTATION 1. Open (Guillotine) -one in which the entire cross-section is left open (flapless) for dressing. Indication: INFECTION 2. Closed (Myoplastic / Flap) -one in which flaps are made from skin and subcutaneous tissue and sutured over the bone end of the stump.
Figure A: After the surgeon creates two flaps of skin and tissue, the muscle is cut and the main artery and veins of the femur bone are exposed.
Figure B: The surgeon severs the main artery and veins.
Figure C: The surgeon saws through the exposed femur bone.
Figure D: The muscles are closed and sutured over the bone. The remaining skin flaps are then sutured together, creating a stump.
NURSING MANAGEMENT 1. Relieving pain: Pain r/t soft tissue injury Administer Narcotic Drugs as ORDERED Meperidine (Demerol) Morphine sulfate
2. Minimizing Phantom Limb Pain NSG MGT: - Divert the attention of the patient. - Massage the stump using gentle strokes. - Pain medications as prescribed 3. Elevate stump for the first 24 hours after surgery then stump is placed flat.
4. Promote wound healing - Provide SKIN CARE: -Massage the stump 5. Look for bleeding or oozing
4. PROMOTE PHYSICAL INDEPENDENCE - Perform exercises to the trunk and upper extremities - Plan short term and long term goals SHORT TERM –
identify skills, passion and interests,
participate in therapy
LONG TERM – lifestyle change
5. PREPARE STUMP FOR PROSTHESIS - Residual limb must be shaped into a CONICAL FORM. - Maintain application of an Ace wrap or elastic stump shrinker - Remove and rewrap every 3-4 times daily
STUMP CARE— Daily washing; Wash with mild soap and dry. Apply NOTHING to the stump after it is bathed. — Assess for blisters, adhesions (use mirror to examine all sides — Apply elastic bandage — Do not elevate beyond 24 hours
- move your stump frequently to help stimulate circulation
you will begin physical therapy within 48 hours after surgery.
— Range of Motion Exercises — Psychological support
Don’ts on the stump — Hang stump over the bed — Sit in wheelchair with stump flexed — Place pillow under hip or knee — Place pillow between thighs — Rest AK stump on crutch handle — Use of irritating substances such as lotions, alcohol, powders
6. MONITOR AND MANAGE POTENTIAL COMPLICATIONS HEMORRHAGE N/R: -prepare at bed side a TOURNIQUET -Mark bleeding and drainage on the dressing if it occurs. -Immediately notify the physician for any signs of bleeding.
CONTRACTURES GOAL: Prevent FLEXION CONTRACTURES of the lower extremities CONTRACTURES to be AVOIDED: BKA: Prevent KNEE FLEXION CONTRACTURE
DO NOT hang the residual limb over the EDGE of the bed.
Do NOT put pillows below the KNEE
AKA: Prevent HIP FLEXION CONTRACTURE
PRONE *Patient must be assisted to the proneposition every 3-4 hours for 20-30 minutes
MEASURES to AVOID HIP FLEXION -Don’t put pillow under the thigh -Avoid sitting for long periods -LIMB should be in NEUTRAL alignment
ASSISTIVE DEVICES FOR WALKING PURPOSE: -Widens base of support. - Reduce weight bearing on the affected leg. - Provide mobility to the patient.
A. CRUTCHES IMPORTANT MUSCLES Shoulder Depressor or Latissimusdorsi - needed first to advance the body forward. -needed to lift the pelvis off the ground.
b. elbow extensors/ triceps
needed to prevent
buckling of the elbow joint. c. finger flexors -needed to grasp the hand grip.
Measurement: Let the patient lie down From the anterior fold of the axilla to the sole of the foot then ADD 5CM (2 INCHES)
GOING UP & GOING DOWN THE STAIRS “Good goes to Heaven, Bad goes to hell”
GUIDELINES FOR THE USE OF CRUTCHES: 1. Look forward. 2. Weight must be on the hand grip. 3. Two to three finger breadths between the axilla and the axillary bar. 4. Elbows are slightlyflexed 20-30 degrees. 5. Teach patient how to assume a tripod gait by advancing the crutches 6 inches in front. (weight must be on the palms) 6. Tips should be fitted with rubber soles. 7. Stop ambulation if there is numbness and tingling of the hands or arms.
30° Prevents Crutch Palsy 6 inches
Straight and quad cane.
Stand at affected side of client when ambulating.
Flex elbow 15-30 degrees angle.
Tip of cane should be 15 cm (4-6 inches) lateral to the base of the fifth toe.
Hold cane inunaffectedside.
Handles should be at the level of client’s greater trochanter.
Advance cane and affected leg together.
Lean on cane when moving good leg.
Instruct the client to inspect the rubber tips regularly.
To go up and down the stairs: a. Step up on good extremity. b. Place cane and affected extremity on step. Reverse when going down.
SEQUENCE: 3-STEP a. Advance the cane. b. Advance the affected leg c. Advance UNAFFECTED leg. 2-STEP a. Advance the cane TOGETHER with the affected leg b. Followed by unaffected leg.
C. WALKER 1. Elbows flexed 20-30 degrees angle. 2. Lift and move walker forward 8-12 inches. 3. With partial or non-weight bearing leg, put weight on wrists and arms and step forward with affected leg, supporting self on arms and follow with good leg. 4. Stand behind patient when ambulating. 5. Patient should wear sturdy shoes.
A diabetic client with a right below-the-knee amputation tells the nurse that he feels pain in the amputated leg, even though the leg is gone. The nurse’s response is based on what information? “The condition is called phantom pain, and it is experienced by most amputees.” “Phantom pain is pain the client feels, but it is actually a response to his denial.” The nurse cannot adequately assess the pain; therefore medication cannot be given. The nerve endings have not adjusted to the loss of the extremity; offer him pain medication.
The nursing care plan for a postoperative client who has had a right leg amputation includes what measures to decrease edema? Apply ice packs to the stump for 72 hours. B. Elevate the stump by raising the foot of the bed for 24 hours. C. Wrap the stump with Ace bandages from proximal to distal area. D. Administer anti-inflammatory medications as ordered.
A patient has had a right hip replacement surgery. Which of the following technique when turning in bed should be carried out? Bring his knees to his chest before turning Keep an abductor wedge between the knees Maintain flexion of the affected hips Move one affected leg with one unaffected foot.
A 12 year old girl has a long leg cast applied to her left leg. She is being instructed in crutch walking with no weight bearing on her left leg. Which of the following observations indicates that the girl needs further teaching? She is using a 3 point gait Her elbows are slightly flexed She places the crutches approximately 6-8 inches in front of her with each step She is supporting her weight on the axillary bars and hand pieces of the crutches.
In the immediate post operative period following a hip replacement, the patient should be assisted to perform which of the following exercises on the affected extremity? Leg raising Dorsiflexion and extension of the foot Flexion and extension of the knee Quadriceps setting
A nurse is assessing a patient who is at risk for developing compartment syndrome. To which of the following assessment would the nurse give priority? Apical pulse Pupillary responses Neurovascular status Deep Tendon Reflexes
To promote skin integrity on a patient who is in Russell’s traction, which of the following measures should be included in the plan of care? Having the patient lie on the right side for 20 minutes ever 2-3 hours Placing pillows under the patient’s sacral and scapular areas Massaging the patient’s back and buttocks frequently Applying an antiseptic lotion to the patient’s bony prominences after bathing.
Which of the following nursing measures is appropriate when caring for a patient who has undergone a right above-the-knee amputation? Ambulating the patient in the hallway with crutches Placing the patient in a chair during waking hours Keeping the patient’s stump elevated on a pillow Encouraging the patient to lie prone in bed.
A six year old child who has sustained a fracture, has a long leg cast applied on the left leg. Which of the following statements, if made by the client’s father would indicate the need for further teaching? I will call the clinic if my child complains of sudden pain in his foot I will check the skin temperature of my child’s toes frequently I should not expect my child to have sensation in the toes while the cast is on. I should not let my child put anything inside the cast to relieve itching.
Which of the following nursing measures should be included in the care plan of a patient whose left leg is in traction? Checking the feet for presence of involuntary muscle contractions Noting the color of the toenail after applying temporary pressure Assessing the femoral arteries for equality of pulses Percussing the knee for a patellar reflex
A doctor tells a 30 year old man who has had an above the knee amputation that he will not be able to return to his construction work. Which of the following long term goals would be an appropriate expectation of the man? He will develop alternative vocational skills He will acknowledge his loss He will identify his areas of interest He will engage in occupational therapy
A patient who has a fractured hip is placed in Buck’s traction. A nurse would explain to the patient that the purpose of Buck’s traction is to: Prevent contractures Promote circulation Conserve body energy Maintain body alignment
A client undergoes a total hip replacement. Which statement Prevent contractures Promote circulation Conserve body energy Maintain body alignment
A client undergoes a total hip replacement. Which statement by the client indicates that she requires further teaching? I’ll need to keep several pillows between my legs at night I’ll need to remember not to cross my legs. It is such a bad habit. The occupational therapist is showing me how to use a sock puller to keep me get dressed. I don’t know if I’ll be able to get off that low toilet seat at home by myself.
When caring for a two month old child in Bryant’s traction, the nurse observes that his buttocks are resting on the bed. The nurse should: Elevate the foot of the bed Increase the weights Lift his buttocks off the bed Take no action
Which of the following is the best indication of adequate circulation to the extremities for a child with hip spica cast? Blanching of toe nails is seen when pressure is applied Circulation of toenails returns within 3seconds after blanching The child is wiggling the toes Toes on each foot feel warm to touch
When assessing a client in Buck’s traction, the nurse observes the client’s affected foot resting on the foot of the bed. The appropriate intervention is to: Place a pillow between the affected food and the foot of the bed Pull a client up in the bed Take no action Turn the client to the side
Which of the following is an early sign of fat embolism and should alert the nurse to the need for medical intervention? Irritability and confusion Fat in the stool Hyperglycemia Pruritus
Clients who have cast applied to lower extremities must be monitored for complications. Therefore, the nurse should assess the extremities of these clients for: Warmth Numbness Skin desquamation Generalized discomfort
Three days after a cast is applied to a client’s fractured tibia, the client states that there is burning pain over the ankle. The cast over the ankle feels warm to touch and the pain is not relieved when the client changes position or by any analgesic. The nurse’s priority action is to: Obtain an order for an antibiotic Explain that it is a typical response to a cast Report the client’s complaint to the physician Administer additional medications
The physician orders non weight bearing with crutches for a client with a leg injury. The nurse understands that, before ambulation is started, the most important activity to facilitate walking with crutches is: Sitting up in a chair to help strengthen back muscles Keeping the unaffected leg in extension and abduction Exercising the triceps, finger flexors and elbow extensors Using the trapeze frequently to strengthen the biceps muscles
The nurse would recognize that the demonstration of crutch walking with a tripod gait was understood when the client places weight on the: Axillary regions Palms of the hands Feet, which are set wide apart Palms of the hands and axillary regions
A client had an above-the-knee amputation because of a gangrenous leg ulcer. After 2nd postoperative day, to prevent deformities, the nurse should: Keep the client’s stump elevated on a pillow Place an abduction pillow between the client’s legs Encourage the client to lie supine or prone Teach the client to press the stump against a hard surface
After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client demonstrates cyanosis, tachycardia, dyspnea and restlessness. Initially, the nurse should: Administer O2 by mask Immediately call the physician Place the client in supine position Place the client in high fowlers position
A client is admitted to the hospital for a total hip replacement. The nurse’s preoperative teaching plan for the early postoperative period should include instructions related to: Abduction of the operative hip Adduction of the operative hip Turning 45 degrees onto the operative side Hip flexion of 90 degrees on the operative side
A client with distal femoral shaft fracture is at risk for developing fat embolus. A distinguishing sign that is unique to a fat embolus is: Oliguria Dyspnea Confusion Petechiae
4 weeks following a total hip replacement, a client asks when daily walks can be resumed. The nurse bases the answer on the knowledge that after surgery: Full weight bearing is usually restored after 4months Full weight bearing is usually weight bearing after 6 weeks Partial weight bearing restrictions will be enforced for at least 12 weeks Partial weight bearing and positional restrictions will be in effect for 8 weeks
A young client in the hospital with his left leg in buck’s traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to: Anchor the traction Prevent foot drop Keep the patient from sliding down in bed Prevent pressure areas on the foot
Russell’s traction is easily recognized because it incorporates a: Sling under the knee Cervical halter Pelvic girdle Pearson attachment
When the client is being instructed in crutch walking using the swing through gait, the most appropriate directions are: Look down at your feet before moving the crutches to ensure you won’t fall as you move them Place one crutch forward with the opposite foot and then place the second crutch forward, followed by the second foot. Move both crutches forward, then lift and swing body past the crutches. Use crutch bar to balance yourself to prevent fall.
When the client is in cervical halter traction to immobilize the cervical spine, countertraction is provided by: Elevating the foot of the bed Elevating the head of the bed Application of the pelvic girdle Lowering of the head of the bed
IV. MSK DISORDERS OSTEOPOROSIS B.RHEUMATOID ARTHRITIS C. OSTEOARTHRITIS D. GOUTY ARTHRITIS HNP
Occurs when there is imbalance between bone absorption & bone resorption.
There is an increase rate of bone resorption, thus decreasing bone mass.
OSTEOPENIA LOW BONE MINERAL DENSITY (BMD)
“Porous bones”; “Silent disease”
LONGITUDINAL GROWTH – AROUND 20 YRS OLD PEAK BONE MASS – AROUND 30 YRS OLD
TYPES • PRIMARY OSTEOPOROSIS -most common type -consequence of aging WOMEN: *begins @ age 30; peaks @ 45 y.o. RAPID BONE LOSS IN WOMEN: 1.5 – 2 YRS BEFORE MENOPAUSE 1.5 YRS AFTER MENOPAUSE MEN: *starts at 60 years of age
7. Other Conditions - Hypothyroidism - Hyperparathyroidism
Signs & Symptoms Usually Asymptomatic Sudden onset of severe back pain (subsides w/in 2-6 wks) Skeletal Deformity Loss of teeth; Poorly fitting dentures Bone pain and Tenderness
DIAGNOSTIC TESTS Dual Energy X –ray Absorptiometry(DEXA) – GOLD STANDARD
*OSTEOPOROTIC* T-score of -2.0
NOTE: If you are taking calcium supplements, stop taking them for 24-48 hours before your test.
MANAGEMENT OSTEOPOROSIS IS... PREVENTABLE!!!
MANAGEMENT 1. Provide adequate, balanced diet. *Ca intake - 1200-1500 mg/day *Vitamin D - 400-800 IU/day * Protein 2. Regular weight bearing exercises. 3. Prevent Fractures. *wear slippers or shoes with a nonskid sole *rails or grab bars in comfort rooms *adequate lighting & remove rugs 4. Keep BED AS LOW AS POSSIBLE.
5. Hormone Replacement Therapy a. Calcitonin (Calcimar or Miacalcin) *Increases bone formation *taken by shot or nasal spray b. Raloxifen (Evista) – SERM (selective estrogen receptor modulator) *Increases collagen formation & bone thickness *only given to women c. Teriparatide (Forteo) - recombinant PTH *Increases Osteoblastic action *daily SC injection
6. Administer Drugs as ordered: Biphosphonates Alendronate (Fosamax) Risedronate(Actonel) Ibandronate (Boniva) = potent inhibitors of bone resorption = taken in the morning at least 30 minutes before any food, beverage, or other medicines = take with a full glass of fluid = remain upright for at least 30minutes after taking the drug
2. Alendronate (Fosamax) is ordered for a client with osteoporosis. Which information should the nurse include in teaching the client about this drug? A. It is a selective estrogen receptor modulator. B. It increases bone mass. C. It may be obtained as a nasal spray. D. It prevents bone resorption and is taken orally.
B. RHEUMATOID ARTHRITIS
Autoimmune reaction in the synovial fluid
Characterized by periods of remission and Exacerbation
Incidence increases with age
Presence of rheumatoid factor (RF) – an autoantibody directed against IgG.
RF ANTIBODIES CONSIDER IgG AS AN ANTIGEN MACROPHAGES & LYMPHOCYTES RUSH TO THE AREA DESTROY IgG INFLAMMATION SYNOVIAL MEMBRANE & CARTILAGES ARE ALSO ATTACKED EDEMA PROLIFERATION OF SYNOVIAL MEMBRANE PANNUS FORMATION ERODES AND DESTROYS CARTILAGE FISSURES & BONE SPURS
PATHOPHYSIOLOGY MUSCLE FIBERS UNDERGO DEGENERATIVE CHANGES ENZYMES BREAKDOWN COLLAGEN LOSS OF ARTICULAR SURFACES AND JOINT MOTION AUTOMIMMUNE REACTION PRODUCTION OF ENZYMES DESTRUCTION OF CARTILAGE AND BONE EROSION TENDON AND LIGAMENT ELASTICITY AND POWER ARE LOST PROLIFERATION OF SYNOVIAL MEMBRANE PHAGOCYTOSIS EDEMA PANNUS FORMATION
RISK FACTORS Age of Onset: 30 – 40 years old Genetics Common in Women Exposure to infection
Signs & Symptoms Signs of inflammation BILATERAL or SYMMETRICAL joints are affected Joint Stiffness Joint swelling Joint Deformities
Swan – Neck Deformity
Presence of Subcutaneous nodules
DIAGNOSTIC TESTS 1. X – ray 2. Laboratory: (only positive for clients with advanced arthritic changes) Rheumatoid Factor -determines presence of autoantibodies of the IgG and IgM type. (N: 23 Units) Antinuclear Antibody -measures the presence of Ab that destroy the nucleus of cells. (1:40) Erythrocyte Sedimentation Rate
NURSING MANAGEMENT PAIN RELIEF REDUCTION OF INFLAMMATION SAFE JOINT MOBILITY AVOIDANCE OF FURTHER DAMAGE 1. Apply Heat compress to the affected part. 2. Minimize muscle spasms and joint stiffness. 3. Avoid prolonged sitting or standing. 4. Avoid prolonged flexion of joints. (Best position: __________) 5. Encourage ROM exercises after taking pain meds. 6. Exercises like walking should be done only when pain is not severe. prone
7 Adequate rest: = Provide rest periods between activities = Bed rest during acute exacerbations 8. During acute exacerbations: = provide firm mattress = maintain alignment = avoid pillows under knees = keep joints in extension; not in flexion = Avoid applying direct pressure on the joints 9. Diet: Omega-3 Fatty Acids Examples: walnuts, salmon, sardines, soybeans, shrimp, raw tofu, scallops
MEDICAL MANAGEMENT 1. Administer Medications *ASA *NSAIDS *DMARDs – DISEASE MODIFYING ANTI RD -etanercept (Enbrel) -infliximab (Remicade) *Immunosuppressant -Methotrexate *Gold therapy: -Sodium Thiomalate (Myochrysine) a. given IM once a wk for 3-6mos. -Auranofin (Ridaura) a. analgesic; corticosteroid; oral
C. OSTEOARTHRITIS Also known as degenerative joint disease (DJD) Characterized by the progressive deterioration and loss of cartilage in one or more joints Non-systemic and Non-inflammatory disease Etiology: UNKNOWN
PHYSIOLOGY HEALTHY CARTILAGE – SMOOTH, GLISTENING & WHITE CHONDROCYTES – CELLS THAT PRODUCE CARTILAGE; CONSTANTLY REMODEL BY CREATING CARTILAGE MATRIX CARTILAGE MATRIX PRODUCTION – TYPE 2 COLLAGEN & PROTEOGLYCANS
PATHOPHYSIOLOGY DECREASE IN PROTEOGLYCANS SOFTENING AND LOSS OF CARTILAGE ELASTICITY CHONDROCYTE COMPENSATES PROLIFERATION OF CHONDROCYTES INCREASE SYNTHESIS OF PROTEOGLYCANS & COLLAGEN INJURY LYSOSOMAL ENZYMES RUSH IN DAMAGE NEW BONE GROWTH INEQUALITY OF JOINT SURFACES
Risk factors: Greater in Women Age of Onset: 30’s Obesity Joint Trauma
Signs & Symptoms a. No signs of inflammation b. Pain aggravated by use & relieved by rest; usually less than an hour c. Joint discomfort is ASYMMETRICAL d. Joint Stiffness e. Joint Deformity -Bouchard’s Nodes -Heberden’s Nodes f. Crepitation/Crepitus g. Tenderness on palpation and pain on passive motion --late stage: pain constant; limitation of movement; unrelieved by rest; night pain
DIAGNOSTIC FINDINGS No lab Exams 2. X – ray
Nursing Management GOAL: Pain Management and Optimize Functional Ability 1. Implement pain relief measures. 2. Careful balance between rest and exercise 3. Avoid sedentary lifestyle WEIGHT GAIN 3. Maintenance of activity with joint protection. 4. Plan activities or exercises when pain is least severe. 5. Encourage weight reduction. MEDICAL MANAGEMENT 1. Administer Medications as ordered: Give Analgesic -NSAID’s/ACETAMINOPHEN -ASA -COX-2 Inhibitors (ETORICOXIB)
D. GOUTY ARTHRITIS - A metabolic bone disorder in which PROTEIN METABOLISM is altered and uric acid accumulates.
D. GOUTY ARTHRITIS CLASSIFICATIONS 1. Primary Gouty Arthritis – inherited defect of purine metabolism 2. Secondary Gouty Arthritis Due to Acquired Conditions Starvation Renal Failure
How does our body make uric acid?
Gout is usually due to: Overproduction of uric acid underexcretion of uric acid
PATHOPHYSIOLOGY URATE CRYSTALS DEPOSIT WITHIN A JOINT ACCUMULATION OF URATE CRYSTALS CALLED TOPHI HYPERURICEMIA INFLAMMATION
RISK FACTORS Common among MEN High PurineDiet
Signs & Symptoms Inflammation of the joints Pruritus TOPHI Formation Skin Ulceration Intolerance to bed linens Podagra
DIAGNOSTIC FINDINGS Laboratory: Uric acid: Normal value: 3.0 to 7.0 mg/dL 2. X – ray 3. arthrocentesis
MANAGEMENT 1. Assess affected joint for pain motion and appearance. 2. Educate patients in recognition of early symptoms. 3. Increase Fluid intake (3 – 5 L). 4. Encourage gradual weight loss. 5. Bed rest until pain subsides.
7. Low purinediet (AVOID:seafoods such as shellfish. Meats such as chicken, liver, and pork. Foods like asparagus and spinach) Foods low in purine are: Low fat dairy, tomato, radishes, onions, apples, pears, white rice, cereals, softdrinks, coffee & tea) 8. Administer medications as ordered: ANALGESICS: Aspirin NSAID’s
ANTIGOUT Colchicine (Colgout) -Mechanism of action: DECREASE URATE CRYSTAL DEPOSITION -Drug of choice for: RELIEF OF SYMPTOMS Allopurinol (Zyloprim) -Mechanism of Action: REDUCES PRODUCTION OF URIC ACID Probenicid (Benemid) Mechanism of Action: INHIBITS TUBULAR REABSORPTION OF URATE Sulfinpyrazone (Anturane) -Mechanism of action: IN COMBINATION WITH COLCHICINE; INHIBITS TUBULAR REABSORTION OF URATE -Drug of choice to prevent TOPHI formation.
1. Which of the following guidelines should a nurse include in the teaching plan for a patient with osteoarthritis? Achieve ideal body weight Increase daily calcium intake to 1500mg Maintain a high fiber diet Sleep at least 10 hours a day
A woman who has rheumatoid arthritis would understand her exercise program if she performs which of the following of her affected joints? Aerobic exercise ROM exercise Isometric exercise Resistive exercise
The nurse expects a person with rheumatoid arthritis to have the most difficulty with pain and stiffness after: ADL Heat application Meals Sleep
Before a client who suffered an attack of gout is discharged from the hospital, it is important to evaluate his knowledge of dietary management. Which of the following diet choices would indicate the nurse that he understands his dietary restrictions? Liver, potato, spinach Crab cake, rice and peas Beans, rice and asparagus Steak, baked potato and green salad
A client has painful swelling of multiple joints, and a tentative diagnosis of rheumatoid arthritis is made. During a subsequent visit, the client tells the nurse, “I’m so confused. The doctor said I probably have arthritis, but my lab tests were negative. I don’t see how that can be when I’m always so uncomfortable.” The nurse’s best response would be: It might help if you try not to think about your discomfort Don’t let that upset you; eventually these tests will be positive. Laboratory tests are of ten negative in the early stages of arthritis. Did the doctor say whether the laboratory tests were going to be repeated?
A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. The nurse should suggest: Wearing loose but warm clothing Avoiding excessive physical stress and fatigue Taking a hot tub bath or shower in the morning Planning a rest break periodically for about 15minutes
A client is brought to the hospital for an acute episode of rheumatoid arthritis. During the initial assessment, the nurse observes that the client’s finger joints are swollen. The nurse understands that this swelling is most likely related to: Urate crystals in the synovial tissue Inflammation of the synovial tissue Formation of bony spurs on the joint surfaces Escaped fluids from the capillaries to the insterstitial space.
As an acute episode of rheumatoid arthritis subsides, active and passive ROM exercises are ordered for the client. The nurse should avoid applying direct pressure to the client’s joints because this may precipitate: Pain Swelling Nodule formation Tophaceous deposits
The physician orders bed rest for a client with RA who has bilateral painful swollen knee and wrist joints. To prevent flexion deformities during the acute phase, the client’s positioning schedule should include placement in the: Sim’s position Prone position C-curve Trendelenburg
After a painful exacerbation of rheumatoid arthritis , a client is to begin a walking and exercise program. An appropriate outcome would be that the client: Avoids exercising when there is some discomfort Is pain free while engaging in the program Walks and exercises even when the pain is severe Exercises unless the discomfort is too great
Karen, your patient with osteoporosis, asks you when is the best time to take Fosamax. The correct nursing statement is: With meals to enhance absorption After meals to prevent GI upset that might cause esophageal reflux At least half an hour before meals because Fosamax is a drug that is poorly absorbed There is no particular timing in taking Fosamax. You can take it anytime.
Karen, your patient with osteoporosis, asks you when is the best time to take Fosamax. The correct nursing statement is: With meals to enhance absorption After meals to prevent GI upset that might cause esophageal reflux At least half an hour before meals because Fosamax is a drug that is poorly absorbed There is no particular timing in taking Fosamax. You can take it anytime.
OSTEOMALACIA Characterized by INADEQUATE BONE MINERALIZATION
VITAMIN D DEFICIENCY
RENAL AND HEPATIC FAILURE
MUSCLE WEAKNESS UNSTEADY GAIT BONE PAIN BONE TENDERNESS FRACTURES
Diagnostic Tests XRAY LOOSER’S LINE FX OF THE FEMUR AND RIBS
Encourage clients to have sun exposure. Recommend that clients exercise 3 times a week for 20-30 minutes. Instruct the client to take Vitamin D-rich foods: Milk, Yogurt & Dairy products Soy, Tofu, Vitamin D fortified Cereals Eggs, Tuna, Salmon, Chicken, Liver
E. HERNIATED NUCLEUS PULPOSUS (aka “ruptured or slipped disk”) -Could lead to compression of the spinal nerves.
CAUSES a. Aging b. Trauma c. Overweight COMMON SITE AFFECTED: -Between C5-C6, C6-C7; - L4 & L5 or L5 &S1
SIGNS & SYMPTOMS
Loss of sensation
LOWER BACK PAIN
Lasegues Test or (+) (SLR) Straight Leg Raising
-(+) if there is radiating pain when the legs are raised in a straight position up to 70°
DIAGNOSTIC TESTS 1. X-Ray 2. Myelogram: - X-ray examination of the spinal cord & vertebral canal. PREPARATION: - Informed consent - Assess for allergies to seafood or iodine - HYDRATION for at least 12 hours prior procedure. SITE of ADMINISTRATION: L3-L4 OR L4-L5 POSITION: Side-lying in a KNEE CHEST, FETAL, C-curve position.
2 TYPES OF DYES
a. Water-based dye ex.Amipaque Post-Procedure: Elevate the HOB 15-45 degrees for 8 Hours
b. Oil-based dye ex. Pantopaque, Hyapaque Post-Procedure: Flat in bed for 6-8 Hours
MEDICAL MANAGEMENT: 1. Give muscle relaxants as ordered Ex. cyclobenzaprine (Flexeril) methocarbamol (Robaxin) metaxalone (Skelaxin)
2. Give NSAIDS or Corticosteroids Ex. aspirin , ibuprofen (Motrin, Advil) naproxen (Naprosyn, Anaprox)
SURGICAL MANAGEMENT 1. LAMINECTOMY -Surgical removal of the lamina to relieve compression.
NURSING MANAGEMENT: -Monitor for wound hemorrhage -Assess for neurovascular status GOAL of CARE: To maintain a STRAIGHT SPINE postoperatively Make use of FIRM MATRESS -POSITION: FLAT with a pillow placed under the head and knee. 2. Pt may assume: Semi-Fowlers with moderate hip & knee flexion. HOW TO GET OUT OF BED: Patient lies on one side WHILE PUSHING UP to a sitting position.
3. Make use of LOG-ROLLING technique when turning the patient with pillow between the leg. Turn Px q2H. 4. AVOID PRONE POSITION. 5. Assist the pt to apply the BRACE (milwaukee brace).
6. Assess for complications — Monitor sensory and motor status every 2-4h — With cervical spinal surgery: *assess swallowing, coughing; check for respiratory distress. *suction and tracheostomy set at bedside.
9. Assist with ambulation — OOB day after surgery — Brace or corset if ordered — If patient is allowed to sit, use straight back chair and keep feet flat on floor.
üTHANK YOU VERY MUCHü GOD BLESS!!!
HALO VEST Nursing Care for Halo Vest
Nursing Management for patients with Halo Vest
Inspect & clean the pin site 1-2 times daily
Check pins to be sure they are secure & tight
Administer mild analgesics as ordered to control headache & discomfort around the pin site.
Teach patient to use EYE, rather than head & neck movements for visual scans.
Help patient adapt to the distorted body image the halo device can create.
Instruct patient to sleep using 2 pillows.
Diaphysis, Epiphysis, Epiphyseal Plate
Carpals & Tarsals
Magnetic Resonance Imaging - non-invasive diagnostic scanning technique that uses magnetic fields, radio waves and computers. Preparation: Assess for implanted metal devices in the body. Remove metallic accessories. Assess for claustrophobia. Instruct to remain still during the procedure. Instruct the Px that the machine produces loud thumping and humming noises. Sedation may be done. Contrast medium may be used. Contraindications:
Pts with metallic implants
Pts with pacemakers
Internal Fixation Device
External Fixation Device Care of pts with EXTERNAL FIXATORS
Short Arm Cast
Long Arm Cast
Short Leg Cast
Long Leg Cast
Balanced Suspension Traction
FAT EMBOLISM SYNDROME
Intracapsular and Extracapsular Hip Fracture
Total Hip replacement
Austin Moore Prosthesis
SOCK PULLER & REACHERS
LOG ROLLING TECHNIQUE
1. FLEXION -Bending at a joint; decreasing the angle between the joints. 2. EXTENSION -Straightening at a joint; increasing the angle between the joints. 3. ABDUCTION -Movement of a body part away from the midline. 4. ADDUCTION -Movement of a body part toward the midline.
5. ROTATION -Turning around a specific axis. 6. CIRCUMDUCTION -Cone – like movement 7. SUPINATION -Turning upward of palm 8. PRONATION -Turning downward of palm 9. INVERSION -Sole is pointed inward 10. EVERSION -Sole is pointed outward
11. PROTRACTION -Pushing forward 12. RETRACTION -Pulling backward 13. DORSIFLEXION -Pointing toes upward toward the body 14. PLANTAR FLEXION -Pointing toes downward away from the body 15. ULNAR DEVIATION -Hand wrist towards the ulna 16. RADIAL DEVIATION -Hand wrist towards the radius