Medical Surgical Nursing - Musculoskeletal Disorders


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Medical Surgical Nursing - Musculoskeletal Disorders

  1. 1. Musculoskeletal Disorders Physiology Functions - Provide protection for vital organs o Bones – ribs, sternum, thoracic vertebrae o Muscles – internals and intercostal muscles, diaphragm - Support body structures by providing a strong and sturdy framework - Locomotion and movement - Mineral storage o For metabolism o 99% of the total calcium content of the body is located in the bone - Haematopoiesis o RBC and WBS are produced according to their nature stem cells - Heat production o Through contraction = contain and control heat inside the body Anatomy - 206 bones in total - Classified according to their location o Axial (80)  Skull  Vertebral column o Appendicular (126)  Pectoral girdle Scapula Clavicle Radius Ulna  Pelvic girdle Iliac Ischium Femur - Basic Cell types o Osteoblasts- the CARPENTER  Bone formation Made possible through the secretion of matrix – calcium is the main component  Initiates bone formation via calcification Process where there is mineralization of the collagen fiber  MATRIX and CALCIUM – THE CEMENT; THE FOUNDATION o Osteocytes – MAINTAINS THE HOUSE  Mature type of the osteoblasts  Main cell found in the bone  Maintenance of bone  Excretion of waste materials  Is found inside the spaces called lacunae
  2. 2. o Osteoclasts – THE ANAYS (THE ONE THAT DESTROYS THE HOUSE)  Huge cells derived from the fusion as many as 50 monocytes  Usually concentrated at the endosteum of the bone Endosteum – at the lumina area, where the medullary cavity is  For bone resorption: bone destruction or bone remodelling  Bone destruction Ca is removed - According to General Features o Long Bone  Longer than they are wide  Upper and lower limbs Humerus and Femur o Short Bones  As broad as they are long Wrist and Ankle o Flat Bones  Relatively thin; flattened shape  Certain skull bones, ribs, scapulae (shoulder bones, blades and sternum) o Irregular  Do not fit readily into the other three categories  Vertebrae and facial bones (mandible, maxillary, zygomatic arch, among others) o Each long bones consists of a central shaft called diaphysis o While the two ends is called epiphysis o A thin layer of the articular cartilage covers the end of the epiphyses where the bone articulates with other bones o A long plate that is still growing has an epiphyseal plate or growth plate, composed of cartilage, between each epiphyses and the diaphysis o Bones contain cavities such as the large medullary cavity in the diaphysis, as well as smaller cavities in the epiphyses of long bones and in the interior of other bones o These spaces are filled with either yellow ro red marrow o Marrow  The soft tissue in the medullary cavities o Yellow marrow  Consists of mostly fat o Red marrow  Blood forming cells and is the only site of blood formation in adults o Most of the outer surface of the bone is covered by dense connective tissue called periosteum which contains blood vessels and nerves o The surface of the medullary cavity is lined with a thinner connective tissue membrane called endosteum o The periosteum and endosteum contain osteoblasts which function in the formation of bone as well as the repair and remodelling of the bones o When osteoblasts become surrounded by matric, they are referred to as osteocytes o Bones is formed in thin sheets of extracellular matrix called lamellae, with osteocytes located between the lamellae o The osteocytes are located with spaces called lacunae o Cell processes extend from the osteocytes across the extracellular matrix of the lamellae with tiny canals called canaliculi Histological Structure - Compact Bone o Forms most of the diaphysis of long bones and the thinner surfaces of all other bones
  3. 3. o Most of the lamellae of compact bone are organized into sets of concentric rings with each set surrounding a central or haversian canal o Blood vessels that run parallel to the long axis of the bone are contained within the central canals o Each canal with the lamellae and osteocytes surrounding it is called osteon or haversian system o Each osteon looks like a microscopic target with the central canal as the bull’s eye o Osteocytes located in lacunae are connected to one another by cell process in canaliculi o The canaliculi give the osteon the appearance of the having tiny cracks in lamellae - Cancellous Bone o Spongy bone because of its appearance o Located mainly in the epiphyses of long bones and it forms the interior of all other bones o Consists of delicate interconnecting rods or plates of bone called trabeculae which resemble the beams of scaffolding of a bulding Articulations - The site where bones meet with each other - Joints o Synarthrosis (sutures) o Ampiarthrosis (vertebral and pelvic) o Diarthrosis (maximum movement) o Fibrous (sutures area: coronal, frontal, sagittal), cartilaginous and synovial o Prevent direct contact to two opposing bones o Provides gliding motion o Shock absorption o Bursa – sock filled with synovial fluid; important for shock absorption o Position and movement of bones  Ligaments – retinaculum (hands)  Tendon- structures that connects /attach muscles to bones o Specific Types  Fibrous joints Consists of two bones that are united by fibrous tissue and exhibit little or no movement Sutures o Fibrous joints between the skull Gomphoses o Consists of pegs fitted onto sockets and held in place by ligaments  Cartilagenous Joints Untie two bones by means of cartilage. Only slight movement can occur at these joints Fibrocartilage o Is a type of cartilage that reinforces by additional collagen fibers. It is the kind of cartilage where much strain is placed on the joint  Synovial Joint Freely movable joints that contain synovial fluid in a cavity surrounding the ends of articulating bones Articular Cartilage o Provides a smooth surface where the bones meet Joint Cavity o Filled with synovial fluid Joint Capsule o Helps hold the bones together and allows movement Synovial Membrane
  4. 4. o Produces synovial fluid Bursa  Diarthrosis joint Plane of gliding joints o Joints in carpal bones Saddle Joints o Joints at the base of thumb Hinge joints o Elbow and knee joint Pivot Joint o Radius and ulna Ball and socket o Hip and shoulder o Functions  Prevents direct contact btw two end bones  Allow gliding or sliding motions  Absorb shock o Bone Maintenance and Healing  Regulatory factors determining both formation and resorption Physical activity Diet Calcitonin o For bone mineralization; stimulated if px is hypercalcemic Parathyroid hormone Thyroid hormone o Hyperthyroidism = bone dimineralization Cortisol Growth hormone Sex hormones o Dec Estrogen = bone deminiralization = osteoporosis  Weight bearing stress stimulate local bone formation and resorption; in mobility, where weight bearing is prevented, Calcium is lost in the bone  Vit. D promotes absoption of calcium from the GI and accelerates Vit D – maintain increase Serum Ca levels  Types Intramembranous o Compact bone Endochondreal o Cancellous  Bone marrow  osteoblast  Bone cortex  osteon  Periosteum hard callus is formed (intramembranous)  Cartilage endochondrial ossification  Phases Reactive o Hematoma/recruitment of inflammatory cells. Angiogenesis and granulation Reparative o Pre-callus precursor (3-4 weeks) Remodelling o Nursing Consideration  Age
  5. 5. Very young = immature bones  give all supplements to promote bone growth Very old = osteoporosis  quite at risk for fractures  consider displacement and site of fracture  Displacement of fracture  Site of fracture  Nutritional level  Blood Supply to the area of injury  CAN AFFECT TIME REQUIRED FOR BONE HEALING Anatomy of Muscular System - 3 Types o Smooth  Found in the hollow organs of the body Eg. Stomach (capable of mixing waves), small and large intestine, airways (capable of peristalsis), blood vessels  Slightly striated  involuntary o Skeletal  Striated because of the alternating lines myocinand myofilaments  Voluntary  Lower neurons control the activity of the skeletal muscles  Energy is consumed when the skeletal muscles contract in response to stimulus  Lactic Acid By-product of muscle metabolism when O2 available to cell is not sufficient Muscle fatigue results from increased work of the muscle o Depleted glycogen and energy stores o Accumulation of lactic acid  muscle cramps o Cardiac  Exclusively found in the myocardium  Intercalated disks gives automaticity  involuntary - types of Muscle Contraction o Isometric Contraction  Length of muscle remains constant but the force generated is increased o Isotonic Contraction  Shortening if muscles, but no increase in muscle tension - Muscle Tone o Flaccid (Limp) o Spastic o Atonic (soft and flabby – px who are post-stroke) - Muscle Action o Prime Mover  Deltoid muscle o Synergist  Same actions  Biceps o Antagonist  Biceps - Types of motions o Flexion o Extension
  6. 6. o Abduction o Adduction - Older Adult Care Focus o Decreased bone density (most are osteoporotic)  Ensure safety o Decreased in subcutaneous tissue  less soft tissue over bony prominences o Degenerative changes in the spine alter posture and gait o Degenerative changes in cartilage and ligaments leads to decreased movement of joints o ROM decreases o Slowed movements and decreased muscle strength Assessment - Health history - Past health, social and family history - Physical Assessment o Posture: Kyposis (forward curvature of the thoracic spine), lordosis (lumbar), scoliosis (lateral curvature) o Gait o Bone integrity (crepitus) o Joint function (contracture, dislocation, subluxation) o Muscle strength and size (clonus/fasciculation) o Skin o Neurovascular status (circulation, motion, sensation) Laboratory/Diagnostic Tests - Blood Tests o ESR (elevated in SLE and arthritis) o Rheumatoid factors (+ in rheumatoid arthritis) o Lupus erythematosus cells (LE Cells) o Antinuclearantibodies (ANA) (+rheumatoid arthritis) o Anti-DNA (+ in SE) o C – Reactive protein ( o Minerals  Calcium Decreased levels in osteomalacia, osteoporosis Increased in levels in bone tumors, healing fractures, Paget’s disease  Alkaline Phosphatase Elevated levels in bone cancer, osteoporosis, osteomalacia, Paget’s disease/metastatic ca (acid phosphatase)  Phosphorous Increased levels in healing fractures, bone tumors o Muscle Enzymes  Aldolase Elevated in muscle dystrophy, dermatomyositis  AST  CK (Creatine Phosphokinase) Elevated in traumatic injuries  LDH (Lactic Dehydrogenase) Elevated in skeletal muscle necrosis, extensive cancer - X-Rays (Roentgenography) - Bone Scan
  7. 7. o Measures radioactivity in bone 2 hours after IV injection of radio isotope; detects bone tumors, osteomyelitis o Nursing care:  Patient must void immediately before procedure  Determine allergies  Patient must remain still during scan - Arthroscopy o Insertion of fiberoptic scope into a joint to visualize it, perform biopsies or remove loose bodies o Performed in OR under sterile technique o Nursing care:  Pressure dressing for 24 hours  Patient must limit activity for several days  Assess neurovascular status - Arthrocentesis: removal or synovial fluid, blood or pus from a joint - Myelography o Lumbar puncture used to withdraw a small amount of CSF, which is replaced with a radiopaqued dye; used to detect tumors or herniated intervertebral discs o Nursing care:  Consent must be signed  Check for iodine allergy  Keep NPO after liquid breakfast o Nursing care post test:  If dye has been completely removed (oil dye), keep patient flat for 12 hours  If dye has not been completely removed (water based dye – Amipaque), keep head of bed elevated (30- 45) to prevent causing meningeal irritation and seizures.  If water based dye is used , put patient on seizure precaution and do not  administer any phenothiazine drugs (or any sedating drug to assess the level of consciousness) - CT Scan and MRI o CT Scan – tumors o MRI – any lesions concerning the posterior fossa - Electromyography(EMG) – Lower motor neuron/Peripheral nervous system o Measures and records activity of contracting muscles in response to electrical stimulation; helps differentiate muscle disease from motor neuron dysfunction. o Explain procedure to patient and prepare him for discomfortof needle insertion Traumatic Injuries Open type bone fracture – has a communication with the environment which orgs can enter  osteomyelitis - Strain o Is an injury to the muscle when it is stretched or pulled beyond its capacity o Common cause: overstretching - Sprain o Is injury to the ligaments surrounding a joint o Common cause: over twisting - Contusion o Soft tissue injury with ecchymosis or bruising o Common cause: blunt force o Head trauma o Opening  concussion Grading - First Degree
  8. 8. o Mild stretching o s/sx:  minor edema  tenderness  mild muscle spasm o requires immobilization and NSAIDS - Second Degree o Partial tearing o s/sx:  loss of load bearing strength  edema  tenderness  muscle spasm  ecchymosis related to the partial tearing, expect blood vessel involvement o requires surgical intervention - Third Degree o Sever damage with complete rupturing or tearing o s/sx:  severe pain  tenderness  increase edema  abnormal motion o requires surgical intervention General Nursing Management: R – rest - immobilize patient - check for neurovascular integrity (pulse, sensation and movement) I – ice - first 24 hrs, use Ice (vasocontrict blood vessel = minimize s/sx). After 24-48 hours, use warm compress (absorb any ecchymosis/hematoma that accumulated because of vasodilation) C – compress E – elevate Carpal Tunnel Syndrome - compressed median nerve by the transverse carpal ligament (wrist) - involves thumb, portion of the ring finger, middle finger and pointer finger - causes: o repetitive and constant flexion of the wrist - s/sx: o paresthesia o muscle weakness o “clumsiness” when using the hand o PAIN - Diagnosis: o (+) Tinel’s Sign o (+) Phalen’s Test - Nursing management o Goal no. 1: to prevent further compression of the nerves  Rest hands  Avoid excessive use of involved hand  Instruct patient not to sleep over the involved hand
  9. 9.  Administer medication as ordered NSAIDS o Goal no. 2: to prevent injury  Instruct patient to wear gloves - Medical Management: o Analgesics  Minimize/relief pain  ASA (acetylsalicylic acid / aspirin)  NSAIDS  Taken with full stomach  can cause hyperacidity o Corticosteroids  Oral Prednisone - Surgical Management: o Carpal tunnel release Fracture - 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 - Causes: o Direct blows  vehicular accidents o Crashing forces o Sudden twisting motions o Extreme muscle contractions - Types o According to skin involvement  Open / Compound Communication to the skin Seriousness depends to the degree of opening Infection and bleeding  Closed / Simple Patient just need to be immobilized o According to Breaks  Complete Up to the shaft  Incomplete Linear break o According to Line  Comminuted Different angles  Greenstick One side is fractured, other side is uninjured  Spiral/Torsion Linear fracture that twisted  Transverse  Oblique Can reach the skin  Impacted Related to the skull and vertebrae  Depressed  Compression
  10. 10.  Pathological/Spontaneous Common to osteoporotic or malignancy of the bone o Intracapsular and Extracapsular Hip Fracture  Require fixation - Clinical Manifestation o Pain o Muscle spasm  There will be injury to the nerves  Nerves and blood vessels are located in the periosteum o Loss of function  Particularly if complete fracture and it is an open type o Deformity o Shortening  Extremity and limb because of the muscle spasm o Swelling and discoloration o Crepitus / crepitations  Particularly of the joint area is involved o Localized edema and ecchymosis - Diagnostic tests o Radiography /x-ray  fastest o CT Scan  cranium o MRI  Posterior fossa (brain stem, vertebra) - Goal of interventions: o To prevent further damage  Immobilization  Support extremity  Provide adequate splinting  Control bleeding Leads to compartment syndrome Check peripheral pulses distal to the injury  Cover wound with sterile or cleanest material available To control / prevention osteomyelitis - Medical management: o Reduction  Closed Casting, traction, manual manipulation  Open Requires sterile area surgical procedure 2 types o Open reduction with internal fixation (ORIF) o Open reduction with external fixation (OREF)  At risk for infection  Complication for external fixator: Infection o Staph areus o Nursing management:  Asses for redness, tenderness, pain, swelling, and loosening of pins.
  11. 11.  Prevent crust formation - Nursing management: o Closed fracture  Instruction on control of pain and edema  Use assistive device properly  Modify environment to provide safety  Self-care o Open fracture  Risk of osteomyelitis (give antibiotics as ordered), tetanus (toxoids (preformed antibodies and immediate protection) and vaccines), gas gangrene (clostridium tetani)  IV Antibiotics  Delayed primary wound closure  Elevate to minimize edema  Neuromuscular assessment CMS (circulation, motion and sensation) - Fracture Healing and Complication o Early  Hypovolemic Shock Femur  femoral artery (is a very pulsatile artery, direct to the abdominal aorta  common iliac); high pressure Resulting to massive bleeding o Give fluids o Blood transfusion  Fat Embolism ( 40 y/o, Male, multiple fracture) Sx: sudden hypotension, sudden dyspnea  Compartment Syndrome Sudden decrease in blood flow distally (PAIN) Majority of the compartments of the body is found in the extremities  Venous Thromboembolism  DIC (Disseminated Intravascular Coagulopathy) Decrease in platelet o Delayed  Delayed Union  Malunion  Nonunion o Nursing Management:  Pain control - Fracture of Specific Sites o Clavicle (Collar Bones): Middle 3 rd of the clavicle  Figure of eight bandage o Humerus (shaft or neck) o Elbow: Supracondylar fracture of the humerus (Volkmann’s contracture)  Assess volkmann’t contracture o Radial head: fall on an outstretched hand o Radial/Ulnar shaft: common among childen o Distal Radius (Colles Fracture): Open dorsiflexed hand, commonly in elderly o Pelvic: rule out other internal damage because of the proximity of the two structures o Femoral shaft: fall or motor vehicle crash o Thoracolumbar spine: vertebral body, laminae, and articulating process, spinous process Osteomyelitis - Infection of the bone; Staphylococcus Aureus
  12. 12. - Haematogenous spread (infection elsewhere then septecemia then to the bone) / direct trauma / VI - Acute / Chronic osteomyelitis - Risk factors: o Age o Nutrition o Blood vessels involvement o Immune system o Co morbidities (CM) - Infection sets in  inflammatory reaction (pain, swelling, heat)  causes devascularisation of the bone, bone ischemia and necrosis - Sequestrum (cavity with abscess)  abscess will be necrotic debris - necrotic bone tissue encased by involucrum - Pathologic fractures can occur - Only when all dead bone tissue is removed will full healing occur o Require surgical intervention - Pathophysiology o Risk factors: Acute OM  inflammation (Increase vascularity and edema)  2-3 days: thrombosis (ischemia then necrosis)  medullary area and periosteum involvement sequestrum (abscess cavity)  surrounded by new bone growth: involucrum (new bone growth)  recurring abscess  chronic osteomyelitis - Assessment and Diagnostic o Isotope labelled WBC, MRI o X-ray: tissue edema  2-3 weeks: periosteal elevation and bone necrosis  Chronic OM: large irregular cavities, raised periosteum, sequestra, dense bone formation  Blood culture On two different sites - Interventions o Administer antibiotics o Debridement / incision and drainage o Antibiotic beads  Made up of Ca  Little to no systemic effect  Advantage: it is absorbed while being replaced by new bones. No need for grafting anymore o Sequestrectomy o Saucerization o Bone grafting/muscle flap CAST - A rigid external immobilizing device that is moulded to the contour of the body - Purpose: o To immobilize a reduced fracture o To maintain body alignment o To correct deformity o To apply uniform pressure to underlying soft tissue o To support and stabilize weakened joints - When casting a joint, include the proximal as well at the distal area to stabilize the injured site / extremity Types of Casting Materials - Plaster of Paris o Traditional cast
  13. 13. o Rolls of plaster bandage are wet in cool water and applied smoothly to the body o Heavy and has a rough surface o Crystallization: rigid dressing 15-20 mins o Exposed to circulating air to dry o Disadvantage: absorbs moisture  Avoid in water contact o Complete dryness: 24-72 hours after application  No not cover with towel o Lest costly o Achieved a great mold; less durable (compared to fiber glass) o Exothermic characteristic  When you apply it, it exclude heat and warm  Hindi nagkakaroonng panic o anxiety ang patient DRY WET Appearance White and shiny Grey Percussion Resonant Dull Odor Odourless Musty Texture Firm, hard and rough Damp to touch - Non –Plaster / Synthetic Cast o Fiber Glass  Water activated polyurethane materials, lighter in weight, stronger and more durable  Lightweight and has smooth surface  Should never be exposed to any plastic surface (it will get deformed) because it is hot  Inform patient to prevent anxiety or panic attack  Make sure to prevent they are placed in edges or corner to prevent denting of the fiber glass Avoid denting  any disfigurement to the fiber glass could lead to skin irritation or breakage/lesion  Water-prof lining (Gore-Text)  Complete dry: 24-72 hours o Splints  Used for conditions that do not require rigid immobilization  Expect swelling  It can be easily removed  Require special skin care  Overwrapped with an elastic bandage applied in spiral fashion  Short term in use o Braces  Provide support, control, movement and prevent additional injury Cervical brace, collar  Custom fitted to various parts of the body  Expensive  Indicated for longer use (at least 8 years) Short Arm Cast Long Arm Cast - Elbow is at a right angle Short Leg Cast - Knee down to the sole/base of the toe - Foot is at a right angle, neutral position
  14. 14. Long Leg Cast - Extends from the upper, middle third of the thigh to the base of the foot - Knees slightly flexed Walking Cast - Long and Short - To re-enforce strength Body Cast - Encircles the trunk Spica Cast - At least two types: o Shoulder  Body jacket that encloses the trunk, shoulder and elbow o Pelvic  Shoulder, lower extremity (one or both) Nursing Management - Carry cast with palms of the hands when WET - Elevate with pillow support - Expose to dry environment - Keep clean and dry - Observe for signs of inflammation then infection - Maintain skin integrity - Neurovascular assessment meticulously and regularly - Move patient every 2 hours (patient with body casts) to relieve pressure - In turning, use of trapis or railings can be done CAST SYNDROME - Due to immobilization - Decrease gastric mobility  accumulation of air in the stomach and lung  bloated patient  gastric acid reflux, constipation  abdominal distention anorexia COMPARTMENT SYNDROME - Increase in pressure in a confined space  there is decrease blood flow affecting important structures such as blood vessels and nerves - Asses neurovascular status o Peripheral pulses o Motion o Sensation - 5 P’s o Pain – primary symptom o Pallor o Pulselessness o Paresthesia o Paralysis - Management o Assess neurovascular status o Elevate the affected limb to the level of the heart  To minimize edema (normal reaction of body against trauma) - Surgical Intervention o Fasciotomy (opening of the fascia to relieve the pressure) o Remove the tight cast or dressing o Bivalving/Use of posterior mold
  15. 15. PRESSURE ULCERS - Take note of the body prominence - Inform patient that they should inform you if there is pain or tightness in the area DISUSE SYNDROME - Muscle atrophy and loss of strength - Tense or contract muscle (isometric contraction) without moving the part TRACTION - Application of the pulling forces - Short term intervention - Purposes o To reduce, align and immobilize fractures o To minimize muscle spasms o To reduce deformity o To increase space between opposing surfaces - Principles o Continuous to be effective o Never interrupted o Weight are not removed unless it’s an intermittent traction o Eliminate any factor that may reduce its effectively o Good body alignment in the center of the bed o Ropes must be un obstructed o Weight must hang freely o Knots in the ropes or foot plates must not touch the pulley or foot of the bed - Types o Straight or Running Traction  Applies the pulling force in a straight line with body part resting on the bed (Buck’s Traction) o Balance Suspension Traction  Supports the affected extremity off the bed and allows some movement without disruption of the line of pull Another Types - Skin Traction  Buck’s Extension Traction (leg) Indication: femur / hip involvement Simplest form of traction o Russel’s Traction  Indication: Femur/hip joint fracture  Incorporates the use of knee sling  Hip is flexed to 20 degrees from the mattress o Bryant’s Traction  Indication: children with 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 assess neurovascular status of the lower extremity o capillary refill o Cervical Traction  Indication: cervical spine fracture  Make use of a cervical halter or cervical lining
  16. 16.  HOB is elevated to 30-40 degrees o Pelvic Traction  Indication: pelvic bone fracture  Used for lumbar fracture  Make use of a pelvic halter  Supine position - Skeletal Traction o Weights are attached directly to the bone o Make use of pins, screws, wires or tongs o At risk for osteomyelitis o Balanced Suspension Traction  Make use of Thomas Splint with Pearson Attachment  Part of the body is off the bed  Hips are fixed 30 degrees  Care of pin site: Clean with antiseptic Apply antibiotic No betadine rust pins No peroxide  aerobic infection  Nursing management Principles of Effective Traction o Continuous to be effective o Never interrupted o Weights are not removed o Observe food body alignment o Ropes must be unobstructed Complications o Atelectasis (inability of the patient to do deep breathing exercises) and Pneumonia  Auscultate the lungs q 4-8 hours  Deep breathing and coughing exercise o Constipation and anorexia  Diet must be high fiber and increase fluids  Stool softener as prescribed  Improve appetite o Urinary Stasis and Infection  Observe the characteristic of the urine  Monitor fluid intake  Monitor s/sx of infection Hesitancy Urgency Frequency Dysuria o Venous Thromboembolism  Exercise muscles not in traction to prevent deterioration, deconditioning and venous stasis  Monitor for tenderness, warmth, redness and swelling  Check for Homan’s Sign Fat Embolism - An embolism originating in the bone marrow that occurs after a fracture - Usually occurs 48 hours after a fracture and clients with long bone fractures are more at risk - Restlessness, changes in LOC, tachycardia, tachypnea, dyspnea, petechial rash over upper chest
  17. 17. - Nursing Interventions o Immediate Mobilization o Minimal fracture manipulation o Adequate support of fractures bones during positioning and turning o Support respiratory function o Initially administer oxygen then position in Fowler’s position o 48-72 hours  immediately immobilize o In there is already management  immediate mobilize Hip Fractures - Common among elderly women - Affected leg is always adducted, externally rotated and the limb is shortened o Nakalabas is femoral head - Complaints of pain in the GROIN or in the medial side of the bone - Same signs and symptoms with fractures - Total or Partial Hip Replacement o Intertrochanteric hip fracture  Metal ball and stem are inserted in the femur and a plastic socket o Total Hip Replacement - Post Op Care o Maintain legs in abduction (place pillows between legs) – adduction will displace prosthesis o Avoid bending o Use trochanter roll to prevent external rotation o No low chairs DEVICES - Purpose o Widens base of support o Reduce weight bearing on the affected leg o Provide mobility to the patient - Crutches o 2 inches below axilla o 6 inches front to foot o 2 inches to the side of the foot o Elbow flexion (20-30 degrees) o Exercises to prepare for CW:  Hand muscle ex  Arm muscle ex o Gaits o Stair climbing  UP: good leg crutches with bad leg (Going to HEAVEN  so use your GOOD leg)  DOWN: bad leg with crutched  good leg (Going to HELL  so use your BAD leg first) o Important Muscles  Shoulder Depressor / LatissimusDorsi Needed first to advance the body forward Needed to lift the pelvis off the ground  Elbow Extensors / Triceps Needed to prevent buckling of the elbow joint  Finger Flexors Needed to grasp the hand grip o Crutch Walking  Crutch gaits
  18. 18.  When only one leg can bear weight Swing to gait: crutches forward; swing body to crutches Swing thru gait: crutches forward; swing body thru crutches 3 point gait 2 point gait - Cane o Held on the non-affected side o Cane walked together with the weak leg - Walker o The most stable among the assistive devices o Sequence:  Advance walker within arm’s length (Approx 10-20 inches in front of the patient  Walk beside the walker OSTEOPOROSIS - Abnormal increase in bone resorption causing a decrease in bone density - Loss of bone mass with aging, decrease calcitonin and estrogen and increased parathormone - Deminiralization (Loss of Ca and phosphate salts)  bone becomes porous, brittle, fragile structural weakness – pathologic fractures - Fractures of thoracic, lumbar neck and intertrochanteric fx of femur and Coll’sfx of wrist - Risk factors: o Menopause o Sedentary lifestyle o Genetics o Age o Nutrition o Physical Exercise o Medications - Dowager’s Hump / Kyposis - Signs and Symptoms o Usually asymptomatic o Sudden onset of sever back pain o Skeletal deformity o Bone pain and tenderness o May show s/sx of pulmonary insufficiency o Dec calcitonin and estrogen o Inc PTH - Dx Assessment o X-ray o Bone scan - Nursing management o Recognize risk factors and prevent further injuries o Adequate dietary intake of Ca and other minerals, CHON and CHO o Calcium supplements with Vitamin D o Physical therapy – moderate exercise – mechanical stress stimulates bone formation o Fracture management o Biphosphates – Etidronate (Didronel)  Nephrotoxic  Increase bone density and restore lost bone  Inhibit resoprtion of bone  Monitor for nephrotoxicity and seizures o Fluoride – Alendronate (Fosamax)
  19. 19.  Stimulate bone formation  Strict GI precautions  Causes GI distress, esophagealerosin  Administer on empty stomach  Do not eat or crink 30 mins  Take with water 6-8 onz not juice and  Remain upright for 30 mins after taking drug  Monitor: hypercalcemia and tetany serum electrolytes  Increase fluid intake and calcium rich foods Rheumatoid Arthritis - Autoimmune bone disease and hereditary - Bilateral, symmetrical, inflammatory, systemic - Progression through stages o Synovitis – pannus formation (scar tissue) – fibrous ankylosis – bone alkylosis - Signs o Fatigue, anorexia, malaise, weight loss, slight temperature elevation - Usually affects joints symmetrically (on both side equally) - Pathophysio o Presentation of antigen to T cell  t and B cells proliferation, angiogenesis in synovial lining  swelling in small joints, associated with pain, stiffness and fatigue  neutrophil accumulation in synovial cell proliferation. No cartilage invasion  2 possibilities: 1) warm effusions, pain and decreased motion with possible rheumatoid ndules 2) synovitis, early pannus invasion, chondrocyteactiviation, degredation or cartilage subchondral bone erosion; pannus invasion - Painful, warm, swollen joints with limited motion, stiff in the morning and after period of inactivity - Crippling deformity/swan-neck or buotonierre’s deformity - Muscle weakness - History of remission and exacerbations - Severe anemia - Sjoren’s syndrome - Felt’s syndrome o A disorder that can affect people who have rheumatoid arthritis (RA) o It is defined by the presence of three condition: RA, enlarged spleen and low WBC count - Dx test o X-ray o Laboratory  (+) Rheumatoid Factor - Nursing Management o Apply cold compress to the affected part o Minimize muscle spasms and joint stiffness o Avoid prolonged sitting or standing o Encourage ROM exercises after taking pain meds - Surgical Management o Osteotomy, synovectomy, or arthroplasty - Pharmacotherapy o Aspirin o NSAIDs  Indomethacin (Indocin)  Phenylbutazone(Butazolidin)  Ibuprofen o Gold Compounds (Chrysotheraphy)  Arrest progression of the disease  Sodium thiomalate
  20. 20.  Aurothioglucose  Auranofin o Corticosteroids  Intra-articular injections Osteoarthritis - Degenerative joint disease - Idiopathic or secondary - 3 rd decadeof life and peaks between the 5 th and 6 th decades - Affects the articular cartilage, subchondral bone and synovium - Cartilage degeneration, bone stiffening, reactive inflammation - “wear and tear” - Risk factors: age, obesity, previous joint damage, repetitive use, anatomical deformity - Manifestations o Pain (osteophytes) o Stiffening o Functional impairment - Dx o Progressive loss of joint cartilage o Osteophytes o Joint space narrowing (x-ray) - Management o Relieve strain and further trauma to joints o Cane or walker if indicated to relieve stress o Proper body mechanics o Avoid excessive weight bearing and standing o Physical therapy o Relief of pain (NSAIDS) o Joint replacement as needed Gouty Arthritis - Classifications o Primary o Secondary  Due to acquire condition  Starvation  Alcohol intoxication  Renal failure - Risk factors o Common among males o 20 x greater than females o 30 y/o and above - s/sx o inflammation of the joint o pruritus o TOPHI formation  Subcutaneous nodules o Skin ulceration o Late Stage  Bone deformity  Intolerance to bed linens - Management o Asses affected joint for pain motion and appearance
  21. 21. o Educate patients in recognition of early symptoms o Increase fluid intake (3-5 L) o Bed rest until pain subsides o Report any decrease in urine output o Low purine diet o Admin medications as ordered  Allopurinol (Zyloprim) MOA: prevents formation of uric acid  Probenicid (Benemid)  Colchicine (Colgout) MOA: dec deposition of uric acid to the joint Drug of choice to prevent attacks Amputation - Surgical removal of a part of a limb - Levels: Syme, BKA(Below the Knee Amputation), AKA (Above the Knee Amputation), stage amputation - Guillotin Amputation o Stage type amputation - Post op care o Monitor VS o Evaluate for phantom limb sensation and pain; explain to the patient o During the 1 st 24 hours, elevate stump; after that flat on bed to prevent flexion hip contractures o After 48hours, instruct also to be one prone position several times a day o Maintain application of ace wrap to promote stump shrinkage - Stump Dressing o Soft- greater potential for haemorrhage and rehabilitation is longer but easier to assess o Rigid – facilitates earlier ambulation but difficult to assess - Post op complications o Haemorrhage o Infection o Contracture Bone Tumors / Malignancy - Classified according to its characteristics o Benign  Most common: osteochondroma  Endochondroma: hyaline cartilage (joint spaces and synovial cavity)  Bone cyst (collection of fluids found in a confined area)  Osteoid osteoma  Giant Cell Tumors (osteoclastomas) – common in children o Malignant  Most common: Osteosarcoma Bone tumors: primary or secondary Commonly seen to 10-25 years of age Most of the time they are just accidental finding o Suddenly there will be palpated mass; no pain o Palpable mass or hard lump, pain, pathologic fractures, decreased sensation, numbness and limited movements Tumor erodes the bone cortex elevating the periosteum Most common site: distal femur, proximal tibia and humerus Increased serum alkaline phosphatase because of bone lysis DX: bone biopsy
  22. 22. Radiation, chemotherapy, surgical removal or tumor Radiological finding: periosteal elevation o Demineralized bone Pathognomonic hallmark: Codman’s Triangle and Sun Ray Spicules (both suggests malignancy) After surgery, potential complications: o Delayed wound healing  Related to tissue trauma  Effect of Radiation therapy  Poor nutrition (with malignancy, there is hypercatabolic anorexia  effect of cytokines hyperleukines  Infection(wound) o Inadequate nutrition o Osteomyelitis and wound infection o Hypercalcemia common problem is arrhythmia, clogging of the blood vessel, calcium stone  renal failure Scoliosis - Lateral curvature of the thoracic, lumbar or thoracolumbar spine. Rotation of the vertebral column causes rib cage deformity. - When deviates to the RIGHT: DEXTROscoliosis - When deviates to the LEFT: LEVOscoliosis - Types: o Functional: poor posture or discrepancy in the leg length o Structural: deformity of the vertebral bodies  Loss in the height of the vertebral bodies  Common with those with osteoporosis or congenital, neuromuscular idiopathic scoliosis (infantile, juvenile and adolescent)  Can happen anytime during bone formation o Different stresses on the vertebral bodies causes imbalance of osteoblastic activity; curve progresses rapidly during adolescent growth spurt - Signs o Uneven hemlines, one hip higher than the other, unequal shoulder, heights and iliac crests, asymmetric thoracic cage - Sugrical o Posterior fusion o Harrington Rod instrumentation  Wisconsin wire technique and Luque technique o Zielke System  For thoracolumbar scoliosis (severe)  Makes use of wiring to maintain alignment of the thoracic spine - Dx o Observation / Inspection o Thoracic X-Ray (Cobb’s Method) – done to see R or L deviation of the spine o Adam’s Forward Bending Test o Scoliometer – to look at the angle of the scoliosis (>30 percent: not only deformity but also sever pain because of the compression of the spinal nerves) - Complications o Pulmonary insufficiency, back pain, HPN, sciatica (Radiating pain, back to foot), degenerative arthritis of the spine - Tx o Depends on the age where is was diagnosed
  23. 23.  10-20 y/o – leg exercises and pelvic tilt: strengthen torso muscles  20-40 y/o – exercises + braces: worm until the bone growth is complete  40 y/o and above: spinal surgery – instrumentation with fusion Cannot bend much because of the instrumentation with fusion - Nursing Consideration o Suggest loose, fitting clothes – wear undergarments when wearing the brace o Wear the brace for 23 hours a day (1 hour for taking a bath) for 7 days o Advise to increase activities gradually o After corrective surgery  Check neurovascular status q 2-4 hrs, logroll  Monitor I and O, watch out for signs of bleeding  Patient will have splinting, so teach deep breathing exercises to prevent atelectasis pneumonia  Medicate for pain, do ROM  Offer emotional support for altered body image o Crankshaft Phenomenon  Observed after spinal fusion there is continuous growth of anterior vertebral body  Prevention: Delayed the surgery until the child is older than 10 years Addition of anterior fusion plate Use of specialized instrumentation that allows subsequent expansion of the vertebra TB of the Spine - Pott’s disease is a presentation of extrapulmonary (originates from the lungs, hematogenuous spread) tuberculosis that affects the spine, a kind of tuberculosis arthritis of the intervertebral joints. - s/sx o back pain o fever o night sweating o anorexia o weight loss o massive destruction of the vertebra – swelling o spinal mass sometimes associated with numbness, tingling sensation or muscle weakness of the legs - infections o Pott’s disease  Organism: TB Bacilli  Primary Focus: Lungs  Pathology: Infection  bone destruction  collapse of the vertebrae Gibbus Formation  Spinal Cord compression  Mgmt Anti-Koch’s medicaiotns, spinal brace Tx minimum of 12 months  Surg Anterior Decompression Spinal Fusion  Bone infections are difficult to treat because they are relatively inaccessible to protective macrophages and antibodies
  24. 24. PediatricOrthopedic Conditions Congenital Clubfoot - Congenital malformation of the lower extremities - Unilateral or bilateral - Defects are rigid and cannot be manipulated into a neutral position - Talipesvarus – an inversion or bending inward - Talipes valgus – eversion or bending outward - Talipesequinus – plantar flexion in which the toes are lower than the heels - Talipes calcaneus – dorsiflexion - Nursing care and treatment o Serial manipulation and casting weekly and if correction not achieved in 3-6 months then surgery is indicated - Surgical o Usually done 4-12 months of age (Kyzer, 1991) o After surgery, a cast holds the clubfoot still while it heals o Special shoes or braces will likely be used for up to a year or more after surgery o Same as any child with a cast Congenital Hip Dislocation - Dysplasia of the hip wherein the head of the femur is not properly anchored in the acetabulum - Can be congenital or develop after birth - Assessment o Asymmetry of the gluteal and thigh skin folds when child is placed prone o Limited ROM on affected hip o Apparent short femur on the affected side o Positive Ortolani or Barlow Maneuver o Waddling gait; positive Trendelenburg sign - You see that the head of the femur is far from the acetabular fossa - Nursing care and treatment o Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation o Traction and surgery to release muscles and tendons o Following surgery, positioning and immobilization in a spica cast then use of abduction splint *READ ACUTE LOW BACK PAIN *READ BRURITIS and TENDINITIS *READ Ganglion Cyst *READ DUPUYTREN’S CONTRACTURE FOOT PROBLEMS - Plantar Fasciitis - Corn - Callus - Ingrown Toenail - Hammer Toe - Hallux Valgus - PesCavus - Flatfoot (PesPlanus)