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ORTHOPEDIC_NURSING-1 BSN batch 1 adult had nursing
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- 2. INTERACTION OF SKELETAL& MUSCULAR SYSTEMS: Skeletal and Muscular systems – Ligaments – Tendons- Skeletal muscles – Skeleton – Muscles - Works together to allow movement Attach bone to bone Attach muscle to bone Produce movement by bending the skeleton at movable joints. Muscles work in antagonistic pairs. Provides structure of body Allow skeleton mobility – pull by contraction of muscle.
- 4. Skeletal System Functions: Support& shape to body Protection of internal organs Movement in union with muscles Storage of minerals (calcium, phosphorus) & lipids Blood cell production
- 5. Muscles Skeletal (voluntary) Allowsvoluntary movement Smooth (involuntary) Muscle movement controlled by internal mechanism e.g., muscles in bladder wall and GI system Cardiac (involuntary) Found in heart
- 6. Types of MuscleTissue
- 7. Skeletal Muscle 600 skeletalmuscles Made up of thick bundles of parallel fibers Each muscle fiber made up of smaller structure myofibrils Myofibrils are strands of repeating units called sarcomeres
- 8. The myofibril iscomposed of “thick” and “thin” filaments. Each of these filaments is made up of strands of protein.
- 9. Skeletal Muscle Skeletal musclecontracts with the release of acetylcholine The more fibers that contract, the stronger the muscle contraction
- 10. Smooth Muscle Found inthe digestive tract, large blood vessels, and several organs. Have contractile fibers, but lack orderly striations of skeletal muscle.
- 11. Muscle tissue capable of voluntarycontrol. Orderly striations are due to arrangement of contractile fibers. Produces locomotion. Skeletal Muscle
- 12. Cardiac Muscle Locatedonly in the heart. Influenced by nerves and hormones, but has “electrical” system of its own to initiate and coordinate contractions.
- 13. Muscle Fibers Amuscle cell is a “fiber.” Fibers are multinucleated and contain myoglobin. Myofibrils contain the contractile fibers.
- 14. Changes in OlderAdult Musculoskeletal changes can be due to: • Aging process • Decreased activity • Lifestyle factors Loss of bone mass in older women Joint and disk cartilage dehydrates causing loss of flexibility contributes to degenerative joint disease (osteoarthritis); joints stiffen, lose range of motion
- 15. Changes in OlderAdult Cause stooped posture, changing center of gravity Elderly at greater risk for falls Endocrine changes cause skeletal muscle atrophy Muscle tone decreases
- 16. Assessment Health history Chief complaint Onsetof problem Effect on ADLs Precipitating events, e.g., trauma
- 17. Assessment Examine complaintsof pain for location, duration, radiation character (sharp dull), aggravating, or alleviating factors Inquire about fever, fatigue, weight changes, rash, or swelling
- 18. Physical Examination Posture Gait Ability to walk with or without assistive devices Ability to feed, toilet, and dress self Muscle mass and symmetry
- 22. Physical Examination Inspect andpalpate bone, joints for visible deformities, tenderness or pain, swelling, warmth, and ROM. Assess and compare corresponding joints. Palpate joints knees and shoulder for crepitus.
- 23. Physical Examination Neverattempt to move a joint past normal ROM or past point where patient experiences pain. Bulge sign and ballottement sign used to assess for fluid in the knee joint. Thomas test performed when hip flexion contracture suspected
- 24. Checking for thebulge sign.
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- 26. Diagnostic Tests Bloodtests Arthrocentesis X-rays Bone density scan CT scan MRI Ultrasound Bone scan
- 27. Diagnostic Evaluation ImagingProcedure- Nuclear Studies – Endoscopic Studies – Other Studies – Electromyography Myelography* Laboratory Studies CT, Bone Scan, MRI Radioisotope bone density Arthrocentesis, arthroscopy Biopsy, synovial fluid, Arthrogram, venogram
- 28. Musculoskeletal Assessment – DiagnosticTest Laboratory Urine Tests 24 hour creatine- creatinine ratio Urine Uric acid –24 hr specimen Urine deoxypyridino line Laboratory • Blood Tests Serum muscle enzymes Rheumatoid Factor LE Prep/Antinuclear Antibodies(ANA) Erythrocyte Sedimentation Rate Calcium, Phosphorous, Alkaline phosphatase
- 29. Muscoluloskeletal Assessment – Diagnostic Cont. to Blood test CBC – Hgb, Hct Acid phosphatase Metabolic/Endocrine Enzymes Increase creatine kinase, serum increase glutamin-oxaloacetic due to muscle damage, aldolase, SGOT
- 30. INTERVENTIONS FOR CLIENTS WITHMUSCULOSKELETAL TRAUMA
- 31. Musculoskeletal Trauma Mildto severe Soft tissue Fractures Affect function of muscle, tendons, and ligaments Complete amputation
- 32. Musculoskeletal Trauma Tissue issubjected to more force than it can absorb Severity depends on: Amount of force Location of impact
- 33. Preventing Trauma Teach importanceof using safety equipment Seat belts Bicycle helmets Football pads Proper footwear Protective eyewear Hard hats
- 34. Soft Tissue Trauma Contusion Bleedinginto soft tissue Significant bleeding can cause a hematoma Swelling and discoloration (bruise)
- 35. Soft Tissue Trauma- Sprain Ligament injury (Excessive stretching of a ligament) Twisting motion Overstretching or tear ◦ Grade I—mild bleeding and inflammation ◦ Grade II—severe stretching and some tearing and inflammation and hematoma ◦ Grade III—complete tearing of ligament ◦ Grade IV—bony attachment of ligament broken away
- 36. Sprain Treatment ofsprains: First-degree: rest, ice for 24 to 48 hr, compression bandage, and elevation. Second-degree: immobilization, partial weight bearing as tear heals. Third-degree: immobilization for 4 to 6 weeks, possible surgery
- 37. Soft Tissue Trauma– Strain Microscopic tear in the muscle May cause bleeding “Pulled muscle” Inappropriate lifting or sudden acceleration-deceleration
- 38. Soft Tissue Trauma To decrease swelling and pain, and encourage rest: Ice for first 48 hours Splint to support extremities and limit movement Compression dressing Elevation to increase venous return and decrease swelling NSAIDs
- 39. Soft Tissue Trauma Diagnosis: X-ray to rule out fracture MRI
- 41. Fractures Break in thecontinuity of bone Direct blow Crushing force (compression) Sudden twisting motions (torsion) Severe muscle contraction Disease (pathologic fracture)
- 42. Classification of Fractures Closed or simple Open or compound Complete or incomplete Stable or unstable Direction of the fracture line Oblique Spiral Lengthwise plane (greenstick)
- 44. Stages of BoneHealing Hematoma formation within 48 to 72 hr after injury Hematoma to granulation tissue Callus formation Osteoblastic proliferation Bone remodeling Bone healing completed within about 6 weeks; up to 6 months in the older person
- 45. Emergency Care Immobilize beforemoving client Joint above and below Check pulse, color, movement, sensation before splinting Sterile dressing for open wounds Fracture reduction Closed—external manipulation Open—surgery
- 47. Musculoskeletal Assessment -Fracture Change in bone alignment Alteration in length of extremity Change in shape of bone Pain upon movement Decreased ROM Crepitation Ecchymotic skin
- 48. Cont. Subcutaneous emphysema with bubblesunder the skin Swelling at the fracture site
- 49. Special Assessment Considerations For fractures of the shoulder and upper arm, assess client in sitting or standing position. Support the affected arm to promote comfort. For distal areas of the arm, assess client in a supine position. For fracture of lower extremities and pelvis, client is in supine position.
- 51. Musculoskeletal – FracturesTreatment Primary Goal – reduce fracture- Realign and immobilize Medications Analgesics, antibiotics, tetanus toxoid Closed Reduction – Manual and Cast; External Fixation Device Traction; Splints; Braces Surgery Open reduction with internal fixation Reconstructive surgery Endoprosthetic replacement
- 54. Musculoskeletal Nursing Care -Casts • Neurovascular Check color/capillary refill Temperature Pulse Movement Sensation Traction Nursing Care Pin Site care Skin and neurovascular check
- 55. Cont. Elevate Extremity Exercises – to unaffected side; isometric exercises to affected extremity Keep heel off mattress Handle with palms of hands if cast wet Turn every two hours till dry Notify MD at once of wound drainage Do not place items under cast.
- 56. Care of clientin Traction T= Temperature Extremity Infection R= Ropes hang freely A= Alignment C= Circulation check (5 P’s) T= Type & location of fracture I= Increase fluid intake O= Overhead trapeze N= No weight on bed or floor
- 57. Musculoskeletal Nursing Care Promotecomfort Assess infection Promote mobility Teach safety Vital Signs Flotation, sheep skin Nutrition Vital Signs Monitor elimination Elevate extremity to decrease swelling/ ice pack Teach skin care, cast care, diet, complications
- 58. Risk for Infection •Interventions include: Apply strict aseptic technique for dressing changes and wound irrigations. Assess for local inflammation Report purulent drainage immediately to health care provider. Assess for pneumonia and urinary tract infection. Administer broad-spectrum antibiotics prophylactically.
- 59. Imbalanced Nutrition: Less ThanBody Requirements Interventions include: Diet high in protein, calories, and calcium, supplemental vitamins B and C. Frequent small feedings and supplements of high-protein liquids. Intake of foods high in iron
- 60. Amputations Surgical amputation Traumatic amputation Levelsof amputation Complications of amputations: hemorrhage, infection, phantom limb pain, problems associated with immobility, neuroma (a growth or tumour of nerve tissue), flexion contracture
- 61. Amputations Nursing Management Relieving pain Minimizingaltered sensory perception Promoting wound healing Enhancing body image Self-care
- 63. Phantom Limb Pain Phantom limb pain is a frequent complication of amputation. Client complains of pain at the site of the removed body part, most often shortly after surgery. Pain is intense burning feeling, crushing sensation or cramping. Some clients feel that the removed body part is in a distorted position
- 64. Management of PhantomPain Phantom limb pain must be distinguished from stump pain because they are managed differently. Recognize that this pain is real and interferes with the amputee’s activities of daily living. (Continued)
- 65. Management of PhantomPain (Continued) Some studies have shown that opioids are not as effective for phantom limb pain as they are for residual limb pain. Other drugs include intravenous infusion calcitonin, beta blockers, anticonvulsants, and antispasmodics.
- 66. Exercise After Amputation ROM to prevent flexion contractures, particularly of the hip and knee Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours Elevation of lower-leg residual limb controversial
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- 68. Osteoporosis A diseasein which loss of bone exceeds rate of bone formation; usually increase in older women, white race, nulliparity. Clinical Manifestations – bone pain, decrease movement. Treatment – Calcium, Vit. D, estrogen replacement, Calcitonin, fluoride, estrogen with progestin, SERM (Selective Estrogen Receptor Modulator) with anti-estrogens, exercise. Pathologic fracture-safety.
- 69. Classification of Osteoporosis Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s. Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility. Regional osteoporosis occurs when a limb is immobilized.
- 70. Health Promotion/Illness Prevention -Osteoporosis Ensure adequate calcium intake. Avoid sedentary life style (a type of lifestyle with a lack of physical exercise) Continue program of weight-bearing exercises.
- 71. Osteoporosis – Assessment Physical assessment Psychosocialassessment Laboratory assessment Radiographic assessment
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- 74. Drug Therapy Osteoporosis Hormone replacementtherapy Parathyroid hormone Calcium and vitamin D Bisphosphonates Selective estrogen receptor modulators Calcitonin Other agents used with varying results
- 75. Diet Therapy – Osteoporosis Protein Magnesium VitaminK Trace minerals Calcium and vitamin D Avoid alcohol and caffeine
- 76. Fall Prevention – Osteoporosis Hazard-freeenvironment High-risk assessment through programs such as Falling Star protocol Hip protectors that prevent hip fracture in case of a fall
- 77. Others - Osteoporosis Exercise Painmanagement Orthotic devices
- 78. Osteomalcia Softening ofthe bone tissue characterized by inadequate mineralization of osteoid Vitamin D deficiency, lack of sunlight exposure Similar, but not the same as osteoporosis Major treatment: vitamin D from exposure to sun and certain foods
- 79. Paget’s Disease ofthe Bone Metabolic disorder of bone remodeling, or turnover; increased resorption (the process by which osteoclasts break down bone and release the minerals, resulting in a transfer of calcium from bone fluid to the blood) of loss results in bone deposits that are weak, enlarged, and disorganized. Nonsurgical management: calcitonin, selected bisphosphonates, mithramycin Surgical management: tibial osteotomy or partial or total joint replacement
- 80. Paget’s Disease Animbalance of increase osteoblast and osteoclast cells; thickening and hypertrophy. Bone pain most common symptom; bony enlargement and deformities usually bilateral, kyphosis, long bone. Analgesics, meds bisphosphonates and calcitonin, NSAID, assistance devices, and hot/cold treatment.
- 81. Osteomyelitis A condition causedby the invasion by one or more pathogenic microorganisms that stimulates the inflammatory response in bone tissue Exogenous, endogenous, hematogenous, contiguous
- 82. Osteomyelitis Infection ofbone; causative agent – Staph/Strept Typical signs and symptoms : Acute osteomyelitis include:- Fever that may be abrupt Irritability or lethargy in young children Pain in the area of the infection Swelling, warmth and redness over the area of the infection
- 83. Osteomyelitis (cont.) Chronicosteomyelitis include: Warmth, swelling and redness over the area of the infection Pain or tenderness in the affected area Chronic fatigue Drainage from an open wound near the area of the infection Fever, sometimes Treatment – IV antibiotic; long term for 4-6 months
- 84. Surgical Management Osteomyelitis Sequestrectomy(Surgical removal of a sequestrum), a detached piece of necrotic bone that often migrates to a wound, abscess, etc.) Bone grafts Bone segment transfers Muscle flaps Amputation
- 85. Bone Tumors Benign BoneTumors Malignant Bone Tumors Metastatic Bone Disease
- 86. Cont. Bone Tumors Benign bone tumors (noncancerous): Chrondrogenic tumors: osteochondroma, chondroma Osteogenic tumors: osteoid osteoma, osteoblastoma, giant cell tumor Fibrogenic tumors
- 87. Interventions Nondrug pain reliefmeasures Drug therapy: analgesics, NSAIDs Surgical therapy: curettage (simple excision of the tumor tissue), joint replacement, or arthrodesis
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- 89. Be prepared forthe text next week (Monday)
Editor's Notes
- #16 ADLs
- #17 ADLs= Activity of Daily Life
- #23 Thomas test
- #28 Urine Tests – creatine-creatinine rtio for test presence of muscle disease; Urinary uric acid – gout – 24 hr specimen Urine deoxypyridinolie – assess bone resorption process Blood Serum muscle enzymes – aldolase, C’PK – muscle damage, c-reactive protein, Rheumatoid factor - latex fixation; certain antibodies indicative rheumatoid condition, Anti-DNA antibody Le-Prep/Antinuclear antibodies (ANA) – check protein (certain ones) increase, SLE Erythrocyte Sedimentation Rate (ESR), Alkaline poshpatase – bone tumor and infection Fx, Paget’s disease; increase osteoblastic activity
- #29 Lab blood work – inc. creatine kinase – Serum increase glutamin – oxaloacetic due to muscle damage Aldolase – muscluar dystrophy Venous system – check for vein thrombosis - venogram Myelopgraphy – radiopaque or contrast medium injected into arachnoid space. Pt assume a lateral sitting/position; used with MRI, CT Scan; same concerns with dye Nursing Care – Post Test – F.F., if dye oil based – flate in bed for 8 hours; if dye water based – BR with HOB inc. 30 –24 hour; air – head of bed kept lower than trunk 48; side effects dye – nausea, vomiting, headache; I & O, neuro check, F.F.; Discharge – 24-48 hours – no lifting, strenous activity 24; Check incision/puncture site Arthroscopy – visualization of joint with arthroscope; common knee used for other joints; arthrography – visualization, use of radiopaque dye – contract medium or air or both. Radio. Bone Scan – presence of metabolic disease, timors, infectionk, osteomylitis, Arthrocentesis - CT scans x-rays, MRI
- #34 Contusion= Bursies
- #38 NSAIDs
- #39 Magnatic Resonance Image
- #47 Ecchymotic=
- #53 Paresthesia= numness
- #56 Put Pt. On firm mattress Ropes and pulleys should be aligned. The pull should be in line with the long axis of the bone. Any factor that might reduce the pull or alter it’s direction must be eliminated. Weighs should hang freely. Ropes should be unobstructed and not in contact with bed or equipment. Help the patient pull himself up in bed at frequent intervals. Traction is not accomplished if knot in rope or footplate is touching the pulley or foot of bed or weight’s rest on floor. Never remove the weights when repositioning the patient who is in skeletal traction because this will interrupt line of pull. Every complaint of patient in traction should be investigated immediately.
- #63 A distortion is a change, twist, or exaggeration that makes something appear different from the way it really is. You can distort an image, a thought, or even an idea. To say that I never take out the garbage is a distortion of the facts.
- #65 calcitonin,
- #68 Metabolic disease, in which bone demineralization results in decreased density and subsequent fractures. Osteopenia (low bone mass, which occurs when there is a disruption in the bone remodeling process. Bone density scan altered, decrease density. Bone resorption exceeds bone formation. SERM – Selective Estrogen Receptor Modulators. “Nulliparous” is a fancy medical word used to describe a woman who hasn't given birth to a child. It doesn't necessarily mean that she's never been pregnant — someone who's had a miscarriage, stillbirth, or elective abortion but has never given birth to a live baby is still referred to as nulliparous.
- #74 Bisphosphonates are a class of drugs that prevent the loss of bone density, used to treat osteoporosis and similar diseases. They are the most commonly prescribed drugs used to treat osteoporosis. They are called bisphosphonates because they have two phosphonate (PO(OH) ) groups Calcitonin is a hormone that is produced in humans by the parafollicular cells (commonly known as C-cells) of the thyroid gland. Calcitonin is involved in helping to regulate levels of calcium and phosphate in the blood, opposing the action of parathyroid hormone.
- #80 NSAID= non steroid anti-inflamatory drugs
- #81 Contiguous = closest
- #84 A sequestrum (plural: sequestra) is a piece of dead bone that has become separated during the process of necrosis from normal or sound bone. It is a complication (sequela) of osteomyelitis.
- #86 An osteoma (plural: "osteomata") is a new piece of bone usually growing on another piece of bone, typically the skull. It is a benign tumor. When the bone tumor grows on other bone it is known as "homoplastic osteoma"; when it grows on other tissue it is called "heteroplastic osteoma".