Professional Documents
Culture Documents
Musculoskeletal System
The supporting framework of the body it consists of your bones, joints cartilage, tendons, muscle and
ligaments.
Joints
The junction where two or more bones that are articulated (close to each other) and provide motion and
flexibility in several directions.
Types of Joints
Synarthrosis – immovable (skull sutures, sacrum)
Amphiarthrosis – limited movement (vertebral joints, symphysis pubis)
Diarthrosis – freely movable
Ball & socket – full freedom of movement (hip, shoulder)
Hinge – bending in one direction (elbow, knee)
Saddle – movement in two planes at right angles (base of the thumb)
Pivot – rotation turning a door knob (articulation between radius & ulna)
Gliding – limited movement in all directions (wrist)
Cartilage
Connective tissue that provides support to soft tissue
Found in between articulated surfaces
Avascular (no blood supply) – fed by synovial fluid
Muscle
Used for body movement, posture and heat production
Skeletal- More than 55% of muscle in body
Smooth- Inside of arteries, inside of bladder, inside lining of GI tract
Cardiac- Found in heart
Causes spontaneous contractions and relaxations in the heart
When muscle contracts it brings two points of attachment closer together
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Ligaments and Tendons
Ligaments- attach bone to bone
Tendons – attach muscle to bone
Both are made up of connective tissue
Both have poor blood supply (avascular) so nutrition is gained from synovial fluid
Fascia
Think of an envelope
Fibrous connective tissue that encapsulates muscles
Smooth tissue that allows gliding of muscle over muscle
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Musculoskeletal Assessment
Patient History Past medical history- specifically:
Description of health problems
Family history of M.S. problems
Medication history (otc drugs, rx drugs, nutritional supplements)
Hx of bone infection (osteomylitis)
Assess for muscle spasms. What do they use to treat?
Surgical hx r/t m.s problems
Was patient ever immobilized for long periods of time (risk of renal
calculi and osteoporosis)
ADL assessment- independent, needs assistance
Are they able to move joints independently without restriction?
Elimination- can they get to the bathroom on time?
Use of assistive devices
Nutritional intake (24 hr recall, supplements, weight loss or gain.)
Pain
Assess for:
intensity - pain scale 1-10
quality - sharp, dull, throbbing, burning
onset – when did it start
timing – when is pain worse (morning, evening.)
aggravating factors – what seems to make it worse
association – is it linked to anything else
If unrelenting pain to an area after medication, it may indicate compartment
syndrome. This means device being used (traction, casts, splints etc.) will need
to be removed immediately. Neurovascular compromise is occurring.
Lab Tests
CBC – WBC (infection), H&H (anemia)
Electrolyte imbalance – Ca (immobile pt, calcium leaves bone and enters blood),
Phosphorous, uric acid (gout)
Alkaline phosphatase – elevated during initial bone healing
Sedimentation rate – ESR elevated during inflammation
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Soft Tissue Injuries
Cold Therapy
When – between the first 24-48 hours to prevent swelling, pain, and muscle spasms by promoting,
vasoconstriction
How –
Use ice bags, cold packs – 20 minutes on 20 minutes off
Compress with compression bandage
Elevate above level of heart b/c of swelling and excessive fluid to the area, elevation increases
venous return
RICE = R-rest, I-ice, C-compress, E-elevate ,
Hot Therapy
About 48 hours after injury
Promote circulation, analgesic, reduce muscle spasm, enhances flexibility
How – light/radiation, hot pack, heat pads
Use intermittent 15-30 minutes on and off
Not over 100 degrees
Care in elderly, young, diabetics or spinal injury patients due to loss of sensation in extremities.
NI -
Protect skin from irritation
Subjective info from pt to monitor response
Contusions
A soft tissue injury produced by blunt force trauma such as a blow, kick or fall
No damage to bones of the M.S. system
Clinical manifestations
Pain
Swelling
Skin discoloration
Limited ROM
No loss of joint function
*****WITH BOTH SPRAINS AND STRAINS THERE ARE THREE CLASSIC SYMPTOMS, PAIN,
TENDERNESS AND SWELLING.
Strains
An excessive stretching of the muscles and its facia sheath
May also involve tendons
Caused by overuse, over-stretching, twisting and excessive stress.
Tiny microscopic tears occur with some bleeding into the soft tissue
Heals in 2-6 weeks
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S/S:
Sudden pain with out muscle movement
Muscle soreness and tenderness
Pain
Swelling,
Bruising and redness
Muscle spasms and decreased movement
Initially will not be able to bear weight on that extremity
Sprains
An injury to the ligament structures surrounding a joint
Caused by wrenching or twisting motion
May take weeks or months to heal
Joint is stretched beyond normal ROM tearing ligaments, capsule or synovium of joint
Blood vessel rupture and edema occurs
An avulsion may occur (bone fragment is pulled away by a ligament or tendon)
Common areas for sprains:
Ankles and wrists
Common in people who are in to sports
S/S:
Swelling
Joint tenderness
Limited joint mobility
Severe Pain with sprain b/c of amount of nerve endings where it occurs.
Diagnosis:
History
Physical exam
X-ray to r/o fracture and to see if there is a widening of the joint area itself.
Treatment:
RICE technique in acute phase
Medications:
Mild analgesics (NSAID’s)
Heat in post-acute phase
Protected exercises
Surgical repair if necessary
Immobilize if necessary
ACL Injury–
Anterior cruciate ligament
A common sports injury in which the stabilizing ligaments of the knee are lost or compromised
S/S:
Snapping sound, pain, swelling
Unable to bear weight on that leg.
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Management:
Surgical repair and use of full leg immobilization device
Torn meniscus
Tear in the fibro-cartilaginous semicircular structure of the knee joint
S/S:
Popping sound, tearing sensation, swelling, inability to extend knee
Management:
Surgery - total Menisectomy
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Joint Dislocations and Subluxations
Subluxation
Partial joint dislocation
Etiology 3 categories
• Congenital : Children or babies that are born with hip displasia
• Spontaneous: Actual disease osteoporosis, pagets disease, bone tumor or cyst
• Somatic: Sports injuries
Diagnosis:
• Patient hx
• Incident of what happened
• Physical exam
• X-ray to visualize how much structures have shifted
Treatment:
Orthopedic Emergency
Goal is to re-align dislocated portion and relieve pain
• Analgesics
• Muscle relaxants
• RICE
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• Immobilize area to protect injured joint in acute phase
o Once joint is stabilized, gentle ROM exercises can be performed
Nursing Dx
• Acute Pain:
o Pt will be medicated
Be sure extremity is elevated because of swelling you want to decrease edema,
If patient is using an immobilizer make sure patient uses it correctly
• Impaired mobility
• Altered health maintenance
o Teach and demonstrate and have patient demonstrate back how to use an immobilizer
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Fracture
• It is a break in the continuity if bone and it is defined according to the type and extent.
• Occurs from trauma or a blow to a direct area
• Crushing sports injury and sudden
Pathophysiology
4 categories
Closed fractures: bone is broken on the inside and there is no external injury, bone is broken
but skin is intact.
Open fractures: There is a break in the skin causes by fractured bone protruding out.
Stable fractures: break occurs, but bone is not completely broken off
Unstable fractures: bones are grossly misplaced. Another name for this is an open fracture.
• Ie-Compound fracture
• Pathological bone diseases like osteoporosis where there is bone demineralization, bone tumors
• Long term steroid use makes your bones very porous and brittle which means more prone to breakage
Stable fractures:
• Greenstick fracture: a fracture in which one side of a bone is broken and the other side is still stable
(not broken); seen in long bones
• Transverse fracture: a fracture that is straight across the bone; seen in long bones.
• Spiral fracture: a fracture that twists around the shaft of the bone; climbs or decends in a wrap around
fashion.
Unstable Fractures:
Compound Fracture: Bone is broken off altogether and is protruding out of the skin.
• Comminuted fracture: a fracture in which bone has splintered into several fragments. Most likely to
hear crepitus with this type of fracture.
• Depressed fracture: a fracture in which fragments are driven inward; skull and facial bones.
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• Oblique fracture: a fracture occurring at a slant across the shaft of the bone
• Impacted fracture: a fracture in which a bone fragment is driven into another bone fragment; one bone
driven into another
Can be stable or unstable:
Compression fracture: a fracture in which bone has been compressed; seen in vertebral fractures; seen
in osteoporosis.
• Pathologic fractures: a fracture that occurs through an area of diseased bone, can occur without trauma
Can occur with osteoporosis, Paget’s disease, bone tumors, osteosarcoma, osteomalacia, bone cyst.
Which fracture is the worst one, the one you are prone to infection and takes a longer time to heal?
Compound fractures cause the bone to protrude out
Clinical Manifestations
• Pain
• Tenderness
• Muscle spasms
Diagnosis of a fracture:
• X-ray
• Patient hx
• Physical exam
• MRI
• Ct-scan depending on the location and extent of the fracture
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How to manage a fracture:
• Do not realign a bone
• If it is an open fracture and you see bone sticking out = cover it w/sterile gauze or clean lint free material to
decrease risk of contamination
• Immobilize that part of the body and if you are moving that person you are going to support above and below the
area that is affected.
•
• Open reduction: ORIF (Open Reduction Internal Fixation) done in OR under general anesthesia,
o Patient is given pain meds, incision is made, bones are realigned, then insertion of pins, rods, nails, or
screws are used to put that bone back together into anatomical position
o Higher risk than closed reduction b/c of risk for infection, and riskd from anesthesia especially in young
and elderly.
Traction
The application of a pulling force on a fractured extremity to maintain alignment
Minimizes muscle spasms, reduces, aligns and aligns fractures & reduces deformities
Indications
Stabilize and reduce fractures
Increase space between opposing forces
Limb lengthening
Reduce deformities
Maintain anatomical alignment
Prevent contractions
Types of traction:
Skin –
Applied directly to Pts skin and soft tissue by use of ace bandages and traction boot
Pulley system at the end of the bed with weights
Weight 5-10 pounds maximum which hangs freely
Don’t put traction device on floor
Don’t cover device with sheets
Two forces working against each other- the weights, and the force of the body which is pulling back and
serving as counter traction.
Wrap and boot on extremity are not put over boney prominences
Short term use (will be used pre-op b/c pt is in a lot of pain with muscle spasms- traction helps to reduce the
muscle spasms and the pain
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Assess area before applying, shave, avoid wrinkles in material used to wrap limb
Contraindications:
Rash, impaired circulation, varicose ulcers, and numbness
Complications
Allergies to tape, irritation, nerve palsy from pressure (foot drop), circulatory impairment (cold,
cap refill poor, poor pulse)
Skeletal –
Longer term use- can be weeks or months
Used to align joints, bones, restriction of movement
Traction applied directly to boney skeleton
Done surgically in OR
Pins inserted in bone distal to fracture
Weights are 5-45 pounds
Examples of skeletal traction: Halo traction, 4 pins in skull attached to vest
Cervical spine traction
NI:
Assess for six P’s every shift
Neuro assessment every hour post surgery than every 4 hours
Check for possibility of DVT’s with Homans sign (pain in calf with dorsiflexion)
Pin care
Risk for infection, osteomylitis(bone infection.)
Manual traction –
Traction applied with hands to realign a joint or fracture
While applying cast
Nursing Diagnosois:
Risk for infection
N.V. assessment
Wound drainage
Pain meds
S/S infection
Integrity of device
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Teach relaxation (deep breathing, imagery)
Complications
Skin breakdown, circulation problems, foot drop, pneumonia, DVT, anorexia
Fracture immobilization
Once area has been fixed and back in place the patient may have to wear a cast, splint and they may have to
have internal or external fixation devices.
Splints
Immobilization device that supports one or both sides of a part of the body and is secured with tape or ace bandage plastic,
thermoplastic
Purpose –
In an emergency or for non rigid immobilization
To stabilize fracture during anticipated swelling and edema
Provide functional support & positioning before cast application
Nursing interventions
Well padded to prevent pressure and prevent skin abrasions & skin breakdown
Assess NV status frequently and 6 p’s
Wrap splint with elastic bandage
Teach patient to apply brace
Teach patient to protect skin
Teach patient to assess for 6p’s
Casts
Cast – rigid external immobilizing device molded to contours of the body
Purpose – immobilize part of body, support weakened joints, and treat deformities
Examples:
Short arm cast for fractures of the wrist area
Long arm cast for unstable wrist fracture or forearm fracture
Body jacket for fractures of thoracic or lumbar area to stabilize vertebral column
Hip/biker cast for pt’s that have suffered hip fractures
Types –
Plaster –
Does not have full strength until dry
Takes time to harden
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Can be dented during hardening
New – white, shiny, odorless
Wet – grey, dull, musty
Fiberglass –
Better of the two choices
Light weight
Stronger, h2o resistant and durable
Hardens within minutes
Cast application
Skin assessment –
Clean and dry
Unusual swelling, bruising or edema
Body part in proper alignment
Marked area around bony prominences
Layer of stockingette to pt skin- make sure no wrinkles or creases
Thin layer of padding added especially over boney prominences
Apply cast material
Nursing interventions
Initially ice will be applied to areas above and below the cast to reduce swelling
Elevate cast limb on plastic covered pillow to encourage venous return to reduce edema
ROM exercises for joints above and below cast
Do skin assessment to assess for problems (ie discoloration of the toes, unusual pain, burning and tingling under cast, foul
odor coming from cast)****see complications below****
Check 6 P’s - pulse, pressure, pallor, pain, pulselessness, paresthesias, paralysis
Check for stain on casts- if present , circle it, time ,date and initial it. When re-checked later be sure stain has not spread
The best place to assess for bleeding w/in a cast is to lift the cast up, and check underneath.
Nursing Diagnosis
Risk for peripheral neurovascular dysfunction R/T cast too tight
Patient teaching
Itching under cast – do not stick sharp object, use cool blow drier
This is because you can’t see under cast, and an object can cut you and you wouldn’t know. May lead to
Osteomylitis
Do not get cast wet-only cover when showering b/c of risk of moisture build-up
If cast does get wet use hairdryer on cool setting to dry
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Do not remove any padding either above or below the cast.
Do not put powder in cast
Do not cover with plastic for long, only for showering.
Do not bear weight on it for first 48 hours.
Exercise unaffected limb to avoid disuse syndrome
Compartment syndrome –
Increase in tissue pressure within a limited space that compromises circulation and function of tissue within a confined area
Caused by cast that is too tight
Remove cast, considered a medical emergency
Symptoms – unrelenting pain not relieved by meds
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*******Do not cover cast with plastic or rubber except to take shower
Cast syndrome
Only with a body cast
Restricted chest expansion, compression of mesenteric artery causes decrease of GI motility
S/S:
Anorexia, accumulation of gas, N.V., abdominal discomfort
Risk of gangrene of intestines due to lack of blood supply to GI tract
Do thorough abdominal assessment every shift, best right lower quadrant at the ileocecal valve
Listen 3-5 minutes
Foot drop –
Caused by perineal nerve damage
Internal Fixation
Used for stable fractures
Put the fracture back together internally with the use of pins, rods and screws attached permanently to bone
Products are mostly made out of stainless steel and titanium
Post-op:
X-ray to be sure has been correctly aligned
F/U X-rays over next few weeks or months to be sure alignment is maintained
Indications
For stabile support of severe fractures, crushed or splintered bone while permitting active treatment of damaged
tissue
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Provides access to open wounds for debridement, irrigation & skin grafts
Provides limb lengthening (telescoping rods, turned by pt)
Reduce, align & immobilize fracture by a series of pins inserted into bone
Position is maintained by attachment to external frame
Contraindications
Patients with diabetes
Elderly (esp. those that are confused)
Immunocompromised r/t high risk of infection.
Nursing assessment
Pin site assessment 1x/shift (redness, drainage, tenderness, pain & loosening of the pins)
Nurses do not tighten pins or clean device , patients are taught how to do this
If pins were to become loose, and patient is unsure of how to tigten, call Orthopedics, who will show
them
When Patient cleans device it will be with sterile water, and sterile cotton swabs
Extremity elevated to reduce swelling
Cover sharp points on External Fixator to reduce device induced injury to patient or others
Assess 6-P’s
Neurovascular status check q2-4 hours
Isometric and active exercise within limits of tissue damage
Encourage patient to adhere to weight bearing order from MD to avoid pin loosening
Do not pull on rods- lift extremity to move patients.
Complications
Anestesia (esp in older patients)
May prolong periods of immobility
Pt will not have a lot of use of this extremity- probably will only be able to move toes or fingers
Risk for infection (watch for purulent drainage( serous normal)
Administer antibiotics
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Complications with fractures:
Infection
Especially if it is an open (compound) fracture. If area is contaminated surgical debridement will be necessary.
Patient will be on antibiotics. When area is irrigated topical antibiotics will be used also.
Hypovolemic Shock
Shock from hemorrhage loss and from loss of extra-cellular fluid into damaged tissue. May occur from fracture to
extremities, thorax, pelvis or spine
Assessment
Decreased BP, increase HR & Resp, cool and clammy, restlessness and decreased LOC
Management
Replace fluid loss, keep warm, monitor V.S. & O2 status, restore blood volume and circulation, and monitor labs
especially hct, hmb
Fat Embolism
Fat globules in blood stream that results from a fracture of the long bones in the body (Tibia, Femur)
Fat globules lodge in the capillary bed of the lungs, and also may make it to the brain
Usually seen within 24-48 hours of fracture long bones
Seen frequently in young adults (20-30)
Assessment –
ARDS- acute respiratory distress syndrome:
Chest pain
Difficulty breathing /wheezing
Use of accessory muscles while breathing
Hypoxic
Headache
Change in mental status (memory loss, irritable, confused, agitated, sense of impending doom)
Increased HR (tachycardia) & Respirations (tachynpea)
Petechiea
Management – coughing
Deep breathing and coughing exercises (mainstream treatment)
Anti-coagulants (ie – lovenox)
Aspirin
Administer O2
Bed rest
Chest X-ray to visualize areas that have consolidated w/in the lung
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Intubation if none of the previous interventions work.
Compartment Syndrome
Tissue perfusion in the muscles is less than that required for tissue viability
Rise in inter-compartmental pressure within the muscle itself that results in tissue damage. Usually associated with
IV infiltration into tissues instead of veins
Cast or splint too tight.
Tissue death within 4 hours
Normal pressure 8 mm of mercury, above 8mm tissue perfusion will be impaired.
Manifestations-
Unrelenting deep throbbing pain not relived by meds
Swelling, numbness, tingling
Nail beds cyanotic, poor cap refill, loss of distal pulse
Paralysis
Management
Notify MD STAT- Medical emergency
Remove constricting dressing or cast
Measure pressure
Management
Anticoagulant therapy
Avascular Necrosis
Caused by blood supply to bone being sluggish or lost, and as a result bone loses its blood supply
Occurs mostly at femoral head, talus bone of the ankle or lunate bone of the wrist
Occurs with steroid use, chronic renal failure, prior bone transplant, sickle cell disease
Assessment:
Pain numbness and tingling in extremity,
Limb unstable
Decreasing ROM
DX:
X-ray, bone scan, CT scan
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Management:
No weight bearing to bone
Removal of bone or bone graft or prosthesis
Joint fusion, replacement or amputation
Delayed Union
Healing does not occur at a normal rate for the type and location of fracture
Non-Union
Failure of the ends of the fractured bone to unite
Manifestation
Painful fracture (localized pain to wrist)
Swelling to surrounding area
Dorsal displacement of the distal fragment (X-ray shows dinner fork deformity)
Loss of sensation due to pressure on median nerve
Complications
Vascular insufficiency
Management
Closed reduction (manipulation)- no surgery involved
Immobilized with splint or cast
Pain meds before reduction and prn.
Follow up with X-ray to be sure bones have been reduced to normal anatomic alignment
Elevate first 48 hours
Exercise immediately fingers and hands
Nursing Dx
Altered peripheral tissue perfusion
Risk for impaired skin integrity
Self care deficit
Hip Fractures
Most common fracture in older adults
Different types –
Intracapsular –
Occurs in hip join itself-( ie- head of femur,acetabulum area)
Harder fracture to heal b/c it it difficult for the blood supply to get to the
intracapsular area of the hip joint
Occult – Fracture, little trauma, minor discomfort
Impacted & Non-displaced – moderate pain, no deformities
Displaced – lot of groin pain, externally rotated leg, ORIF to fix
Causes:
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Osteoporosis
Extracapsular –
Occurs outside of joint capsule itself
Trochanteric
Subtrochanteric
Causes:
Falls (esp on snow or ice)
Direct trauma to hip (ie-car accidents
Manifestations
External rotation of leg
Lots of muscle spasms
Shortening of the affected leg
Excruciating pain (Localized) and tenderness at site of injury
Disruption of blood supply to area
Diagnosis:
X-ray- definitve test
CT scan
MRI
Patient History and physical exam- will note shortening of the affected leg, swelling
Medical Management :
Prior to surgery temporary skin traction (Bucks Traction- no more than 5-10 lbs, wrap is applied directly to
skin.) to relieve pain and spasms
Not left on for more than 48 hours.
Sand bags for alignment and prevention of rotation
Analgesics
Muscle relaxants r/t muscle spasms
Surgical repair
Pre-op-
Administer pain meds for pain management
Muscle relaxants
Teach use of overhead trapeze to maintain correct realignment achieved with traction
Post Surgery –
Monitor VS
Monitor I&O with foley
Lung assessment r/t risk of pneumonia- teach pt to cough and deep breathe, use of incentive spirometer
Continue to administer pain meds
Address dressing area for unusual drainage, bleeding or bulging
Neurovascular assessment- color, temp, cap refill, distal pulse (always assess good leg first to
get a feel for what the pulse should be and use that as a reference point to compare) edema, lack of
sensation or unusual sensation
Post-op teaching:
DO NOTS: ****Look at pictures in book****
Do not force into more than 90* of flexion
Can sit in an upright 90* angle, but no bending over more than 90*
Force hip into internal rotation (do not turn leg inward when lying down)
Force hip into adduction- leg must remain slightly abducted.
****All are achieved by use of an abductor pillow****
Never cross legs
Sit on chairs without arm rests
Arm rests are used for pt to push themselves out of chair.
DO:
Wear shoes, but adaptive devices are needed to put shoes on b/c no bending over
Elevated toilet seats
Abductor pillow b/t legs (while in bed ) for first 8 weeks s/p surgery***look at picture***
Keep hip in neutral position
Notify MD if severe pain, deformity or loss of function in leg (difficulty moving)
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Complications of hip fractures:
Avascular necrosis (esp with intracapsular fractures where blood supply has been cut off)
Dislocation-
Patient will hear a popping sound
Will manifest as pain to buttocks area
Pt will have to be re-xrayed and f/u surgery may have to be done.
Leg shortening (pt. may end up with a deformity)
May need lift for shoe
Non-union
Failure of bones to heal and fuse and align appropriately
Bone infection (osteomylitis)
Osteomylitis is dangerous b/c bone is hard and dense and it is difficult for antibiotics to reach abscess
(casing around infection
Blood vessel and nerve damage as a result of avascular necrosis
Interventions
Post-op care
Medication, IV antibiotics
Deep breathing – strength exercises
Foot exercises, flexion, extension
Anti-embolic stockings to compress and increase circulation
Nutrition, urinary output,
Abductor pillow in proper alignment
Monitor for DVT, skin assessment, NV complications
Breath sounds every shift
Patient teaching prior to and post surgery
Nursing Dx-
Pain
Impaired Skin Integrity
R/F Infection
Self care deficit
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Nursing Diagnosis for Fractures
Impaired skin integrity
Risk for impaired Skin Integrity
Acute Pain
Risk for infection
Impaired physical mobility
Risk for impaired peripheral vascular dysfunction
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Open / Compound fractures
• Prevent infection
• Give patient prophylaxis direction
• Culture area to make sure there are no harmful organisms growing in there
• Elevate extremity: you want to eliminate edema to that area
• Neuro assessment a q4hrs
• Monitor v/s especially temp( first sign of a brewing infection an increase in temp)
Assistive Devices
Canes
Help pt walk with greater balance and support and relieves pressure from weight bearing joints by redistributing the
weight.
Types – single legged, tripod (three feet), quad (best stability)
Measurement –
Patient standing upright
Slightly flex elbow at 30* angle
Handle of cane at same level as greater trochanter
Tip of cane 6” to the right or left of the base of the 5th toe
Must have non skid rubber tip at base
Pt must wear good shoes
Hold cane in hand of good side (opposite side of affected extremity)
Advance cane at same time as affected leg to relieve pressure
Walker
A four point assistive device that provides a much broader base of support
With and w/o wheels
Measurement –
Standing upright
20 – 30* flex at elbow
Top of walker is level with thumb joints, and there should be NO flexion of thumb joints
Wear sturdy shoes
Use walker to assist in getting up with good leg assist
Push off bed/chair to stand- never pull walker towards them
Look up as you walk- towards the horizon, not down.
3 pt gait –
For no weight bearing on one leg
Think of patient with cast on.
There are three points on the floor (two crutches and one leg)
4pt gait –
PWB on both legs
Slow version of 2 pt for support
Reserved for pt’s with poor balance
Four points on floor at all times (two crutches and two feet)
Advance left foot, right crutch, then right foot, left crutch (one foot then crutch)
Swing through/Swing To –
Variation of three point gait for pt’s who are NWB to one leg
Swing To-
Usually used in the beginning, when pt’s are adjusting to crutches
Swing good extremity to the level of the crutch (tripod)
Swing Through-
Usually reserved for when pt can go faster, and it more sure of themselves on crutches
Swing good extremity through the crutches so it ends up in front of them.
Environmental safety
Avoid wet floors, polished floors, loose rugs, wear proper fitting shoes
Crutch up and down stairs same as cane (good to heaven, bad to hell)
******Look at pictures****
Up good leg 1st, then advance crutches
Down bad leg 1st with crutches
Nursing diagnosis:
Risk for falls
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Amputations
Removal of body part, usually and extremity (arm or leg)
Indications depend on underlying disease or cause
May be traumatic or therapeutic
What is left? – Stump
BKA / AKA – below knee amputation, above knee amputation
AEA/BEA- above/below elbow amputation
Goal of Amputation:
Removal of as little of the extremity as possible to preserve function, but at the same time removal of
dead, infected or ischemic tissue
Relieve symptoms such as pain and compromised circulation, improves quality of life
Causes of amputations:
Traumatic accident, crushing injury, frostbite, gangrene
Therapeutic – diabetes with poor circulation
Indications
Peripheral vascular disease
Traumatic crushing injuries
Malignant tumors
Local or systemic infections
Congenital deformities
Chronic pain
Uncontrolled diabetes
Types of amputations
Closed – remove bone, suture skin and put muscle flap over area
Open – remove everything bone, muscle soft tissue than corterise
Disarticulation – removal of an actual joint itself
Diagnosis
Patient history and physical exam
Physical appearance of soft tissue
Skin Temperature
Sensory function (using cold or hot, sharp or dull, tuning fork to see if vibration felt)
Presence of peripheral pulses ( if distal pulse can not be felt f/u with Doppler study)
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*****assess good leg first to get baseline and if deviation is noted in bad leg
Arteriography for circulatory status
Doppler Recording for info r/t blood flow to extremity
Complications
Hemorrhage – major complication
Infection- may infect bone (osteomylitis)
Delayed healing – especially in pts with circulatory problems
Flexion contracture–Especially to hip area
We want patient to get OOB, and sit in chair, but for no longer than 1 hour b/c longer than an hour forces
hip into contracted state.
Place patient on stomach (prone position) for 20-30 minutes a day x 3-4 times a day. The rationale behind
this is to keep leg in extension
No elevation of stump
Skin irritations r/t prosthesis
Phantom limb pain – very real especially if traumatic injury
Pre-op – explain phantom pain
Edema
Compression dressing, NO elevation of stump
Nursing Dx
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Pain
Alteration in sensory perception
Impaired skin integrity
Body image disturbance
Dysfunctional grieving
Risk for infection
Impaired mobility
Risk for depression
Indications:
Osteoarthritis r/t excessive weight bearing on joints- seen in people who play sports- most common cause
Avascular necrosis
Rheumatoid arthritis
Failed prior reconstructive surgeries
Congenital hip disease
Fractures
Nursing intervention
Preop baseline assessment to compare to postop
Prevent infection, aseptic technique, antibiotic therapy, C&S
Promote ambulation ASAP per MD orders
Prevent dislocation:
Sit patient in high seats
Fracture pan for voiding
No driving
No adduction
No crossing legs
Bed elevation less than 60*
No hip bending more than 90*
Safe transfer OOB – get out of bed on either side with assist of 2
S/S of dislocation :
Shortening of leg
Leg not aligned
Abnormal rotation
Pain, pop heard by patient
Complications
Infection-considered most serious complication of joint surgery
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If infection occurs in area joint was replaced, further surgeries will need to be done, and the
following surgery will be more intense
If area becomes infected it will almost always lead to pain, loosening of prosthetic device and
dislocation
Bleeding - hip 200- 500cc drainage within first 24 hours
Within 48 hours down to less than 30cc
Knee 200-400cc first 24 hours
Within 48 hours down to 30cc
Injury to nerves
Excess wound drainage
Loosening of prosthetic
Shortening or misalignment of extremity
Heterotrophic ossification-development of new bone in space of device
Avascular necrosis
DVT
Pt’s will be on Lovenox post surgery to prevent DVT, and sent home on low dose aspirin
Important to note:
If patient returns home and starts running fever of unknown origin, increased pain
locally to replaced joint area, unusual drainage at incision site, these are all indications that there
is an infection. Notify MD ASAP.
Nursing Diagnosis:
Pain
-meds
Impaired physical mobility
-maintain alignment, assistive devices
Self care deficit
Impaired tissue integrity
Risk for infection
Risk for ineffective neurovascular dysfunction
Anxiety
-diversion therapy
Infection
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Osteomylitis
A severe Infection of the bone, bone marrow and soft tissue surrounding bone
Risk factors
Malnutrition
Obesity / elderly / children
Surgery
Impaired immune system, diabetics
Wound dehiscence
Long term steroid therapy
Diagnostic history
History (esp of previous surgeries)
Assess for recent trauma
Recent illness
S/S infection
Clinical manifestation
Localized:
Constant dull bone pain
**Bone pain is a dull, aching pain that is constant
Swelling
Tenderness
Warmth over site of infection
Restricted movement to area
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Muscle spasms
Thin, scarred skin
Systemic
Fevers
Nightsweats
Chills
Restlessness
Nausea
Malaise
Increased temp, pulse, heart rate
Fatigue,
Leukocytosis
Lymphademyopathy (swollen,tender lymph nodes)
Dx tests
*** MRI and CT scan (early definitive test)- Identifies area of infection in bone and soft tissue
Blood or wound cultures- to Id organism
Will show elevated WBC, ESR (Indicates infection in body, but not where)
X-ray irregular – decalcification of bone site will be seen
Radionuclide bone scan- Used to ID area within bone that is infected
Ultra sound – to visualize fluid abscess
Bone or soft tissue biopsy- to ID organism causing osteomylitis
Treatment
Treat aggressively with IV antibiotics for 6 weeks-3 months
Harsh antibiotics- aminoglycosides- (end in –ycin) which cause ototoxicity
Also preventing spread with prophylactic antibiotics
Surgical debridement
Hyperbaric O2 therapy
100% O2 administered directly to area that has osteomylitis
Believed to stimulate circulation and heal infected tissue
Bone Grafting
****If none of the above procedures work pt may be candidate for amputation.
Needle aspiration for sample for C&S
Pharmacology –
Antibiotics
NSAIDS
Narcotic Analgesics
Muscle Relaxants
Non-pharmacological-
Hypnosis
Guided imagery
Diet –
Increase protein, calories, vit C, calcium
Monitor for complications
Complications:
Flexion Contractures
Footdrop
High dose antibiotics adverse/toxic reactions
Ototoxicity, photosensitivity, GI Upset, colitis, Candida overgrowth (yeast infections, oral infections)
Use Probiotics, acidophillus ,yogurt to reintroduce yeast back into the body wile on antibiotics
Nursing Dx
Acute Pain
Impaired physical mobility
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Knowledge deficit
Risk for infection
Hyperthermia
Ineffective Therapeutic Regimen Management
R/t patient has an illness that they are going to be treated for long term. Will include a lot of patient
teaching re: medications, diet
Osteoporosis
A chronic, insidious progressive metabolic systemic bone disease characterized by low bone mass and structural
deterioration of bone tissue leading to bone fragility, and in turn fractures
A reduction of bone density and a change in bone structure both of which increase susceptibility to fractures
Risk factors
Pregnancy and lactation
Increased age increases risk
Females Increased risk (but males can get too, but they get a much higher intake and lower output of ca+)
Having a thin,small, frame
Family History of osteoporosis
Diet Low in CALCIUM
Lactointolerant, vegetarians
Race – White, Asian more susceptible
Endocrine – menopause r/t sharp decline in estrogen (rapid bone loss occurs at same time)
Neurological disease- Parkinson’s,
Medications –Long term use of corticosteroids, anti-seizure meds, aluminum containing antacids,
thyroid hormones
Secondary osteoporosis caused by external forces like meds, and diseases like Parkinson’s
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Hormones r/t osteoporosis
Calcitonin – (secreted by thyroid gland) maintain serum Calcium, phosphorous levels
To prevent bone destruction and promote bone formation
Calcitonin production deceases with age
Parathyroid hormone–
Regulates calcium and phosphorous
Vitamin D – calcium absorption and bone health, comes from sunshine, and foods high in vit d.
You need Vit. D to absorb calcium
Prevention:
Diet:
Calcium- 1,000 mg/day premenopausal
1,500 mg/day postmenopausal
Vitamin D- To ensure calcium absorption
Exercise:
Moderate weight bearing (walking 3-4 times a week,hiking,stairclimbing)
Medications:
Want to be sure they are using their medications correctly ***see medications below**
Manifestations
*****will not usually be able to see symptoms
Back pain
Loss of height
In severe cases Spinal deformities-
Dowgers hump – kyphosis
Very prone to fractures-
Vertebral fractures, or compression fractures (most common), hip, wrist
Severely stooped posture
Diagnosis
**Based on patient history and PE
Bone mineral density test (BMD)
– Measures how tightly packed bone is on the
X-ray
–Will only show after 30% of bone destroyed
Quantitative computer tomography (QCT)
– Good for spine
*** Dual energy x-ray absorptionmetry (DEXA)
-Reserved for patients who are on meds for osteoporosis to see if improvement in condition is occurring,
Lab studies
Serum calcium, phosphorous, alkaline phosphotate,These all work together for ca+ absorption.
calcitonin, vit.d ****look up levels****
Bone Biopsy
Medical Management
Biphosphonates – Fosomax, inhibits bone reabsorption to prevent osteoporosis, helps to build bone
Can be given daily or weekly PO
Give 30 min before meals on empty stomach
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Sitting in an upright position to lessen the change of esophageal irritation
Can be standing and moving around, just not lying or reclining
S/E- Anorexia, weight loss, gastritis, esophageal irritation
Calcitonin –Replacement hormone to increase bone mass
HRT - estrogen
Evista – SERM - selective estrogen receptor modulator, works like estrogen
Exercise – weight bearing (walking) and resistance training
Nutrition – calcium, vit D, milk, cheese, fish oil, supplements, green leafy veg.
Cut down/out drinking and smoking
Nursing Diagnosis:
Pain
Risk for injury
Knowledge deficit
Patient history
*** Generalized stiffness in morning lasts from an hour to several hours for more than 6 weeks
*** Symptoms bilateral and symmetrical
Joint pain w/warmth and tenderness to the touch
Swelling of 3 or more joints for more than 6 weeks
Nodules over joints as disease progresses
*** Acute- comes on quickly in starts in small joints of hand, wrist and feet
Manifestations
Systemic
Symptoms occur symmetrically
Onset is insidious
Systemic-
Low grade fevers, fatigue malaise, weight loss, sleep disturbances
Musculoskeletal –
Bilateral and symmetrical joint involvement, swelling, redness, heat, pain,. loss of function , limitation
of motion, contractures of the joint
Hands –
Ulna deviation, swan neck deformities (hands twist outward)
Exocrine –
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Dry eyes and dry mucous membranes
Respiratory –
Lung issues and pneumonia
C.V-
Rainards Disease – effect extremities r/t poor perfusion
Blood level –
anemic
Diagnosis
Patient Hx and PE
*** Blood test – rheumatoid factor, ESR, WBC, C-reative protein will be elevated
Normal ESR is
Elevated ESR indicates that there is an active inflammation somewhere , but not where.
Normal RH Factor is less than 60- anything over seven may indicate RA
In over 80% of patients with RA blood test for RF will come back positive indicating
autoimmune response, probably RA
Normal WBC is 5,000-10,000 mm3 in pt’s w/ RA WBC will be over 10,000
C - reactive protein elevated- Normal is <1.0 mg/dl or 10 mg/L (SI units)
Medical management
Pharmacology – early treatment
NSAIDS – inhibit prostaglandins
DMARDS – disease modifying anti-rheumatic drugs
Ie- Methotrexate, gold therapy
Goal of these drugs is to slow down or prevent progression of disease
Immunosuppressive therapy (corticosteroids)
IM injections into joints that should provide pain relief for several months
OT / PT therapy
PT- helps patient to maintain joint motion and muscle strength
OT-help patient to develop upper body strength to gain strength for the use of possible assistive devices
Apheresis –
Filtering of blood to remove antibodies (ie Rheumatoid factor). Remaining blood is reinfused back to
patient.
Done once a week for about 12 weeks
Similar to plasmaphoresis
Surgery
Patient teaching:
Rest- esp. during flare ups and in between activities such as ADL’s
Joint protection- esp about use of assistive devices to protect joints during periods of exacerbations
Heat and cold therapy- max 15-30 min
Heat seems to bring RA patients most relief (Warm shower in AM, hot packs to neck and shoulders
Exercise-
No aggressive exercise. Stationary bike, walking, gardening, swimming
Non-pharmacological techniques
Yoga, massage. Guided imagery
Nursing DX
Pain r/t chronic state of inflammation, joint overuse
Impaired physical mobility r/t pain, stiffness
Body image disturbance r/t nodules
Self care deficit r/t joint immobility, contractures, progression of disease
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Osteoarthritis (aka Degenerative Joint disease)****Look at pictures***
Slowly progressive
A degenerative Non-Inflammatory joint disease characterized by:
Usually unilateral (but can be bilateral) degeneration of joints
Cartilage disruption-Loss of articular cartilage of weight bearing joints
Mostly affects adults usually in the 3 decade peaks around the 5th 6th decade
Incidence increases with age
Non-systemic
Etiology
Primary – genetics, female, congenital development, age, obesity
Secondary –
Mechanical stress to joint caused by repetitive motion (ie sports players)
Joint trauma such as dislocations, fractures, reductions or surgeries where avascular necrosis develops
Inflammation r/t release of enzymes locally at that site that causes further disruption of articular cartlidge
Joint instability esp. with damage to structures surrounding joint capsule itself
Skeletal deformities esp. congenital in nature
Risk factors –
Age, obesity, previous joint damage, repeated use, genetics
Pathophysiology
Cartilage damage triggers a metabolic response
Smooth white translucent articular cartilage becomes yellow, dull, and granular
Cartilage b/c soft, less elastic, and less able to resist wear on the joints
Erosion of cartilage
Cartilage becomes thin, less able to stand pressure.
Bony outgrowths on the corners of the bone itself (osteophites or spurs) later in disease
Cysts may develop in bone
Eventually you will lose most of cartilage in joint
X-ray –
Loss of joint cartilage- cartilage breakdown
Joint space narrowing b/t joints
Erosions
Later in disease bony outgrowths (osteophites)
Arthrocentesis with synovial fluid analysis
To differentiate b/t Osteo and RA (Pt’s with RA will have WBC’s in synovial fluid, and pt’s w/
OA fluid will usually be normal- clear, yellow, no WBC’s)
Management
Rest and joint protection esp. during acute episodes of exacerbation
Heat and cold therapy
Heat is more effective for stiffness
20-30 minutes on then off for both
Nutritional therapy/ exercise
Limit weight bearing on joint
Isometric exercises (NWB exercises are best- ie swimming)
Complementary and alternative therapy
Acupuncture has been shown to be very effective for chronic pain
Yoga, massage, guided imagery
Glucosamine
It is believed that Glucosamine works by preventing breakdown of cartilage
Take with food
Use cautiously in pt’s who are diabetic b/c if they are taking oral hypoglycemics together
w/ glucosamine some reports have shown that it lowers blood sugar to a much lower level
Meds –, NSAIDS ie Motrin or ibuprophen
Three A’s- anti-inflammatory, anti-pyretic, analagesic
S/E GI Bleeding and erosion
Look for melena (dark tarry stool)
Corticosteroids- Given as an IM injection into the joint itself.
Usually lasts for several months
Reduces inflammation and relieves pain in patient
Topical analgesics
Surgery –
Arthroscopy
Osteomoty (incision in bone to realign joint)
Joint replacement
Patient Teaching
Lose or maintain weight to put less weight on joints
39
Use of assistive devices esp. during acute flare up (ie-braces, splints, canes)
Avoid forceful repetitious movement
Use good posture and body mechanics
To pick up something from the floor do not bend at the waist, bend at the knees and use leg muscles
Pace activities and routine tasks to lace less stress on joints
Periods of rest
Nursing diagnosis
Pain (acute or chronic) r/t inflammation
Disturbed sleep pattern r/t pain
Impaired physical mobility r/t weakness or stiffness of joint
Self care deficit r/t joint deformity and pain.
40
Chapter 11
Assistive technology – item or piece of equipment used to improve the functional capability of individuals
with disabilities
Habilitation – making able – learning new skills and abilities to meet maximum potential
Impairment – loss or abnormality of psychological, physiologic or anatomic structure or function at the organ
level
Instrumental activities of daily living (IADLs) – complex aspects of independence including meal
preparation; grocery shopping, household management, finances and transportation
Hardiness – a personality characteristic that is a buffer in the stress and depression dynamic and increases a
person’s capability of having a positive psychological reaction to a stressor
Different Scales/Scores
• Health-Related hardiness Scale (HRHS) – high score – hardiness
• Zung Self-Rating Depression Scale (ZSDS) – measured depression – high level – indicates
depression
41
• Clinical Response Scale (CRS) – physical health status is measured – high measured worsened
health status
• Barthel Activities of Daily Living Index (BADL)– measured disability - a high score indicated
independence and a low sore indicated disability.
• FIM – measures level of independence
• PULSES – measures physical condition
A joint should be moved through its ROM three times – twice a day. The joint should be supported, the bones
above the joint stabilized and body part distal to the joins is moved through the range of motion of the joint.
Weight bearing exercises may slow the bone loss that occurs with disability. There are 5 types:
1. Passive – carried out by therapist without assistance from patient
2. Active-Assisted – both therapist and patient do together
3. Active – patient does it themselves
4. Resistive – carried out by the patient working against resistance produced by either manual or
mechanical means
5. Isometric – contracting and relaxing a muscle while keeping the part in a fixed position.
Performed by patient.
Orthostatic Hypotension may develop when the patient assumes a vertical position. Because of inadequate
vasomotor reflexes, blood pools in the splanchnic (visceral) area and in the legs, resulting in inadequate
cerebral circulation. Symptoms include: diaphoresis (sweating), nausea, tachycardia, dizziness, drop in blood
pressure & pallor).
Crutch
Measuring laying down – from the anterior fold of the axilla to the sole of the foot and then 2 inches is
added. The hand piece should be adjusted to allow 20 t 30 degrees of flexion at the elbow. The wrist should
42
be extended and the hand dorsiflexed. A foam rubber crutch r pad on the underarm piece is used to relieve
pressure of the on the upper arm and thoracic cage.
Place patient against the wall with feet slightly apart and away from wall. A distance of 2 inches is
marked on the floor, to the side from the tip of the toe. 6 inches is measured straight ahead from the first
mark. Next 2 inches is measured below the axilla to the second mark for the approximate crutch length.
Crutch Gaits
4 point gait
PWB on both feet
Maximal support provided
Requires constant shift of weight
Right foot, left crutch, left foot, right crutch
3 point gait
NWB
Need good balance
Need good arm strength
Faster gait
Can use with walker
Right foot
Left foot (NWB) and both crutches
Swing To
WB both feet
Stability
Need arm strength
Both Crutches
Both Feet next to crutches
Swing through
WB
Need arm strength
Need coordination/balance
Most advanced gait
Both crutches
Swing both feet ahead of crutches
Stairs:
Up with the good, down with the bad
When going up the stairs, put the good foot up first or the crutches and follow with the bad
When going down the stairs, put the bad foot first and then down with the good.
43
Cane
To fit the patient with a cane, the patient is instructed to flex the elbow at a 30 degree angle, hold the
handle of the cane about level with the greater trochanter, and place the tip of the cane 6 inches lateral to the
base of the fifth toe.
Hold the cane in the hand opposite the affected extremity to widen the base of support and to reduce
the stress on the involved extremity. Advance the cane at the same time that the affected leg is moved.
Orthosis is an external appliance to provides support, prevents or corrects deformities and improves function.
They include braces, splints, collars, corsets or supports that are fitted an orthotist or prosthetist.
• Static orthoses (no moving parts) are used to stabilize joints and prevent contractures
• Dynamic Orthoses are flexible and are used to improve function by assisting weak muscles.
• prosthesis is an artificial body part; it may be internal or external
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Chapter 54
Antibody – protein substance developed by the body in response to and interacting with a specific antigen
Joint Effusion – the escape of fluid from the blood vessels or lymphatics into the joint space
Tophi – accumulation of crystalline deposit in articular surface, bones, soft tissue and cartilage
Rheumatic disease include common disorders such as osteoarthritis, systemic lupus erythematosus or
scleroderma. It affects skeletal muscles, bones, cartilage, ligaments, tendons and joints
Degeneration
• Mechanical Stress – wear and tear
• Altered lubrication – lessened lubrication of the joint
• Immobility – loss of pumping action because of immobility – encourage slow range of motion
to remobilize joint
• Arthrocentesis – needle aspiration of synovial fluid to test and to relieve pain. Patient is
observed for infection and hemathrosis (bleeding into the joint).
o Fluid is clear, viscous, straw-colored and scanty when it is healthy
o Milky, dark yellow complement – usually is inflammatory
o Arthrocentesis of small joints is difficult. Mostly done in knee & shoulder
• X-ray
• Arthrography - a radiopaque substance or air is injected into the joint cavity to outline the
contour of the joint. The joint is then put through passive ROM while several x-rays are taken.
• Joint scan – most sensitive study, allows determination of joint damage through the body. Not
used often because of cost.
• Tissue Biopsies – done in surgery
• Muscle biopsy – to diagnosis myositis
• Skin biopsy – to confirm inflammatory tissues diseases such as lupus or scleroderma
• Blood Tests
o Creatine – may indicate renal damage in SLE, scleroderma and polyarteritis
o Erythrocyte Sedimentation Rate (ESR) – increase may indicate inflammatory connective
tissue disease
o Hematocrit decrease can be seen in chronic inflammation
o RBC – decrease can be seen in RA & SLE
o WBC – decrease can be seen in SLE
Gout or infectious arthritis – the presence of crystals or bacteria in the synovial fluids
NI
Heat application are helpful in relieving pain, stiffness & muscle spasm
Maximum benefit is achieved in 20 minutes
If acute – cold applications may be tried
Use one pillow under head to reduce dorsal kyphosis
Pillow should NOT be placed under knees because it will promote flexion contracture
Rheumatoid Arthritis
• Seen in women
• The prototype for inflammatory arthritis
46
• Types
o Early stage RA –
o Moderate, Erosive RA
o Persistent, Erosive RA
o Advanced, unremitting RA
Scleroderma
• Called Systemic Sclerosis
• Starts with Reynaud’s phenomenon and swelling in the hands
• Known as the “hard Skin” disease and is a rare disease
Polymyositis
• Shows first as muscle weakness
• Idiopathic
• Rare
Polymyalgia Rheumatica
• Severe proximal muscle discomfort with mild joint swelling.
• Severe aching the neck, shoulder & pelvic muscles.
• Mostly in people over 50
Osteoarthritis
• Known as degenerative joint disease or osteoarthrosis - without inflammation
• Most common and frequently disabling of the joint disorders
• Over diagnosed and trivialized
• Peaks in the 5th & 6TH decade of life
• Affects the articular cartilage, subchondral bone (the bony plate that supports the articular
cartilage) and synovium
• A combination of cartilage degradation, bone stiffening and reactive inflammation of the
synovium occurs
• Risks: age, obesity, previous joint damage, genetic susceptibility
• s/s are pain, stiffness & functional impairment
• Occurs in WB joints but also proximal and distal finger joints are involved
• Bony nodes may be present and are usually painless, unless inflamed
• Characterized by progressive loss of joint cartilage, which appears on an x-ray as a narrowing
of joint space.
• Osteotomy (to alter the force distribution in the joint) & arthroplasty (joint replacement) are
used to ease pain
• Viscosupplementation - the reconstitution of synovial fluid viscosity
• Hyaluronic acid is used in the procedure
• Tidal irrigation – intro and then removal of large volume of saline into the joint.
47
Spondyloarthropathies – another category of systemic inflammatory disorders
• Medical Management is treating pain and maintaining mobility by suppressing inflammation.
• Ankylosing Spondylitis – affects the cartilaginous joints of the spine and surrounding tissues
o Usually diagnosed in 20 – 30’s
o Not as severe in females
o Back pain is a feature
o Can lead to respiratory compromise and complications
o Good body position is important in case ankylosis (fixation) occurs
• Reactive arthritis (Reiter’s syndrome)
o Arthritis occurs following an infection.
o Affects young adult males and is characterized by urethritis, arthritis and conjunctivitis
o Dermatitis of the mouth & penis may be present
• Psoriatic arthritis
o Characterized by Synovitis, polyarthritis & spondylitis.
o Psoriasis and arthritis are common conditions
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Chapter 66
Definitions:
Bursa – fluid filled sac found in connective tissue, usually in the area of joints
Crepitus – grating or crackling sound or sensation; may occur with movement of ends of broken bone or
irregular joint surface
Endosteum – thin, vascular membrane covering the marrow cavity of long bones and the spaces in cancellous
bone
Joint capsule – fibrous tissue that encloses bone ends and other joint surfaces
Osteoarthritis – degenerative joint disease characterized by destruction of the cartilage and overgrowth of
bone.
50
Osteoblast – bone-forming cell
Osteoid – pre-bone
Hematopoeiesis – red bone marrow located w/in the bone cavities produces red and white blood cells
Joints - hold the bones together and allow the body to move
Muscles attached to the skeleton contract, moving bones and producing heat, which helps maintain body temp.
Flat bones – provide organ protection and are am important site for hematopoiesis. They are made up of
cancellous bone layered between compact bone.
51
Important regulating factors in bone include:
• Stress
• Vitamin D
• Calcium
• Calcitonin
• Parathyroid hormone
• Blood supply
Weight bearing is important. Without it, the bones loses calcium (resorption) and become osteopenic and
weak which may fracture easy
Parathyroid hormone and Calcitonin are the major hormonal regulators of calcium homeostasis. Parathyroid
hormone regulates the concentration of calcium in the blood, in part by promoting movement of calcium from
the bone.
Calcitonin, secreted by the thyroid gland in response to elevate blood calcium levels, inhibits bone resorption
and increase the deposit of calcium in bone
Blood supply to the bone also affects bone formation. With diminished blood supply or hyperemia
(congestion), Osteogenesis and bone density decrease. Bone necrosis occurs when the bone is deprived of
blood.
Bone Healing
1. Hematoma and inflammation – last several days
2. Angiogenesis and cartilage formation – blood vessels and cartilage overlie the fracture
3. cartilage calcification -
4. cartilage removal – calcified cartilage is removed by Osteoclast and replaced by woven bone
5. bone formation – ossification
6. remodeling – may take months or years
Bone mass peaks at about 35 years of age, after which there is a universal gradual loss of bone
Pain:
Bone Pain – dull, deep ache – that is boring in nature
Muscular Pain – soreness or aching – muscle cramps
Fracture Pain – sharp and piercing and relieved by immobilization
Bone infection with muscle spasm or pressure on sensory nerve may be sharp
Pain that increases with activity may indicate joint sprain or muscle strain
Steadily increasing pain points to progression of an infection, a malignant tumor or neurovascular
complication
Radiating Pain – when pressure is exerted on a nerve root.
52
Joints:
• Synarthrosis – immovable – skull
• Amphiarthrosis – vertebral & symphysis – allow limited movement
• Diarthrosis – freely movable
o Ball & Socket – hip and shoulder
o Hinge – bending in one direction – elbows & knee
o Saddle joint – movement in 2 planes at right angles to each other – thumb
o Pivot joint – permit rotation – ex turning a doorknob – wrist
o Gliding joint – limited movement in all directions – carpal bones of the wrist
Muscle Actions
• Synergists – muscles assisting the prime mover
• Antagonists – muscles causing movement opposite that of the prime mover – when biceps are
contracted – triceps is the antagonist
Gait – assessed by having the patient walk away from the examiner for a short distance. It is examined for
smoothness and rhythm. Any unsteadiness or irregular movements are considered abnormal.
Joint Deformity:
Contracture – shortening of surrounding joint structure
Dislocation – complete separation of joint surfaces
Subluxation – partial separation of articular surfaces
RA – subcutaneous nodules are soft and occur within and along tendons
Gout – nodules are hard and lie within and adjacent to joint capsule
Osteoarthritic nodules are hard and painless and represent bony overgrowth from destruction of cartilaginous
surface of bone within the joint capsule.
Muscle Strength/weakness/disease
• Polyneuropathy
• Electrolyte disturbances – potassium & calcium
• Myasthenia gravis
• Poliomyelitis
• Muscular dystrophy
Neurovascular status
• Compartment syndrome – pressure within a muscle that increases to such an extent that
microcirculation diminishes, lead nerve damage and muscle anoxia and necrosis. Function can
be permanently lost if the anoxic situation continues for longer than 6 hours. CMS is an
assessment – Circulation, Motion, Sensation
Diagnostic Procedures
• X-ray
• CT – can reveal tumors of the soft tissue or injuries to ligaments or tendons
53
• MRI – uses magnetic fields, radio waves to show, tumors or narrowing of tissue pathways
through bone & soft tissue
• Arthrography – radiopaque substance or air is injected into a joint cavity to outline the soft
tissue structures and the contour of the joint. The joint is put through ROM to distribute the
contract agent while a series of x-rays are obtained. If a tear is present the agent leaks out of
the joint
o Joint is rested for 12 hour after procedure and an compression bandages is applied. Normal
to hear clicking up to 2 days
• Bone Densitometer – used to estimate bone mineral density (BMD). Done using X-rays or
ultrasound
• Bone Scan – detects metastasis and primary bone tumors, osteomyelitis, certain fractures and
aseptic necrosis. A bone-seeking radioisotope is injected intravenously. The scan is performed
2 to 3 hours after the injection. An increased uptake of isotope is seen in primary skeletal
disease (osteosarcoma), metastatic bone disease, inflammatory skeletal disease (osteomyelitis)
and fractures
o Need to check if patient is allergic to radioisotope. Patient needs to drink plenty of fluid to
help distribute and eliminate the isotope
• Arthroscopy – camera to look at the joint. Done in the operating room. Injection of a local
anesthetic into the joint or general anesthesia is used. A large bore needle is inserted and the
joint is distended with saline. Complications are infection, Hemarthrosis, neurovascular
compromise, etc..
• Arthrocentesis (joint aspiration) – obtain synovial fluid for examination or to relieve pain due
to effusion. Helps to diagnose septic arthritis. Reveals Hemarthrosis (bleeding into the joint
cavity). Normal fluid is scanty, clear, pale or straw-colored
• EMG (Electromyography) provides information about the electrical potentional of the muscles
and the nerves leading to them
• Biopsy – determines the structure and composition of bone marrow, muscle or synovium to
help diagnose disease
• Blood/Urine – can provide info about primary skeletal disease (Paget’s), a developing
complication (infection, baseline for therapy (anticoagulant) or response to therapy
54
Chapter 67
Definitions
External fixator – external metal frame attached to and stabilizing bone fragments – used to manage open
fractures with soft tissue damage. Used for severe comminuted (crushed or splintered) fractures. Fractures of
the humerus, forearm, femur, tibia and pelvis are managed by external fixator
• Monitoring of neurovascular status of the extremity is every 2-4 hours and assessment of pin
sites for infection and loosening.
• Nurse NEVER adjusts the clamps on the external fixator
• Encourage isometric and active exercise
• Ilizarov EF used to correct angulations and rotational defects to treat nonunion fracture and to
lengthen limbs
Fasciotomy – surgical procedure to release constricting muscle fascia to relieve muscle tissue pressure
Joint Arthroplasty or replacement – replacement of joint surfaces with metal or synthetic materials
Bone graft – placement of bone tissue to promote healing, to stability or replace diseased boned
PMMA – bone –bonding agent that has properties similar to bone. Loosening of the prosthesis due to
cement-bone interface failure is a common reason for prosthesis failure
ORIF – Open reductions with internal fixator – surgery to repair and stabilize a fracture
55
Osteomyelitis – infection of bone
Cast – a rigid immobilizing device that is molded to the contours of the body. The purpose is to immobilize a
body part in a specific position and to apply uniform pressure on encased soft tissue.
• Cracking or denting of the cast is prevented by supporting the patient on a firm mattress and
with flexible, waterproof pillows until the cast dries. The nurse turns the patient to a prone
position, twice daily, to provide postural drainage of the bronchial tree and to relive pressure on
the back.
Complications of Traction
• Pneumonia – ausculate lungs every 4 to 8 hours to determine respiratory status and teach
patient deep breathing and coughing exercise to fully expand lung and moving pulmonary
secretions
• Constipation and Anorexia – reduced gastrointestinal motility results in constipation and
anorexia – a diet high in fiber may help gastric motility
• Urinary Stasis and Infection – lots of liquid and urinate every 3 to 4 hours
• Venous Stasis & DVT – check every 1 to 2 hours
Hip Precautions
• Never cross legs
• Never bend at hip more than 90 degrees
• Do not elevate head of bed more than 60 degrees
• Keep legs abducted (apart)
• When sitting patient’s hips should be higher than knees
• Avoid internal and external rotation, hyperextension and acute flexion
• Needed for 4 months following surgery
• Dislocation can occur
o Increased pain at surgical site
o Acute groin pain in affected hip
o Shortening of the leg
o Abnormal external or internal rotation
o Restricted ability or inability to move leg
o “popping” sensation in hip
o If it happens, hip must be stabilized to legs does not sustain circulatory and nerve damage.
o After closed reduction, limb may be stabilized with bucks traction or brace to prevent
recurrent dislocation.
Knee Replacement
• Post-op – knee is in a compression bandage
• Ice may be applied to control edema and bleeding
• Assess neurovascular status of leg
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• Encourage active flexion of foot every hour when patient is awake
• Wound drainage is 200-400 ml first 24 hours and then 25ml by 48 hours
• CPM device -10 degrees of extension and 50 degrees of flexion are prescribed initially,
increasing to 90 degrees of flexion with full extension by discharge
• Pre-op – ask patient about occurrence of colds, dental problems, UTI and other infections 2
weeks before surgery. Osteomyelitis could develop through hematologous spread
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Chapter 68
Definitions
Sciatica – sciatic nerve pain; pain travels down back of thigh into foot
Osteoporosis
• Reduction in bone density and bone structure
• Bone resorption is greater than the rate of bone formation
• Bones become porous, brittle and fragile
• Results frequently in compression fractures
• Higher in caucasion & Asian, small framed, older women
• Sometimes develops Kyphosis – dowager’s hump
• Loss of height
• Protruding abdomen
• Reduce caffeine, cigarettes and alcohol early
• Some diseases bring on osteoporosis – celiac disease and hypogonadism and medications
(corticosteroids and anti-seizure)
• Calcitonin, which inhibits bone resorption is decreased in the elderly
• Estrogen, which inhibits bone breakdown, decreases with age
• PTH –parathyroid hormone – increases with aging, increasing bone turnover and resorption.
• Need to exercise with WB exercise
• Co-morbidity – anorexia, hyperthyroidism, malabsorption syndrome, renal failure
• Relieve pain
• High fiber diet to reduce constipation
• Reduce risk of falls
Osteomyelitis
• Bone infection
• Three modes:
o Extension of soft tissue infection
o Direct bone contamination from bone surgery, open fracture of traumatic injury
o Hematogenous – blood born spread from other sites and infections
• Stage I – acute, occurring during first 3 months
• State II – delayed onset – occurring between 4 and 24 months
• State III – late onset – occurring 2 or more years after surgery – usually as a result of
Hematogenous spread
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• Staphylococcus auerus causes 70-80%
• S/s of osteomyelitis
o Inflammation
o Edema
o Thrombosis of the blood vessels occurs in the area, resulting in ischemia with bone necrosis
o Bone abscess can form if not treated
o Onset is sudden when it is blood borne
Chills, high fever, rapid pulse, general malaise
o patient may complain of a constant, pulsating pain that intensifies with movement as a
result of the pressure of the collecting pus.
• If patient does not respond to therapy, infected bone is surgically exposed, and purulent and
necrotic material is removed and area is irrigate with sterile saline solution.
• IV Therapy can be done at home.
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Chapter 69
Definitions
Autograft – tissue harvested from one are of the body and used for transplantation to another are of the body
Contusion – a soft tissue injury produced by blunt force. Small blood vessels rupture and bleed into soft
tissues.
Fracture reduction – restoration of fracture fragments into anatomic alignment and rotation
Meniscus – crescent shaped fibrocartilage found in certain joints, such as the knee joint
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Tendonitis – inflammation of a tendon
Types of Fractures
Greenstick – where one side of the bone is broken and the other side is bent.
Transverse – fracture is straight across bone – mostly seen in long bones
Oblique – Fx line slants on an angle across shaft of bone
Spiral – like oblique but wraps around and climbs
Comminuted – bone splinters – not good
Depressed – skull – bone fragments are inward (facial & cranial)
Compression – vertebral – fragments are pushed together
Pathologic – disease – Paget’s, Osteomylitis – bone infection
Impacted – one bone fragment is impacted to another
Compound – worst – breaks through the skin
DX of fracture
History of incident
Assessment
CT or X-ray
Manage
• Emergency Care
• Cover open wounds with sterile, lint-free materials to prevent infection.
• DO NOT REALIGN
• Closed reduction – done manually and bone set in place. X-ray first – closed reduction – x-ray
again
• Open reduction – Surgery – ORIF
• FX immobilization – casts
• Exercises – isometric exercises of affected and unaffected
• Help patient – with ADL’s
Bone Healing
• Immobility/timely correction
• Ice
• Sufficient Blood Supply
• Sufficient Nutrition
• WB exercises
• Hormones
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Bone Healing Complications
Extensive trauma/delay
Infection
Declining Circulation
Bone disease
Malnutrition
Age/Immune
Open Fracture
Closed Fx:
Self care
Meds
Possible complications
Open Fx:
Possible Complications
Wound Irrigation
Osteomyelitis – bone infection
Complications of Bone:
Hypovolemic Shock – resulting from hemorrhage and from loss of extra-cellular fluid into damaged tissues
Fat embolism
• Fat globule in blood stream
• Seen within 24-72 hours with fracture of long bones
• Seen frequently in young adults (20 – 30 years old)
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Assessment/Signs & Symptoms of Fat Embolism
• Hypoxia – inadequate oxygen
• Headache/Pyrexia
• Irritability, confusion & agitation
• Feelings of Doom
• Tachycardia
• Tachypnea
• Wheezing
• Petechia – red spots on skin
• Use of accessory muscle/ARDS
Compartment Syndrome
• Tissue perfusion in the muscle is less than required for tissue viability
• Rise in the intra-compartmental pressure with tissue damage (30 min) and death (4 hours)
• Average 8 or less
• 30 bad
Vascular Necrosis
• Bones loses its bloods supply
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• Bones cells die
• Frequently seen in femoral head, talus bone of ankle and lunate? bone of the wrist
• Steroid Therapy – Tape
Other FX complications
• Infection
o Organ injury
o Ruptured tendons
o Severed (tape)_
• Hip Fx
o Fx of proximal end of femur
Etiology
• Weak muscle
• Decreased cerebral blood flow
• Renal disorder
• Osteoporosis
2 Types of Hip Fx
Intracapsular
• Occult – groin pain & weight bearing
• Impacted and non-displaced moderate discomfort, groin & knee pain – non visible
• Displaces leg externally, rotated, painful
Extra capsular
• Trochanteric
• Subtrochanteric
NI for Hip Fx
• Temporary Skin Traction (Bucks)
• Sandbags
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• Surgical repair
Wrist FX
• Fx of distal radius (Polle’s Fx) and Ulnar
Amputations
• Closed – bone area is removed and muscle flap
• Open – all is removed – cauterize stump
• Disarticulation – removal of a body part through a joint
Performed at most distal site – determined by circulation
Complications of Amputation:
• Hemorrhage
• Infection
• Delayed healing
• Flexion deformity
• Skin irritation
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• Phantom limb
• Sensation reduced
Compare RA & OA
Rheumatoid Arthritis
• Chronic systemic inflammatory disorder characterized by swelling/pain and includes
• Symptoms are acute
• Autoimmune
• Seen mostly in females
• Symptoms appear between 30 & 50
• Exhabesence
Muscoskeletal
Bilateral, Symmetrical, swelling, joint pain, hot
OA
Swimming is best
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Independent Study
68
Disc Herniation
• Most back problems are r/t disc problems
Pathophysiology:
• In herniation of the disc (ruptured disc) the nucleus of the disc protrudes and causes nerve
compression.
• Propulsion or rupture is usually associated with degenerative changes that occur w/ aging
o Loss of protein
o Development of radial cracks in annulus
• Also , after falls, and repeated trauma, such as lifting cartlidge may be injured
o For most pt’s the immediate s/s of trauma are short lived, and injuries to the disc are not
apparent for months or years. When the disc starts to degenerate later on it may herniate or
rupture and compress spinal nerves
• A ruptured or herniated disc produces pain due to pressure on nerve endings (Radiculopathy)
• Continued pressure may produce degenerative changes in the involved nerve, such as changes in
sensation and deep tendon reflexes.
Manifestations:
o A herniated disc with accompanying pain may occur in any portion of the spine
o Spondylosis- degenerative changes occurring in disc and vertebrae which lead to herniation
o Cervical disc herniation usually occurs at the C5-6 and C6-7 spaces.
Pain and stiffness may occur in the neck, shoulders, and scapula area
Sometimes pts mistake this for heart trouble or bursitis
Pain may also occur in the upper extremities and head accompanied by paresthesia and
numbness of UE
Cervical MRI confirms dx
Cervical spine may be immobilized by use of cervical collar, brace or traction
Bed rest is important (1-2 days) b/c it eliminates the stress of gravity of the head on the
cervical spine
o Thoracic herniation is rare
o Lumbar disc herniation usually occurs at the L4-5or L5-S1 spaces
Herniated lumber disc produces low back pain, and varying degrees of sensory and
motor impairment
Low back pain may be accompanied by radiation of the pain into one hip and down the
leg (sciatica)
Pain is aggravated by actions that increase intraspinal fluid pressure (lifting, bending,
sneezing and coughing and straining)
Pain is usually relived by bed rest
There is usually some sort of postural deformity associated w/ lumbar herniation r/t pain
Medical management:
Usually managed conservatively w/ bed rest and medication
If this does not work, there are several surgeries available to correct disc herniation
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Surgical excision of a herniated disc is performed when there is evidence of a progressive neuro deficit
(muscle weakness and atrophy, loss of sensory and motor fxn, loss of spinchter control), or continuing
pain and sciatica that does not respond to conservative treatment.
The goal of surgical tx is to reduce pressure on the nerve root, relive pain and reverse neuro deficits.
Types of surgical interventions:
o Discectomy-
Removal of herniated fragments of disc
w/ fusion- bone graft is used to fuse the vertebral spinous process
• the object of spinal fusion is to bridge over the defective disc to stabilize the
spine and reduce the rate of reoccurance
Laminectomy-
Removal of part of vertebral bone in order to expose neural elements of spinal canal
Hemilaminectomy
Removal of a smaller part of the vertebrae
Partial laminectomy-
Creation of a hole in the vertebrae
Foraminotomy-
Removal of vertebral foramen to increase space for exit of the spinal nerve
Results in reduced pain, compression and edema.
Sports Injuries
• Contusions, sprains, strains
• Tendonitis – inflammation of a tendon caused by overuse
o Tennis Elbow and Achilles tendonitis in runners and gymnasts and intrapatellar tendonitis in
basketball players
• Meniscal injuries of the knee occur with excessive rotational stress
• Fractures such as colles fx in skaters and bikers, metatarsal fx in ballet and track and field, stress fx
with repeated bone trauma from activities such as jogging, gymnastics, basketball or aerobics.
• Tibia, fibula and metatarsals are most likely to be fx’d
Gout
• Gouty arthritis – the presence of crystals in the synovial fluids r/t hyperuricemia (high uric
acid)
• Hyperuricemia may be r/t starvation, excessive intake of foods high in purines (shellfish, organ
meat) or genetic
Manifestations:
• High uric acid in blood
• First sign is usually acute arthritis in the big toe
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• Acute attack may be triggered by trauma, ETOH ingestion, dieting, medications and illness
• Pt may also have renal calculi
NI for Gout
• Heat application are helpful in relieving pain, stiffness & muscle spasm
• Maximum benefit is achieved in 20 minutes
• If acute – cold applications may be tried
• Use one pillow under head to reduce dorsal kyphosis
• Pillow should NOT be placed under knees because it will promote flexion contracture
• Crystals in synovial fluid are sodium urate crystals (Tophi)
• Tx w/ allpurinol, but cautiously b/c of s/e.
•
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o Administration of NSAIDS, walking aids, shoe lifts and PT
o Administration of Calcitonin subq or nasal inhalation.
S/E- flushing of face, nausea
o Fosamax & Didronel also used for rapid reduction in bone turnover.
o Mithracin – a cytotox antibiotic maybe be used to control the disease – IV
o Adequate calcium – 1500 mg and vit D (400-600 IU)
Osteomalacia
• Metabolic bone disease characterized by mineralization of bone. Because of faulty mineralization,
there is a softening and weakening of the skeleton, causing pain and tenderness to touch, bowing of
the bones and pathologic fractures.
• Pathophysiology:
o Deficiency of activated Vitamin D (calcitrol) which promotes calcium absorption
o May result from failed calcium absorption and from excessive loss of calcium
o GI disorders (celiac disease, chronic biliary tract obstruction, chronic pancreatitis, small bowel
resection) in which fats are not absorbed are likely to produce ostomalacia
o Also liver and kidney disease can produce a lack of vitamin D because these are the organs that
convert Vitamin D to its active form
o Hyperparathyroids leads to skeletal decalcification and then to osteomalacia by increasing
phosphate excretion in the urine
o Prolonged use of anti-seizure meds increases risk
• S/S
o Spinal Kyphosis and bowed legs
o X-rays show generalized demineralization of bone
o Decrease in serum CA+ and phosphorus levels, and mildly elevated alkaline phos.
•
• Nursing Interventions:
o Spend time in the sun to promote Vitamin D
o Increase Vitamin D and calcium.
o Eat eggs, chicken livers, milk and cereals high in Vitamin D
o Monitor serum calcium levels to reduce risk of hypercalcemia when vit d intake is increased
o Can be helped with diet control
Bone Tumors
****Primary complaint: Pain for all bone tumors
• Metastatic bone tumors are more common than primary bone tumors
• Benign bone tumors
o More common and not a cause of death
o Some benign tumors have the potential to become malignant
o Osterochondroma is the most common bone tumor
Seen as a large project of bone at the end of a long bone (knee or shoulder)
o Enchodroma – common tumor of the hyaline cartilage that develops in the hand, femur, tibia
or humerus.
Usual symptom is mild ache
o Bone cysts are expanding lesions within the bone.
Seen in young adults who present with a painful, palpable mass of the long bones,
vertebral or flat bone
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Unicameral bone cysts occur in children and cause mild discomfort and possible
pathologic fractures of the upper humerus and femur
o Osteoid Osteoma – painful tumor that occurs in children and young adults. Neoplastic tissue
is surrounded by reactive bone formation
o Osteoclastomas are giant cell tumors that are benign for long periods but may invade local
tissue and cause destruction.
Occurs in young adults and are soft and hemorrhage
May undergo malignant transformation and metastasize
•
•
• Malignant Bone Tumors
o Primary tumors that cause bone destruction, weakening of bones and fractures
o Rare that arise from sarcomas or bone marrow elements
Osteogenic sarcoma (osteocarcome) is the most common and most fatal primary
malignant bone tumor.
• Prognosis depends on whether it has metastasized to the lungs
• Appears in males between 10 & 25 years old, in older people with Paget’s
disease and a result of radiation exposure.
• S/s – weight loss, pain, swelling, limited motion, Increased alk. Phos..
• Most common sites are distal femur, proximal tibia and proximal humerus
• Bony mass may be palpable, tender and fixed w/ venous distention
Chondrosarcomas
• Tumor of the hyaline cartilage
• Common primarily malignant bone tumor
• Large, bulky, slow-growing tumors that affect adults
• Includes pelvis, femur, humerus, spine, scapula and tibia
• Large bloc excision or amputation of the affected extremity results in increased
survival rate
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