(01) orthopedic nursing

7/31/2019 (01) Orthopedic Nursing

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Medical-Surgical Nursing 2 Prepared by Dr. Jhason John J. Cabigo

Orthopedic Nursing: Nursing Management of Patients with Musculoskeletal Dysfunction*Deals with the musculoskeletal system: bones (206), cartilages, joints, muscles, tendons and ligaments

Review of Anatomy and PhysiologyA. Classification of Bones

1. According to location: Axial & Appendicular

a. Axial skull (cranium and facial bones), vertebra (cervical, thoracic, lumbar, sac

coccygeal) and ribs (7 true and 5 false; last 2 floating ribs)b. Appendicular bones of the shoulder, pelvis, upper and lower extremities

2. According to osseous tissue: Spongy (or Cancellous) & Compact (or Cortical)

a. Spongy or Cancellous composed of trabeculae (small needle-like pieces of bon

that form a network) and lots of open spaces

b. Compact or Cortical dense, smooth and homogenous

3. According shape:

a. Long composed of central shaft (diaphysis) and 2 ends (epiphysis); ex. Humer

and Femur

Diaphysis is a compact bone covered by the periosteum and has a spawithin (medullary cavity) which is filled with adipose tissues (yellow marrow)

Epiphysis is a cancellous bone covered by the articular cartilage acontains red marrow (site of hematopoiesis)

b. Short cancellous bone covered by a layer of compact bone; ex. Carpals and Tarsa

c. Flat 2 layers of compact bone separated by a cancellous bone; also contains r

bone marrow; ex. Sternum, Ribs, Iliac Crest

d. Irregular no definite shape; ex. Vertebrae and Mandible

B. Functions of Bones

1. Provide structural framework of the body2. Provide a means for movement by acting as lever for muscle3. Protect vital organs and soft tissues4. Site of storage for calcium and phosphorus5. Hematopoiesis (blood cell formation) in the red bone marrow

C. Joints articulations; hold bones together and provides mobility; All bones (except the hyoid) forms a joint with at lea

1 other bone

D. Classification of Joints1. Functional classification

a. Synarthrosis: immovable (ex. Sutures)b. Amphiarthrosis: slightly movable (ex. Intervertebral joints)c. Diarthrosis: freely movable (ex. Shoulder and Hip joint)

2. Structural classificationa. Fibrous: united by fibrous tissue; ex. Suturesb. Cartilagenous: united by cartilage; ex. Intervertebral discs, Pubic symphysis, Costal cartilagesc. Synovial fluid-filled joints; characteristics

Articularcartilage

Fibrousarticular capsule

Synovialcavity filled with synovial fluis

Reinforcing ligaments

E. Types of Muscle Tissues

1. Cardiac muscle involuntary, striated, branching; found in the heart

2. Smooth muscle involuntary, non-striated, spindle-shaped; usually found in hollow organs (stoma

intestines, bladder, bronchi)3. Skeletal muscle voluntary, striated, cylindrical

Prepared by Dr. Jhason John J. Cabigon


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F. Characteristics of Skeletal Muscles

1. Have at least 2 attachments: origin (proximal) and insertion (distal)

2. Have 2 properties: Contraction and Elasticity

3. Have 2 types of contraction: Isotonic (same tone) and Isometric (same length)

G. Functions of Muscles1. Producing movement2. Providing shape3. Maintaining posture4. Stabilizing joints5. Generating heat

H. Cartilages soft bones; a type of connective tissue with firm matrix

I. Functions of Cartilages

1. To cushion body prominences

2. To serve as protection where resiliency is required

J. Tendons attaches muscles to bones while ligaments attaches bone to another bone

Assessment of Patients with Musculoskeletal DisordersA. Health History

1. History and description of injury; focused on pain and altered sensations

2. Concurrent health conditions and family history3. Medications used and response; including alcohol, tobacco and herbal meds4. ADLs

5. Learning ability6. Occupation and Economic status

B. Physical Examination1. Posture2. Gait

3. Symmetry and Swelling

4. Mobility and crepitation (palpable or audible crunching as the bones rub together)

5. Muscle strength and size6. BP and HR monitor for shock

7. Neurovascular assessment or CMS (Circulation, Motion, Sensation) assessment: skin color, temperatu

capillary refill, pulse, sensation, painC. Diagnostic Tests

1. X-RAY reveals bone density, texture, erosion, fracture and other bone irregularities; Nursing implication:

assess for pregnancy and inability to tolerate required positioning due to age or disability

2. COMPUTED TOMOGRAPHY detailed specific plane of involved bone and can reveal tumors of the soft

tissue or injuries to the ligaments or tendons; Nursing implications: should contrast agent be used, assess for possibleallergy; assess for claustrophobia

3. MRI uses magnetic fields, radiowaves and computers to demonstrate abnormalities of soft tissues such as

muscle, tendon, cartilage, nerve and fat; Nursing implication: assess for metal implants and pacemakers; these patienare not candidates for MRI

4. ARTHROGRAPHY a radio-opaque contrast or air is injected into the joint cavity to reveal tears in joint

capsules and ligaments; Nursing implications: should contrast agent be used, assess for possible allergy; joint must bapplied with compression elastic bandage and rested for 12 hours; mild analgesics and ice may also be helpful

5. BONE DENSITOMETRY used to estimate bone mineral density (BMD) to detect osteoporosis; hip BMD

testing is the most accurate test for osteoporosis and for predicting risk of hip fracture

6. BONE SCAN allows exam of skeleton after injection of a bone-seeking radioisotope. Detects metastasic orprimary bone tumors, osteomyelitis, certain fractures and bone necrosis. It is helpful but not specific. Counter indicatein pregnancy. Nursing indications: assess for possible allergy and pregnancy; before scan, advise patient to emptybladder for accurate scanning of the pelvic bones; encourage fluids to flush out isotope

7. ARTHROSCOPY direct visualization of a joint (mainly the knee) by an arthroscope; Done in OR; #1 risk is

infection; Nursing Interventions: Consent, NPO after 12MN, shave and prep area; compression dressing, ice andelevation to control edema

8. ARTHROCENTESIS aspiration of joint fluid for testing of knee infection, hemarthrosis and other inflammato

arthropathies; normal synovial fluid is clear, pale, straw-colored and scanty. Anti inflammatory drugs can be injectedinto a joint. Nursing Interventions: Consent, ice and elevation for post-op swelling; sterile dressing to prevent infection



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9. ELECTROMYOGRAPHY (EMG) provides information about the electrical potential of the muscle and nerv

leading to them; used to evaluate weakness, pain and disability; Nursing implication: warm compress may relieresidual discomfort

D. Laboratory Exams1. Complete Blood Count (CBC) may indicate hemorrhage (low hemoglobin), infection (high WBC) and bleedtendencies (low platelets)

2. Serum calcium altered calcium in the blood indicates possible destruction of bone, osteomalacia, prolonge

immobilization, metastatic bone tumors, parathyroid dysfunction and Pagets disease.

3. Phosphorus inversely proportional with calcium. Calcium up, phosphorus down

4. Uric acid by-product of protein metabolism which is normally excreted via urine. Gouty arthritis is the resultnot being able to excrete.

5. Erythrocyte Sedimentation Rate (ESR) determines how long it takes RBCs to settle on the bottom of test

tube. Elevated ESR indicates Arthritis, cancer, infection and inflammation.

6. Rheumatoid factor identifies both lupus and rheumatoid arthritis.

7. Acid phosphatase elevated in Pagets disease and metastatic cancer.

8. Alkaline phosphatase enzyme present in bone, teeth. Elevated in early fracture healing and metastatic bon

tumors.

9. Creatine phosphokinase (CPK) an enzyme found mainly in the heart, brain, and skeletal muscle; increa

with muscle damage. No IM injections prior to lab.

Nursing Diagnosis (NANDA)A. Risk for trauma

B. Acute painC. Risk for Peripheral Neurovascular DysfunctionD. Impaired Physical Mobility

E. Deficient Knowledge regarding healing process, therapy requirements and potential complications

F. Self care needs

Common Types of Trauma/Injuries to the Musculoskeletal SystemA. Contusion soft tissue injury produced by blunt force, such as blow, kick, or fall; small blood vessels rupture producecchymosis (bruising) or hematoma

S&S: Pain, swelling and discoloration

Treatment: application of cold packs; resolves in 1-2 weeks

B. Sprain complete or incomplete tear of ligament (normally caused by twisting)

S&S: Pain, swelling and discoloration Diagnosic: X-ray and/or arthroscopy

Severity:

o First Degree: minor stretch or stretch of ligament

o Second Degree: tear of ligament

o Third Degree: complete rupture

o Fourth Degree: complete separation of a ligament to the bone, or along with small broken bon

requires surgery to heal

Treatment: P R I C E ( Protect, Rest, Ice, Compression, Elevation)o Protect the affected area for further injury

o Rest: Immobilize affected limb

o Ice: first 24-36 hours (reduces swelling)

o Compression Elastic Bandage: controls bleeding, reduces edema, provide support for the injured tissueso Elevation: controls swelling

o Appropriate pain medications

o Crutches

o Surgery if severe (torn muscles and disrupted ligaments)

C. Strain overstretching of ligaments or muscles

S&S: Same as sprain

Treatment: Rest muscle for one week. Teach stretching exercises

D. Dislocations or luxation occurs when bones in ajoint become displaced or misaligned; can be thru trauma

congenital disease; subluxation partial dislocation

http://en.wikipedia.org/wiki/Jointhttp://en.wikipedia.org/wiki/Joint


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S&S: Pain, swelling, discoloration, unequal length of extremity, change in contour of bone, loss of normal mobility

Diagnostic: X-ray

Types:1. Traumatic resulting from injury in which the joint is disrupted by force2. Congenital present at birth (ex. Developmental dysplasia of the hip)3. Spontaneous or Pathologic caused by disease of the articular or periarticular structures

Treatment: prompt reduction to prevent avascular necrosis (tissue death due to anoxia and diminished blood suppand nerve palsy

E. Fractures break in the continuity of the bone due to exertion or excessive force of stress

S&S: Signs of inflammation (pain, swelling, redness, heat, loss of function), Bruises or Ecchymosis, DeformitiCrepitus sound

Predisposing Factors:1. Trauma or Injury

2. Bone Pathology, such as Malignancy and Osteoporosis

3. Aging

General Classification of Fractures:1. Complete Fracture fracture involving the entire cross section of the bone2. Incomplete Fracture fracture involving only a portion of a cross section of the bone3. Closed/Simple Fracture fracture within an intact skin; fracture with no communication with outside air

4. Open/Compound Fracture fracture in which there is a communication between fracture site and external ai

a. Grade I Open Fx clean wound less than 1 cm longb. Grade II Open Fx larger wound without extensive soft tissue damage

c. Grade III Open Fx highly contaminated, has extensive soft tissue damage; most severe Classification of Fractures According to Etiology

1. Pathologic Fracture is due to local or general bone disease causing the bone to be unduly brittle whpredisposes fracture even with minimal traumatic force; conditions predisposing patients to pathologic fractuinclude new growths, cysts, osteomalacia, osteoporosis, osteomyelitis and Pagets disease which results to losscalcium in the bones2. Traumatic Fractures

a. Violence the bone is normal but due to maximal force applied, resulted to fracture

Direct Violence fracture occurs on the point of impact by an object or to the ground

Indirect Violence these occurs when the force is transmitted to the bone through some partsthe body

b. Muscular Action powerful sudden contraction of muscle that causes fracture of the bone; ex. Patel

fracture due to sudden contraction of quadriceps, Fracture of Humerus due to contraction of biceps brachii

Classification of Fractures According to Completeness1. Incomplete Fracture

a. Greenstick usually occurring in children wherein the bone is still soft and pliable; the bone is being bent a

the convex part is fractured

b. Fissured consisting of a mere split of the bone without displacement of the bone

c. Perforating those made by bullets making a hole on the boned. Depressed saucer or gutter-shaped, one in which the bone fragments are driven inward; ex. Skull fx

e. Compression the bone is forced against the adjacent bone; usually in the vertebrae

2. Complete Fracturea. Impacted portion of bone is driven into anotherb. Comminuted bone is broken into 2 or more fragmentsc. Complicated fracture that causes injury to surrounding tissues, such as organs and blood vessels

Classification of Fractures According to Displacement

1. Transverse Fx fracture surface run perpendicular to the long axis of the bone2. Oblique Fx fracture surface runs in slanting line or forms an angle with the axis or shaft of the bone

3. Spiral Fx the fracture line coils around the bone due torsion or twisting motion

Specific Types of Fractures

1. Avulsion Fx fragment of bone chipped away when ligament/tendon is injured

2. Colles Fx (Silver fork deformity) fracture of the distal epiphysis of RADIUS within to 1 inch of articusurface3. Condylar Fx fracture of round end of hinge joint usually occurring at the distal humerus or femur4. Galleazis Fx fracture of the distal radius with dislocation of distal ulna



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5. Hangmans Fx fracture or posterior elements of cervical vertebra with anterior dislocation of 2nd and

cervical vertebra6. Intercondylar Fx fracture between condyles of bone

7. Intertrochanteric Fx fracture of femur within the greater and lesser trochanter

8. Jeffersons Fx bursting type of fracture at the ring of the atlas9. Malgaine Fx fracture of both superior and inferior pubis rami of the pelvic bone10. Monteggias Fx fracture of proximal third of ulna associated with radial dislocation11. Pillon Fx T-shaped fracture of distal femur with displacement of condyle posterior to femoral shaft12. Potts Fx fracture dislocation of the ankle joint13. Smiths Fx fracture of the lower end of the radius with anterior displacement

14. Subtrochanteric fx fracture of the femur just below the lesser trochanter15. Supracondylar fx fracture above the condyle of either the femur of humerus

F. Complications of Fracture1. Infections usually for open/compound fractures and patient with soft tissue injuries

Tetanus Clostridium tetani

Gas gangrene Clostridium perfringes

Osteomyelitis Staphylococcus aureus2. Hemorrhage due to tearing of large vessels

3. Shock hypovolemic or traumatic shock due to hemorrhage (either external or internal hemorrhage)

4. Ischemia and other vascular disturbances may follow injury of main artery5. Nerve Injury laceration, compression or anoxia of nerves

6. Injury to Muscles, Tendons and Ligaments

7. Fat Embolism esp. for patient with multiple fractures, particularly of the long bones

8. Thromboembolic complications (DVT and Pulmonary Embolism) mostly due to immobility; institute measuto prevent thrombus formation:

Encourage adequate amounts of fluid

Apply elastic bandage

Encourage plantar flexion and dorsiflexion exercises hourly while awake

Administration of anticoagulants9. Compartment Syndrome

Compression of nerves, blood vessels and muscle inside a closed space (compartment) within the body

This leads to tissue death due to lack of oxygenation as the blood vessels are compressed by the raised pressuwithin the compartment

Function can be permanently lost if anoxia continues for more than 6 hours (ex. VOLKMANNS ISCHEMCONTRACTURE prolonged obstruction of brachial artery leading to permanent flexure of hand and wrist)

Causes of compartment syndrome:

o Decrease in compartment size due to tight surgical closure or tig

application of bandage and casto Increase in compartment content due to edema or hemorrhage

To relieve the pressure, the cast must be bivalved (cut in hlongitudinally) or may undergo fasciotomy

10. Delayed complications

Delayed Union

Non-union

Mal-union failure to restore back on its normal position; ex. Angulation: bone heals, but wdistorted angle

Avascular necrosis

Joint Contractures and Muscle Atrophy encourage exercise of unaffected joints (ex. Encouratoe and finger exercises); also encourage isometric contractions unto immobilized muscles to reduce atrophy (Quadricep-setting and Gluteal-setting exercises)

G. Management Goal of Fractures: to accurately approximate the bone fragments in its anatomical alignment so that bo

can heal normally and to prevent permanent deformitiesH. Principles in the Treatment of Fractures (4 Rs)

1. Recognition check the possibility of fracture through PE observation of S&S

2. Reduction the process of returning the bone to its proper position; casts are often required after reduction

maintain position until healing occurs

Closed Reduction surgery not required; performed by manual manipulationPrepared by Dr. Jhason John J. Cabigon


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Open Reduction surgery required

3. Retention immobilize the affected part by use of immobilizing devices, such as cast, traction, braces, splin

and bandages; also includes fixation devices:a. External Fixation application of rods and pins through skin to boneb. Internal Fixation surgical application of screws, plates, pins or nails (ex. ORIF open reduction winternal fixation)

4. Rehabilitation restoration to normal function

I. Stages of Fracture Healing

1. Hematoma formation cleaning occurs from the damage bone ends (24-72 hours)

2.Cellular Proliferation during the first week after injury, the hematoma becomes invaded and replaced granulation tissue (growth of new capillaries)

3. Fibrocartilage Callus Formation connective tissue cells produce cartilage and bone matrix to close the gap

4. Bony Callus Formation as more osteoblasts and osteoclasts migrate into the area, the fibrocartilage callus

gradually replaced by the bony callus

5. Bone Remodelling over the next few weeks to months, the bony callus remodels in response to mechanic

stress, so that it forms a strong permanent patch at the fractured site

J. Musculoskeletal Care Modalities Traction, Casts, Molds, Braces

1. Traction application of a pulling force to a part of the body which is associated with countertraction; usprimarily as a short-term intervention until other modalities, such as internal or external fixation, are possible

Purposes of Traction:o Used to minimize fractures

o To regain normal length and alignment of injured extremity

o To reduce muscle spasm and relieve pain

o Prevent deformity

o To give freedom for intent activity

Types:o Skin Traction accomplished by using a weight to pull on traction tape or on a foam boot attached to

skin:

a. Bucks extension traction the affected extremity is pulled in a straight line with the body; used

immobilize fractures of the proximal femur before surgical fixation; Nursing care: prevent damage to deperoneal nerve (resulting to foot drop) by providing foot board and encouraging plantar flexion adorsiflexion; may turn patient to unaffected side (place pillow between legs before turning)

b. Russells traction the knee is suspended in a sling attached to a rope and a pulley on a fram

creating an upward pull on the knee; weights are attached to the foot creating a horizontal force; used

stabilize fracture to femoral shaft; Nursing care: watch out for signs of thrombophlebitis (becausepressure in popliteal space, in addition to immobility); check popliteal area frequently; pad sling

c. Bryants traction used for children under 3 years and 30 lbs to treat fractures of the femur and

dislocation; Both legs raised 90 angle to bed; Buttocks must be slightly off mattress with knees slighflexedd. Cervical traction used for soft tissue neck injuries to reduce muscle spasm and maintain alignmeelevate head to provide countertraction; Nursing care: pad chin area and protect ears

e. Pelvic Traction pelvic girdle with extension straps are attached to a rope or weight; used for low ba

pain, pulled muscle (spasms), sciatica; knees are supported with pillow to take pressure off back

o Skeletal Traction applied to the bone by means of a metal pin: Steinman pin (straight metal ro

Kirschner wire (sharpened, smooth, stainless pin), Crutchfield or Gardner-Wells Tongs (screwed at sidesskull); often used with balanced suspension; most reliable type of traction; Nursing care: observe signsinfection (odor, redness, drainage) in the insertion site and use sterile technique to clean

o Manual use of physicians hands for manual pulling; used as temporary traction when applying a cagiving skin care under a Bucks extension foam boot, or adjusting the traction apparatuso Straight or Running Traction applies the pulling force in a straight line with the body part resting on t

bed (ex. Bucks extension traction)o Balanced Suspension Traction supports the affected extremity off the bed and allows for some patie

movement without disruption of the line of pull; accomplished by a Thomas splint and Pearson attachment

Complications of Traction

o Pressure ulcers (Bed sores) proper skin care, good perineal care, turning buttocks

o Pneumonia encourage deep breathing

o Constipation and anorexia fear of apparatus, lack of privacy, lack of fluids; perineal care

o Urinary stasis and infection good perineal care, increase fluid intakePrepared by Dr. Jhason John J. Cabigon


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o Pin site infection observe for S&S of infection (loosening pin tract, pus, foul-smelling odor, fever)

o Venous stasis and deep vein thrombosis

o Deformities and contractures

Nursing Care:1. Care of equipments:o Ensure that weights are hanging freely and not touching the floor

o Ensure that pulleys are not obstructed

o Check ropes in the pulley if they move freely

o Secure knot of the rope to prevent slipping

o Do not remove or lift weights without specific order except in a pelvic and cervical traction which a

removed in intervalso Cover sharp edges of the traction apparatus

2. Maintain proper body alignment

3. General hygiene and comfort skin care, hair care, care of nails and perineal hygiene, sponging of

affected leg by starting on the anterior portion and posterior by removing the sling one at a time

4. Conditioning Exercises deep breathing and coughing exercise, Active ROM exercises of unaffect

extremities, encourage independence5. Prevention of possible complications:o Pneumonia deep breathing exercises, keep back dry and teach patient to sit even with traction, usi

overhead trapeze

o Bedsore/Decubitus ulcer keep linen free from wrinkles, keep back dry, lift buttocks and massage t

back esp. the bony prominences

o Joint contractures and muscle atrophy active exercise of the unaffected extremities and isomeexercise for the affected one

o Constipation increase fluid intake, exercise as permitted, offer bed pan at regular intervals

o Infection of the pin insertion site maintain aseptic technique during dressing

6. Provide diversional activities to prevent boredom7. Meeting the nutritional needs high protein, vitamin C and calcium

8. Making pertinent observations see to it that traction is not the source of undue discomfort to the patient

2. Cast a rigid external immobilizing device that is molded to the contours of the body; to immobilize a reduc

fracture, to correct/prevent deformity, to apply uniform pressure to underlying soft tissues and to support weakenjoints; casts must extend beyond the joints above and below fracture

Types of Castso Short-arm cast

o Long-arm cast

o Short-leg cast

o Long-leg cast

o Walking cast

o Body cast

o Shoulder spica cast

o Hip spica cast

Types of Casting Materials

o Plaster 48 hours to dry; handle with palms; elevate on pillow; will create heat while drying (ice bags c

be placed beside the cast, not on top); powder should not be put in cast

o Non-plaster (Fiberglass) lighter, durable, stronger, dries quickly and water-resistant

Nursing Care:o Elevate wet cast on pillows to prevent flattening

o Elevate cast above level of heart to prevent edema and stimulate blood circulation

o Handle wet cast with palm of the hand to prevent dents

o Turn patient every 2 hours to allow cast to dry faster

o

Regularly assess pain; intermittent cold packs on each side of cast, elevation and administering analgesmay improve paino Observe for wound drainage, signs of systemic infection and odors from the cast

o Monitor neurovascular function

o Administer care to skin near cast edges to prevent PRESSURE SORES AND ULCERS

o For itching, advise use of cool hairdryer

o Watch out for CAST SYNDROME (tight body casts causes pressure on mesenteric artery that leads

gastric intestinal ileus; it is manifested by vomiting, decreased or absent bowel sounds, abdominal pain adistention)



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o Watch out for COMPARTMENT SYNDROME (compression of nerves, blood vessels and muscle inside

closed space/compartment within the body; manifested by 5 Ps pain, paresthesia, pallor, paralysis apulselessness); Report unrelieved pain, swelling and poor capillary refill timeo Encourage exercise of joints that are not immobilized (ex. Encourage toe and finger exercises); a

encourage isometric contractions unto immobilized muscles to reduce atrophy (DISUSE SYNDROME)

K. Fractured Hips occurs most often in elderly women

1. Types:

Intracapsular fracture of the head and neck of femur

Extracapsular fracture of the trochanteric area of femur

2. Predisposing factors:

Osteoporosis

Degenerative changes of the bone3. Assessment: pain in the affected limb, limb appears shorter, there is external rotation and abduction4. Diagnosis: X-ray5. Management

Medicalo Bucks or Russells Traction to maintain alignment, reduce pain and spasm

o Analgesics

Surgical

o ORIF open reduction with internal fixation

o Hemiarthroplasty surgical procedure which replaces one half of the joint with an artific

surface and leaves the other part in its natural (pre-operative) state; uses prosthesis (Austin-Moore) to repla

head of femuro Total Hip Replacement replacement of both acetabulum and head of femur

L. Total Hip Replacement

To prevent dislocation of prosthesis, maintain abduction of affected limb at all times with an abduction splint, wedge pillow or 2-3 pillows between the legs

If ordered to turn, keep operative hip in abduction

Never flex hips more than 90 degreeso Do not elevate head of the bed more than 60 degrees (better if head flat on bed)

o Upon use of fracture bedpan, flex the unaffected hip and use trapeze to lift pelvis into the pan

o May raise bed to 45 degrees for meals if allowed

Always keep operative side in the neutral position, toes pointing up; to maintain position, roll up towel and plait on the legs outer side to prevent from rotating externally

Some institutions would turn the patient to the operative side, but some to the unaffected side; when turning,lower head and place pillows between legs, then turn slowly

Favor the unaffected side; When assisting patient out of bed, let patient move to the edge of the bed by hersethen have patient step down with the unaffected side and maintain abduction (an abduction splint or pillows are keptbetween legs and avoid weight bearing)

Instruct client to use high-seat (orthopedic) chairs and semireclining wheelchairs and raised toilet seats

Do not cross legs; do not bend down to put pants, socks and shoes; do not pick up an object on the floor

Watch out for signs of dislocation of prosthesis:o Increased pain at the surgical site, swelling and immobilization

o Acute groin pain in the affected hip or increased discomfort

o Shortening of the leg

o Abnormal external or internal rotation

o Restricted ability or inability to move leg

o Reported popping sensation in the hip

Immediately report the dislocation to the surgeon, because the hip must be reduced and stabilized promptly sthat the leg does not sustain circulatory and nerve damage

Monitor wound drainage

Prevent DVT

Prevent infection

Upon discharge:o Emphasize the importance of daily exercise program in maintaining the functional motion of the h

o Use of assistive devices until sufficient muscle tone has developed to perform normal gait

o In general, can resume ADLs by 3 months

o Stair-climbing kept to a minimum for 3-6 months



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o Sexual intercourse should be carried out with a dependent position (flat on back) for 3-6 months

o Do not cross legs or flex hips more than 90 degrees for the first 4 months

o Avoid low chairs and avoid sitting for more than 45 minutes

o Avoid long-distance travel

o Other activities to avoid: tub baths, jogging, lifting heavy loads, and excessive bending and twisting

Joint Disorders

A. Rheumatoid Arthritis chronic, autoimmune, systemic, recurrent, inflammatory disease of the synovium or lining of th

joint

Incidence: Women > Men (occurs at 20-30 y/o)

Etiology: unknown

Predisposing Factors: fatigue, cold, infection, stress

Joints affected: small, peripheral joints of the hands and wrists; elbow, shoulder, hip, knees, ankles, jaw

Assessment:o Joint pain, swelling, heat, redness, limitation of function

o Morning stiffness

o Systemic manifestations: anorexia, weight loss, slightly inc. temp

o Extra-articular manifestations: subcutaneous nodules secondary to pannus formation; can also

produce diffuse inflammation of the lungs, pleura, pericardium and sclerao Remission and exacerbation

4 stages of deteriorationo Stage I: Synovitis

o Stage II: Inflammed synovial tissue proliferates and begins to grow into joint cavity across articularcartilage, which it gradually destroys

o Stage III: Formation of Pannus (newly formed synovial tissue infiltrated with inflammatory cells)

o Stage IV: End-stage; fibrous or bony ankylosis of joint

Diagnostics:o Rheumatoid factor (RF)

o Anti-nuclear antibody (ANA)

o Human Leukocyte Antigen (HLA)

o Inc. IgG, M, A, D

o Inc. ESR

o Inc. C-reactive protein

o X-ray early in rheumatoid arthritis, the X-ray may be normal or show only soft-tissue swelling, but

damage can still be occurring; over time, the usual finding is erosion of the bony part of the joint Management:

o Administer drugs as order

1. NSAIDs (ex. Mefenamic Acid, Ibuprofen, Naproxen, Diclofenac, Ketorolac)

MOA: Relieves mild-moderate pain by inhibiting synthesis of prostaglandin

SE: GI distress, ulcer, bleeding, nausea, vomiting, diarrhea, anorexia, hepatotoxicity

2. Anti-inflammatory Steroids (ex. Prednisone) may be given intra-articularly

MOA: drugs that act by blocking the inflammatory, allergic, and immune responses bysuppressing many components of the inflammatory process

SE: susceptibility to infection, salt and water retention, hypokalemia, hyperglycemia, gas-trointestinal irritation and ulceration

o Physical and Rehab therapy to maintain joint mobility and muscle strength

o Assistive devices use of canes, walkers, crutches to stabilize joints, prevent deformities, encourage

dependence and to conserve energy

o Surgery to correct deformity; ex. Synovectomy and Joint Replacement

Nursing Diagnosiso Alteration in mobility related to inflammatory changes

o Alteration in comfort

o Pain related to inflamed joints

Nursing Careo Promote maintenance of joint mobility and muscle strength

Perform ROM

Use of heat prior to exercisePrepared by Dr. Jhason John J. Cabigon
http://www.emedicinehealth.com/script/main/art.asp?articlekey=6032http://www.emedicinehealth.com/script/main/art.asp?articlekey=9562http://www.emedicinehealth.com/script/main/art.asp?articlekey=6032http://www.emedicinehealth.com/script/main/art.asp?articlekey=9562


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Stop exercise at the point of pain

Use isometric exercises to strengthen muscles

o Change position frequently alternate sitting, standing, lying

o Promote comfort and relief of pain

Ensure balance between activity and rest

Provide 1-2 hours scheduled rest period throughout the day

Rest and support inflamed joints if resting; splint is usedo Ensure bed rest during acute exacerbation

Provide firm mattress with a small pillow

Maintain proper body alignment

Have patient in prone position 30 mins 2x/day to prevent pressure sores

Avoid pillows under knees to prevent knee contracture

Keep joint mainly in extension, not flexion, to prevent deformity

Prevent complication of immobilityo Provide Heat

More effective in chronic pain

Warm, moist compresses

Hot, moist pack (36.6-40.5oC)

Parafin wax bath (125-129oF or 51.7-53.9oC)o Provide Cold

Most effective for acute pain

Ice packs, ice massage

o Provide psychological support and encourage patient to express feelings; depression is common du

to body imageo Assist patient in setting realistic goals

o Provide patient teaching and discharge planning

Medications

Self-help devices to assist in ALDs to increase independence

Maintain balance between activity and rest

Energy conservation method

Perform ROM, isometric and prescribed exercises

Apply resting splint as ordered

Avoid physical and emotional stress

Emphasize importance of follow-up care

B. Osteoarthritis chronic, non-systemic, degenerative disease of the joint characterized by degeneration of the articula

cartilage; most common cause of arthritis

Incidence: Men > Women; occurs before age 45 for men and occurs after age 55 for women

Etiology: unknown; some wear and tear

Predisposing Factorso Trauma; injury

o Obesity

o Prior inflammatory disease

o Hereditary

o Metabolic disturbance, like DM

o Aging

Joints affected: weight-bearing joints (hips, lower spine, knees, ankles); men usually hip joint, women usuallyfingers (interphalangeal joints or IPJ)

Assessment

o Pain, decreased ROM, possible crepitation, limping gait

o Bony enlargement of the proximal IPJ (Bouchards nodes) and distal IPJ (Heberdens nodes)

secondary to bony spurs (or osteophytes)

Diagnostics no specific; x-ray may reveal joint space narrowing, spur formation (osteophytes), subchondralsclerosis, subchondral cyst formation and subluxation

Management: same as RA

Nursing Diagnosis: same as RA

Nursing Care:



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o Relieve strain and prevent further trauma to joint

o Maintain joint mobility and muscle strength

o Promote comfort and relief of pain

o Prepare patient for joint replacement surgery

o Provide patient teaching and discharge planning

C. Gouty arthritis acute inflammation of the bone caused by deposits of uric acid crystals

Incidence: men > women; usually men over 30 y/o

Joints affected: usually the big toe

Types:

o Primary hereditaryo Secondary usually due to drugs that increase uric acid (thiazide diuretics, vitamin B12 among

patients with pernicious anemia, anti-TB PZA)o Idiopathic unknown

Pathology:1. Inability to metabolize purines2. Acummulation of uric acid in the blood (hyperuricemia)3. Deposition of urate crystals in the joints4. Local irritation and inflammation

Assessment: Pain on big toe, typically at night; swelling, heat, redness, limitation of function; fever; formationtophi (accumulation of crystalline deposits in articular surfaces, bones, soft tissues and cartilage); HPN

Diagnostic: Inc in serum uric acid

Nursing Care:1. Medications

a. Xanthine oxidase inhibitor Allopurinol (Zyloprim, Llanol); MOA: inhibits uric acid synthes

(acts as prophylaxis for acute attacks of gouty arthritis); SE: gastric irritation, rashes, dizziness, anorexia

b. Uricosuric Agent Probenacid (Benemid); MOA: promotes excretion of uric acid

c. Colchicine MOA: drugs that inhibit the migration of leukocytes to the inflamed site (effective

for acute symptoms only); SE: diarrhea (oral), nausea, vomiting, abdominal pain, aplastic anemia; given IV 2mg, if patient not relieved, additional 0.5 mg until max: 4 mg; dilute with 20 ml of normal saline to preventvenous sclerosisd. NSAIDs

e. Corticosteroids

2. Diet: decrease purine (alcohol, anchovies, internal organs, beans, sardines, shellfishes, nuts,

chocolate)

3. Increase fluids 3,000 ml/day to prevent renal calculi4. CBR5. Alternate warm and cold compress (contrast bath)6. Encourage exercise to prevent deformity7. Use of bed cradle8. Monitor BP9. Provide patient teaching and discharge planning

a. Use of medsb. Diet modificationc. Limit alcohol used. Increase fluidse. Weight reductionf. Importance of exercise

D. Total Knee Replacement1. Dress knee with compression bandage2. Ice to control edema3. Assess neurovascular status of the leg (CMS)4. Encourage foot flexion every hour when the patient is awake5. Prevent complications (thromboembolism, peroneal nerve palsy, infection, limited ROM)6. Monitor color, type, and amount of drainage until the surgeon removes the wound suction drain7. Patients leg may be placed on a CONTINUOUS PASSIVE MOTION (CPM) device to increasecirculation and ROM of the knee joint; usually 10 degrees of extension and 50 degrees of flexion initially, increasing to90 degrees of flexion with full extension (0 degrees) by discharge8. Protect knee with an immobilizer (splint, cast or brace)9. Progressive ambulation, using assistive devices and within the prescribed weight-bearing limits



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Assisted LocomotionA. Canes

Hold the cane on good side. Move the cane and the bad leg at the same time first (simultaneously), thenadvance the good leg.

The cane handle should be held with the elbow flexed at 30 degrees, it should be at the levelthe femur.

B. Walkers

The top of the walker should be at the same level as the cane (head at the femur level with elbow flexed at 30degrees.

When using a walker, advance it and then move into it.C. Crutches

Two-Point gait- used for a bilateral amputee with prosthesiso advance left crutch and right foot

o advance right crutch and left foot

Three point gait used for non- bearing person with a fracture of he hip and lego advance both crutches forward with the affected leg and shift weight to crutches

o advance unaffected leg and shift weight onto it

Four point gait used for patients affected by polio and cerebral palsy

o advance left crutch (good side)

o advance right foot (affected side)

o advance right crutch

o advance left foot Tripod crutch gait - initial pattern for patients with paraplegia learning to do swinto gait pattern

o Alternate: advance right crutch, then left crutch, then drag body and legs to crutches

o Simultaneous: advance both crutches, then drag body and legs to crutches

Swinging crutch gait used for patients with weakness of both lower extremities

o Swing-To crutch gait: advance both crutches forward then, while bearing all weight down

through both crutches, swing both legs forward at the same time to (not past) the crutches

o Swing-Through gait: advance both crutches forward then, while bearing all weight down

through both crutches, swing both legs forward at the same time past the crutches; fastest gait

Impairment of Back and Spine

A. Scoliosis lateral deviation of spine Dextroscoliosis deviated to the right

Levoscoliosis deviated to the left

B. Kyphosis thoracic convexity; humpback

C. Lordosis lumbar or cervical concavity

D. Low Back Pain usually due to muscle strain of muscles and soft tissuof the back especially during physical loading; may be also due to other conditions, such as UTI, osteoporotic fractures aherniated nucleus pulposus (slipped disk)

Types:o Acute less than 3 months

o Chronic more than 3 months

Non-specific Treatment: rest, warm compress, analgesics, physical rehabilitation, pelvic traction

E.Herniated Nucleus Pulposus (Herniated or Slipped Disk) a conditionwhen the nucleus pulposus (the soft center of the intervertebral disk) protrudes through the weakened part of the disk; the

herniated disk may compress a spinal nerve as it exits the spinal cord

CERVICAL AND LUMBAR REGION (4th and 5th intervertebral space of the lumbar region) are most common sites assess level of pain and signs and symptoms of nerve root compression causing neuralgia and dysfunction of nervetransmission

Incidence: more often in men

Predisposing factors: heavy lifting and pulling, trauma

Assessment (Lumbosacral disk):

1. Back pain radiating across the buttock and down the leg2. Weakness of the leg



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3. Numbness and tingling in the toes and foot4. (+) Straight-leg test (reproduction of pain in the leg and low back upon lifting an extended leg; positive test ifpain occurs at 30-70 degrees of hip flexion)5. Decreased or absent Achilles reflex6. Muscle spasm in the lumbar region

Assessment (Cervical disk):1. Shoulder pain radiating down the arm and hand2. Weakness of the affected extremity3. Paresthesia and sensory disturbances (numbness, tingling)

Diagnosis: CT Scan, MRI, EMG, Myelogram

Medical Management1. Rest and Positioning "Williams position"; use firm mattress2. Exercises; teach proper body mechanics; avoid prone position3. Medications4. Heat/Ice

5. Traction (pelvic or cervical) to relieve muscle spasm6. Bracing (Lumbosacral Corset; Cervical Collar)7. Weight reduction

8. Transcutaneous electrical nerve stimulation (TENS) unit a pocket size, portable, battery-operated device thsends electrical impulses to certain parts of the body to block pain signals

Surgical Management

1. Microdiskectomy surgical removal of herniated disc material that presses on a nerve root or the spinal cord

small incision, in hospital two days; may use with laser2. Laminectomy more extensive; long incision because surgeon has to remove portions or the lamina to get tothe protruding portion of the disk and remove it

a. Bedrest with logrolling side to side to keep spine straight; keep bed flat and when patient geup, keep his/her back straight

b. Check dressing frequently for CSF leakage; check incision for bulging; measure Hemovac

drainage should be minimalc. Assess neurovascular status, bowel and bladder functiond. Check with surgeon as to whether coughing will be encouraged post-ope. Reassure patient that pain is from trauma of surgery, not continued nerve root compression

3. Spinal Fusion (spondylodesis or spondylosyndesis) asurgical technique used to fuse two or more vertebraesupplementary bone tissue (either autograft orallograft) is used in conjunction with the body's natural osteoblasticprocesses

a. Anterior or Posterior approach to spineb. Bone grafts from iliac crest or bone bankc. Bone grafts laid in along bony defect created surgically, and supported by metal apparatus such as Harringto

rods, C-D rods or "cages"; these remain in as long as no complications result from themd. Portion of spine that is fused is not flexible--"rigid"e. Stay in bed longer than laminectomy and have a brace fitted to get out of bed--must wear for several weeks

months

Nursing Care:

1. Ensure bedrest on the firm mattress

2. Assist patient in applying pelvic or cervical traction3. Maintain proper body alignment4. Administer drugs as ordered5. Prevent complications of immobility

6. Provide pre-op and post-op care7. Monitor for neurologic deficit8. Provide discharge plans

a. Back strengthening exercises

b. Maintain good posturec. Use of proper body mechanics on how to lift objects correctlyd. Use of medications and side effectse. Proper application of corset and collarf. Weight reduction

Bone Tumors

http://en.wikipedia.org/wiki/Orthopedic_surgeryhttp://en.wikipedia.org/wiki/Vertebraehttp://en.wikipedia.org/wiki/Allografthttp://en.wikipedia.org/wiki/Osteoblasthttp://en.wikipedia.org/wiki/Orthopedic_surgeryhttp://en.wikipedia.org/wiki/Vertebraehttp://en.wikipedia.org/wiki/Allografthttp://en.wikipedia.org/wiki/Osteoblast


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A. Benign Bone Tumors slow growing, well circumscribed and encapsulated; examples:

1. Osteochondroma most common benign bone tumor; large projection of bone at the epiphysis (at th

knee or shoulder)2. Enchondroma tumor of the hyaline cartilage that develops in the hand, femur, tibia or humerus3. Bone cysts expanding lesions within a bone; aneurismal (widening) cysts are seen in young adultspresenting with a painful, palpable mass of the long bones, verterbra or flat bones4. Osteoid osteoma painful tumor surrounded by reactive bone formation

5. Osteoclastoma giant cell tumors; may invade local tissue and cause destruction; occurring in young

adults and are soft and hemorrhagic; may undergo malignant transformation6. Others rhabdomyoma, fibroma

B. Malignant Bone Tumors

1. Osteosarcoma (osteogenic sarcoma) most common malignant bone tumor and most often fatal;

more frequent in males 10-25 y/o, in older people w/ pagets disease, and as a result of radiation exposure; mosttumors occur in metaphyseal region of long bones, particularly distal femur and proximal tibia, also in proximal humerand pelvis; most frequency of metastasis in the lungs

2. Ewings sarcoma most common primary malignant tumor of the bone and soft tissues; characterize

by rapid growth within the medullary cavity of the bone especially, femur, tibia, humerus, pelvis and ribs; commonlyoccurs between age 5 and 20; metastasis occurs early and in the lungs

3. Chondrosarcoma malignant tumor of the hyaline cartilage; occurs most commonly in patients 40 to

70 years of age; most cases occur around the hip and pelvis or shoulder4. Fibrosarcoma

C. Metastatic Bone Disease (Secondary Bone Tumors) tumors arising from elsewhere in the body and produce localiz

bone destruction (lytic lesions) or bone overgrowth (blastic lesions)D. Assessment: pain, bone growth, weight loss, malaise, fever, may be diagnosed only after pathologic fracture; spinalmetastasis may manifest with compression and neurologic deficits (must undergo decompressive laminectomy to preventpermanent SC injury

E. Diagnostics: CT Scan, Bone Scan, MRI, Biopsy, Myelography, Arteriography, Biochemical assays of blood

F. Management Goals:

Primary: destroy or remove tumor surgical excision (local excision, amputation, disarticulation), chemotherapy forpossible micrometastasis, radiotherapy for radiosensitive tumors; Limb-sparing (salvage) procedures

Secondary palliative (relieve pain and discomfort while promoting quality of life)

Amputation removal of a body part, usually an extremity (lower > upper extremity)A. Causes of Amputation

1. Peripheral Vascular Disease (most common cause)

2. Fulminating gas gangrene3. Trauma and injuries4. Burns and Frostbites5. Congenital deformities6. Chronic osteomyelitis7. Malignant tumors

B. Factors that Determine Site of Amputation1. Circulation in the part2. Functional usefulness (i.e. meets the requirements for the use of prosthesis)

C. Goal of Surgery: to conserve as much as extremity length as needed topreserve function and possibly to achieve a good prosthetic fitD. Levels of Amputation

1. BKA: below the knee amputation

2. AKA: above the knee amputation3. AE: above the elbow

4. BE: below the elbow

5. Knee disarticulation6. Shoulder disarticulation

7. Hemipelvectomy

8. Syme amputation modified ankle disarticulation

E. Types of Surgery

1. Closed (Flap) amputation with skin closure

2. Open (Guillotine) amputation the wound is open to allow drainage and

removal of necrotic and infected tissuesPrepared by Dr. Jhason John J. Cabigon


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F. Post-Operative Care1. Elevate the stump by raising the foot of the bed; use a pilloto raise the stump for the first 24 hours only. After this, remove the pillow to prevent hip flexion contracture and pronathe patient as tolerated several times a day to promote hip extension.2. Have a tourniquet by the bedside in case hemorrhageoccurs; apply tourniquet and immediately call surgeon; patient must return to O.R. for repair

3. Reinforce dressings surgeon does first dressing; if cast is

present on end of stump, mark drainage as needed

4. Manage and explain "phantom pain" this is real pain

5. Support pt. through grieving process and change in body

image6. Teach pt. principles of stump care7. Refer to rehab, prosthetist and home care

Metabolic Bone Disorders

A. Osteoporosis age related metabolic bone disease wherein bone demineralization leads to porous bone with

subsequent fractures. The wrist, hip and vertebral column are most affected

Predisposing factors1. Post-menopausal status2. Prolonged immobilization3. Long-term corticosteroid use4. Nutritional deficiency and malabsorption syndrome

Pathophysiology: if rate of bone loss (resorption) exceeds bone formation decrease in total bone mass bonebecomes porous, brittle and prone to fracture

Assessment1. Fractures (esp. vertebral compression fracture, hip fracture)2. Bone pain3. Visible deformity4. Loss of height5. Constipation

Diagnosis1. Radiographic and Bone density scan2. Serum calcium, phosphorus and alkaline phosphate are within normal ranges

Nursing Care

1. Monitor drugs and side effects

a. Non-narcotic analgesics (SE: gastric irritation, ulcer, bleeding tendencies)b. Calcium supplements (SE: constipation, hypercalcemia, renal calculi, gastric irritation)

c. Vitamin D to aid in calcium absorption

d. Stool softeners for constipation

e. Estrogen in post-menopausal women (SE: vaginal bleeding, embolism)

2. Use caution in turning, lifting and transferring patient3. Apply a lumbosacral corset to promote spinal stability4. Increase intake of calcium (milk, cheese, salmon, broccoli, spinach)5. Instruct client to perform ROM exercises at least twice a day6. Teach client to move trunk as a unit and maintain good posture and body mechanics7. Encourage regular moderate exercise (ex. Walking)8. Teach patient about disease process and prevention of progression9. Teach patient measur4s to prevent injury from falling (ex. use side rails in beds)

B. Osteomalacia softening of bones due to defective bone mineralization; is a type ofmetabolic bone disease in whichthe essential problem is a lack of available calcium or phosphorus (or both) for mineralization of newly formed osteoid; theprimary defect is the deficiency of activated Vitamin D (Calcitriol), which promotes calcium absorption and mineralization

C. Pagets Disease disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic

bones and vertebra

Incidence: occurs in 2-3% of the population older than 50 y/o; men > women

Cause: Unknown

Pathophysiology: osteoclast activity (bone resorption) > osteoblast activity (bone formation)

Musculoskeletal Infections

A. Osteomyelitis an infection of the bone; usually caused by S. aureus

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The bone becomes infected in 3 ways:1. Extension of soft tissue infection (e.g. infected pressure ulcer, incisional infection)2. Direct bone contamination (e.g. bone surgery, open fracture)3. Hematogenous (bloodborne) spread from other sites (e.g. from infected tonsils, boils, respiratory infections)

Assessment1. Body malaise and fever2. Signs of inflammation3. Difficulty in weight bearing4. Drainage from wound site

Diagnosis

1. CBC leukocytosis, neutrophilia2. Blood Culture

Nursing Care1. Administer analgesics and antibioticsa. Penicillin 4.8-6 million units q4 ANST IV push, then shift to oral penicillin 500 mg q8 for 7-14 days2. Use sterile technique during dressing3. Maintain proper body alignment and change position frequently to prevent deformities4. Provide immobilization of affected side5. Provide psychological support and diversional activities6. Prepare patient for surgery if indicateda. Incision and drainageb. Sequestrectomy (removal of dead, infected bone and cartilage)c. Bone grafting after repeated infection

d. Leg amputation7. Provide patient teaching and discharge plana. Use of prescribed antibiotics

b. Importance of recognizing and reporting signs of complication (deformity, fracture recurrence)

B. Septic (Infectious) Arthritis infection of the joints

Joints can be infected through:1. Hematogenous spread infection from other parts of the body2. Direct through trauma or surgical instrumentation

Etiologic agents: S. aureus causes most adult joint infections, followed by streptococci and gonococci

Other Musculoskeletal Disorders

A. Systemic Lupus Erythematosus (SLE) a result of disturbed immune regulation that causes an exaggerated producti

of auto-antibodies; an autoimmune disease that can affect any system

Prevalence: 10 times more frequent in women than in men; 3x more frequent in African-americans than inCaucasians

Factors:1. Genetic factors2. Hormonal factors (as evidenced by the usual onset during the child-bearing years)3. Environmental factors (sunlight, thermal burns)4. Medications (Drug-induced SLE)a. Hydralazineb. Isoniazidc. Chlorpromazined. Some anti-seizure meds

Assessment:

1. Arthralgias and arthritis most common presenting feature of SLE2. Skin lesionsa. Subacute cutaneous lupus erythematosusb. Discoid lupus erythematosusc. Butterfly rash most familiar rash occurring in more than 50% of patients; across the bridge of nose and

cheeks3. Pericarditis4. Renal involvement monitor serum creatinine and urinalysis

5. CNS involvement change in behavior and cognitive ability; depression and psychosis

6. Fever, fatigue, weight loss

Management1. Corticosteroids most important medication



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2. Anti-malarials are effective for managing cutaneous, musculoskeletal and mild SLE

3. NSAIDs4. Immunosuppressive agents alkylating agents and purine analogues

Nursing Care:1. Teach client to avoid exposure to sunlight or to protect themselves with sunscreen and clothing2. Emphasize the need for routine periodic screenings3. Need for dietary consultation to ensure patients knowledge about dietary recommendations, given theincreased risk of cardiovascular disease, including HPN and atherosclerosis4. Patient may benefit from support groups5. Instruct the client to importance of continuing prescribed meds

6. Advise client to monitor for systemic involvement, including renal and cardiovascular effectsB. Carpal Tunnel Syndrome an entrapment neuropathy that occurs when the median nerve at the wrist is compressed

compression may be due to a thickened flexor tendon sheath (flexor retinaculum), skeletal encroachment, edema, or a sotissue mass; commonly caused by repetitive hand and wrist movement

Assessment: patient complains of numbness, pain and possibly weakness along the median nerve (thumb,index and middle finger)

Treatment:1. Wrist splints to prevent hyperextension and prolonged flexion2. Drugs: NSAIDs and carpal canal cortisone injections

3. Surgery: Open nerve release and Endoscopic laser surgery

C. Dupuytrens Disease slow progressive contracture of the palmar fascia, which causes flexion of the 4th and 5th finger

and frequently the middle finger; autosomal dominant trait that usually occurs in men > 50 y/o; it starts as a nodule that mprogress so that the fibrous thickening extends to involve the skin in the distal palm and produces a contracture of thefingers; patient experiences discomfort, morning numbness, cramping and stiffness of affected fingers; finger-stretchingexercises may prevent contracture; palmar and digital faciectomies may improve function

D. Hammer Toe a deformity of the proximal IPJ of the 2nd, 3rd or 4th toe causing it to be permanently bent, resembling a

hammer; caused by wearing poorly-fit shoes

E. Hallux Valgus (Bunion) deformity in which the great toe deviates laterally, associated with marked prominence of th

medial aspect of the 1st metatarsophalangeal joint; factors include heredity, ill-fitting shoes, and gradual lengthening andwidening of the foot associated with aging

Pediatric Alterations

A. Congenital Clubfoot (Talipes Equinovarus) congenital malformation in which the foot twisted inward; may affect on

or both feet

Incidence: Males are affected twice as often as females

Etiology: Unknown Predisposing Factors:

1. Arrested development in-utero during 1st trimester

2. Genetic predisposition3. Seen in conjunction with congenital abnormalities, such as cerebral palsy

Assessment:1. Unilateral or bilateral defect; 3 components of clubfoot defect:

a. Foot pointed downwardb. Foot turned inwardc. Sole of foot turned inward

2. The affected foot is rigid and difficult to move3. The Achilles tendon is thin and the foot is small

Diagnostics: Visual inspection; Radiograph (X-ray)

Treatment: Begin as soon as possible after birth (if not treated, bones, muscles and tendons continue to developabnormally)

1. Serial casting major method of non-surgical treatment

a. Manipulation of foot in correct anatomic position and application of series of castsb. The cast is change every 1-2 weeks until complete correction (usually 3 months)

2. Surgical intervention if casting does not achieve correction; cutting the joint and tendon, then re-aligning the bo

Nursing Care:1. Assess severity and degree of deformity2. If surgery is done, provide post-op care

a. Check neurovascular status, edema, drainage of the operative sideb. Icebag may be applied at sides of cast



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c. Elevate foot to reduce swellingd. Administer analgesics

3. Provide support and education:a. Teach patient how to do sponge bathb. Skin carec. Teach safety tips that promote babys safety

4. Provide emotional support to the family

B. Scoliosis lateral deviation or sideway curve of the spine that usually occurs during growth spurt

Types of Scoliosis

1. Structural Scoliosis rotation of vertebrae occurs with lateral deviation;

progressive; congenital, neuromuscular or idiopathic

2. Functional Scoliosis fix rotation does not occur and the curvature is

usually non-progressive; may be corrected by bending; classification:a. Postural

b. Compensatory commonly due to a short leg

Incidence: more girls than boys; rarely occurs in adults

Types of Curve1. Thoracic curve most common pattern in idiopathic scoliosis; 90% occon the right side (dextroscoliosis)2. Thoracolumbar curve 80% occur on the right side3. Lumbar curve least common pattern; 70% on the left side(levoscoliosis)

4. Double curve right thoracic and left lumbar curves Signs of Scoliosis

1. One shoulder higher than the other 2. One shoulder blade appear to be more prominent than the other 3. One hip higher that the other 4. Uneven waist5. Poor posture, leaning on one side

Factors Affecting Development of Curve1. Sex curve in girls are usually worse2. Age the younger the child when scoliosis appeared, the greater changin curve3. Angle of curve the greater angle of curve, the greater complications4. Location curve in the middle to lower spine are less likely to progress

than those in the upper spine5. Spinal problem children born with congenital scoliosis may have rapidprogression of the curve

Diagnostics1. Physical Examination (shoulders, hips, legs, rib cage)

2. Radiograph (X-ray) to confirm diagnosis and to monitor progression

Treatment

1. >25o no treatment; re-examine every 4-6 months

2. 25-30o back brace may be used for treatment (Milwaukee brace)

3. >45o will need to be evaluated for surgical correction; fusing vertebra

together to correct curvature; may even require rods next to the spine to reinforce surgery (Harrington rod)

4. Treatment option depend on likelihood of curve worsening; a child with

20

o

curve and four more years of growth may require treatment while a child with 29

o

which stopped growing, maynot require surgery

Complications of Scoliosis

1. Lung and Heart damage in severe scoliosis (>70o), the rib cage presse

against the lungs and heart leading to breathing compromise and risk of infection (like pneumonia)2. Back problems

3. Body Image

C. Congenital Dislocation of the Hips congenital defect caused by shallow acetabulum, resulting in partial or complete

displacement of head of femur; often bilateral; most common congenital malformation; present at birth but not alwaysdiagnosed immediately

Incidence: more common in girls and associated with spina bifida



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Etiology: unknown

Predisposing factors:1. Fetal position in-utero (breech presentation)2. Genetic predisposition3. Laxity of Ligament

Assessment:1. Maybe unilateral or bilateral, partial or complete; there is limited abduct(cannot spread legs to change diaper)2. Asymmetry of gluteal and thigh folds on affected side

3. Ortolanis click with infant supine, flex hips and knees to 90o

(examiners palms at knees while fingers at hip joint) then gently abduct (bringing the femoral head from itsdislocated posterior position into the acetabulum, thus reducing the femoral head); a positive sign is when there ispalpable or audible clunk or pop as hip reduces

4. Barlows test hip is flexed, then thigh adducted while pushing posterio

in line of shaft of femur; positive sign if the femoral head dislocate posteriorly from the acetabulum

5. Trendelenburg test use if child is old enough to walk; ask child to stan

unassisted on each leg in turn; positive sign is when standing on one leg, the pelvis drops on the opposite side

Management (aimed to keep the bone in the socket and stimulate normal hip development):1. Early treatment is initiated; short-term and less traumatic2. Double or triple diapering can be sufficient to maintain abduction in thenewborn3. Soft positioning devices, like Pavlik harness will keep the bone in the

socket4. Hip spica cast applied to maintain abduction in older infant; brace or spmay also be used

5. If unsuccessful, surgery maybe advised

Nursing Care:1. Teach family care of infant

a. Monitor area around cast for skin breakdownb. Teach parents how to keep cast dry and free of urinec. Warn parents not to let child put anything down cast

2. Provide emotional support to infant and family

D. Muscular Dystrophies group of hereditary muscular diseases in children characterized by progressive muscle

wasting, weakness and deformity

Types:

1. Duchenne (Pseudohypertrophic) most common and most severe type; X-linked recessive (affect only boys); rapprogression of muscle degeneration, manifest in first 4 years; patients typically require wheelchair by age 10-12;may be linked to absence of the protein dystrophin

2. Becker (Benign Pseudohypertrophic) less severe than Duchennes; slow progressive weakness of legs and

pelvis; caused by production of partially functional dystrophin; survival usually into old-age

3. Faciosapulohumeral autosomal dominant; mild form with weakness of facial, shoulder girdle and upper arm

muscles; onset is usually in adolescence

4. Limb Girdle autosomal; affects boys and girls; onset usually adolescence; affects both upper arms and legs

5. Congenital onset at birth; slow progression, shortened life span; some forms are associated with severe brain

malformations, such as hydrocephalus

6. Myotonic autosomal dominant; common in boys; onset in 20-40 years (most common adult form)

7. Oculopharyngeal onset 40-70 years; affect muscles of eyelids, face and throat followed by pelvic and shoulder

muscle weakness8. Distal onset in hands and feet

9. Emery-Dreifuss present in child and the early teenage years with contractures; most patients also present with

cardiac conduction defects and arrhythmias

Prognosis in children:

1. Causes progressive disability; some mild and slow, but some produce severe

muscle weakness2. Most children are confined in wheelchairs

3. Death occurs by age 20 in 75% of patients with Duchennes

Assessment:



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1. Pelvic Girdle Weakness difficulty in walking, a waddling gait, and difficulty instanding upo Gowers sign child uses hand to push up from the floor

2. Pseudohypertrophy enlargement of calf and deltoid muscles3. Scoliosis secondary to weakness of shoulder girdle and hypertrophy of musclof ankles, knees and hips4. Delayed motor development in infants and toddlers; frequent falls, clumsiness5. Progressive respiratory muscle weakness6. Tachycardia and large heart

Diagnosis:

1. Muscle Biopsy reveals histologic changes; degeneration of muscle fibers andreplacement of fibers with fats2. Electromyography shows decrease in amplitude and duration potential

3. Serum Enzymes increase in Creatinine Phosphokinase/CPK (usually by 2-3

years of life)4. Genetic testing identifies carriers, genetic counseling and prenatal diagnosis

Nursing Care:1. Assess airway control; provide support as needed (percussion, postural drainage, suctioning, tracheostomy and

mechanical ventilator care)2. Ensure appropriate posture when using braces and wheelchair3. Maintain skin integrity (provide frequent skin care, turning, assess pressure areas with assistive devices)4. Reposition frequently to prevent immobility-related complications5. Provide activities that require ROM and use of muscles

6. Provide adequate nutrition using enteral feeding as needed (provide high fiber, low fat diet with adequate fluidintake)

7. Assist the child with communication8. Collaborate with family in providing physical occupational speech and recreation therapy9. Assist child in meeting social education and school needs10. Assist the family in setting realistic long and short-term goals

Complications:1. Pneumonia2. Contractures3. Skin breakdown

4. Cardiopulmonary complications (cardiomyopathy and arrhythmias)

5. Developmental delay6. Learning disabilities

7. Mental retardation8. Low self-esteem related to body image9. Shortened life span

E. Juvenile Arthritis systemic disease with chronic inflammation of one or more joints

Etiology: infectious or autoimmune theories

Symptoms: edema, congestion, and visible swelling of joints and synovial tissues; redness and warmth at involvedjoints, intermittent rheumatoid rash (macules), may also involve eyes (photophobia, redness, discomfort and visionproblems)

F. Legg-Calve-Perthes Disease (Osteochondritis Deformans Juvenilis) avascular necrosis of the head of femur during

rapid growth, followed by slow regeneration; commonly involves white boys between 4-10 years

Goal of nursing care to keep head of femur within acetabulumo Supportive devices, such as abduction brace, bed rest, traction, and casts, must be continued for 2-4 years

o Surgical correction usually permits child to return to normal activities within 3-6 months

Emotional support crucial to normally active child suddenly immobilized; family support extremelyimportant

Activities need to be creatively used to maintain development of child; encourage child to begin hobbthat can be done in bed

G. Other Musculoskeletal Malformations

Pes Cavus (Clawfoot)

Pes Planus (Flatfoot)



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