below the knee amputation

Below the knee amputation

Nursing Intervention

• Preoperative• Offer support/encouragement• Discuss:

• Rehabilitation program & use of prosthesis• Upper extremity exercise such as push ups in bed • Crutch walking• Amputation dressing/cast• Phantom limb sensation as a normal occurrence

• Observe stump dressing for signs of hemorrhage and mark outside of dressing so rate of bleeding can be assessed (tourniquet at bedside)

Post-operative Care

• Prevent edema• Raise extremity with pillow support for first 24 h

• Prevent hip/knee contractures• Avoid letting patient sit in chair with hips flexed for long

periods of time• Have patient assume prone position several times a day and

position hip on extension• Avoid elevation of stump after 24 hrs• For BKA: hip & knee exercises• For AKA: hip exercises

• Pain medication as ordered (phantom limb pain)• Ensure that stump bandages fit tightly and are applied

properly to enhance prosthesis fitting

Inflammatory Disorders of the Musculoskeletal System

Rheumatoid arthritis• chronic systemic

inflammatory disease• destruction of connective

tissue and synovial membrane within the joints

• weakens and leads to dislocation of the joint and permanent deformity

Risk Factors• exposure to infectious

agents• fatigue• stress

Rheumatoid ArthritisSigns and Symptoms• Morning stiffness• Fatigue • Weight loss• Joints are warm,

tender, and swollen• Swan neck deformity-

lateDiagnostic Studies• X-ray• Elevated WBC,

platelet count, ESR*, and positive RF

TreatmentNo cure for RA

Swan neck deformity

Rheumatoid Arthritis

Pharmacotherapy • Aspirin- mainstay of treatment, has both analgesic

and anti-inflammatory effects• Nonsteroidal anti-inflammatory drugs (NSAIDs):

• Indomethacin (Indocin)• Phenylbutazone (Butazoldin)• Ibuprofen (Motrin)• Fenoprofen (Nalfon)• Naproxen (Naprosyn)• Sulindac (Clinoril)

• Immunosuppressives: Methotrexate• Gold Standard for RA treatment• Teratogenic

Pharmacotherapy

• Gold compounds • Injectable form: sodium thiomalate,

aurothioglucose; given IM once a week; takes 3-6 months to become effective

• Oral form: auranofin- smaller doses are effective; diarrhea is a common side effect

• Corticosteroids• Intra-articular injections

Rheumatoid ArthritisTreatment• Surgical Procedures: synovectomy, arthrotomy,

arthrodesis, arthroplasty

Nursing Management• Advised bed rest during acute pain• Passive ROM exercise of joints• Splint painful joints• Heat & Cold application• Advised warm bath in the morning• Protect from infection• Advised well-balanced diet

Arthrotomy

ArthrodesisArthroplasty

Osteoarthritis (Degenerative Joint Disease)

• Progressive degeneration of the joints as a result of wear and tear

• affects weight-bearing joints and joints that receive the greatest stress, such as the knees, toes, and lower spine.

OsteoarthritisRisk Factors• aging (>50 yr)• rheumatoid arthritis• arteriosclerosis• obesity• trauma• family history

Signs and Symptoms• Dull, aching pain,* tender

joints• fatigability, malaise• crepitus• cold intolerance*• joint enlargement• presence of Heberden’s nodes

or Bouchard’s nodes• weight loss

MedicationsAspirin• inhibits cyclooxygenase enzyme, diminishes the formation of

prostaglandins• anti-inflammatory, analgesic, antipyretic action• inhibit platelet aggregation in cardiac disordersAdverse effects• Epigastric distress, nausea, and vomiting• In toxic doses, can cause respiratory depression• Hypersensitivity• Reye’s syndrome

Ibuprofen• use for chronic treatment of rheumatoid and osteoarthritis• less GI effects than aspirinAdverse effects• dyspepsia to bleeding• headache, tinnitus and dizziness

Medications

Indomethacin

• inhibits cyclooxygenase enzyme

• more potent than aspirin as an anti-inflammatory agent

Adverse effects:

• nausea, vomiting, anorexia, diarrhea

• headache, dizziness, vertigo, light-headedness, and mental confusion

• Hypersensitivity reaction

OsteoarthritisNursing Intervention• Promote comfort: reduce pain, spasms, inflammation,

swelling• Heat to reduce muscle spasm• Cold to reduce swelling and pain

• Prevent contractures: exercise, bed rest on firm mattress, splints to maintain proper alignment

• Weight reduction• Isometric and postural exercisesNursing Diagnosis• Pain related to friction of bones in joints• Risk for injury related to fatigue• Impaired physical mobility related to stiff, limited

movement

Gouty Arthritis

• Metabolic disorder that develops as a result of prolonged hyperuricemia

• Caused by problems in synthesizing purines or by poor renal excretion of uric acid.

• Acute onset, typically nocturnal and usually monarticular, often involving the first metatarsophalangeal joint

Risk Factors• Men• Age (>50 years)• Genetic/familial tendency

Gouty Arthritis

Signs and Symptoms• extreme pain• swelling• erythema of the involved

joints• fever• TophiLaboratory Findings• elevated serum uric acid

(>7.0 mg/dl)*• urinary uric acid• elevated ESR and WBC• crystals of sodium urate

aspirated from a tophus confirms the diagnosis*

TreatmentAllopurinol - a purine analog

- reduces the production of uric acid by competitively inhibiting uric acid biosynthesis which are catalyzed by xanthine oxidase.

Effective in the treatment of primary hyperuricemia of gout and hyperuricemia secondary to other conditions (malignancies).

• Adverse effects: hypersensitivity reactions, nausea and diarrhea

Colchicine• Effective for acute attacks• Anti-inflammatory activity alleviating pain within 12 hours • Adverse effects: nausea, vomiting, abdominal pain, diarrhea, agranulocytosis,

aplastic anemia, alopecia

Probenecid/Sulfinpyrazone• uricosuric agents• increases the renal excretion of uric acid• Sulfinpyrazone used as a preventive agent.• Adverse effects: nausea, rash & constipation

Nursing Implementation• Maintain a fluid intake of at least 2000 to 3000 ml a day to avoid kidney stone.

• Avoid foods high in purine such as wine, alcohol, organ meats, sardines, salmon, anchovies, shellfish and gravy.

• Take medication with food.

• Have a yearly eye examination because visual changes can occur from prolonged use of allopurinol

• Caution client not to take aspirin with these medication because it may trigger a gout attack and may cause an elevated uric acid levels.

• Encourage rest and immobilize the inflamed joints during acute attacks

• Avoid excessive alcohol intake

• Notify physician if rash, sore throat, fever or bleeding develops.

Osteomyelitis

• Infection of the bone

• Staphylococcus aureus is the most common pathogen.

• Other organisms include Proteus, Pseudomonas and E. Coli

OsteomyelitisRisk Factors• poorly nourished, elderly or obese• impaired immune systems• chronic illnesses• long term corticosteroid therapy

Clinical Manifestation• area appears warm, swollen and

extremely painful• systemic manifestations (fever, chills,

tachycardia)

Diagnostic Studies• X-ray• Bone Scan• Blood and wound culture

Nursing ManagementPromote comfort• Immobilized affected bone by maintaining

splinting.• Elevate affected leg• Administer analgesics as needed.Control infectious process• Apply warm, wet soaks 20 min. several times a

day.• Administer antibiotics as prescribed.• Use aseptic technique when dressing the wound.Encourage participation in ADL within the physical

limitations of the patient.

Osteoporosis

• reduction of total bone mass

• change in bone structure, which increases susceptibility to fracture

• bone becomes porous, brittle, and fragile

Risk Factors• Menopause• aging• long term corticosteroid

therapy• high caffeine intake• smoking• high alcohol intake• sedentary lifestyle or

immobility• insufficient calcium intake

or absorption• hereditary predisposition• coexisting medical

conditions (hyperparathyroidism, hyperthyroidism)

OsteoporosisClinical Findings• loss of height• fractures of the wrist, vertebral column and hip• lower back pain• kyphosis• Respiratory impairment

Diagnostic Findings• X-rays• Dual-energy x-ray absorptiometry (DEXA)• Serum calcium• Serum phosphatase• Urine calcium excretion

Medical Management

Pharmacologic Therapy

• Hormone replacement therapy

• Alendronate (Fosamax)

• Calcitonin- ↓ plasma levels of Ca, ↑ deposition of Ca in the bone

Nursing ManagementPrevention• Adequate dietary or supplemental calcium• Regular weight bearing exercise• Modification of lifestyle• Calcium with vitamin D supplements• Administer HRT, as prescribed• Relieving pain• Improving bowel elimination• Preventing injury

Nursing Activities• Encourage use of assistive devices when gait is unstable• Protect from injury (side rails, walker)• Encourage active/passive ROM• Promote pain relief• Encourage good posture and body mechanics

Bone Tumors

Osteosarcoma

• Most common primary bone tumor

• Occurs between 10-25 years of age, with Paget's disease and exposure to radiation

• Exhibits a moth-eaten pattern of bone destruction.

• Most common sites: metaphysis of long bones especially the distal femur, proximal tibia and proximal humerus

OsteosarcomaClinical Manifestation• local signs – pain ( dull, aching

and intermittent in nature), swelling, limitation of motion

• palpable mass near the end of a long bone

• systemic symptoms: malaise, anorexia, and weight loss

Diagnostic Findings• Biopsy- confirms the diagnosis• X-ray• MRI• Bone Scan• Increase alkaline phosphatase

Medical Management

• Radiation

• Chemotherapy

• Surgical management• amputation• limb salvage procedures

• Prognosis: poor prognosis (rapid growth rate)

Nursing Management• Promote understanding of the disease

process and treatment regimen

• Promote pain relief

• Prevent pathologic fracture

• Assess for potential complications (infection, complications of immobility).

• Encourage exercise as soon as possible (1st or 2nd post-op day)

Total Hip Replacement

• a plastic surgery that involves removal of the head of the femur followed by placement of a prosthetic implant

Nursing Management• Teach client how to use crutches

• Teach client mechanics of transferring.

• Discuss importance of turning and positioning post-op.

• Place affected leg in an abducted position and straight alignment following surgery

• Prevent hip flexion of more than 90 degrees.

• Apply support stockings

• Advise client to avoid external/internal rotation of affected extremity for 6 months to 1 year after surgery

• Instruct client to avoid excessive bending, heavy lifting, jogging, jumping

• Encourage intake of foods rich in Vitamin C, protein, and iron.

• Administer prescribed medications.

Metallic implant

Complications• Infection

• Hemorrhage

• Thrombophlebitis

• Pulmonary embolism

• Prosthesis dislocation

• Prosthesis loosening

Dysplasia of the Hip

• condition in which the head of the femur is improperly seated in the acetabulum, or hip socket, of the pelvis.

• Congenital or develop after birth

AssessmentNeonates: laxity of the

ligaments around the hip, allowing the femoral head to be displaced from the acetabulum upon manipulation.

Implementation:

• Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation (neonatal period)

Pavlik harness

AssessmentInfants • Asymmetry of the gluteal and

thigh skin folds when the child is placed prone and the legs are extended against the examining table.

• Limited range of motion in the affected hip.

• Asymmetric abduction of the affected hip when the child is placed supine with the knees and hips flexed.

• apparent short femur on the affected side

Congenital Hip DysplasiaImplementation• Traction and/or surgery

to release muscles and tendons

• Following surgery, positioning and immobilization in a spica cast until healing is achieved.

Assessment

The walking child• minimal to pronounced

variation in gait with lurching toward the affected side; positive Trendelenburg sign

• Positive Barlow or Ortolani’s maneuver Ortolani’s

maneuver Barlow maneuver

SCOLIOSIS

• Lateral curvature of the spine

• Most common during the growth spurt, early adolescent stage

• F>M

ASSESSMENT: SCOLIOSIS• visible curve fails to

straighten when the child bends forward and hangs arms down toward feet (Adam’s position)

• Asymmetrical shoulder height, scapula and flank shape

• rib prominence and rib humps

• Screening begins at 8 yrs

MANAGEMENT: SCOLIOSIS• Milwaukee Brace- worn between

16-23 hrs/day• Not curative, but preventive:

Slows/Halts progression of the curvature when child reaches skeletal maturity

• Inspect the skin for signs of redness or breakdown

• Keep the skin clean and dry, avoid lotions and powders

• Advise the child to wear soft, nonirritating clothing under the brace

MANAGEMENT: SCOLIOSIS

• Supplemental exercises: to prevent atrophy of spinal and abdominal muscles

• Support in coping: Adolescents may modify lifestyle, may feel stigmatized from peers by being “different”

MANAGEMENT: SCOLIOSIS

MANAGEMENT: SCOLIOSIS• Surgery: Internal Fixation and Instrumentation

combined with Spinal arthrodesis (fusion)• Logroll when turning, to maintain alignment

post-op• Assess extremities for neurovascular status• Promote coughing & DBE, incentive spirometry• Give pain meds as ordered• WOF vomiting, abdominal distention: Superior

Mesenteric Artery syndrome r/t mechanical changes in position of abdominal contents during surgery

• Prepare child in using molded plastic jacket during activity

Laminectomy

• Surgical incision of part of posterior arch of vertebrae and removal of protruded disc

• Nursing InterventionPreoperative

• Teach patient log rolling and use of bedpanPostoperative• Position as ordered• Lower spinal surgery- flat• Cervical spine surgery: slight elevation of head of

bed• Proper body alignment- cervical spinal surgery:

avoid flexion of neck and apply cervical collar

Laminectomy: Postoperative Care

• Avoid:• Acute hip flexion (bending, stooping, crossing the

legs)• Prolonged sitting/standing• Running, jogging, horseback riding• Lie in side- lying with hip flexion

• Back- strengthening exercises• Prone position• Walk in seawater

Laminectomy: Postoperative Care

• Patient teaching and Discharge Planning• Wound care• Good posture and proper body mechanics• Activity level as ordered• Recognition and reporting of complications such

as wound infection, sensory or motor deficits

CGFNS/NCLEX Question

• A bone mineral analysis reveals that a pt. who is post menopausal has severe osteoporosis. Which of the following instructions should the RN give to the pt’s family to ensure a safe environment for the pt?A. disinfect the bathroom weeklyB. carpet floor surfacesC. install handrails on stairwayD. keep the light dim


• Which of the following guidelines should a RN include in the teaching plan for a pt with osteoarthritis?

A. achieve IBW (ideal body weight)

B. increase daily calcium to 1,500 mg

C. maintain high fiber diet

D. sleep at least 10 hrs/day


• Which of the following measures would a nurse encourage to a pt with acute stages of gout attack to minimize complications?

A. drinking a minimum of 3L of fluid/day

B. eating a minimum of 2,500 cal/day

C. walking at least 3 miles/day

D. resting at least 3 hrs/day


• A pt with a leg length discrepancy is being discharged with an Ilizarov External Fixator (IEF). Which should be included in the discharge teaching?


A. Methods to manage bed rest at home until IEF is removed

B. Daily observations of the color and movement of LE

C. Importance of not touching the pins and keeping pins free from any moisture

D. Importance of returning to the MD for all distractions to be done


• While a pt is in pelvic traction for low back pain, which of the following assessments should be included in the pt’s plan of care?


A. Checking for skin excoriation over the hips due to irritation by traction belt

B. Checking for inequality of femoral pulses due to pressure of the traction on common iliac artery

C. Checking for swelling in the feet and ankles associated with immobility

D. Checking for foot drop resulting from pressure on peroneal nerve


• A pt who has fractured hip is placed on Buck’s traction. A RN would explain to the pt that its purpose is to?

A. prevent contractures

B. promote circulation

C. conserve body energy

D. maintain body alignment


• A pt who has a R hip replacement should be instructed to carry out which of the following techniques when turning in bed?

A. bring both knees to the chest before turning

B. keep an abductor pillow between legs

C. maintain flexion of affected hip

D. move affected leg with unaffected foot


• Which of the following statements if made by a pt who had total hip replacement would indicate to a RN that the discharge teaching has been effective?A. “I will need to buy an exercise bike.”B. “I can bend to tie my shoelaces.”C. “I can sit with my legs crossed at the knees.” D. “I will need to make my toilet seat higher.”


• Following a hip replacement, a pt should have the affected hip placed in which of the following positions?

A. extended with a wedge between legs

B. flexed with the knee supported on sandbags

C. elevated with pillows under the leg from knee to ankle

D. rotated externally with trochanter roll in place


• In the immediate post-op period following a hip replacement, the pt should be assisted to perform which of the following exercises on the affected extremity?

A. leg raising

B. dorsiflexion and extension of feet

C. flexion and extension of knee

D. quadriceps setting


• Prior to surgery for correction of congenital hip dysplasia in a 4-month old infant, which of the following home instructions should be included in the child’s plan of care?A. apply double diapers B. perform passive ROM exercises on LEC. support legs in adducted position with pillows during sleepD. avoid placing the infant in upright position


• A pt with long leg cast on her L leg is instructed in crutch walking without weight bearing on her L leg. Which of the following observation indicates further teaching?A. She is using 3-point gaitB. Her elbows are slightly flexedC. Places the crutches approx. 6-8 in (15-20 cm) in front of her with each stepD. She is supporting her weight on the axillary bars and hand pieces of the crutch


• A 6 y/o child who sustained a fracture has a long leg cast on L leg. Which of the following statements is made by the parent, would indicate need for further teaching?


A. “I will call the clinic if my child complains of sudden pain on his foot.”

B. “I will check the skin temperature of my child’s toes at least once each day.”

C. “I should not expect my child to have sensation in the toes while the cast is on.”

D. “I should not let my child put anything inside the cast to relieve itching.”


• Which of the following nursing measures is appropriate when caring for a pt who has undergone R AKA?

A. ambulating the pt in the hallway

B. placing the pt in chair during waking hours

C. keeping the pt’s stump elevated on pillow

D. encouraging the pt to lie prone in bed


• A pt is to begin taking Fosamax. Which of the following statements should be included in the pt’s teaching plan?

A. Crush the meds and mix with food

B. Take the meds with swallow of water

C. Dissolve meds under the tongue

D. Remain upright for 30 minutes after swallowing the meds


• Which of the following manifestations should indicate to a RN that a pt receiving Ibuprofen (Motrin) requires follow up before another dose is given?

A. Loss of hair

B. Sensitivity to light

C. Ringing in the ears

D. Swelling of gums


• A 12 year-old child diagnosed with scoliosis is to be treated with a Milwaukee brace. Which of the following nursing diagnosis would a RN give priority?

A. Skin integrity

B. Self care deficit

C. Impaired gas exchange

D. Sleep pattern disturbance


• A 15 year-old boy has undergone spinal instrumentation at T4-T5 level for scoliosis. Because there is an order to maintain strict bed rest, a RN should use which of the following techniques when repositioning the boy?


A. Assist pt in pulling himself up with the overbed trapeze bar

B. Turn the pt’s head to one side and then have him reach for the rail to turn

C. Place the bed in Trendelenburg position then have the boy roll to one side

D. Use an assistant and logroll the pt to desired side


• A RN would assess the pt who has undergone lumbar laminectomy for which of the following after surgery complication?

A. Deep vein thrombosis

B. Urinary frequency

C. Intermittent claudication

D. Flank pain

below the knee amputation

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