chapter 44 care of the patient with a musculoskeletal disorder jeanelle f. jimenez rn, bsn, ccrn...
TRANSCRIPT
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Chapter 44Chapter 44
Care of the Patient with a
Musculoskeletal DisorderJeanelle F. Jimenez RN, BSN, CCRN
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
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Slide 2Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
ANOTHER SPECIALTY…ANOTHER SPECIALTY…
• Orthopedics The specialty of medicine that examines and treats
diseases and injuries of the musculoskeletal system
• Orthopedists Surgeons who specialize in orthopedics
• Orthopedic nursing Involves preventing further complications for clients
with musculoskeletal conditions
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Slide 3Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology
• Functions of the skeletal system Support Protection Movement Mineral storage Hemopoiesis
• Structure of bones Four classifications based on form and shape
• Long, short, flat, and irregular
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Slide 4Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-2Figure 44-2
Skeleton, anterior view.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Slide 5Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-3Figure 44-3
Skeleton, posterior view.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Slide 6Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology
• Articulations (joints) Allow movement Three types according to degree of movement
• Synarthrosis—no movement
• Amphiarthrosis—slight movement
• Diarthrosis—free movement
• Divisions of the skeleton Axial skeleton Appendicular skeleton
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Slide 7Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-1Figure 44-1
Structure of a freely movable (diarthrotic) joint.
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
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Slide 8Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology
• Functions of the muscular system Motion Maintenance of posture Production of heat
• Skeletal muscle structure Epimysium Perimysium Endomysium
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Slide 9Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-5Figure 44-5
Anterior view of the body.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Slide 10Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-6Figure 44-6
Posterior view of the body.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Slide 11Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology
• Nerve and blood supply Blood vessels provide a constant supply of oxygen
and nutrition, and nerve cells/fibers supply a constant source of information
• Muscle contraction Muscle stimulus—when a muscle cell is adequately
stimulated, it will contract Muscle tone—skeletal muscles are in a constant state
of readiness for action Types of body movements—flexion, extension,
abduction, adduction, rotation, supination, pronation, dorsiflexion, and plantar flexion
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Slide 12Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations
• Radiographic studies Myelogram Nuclear scanning/Bone Scan Bone Density Scan Magnetic resonance imaging (MRI) Computed axial tomography (CT or CAT scan)
• Endoscopic examination Arthroscopy Endoscopic spinal microsurgery
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Slide 13Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Nuclear ScanningNuclear Scanning
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Slide 14Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
ArthroscopyArthroscopy
• Invasive procedure using an endoscope/arthroscope to view joints
• Local anesthesia• Used to treat & diagnose joint disorders• Can remove samples, perform biopsies as well as
repair injury• Less invasive & cost effective than open surgery• Elevate joint & apply cooling measures• Loose bodies may be removed and cartilage
trimmed
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Slide 15Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Performing an ArthroscopyPerforming an Arthroscopy
04/20/23 15
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Slide 16Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Arthroscopy nursing interventionsArthroscopy nursing interventions
• Fast 8-12 hrs prior
• Informed consent
• Pain meds pre and post
• Assess neurovascular status of the affected extremity
• Place an elastic compression bandage for 2-4 days post procedure
• Weight bearing is usually permitted after sensation returns but to limit activity 1-4 days post-procedure
• Elevate ext often for 2 days & may apply ice
• Crutches may be used 5-7 days post for walking
• Notify physician if fever or increased knee pain occurs of if edema continues for more than 3 days post-procedure
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Slide 17Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Arthrogram or ArthrographyArthrogram or Arthrography
• X-ray study of a joint or ligament in which a radiopaque dye is injected then followed by a sequence of x-ray films
• Local anesthesia is used
• Contrast is injected
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Slide 18Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Arthrogram Nursing InterventionsArthrogram Nursing Interventions
• Usually NPO 8 hrs prior to procedure• Inquire of any allergies (iodine/shellfish)• Ensure informed consent is obtained• Patient must remain still• Minimize the use of the joint for 12 hrs post-
procedure• Educate client that the joint may be edematous &
tender 1-2 days post-procedure
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Slide 19Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Arthrogram Nursing Interventions continued…Arthrogram Nursing Interventions continued…
• Administer ice packs and analgesics as prescribed
• Client should notify physician if edema and tenderness last longer than 2 days
• An ace wrap to the knee may be prescribed for 3-4 days
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Slide 20Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations
• Aspiration Synovial fluid aspiration
• Electrographic procedure Electromyogram (EMG)
• Laboratory tests Calcium Erythrocyte sedimentation rate (ESR) Lupus erythematosus (LE) preparation Rheumatoid factor (RF) Uric acid (blood)
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Slide 21Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
ArthrocentesisArthrocentesis
• Aspiration of synovial fluid, blood, or pus from a joint cavity
• Helpful in diagnosing infections, inflammatory conditions, and bleeding
• Medication may also be instilled during the procedure to reduce swelling
• Informed consent required
• Compression dressing & rest joint for 1 day
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Slide 22Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
ArthrocentesisArthrocentesis
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Slide 23Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Rheumatoid arthritis Etiology/pathophysiology
• Most serious form of arthritis
• Chronic, systemic disease
• Most common in women of childbearing age
• Autoimmune disorder, but may also be genetic
• May affect lungs, heart, blood vessels, muscles, eyes, and skin
• Chronic inflammation of the synovial membrane of the diarthrodial joints (movable)
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Slide 24Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Rheumatoid arthritis (continued) Clinical manifestations/assessment
• Characterized by periods of remission and exacerbation
• Malaise
• Muscle weakness
• Loss of appetite
• Generalized aching
• Edema, tenderness, warmth, swelling of joints
• Limited range of motion (morning stiffness)
• Systemic effects
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
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Slide 25Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-7Figure 44-7
Rheumatoid arthritis of hands.
(From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.)
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Slide 26Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Early RAEarly RA
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Slide 27Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Late RALate RA
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Slide 28Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Rheumatoid arthritis (continued) Diagnostic tests
• Radiography studies show loss of articular cartilage and change in bone structure
• Laboratory tests Erythrocyte sedimentation rate (ESR) Rheumatoid factor (RF) Latex agglutination test Synovial fluid aspiration
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Slide 29Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Rheumatoid arthritis (continued) Medical management/nursing interventions
• Pharmacological management Salicylates, NSAIDs, COX-2 inhibitors, anti-inflammatory
agents/corticosteroids, disease-modifying antirheumatoid drugs, immunosuppressants
• Rest: 8 to 10 hours of sleep a night
• Exercise: Range of motion two to three times per day
• Heat: Hot packs, heat lamp, and/or hot paraffin
• Rehabilitation (PT/OT)
• Adequate, well-balanced diet
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Slide 30Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Ankylosing spondylitis Etiology/pathophysiology
• Chronic, progressive disorder of the sacroiliac and hip joints, the synovial joints of the spine, and the adjacent soft tissues
• Most common in young men
• Strong hereditary tendency Clinical manifestations/assessment
• Pain and stiffness in back; decreased ROM
• Elevated temperature; tachycardia; hyperpnea
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Slide 31Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Anklyosing SpondylitisAnklyosing Spondylitis
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Slide 32Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Ankylosing spondylitis (continued) Diagnostic tests
• Hemoglobin, hematocrit, ESR, alkaline phosphatase
• Radiographic Medical management/nursing interventions
• Pharmacological management Analgesics, NSAIDs
• Exercise program: swimming and walking
• Surgery: replace fused joints
• Maintain spine alignment
• Turn, position, and breathing exercises every 2 hours
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Slide 33Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Osteoarthritis (degenerative joint disease) Etiology/pathophysiology
• Nonsystemic, noninflammatory disorder that progressively causes bones and joints to degenerate
• Primary Cause is unknown
• Secondary Caused by trauma, infections, previous fractures,
rheumatoid arthritis, stress on weight-bearing joints
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Slide 34Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
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Slide 35Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-9Figure 44-9
Heberden’s nodes.
(From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.)
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Slide 36Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Osteoarthritis (degenerative joint disease) (continued) Clinical manifestations/assessment
• Joint edema, tenderness, instability, and deformity
• Heberden’s nodes
• Bouchard’s nodes Diagnostic tests
• Radiographic studies
• Arthroscopy
• Synovial fluid examination
• Bone scans
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Slide 37Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Osteoarthritis (degenerative joint disease) (continued) Medical management/nursing interventions
• Pharmacological management Salicylates, NSAIDs, corticosteroids, glucosamine
supplements
• Exercise balanced with rest
• Heat applications
• Gait enhancers (canes, walkers, etc.)
• Surgery Osteotomy Joint replacement
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Slide 38Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Gout (gouty arthritis) Etiology/pathophysiology
• Metabolic disease resulting from an accumulation of uric acid in the blood
• Caused by an ineffective metabolism of purines
• Primary: hereditary factors
• Secondary: use of certain drugs, complication of other diseases, or idiopathic
• Affects men more frequently than women
• Does not occur before puberty in males or before menopause in females
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Slide 39Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Gout (gouty arthritis) (continued) Clinical manifestations/assessment
• Excruciating pain
• Edema
• Inflammation (most common in the great toe)
• Tophi Diagnostic tests
• Serum and uric acid level, CBC, ESR
• Radiography studies
• Synovial fluid aspiration
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Slide 40Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
GoutGout
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Slide 41Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflammatory Disorders of the Musculoskeletal SystemInflammatory Disorders of the Musculoskeletal System
• Gout (gouty arthritis) (continued) Medical management/nursing interventions
• Pharmacological management Colchicine, phenylbutazone (Butazolidin), indomethacin
(Indocin), corticosteroids, allopurinol (Zyloprim), sulfinpyrazone (Anturane)
• Encourage fluid intake
• Monitor intake and output
• Bed rest and joint immobilization
• Dietary restrictions
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Slide 42Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Disorders of the Musculoskeletal SystemOther Disorders of the Musculoskeletal System
• Osteoporosis Etiology/pathophysiology
• Reduction of bone mass
• Most common in women ages 55 to 65
• Contributing factors: immobilization; steroids; high intake of caffeine; diet low in calcium, high in protein; smoking; sedentary lifestyle
Primary vs Secondary Osteoporosis Clinical manifestations/assessment
• Backache
• Porous and brittle bones
• Dowager’s hump
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Slide 43Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
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Slide 44Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Disorders of the Musculoskeletal SystemOther Disorders of the Musculoskeletal System
• Osteoporosis (continued) Diagnostic tests
• Serum calcium, phosphorus, thyroid function tests
• Radiography studies Medical management/nursing interventions
• Pharmacological management Calcium supplements, vitamin D Estrogen, alendronate (Fosamax)
• Weight-bearing exercises
• Dietary recommendations
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Slide 45Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Disorders of the Musculoskeletal SystemOther Disorders of the Musculoskeletal System
• Osteomyelitis Etiology/pathophysiology
• Local or generalized infection of the bone and bone marrow
• Staphylococci are the most common cause
• Introduced through trauma (injury or surgery) or via the bloodstream from another site in the body to the bone
• Bacteria invade the bone and degeneration of bone occurs
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Slide 46Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Disorders of the Musculoskeletal SystemOther Disorders of the Musculoskeletal System
• Osteomyelitis (continued) Clinical manifestations/assessment
• Persistent, severe, and increasing bone pain
• Wound draining purulent fluid
• Signs and symptoms of infection: temperature, tachycardia, and tachypnea
• Edema of affected area Diagnostic tests
• Radiography studies; bone scan
• CBC; ESR; cultures of blood and drainage
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Slide 47Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Disorders of the Musculoskeletal SystemOther Disorders of the Musculoskeletal System
• Osteomyelitis (continued) Medical management/nursing interventions
• Pharmacological management Antibiotic therapy
• Surgery: removal of necrotic bone
• Absolute rest of affected extremity
• Wound care Irrigate with hydrogen peroxide or antibiotic solution;
cover with sterile dressing
• Drainage and secretion precautions
• Dietary recommendations: high in calories, protein, and vitamins
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Slide 48Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Disorders of the Musculoskeletal SystemOther Disorders of the Musculoskeletal System
• Fibromyalgia syndrome (FMS) Etiology/pathophysiology
• Musculoskeletal chronic pain syndrome
• Unknown etiology Clinical manifestations/assessment
• Generalized aching
• Irritable bowel syndrome
• Tension headache
• Paresthesia of upper extremities
• Sensation of edematous hands
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Slide 49Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Other Disorders of the Musculoskeletal SystemOther Disorders of the Musculoskeletal System
• Fibromyalgia syndrome (FMS) (continued) Diagnostic tests
• No specific laboratory or radiographic tests diagnose FMS
Medical management/nursing interventions• Pharmacological management
Tricyclic antidepressants
• Patient education and reassurance
• Exercise
• Relaxation techniques
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Slide 50Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Surgical Interventions for Total Knee or Total Hip ReplacementSurgical Interventions for Total Knee or Total Hip Replacement
• Knee arthroplasty (total knee replacement) Replacement of the knee joint Restore motion of the joint, relieve pain, or correct
deformity
• Hip arthroplasty (total hip replacement) Replacement of the hip joint
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Slide 51Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-11Figure 44-11
A, Tibial and femoral components of total knee prosthesis. B, Total knee
prosthesis in place.
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.)
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Slide 52Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-14Figure 44-14
Hip arthroplasty (total hip replacement).
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Slide 53Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Surgical Interventions for Total Knee or Total Hip ReplacementSurgical Interventions for Total Knee or Total Hip Replacement
• Arthroplasty Nursing interventions
• Intake and output Drainage from operative drains Oral and intravenous intake Urinary output
• Promote respiratory function Give oxygen 2 to 3 L/min Incentive spirometer; cough and deep-breathe
• Bed rest for 24 to 48 hours
• Change dressing as ordered
• Diet as ordered
• Neurovascular checks and vital signs every 4 hours
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Slide 54Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Surgical Interventions for Total Knee or Total Hip ReplacementSurgical Interventions for Total Knee or Total Hip Replacement
• Arthroplasty (continued) Nursing interventions (continued)
• Physical therapy will initiate ambulation and prescribe routine
• Antiembolisim stockings
• Avoid dislocation of prosthesis Avoid adduction and hyperflexion of hip Use toilet riser to prevent hyperflexion of hip
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Slide 55Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Fracture of the hip Etiology/pathophysiology
• Most common type of fracture
• Women at higher risk due to osteoporosis
• Types: intracapsular and extracapsular Clinical manifestations/assessment
• Severe pain at site
• Inability to move the leg voluntarily
• Shortening or external rotation of the leg
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Slide 56Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-16Figure 44-16
Fractures of the hip.
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.
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Slide 57Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Fracture of the hip (continued) Diagnostic tests
• Radiographic examination
• Hemoglobin Medical management/nursing interventions
• Buck’s or Russell’s traction until surgery
• Surgical repair Internal fixation Neufeld nail and screws, Kuntscher nail Prosthetic implants
o Austin Moore prosthesis, bipolar hip replacement
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Slide 58Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Fracture of the hip (continued) Medical management/nursing interventions
(continued)• Postoperative interventions
Wound and drain assessment Vital signs Incentive spirometer and turning every 2 hours Antiembolic stockings; anticoagulation therapy Maintain leg abduction Limit weight-bearing on affected side Chairs and commode seats should be raised to prevent
flexion of hip beyond 60 degrees
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Slide 59Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Fracture of the hip (continued) Medical management/nursing interventions
(continued)• Patient teaching for open reduction internal fixation
(ORIF) Assess ability to understand Assist to dangle at bedside No weight on operative side Turn every 2 hours, maintain abduction Physical therapy will instruct as to ambulation and
weight-bearing As patient progresses, encourage continuing ambulation
only with assistance
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Slide 60Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Fracture of the hip (continued) Medical management/nursing interventions
(continued)• Patient teaching for hip prosthetic implant
Avoid hip flexion beyond 60 degrees for approximately 10 days; beyond 90 degrees for 2 to 3 months
Avoid adduction of the affected leg beyond midline for 2 to 3 months (maintain abduction)
Maintain partial weight-bearing for approximately 2 to 3 months
Avoid positioning on the operative side
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Slide 61Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Other fractures Etiology/pathophysiology
• A traumatic injury to a bone in which the continuity of the tissue of the bone is broken
• Pathological or spontaneous fractures
• Types of fractures: open, closed, greenstick, complete, comminuted, impacted, transverse, oblique, spiral, Colle’s, and Pott’s
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Slide 62Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Other fractures (continued) Clinical manifestations/assessment
• Pain
• Loss of normal function
• Obvious deformity
• Change in the curvature or length of bone
• Crepitus (grating sound with movement)
• Soft tissue edema
• Warmth over injured area
• Ecchymosis of skin surrounding injured area
• Loss of sensation distal to injury
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Slide 63Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Other fractures (continued) Diagnostic tests
• Radiographic examination Medical management/nursing interventions
• Splinting to prevent edema
• Body alignment
• Elevation of body part
• Application of cold packs, first 24 hours
• Administration of analgesics
• Assess for change in color, sensation, or temperature
• Observe for signs of shock
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Slide 64Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Other fractures (continued) Medical management/nursing interventions
(continued)• Closed (simple)
Closed reduction; immobilization; traction Open reduction with internal fixation device
• Open (compound) Surgical debridement and culture of wound Administration of tetanus toxoid Observation for signs of infection Closure of wound Reduction and immobilization of fracture
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Slide 65Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Fracture of the vertebrae Etiology/pathophysiology
• Diving accidents
• Blows to the head or body
• Osteoporosis
• Metastatic cancer
• Motorcycle and car accidents
• Displaced fracture may place pressure on or sever the spinal cord nerves
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Slide 66Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Fracture of the vertebrae (continued) Clinical manifestations/assessment
• Pain at site of injury
• Partial or complete loss of mobility or sensation
• Evidence of fracture/fracture dislocation on x-ray Medical management/nursing interventions
• Stable injuries Pain medication, muscle relaxants Back support, brace, or cast
• Unstable fractures Traction, open reduction
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Slide 67Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
FracturesFractures
• Fracture of the pelvis Etiology/pathophysiology
• Falls, automobile accidents, crushing accidents Clinical manifestations/assessment
• Unable to bear weight without discomfort
• Pelvic tenderness and edema
• Signs of shock Medical management/nursing interventions
• Bed rest—More severe fractures may require surgery and/or spica or body cast
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Slide 68Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Complications of FracturesComplications of Fractures
• Compartment syndrome Cause
• Progressive development of arterial vessel compression and reduced blood supply to an extremity
Clinical manifestations/assessment• Sharp pain with movement, numbness or tingling in the
affected extremity, cool and pale or cyanotic, slow capillary refill
Medical management/nursing interventions• Fasciotomy (incision into the fascia)
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Slide 69Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-26Figure 44-26
Compartment syndrome.
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
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Slide 70Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Complications of FracturesComplications of Fractures
• Shock Cause
• Blood loss, pain, fear Clinical manifestations/assessment
• Altered level of consciousness, restlessness• Hypotension, tachycardia, and tachypnea• Pale, cool, moist skin
Medical management/nursing interventions• Restore blood volume; shock trousers• Oxygen
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Slide 71Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Complications of FracturesComplications of Fractures
• Fat embolism Cause
• Embolization of fat tissue with platelets Clinical manifestations/assessment
• Irritability, restlessness,disorientation, stupor, coma, chest pain, and dyspnea
• Petechiae Medical management/nursing interventions
• IV fluids
• Steroids, digoxin
• Oxygen
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Slide 72Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Complications of FracturesComplications of Fractures
• Gas gangrene Cause
• Infection of skeletal muscle by Clostridium Clinical manifestations/assessment
• Pain at site of injury
• Signs of infection; gas bubbles under the skin
• Necrotic skin at site; foul odor from wound Medical management/nursing interventions
• Excision of gangrenous tissue
• Antibiotics; strict aseptic technique
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Slide 73Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Complications of FracturesComplications of Fractures
• Thromboembolus Cause
• Blood vessel is occluded by an embolus Clinical manifestations/assessment
• Area tingles and is cold, numb, and cyanotic
• Pulmonary embolus causes a sharp thoracic pain Medical management/nursing interventions
• Anticoagulants
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Slide 74Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Complications of FracturesComplications of Fractures
• Delayed fracture healing Healing is delayed but will eventually occur
• Nonunion The ends of the fracture fail to stabilize and heal after
6 to 9 months
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Slide 75Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Skeletal Fixation DevicesSkeletal Fixation Devices
• External fixation devices Skeletal pin external fixation
• Immobilizes fractures by the use of pins inserted through the bone and attached to a rigid external metal frame
• Casts/cast brace Made of layers of plaster of Paris, fiberglass, or plastic
roller bandages Stockinette applied, then a sheet of wadding, and
casting material
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Slide 76Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Fiberglass CastFiberglass Cast
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Slide 77Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Plaster CastPlaster Cast
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Slide 78Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Nonsurgical Interventions for Musculoskeletal DisordersNonsurgical Interventions for Musculoskeletal Disorders
• Traction The process of putting an extremity, bone, or group of
muscles under tension by means of weights and pulleys to:
• Align and stabilize a fracture site
• Relieve pressure on nerves
• Maintain correct positioning
• Prevent deformities
• Relieve muscle spasms Skeletal or skin
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Slide 79Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
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Slide 80Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Bryant’s TractionBryant’s Traction
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Slide 81Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Halo DeviceHalo Device
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Slide 82Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Crutchfield TongsCrutchfield Tongs
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Slide 83Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Head Traction with TongsHead Traction with Tongs
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Slide 84Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Contusion: A blow or blunt force that causes local bleeding under the skin
• Sprains: Wrenching or hyperextension of a joint
• Whiplash: Injury at cervical spine caused by hyperextension
• Strains: Microscopic muscle tears as a result of overstretching muscles and tendons
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Slide 85Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Contusions, sprains, whiplash, strains Medical management/nursing interventions
• Elevate injured area
• Cold compresses for 15 to 20 minutes intermittently for 12 to 36 hours
• Warm compresses for 15 to 30 minutes four times a day after 24 hours
• Compressive dressings and/or splint
• Surgery
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Slide 86Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Dislocations Etiology/pathophysiology
• Temporary displacement of bones from their normal position
Clinical manifestations/assessment• Erythema; discoloration
• Edema
• Pain
• Limitation of movement
• Deformity or shortening of the extremity
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Slide 87Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Dislocations (continued) Medical management/nursing interventions
• Closed reduction
• Open reduction
• Cold compresses first 24 hours and warm compresses after 24 hours
• Elevate injured extremity
• Elastic bandage
• Immobilize
• Analgesics
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Slide 88Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Carpal tunnel syndrome Etiology/pathophysiology
• Compression of the median nerve between the carpal ligament and other structures
• Predisposing factors Obese, middle-aged women Employment in occupations involving repetitious motions
of the fingers and hands
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Slide 89Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-38Figure 44-38
A, Wrist structures involved in carpal tunnel syndrome. B,
Decompression of median nerve.
(From Thompson, J.M., et al. [2002]. Mosby’s clinical nursing. [5th ed.]. St. Louis: Mosby.)
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Slide 90Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Carpal tunnel syndrome (continued) Clinical manifestations/assessment
• Paresthesia
• Hypoesthesia
• Burning pain or tingling in the hands
• Inability to grasp or hold small objects
• Edema of the hand, wrist, or fingers
• Muscle atrophy
• Depressed appearance at the base of the thumb on the palmar side
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Slide 91Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Carpal tunnel syndrome (continued) Diagnostic tests
• Physical exam—Tinel’s sign
• Electromyogram
• MRI Medical management/nursing interventions
• Immobilizer
• Elevate extremity
• ROM exercises
• Hydrocortisone injections
• Surgery
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Slide 92Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Herniation of intervertebral disk Etiology/pathophysiology
• Rupture of the fibrocartilage surrounding an intervertebral disk, releasing the nucleus pulposus that cushions the vertebrae above and below
• Lumbar and cervical herniations are most common
• May occur from lifting, twisting, trauma, or degenerative changes
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Slide 93Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-39Figure 44-39
Sagittal section of vertebrae showing both normal and herniated disks.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Slide 94Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Herniation of intervertebral disk (continued) Clinical manifestations/assessment
• Lumbar Low back pain that radiates over the buttock and
numbness and tingling in affected leg
• Cervical Neck pain, headache, and neck rigidity
Diagnostic tests
• CAT scan, myelography, and electromyelography
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Slide 95Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Traumatic InjuriesTraumatic Injuries
• Herniation of intervertebral disk (continued) Medical management/nursing interventions
• Pharmacological management Analgesics Muscle relaxants
• Bed rest
• Physical therapy
• Traction
• Surgery Laminectomy, spinal fusion, diskectomy,
chemonucleolysis
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Slide 96Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
TumorsTumors
• Tumors of the bone Etiology/pathophysiology
• May be primary or secondary
• Benign or malignant
• Osteogenic sarcoma
• Osteochondroma Clinical manifestations/assessment
• Spontaneous fractures
• Anemia
• Pain especially with weight-bearing
• Edema and discoloration of skin at site
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Slide 97Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
TumorsTumors
• Tumors of the bone (continued) Diagnostic tests
• Radiography studies
• Bone scan; bone biopsy
• CBC; platelet count; serum protein levels
• Serum alkaline phosphatase level Medical management/nursing interventions
• Surgery
• Chemotherapy and radiation
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Slide 98Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
AmputationAmputation
• Amputation of a portion of or an entire extremity Malignant tumors, injuries, impaired circulation,
congenital deformities, infections
• Postoperative nursing interventions Raise foot of bed to elevate extremity Encourage movement Place in prone position at least two times a day Teach strengthening exercises Elastic wraps to shape residual extremity Assess for respiratory complications Phantom-limb pain is normal
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Slide 99Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
BKABKA
04/20/23Jeanelle J .Garcia RN, BSN, CCRN - North West College
99
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Slide 100
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 44-40Figure 44-40
Correct method of bandaging amputation stump.
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
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Slide 101
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. 04/20/23Jeanelle J .Garcia RN, BSN, CCRN - North West College
101
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Slide 102
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Diabetic Wound of an AmputationDiabetic Wound of an Amputation
04/20/23Jeanelle J .Garcia RN, BSN, CCRN - North West College
102
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Slide 103
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing ProcessNursing Process
• Assessment Scoliosis
• Lateral curvature of the spine Kyphosis
• A rounding of the thoracic spine
• Hump-backed appearance Lordosis
• An increase in the curve at the lumbar region Blanching test
• Capillary nail refill
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Slide 104
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing ProcessNursing Process
• Nursing diagnoses Mobility, impaired physical Mobility, impaired bed Coping, ineffective Anxiety Pain Knowledge, deficient