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1. ESR
2. C-reactive protein
3. CBC
4. Serum cultures
5. Serum Calcium
6. ANA
7. Creatinine
X-rays (roentgenograms)
Contrast radiography
Casts
5. Cast application
a. cast must extend to the joint above and below the point of fracture
b. assessment prior to cast application
i. skin: inspect for irritation, laceration, skin breakdown
ii. neurovascular status check
iii. edema/swelling
c. windowing:
i. square or diamond hole cut in cast over certain area
ii. indications
• observation of surgical incision
• observation of skin
• relieve pressure over bony prominence
iii. nursing interventions
• cast may crack at window site - weakest part of the cast
• appropriate padding/petaling of open window
d. bivalving
i. indications
• swelling
• infection or high potential for infection
• pain
ii. techniques
• lengthwise splitting of the cast with cast saw
• apply ace wrap or tape to hold cast together
• still immobilizes
e. petaling
i. edging the cast with soft padding or moleskin
ii. indications
• prevent irritation or skin breakdown at rough edges of
cast
• protect cast from perspiration, feces, urine
• protect perineal area
6. Types of traction
a. manual traction
i. use of the hands to exert a pulling force
ii. generally used during an emergency
iii. temporary measure - cannot be maintained for extended periods
b. skin traction
i. pulling force is applied directly to the skin through the use of
foam splints, skin traction strips and tape
ii. temporary measure
1. Frame - Should be loaded to maximize its stability before adding additional traction
systems
2. Plain Bars
3. Cross Clamps - Positioned so that turn knobs are on top of horizontal bars
4. Traction Bars
5. Pulleys
a. do not lubricate- Decreased friction markedly changes the line of pull
b. must move freely
PRINCIPLES OF TRACTION
iv. complications
• skin breakdown
• detachment of traction device
v. limitation: can apply only five to seven lbs. loading force
vi. must remove traction and perform skin care
c. skeletal traction
i. traction applied directly to the bone \
ii. pins are placed through the affected limbs and attached to pulling force
iii. can be tolerated for longer periods - up to four months
iv. greater weight can be used - 15-40 lbs.
v. types of skeletal traction
• balanced suspension
1. used for displaced, overriding or comminuted
fractures
2. preoperative treatment prior to surgical pinning
d. skull tong/halo traction
i. burr holes drilled into skull and tongs inserted and
attached to weights or halo bolts inserted then attached to body
cast
ii. tongs used for cervical fractures preoperatively
a. static traction
b. continuous traction pull
c. dynamic traction
d. intermittent application of traction
e. straight traction
f. running
7. Complications
1. infection at pin site
2. skin breakdown
3. muscle weakness
4. osteomyelitis
8. Nursing interventions
a. explain procedure to client / assess neurovascular status of
affected area/limb at least every four hours
a. color
b. temperature
c.motion
d. sensation
e. pulse quality
f. presence/absence of edema
b. always compare affected limb to unaffected limb for baseline
measurement
c. skeletal cervical or halo traction: assess cranial nerves III - IX
d. skin assessment
i. high risk for developing pressure sores
ii. remove Buck's traction boots every two hours to inspect skin
integrity
iii. assess pressure areas every two hours
e. pin assessment: observe for drainage, signs of infection
f. medical asepsis with open skin
g. maintain principles of traction
h. administer appropriate medications
i. beware of immobility's multi-system effects
j. allow patient to verbalize fear and concerns
k. encourage involvement of family members
l. provide diversional activities
1. Orthotic
a. braces designed to prevent deformity, increase efficacy of gait, control
alignment and/or promote ambulation
b. types of orthotic
i. ankle/foot (AFO)
ii. knee/ankle/foot (KAFO)
iii. hip/knee/ankle/foot (HKAFO)
iv. thoracolumbar or sacral (TLSO)
2. Prosthetic: artificial limbs for all extremities
3. Crutches
a. a wooden or metal staff
b. used when no or minimal weight bearing is desired
c. may be temporary or permanent
d. types
i. axillary: a padded curved surface at top which fits under the
axilla and a crossbar forms the handgrip
• for axillary crutches, measure client's height; distance
between crutch pad and axilla; distance from axilla to
client's heel; Crutch pads should be three to four finger
widths under axilla
• complication: crutch palsy--paralysis of elbow and wrist
due to crutch pressure on axilla
e. forearm (Lofstrand): an adjustable metal band that fits around the
forearm with an adjustable handgrip
For client to navigate stairs with crutches, remember "up with the good, down with the bad."
To go up stairs, lead with the unaffected "good" leg, and follow with the affected "bad" leg.
To go down stairs, lead with the affected "bad" leg, and follow with the unaffected "good" leg.
1. Functions
a. supports and protects structures of the body
b. anchors muscles
c. some bones contain hematopoietic tissue which forms blood cells
d. participates in the regulation of calcium and phosphorus
2. Joints
a. bursa - enclosed cavity containing a gliding joint
b. synovium - lining of joints which secretes lubricating fluid that nourishes
and protects
c. classification of joints - synarthrosis, amphiarthrosis, diarthrosis
B. Strains
1. Definition - lesser injury of the muscle attachment to the bone
2. Etiology and pathophysiology
a. caused by overstretching, overexertion, or misuse of muscle
b. acute: recent injury to muscle or tendon; classified by degree
i. first degree: mild; gradual onset; feels stiff, sore locally
• assessment of acute first-degree strain
o tenderness to palpation
o muscle spasm
o no loss of range of motion
o little or no edema or ecchymosis
• management of acute first-degree strain
o comfort measures
o apply ice
o rest, possibly immobilize for short term, elevate
ii. second degree: moderate stretching, sudden onset, with acute
pain that eventually leaves area tender
• assessment of acute second-degree strain
o extreme muscle spasm
o passive motion increases pain
o edema develops early; ecchymosis later
• management of acute second-degree strain
o keep limb elevated
o apply ice for the first 24 to 48 hrs - then moist heat
o limit mobility, ace wrap
o muscle relaxants, analgesics, NSAIDS
o physical therapy for strength and range of motion
3. Third-degree: severe stretching with tear; sudden; snapping or burning
sensation
a. assessment of acute third degree strain
i. muscle spasm
ii. joint tenderness
iii. edema (may be extreme)
iv. client cannot move muscle voluntarily
v. delayed ecchymosis
b. management of acute third degree strain
i. keep limb elevated
ii. apply ice for 24 to 48 hrs, then moist heat
iii. either immobilize or limit mobility of the limb
iv. medication - muscle relaxants, analgesics, NSAIDs
v. physical therapy for strength and range of motion
4. Chronic strain
a. long-term overstretching of muscle/tendon
b. repeated use of the muscle beyond physiologic limits
C. Sprains
1. Definition - greater than strain; injury to ligament structures by stretching,
exertion or trauma
2. Classification/findings/assessment/management
a. first degree sprain
i. minimal tearing of ligament fibers
ii. localized edema or hematoma
iii. no loss of function
iv. no weakening of joint structure - joint integrity remains intact
v. mild discomfort at location of injury
vi. pain increases with palpation or weight bearing
vii. management of first degree sprain
• compress it with ace bandage to limit swelling
• keep limb raised to decrease edema
• apply ice 24 to 48 hours following injury
• analgesics for discomfort
• isometric exercises to increase circulation and resolve
hematoma
b. second degree sprain
i. up to half of the ligamentous fibers torn
ii. increased edema and possible hematoma
iii. decreased active range of motion
iv. increased pain
v. mild weakening of the joint and loss of function
vi. management
• protectively dress/splint the joint, immobilize it
• elevate the limb to decrease edema
• for 24 to 48 hours, alternate
o ice
1. to produce vasoconstriction to decrease
swelling
2. to reduce transmission of nerve impulses
and conduction velocity to decrease pain
o moist heat
1. to reduce swelling and provide comfort
ASSESSMENT AND EARLY MANAGEMENT
• analgesics OF THE TRAUMA CLIENT
for discomfort
I. Primary survey: ABC • physical therapy to increase circulation and maintain
A. Airway maintenance with spinal cord control
nutrition to -the
cervical stabilization
cartilage
B. Breathing
C. Circulation
c. third degree sprain
II. Cognitive level: glasgow coma i. scale
complete rupture of the ligamentous attachment
A. Eye opening ii. severe edema with hematoma
B. Verbal response iii. usually, severe pain
C. Motor response iv. dramatic decrease in active range of motion
III. Ask about: A-M-P-L-E v. loss of joint integrity and function
A. Allergies vi. management
B. Medications • casting
C. Past illness • surgery to restore integrity of joint
D. Last meal • see second degree treatment
E. Events preceding the injury
IV. D. Fractures:
Life threatening classification
injuries of extremityand diagnosis
A. Massive open comminuted fractures
B. Bilateral femoral shaft fractures
C. Vascular injuries
D. Crush injuries of the abdomen or pelvis
E. Traumatic amputation of the arm or leg
V. Mechanism of injury
A. Force: amount of energy transferred from one object to human body
B. Injuring agent: sharp or blunt instrument
C. Predictable musculoskeletal injuries
1. Child/pedestrian injuries "Waddell's triad":
a. point of impact with the car bumper
b. point of impact with the car hood
c. point of impact where the body is thrown
2. Adult/pedestrian injuries
a. point of impact with the car bumper
b. point of impact with the car hood
c. injuries to opposing ligaments
3. Unrestrained driver
a. head
b. larynx and sternum
c. knee/femur
d. posterior hip dislocation
4. Fall from a height (Don Juan syndrome)
a. bilateral calcaneal fractures
b. hyperflexion of the lumbar spine
c. bilateral Colles' fractures
d. compression fracture of vertebrae
5. Blast injuries
a. gunshot/missile type injuries
b. source of infection: when energy travels it leaves a vacuum behind it, drawing in
debris/body hair
c. results in both entry and exit wound
d. shock waves throughout body
VI. Findings of trauma
A. Deformity/angulation of extremity
B. Swelling
C. Pain
D. Paresis/paralysis
E. Paresthesia
F. Pallor
G. Absent pulses
VII. Goals of nursing care
A. Sustain life
B. Maintain function
C. Preserve appearance
VIII. Goals of rehabilitation
A. Decrease pathology
B. Prevent secondary disabilities
C. Increase function of unaffected and affected systems
1. Definition: fracture is any alteration in the continuity of a bone
2. Fracture dislocation
a. a fracture in which the joint is dislocated in that position, fracture will not
heal completely
3. By completeness
a. complete (bone broken in two or more pieces)
b. incomplete (bone broken but still in one piece)
4. By wound
a. closed = simple; does not break skin
b. open = compound = complex
i. bone fragments break through skin
ii. injures soft tissue and often infects tissue
iii. subdivided by degree of soft tissue injury
5. By fracture line
a. longitudinal = linear fracture
b. oblique is produced by a twisting force, and requires traction to heal
properly.
c. spiral also results from twisting force, may accompany damage to soft
tissue, and requires traction or internal fixation.
d. transverse is caused by angulation, common in pathological fractures,
and generally stable after reduction.
6. By type of fracture
a. avulsion fractures
i. bone fragments and soft tissue are pulled away from the bone
ii. results from a direct force on the bone
b. comminuted fractures
i. produced by high energy forces
ii. results in two or more bone fragments
iii. splinters the fragments
iv. injures soft tissue severely
c. compression fractures
i. often seen in the lumbar spine
ii. may be pathological (a disease weakens bone)
d. greenstick fracture
i. results in an incomplete fracture
ii. caused by
• compression forces
• angulation forces
iii. cortex of the bone bends to one side and buckles on the other
iv. cortex stays intact on the side subject to tension forces and
fractures on the opposing side
v. requires reduction or completion of the fracture line through the
cortex
e. impacted fractures (telescoped)
i. direct force breaks bone and telescopes the fragment with the
smaller diameter into the fragment with the larger diameter
ii. fracture fragments move in unison
iii. rapid union occurs
f. stress fracture
i. incomplete fracture
ii. result of repetitive trauma to region
iii. two types:
• fatigue - from repeated trauma
• insufficiency - pathological fracture
7. Classification by location in the bone
a. apophyseal
b. articular
c. condylar
d. cortical
e. diaphyseal
f. epiphyseal
g. extracapsular
h. intraarticular
i. intracapsular
j. metaphyseal
k. periarticular
l. subperiosteal
m. supracondylar
2. Fractures: pathophysiology
6. Predisposing factors
a. biologic
i. bone density
ii. client's age
7. Extrinsic factors
a. force - direct or indirect
b. rate of loading (how fast the force strikes)
8. Intrinsic factors - bone capabilities
9. Pathological fractures
a. bone is weakened by disease
b. fractures occur in response to minimal or no applied stress
c. classification by cause: general or local disorder
i. general: developmental, nutritional, hormonally controlled
ii. local: neoplasm, infection, cystic lesion
10. Behavioral factors - high-risk activities (such as football, ballet)
3. Fractures: management
6. Closed reduction
a. purposes: realign bone fragments for healing, minimal deformity,
minimal pain.
b. pre- and post-reduction x-rays are essential to determine successful
reduction of fracture
7. Immobilization
a. purposes
i. relieve pain
ii. keep bone fragments from moving
1. Radiographs
a. two dimensional representation of the bone and soft tissue
b. include joints above and below suspected fracture
c. clinical evidence of fracture overrides negative x-ray analysis
d. will also offer evidence of
i. bone pathology
ii. bone density (in advanced cases of osteoporosis)
2. Computerized tomogram (CT) scan - specialized tomograms
a. hematoma formation
b. fibrocartilage/granulation tissue formation
c. callus formation
d. ossification
e. consolidation/remodeling
9. Evidence of healed fracture
a. radiographic
3. Magnetic resonance imaging (MRI) scan - clearer views of soft tissue structures
2. Delayed complications
a. joint stiffness
b. post-traumatic arthritis (osteoarthritis, type II)
c. reflex sympathetic dystrophy
i. painful dysfunction and disuse syndrome
ii. characterized by abnormal pain and swelling of the extremity
d. myositis ossificans
i. formation of hypertrophic bone near bone and muscles
ii. forms in response to trauma
iii. hypertrophic bone is removed when bone is mature
e. malunion
i. fracture healing is not stopped but slowed
ii. prevention of malunion
• reduce and immobilize properly
• be sure client understands limits on activity and position
f. delayed union
i. fracture does not heal
ii. more common with multiple fracture fragments
iii. no evidence of fracture healing four to six months after the
fracture
g. loss of adequate reduction
h. refracture
2. Nursing interventions
2. Risk for peripheral neurovascular deficit
a. check neurovascular status often
b. elevate limb above level of heart (except with compartment
syndrome)
COMPARTMENT SYNDROME
1. Hip
a. contracture in adduction and flexion
b. decrease in internal and external rotation
c. limb shortening
d. referred pain to the
i. knee
ii. groin
iii. thigh
2. Knee
a. decreased range of motion
b. flexion contracture
i. hip
ii. knee
c. varus deformity: bow legged appearance
d. valgus deformity: knock-kneed appearance
e. positive apprehension sign
i. push the patella laterally with the leg in full extension
ii. client will stop the examiner from pushing the patella further
a. joint stiffness after periods of rest
b. pain in a movable joint, typically worse with action, relieved by rest
c. paresthesia
d. joint enlargement: bones grow abnormally; spurs form and synovitis sets
in.
i. Heberden's nodes
HEBERDEN'S NODES
BOUCHARD'S NODES
6. Diagnostics
a. to rule out autoimmune disorders
i. sedimentation rate
ii. rheumatoid factor
iii. c-reactive protein
b. CBC
i. analyze before NSAID therapy
ii. within normal limits
c. kidney and liver
i. especially in older clients, analyze before starting NSAID therapy
ii. repeat every six months
d. purified protein derivative (PPD)
i. analyze before starting steroids
ii. clients testing positive for tuberculosis must receive INH at same
time as steroid.
e. antinuclear antigen (ANA) titer
i. may be lower in the elderly
ii. does not necessarily prove a connective-tissue disease
f. synovial fluid analysis distinguishes osteoarthritis from rheumatoid
arthritis.
g. radiographs
i. taken in standing, weight-bearing condition
ii. shows the prime sign of OA: joint space narrowing
iii. x-ray does not necessarily reflect severity of disease
iv. joint loses space asymmetrically because cartilage narrows from
production of osteophytes or bone spurs
v. later stages may show bony ankylosis, spontaneous fusion
h. bone scans
i. radionuclide imaging
ii. shows skeletal distribution of osteoarthritis
iii. monitors complications of joint replacement surgery
i. MRI scans show the extent of joint destruction
j. computerized tomograms (CT) scans show cortical and cancellous bone
density
7. Management: conservative treatment
a. education should cover
i. exercise patterns
ii. relaxation techniques
iii. nutritional assessment
iv. counseling about maintaining a normal weight
b. nutritional management - weight reduction
c. activity and rest management
i. preservation of joint motion through a balance of
1. rest (protection)
2. activity (rehabilitation)
ii. individualized activity rehabilitation program
iii. physical or occupational therapist may be helpful
iv. passive range of motion exercises
REMISSION-INDUCING MEDICATIONS IN ARTHRITIS
9. Nonmedication assistance
a. assistive devices
i. canes
ii. walkers
b. non-traditional techniques
i. guided imagery - the use of one's imagination to acheve
relaxation and control
ii. therapeutic massage
iii. biofeedback
iv. hypnosis
v. relaxation techniques
10. Surgical management
a. arthrodesis
b. arthroplasty
c. osteotomy
d. total joint replacement
11. Home care considerations in arthritis
a. safety measures
i. no scatter rugs at home
ii. well-fitted, supportive shoes
iii. night light, handrails at stairs and bathtub or shower
iv. assistive devices
1. canes
2. walkers
3. elevated toilet seats
4. grab bars
5. handrails in stairways
v. splints and orthotic devices
b. management of surgical pain by patient controlled analgesia pumps
c. referral to agency and support group
C. Charcot joints (also called neuropathic joint disease)
2. Etiology
a. diabetes mellitus leading to foot neuropathy
b. syringomyelia results in Charcot's joint of the shoulder
c. tertiary syphilis
d. peripheral neuropathies
e. spina bifida with myelomeningocele
f. leprosy
g. multiple sclerosis
h. long term intra-articular steroid injections
3. Findings
a. inspection: foot is everted, widened, and shorter than normal
b. examination
i. joint instability
ii. soft tissue swelling
iii. pain secondary to inflammation
4. Diagnostics
a. laboratory analysis of synovial fluid
i. fluid is non-inflammatory
ii. low protein content
iii. no hemorrhage noted
b. radiographs
i. chronic destructive arthritis of the foot
ii. severe destruction of the articular cartilage, subchondral
sclerosis
iii. fragments of bone and cartilage in joint
5. Management
a. conservative treatment
i. protection from overuse/abuse
ii. braces and splints
b. surgical management: arthrodesis
i. treatment of choice for unstable joints
ii. fusion of the involved joint
6. Nursing interventions
a. expected outcome: preserve the joint
b. education can prevent further injury
c. protection of the joint
i. braces
ii. orthopedic shoes
d. prolonged immobilization
i. eight to 12 weeks to decrease swelling
ii. leads to minimal joint deformity and a functional painless foot
D. Chondromalacia patellae (also called patellofemoral arthralgia)
1. Definition: progressive, degenerative softening of the bone; follows a knee
injury
2. Etiology
I. lateral subluxation of the patella (kneecap)
II. direct or repetitive trauma to the patella produces chondral fracture
III. underdevelopment of the quadriceps muscles
3. Findings
I. pain with flexed knee activities (poorly localized)
II. mild swelling
III. occasional episodes of buckling of the affected knee
IV. minimal joint effusion
V. evidence of 'squinting kneecaps'
VI. atrophy of quadriceps
VII. inverted 'J' tracking of the patella in the final 30 degrees of extension
VIII. excessive quadriceps angle
IX. positive apprehension sign
X. crepitation upon range of motion
4. Diagnostics
I. radiographs
I. anterior posterior (AP) and lateral views are not helpful
II. sunrise views with the knee in 30 degrees, 60 degrees and 90
degrees of flexion
II. bone Scans
III. MRI Scans
IV. arthroscopy
5. Conservative management
a. progressive resistive exercises
i. quadriceps setting - isometric
ii. hamstrings - isotonic
b. medication: NSAIDs
c. nonmedication assistance: application of ice or moist heat
d. activity restriction
6. Surgical management
a. indicated if findings remain after six months of conservative treatment
b. arthroscopy (see Orthopedic Surgery section that follows)
c. arthrotomy
i. realignment of proximal and/or distal soft tissue
ii. tibial tubercle elevation
iii. patellectomy
7. Nursing interventions (see previous Osteoarthritis section)
IV. Inflammatory Disorders
A. Rheumatoid arthritis (RA)
1. Definition - chronic systemic inflammatory disease of the connective tissue
2. Findings
I. starts in feet and hands, gradually destroys these peripheral joints
II. affects diarthroidial joints
III. bilateral involvement
3. Etiology
I. cause is not fully understood
II. rheumatoid arthritis is an autoimmune disorder
III. genetic tendency; but may involve bacteria, or viruses
IV. may affect the connective tissue of the lungs, heart, kidneys, or skin
4. Incidence
I. two to three times more common in women than in men
II. strikes between the ages of 20 and 50 years of age
5. Pathophysiology
6. Findings
a. in early RA joints will be
i. painful, stiff
ii. warm, red, swollen at capsules and soft tissues
iii. incapable of full range of motion
b. in late RA, joints will show
i. bony ankylosis
ii. destruction of joint - reactive hyperplasia
iii. adhesions
iv. inflammation and effusion that will be
• symmetrical
• polyarticular
c. general signs
i. fatigue
ii. loss of appetite and weight
iii. enlarged lymph glands
d. rheumatic nodules
i. in 20% of cases
ii. firm, oval, nontender masses under the skin
iii. presence indicates poor prognosis
e. physical assessment should also include
i. accurate patient history - history may include
• malaise
• fatigue
• weakness
• loss of appetite and weight
• enlarged lymph glands
• Raynaud's syndrome
ii. examination may reveal deformities
• ulnar deviation
• deformed hands: swan neck/boutonniere
f. neurological examination
i. foot drop
ii. evidence of spinal cord compression
7. Diagnostics
a. laboratory analysis
i. elevated ESR
ii. decreased RBC
iii. positive C-reactive protein
iv. positive antinuclear antibody in 20% of cases
v. positive rheumatoid factor (RF)
b. radiographic studies
i. bony erosion
ii. decreased joint spaces
iii. fusion of joint
c. aspiration of synovial fluid; analysis shows
i. cloudy appearance
ii. more white blood cells than normal
8. Management
a. NSAIDS (see Osteoarthritis)
b. hydroxychloroquine sulfate (Plaquenil)
c. immunosuppressive agents
i. azanthioprine (Imuran)
ii. cyclophosphamide (Cytoxan, Procytox)
iii. methotrexate (Rheumatrex) (most commonly used)
d. prednisone
e. sulfasalazine (Azulfidine)
f. leflunomide (Arava)
g. biological response modifiers (BRMs)
i. etanercept (Enbrel)
ii. infliximab (Remicade)
iii. adalimumab (Humira)
iv. anakinra (Kineret)
h. psychological support
i. splinting: resting, correction or fixation
2. Etiology unknown
I. most cases are women
II. African Americans, Hispanics, Asians, and Native Americans are two to
three times as likely as whites to have lupus
III. antigen stimulates antibodies, which form soluble immune complexes,
deposited in tissues; number of T suppressor cells dwindles.
C. Gout
a. Definition
a. monoarticular asymmetrical arthritis
b. characterized by hyperuricemia
b. Etiology
a. primarily affects men
b. peak incidence 40 to 60 years of age
c. familial tendency
d. abnormal purine metabolism or excessive purine intake results in
formation of uric acid crystals which are deposited in the joints and
connective tissue.
e. deposits are most often found in the metatarsophalangeal joint of the
great toe or in the ankle.
c. Findings
a. tight, reddened skin over the inflamed joint
b. elevated temperature
c. edema of the involved area
d. hyperuricemia
e. acute attacks commonly begin at night and last three to five days
f. gout attacks may follow trauma, diuretics, increased alcohol
consumption, a high purine diet, stress (both psychological and
physical) or suddenly stopping of maintenance medications
g. warning signs of flare-up include the exacerbation of previous findings
or the development of a new one
h. systemic manifestations may include fever, renal disease, tophus
d. Diagnostics: lab test findings
a. increased urinary uric acid following a purine restricted diet
b. hyperuricemia
e. Management
a. expected outcomes: control symptoms; prevent attacks
b. medical
1. NSAIDs
2. colchicine (used when NSAIDs are contraindicated) - enhances
the excretion of uric acid
3. to prevent flareups: antihyperuricemic agents such as allopurinol
(lopurin) or probenecid (benemid) - minimize the production of
uric acid
4. heat or cold therapy
c. dietary
1. avoid purine foods such as meats, organ meats, shellfish,
sardines, anchovies, yeast, legumes
2. control weight
3. drink less alcohol - all types
f. Nursing care
a. pain management strategies
b. elevate the affected limb; provide bed rest and immobilize joint
c. avoid pressure or touching of bed clothing on affected joint
d. reinforce dietary management and weight control
e. administer anti-gout medications as ordered
f. increase fluid intake to prevent renal calculi (kidney stones)
B. Osteoporosis
1. Definition
I. multifactorial disease results in
I. reduced bone mass
II. loss of bone strength
III. increased likelihood of fracture
II. types
I. type one osteoporosis (estrogen related)
TYPE I OSTEOPOROSIS
TYPE II OSTEOPOROSIS
A. Age-related loss of cortical/trabecular bone in men and women occurring after age 70
B. Long-term remodeling
C. Results in fractures of humerus and femoral neck
a. Etiology/epidemiology
a. most common metabolic disease of bone
1. affects an estimated 25 million Americans
2. contributor of 50% of all adult fractures
b. onset is insidious
c. women affected twice as often as men before the age of 70
d. skeletal changes result from the aging process
e. bone loss due to
1. immobilization
2. lack of gravitational stress
b. Factors related to osteoporotic fractures
a. premature menopause
b. hyperthyroidism increases bone turnover and remodeling
c. hyperparathyroidism
d. increases bone turnover and remodeling
e. increased parathyroid hormone (PTH)
4. Findings
a. client history
i. acute fracture
ii. prior history of a traumatic fracture; no trauma
iii. history of falls
b. pain
i. greater when active, less while resting
ii. early in disease, pain in mid to low thoracic spine
c. anxiety
i. about further falls/fractures
ii. about ability to perform ADLs
d. kyphosis - 'Dowager's hump' may reflect multiple spinal fractures
e. loss of height
A. Skull
1. Cranial nerve damage
2. Hearing loss
3. Obstructive hydrocephalus
B. Vertebrae
A. There are a variety of hip prostheses. The choice is usually made by the health care
provider.
B. Prostheses have two components: acetabular socket and femoral shaft
1. Acetabular socket is screwed into pelvis
2. Femoral shaft may be cemented into femur or may have a special coating which
promotes bone growth around prosthesis
a. The femoral shaft of a prosthesis used for revision is much longer than that
used for the original surgery
A. The residual limb must be shrunk and shaped into a conical form to secure a proper fit within
the prosthesis, through
1. Proper bandaging of the stump in a figure eight manner
2. An elastic residual limb shrinker
3. An air splint
B. Problems that delay prosthetic use are
1. Non-shrinkage of the residual limb
2. Flexion deformities
3. Abduction deformities of the hip
c. stiffness
Nursing intervention
obtain operative permit prior to procedure
apply pressure dressing and ice
caution client to avoid excess use of joints for 48 hours
may permit bearing
mild analgesics may relieve post-procedure pain
E. External fixator
1. Definition
2. Indication: the device will stabilize fracture with soft tissue injury like crush
fractures
3. Procedure: fracture aligned and immobilized by pins of Kirschner wires inserted
in the bone and attached to a rigid frame outside the body
4. Nursing interventions
a. monitor neurovascular status every two hours
b. elevate extremity to reduce edema
c. assess pin insertion sites for infection: erythema, drainage and
increased warmth
d. isometric and active exercises as prescribed
e. non-weight bearing ambulation depends on soft tissue injury
f. discharge teaching
1. ambulation with assistive device (crutches, walker)
2. care of pin site
3. extremity is repositioned by lifting frame instead of extremity
Points to remember
• After hip replacements, pulmonary embolism may occur even without thrombosis in foot or leg.
• Clients should sit in a straight, high chair; use a raised toilet seat; and never cross their legs.
• In hip or knee replacement, clients will need assistive devices for walking until muscle tone
strengthens and they can walk without pain.
• After an amputation, the home must be assessed for any modifications needed to ensure
safety.
• Some clients will need transportation to continue rehabilitation.
• Amputee support groups can help clients and family.
• After arthroscopy, outpatient rehab may be prescribed depending on procedure; health care
provider may prescribe knee immobilizer.
• External Fixator - If possible, prepare the client preoperatively to reduce anxiety. Device looks
clumsy, but patient should be reassured that discomfort is minimal.
• After a hip pinning or femoral-head prosthesis, caution client not to force hip into more than 90
degrees of flexion, into adduction or internal rotation which will cause dislocation and severe
pain and this would be a nursing emergency.
• Caution clients with a new prosthesis not to use any substances such as lotions, powders etc.
unless prescribed by the health care provider.
• Osteoporosis cannot be detected by conventional X-ray until more that 20% of bone calcium is
lost.
• Foods high in calcium include milk, cheeses, yogurt, turnip greens, cottage cheese, sardines,
and spinach.
• When performing a musculoskeletal assessment on a client with Paget's disease, note the
size and shape of the skull. The skulls of these clients will be soft, thick and enlarged.
• Clients at high risk for acute osteomyelitis are: elderly, diabetics, and clients with peripheral
vascular disease.
• When clients receive corticosteroids long-term, evaluate them continually for side effects.
• Immunosuppressed clients should avoid contact with persons who have infections.
• Steroids may mask the signs of infections, so client should promptly report slightest change in
temperature or other complaints.
• Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours and
wear sun block.