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Preoperative

Offer support/encouragement Discuss:

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

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

Prevent edema

Prevent hip/knee contractures

Raise extremity with pillow support for first 24 h 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

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

Signs and Symptoms Morning stiffness Fatigue Weight loss Joints are warm, tender, and swollen Swan neck deformity-late Diagnostic Studies X-ray Elevated WBC, platelet count, ESR*, and positive RF Treatment No cure for RA

Swan neck deformity

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

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

Treatment 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

Arthrodesis

Arthroplasty

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

affects weightbearing joints and joints that receive the greatest stress, such as the knees, toes, and lower spine.

Risk 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 Heberdens nodes or Bouchards nodes weight loss

Aspirin inhibits cyclooxygenase enzyme, diminishes the formation of prostaglandins anti-inflammatory, analgesic, antipyretic action inhibit platelet aggregation in cardiac disorders Adverse effects Epigastric distress, nausea, and vomiting In toxic doses, can cause respiratory depression Hypersensitivity Reyes syndrome Ibuprofen use for chronic treatment of rheumatoid and osteoarthritis less GI effects than aspirin Adverse effects dyspepsia to bleeding headache, tinnitus and dizziness

Indomethacin inhibits cyclooxygenase enzyme more potent than aspirin as an antiinflammatory agent Adverse effects: nausea, vomiting, anorexia, diarrhea headache, dizziness, vertigo, lightheadedness, and mental confusion Hypersensitivity reaction

Nursing Intervention Promote comfort: reduce pain, spasms, inflammation, swelling Prevent contractures: exercise, bed rest on firm mattress, splints to maintain proper alignment Weight reduction Isometric and postural exercises Nursing Diagnosis Pain related to friction of bones in joints Risk for injury related to fatigue Impaired physical mobility related to stiff, limited movement

Heat to reduce muscle spasm Cold to reduce swelling and pain

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

Signs and Symptoms extreme pain swelling erythema of the involved joints fever Tophi Laboratory 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*

Allopurinol - 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

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.

COMPARING ARTHRITIS

Rheumatoid
Etiology Autoimmune + Rh factor 35-45 women Subcutaneaous nodules Morning stiffness Swan neck deformity Joints of hands Aspirin, NSAIDs Paraffin bath

Osteoarthritis
Degenerative senescence Men or more in women

Gouty
Metabolic or familial purine metabolism Men over 40

Incidence Signs and symptoms

Heberdens nodule Tophi

Areas affected Managemen t

Weight bearing joint Symptomatic

Great toe Colchicine Avoid purine diet Allopuyrinol

Bacterial Infection of the bone and soft tissue Staphylococcus aureus is the most common pathogen. Hemolytic streptococcus

Other organisms include Proteus, Pseudomonas and E. Coli

Risk Factors poorly nourished, elderly or obese impaired immune systems chronic illnesses long term corticosteroid therapy Open wound infection

Organism reaches the bone through an open wound

Infection causes bone destruction

Bone fragment necrose -sequestra

New bone cells form over the sequestrum during healing resulting in nonunion

Clinical Manifestation area appears warm, swollen and extremely painful ( localized edema) systemic manifestations (fever, chills, tachycardia) Bone pain Muscle spasm

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

1. 2.

Antibiotics : Cefazolin and Clindamycin Analgesic : Oxycodone,

1. 1015 mg of oxycodone produces an
analgesic effect similar to 10 mg of morphine

3.
4. 5. 6. 7.

Vital Signs and Neurovascular status Diet : High calorie, vitamin C and D Calcium Activity : bed rest Heat therapy Antipyrectic : aspirin, acetaminophen

1. 2. 3. 4. 5. 6.

Monitors the neurovascular status of the affected extremity Elevation reduces swelling and associated discomfort Pain is controlled with prescribed analgesics and other pain-reducing techniques Must be protected by immobilization devices and avoidance of stress on the bone The patient must understand the rationale of for the activity of restriction Encourage patient to have a full participation in ADLs within the physical limitations to promote general well-being

Monitor the patients response to antibiotic therapy Observes the IV access for evidence of phlebitis, infection, or infiltration, With long term intensive antibiotic therapy (monitors the patient for sign of infection like oral or vaginal candidiasis, loose or fouling-smelling stool If surgery is necessary (take measures to ensure adequate circulation to the affected area (wound suction to prevent accumulation, elevation of the area to promote venous drainage, avoidance of pressure on the grafted area) to maintain needed immobility, and to ensure the patients adherence of to weight bearing restrictions. Changes dressings using aseptic technique (to promote healing and to prevent cross-contamination Diet high in protein and Vitamin C (promotes a positive nitrogen balance and healing Encourage adequate hydration as well

Promote 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.

reduction in bone density and a change in bone structures bones become previously porous, brittle and fragile bones fracture easily under stresses that would not break in normal bone

Incidence women older than 80 years old of age is 84%. The average 75 years-old woman has lost 25% of her cortical bone and 40% of her trabecular bone.

Age
1. 2. 3. 4. Post-menopause Advance age Low testosterone in men Decreased calcitonin Low calcium intake Low vitamin D High phosphate intake Inadequate calories

Nutrition
1. 2. 3. 4.

Physical exercise
Sedentary Lack of weight-bearing exercise Low weight and body mass index

Lifestyle choices
Caffeine Alcohol Smoking Lack of exposure to sunlight

Medications
Corticosteroids

Antiseizure medications
Heparin Thyroid Hormone

Back pain. Loss of height and stooped posture. A Curved upper back (dowager's hump). Fracture : hip, spine and wrist. Compression fractures

1.

Primary Osteoporosis :
women after menopause (usually after 45 and 55 years) later in men.

2.

Secondary Osteoporosis
medications or other conditions and disease that affect bone metabolism.

Genetics -Caucasian or Asian -Females -Family history -Small frame Age -Post-menopause -Advance age -Low testosterone in men -Decreased calcitonin Nutrition -Low calcium intake -Low vitamin D -High phosphate intake -Inadequate calories

Predisposes to low bone mass Hormones (estrogen, calcitonin, and testosterone) inhibit bone loss.

Reduces nutrients needed for the bone remodeling

Physical Exercise -Sedentary -Lack of weight-bearing exercise -Low weight and body mass index Lifestyle Choices -Caffeine -Alcohol -Smoking -Lack of exposure to sunlight Medications -Corticosteroids -Antiseizure medications -Heparin -Thyroid Hormone

Bones needed stress for bone maintenance.

Affects calcium absorption and metabolism Reduces osteogenesis in bone remodeling

Dual-energy X-ray Absorptiometry (DEXA)Means of measuring bone mineral densities (BMD) Two xray beams with differing energy levels are aimed at the patient bones.

ray. Serum calcium Serum phosphatase Urine calcium excretion

1.

Hormone replacement therapy (HRT)

1. Raloxifene (Evista) preserving BMD w/o estrogenic effect on the uterus ( prevention and treatment for osteoporosis 2. Bishosphonates 3. Alendronate - inc. bone mass by inhibiting osteoclast function. 4. Calcitonin

Nursing Diagnosis 1. Deficient knowledge about the osteoporotic process and treatment regimen 2. Acute pain related to fracture and muscle spasm 3. Risk for constipation related to immobility or development of ileus 4. Risk for injury:additional fractures related to osteoporosis

Nursing Inteventions Promoting and Understanding of Osteoporosis and the Treatment Regimen 1. Adequate dietary or supplemental calcium (12001500 mg/day) and vitamin D 2. Regular weight-bearing exercise 3. Modification of lifestyle like cessation of smoking, reduce the use of caffeine and alcohol 4. Help to maintain bone mass 5. Instruct to take the calcium supplements with meals 6. Teach patient to drink adequate fluids to reduce the risk of renal calculi 7. For Alendronate users, it must be taken on an empty stomach with water and the patient must not consume foods or liquids for 30-60 minutes.

Relieving Pain
1. Rest in bed in a supine position or sidelying position several times a day. The mattress should be firm and non-sagging. 2. Intermittent local heat and back rubs promote muscle tension 3. Instruct to move the trunk as a unit and avoid twisting.

 primary malignant neoplasm of bones

Also known as Osteogenicsarcom

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.

Risk Factors
Cause is unknown. family history / inherited cancers : Li-Fraumeni Syndrome Retinoblastoma being tall for specific age Previous treatment with radiation for another cancer That usually occurs in children younger than 4 yrs.

Pathophysiology:
1.Osteosarcoma occurs mainly in the metaphyses of long bones, sites of active epiphyseal growth. Distal femur Proximal tibia Proximal humerus 1.As a tumor of mesenchymal cells, osteosarcoma demonstrates production of osteoid cells. 2.It is a bulky tumorthat extends beyond the bone the bone into a soft tissue. 3.This may encircle the bone and destroy the trabeculae of affected area. 4.Osteosarcoma disseminates through bloodstream, usually to the lung. 5.Other sites of metastatic spread include other bones and visceral organs

Predisposing Factors

High grade mesenchymal tumor

Distal femur Proximal tibia Proximal humerus

Formation of osteoid

Bulky tumor that destroys trabeculae of diseased area

Metastasize through blood streams Lungs, bones, visceral organs

Clinical 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

Radiation Chemotherapy (methotrexate (leucovorin/Adriamycin) Cytoxan, Ifosfamide Surgical management

amputation limb salvage procedures

Prognosis: poor prognosis (rapid growth rate)

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)

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

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

Infection

Hemorrhage
Thrombophlebitis Pulmonary embolism Prosthesis dislocation Prosthesis loosening

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

Neonates: 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

Infants 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

Implementation Traction and/or surgery to release muscles and tendons

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

The walking child minimal to pronounced variation in gait with lurching toward the affected side; positive Trendelenburg sign

Positive Barlow or Ortolanis maneuver

Ortolanis maneuver

Barlow maneuver

Caring for Patient with

Osteomalacia involves softening of the bones caused by a deficiency of vitamin D or problems with the metabolism of this vitamin.

In children, the condition is called

rickets and is

usually caused by a deficiency of vitamin D .

In adult, the condition is usually caused by:

1. Inadequate dietary intake of vitamin D 2. Inadequate exposure to sunlight (ultraviolet radiation) 3. Malabsorption of vitamin D

Other conditions:
1. Hereditary or acquired disorders of vitamin D metabolism 2. Kidney failure and acidosis , 3. PO4 depletion associated with low dietary intake or kidney disease 4. Side effects of medications used to treat seizures .

Risk factors are related to the causes.

In the elderly, there is an increased risk for those who tend to remain indoors and who avoid milk because of lactose intolerance

The incidence is 1 in 1000 people.

Deficiency of activated VITAMIN D (Calcitriol)

Decreased absorption, malabsorption or excessive loss of CALCIUM Inadequate MINERALIZATION of bone SOFTENING of the BONE

1. numbness around the mouth & of extremities 2. Carpopedal spasms 3. Bowing of legs 4. Waddling or limping GAIT 5. Decrease in height/ Spinal Deformities (i.e. KYPHOSIS)

diffuse bone pain , especially in the hips muscle weakness symptoms associated with low calcium

In children, symptoms of rickets include:

delayed sitting, crawling, and walking; pain when walking; and the development of bowlegs or knockknees.

1. 2.

3. 4. 5. 6.

Bone biopsy: (+) increase in osteoid Bone X-ray or CT scan of lumbosacral spine shows demineralization. Studies of the vertebrae: (+) compression fx Low serum vitamin D level Low serum calcium & phosphate levels Elevated ALP (Alkaline Phosphatase)

1.

2.

Adequate dietary intake of dairy products that are fortified with vitamin D Adequate exposure of the body to sunlight

Oral supplements of vitamin D , calcium, and phosphorus

Large doses of Vitamin D with exposure to sunlight may be indicated in people with intestinal malabsorption .

Monitoring of blood levels of phosphorus and calcium may be indicated with some underlying conditions. Braces or surgery to correct deformities

30

Protrusion of the nucleus of the disk into the fibrous ring of the disk with subsequent nerve compression May occur in any portion of the vertebral column Signs & Symptoms
1. 2. 3. 4. Pain Sensory changes Loss of reflex Muscle weakness

77

30
1.

Cervical

2.

Lumbar

Pain/ Stiffness head, neck & upper extremities Paresthesia, numbness Weakness
Low back pain radiating to the buttocks and leg Postural deformity of the spine (+) Straight-Leg Raise test Weakness & Asymmetric reflexes Sensory loss

Nursing Alert: Perform repeated assessments of sensorimotor functions/ reflexes to determine progression of condition
80

30
Nursing Interventions
Alleviating pain
1. Anti-inflammatory drugs, muscle relaxants, and narcotic analgesics 2. Use of bed boards under the mattress 3. Bed rest supine or low fowlers or side lying position with slight knee flexion and pillows between knees. 4. Moist heat application 5. Relaxation techniques

82

Surgical incision of part of posterior arch of vertebrae and removal of protruded disc Nursing Intervention Preoperative

Postoperative 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

Teach patient log rolling and use of bedpan

Avoid:
Acute hip flexion (bending, stooping, crossing the legs Prolonged sitting/standing Running, jogging, horseback riding

Back- strengthening exercises

Prone position Walk in seawater

Lie in side- lying with hip flexion

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