MUSCULOSKELETAL SYSTEM DISORDERS

PYRAMID POINTS
Assessment findings in a fracture

Initial care of a fracture

Various types of traction Nursing care of the client in traction Client education for the use of a halo device Client education related to crutch walking Client education related to the use of a cane

or walker

PYRAMID POINTS
Assessment findings and interventions for

complications of a fracture Care of the client following hip pinning and hip prosthesis Care of the client following total knee replacement Treatment measures for the client with a herniated intervertebral disc Care of the client following disc surgery

PYRAMID POINTS
Interventions following amputation

Treatment modalities for the client with

rheumatoid arthritis Client education related to osteoporosis Client education related to gout

INJURIES
STRAINS

An excessive stretching of a muscle or tendon Management involves cold and heat applications, exercise with activity limitations, antiinflammatory medications, and muscle relaxants Surgical repair may be required for a severe strain (ruptured muscle or tendon)

INJURIES
SPRAINS An excessive stretching of a ligament usually caused by a twisting motion Characterized by pain and swelling Management involves rest, ice, and a compression bandage to reduce swelling and provide joint support Casting may be required for moderate sprains to allow the tear to heal Surgery may be necessary for severe ligament damage

INJURIES
ROTATOR CUFF INJURIES Musculotendinous or rotator cuff of the shoulder sustains a tear usually as a result of trauma Characterized by shoulder pain and the inability to maintain abduction of the arm at the shoulder (drop arm test) Management involves nonsteroidal antiinflammatory drugs (NSAIDs), physical therapy, sling support, and ice/heat applications Surgery may be required if medical management is unsuccessful or for those who have a complete tear

FRACTURES
DESCRIPTION

A break in the continuity of the bone caused by trauma, twisting as a result of muscle spasm or indirect loss of leverage, or bone decalcification and disease that result in osteopenia

TYPES OF FRACTURES
CLOSED OR SIMPLE

Skin over the fractured area remains intact

One side of the bone is broken and the other is bent; most commonly seen in children

GREENSTICK

TRANSVERSE

The bone is fractured straight across

The break extends in an oblique direction

OBLIQUE

TYPES OF FRACTURES
SPIRAL The break partially encircles bone COMMINUTED The bone is splintered or crushed, with three or more fragments COMPLETE The bone is completely separated by a break into two parts INCOMPLETE A partial break in the bone

TYPES OF FRACTURES
OPEN-COMPOUND

The bone is exposed to air through a break in the skin, and soft tissue injury and infection are common
A part of the fractured bone is driven into another bone Bone fragments are driven inward

IMPACTED

DEPRESSED

TYPES OF FRACTURES
COMPRESSION

A fractured bone compressed by other bone

A fracture due to weakening of the bone structure by pathological processes, such as neoplasia or osteomalacia; also called spontaneous fracture

PATHOLOGICAL

TYPES OF FRACTURES

From Ignativicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia: W.B. Saunders.

FRACTURE OF AN EXTREMITY
ASSESSMENT

Pain or tenderness over the involved area Loss of function Obvious deformity Crepitation Erythema, edema, ecchymosis Muscle spasm and impaired sensation

FRACTURE OF AN EXTREMITY
INITIAL CARE

Immobilize affected extremity If a compound fracture exists, splint the extremity and cover the wound with a sterile dressing

INTERVENTIONS FOR A FRACTURE

Reduction

Fixation
Traction Casts

REDUCTION
DESCRIPTION

Restoring the bone to proper alignment

REDUCTION
CLOSED REDUCTION

Performed by manual manipulation May be performed under local or general anesthesia A cast may be applied following reduction

CLOSED REDUCTION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

REDUCTION
OPEN REDUCTION

Involves a surgical intervention May be treated with internal fixation devices The client may be placed in traction or a cast following the procedure

FIXATION
INTERNAL FIXATION

Follows open reduction Involves the application of screws, plates, pins, or nails to hold the fragments in alignment May involve the removal of damaged bone and replacement with a prosthesis Provides immediate bone strength Risk of infection is associated with the procedure

INTERNAL FIXATION

From Browner BB et al (1992) Skeletal trauma. Philadelphia: W.B. Saunders.

FIXATION
EXTERNAL FIXATION

An external frame is utilized with multiple pins applied through the bone Provides more freedom of movement than with traction

EXTERNAL FIXATION

From Ignatavicius, D., Workman, M. (2002). Medical-surgical nursing, ed 3, Philadelphia: W.B. Saunders. Courtesy of Smith and Nephew, Inc., Orthopedics Division, Memphis, TN.

TRACTION
DESCRIPTION

The exertion of a pulling force applied in two directions to reduce and immobilize a fracture Provides proper bone alignment and reduces muscle spasms

TRACTION
IMPLEMENTATION Maintain proper body alignment Ensure that the weights hang freely and do not touch the floor Do not remove or lift the weights without a physicians order Ensure that pulleys are not obstructed and that ropes in the pulleys move freely Place knots in the ropes to prevent slipping Check the ropes for fraying

SKELETAL TRACTION
DESCRIPTION Mechanically applied to the bone using pins, wires, or tongs IMPLEMENTATION Monitor color, motion, and sensation (CMS) of the affected extremity Monitor the insertion sites for redness, swelling, or drainage Provide insertion site care as prescribed

SKELETAL TRACTION

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

CERVICAL TONGS AND HALO FIXATION DEVICE

Head and Spinal Cord Injuries

SKIN TRACTION
DESCRIPTION

Traction applied by the use of elastic bandages or adhesive

SKIN TRACTION: SIDE ARM

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

TYPES OF SKIN TRACTION

Cervical traction

Bucks traction
Bryants traction Pelvic traction Russells traction

CERVICAL SKIN TRACTION

Relieves muscle spasms and compression in

the upper extremities and neck Uses a head halter and a chin pad to attach the traction Use powder to protect the ears from friction rub Position the client with the head of the bed elevated 30 to 40 degrees and attach the weights to a pulley system over the head of the bed

CERVICAL SKIN TRACTION

From James, S. Ashwill, R., & Droske, S. (2002). Nursing care of children, ed 2, Philadelphia: W.B. Saunders.

HEAD HALTER TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BUCKS SKIN TRACTION

Used to alleviate muscle spasms; immobilizes

a lower limb by maintaining a straight pull on the limb with the use of weights A boot appliance is applied to attach to the traction Weight is attached to a pulley; allow the weights to hang freely over the edge of bed Not more than 5 pounds of weight should be applied Elevate the foot of the bed to provide the traction

BUCKS SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BRYANTS AND RUSSELLS SKIN TRACTION

Refer to the module entitled Pediatric

Nursing, Musculoskeletal Disorders for information related to these types of traction

PELVIC SKIN TRACTION

Used to relieve low back, hip, or leg pain and

to reduce muscle spasm Apply the traction snugly over the pelvis and iliac crest and attach to the weights Use measures as prescribed to prevent the client from slipping down in bed

PELVIC SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BALANCED SUSPENSION
DESCRIPTION

Used with skin or skeletal traction Used to approximate fractures of the femur, tibia, or fibula Produced by a counterforce other than client

BALANCED SUSPENSION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BALANCED SUSPENSION
IMPLEMENTATION Position the client in low Fowlers, either on the side or back Maintain a 20-degree angle from the thigh to the bed Protect the skin from breakdown Provide pin care if pins are used with the skeletal traction Clean the pin sites with sterile normal saline and hydrogen peroxide or Betadine as prescribed or per agency procedure

DUNLOPS SKIN TRACTION

DESCRIPTION

Horizontal traction to align fractures of the humerus; vertical traction maintains the forearm in proper alignment
Nursing care is similar to Bucks traction

IMPLEMENTATION

DUNLOPS SKIN TRACTION

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

CASTS
DESCRIPTION

Made of plaster or fiberglass to provide immobilization of bone and joints after a fracture or injury

CASTS

From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.

CASTS
IMPLEMENTATION

Keep the cast and extremity elevated Allow a wet cast 24 to 48 hours to dry (synthetic casts dry in 20 minutes) Handle a wet cast with the palms of the hand until dry Turn the extremity unless contraindicated, so that all sides of the wet cast will dry Heat can be used to dry the cast

CASTS
IMPLEMENTATION The cast will change from a dull to a shiny substance when dry Examine the skin and cast for pressure areas Monitor the extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse Notify the physician immediately if circulatory compromise occurs Prepare for bivalving or cutting the cast if circulatory impairment occurs

CASTS
IMPLEMENTATION

Petal the cast; maintain smooth edges around the cast to prevent crumbling of the cast material Monitor the clients temperature Monitor for the presence of a foul odor, which may indicate infection Monitor drainage and circle the area of drainage on the cast Monitor for warmth on the cast

CASTS
IMPLEMENTATION Monitor for wet spots, which may indicate a need for drying, or the presence of drainage under the cast If an open draining area exists on the affected extremity, a cut-out portion of the cast or a window will be made by the physician Instruct the client not to stick objects inside the cast Teach the client to keep the cast clean and dry Instruct the client on isometric exercises to prevent muscle atrophy

COMPLICATIONS OF FRACTURES
Fat embolism

Compartment syndrome
Infection and osteomyelitis Avascular necrosis Pulmonary emboli

FAT EMBOLISM
DESCRIPTION

An embolism originating in the bone marrow that occurs after a fracture Clients with long bone fractures are at the greatest risk for the development of fat embolism Usually occurs within 48 hours following the injury

FAT EMBOLISM
ASSESSMENT Restlessness Mental status changes Tachycardia, tachypnea, and hypotension Dyspnea Petechial rash over the upper chest and neck IMPLEMENTATION Notify the physician immediately Treat symptoms as prescribed to prevent respiratory failure and death

COMPARTMENT SYNDROME
DESCRIPTION

Increased pressure within one or more compartments causing massive compromise of circulation to an area Leads to decreased perfusion and tissue anoxia Within 4 to 6 hours after the onset of compartment syndrome, neuromuscular damage is irreversible

ANTERIOR COMPARTMENT SYNDROME

From Black JM, Hawks JH, Keene AM (2001): Medical-surgical nursing: clinical management for positive outcomes 6th ed., Philadelphia, W.B. Saunders.

COMPARTMENT SYNDROME
ASSESSMENT

Increased pain and swelling Pain with passive motion Inability to move joints Loss of sensation (paresthesia) Pulselessness Notify the physician immediately

IMPLEMENTATION

INFECTION AND OSTEOMYELITIS

DESCRIPTION

Can be caused by the interruption of the integrity of the skin The infection invades bone tissue

INFECTION AND OSTEOMYELITIS

ASSESSMENT Fever Pain Erythema in the area surrounding the fracture Tachycardia Elevated white blood cell (WBC) count IMPLEMENTATION Notify the physician Prepare to initiate aggressive IV antibiotic therapy

AVASCULAR NECROSIS
DESCRIPTION An interruption in the blood supply to the bony tissue, which results in the death of the bone ASSESSMENT Pain Decreased sensation IMPLEMENTATION Notify the physician if pain or decreased sensation occurs Prepare the client for removal of necrotic tissue because it serves as a focus for infection

PULMONARY EMBOLISM
DESCRIPTION

Caused by immobility precipitated by a fracture

PULMONARY EMBOLISM
ASSESSMENT Restlessness and apprehension Dyspnea Diaphoresis Arterial blood gas changes IMPLEMENTATION Notify the physician if signs of emboli are present Prepare to administer anticoagulant therapy

CRUTCH WALKING
DESCRIPTION

An accurate measurement of the client for crutches is important because an incorrect measurement could damage the brachial plexus The distance between the axilla and the arm pieces on the crutches should be two fingerwidths in the axilla space The elbows should be slightly flexed 20 to 30 degrees when walking

BRACHIAL PLEXUS

From Crossman AR, Neary D (1995). Neuroanatomy: an illustrated color text. Edinburgh: Churchill Livingstone.

CRUTCH WALKING
DESCRIPTION

When ambulating with the client, stand on the affected side Instruct the client never to rest the axilla on the axillary bars Instruct the client to look up and outward when ambulating Instruct the client to stop ambulation if numbness or tingling in the hands or arms occurs

CRUTCH WALKING

From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2, St. Louis, 2000, Mosby.

CRUTCH GAITS

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

CANES
DESCRIPTION

Made of a lightweight material with a rubber tip at the bottom

SINGLE- AND QUAD-FOOT CANES

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

CANES
IMPLEMENTATION

Stand at the affected side of the client when ambulating The handle should be at the level of the clients greater trochanter The clients elbow should be flexed at a 25- to 30-degree angle

CANES
CLIENT EDUCATION

Hold the cane close to the body Hold the cane in the hand on the unaffected side so that the cane and weaker leg can work together with each step Move the cane at the same time as the affected leg Inspect the rubber tips regularly for worn places

HEMICANES OR QUAD-FOOT CANES

Used for clients who have the use of only one

upper extremity Hemicanes provide more security than a quad-foot cane; however, both types provide more security than a single-tipped cane Position the cane at the clients unaffected side with the straight nonangled side adjacent to the body Position the cane 6 inches from clients side with the handgrips level with the greater trochanter

WALKERS
Stand adjacent to the client on the affected

side Instruct the client to put all four points of the walker flat on the floor before putting weight on the hand pieces Instruct the client to move the walker forward and to walk into it

TYPES OF HIP FRACTURES

Intracapsular

Extracapsular

INTRACAPSULAR HIP FRACTURE

Bone is broken inside the joint

Skin traction is applied preoperatively to

immobilize and prevent pain Treatment includes a total hip replacement or internal fixation with replacement of the femoral head with a prosthesis Avoid hip flexion to prevent displacement

EXTRACAPSULAR HIP FRACTURE

Fracture can occur at the greater trochanter

or can be an intertrochanteric fracture Trochanteric fracture is outside the joint Preoperative treatment includes balanced suspension traction Avoid hip flexion to prevent displacement Surgical treatment includes internal fixation with nail plate, screws, or wires

INTERNAL FIXATION

From Black JM, Matassarin-Jacobs E (1997): Medical-surgical nursing: clinical management for continuity of care 5th ed., Philadelphia, W.B. Saunders.

HIP REPLACEMENTS

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby. Courtesy of Zimmer, Inc., Warsaw, IN.

TOTAL HIP REPLACEMENT

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

HIP FRACTURE
POSTOPERATIVE

Maintain leg and hip in proper alignment Prevent flexion or external or internal rotation Turn the client from back to unaffected side Do not position to the affected side unless prescribed by the physician Maintain leg abduction to prevent internal or external rotation

HIP FRACTURE
POSTOPERATIVE Use a trochanter roll to prevent external rotation Ensure that the hip flexion angle does not exceed 60 to 80 degrees Elevate the head of the bed 30 to 45 degrees for meals only Ambulate as prescribed by the physician Avoid weight bearing on the affected leg as prescribed; instruct the client in the use of a walker to avoid weight bearing

HIP FRACTURE
POSTOPERATIVE

Keep the operative leg extended, supported, and elevated when getting client out of bed Avoid hip flexion greater than 90 degrees and avoid low chairs when out of bed Monitor the wound for infection or hemorrhage Monitor circulation and sensation of the affected side

HIP FRACTURE
POSTOPERATIVE

Maintain the Hemovac or Jackson-Pratt drain if in place; maintain compression to facilitate drainage and monitor and record output of drainage Drainage should continuously decrease in amount, and by 48 hours postoperatively, drainage should be approximately 30 ml in an 8-hour period

HIP FRACTURE
POSTOPERATIVE

Maintain the use of antiembolism stockings and encourage the client to flex and extend the feet and ankles Instruct the client to avoid crossing the legs and bending over Physical therapy will begin postoperatively as prescribed by the physician

TOTAL KNEE REPLACEMENT

DESCRIPTION

Implantation of a device to substitute for the femoral condyles and the tibial joint surfaces

KNEE PROSTHESIS

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

TOTAL KNEE REPLACEMENT

POSTOPERATIVE

Monitor the incision for drainage and infection Maintain the Hemovac or Jackson-Pratt drain if in place Begin continuous passive motion (CPM) 24 to 48 hours as prescribed to exercise the knee and provide moderate flexion and extension Administer analgesics before CPM to decrease pain

CONTINUOUS PASSIVE MOTION

From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, St. Louis, 1996, Mosby.

TOTAL KNEE REPLACEMENT

POSTOPERATIVE

The leg should not be dangled to prevent dislocation Prepare the client for out-of-bed activities as prescribed Avoid weight bearing and instruct the client in crutch walking

HERNIATION: INTERVERTEBRAL DISC

DESCRIPTION

Nucleus of the disc protrudes into the annulus causing nerve compression Cervical Lumbar

TYPES

DISC HERNIATION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

CERVICAL DISC
DECRIPTION

Occurs at C5 to C6 and C6 to C7 interspaces Causes pain and stiffness in the neck, top of the shoulders, scapula, upper extremities, and head Produces paresthesia and numbness of the upper extremities

CERVICAL DISC
IMPLEMENTATION Provide bed rest to relieve pressure and reduce inflammation and edema Provide immobilization as prescribed via cervical collar, traction, or brace Apply hot, moist compresses as prescribed to increase the blood flow and relax spasms Instruct the client to avoid flexing, extending, or rotating the neck Instruct the client to avoid long periods of sitting

CERVICAL DISC
IMPLEMENTATION Instruct the client that while sleeping, to avoid the prone position and keep the head, spine, and hip in alignment Instruct the client in the use of analgesics, sedatives, antiinflammatory agents, and corticosteroids as prescribed Prepare the client for a corticosteroid injection into the epidural space if prescribed Assist the client with the application of a cervical collar or cervical traction as prescribed

CERVICAL COLLAR
Used for cervical disc herniation

Holds the head in a neutral or slightly flexed

position The client may have to wear a cervical collar 24 hours a day Inspect the skin under the collar for irritation When the pain subsides, the client is taught cervical isometric exercises to strengthen the muscles

CERVICAL COLLAR

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders. Courtesy of Zimmer, Inc., Dover, OH.

LUMBAR DISC
DESCRIPTION Most often occurs at L4 to L5 or L5 to S1 interspaces Postural deformity occurs Produces muscle weakness, sensory loss, and alteration of the tendon reflexes The client experiences low back pain and muscle spasms with radiation of the pain into one hip and down the leg (sciatica) Pain is aggravated by bending, lifting, straining, sneezing, and coughing, and is relieved by bed rest

LUMBAR DISC
IMPLEMENTATION

Provide bed rest as prescribed Apply moist heat and massage as prescribed Instruct the client to sleep on the side with the knees and hips in a position of flexion and with a pillow between the legs Apply pelvic traction as prescribed to relieve muscle spasms

LUMBAR DISC
IMPLEMENTATION

Begin ambulation gradually as the inflammation and edema subsides Instruct the client in the use of muscle relaxants, antiinflammatory medications, and corticosteroids as prescribed Instruct the client in the use of a corset or brace as prescribed Instruct the client regarding correct posture while sitting, standing, walking, and working

LUMBAR DISC
IMPLEMENTATION

Instruct the client to lift objects by bending the knees and keeping the back straight, avoiding lifting anything above the elbows Instruct the client regarding a weight-control program as prescribed Instruct the client in an exercise program as prescribed to strengthen abdominal and back muscles

DORSOLUMBAR ORTHOSIS

From Mosbys medical, nursing, and allied health dictionary, ed 6, (2002). St. Louis: Mosby. Courtesy of Truform Orthotics and Prosthetics, Cincinnati, OH.

LOW BACK CARE

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

TYPES OF DISC SURGERY

CHEMOLYSIS Injections to dissolve affected disc DISCECTOMY Removal of herniated disc tissue and related matter DISCECTOMY WITH FUSION Fusion of vertebrae with bone graft LAMINOTOMY Division of the lamina of a vertebrae LAMINECTOMY Removal of the lamina

DISC SURGERY
PREOPERATIVE

Reassure the client that surgery will not weaken the back Instruct the client regarding coughing and deep-breathing exercises Instruct the client about logrolling and rangeof-motion exercises

DISC SURGERY: CERVICAL DISC

POSTOPERATIVE

Monitor for respiratory difficulty Encourage coughing and deep breathing Monitor for hoarseness and inability to cough effectively because this may indicate laryngeal nerve damage Use throat sprays or lozenges for sore throat and do not use those that may numb the throat to avoid choking

DISC SURGERY: CERVICAL DISC

POSTOPERATIVE

Monitor the wound for drainage Provide a soft diet if the client complains of dysphagia Monitor for sudden return of radicular pain, which may indicate that the cervical spine has become unstable

DISC SURGERY: LUMBAR DISC

POSTOPERATIVE

Monitor for wound hemorrhage Monitor sensation and motor ability of the lower extremities as well as color, temperature, and sensation of toes Monitor for urinary retention, paralytic ileus, and constipation Initiate measures to prevent constipation such as a high-fiber diet, increased fluids, and stool softeners as prescribed

DISC SURGERY: LUMBAR DISC

POSTOPERATIVE

When turning and repositioning the client, place the bed in a flat position and a pillow between the legs; turn the client as a unit (logroll) without twisting the clients back When positioning the client, a pillow is placed under the head with the knees slightly flexed Avoid extreme knee flexion when the client is lying on the side

DISC SURGERY: LUMBAR DISC

POSTOPERATIVE

To assist the client out of bed, raise the head of the bed while the client lies on the side; the client's head and shoulders are supported by the first nurse, the client pushes self to a sitting position, and the second nurse eases the legs over the side of the bed Instruct the client to avoid sitting because it places a strain on the surgical site

DISC SURGERY: LUMBAR DISC

POSTOPERATIVE

Administer narcotics and sedatives as prescribed to relieve pain and anxiety Encourage early ambulation Assist the client with the use of a back brace or corset if prescribed

AMPUTATION OF A LOWER EXTREMITY

DESCRIPTION

The surgical removal of a lower limb or part of the limb

LEVELS OF LOWER EXTREMITY AMPUTATION

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia: W.B. Saunders.

AMPUTATION FLAPS

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

AMPUTATION OF A LOWER EXTREMITY

POSTOPERATIVE

Monitor vital signs Monitor for infection and hemorrhage Mark bleeding and drainage on the dressing if it occurs Keep a tourniquet at the bedside Monitor for pulmonary emboli

AMPUTATION OF A LOWER EXTREMITY

POSTOPERATIVE

Observe for and prevent contractures Monitor for signs of necrosis and neuroma Evaluate for phantom limb sensation and pain; explain sensation and pain to the client, and medicate the client as prescribed Check the physicians orders regarding positioning

AMPUTATION OF A LOWER EXTREMITY

POSTOPERATIVE If prescribed, during the first 24 hours, elevate the foot of the bed to reduce edema, then keep the bed flat to prevent hip flexion contractures Do not elevate the stump itself because elevation can cause flexion contracture of the hip joint After 24 and 48 hours postoperatively, position the client prone if prescribed to stretch the muscles and prevent flexion contractures of hip

AMPUTATION OF A LOWER EXTREMITY

POSTOPERATIVE

In the prone position, place a pillow under the abdomen and stump and keep the legs close together to prevent abduction Maintain application of an Ace wrap or elastic stump shrinker as prescribed to provide stump shrinkage Remove and rewrap the Ace bandage or elastic stump shrinker three to four times daily as prescribed

AMPUTATION OF A LOWER EXTREMITY

POSTOPERATIVE Wash the stump with mild soap or water and apply lanolin to the skin if prescribed Massage the skin toward the suture line to increase circulation Prepare for a cast application if prescribed to prepare the stump for prosthesis Encourage the client to look at the stump Encourage verbalization regarding loss of the body part and assist the client to identify coping mechanisms to deal with the loss

STUMP WRAPPING

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

BELOW-THE-KNEE AMPUTATION
POSTOPERATIVE

Prevent edema Do not allow the stump to hang over the edge of the bed Do not allow the client to sit for long periods of time to prevent contractures

ABOVE-THE-KNEE AMPUTATION
POSTOPERATIVE

Prevent internal or external rotation of the limb Place a sandbag or rolled towel along the outside of the thigh to prevent rotation

AMPUTATION OF A LOWER EXTREMITY

REHABILITATION

Instruct the client in crutch walking Prepare the stump for prosthesis Prepare the client for the fitting of the stump for prosthesis Instruct the client in exercises to maintain range of motion Provide psychosocial support to the client

RHEUMATOID ARTHRITIS (RA)

DESCRIPTION Chronic systemic inflammatory disease; the etiology may be related to a combination of environmental and genetic factors Leads to destruction of connective tissue and synovial membrane within the joints Weakens and leads to dislocation of the joint and permanent deformity Formation of pannus occurs at the junction of synovial tissue and articular cartilage projecting into the joint cavity and causing necrosis

RHEUMATOID ARTHRITIS (RA)

DESCRIPTION

Exacerbations are increased by physical or emotional stress Risk factors include exposure to infectious agents; fatigue and stress can exacerbate the condition Vasculitis can cause malfunction and eventual failure of an organ or system

RHEUMATOID ARTHRITIS (RA)

ASSESSMENT

Inflammation, tenderness, and stiffness of the joints Moderate to severe pain and morning stiffness lasting longer than 30 minutes Joint deformities, muscle atrophy, and decreased range of motion Spongy, soft feeling in the joints

RHEUMATOID ARTHRITIS (RA)

ASSESSMENT

Low-grade temperature, fatigue, and weakness Anorexia, weight loss, and anemia Elevated sedimentation rate and positive rheumatoid factor X-ray showing joint deterioration Synovial tissue biopsy presents inflammation

RHEUMATOID ARTHRITIS EARLY, MODERATE, AND ADVANCED STAGE

From Monahan FD, Neighbers M: Medical-surgical nursing: foundations for clinical practice, ed. 2, Philadelphia, 1998, W.B. Saunders.

RHEUMATOID ARTHRITIS MUSCLE ATROPHY

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

RHEUMATOID NODULE

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

BOUTONNIERE DEFORMITY

From Zitelli BJ, Davis HW: Atlas of Pediatric Physical Diagnosis, ed. 3, St. Louis, 1997, Mosby.

SWAN NECK DEFORMITY

From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts and clinical practice, ed. 6, St. Louis, 1999, Mosby.

RHEUMATOID (RA) FACTOR

DESCRIPTION

A blood test used to diagnose rheumatoid arthritis Nonreactive: 0 to 39 IU/ml Weakly reactive: 40 to 79 IU/ml Reactive: greater than 80 IU/ml

VALUES

RHEUMATOID ARTHRITIS (RA)

PAIN

Salicylates (acetylsalicylic acid [aspirin]) Monitor for side effects including tinnitus, gastrointestinal (GI) upset, or prolonged bleeding time Administer with meals or a snack Monitor for abnormal bleeding or bruising

RHEUMATOID ARTHRITIS (RA)

NONSTEROIDAL ANTIINFLAMMATORY

DRUGS (NSAIDs)

May be prescribed in combination with salicylates if pain and inflammation has not decreased within 6 to 12 weeks following salicylate therapy Monitor for side effects such as GI upset, CNS manifestations, skin rash, hypertension, fluid retention, and changes in renal function

RHEUMATOID ARTHRITIS (RA)

CORTICOSTEROIDS

Administer as prescribed during exacerbations or when commonly used agents are ineffective Administer as prescribed in clients with lifethreatening RA Administer as prescribed in combination with salicylates and NSAIDs to induce remission and decrease pain and inflammation

ANTINEOPLASTIC MEDICATIONS

GOLD SALTS

RHEUMATOID ARTHRITIS (RA)

PHYSICAL MOBILITY

Preserve joint function Provide ROM exercises to maintain joint motion and muscle strengthening Balance rest and activity Splints during acute inflammation to prevent deformity Prevent flexion contractures

RHEUMATOID ARTHRITIS (RA)

PHYSICAL MOBILITY Apply heat or cold therapy as prescribed to joints Apply paraffin baths and massage as prescribed Encourage consistency with exercise program Instruct the client to stop exercise if pain increases Exercise only to the point of pain Avoid weight bearing on inflamed joints

RHEUMATOID ARTHRITIS (RA)

SELF-CARE

Assess the need for assistive devices such as higher toilet seats, chairs, and wheelchairs to facilitate mobility Collaborate with occupational therapy to obtain assistive adaptive devices Instruct the client in alternative strategies for providing activities of daily living

RHEUMATOID ARTHRITIS (RA)

FATIGUE

Identify factors that may contribute to fatigue Monitor for signs of anemia Administer iron, folic acid, and vitamin supplements as prescribed Monitor for drug-related blood loss by testing the stool for occult blood Instruct the client in measures to conserve energy such as pacing activities and obtaining assistance when possible

RHEUMATOID ARTHRITIS (RA)

BODY IMAGE DISTURBANCE

Assess the clients reaction to the body change Encourage the client to verbalize feelings Assist the client with self-care activities and grooming Encourage the client to wear street clothes

RHEUMATOID ARTHRITIS (RA) SURGICAL INTERVENTIONS

SYNOVECTOMY Removal of the synovia to help maintain joint function ARTHRODESIS Bony fusion of a joint to regain some mobility JOINT REPLACEMENT (ARTHROPLASTY) Replacement of diseased joints with artificial joints Performed to restore motion to a joint and function to the muscles, ligaments, and other soft tissue structures that control a joint

OSTEOARTHRITIS
DESCRIPTION

Also known as degenerative joint disease (DJD) Cause is unknown but may be caused by trauma, fractures, infections, or obesity Progressive degeneration of the joints caused by wear and tear

OSTEOARTHRITIS
DESCRIPTION

Causes the formation of bony build-up and the loss of articular cartilage in peripheral and axial joints Affects the weight-bearing joints and joints that receive the greatest stress such as the knees, toes, and lower spine

JOINT CHANGES IN OSTEOARTHRITIS

From Ignatavicius DD, Workman ML, Mishler MA, Medical-surgical nursing across the healthcare continuum, ed. 3, Philadelphia, 1999, W.B.Saunders.

OSTEOARTHRITIS
ASSESSMENT

Joint pain that early in the disease process diminishes after rest and intensifies after activity As the disease progresses, pain occurs with slight motion or even at rest Symptoms are aggravated by temperature change and humidity Crepitus

OSTEOARTHRITIS
ASSESSMENT Joint enlargement Presence of Heberdens nodes or Bouchards nodes Limited ROM Difficulty getting up after prolonged sitting Skeletal muscle atrophy Inability to perform activities of daily living Compression of the spine as manifested by radiating pain, stiffness, and muscle spasms in one or both extremities

SEVERE OSTEOARTHRITIS

From Kamal A, Brockelhurst J: Color atlas of geriatric medicine, ed. 2, St. Louis, 1991, Mosby.

HEBERDENS NODES

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

BOUCHARDS NODES

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

OSTEOARTHRITIS
PAIN Administer NSAIDs, salicylates, and muscle relaxants as prescribed Prepare the client for corticosteroid injections into joints as prescribed Place affected joint in a functional position Immobilize the affected joint with a splint or brace Avoid large pillows under the head or knees Provide a bed or foot cradle

OSTEOARTHRITIS
PAIN

Position the client prone twice a day Instruct the client on the importance of moist heat, hot packs or compresses, and paraffin dips as prescribed Apply cold applications as prescribed when the joint is acutely inflamed Encourage adequate rest recommending 10 hours of sleep at night and a 1- to 2-hour nap in the afternoon

OSTEOARTHRITIS
NUTRITION

Encourage a well-balanced diet Encourage weight loss if necessary

OSTEOARTHRITIS
PHYSICAL MOBILITY Reinforce the exercise program and the importance of participating in the program Instruct the client that exercises should be active rather than passive and to exercise only to the point of pain Instruct the client to stop exercise if pain is increased with exercising Instruct the client to decrease the number of repetitions in an exercise when the inflammation is severe

OSTEOARTHRITIS SURGICAL INTERVENTIONS

OSTEOTOMY

The bone is cut to correct joint deformity and promote realignment Performed when all measures of pain relief have failed Hips and knees are most commonly replaced Contraindicated in the presence of infection, advanced osteoporosis, and severe inflammation

TOTAL JOINT REPLACEMENT (TJR)

RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS CLIENT EDUCATION

Assist the client to identify and correct hazards

in the home Instruct the client in the correct use of assistive adaptive devices Instruct in energy conservation measures Review prescribed exercise program Instruct the client to sit in a chair with a high, straight back

RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS CLIENT EDUCATION

Instruct the client to use a small pillow, only

when lying down Instruct the client in measures to protect the joints Instruct the client regarding the prescribed medications Stress the importance of follow-up visits with the health care provider

OSTEOPOROSIS
DESCRIPTION An age-related metabolic disease Bone demineralization results in the loss of bone mass, leading to fragile and porous bones and subsequent fractures Greater bone resorption than bone formation occurs Occurs most commonly in the wrist, hip, and vertebral column Can occur postmenopausal or as a result of a metabolic disorder or calcium deficiency

OSTEOPOROTIC CHANGES

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

OSTEOPOROSIS
ASSESSMENT

Back pain after lifting, bending, or stooping Back pain that increases with palpation Pelvic or hip pain, especially with weight bearing Problems with balance Decline in height from vertebrae compression

OSTEOPOROSIS
ASSESSMENT

Kyphosis of the dorsal spine Constipation, abdominal distention, and respiratory impairment as a result of movement restriction and spinal deformity Pathological fractures Appearance of thin, porous bone on x-ray

DOWAGERS HUMP

From Seidel HM et al: Mosbys guide to physical examination, ed. 4, St. Louis, 1999, Mosby.

SEVERE OSTEOPOROSIS

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

OSTEOPOROSIS
IMPLEMENTATION

Assess risk for injury Provide a safe and hazard-free environment and assist the client to identify hazards in the home environment Use side rails to prevent falls Move the client gently when turning and repositioning

OSTEOPOROSIS
IMPLEMENTATION Encourage ambulation; assist with ambulation if the client is unsteady Instruct in the use of assistive devices such as a cane or walker Provide ROM exercises Instruct in the use of good body mechanics and exercises to strengthen abdominal and back muscles in order to improve posture and provide support for the spine Instruct the client to avoid activities that can cause vertebral compression

OSTEOPOROSIS
IMPLEMENTATION

Apply a back brace as prescribed during an acute phase to immobilize the spine and provide spinal column support Encourage the use of a firm mattress Provide a diet high in protein, calcium, vitamin C and D, and iron Encourage adequate fluid intake to prevent renal calculi Instruct the client to avoid alcohol and coffee

MILWAUKEE BRACE

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

OSTEOPOROSIS
IMPLEMENTATION

Administer estrogen or androgens to decrease the rate of bone resorption as prescribed Administer calcium, vitamin D, and phosphorus as prescribed for bone metabolism Administer calcitonin as prescribed to inhibit bone loss Administer analgesics, muscle relaxants, and antiinflammatory medications as prescribed

GOUT
DESCRIPTION

A systemic disease in which urate crystals deposit in joints and other body tissues Leads to abnormal amounts of uric acid in the body Primary gout results from a disorder of purine metabolism Secondary gout involves excessive uric acid in the blood that is caused by another disease

GOUTY JOINT

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

PHASES OF GOUT
ASYMPTOMATIC

No symptoms Serum uric acid is elevated Excruciating pain and inflammation of one or more small joints, especially the great toe

ACUTE

PHASES OF GOUT
INTERMITTENT

Asymptomatic period between acute attacks

Results from repeated episodes of acute gout Results in deposits of urate crystals under the skin and within the major organs, especially the renal system

CHRONIC

GOUT
ASSESSMENT Excruciating pain in the involved joints Swelling and inflammation of the joints Tophi (hard, fairly large, and irregularly shaped deposits in the skin) that may break open and discharge a yellow, gritty substance Low-grade fever Malaise and headache Pruritus Presence of renal stones Elevated uric acid levels

GOUT

From Clinical Slide Collection of the Rheumatic Diseases, 1991,1995,1997. Used with permission of the American College of Rheumatology.

GOUT
IMPLEMENTATION

Provide a low-purine diet as prescribed Instruct the client to avoid foods such as organ meats, wines, and aged cheese Encourage a high fluid intake of 2000 ml to prevent stone formation Encourage weight-reduction diet if required Instruct the client to avoid alcohol and starvation diets because they may precipitate a gout attack

GOUT
IMPLEMENTATION

Increase urinary pH (above 6) by eating alkaline-ash foods such as citrus fruits and juices, milk, and other dairy products Provide bed rest during the acute attacks Monitor joint ROM ability and appearance of joints Position the joint in a mild flexion position during acute attack

GOUT
IMPLEMENTATION

Elevate the affected extremity Protect the affected joint from excessive movement or direct contact with sheets or blankets Provide heat or cold for local treatments to affected joint as prescribed Administer NSAIDs and antigout medications as prescribed