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Common Lab tests 1. 2. 3. 4. 5. 6. 7. ESR C-reactive protein CBC Serum cultures Serum Calcium ANA Creatinine

X-rays (roentgenograms) 1. Noninvasive test in which radiation is passed through a specific body part to display a picture of the internal aspects of that part 2. Used to 1. determine shape, size and position of organs 2. indicate presence of fluid lines, foreign bodies, infiltrates 3. determine configuration, density and vascular markings of organs 4. determine injury, fracture, degeneration, inflammation, perforations, calculi (stones) or masses 5. types of x-ray 1. chest 2. musculoskeletal 3. skull 4. spine 5. mastoid 6. sinus 7. breast 8. kidneys, ureters, bladder (KUB) 3. Nursing interventions for x-ray procedures 1. instruct client about procedure 2. shield the client's genitals with lead drape 3. ask if pregnant prior and do not x-ray if pregnant 4. for chest x-ray, assist to dress in institution clothing Contrast radiography 1. 2. intravenously 3. 4. 5. motion Casts 1. 2. a. b. c. d. e. 3. a. Externally applied structure that holds bone in one position Uses immobilization prevent bone or muscle deformity support of a weakened limb promote healing permit early weight bearing on affected limb Types of casting materials plaster of paris i. natural material ii. indicated in cases of • severely displaced fractures • unstable fracture fragments iii. when multiple castings are indicated: serial casting Visualization of x-ray enhanced by using contrast medium Contrast medium may be ingested, injected through a tube or catheter or given Contrast medium may be barium, iodine, or air Cineradiography: rapid sequence x-rays that film motion Fluoroscopy: projection of x-rays onto screen for continuous observation of


4. a. b. c.

application: takes at least 24 hours to dry advantages • low allergic response • offers rigid protection • easy to apply • inexpensive vi. disadvantages • long drying time (24 to 48 hours) - gives off heat while drying (exothermic) • weight - plaster casts are heavy • materials may crumble and disintegrate at edges • not waterproof fiberglass i. synthetic material ii. indicated in cases of • non-displaced fractures • long term casting iii. advantages • light weight • easy to apply • moisture-proof • fast: dries in 15 minutes, cures in one hour • colors and patterns help client adjust to immobilization iv. disadvantages • short drying time requires speed and accuracy • more rigid than plaster; may bind if tissues swell • extra rigidity may cause tissue breakdown under the cast • more expensive than plaster castings Types of casts short arm/leg i. cylindrical cast ii. allows for flexion or extension of elbow and knee long arm/leg i. cylindrical cast ii. does not allow elbow or knee to move spica arm/hip i. support bar is applied between extremities ii. permits greater stabilization iii. cut window over epigastrium for patient comfort after eating

iv. v.


Cast application cast must extend to the joint above and below the point of fracture 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 a. b.


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


Nursing interventions: post cast application plaster of paris casts i. handle fresh cast carefully (first 48 hours) • indentations may cause pressure points under the cast • handle the cast with open palms of hands ii. do not apply pressure to the cast iii. do not cover the cast - allow to air dry iv. do not use heat to dry b. all casts i. repeated neurovascular checks • capillary refill time • warmth • color • motion checks 1. patient can move toes and fingers of affected limb 2. if not, a nerve is compressed 3. sensation: numb or tingling may mean nerve compressed ii. drainage • observe for wound drainage • record size, color, amount; and circle area on cast with felt tipped marker and date and time • check odor of drainage c. teach client i. keep cast dry and intact ii. to avoid placing any objects, powders, or lotions inside of or through cast iii. describe indications and therapeutic use of casting for immobilization iv. proper use of assistive devices v. how to assess environment for potential mobility hazards vi. to inspect cast daily for foul odor, cracks a. Nursing interventions for cast removal with a mechanical saw explain procedure to client inform client that i. cast removal is painless ii. client will feel heat and vibration iii. saw is noisy but will not cut client iv. inspect tissue under cast for signs of inflammation or infection v. if skin is intact apply lotion to moisturize skin c. teach client i. underlying skin may be scaly and dry ii. to perform range of motion exercises as ordered iii. to use moisturizing lotion on dry skin a. b.


Traction - pulling force and opposing force applied to injured extremity 1. Longitudinal - when only one force is applied 2. Traction angle - direction of the force in relation to the affected extremity 3. Countertraction - opposing force to the pull of the traction; most often is provided by the person's body weight 4. Vector force - resultant force produced when two traction forces are applied to a limb


Purposes a. reduce, realign and promote healing of fractured bones b. decrease muscle spasms c. immobilize area of body d. rest inflamed, diseased or painful joint e. treat/correct deformities f. reduce and treat dislocations g. prevent the development of contractures h. expand a joint space during arthroscopy i. reduce muscle spasms in low back pain or cervical whiplash 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 MECHANICS OF TRACTION EQUIPMENT


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 A. Maintain the prescribed line of pull 1. Especially important in patients with fractures 2. Maintain proper body alignment B. Always maintain continuous pull unless intermittent traction is prescribed C. Prevent friction 1. Friction will alter the line of pull 2. Friction will impair the traction's efficiency 3. But never lubricate pulleys D. Identify and maintain counteraction 1. Countertraction is the force opposing the pull of traction 2. Generally provided by the patient's body 3. If countertraction is not maintained the patient is not in traction 4. Sign of loss of countertraction is that the patient slides down in bed 5. Especially problematic with Buck's Traction 6. Keep bed flat 7. Elevate the foot of the bed with shock blocks E. Counter traction for pelvic traction is generally achieved by putting the bed in the William position (both knees and hips are flexed at 30 degrees)

15-40 lbs. overriding or comminuted fractures 2. types of skeletal traction • balanced suspension 1. i. . d. limitation: can apply only five to seven lbs. loading force vi. used for displaced. types of skin traction c. static traction b. iv. preoperative treatment prior to surgical pinning 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. iii. tongs used for cervical fractures preoperatively a. continuous traction pull c.iii. ii. v. must remove traction and perform skin care skeletal traction traction applied directly to the bone \ pins are placed through the affected limbs and attached to pulling force can be tolerated for longer periods . complications • skin breakdown • detachment of traction device v.up to four months greater weight can be used . dynamic traction iv.

hip/knee/ankle/foot (HKAFO) iv. presence/absence of edema b. braces designed to prevent deformity. medical asepsis with open skin g. perpendicular to the ends of the bed 3. ankle/foot (AFO) ii. color b. a wooden or metal staff b. types of orthotic i. types i. muscle weakness 4. osteomyelitis Patient positioning for traction 1. signs of infection f. a trapeze for client to shift position and upper range of motion provided Nursing interventions a. e.d. beware of immobility's multi-system effects j. intermittent application of traction straight traction running Complications 1. head of the bed is flat or semi fowlers (maximum of 20 to 30 degrees elevation) 5. may be temporary or permanent d. skin breakdown 3. knee/ankle/foot (KAFO) iii. increase efficacy of gait. provide diversional activities 7. walker 1. administer appropriate medications i. sensation e. cane. skin assessment i. f. Prosthetic: artificial limbs for all extremities 3.IX d.motion d. affected limb in proper body alignment 4. explain procedure to client / assess neurovascular status of affected area/limb at least every four hours a. infection at pin site 2. crutch. thoracolumbar or sacral (TLSO) 2. used when no or minimal weight bearing is desired c. remove Buck's traction boots every two hours to inspect skin integrity iii. Orthotic a. temperature c. supine 2. Crutches a. pin assessment: observe for drainage. axillary: a padded curved surface at top which fits under the axilla and a crossbar forms the handgrip . high risk for developing pressure sores ii. 8. prosthetic. Mobilization devices: orthotic. skeletal cervical or halo traction: assess cranial nerves III . encourage involvement of family members l. control alignment and/or promote ambulation b. 7. assess pressure areas every two hours e. allow patient to verbalize fear and concerns k. maintain principles of traction h. always compare affected limb to unaffected limb for baseline measurement c. pulse quality f.

• 4. wear stable shoes. assess environmental risks f. resize device as children grow j. don't look at your feet. assess client's readiness including muscle strength and range of motion c. b. electric 7. 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. Canes: straight-legged. remember "up with the good. teach client i. provide emotional support i. quad. May have rollers instead of tips. Walkers a. findings of complications iii. measure client's height. g. chair. how to troubleshoot equipment for defects. and follow with the unaffected "good" leg. Wheelchairs: manual. safety is prime issue d. look ahead vi. nurse should stand close to client during initial attempts at using mobilization devices.for axillary crutches. shower. lead with the affected "bad" leg. Nursing interventions with mobilization devices a. down with the bad. To go down stairs. lead with the unaffected "good" leg. need rubber tips. client moves the walker forward and steps into it. then moves it forward again c. car v. distance between crutch pad and axilla. signs of wear vii. how to maneuver on and off toilet. and follow with the affected "bad" leg. extremely light devices that have four widely placed legs and handgrips on an upper bar. explain procedure to client b. maneuver on various surfaces iv. tub. use a gait belt for maximum support h. forearm (Lofstrand): an adjustable metal band that fits around the forearm with an adjustable handgrip For client to navigate stairs with crutches. caution should be used to avoid overloading client's personal item baskets 6." To go up stairs. observe client initially for orthostatic hypotension e. proper use of device ii. how to climb stairs. all need rubber tips 5. same heel height as when device fitted . distance from axilla to client's heel.

anchors muscles c. Bone 1. Anatomy and Physiology A. supports and protects structures of the body b. 2. participates in the regulation of calcium and phosphorus Joints .I. Functions a. some bones contain hematopoietic tissue which forms blood cells d.

enclosed cavity containing a gliding joint synovium . b. amphiarthrosis. diarthrosis 3.lining of joints which secretes lubricating fluid that nourishes and protects classification of joints .synarthrosis. Cartilage .a. bursa . c.connective tissue covering the ends of bones .

periosteum b. external structure .medullary cavity. Types . B.4. internal structure of bone . d. c.diaphysis.ankles. wrists flat . long . arms i. epiphysis. vertebrae ii.legs. cancellous bone. Muscles . red marrow short . Types of bones a.face.shoulder blades irregular .produce movement of the body 1.

acute: recent injury to muscle or tendon. Management a. Definition . Etiology and pathophysiology a.a fall or blow breaks capillaries but not skin 2.controlled by voluntary nervous system b. striated . Pathophysiology . overexertion.lesser injury of the muscle attachment to the bone 2. Strains. three times a day b. feels stiff.fibrous tissue between muscles and bones Ligaments . B. sore locally .controlled by autonomic nervous system c. Findings .extravasation (bleeding) under skin 3.controlled by autonomic nervous system Fascia . apply ice for 15 minutes.surrounds and divides muscles Tendons . wrap to compress 5. D. Definition . Resolution: should heal within seven to ten days 6. smooth . cardiac . Sprains A.ecchymosis (bruise) and pain when the contusion is palpated 4. classified by degree i. a. for first 24 to 48 hours. E.fibrous tissue between bones and cartilage. first degree: mild. supports muscles and fascia Contusions (bruise) 1.C. then apply heat if necessary c. Strains 1. Trauma: Contusions. gradual onset. or misuse of muscle b.yellow after three to five days to a greenish . Color changes from a blackish . caused by overstretching.

analgesics. minimal tearing of ligament fibers ii. increased pain v. exertion or trauma 2. Chronic strain a. Definition . pain increases with palpation or weight bearing vii. no weakening of joint structure . delayed ecchymosis b. mild weakening of the joint and loss of function vi. snapping or burning sensation a. keep limb elevated ii. then moist heat iii. management of acute third degree strain i. 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. assessment of acute third degree strain i. medication . up to half of the ligamentous fibers torn ii. NSAIDS o physical therapy for strength and range of motion 3. physical therapy for strength and range of motion 4. long-term overstretching of muscle/tendon b. Sprains 1. sudden.muscle relaxants. either immobilize or limit mobility of the limb iv. decreased active range of motion iv. ecchymosis later • management of acute second-degree strain o keep limb elevated o apply ice for the first 24 to 48 hrs . second degree: moderate stretching.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. second degree sprain i. management • . injury to ligament structures by stretching. joint tenderness iii. mild discomfort at location of injury vi. no loss of function iv. first degree sprain i.then moist heat o limit mobility. Third-degree: severe stretching with tear. ace wrap o muscle relaxants. Classification/findings/assessment/management a. analgesics. localized edema or hematoma iii. elevate ii. muscle spasm ii. repeated use of the muscle beyond physiologic limits C.joint integrity remains intact v. edema (may be extreme) iv. sudden onset. increased edema and possible hematoma iii. client cannot move muscle voluntarily v. NSAIDs v. apply ice for 24 to 48 hrs. possibly immobilize for short term.greater than strain. 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.

Unrestrained driver a. knee/femur d. results in both entry and exit wound d. Motor response iv. Last meal • see second degree treatment E. Swelling C. VII. gunshot/missile type injuries b. injuries to opposing ligaments 3. VI. Vascular injuries D. Child/pedestrian injuries "Waddell's triad": a. shock waves throughout body Findings of trauma A. source of infection: when energy travels it leaves a vacuum behind it. Eye opening iii. protectively dress/splint the joint. Paresthesia F. Breathing c. Massive open comminuted fractures B. bilateral Colles' fractures d. II. Events preceding the injury D. Fractures: classification and diagnosis Life threatening injuries of extremity A. point of impact with the car hood c. Verbal response dramatic decrease in active range of motion C. loss of joint integrity and function A. management B. complete rupture of the ligamentous attachment Cognitive level: glasgow coma scale ii. Sustain life B. point of impact with the car bumper b. . severe edema with hematoma A. Pain D. to reduce transmission of nerve impulses and conduction velocity to decrease pain o moist heat 1. III. head b. VIII. point of impact where the body is thrown 2. Crush injuries of the abdomen or pelvis E. IV. Injuring agent: sharp or blunt instrument C. Predictable musculoskeletal injuries 1. to produce vasoconstriction to decrease swelling 2. Absent pulses Goals of nursing care A. point of impact with the car bumper b. Past illness • surgery to restore integrity of joint D. Bilateral femoral shaft fractures C. point of impact with the car hood c. Ask about: A-M-P-L-E v. Circulation i. Paresis/paralysis E. Allergies vi. to reduce swelling and provide comfort ASSESSMENT AND EARLYanalgesics for discomfort MANAGEMENT OF THE TRAUMA CLIENT • Primary survey: ABC • physical therapy to increase circulation and maintain A. Decrease pathology B. compression fracture of vertebrae 5. Preserve appearance Goals of rehabilitation A.I. bilateral calcaneal fractures b. Maintain function C. larynx and sternum c. Deformity/angulation of extremity B. Traumatic amputation of the arm or leg Mechanism of injury A. Blast injuries a. Increase function of unaffected and affected systems • • • V. severe pain B. Prevent secondary disabilities C. Pallor G. hyperflexion of the lumbar spine c. alternate o ice 1. Adult/pedestrian injuries a. third degree sprain C. drawing in debris/body hair c. Fall from a height (Don Juan syndrome) a. usually. Medications • casting C. Airway maintenance with spinal cord control -the cartilage nutrition to cervical stabilization B. posterior hip dislocation 4. Force: amount of energy transferred from one object to human body B. immobilize it elevate the limb to decrease edema for 24 to 48 hours.

Fracture dislocation a. complete (bone broken in two or more pieces) b. fracture will not heal completely 3. subdivided by degree of soft tissue injury 5. does not break skin b. bone fragments break through skin ii. By wound a. open = compound = complex i.1. injures soft tissue and often infects tissue iii. incomplete (bone broken but still in one piece) 4. a fracture in which the joint is dislocated in that position. By completeness a. closed = simple. Definition: fracture is any alteration in the continuity of a bone 2. By fracture line .

articular . d. injures soft tissue severely c. rapid union occurs f. oblique is produced by a twisting force.from repeated trauma • insufficiency . c. apophyseal b. spiral also results from twisting force. often seen in the lumbar spine ii. cortex stays intact on the side subject to tension forces and fractures on the opposing side v. Classification by location in the bone a.pathological fracture 7. results in two or more bone fragments iii. and requires traction or internal fixation. longitudinal = linear fracture b. 6. direct force breaks bone and telescopes the fragment with the smaller diameter into the fragment with the larger diameter ii. result of repetitive trauma to region iii. comminuted fractures i. common in pathological fractures. greenstick fracture i. requires reduction or completion of the fracture line through the cortex e. two types: • fatigue . transverse is caused by angulation. results from a direct force on the bone b. and generally stable after reduction. may accompany damage to soft tissue. splinters the fragments iv. impacted fractures (telescoped) i. caused by • compression forces • angulation forces iii. incomplete fracture ii. may be pathological (a disease weakens bone) d. and requires traction to heal properly. produced by high energy forces ii. results in an incomplete fracture ii. compression fractures i. stress fracture i. avulsion fractures i. By type of fracture a. bone fragments and soft tissue are pulled away from the bone ii. cortex of the bone bends to one side and buckles on the other iv.a. fracture fragments move in unison iii.

Immobilization a. extracapsular h. supracondylar 2. Ilizarov devicenecrosis occurs distal to thecm per month. Granulation tissue teach clients Before discharge. Delay at this stage delayed union or nonunion of bone 8. Hematoma formation Tension wires are inserted into the bone and then attached to rings outside the body. minimal pain. purposes: realign bone fragments for healing. intraarticular i. hormonally controlled ii. manual: applied by pulling on the extremity . diaphyseal f. C.2. fractures occur in response to minimal or no applied stress c. Granulation material is matured into a callus d. Develop collagen i.may be used during E. force . Blood clot forms around the fracture site turn. The gap in the bone is bridged and union occurs V. Closed reduction a. infection.c. periarticular l. formation A. intracapsular j. condylar d. Begins three days to two weeks after fracture To care for pin B. Size and shape of callus in direct response to the amount that follows) D. b. Callus formation iii. client's age 7. Daily adjustment of the rods causes the wires to B. From damaged connective tissue D. minimal deformity. open treatment (see orthopedic surgeryof displacement of fracture fragments C. local: neoplasm. subperiosteal m. biologic i. Three weeks to six months B. Intrinsic factors . which stimulates bone formation.1. classification by cause: general or local disorder i. methods: cast .used to align fracture B. skin: applied by pulling force through the client's skin . Fracture line may still be evidence on radiographs . splints. Osteoblasts c. Clients may have the device on for several months. Osteoclast formation in fibrous matrix of collagen To adjust rod C. keep bone fragments from moving b. Predisposing factors a. Fractures: management 6. bone is weakened by disease b. cortical e. types of traction 1.bone capabilities 9. general: developmental. Six weeks to one year B. From outer layer of the periosteum 2. Fibroblasts E. relieve pain ii. pre. Two to six weeks bone . Pathological fractures a. skeletal: applied directly through pins inserted into the client's A. Vascular and mechanical factors affect healing cast application 1. Motion ii.B.high-risk activities (such as football. cystic lesion 10. braces. Ossification A. I. Stages of bone healing IV. Fractures: pathophysiology 6. metaphyseal k. Consolidation /remodeling A. ballet) 3. Extrinsic factors a. 1. epiphyseal or skeletal. Callus becomes calcified and blends into the bone C. and external fixation External Fixator: Ilizarov Device A. bone density or indirect b. Bone lengthens limbs about one fracture site due C. nutritional.D. These rings are A. Distraction of fracture fragments spasm relax the muscle III. Phagocytosis breaks down and removes the formed hematoma E.synthetic or plaster. From the periosteum and marrow cavity 2. The Ilizarov device is a specialized type of external fixator used for non-union fractures and limb STAGES OF BONE HEALING lengthening needed due to congenital deformities. traction .and post-reduction x-rays are essential to determine successful reduction of fracture 7. to a loss of blood II. Behavioral factors .used to 2. purposes i. One to three rods joined by telescoping days attached to a rigid frame. rate of loading (how fast the force strikes) 8.

hematoma formation b. clinical evidence of fracture overrides negative x-ray analysis d. Bone scan . two dimensional representation of the bone and soft tissue b. will also offer evidence of i. radiographic 3. Magnetic resonance imaging (MRI) scan . include joints above and below suspected fracture c.specialized tomograms a. bone density (in advanced cases of osteoporosis) 2. Radiographs a.DIAGNOSTIC IMAGING 1. Evidence of healed fracture a. ossification e. infection c. callus formation d.increased uptake of contrast may indicate a.clearer views of soft tissue structures 4. fibrocartilage/granulation tissue formation c. consolidation/remodeling 9. bone pathology ii. Computerized tomogram (CT) scan . fracture b. tumor growth .

may require incision and drainage of wound or removal of prosthesis if severe infection is present G. 6. Special complication in knee replacement: flexion failure 1. treatment will be immobilization or open reduction with internal fixation 2. Immediately after operations a. diagnosis is confirmed with x-ray e. b. greatest risk during the first postoperative week but can occur at any time within the first year. findings include pain and external rotation of the leg e. Fat embolism complications 1. May be causedi. Findings include erythema and swelling around suture line. Treated with closed manipulation of the knee joint under general anesthesia . insertion of intermedullary rods 3.ORTHOPEDIC COMPLICATIONS A. If PE is suspected. Continuous G. Fractures: D. Get charge nurse to notify health care provider i. Treated with antibiotics. Deep venous thrombosis (DVT) 1. Special complications in hip replacement 1. Findings include calf pain. inflammation of a vein with the formation of a blood clot b. sudden shortness of breath. femoral vein of external callus or cortical bone across the without by presence manipulation during surgery and therefore occur fracture signs of DVT site 5. Pulmonary embolism (PE) 1. depending on severity. primary finding is severe pain with ambulation d. Deep wound infection may lead to osteomyelitis 3. joint replacements e. risk decreases as muscle tone of the hip increases c. Femoral fracture a. Associated with a. Definition: fat cells enter pulmonary circulation 2. pieces of bone no longer move at fracture site immediately ii. occurs more frequently with elderly. Most common in fractures of bone marrow producing bones F. occurs near distal end of femoral-shaft part of prosthesis b. Occurs in approximately ten percent of patients undergoing hip arthroplasty 4. May be superficial or deep wound 2. or after revision to total hip replacement c. Findings include chest pain (pleuritic). Client cannot flex knee 90 degrees two weeks postoperatively 2. fracture line may remain long after healing not leave client. antiemboli stockings (usually) c. Dislocation of hip prosthesis a. no tenderness over fracture site 7. tachycardia. multiple trauma accidents b. Anterior tibial or femoral veins 2. increased drainage and elevated temperature 4. treated by closed reduction under conscious sedation or open surgical revision H. Most commonly seen after hip fractures and total hip/knee replacements 3. incidence is greatest after trauma or surgery to legs or feet B. sequential compression device (possibly) C. Wound infection 1. Usually occurs 24 to 48 hours after the fracture E. Thrombophlebitis (TP) a. caused by flexion of the hip or poor prosthetic fit d. multiple organ involvement c. IV heparin therapy usually prescribed weight bearing is pain free 8. Hemorrhage 1. Venous thromboembolic problems 1. May be caused by immobility 3. positive Homan's sign 4. fractures of marrow producing bones d. Blood clot from systemic circulation enters pulmonary circulation 2. clinical or change in mental status b. anticoagulant therapy b. Diagnosis confirmed via ventilation/perfusion scan or pulmonary angiography c. clients with osteoporosis. Abnormal loss of blood from the body 2. ii.

post-traumatic arthritis (osteoarthritis. pulmonary embolism .a nursing emergency d. reflex sympathetic dystrophy i. myositis ossificans i. Delayed complications a. Immediate complications of the injury a. forms in response to trauma iii. elevate limb above level of heart (except with compartment syndrome) . hypertrophic bone is removed when bone is mature e. delayed union i. deep venous thrombosis (DVT) e.1.occurs after the initial 24 hours from the injury c. Nursing interventions 2. compartment syndrome . shock . fracture does not heal ii. malunion i. painful dysfunction and disuse syndrome ii. check neurovascular status often b. fracture healing is not stopped but slowed ii.higher risk with pelvic and femur b. type II) c. Risk for peripheral neurovascular deficit a. no evidence of fracture healing four to six months after the fracture g. more common with multiple fracture fragments iii. prevention of malunion • reduce and immobilize properly • be sure client understands limits on activity and position f. joint stiffness b. fat embolism . refracture 2.a complication of DVT 2. loss of adequate reduction h. characterized by abnormal pain and swelling of the extremity d. formation of hypertrophic bone near bone and muscles ii.

pad any bony prominences c. open fractures ii. soft tissue injuries iii. additional factors i. why the fracture is being immobilized c. interventions i. mobilize as soon as possible ii. open fractures ii. Compression occurs of the vessels and nerves c. Acute: 1. II. Internal forces: compartment content increases. Results in necrosis of the tissue B.increased pressure in a limited space (muscle compartment) cramps the circulation and function of the tissues within that space Types: acute and chronic (or exertional) A. related to i. mobilize the client as soon as possible ii. . how bones heal e. manage pain i. position the client properly with alignment in mind iv. frequent and effective pulmonary toileting III. teach relaxation techniques 4. Ischemia-edema pathology cycle B. reposition client iii. space does not 4. May develop rapidly or for up to six days after initial trauma E.when exercise of a limb raises intracompartmental pressure and produces pain and neurologic deficits Pathophysiology A. Following trauma to the muscle 2. monitor for findings of infection c. with drugs ii. A nursing emergency F. neuromuscular damage irreversible C. assess level of pain with a scale of one to ten b. surgical intervention iii. interventions i. apply cold to minimize edema 3. Definition . client risks deep venous thrombosis d. turn the client often at least every two hours iii. preexisting skin conditions or diseases c. how to bear weight and how much (if permitted) d.COMPARTMENT SYNDROME I. If cycle lasts more than six hours.elderly ii. Duration of 24 to 48 hours: extremity may be paralyzed D. how fractures heal b. Risk for impaired skin integrity a. administer antibiotic therapy as indicated 6. Pain a. causes i. External forces: casting/bracing compresses limb 3. accompanies chest trauma b. provide proper wound care d. how to use assistive devices to walk 5. Chronic/exertional . pressure areas b. use orthopedic devices to limit skin impairment 7. age . Risk for infection a. client risks fat embolism c. general condition of client iii. Client teaching a. Impaired gas exchange a. superficial/deep wounds b.

Secondary (Traumatic) Osteoarthritis abnormal distribution of stress on the joint 3.III. interphalangeal joints II. Degenerative Disorders B.degeneration of the 4. b. Family history of degenerative joint disease 3.. Genetic may begin as shown by the presence of by age 70. despite treatment 2. OA affects twice as many women as men b. Osteoarthritis (OA) 3. elbows c. Etiology 3. localized: no in men 6. Findings cervical and lumbosacral joints primarily involves weight-bearing joints c. not necessarily both knees) C. Etiology II. Develops in middle age and progresses slowly Definition . More often affects certain joints articular cartilage and formation of new bone in the weight-bearing joints a. lax ligaments b. over age 55. Hands non-inflammatory disorder III. Do not affect the joints symmetrically (e. Bouchard's Nodes V. early as the 20s and peaks in the 60s 1. Definition 1. Incidence a trauma to the articular cartilage A. Joint abnormality a. I. . Slowly progressive disorders of articular cartilage and subchondral bone 2. most common form of arthritis B. Risk factors for traumatic osteoarthritis 1. results in an II. nearly a. More common in women (slightly) 4.g. two types: primary and secondary 2. Lifestyle: certain occupations predispose to secondary OA. No known cause III. Eventually incapacitate. Obesity 2. Localized OA in one or two joints 1. Fractures: factors that affect healing Types of Osteoarthritis (OA) Primary (Idiopathic) Osteoarthritis A. physical activity b. Underlying condition: I. More common in Caucasians B. injury 4. 1. congenital hip dysplasia 5. more affected in women after menopause 5. shoulders C. subchondral margins of the joint 2. predisposition. Hips are more affectedsystemic effects IV. Worsen progressively 1.3. More common in men 3. Generalized OA in three or more joints. Heberden's Nodes 80% of afflicted people show findings IV. 2. I. Often occurs in a. Excessive joint wear a. Classifications A. wrists b.

c. varus deformity: bow legged appearance d. bone beneath cartilage hypertrophy and osteophytes form at joint margins IV. matrix synthesis and cellular proliferation fail II. flexion contracture i. contracture in adduction and flexion decrease in internal and external rotation limb shortening referred pain to the i. d. articular cartilage is worn away II.4. push the patella laterally with the leg in full extension ii. valgus deformity: knock-kneed appearance e. b. knee ii. stage three: bone remodeling I. cartilage may be digested by an enzyme in the synovial fluid III. condyles of bones rub together: joint swells and is painful III. decreased range of motion b. result: joint degenerates 5. groin iii. Hip a. Knee a. prostaglandins may accelerate degenerative changes II. Findings OSTEOARTHRITIS OF HIP/KNEE: SPECIFIC PHYSICAL FINDINGS 1. positive apprehension sign i. knee c. client will stop the examiner from pushing the patella further . eventually the full thickness of articular cartilage is lost III. cartilage loses cushioning effect: joint friction develops IV. hip ii. Pathophysiology I. thigh 2. stage one: microfracture of the articular surface I. erosion of cartilage II. stage two: bone condensation I.

e. typically worse with action. c-reactive protein b.positive bulge sign may be found g. joints are blocked by osteophyte. A. purified protein derivative (PPD) i. joint in women than men Increase in frequency with age f. B. may involve widely separated areas of the joint ii. joint stiffness after periods of rest b. clients testing positive for tuberculosis must receive INH at same time as steroid. crepitation. mild synovitis may be felt . i. repeat every six months d. pain in a movable joint. especially in older clients. analyze before starting NSAID therapy ii. spurs form and synovitis sets in. analyze before NSAID therapy ii. Heberden's nodes HEBERDEN'S NODES Bony osteophytes at the DIP joint Common presentation of OA in the hand Indicates a strong hereditary tendency Seen more often in women than men (ten times) ii. joint enlargement: bones grow abnormally. gait i. to rule out autoimmune disorders i. Bouchard's nodes BOUCHARD'S NODES A. paresthesia d. analyze before starting steroids ii. antinuclear antigen (ANA) titer i. sedimentation rate ii. abnormal antalgic gait ii. Accompany Heberden's nodes Found at the PIP joint Occur more often deformities e. D. D. kidney and liver i. shortened stance iii. tenderness on palpation i. CBC i. C. C. relieved by rest c. loose bodies iv. shortened step length 6. may be lower in the elderly . crunching when joints are moved v.a. within normal limits c. joint surfaces no longer fit ii. eventual ankylosis i. widened base of support iv. B. pain on passive movement h. muscles spasm and contract iii. rheumatoid factor iii. Diagnostics a. limitation in active range of motion because i.

physical or occupational therapist may be helpful iv. g. joint loses space asymmetrically because cartilage narrows from production of osteophytes or bone spurs v. weight-bearing condition ii. activity (rehabilitation) ii. exercise patterns ii. shows the prime sign of OA: joint space narrowing iii. rest (protection) 2. activity and rest management i.weight reduction c. x-ray does not necessarily reflect severity of disease iv. synovial fluid analysis distinguishes osteoarthritis from rheumatoid arthritis. taken in standing. counseling about maintaining a normal weight b. Management: conservative treatment a.ii. bone scans i. nutritional management . education should cover i. monitors complications of joint replacement surgery i. nutritional assessment iv. preservation of joint motion through a balance of 1. MRI scans show the extent of joint destruction j. passive range of motion exercises . shows skeletal distribution of osteoarthritis iii. radiographs i. radionuclide imaging ii. spontaneous fusion h. individualized activity rehabilitation program iii. does not necessarily prove a connective-tissue disease f. later stages may show bony ankylosis. computerized tomograms (CT) scans show cortical and cancellous bone density 7. relaxation techniques iii.

Used only after NSAID therapy fails to achievemay lead to ulcers and bleeding ii. reduce b. take medication on empty stomach . Side effects diarrhea a. eye protection from further injury by splinting or bracing exam every four to six months d. alteration in taste sensation c. disadvantage: GI problems relief 3. inhibit prostaglandin formation 4.most often recommended penicillamine 1. adrenocorticosteroid injections b.REMISSION-INDUCING MEDICATIONS IN ARTHRITIS A. Nursingd. GI irritation c. advantages: relatively safe and inexpensive 2. Antimalaria drug 2. slow cumulative effect ii. remissive agents implications a. monitor hepatic and renal function Medication C. For use in severely destructive RA 3. retinal changes c. Penicilliamine is more toxic than gold salts iii. Hydroxychloroquine 1. aspirin . Gold salts and a. nonsteroidal anti-inflammatory medications (NSAIDs) a. Slow acting drugs .take several months to show results B. may cause GI bleeding or gastric ulcers or cramping with 5. Side effects a. depression of bone marrow 4. active stretching a. GI irritation b. appropriate skin care c. 8. Nursing implications v. Antirheumatic i. continual evaluation of renal/hepatic function b. Suppresses inflammation b. b. remission inducing pain and inflammation i. urticaria 6.

canes 2. no scatter rugs at home ii. ii. Home care considerations in arthritis a. biofeedback iv. therapeutic massage iii. Surgical management a. walkers 3. assistive devices i.i. relaxation techniques 10. iii. splints and orthotic devices b. night light. safety measures i. total joint replacement 11. arthrodesis b. hypnosis v. gold penicillamine (cuprimine) hydrochloroquinine (plaquenil) 9. referral to agency and support group . grab bars 5. well-fitted. handrails in stairways v. assistive devices 1. osteotomy d. supportive shoes iii. management of surgical pain by patient controlled analgesia pumps c. handrails at stairs and bathtub or shower iv. walkers b. Nonmedication assistance a.the use of one's imagination to acheve relaxation and control ii. canes ii. arthroplasty c. non-traditional techniques i. elevated toilet seats 4. guided imagery .

leprosy g. fusion of the involved joint Nursing interventions a. 4. laboratory analysis of synovial fluid i. widened. low protein content iii. inspection: foot is everted. expected outcome: preserve the joint b. 6. tertiary syphilis d. eight to 12 weeks to decrease swelling ii. surgical management: arthrodesis i. braces and splints b. chronic destructive arthritis of the foot ii. Etiology a. conservative treatment i. multiple sclerosis h. education can prevent further injury c. braces ii.C. soft tissue swelling iii. fluid is non-inflammatory ii. no hemorrhage noted b. subchondral sclerosis iii. severe destruction of the articular cartilage. 5. leads to minimal joint deformity and a functional painless foot . peripheral neuropathies e. 3.multicausal degeneration and deformation of joint. and shorter than normal b. prolonged immobilization i. protection from overuse/abuse ii. radiographs i. long term intra-articular steroid injections Findings a. Definition . pain secondary to inflammation Diagnostics a. syringomyelia results in Charcot's joint of the shoulder c. examination i. orthopedic shoes d. usually ankle. treatment of choice for unstable joints ii. diabetes mellitus leading to foot neuropathy b. joint instability ii. 2. Charcot joints (also called neuropathic joint disease) 1. protection of the joint i. spina bifida with myelomeningocele f. fragments of bone and cartilage in joint Management a.

isotonic b. tibial tubercle elevation iii. quadriceps setting . follows a knee injury 2. 4. minimal joint effusion V. hamstrings . MRI Scans IV. nonmedication assistance: application of ice or moist heat d. 3. mild swelling III. patellectomy 7. 60 degrees and 90 degrees of flexion II. Definition: progressive. arthrotomy i. excessive quadriceps angle IX. arthroscopy (see Orthopedic Surgery section that follows) c. radiographs I. occasional episodes of buckling of the affected knee IV. Nursing interventions (see previous Osteoarthritis section) . sunrise views with the knee in 30 degrees. Etiology I. underdevelopment of the quadriceps muscles Findings I. bone Scans III. activity restriction 6.isometric ii. progressive resistive exercises i. degenerative softening of the bone. realignment of proximal and/or distal soft tissue ii. lateral subluxation of the patella (kneecap) II. crepitation upon range of motion Diagnostics I.D. inverted 'J' tracking of the patella in the final 30 degrees of extension VIII. indicated if findings remain after six months of conservative treatment b. Chondromalacia patellae (also called patellofemoral arthralgia) 1. Surgical management a. Conservative management a. arthroscopy 5. pain with flexed knee activities (poorly localized) II. evidence of 'squinting kneecaps' VI. atrophy of quadriceps VII. anterior posterior (AP) and lateral views are not helpful II. positive apprehension sign X. direct or repetitive trauma to the patella produces chondral fracture III. medication: NSAIDs c.

destruction of subchondral bone III. heart. Prominent joint margins erode 2. Synovial membrane thickens E. or skin 4. general signs i. may affect the connective tissue of the lungs. or viruses IV. warm. present in 85 to 90% of all cases IV.will lead to ankylosis of joint 6. painful. RF factor in serum reacts against immunoglobulin G B. Findings I. Bony ankylosis 3. Pannus 1. starts in feet and hands. inflammation and effusion that will be • symmetrical • polyarticular c. Fibrous adhesions 2. kidneys. rheumatoid factor (RF) I. Inflamed synovial membrane C. worsens the inflammatory response . cause is not fully understood II. Definition . in late RA.reactive hyperplasia iii.IV. Fusion of opposing joint surfaces 5. two to three times more common in women than in men II. bony ankylosis ii.can go on indefinitely V. in early RA joints will be i. affects diarthroidial joints III. Incidence I. genetic tendency. Erodes surface of articular cartilage D. Inflammatory Disorders A. Findings a. Pathophysiology DISEASE PROCESS IN RA: RHEUMATOID FACTOR (RF) A. Joint contractures I. red. Shortens tendon sheaths 6. Rheumatoid arthritis (RA) 1. IgB antibodies are formed II. strikes between the ages of 20 and 50 years of age 5. gradually destroys these peripheral joints II. Manifestations . Vascularized fibrous scar tissue (pannus) 2. rheumatoid arthritis is an autoimmune disorder III. swollen at capsules and soft tissues iii. irreversible . synovitis immune complexes initiate inflammatory response I. loss of appetite and weight iii. joints will show i. adhesions iv.chronic systemic inflammatory disease of the connective tissue 2.early 1. fatigue ii. incapable of full range of motion b. bilateral involvement 3. pannus formation II. but may involve bacteria. Joint destruction 4. destruction of joint . Etiology I. stiff ii.late 1. Manifestations . enlarged lymph glands .

physical assessment should also include i. firm. accurate patient history .d. presence indicates poor prognosis e.history may include • malaise • fatigue • weakness • loss of appetite and weight • enlarged lymph glands • Raynaud's syndrome ii. elevated ESR . examination may reveal deformities • ulnar deviation • deformed hands: swan neck/boutonniere f. Diagnostics a. laboratory analysis i. oval. in 20% of cases ii. rheumatic nodules i. nontender masses under the skin iii. foot drop ii. neurological examination i. evidence of spinal cord compression 7.

immunosuppressive agents i. sulfasalazine (Azulfidine) f. more white blood cells than normal 8. adalimumab (Humira) iv. positive rheumatoid factor (RF) b. biological response modifiers (BRMs) i. NSAIDS (see Osteoarthritis) b. antigen stimulates antibodies. cyclophosphamide (Cytoxan. Systemic lupus erythematosus (SLE) 1. cloudy appearance ii. psychological support i. bony erosion ii. Asians. deposited in tissues. methotrexate (Rheumatrex) (most commonly used) d. II. infliximab (Remicade) iii. the intensity and location of the inflammation reflects findings and organs involved. azanthioprine (Imuran) ii. decreased joint spaces iii. inflammation creates findings I. Definition: chronic. hydroxychloroquine sulfate (Plaquenil) c. and Native Americans are two to three times as likely as whites to have lupus III. 2. aspiration of synovial fluid. most cases are women II. immune complex inflames tissue. positive antinuclear antibody in 20% of cases v. radiographic studies i. clients with central nervous system or renal involvement have poorer prognosis . Procytox) iii. etanercept (Enbrel) ii. Hispanics. IV. Management a. anakinra (Kineret) h. systemic. inflammatory disease of the collagen tissues ii. number of T suppressor cells dwindles. leflunomide (Arava) g. splinting: resting. Etiology unknown I. iii. African Americans. fusion of joint c. which form soluble immune complexes. correction or fixation B.decreased RBC positive C-reactive protein iv. prednisone e. analysis shows i.

Findings: SLE is present if client has four or more of these: a. medical 1. expected outcomes 1. oral ulcers f. primarily affects men b. serositis: pleuritis g. renal disorder: persistent proteinuria h. involving two or more peripheral joints b. strategies to combat weight loss c.3. prevent bad effects of therapy c. peak incidence 40 to 60 years of age c. monoarticular asymmetrical arthritis b. antinuclear antibody: abnormal titer of antinuclear antibody by immunofluorescence or equivalent assay l. familial tendency . Definition a. corticosteroids 4. control system involvement and symptoms 2. pain management strategies b. Management a. hematologic disorder: hemolytic anemia with reticulocytosis or leukopenia j. anti-infectives e. characterized by hyperuricemia b. salicylates 2. neurologic disorder: seizures or psychosis in the absence of drugs or pathology i. emotional support C. Gout a. photosensitivity e. malar rash: characteristic butterfly rash over cheeks and nose c. tenderness and effusion. Etiology a. nonsteroidal anti-inflammatory agents (NSAIDS) 3. arthritis: characterized by swelling. antineoplastics 5. recognize flare-ups promptly d. positive LE cell reaction 4. Nursing care a. discoid lupus skin lesions d. induce remission b. immunologic disorder: positive LE (lupus erythematosus) cell preparation or anti-DNA or anti-Sm or false positive serologic test for syphilis k.

d. sardines. expected outcomes: control symptoms.enhances the excretion of uric acid 3. elevated temperature c. increased urinary uric acid following a purine restricted diet b. muscle weakness III. NSAIDs 2. heat or cold therapy c. shellfish. tight. a high purine diet. possibly inadequate exposure to sunlight I. systemic manifestations may include fever. warning signs of flare-up include the exacerbation of previous findings or the development of a new one h. Findings I. vitamin D deficiency. administer anti-gout medications as ordered f. reinforce dietary management and weight control e. wide stance III.delayed mineralization. legumes 2. gait I. stress (both psychological and physical) or suddenly stopping of maintenance medications g. reddened skin over the inflamed joint b. elevate the affected limb. physical examination I. avoid purine foods such as meats. tophus d. less serum calcium than normal II. hyperuricemia e. Definition . dietary 1. colchicine (used when NSAIDs are contraindicated) . Pathophysiology .similar to rickets I. generalized muscle and skeletal pain in hips II. yeast. avoid pressure or touching of bed clothing on affected joint d. to prevent flareups: antihyperuricemic agents such as allopurinol (lopurin) or probenecid (benemid) . accurate client history includes: I. acute attacks commonly begin at night and last three to five days f. provide bed rest and immobilize joint c. client unwilling to walk II. e. Management a. hyperuricemia e. renal disease. waddling gait II. bones have too little calcium and phosphorus II. increase fluid intake to prevent renal calculi (kidney stones) V.all types f. drink less alcohol . deformities of weight-bearing bones . more renal phosphorus clearance 3. organ meats. more parathyroid hormone III. pain management strategies b. gout attacks may follow trauma. Metabolic Bone Disorders A. bones I.minimize the production of uric acid 4. prevent attacks b. deposits are most often found in the metatarsophalangeal joint of the great toe or in the ankle. resulting bone is softer and weaker 2. increased alcohol consumption. c. control weight 3. diuretics. Osteomalacia 1. edema of the involved area d. abnormal purine metabolism or excessive purine intake results in formation of uric acid crystals which are deposited in the joints and connective tissue. Findings a. similar pain in low back II. Nursing care a. anchovies. Diagnostics: lab test findings a. medical 1.

types I. decreased serum phosphorus III. generalized demineralization II. pseudo fractures III. Loss of height 2. Kyphosis 3. type one osteoporosis (estrogen related) TYPE I OSTEOPOROSIS A. Amenorrhea in younger women C. Results in 1. Theoretically related to a lack of estrogen 1. reduced bone mass II. alkaline phosphatase level is moderately elevated Management I. bones break easily Diagnostic testing I. laboratory studies I. scoliotic or kyphotic deformities of the spine III. decreased serum calcium II. radiographic findings I. Bilateral oophorectomy 2. ultraviolet radiation therapy B. multifactorial disease results in I. bending deformities II. Osteoporosis 1. Loss of trabecular bone after menopause B. diet high in protein IV. Increased risk of fracture . vitamin D daily until signs of healing take place III. loss of bone strength III. increased likelihood of fracture II. calcium gluconate II. 5.4. Definition I. II.

Dysmenorrhea 5. weakens the bones c. Reproductive factors 1. Long-term remodeling C. skeletal changes result from the aging process e. Results in fractures of humerus and femoral neck a. Age-related loss of cortical/trabecular bone in men and women occurring after age 70 B. lack of gravitational stress b. premature menopause hyperthyroidism increases bone turnover and remodeling hyperparathyroidism increases bone turnover and remodeling increased parathyroid hormone (PTH) • • • stimulates osteoclast activity depresses osteoblast activity result is an increase in serum concentration of calcium b. hyperadrenocorticalism . type two osteoporosis (related to old age) TYPE II OSTEOPOROSIS A. bone loss due to 1. thin-boned. Early or surgically induced menopause 3. Family history of hip fracture B. c. Women with post-menopausal osteoporosis may have inherited a lower peak bone mass 4. e. Nulliparity (no pregnancies) C. Amenorrhea in athletes/anorexia nervosa a. immobilization 2. women affected twice as often as men before the age of 70 d. d. low body fat 3. most common metabolic disease of bone 1. decreases bone mass 4. faster bone loss 2. b. short. contributor of 50% of all adult fractures b. Factors related to osteoporotic fractures ADDITIONAL RISK FACTORS FOR OSTEOPOROSIS A. Hypo-estrogenism associated with increased bone remodeling. hypogonadism b. affects an estimated 25 million Americans 2. Endocrine factors in osteoporosis a. Small frame. Etiology/epidemiology a.II. white or Asian 2. onset is insidious c. Female. Daughters of women with osteoporosis averaged less bone mass in lumbar spine and femoral neck 5. Genetic risk factors 1.

history of scoliosis c. x-rays i. detect osteoporosis only after 20% bone mineral content is lost c. loss of height RECALL METHOD FOR HEIGHT DETERMINATION IN OSTEOPOROSIS A. best means of measuring risk for fracture ii. pain i. best indicator of fracture risk in bone densitometry 4. greater when active. calcium 2. Parkinson's disease 3. A two-inch loss of height predicts osteoporosis i. phosphate 3. less while resting ii. alkaline phosphatase b. restorative . complete blood counts ii. quantitative computerized axial tomogram (CAT) measures pure vertebral trabecular bone iii. CVA 2. blood tests i.aims to increase bone density. exercise i. pain in mid to low thoracic spine c. decreased vision from macular degeneration.'Dowager's hump' may reflect multiple spinal fractures e. acute fracture ii. decrease risk for fracture ii. within the client's tolerance iii. two or more inches ii. about further falls/fractures ii. Client is asked to recall maximum adult height B. Management a. help identify fractures and kyphosis of spine ii. Findings a. neurological impairment after 1. Diagnostics a. history of falls b. client history i.a. kyphosis . about ability to perform ADLs d. assesses cortical and trabecular bone in spine and hip 3. low bone density b. technique of choice 2. prior history of a traumatic fracture. anxiety i. complications of diabetes. early in disease. dual energy x-ray absorptionometry (DEXA) 1. must be maintained throughout life . single photon absorptionometry measures cortical bone in long bones 6. no trauma iii. bone densitometry i. etc. less useful in the detection of pre-fracture osteoporosis iii. d. serum levels 1. usually precedes diagnosis of osteoporosis diagnosis 5. Subtract current height from recall height C.

Nursing intervention: teach prevention of osteoporosis and its damage a. calcitonin (Osteocalcin) 1. discourage risk-related behaviors iii. increases bone mass in osteoporotic women 2. biophosphonates 1. estrogen therapy 3. androgens 1. sodium fluoride (Fluoritab) 2. bone-forming agents 1. modestly increases bone mass in osteoporosis 4. inhibit bone resorption 2. nutrition i. calcium and vitamin D ii. do not increase bone mass . 100 to 500 times more potent than etidronate 2. expensive ii. medication i.b.70 per day for osteoporosis iii. increase awareness ii. powerful inhibitor of osteoclastic bone resorption 3. teach proper lifting and movement techniques . not associated with detrimental effects of mineralization 5. anti-resorptive agents 1. reinforce positive behaviors and lifestyles b. deficiencies increase risk of fracture iii. sustained use associated with osteomalacia and Paget's disease 3. sedentary older adults may need supplements c. education i. expensive: average $41. reduce risk of falling i. non-hormonal agent 3.rather prevent further bone loss 2. but androgens virilize and elevate cholesterol levels 7. peptide hormone 2. not shown to decrease osteoporotic fractures 5. taken long-term. alendronate (Fosamax) 1. highly selective inhibitor 4.

Skull 1. sclerotic changes b. cause unknown d. NSAIDs 2. Compression of thoracic vertebrae c. Hearing loss 3. Paget's disease (osteitis deformans) 1. Definition: a slowly progressing resorption and irregular remodeling of bone. Etiology a. thickened areas of bone iii. bone resorbed. possible viral implications e. only treat if symptomatic b. Findings a. femur. Vertebrae a. musculoskeletal i. increased urinary hydroxyproline means osteoblasts more active iii. Management a. serum calcium level will be normal 5. Cranial nerve damage 2. laboratory analysis i.ii. Impaired respiratory ventilation B. family tendency . radiographic findings i. Kyphosis d. Obstructive hydrocephalus B. Cervical Spine: spinal cord compression: spastic quadriplegia c. encourage proper footwear install safety equipment in home C. conservative intervention i. pelvis. pain and point tenderness of affected limbs 4. deformity of long bones ii. tibia. bowing of long bones ii. easily fractured b. iii. Diagnostics a. new bone poorly developed. medication 1. increased alkaline phosphatase means osteoblasts more active ii.noted in siblings 3. Rigid forward bend of spine b. and vertebrae PAGET'S DISEASE EFFECTS SYSTEMIC SEQUELAE OF MALFORMATION OF BONE A. 2. calcitonin (osteocalcin) . asymptomatic initially b. weak. mainly affects major bones: skull. pathological fractures iv.

The choice is usually made by the health care provider. nonunion 2. 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. relieve neurologic impairment iv. used only when Paget's disease bone is damaging nerves c. in first 24 hours. hemiarthroplasty of the hip is the replacement of one of the articular surfaces. clients may require transfusions (autologous is preferred) due to blood loss during surgery. by 48 hours. Surgical modalities SURGICAL MODALITIES FOR HIP REPLACEMENT A. avascular necrosis of femoral head caused by steroids v.1. There are a variety of hip prostheses. The femoral shaft of a prosthesis used for revision is much longer than that used for the original surgery a. rheumatoid arthritis iii. slows bone resorption 2. b. Surgical and immediate postoperative care a. rapidly slows bone resorption 2. malunion VI. osteoarthritis ii. Prostheses have two components: acetabular socket and femoral shaft 1. 3. may relieve pain 4. b. advancing to non-narcotic oral analgesics by the fourth or fifth postoperative day. correct secondary deformity iii. allows normal lamellar bone development 3. wound drainage should be minimal c. femoral neck fractures iv. best pain management is patient controlled analgesia (PCA) for the first 48 hours. disodium etidronate (EHDP) 1. plicamycin (mithracin) 1. total hip replacement (hip arthroplasty) is the replacement of both articular surfaces of the hip joint. lowers levels of alkaline phosphatase and urinary hydroxyproline 3. monitor for signs of deep venous thrombosis (DVT) and pulmonary embolism (PE) or fat embolism . B. the acetabular socket and the femoral head and neck. surgery i. expect wound to drain blood and fluid up to 500ml. failure of previous prosthesis 2. Orthopedic Surgery A. reduce pathological fractures ii. e. d. Indications for surgery i. complications common 1. antibiotic 2. Total hip replacement 1. usually the femoral head and neck.

and pulses m. and increases that amount as client tolerates more h. a second operation is performed for skin closure. client teaching i. to keep abduction device in place. f. within 24 hours. Nursing interventions (knee replacement) a. trauma 4. 4. methods to prevent dislocation iii. best pain management is patient controlled analgesic (PCA) for the first 48 to 72 hours postoperatively. stump can bear full weight. raised toilet seat ii. Below elbow (BE) .preserves elbow joint. presence of pulses. hinged or semiconstrained b. at level of amputation Knee disarticulation -Levels of knee joint Above knee (AK) . 8. use fracture bedpan d. burns. Postoperative complications 5. when the CPM machine is not in use. a knee immobilizer is used i. crutches. progressive peripheral vascular disease (often secondary to diabetes mellitus) b. frequently health care provider prescribes a continuous passive motion machine (CPM) g. Amputation 3.preserves knee joint which facilitates use of prosthesis 6. To avoid flexion of hip. choice of prosthesis depends on the strength of surrounding ligaments to provide joint stability 5. congenital malformations 2.monitor neurovascular status of affected limb. apply ice to the knee to minimize bleeding and edema b. Causes minor changes in gait or balance d. use of assistive devices. monitor for signs of DVT or PE 3. . an abduction device is used during the first postoperative week while the client is in bed or sitting in a chair b. keep leg elevated when the client is out of bed j. start aggressive physical therapy to promote knee flexion f. to prevent flexion of the hip. Purpose: relieve findings.measures undertaken to provide as much length to limb as possible Staged amputation . Indications for surgery a. osteoarthritis b. expect wound drainage up to 200 ml. gangrene c. transfusions are rarely required e. measured in degrees. health care provider prescribes the amount of flexion and extension. metal or acrylic prosthesis. Nursing interventions a. walker.usually as a result of trauma or infection. trauma LEVELS OF AMPUTATION Objective of surgery is to eradicate the malignant tumor b. malignant tumor 5. Surgical modalities a. l. After intensive antibiotic therapy. 5. 7. 9. 3. Upper extremity indications a. color. disease process while conserving as much of the extremity as possible c. rheumatoid arthritis c. improve function. turn client by logrolling c. Guillotine amputation to remove infectious and necrotic tissue is performed. temperature.measures undertaken to provide as much length to limb as possible Hip disarticulation . on first post-op day. temperature. with prosthesis Below knee (BK) . monitor limb's neurovascular status. for first 24 to 48 hrs. Postoperative complications 6. trauma such as crushing injuries. thus eases use of prosthesis Above elbow (AE) . client should be in dependent position for three to six months 2.most often performed due to malignancy.used for infection. By fifth post-op day. 4. or frostbite d. Total knee replacement 3. 6. congenital deformities e. nonnarcotic oral analgesia. Lower extremity indications a. save or improve quality of life 4. Client cannot walk with prosthesis. by 48 hours. c. Toes and portion of the foot . Syme: disarticulation of ankle. client will begin to use crutches or walker k. expect minimal wound drainage d. infection 1. can resume sexual activity when suture line heals. color. in first eight hours.

may require evacuation of accumulated fluid or hematoma c. and eventually care for limb 11. phantom limb pain i. Grief a. or massage 2. through 1. and depression b. anger. Nursing interventions a. myoelectrically controlled e. shock. stump desensitization by kneading. Wound healing a.usually relieved with narcotic analgesics b. Flexion deformities 3. muscle spasms may be relieved by heat or changing position d. An elastic residual limb shrinker 3. The residual limb must be shrunk and shaped into a conical form to secure a proper fit within the prosthesis. muscle strengthening exercises c. foster independence: encourage client to look at. synchronized . distraction 4. caregivers should support and listen actively 12. relieved with 1. amputate to most distal point that will heal successfully b. Altered body image a. Types of prosthesis a. infection c. determined by circulation and functional status 7. transcutaneous electrical nerve stimulation (TENS) 3. Problems that delay prosthetic use are 1. prosthetic preparation PREPARING FOR A PROSTHESIS A. early rehabilitation b. Proper bandaging of the stump in a figure eight manner 2. pneumatic c. skin breakdown 8. Restoring physical mobility a.a. may occur any time up to three months post amputation ii. dull pain 5. hydraulic b. aseptic dressing change technique b. anticonvulsants for sharp and cramping pain 9. must convey acceptance and respect for individual c. Potential postoperative complications a. Abduction deformities of the hip 13. An air splint B. beta-adrenergic blocking agents for burning. may take months to resolve b. biofeedback . compression dressing wrapped in a figure eight fashion or cast to control edema 10. pain management .controlled d. many clients go through a mourning process. feel. hemorrhage b. most common with above-knee (AK) amputations iii. Non-shrinkage of the residual limb 2.

pulmonary embolism may occur even without thrombosis in foot or leg. Definition 2. ambulation with assistive device (crutches. External fixator 1. Indications a. walker) 2. Postoperative care a. drainage and increased warmth d. Clients should sit in a straight. 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. . non-weight bearing ambulation depends on soft tissue injury f. Some clients will need transportation to continue rehabilitation. isometric and active exercises as prescribed e. discharge teaching 1.endoscopic procedure that allows direct visualization of the joint. oral analgesics for pain management d. chondromalacia patellae c. subluxation patella f. care of pin site 3. use a raised toilet seat. assess pin insertion sites for infection: erythema. Arthroscopy 1. intra-articular soft tissue mass g. Indication: the device will stabilize fracture with soft tissue injury like crush fractures 3. health care provider may prescribe knee immobilizer. and never cross their legs. torn medial and lateral meniscus b. the home must be assessed for any modifications needed to ensure safety.most often. thrombophlebitis c. office surgery 4. weight bearing depends on procedure 5. Postoperative complications are rare a. synovitis d. ice may be applied c.D. pyarthrosis 3. monitor neurovascular status every two hours b. Surgical procedure . most often performed on knees and shoulders 2. high chair. clients will need assistive devices for walking until muscle tone strengthens and they can walk without pain. In hip or knee replacement. outpatient rehab may be prescribed depending on procedure. After an amputation. torn cruciate ligament e. compression dressing wrapped in a figure eight fashion to control edema b. extremity is repositioned by lifting frame instead of extremity Points to remember • • • • • • • After hip replacements. Definition . Amputee support groups can help clients and family. infection b. elevate extremity to reduce edema c. After arthroscopy. 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.

into adduction or internal rotation which will cause dislocation and severe pain and this would be a nursing emergency. After a hip pinning or femoral-head prosthesis. limit outdoor activities during peak sun hours and wear sun block. diabetics. thick and enlarged. Immunosuppressed clients should avoid contact with persons who have infections. evaluate them continually for side effects. powders etc. Clients at high risk for acute osteomyelitis are: elderly. Device looks clumsy. When performing a musculoskeletal assessment on a client with Paget's disease. Foods high in calcium include milk. note the size and shape of the skull. prepare the client preoperatively to reduce anxiety. Photosensitive clients should avoid the sun. cheeses. yogurt. When clients receive corticosteroids long-term. unless prescribed by the health care provider. . and clients with peripheral vascular disease. sardines. cottage cheese. so client should promptly report slightest change in temperature or other complaints. Steroids may mask the signs of infections. Caution clients with a new prosthesis not to use any substances such as lotions. Osteoporosis cannot be detected by conventional X-ray until more that 20% of bone calcium is lost. but patient should be reassured that discomfort is minimal. turnip greens. caution client not to force hip into more than 90 degrees of flexion. The skulls of these clients will be soft.• • • • • • • • • • • External Fixator . and spinach.If possible.