CARE OF CLIENTS WITH PROBLEMS IN NUTRITION,

AND GASTRO-INTESTINAL, METABOLISM AND

ENDOCRINE, PERCEPTION AND COORDINATION
(ACUTE AND CHRONIC)

SUBMITTED TO:
MA. DOROTEA AROCENA, RN

SUBMITTED BY:
JORELLE I. CARBONELL
BSN 3-1
WESLEYAN UNIVERSITY-PHILIPPINES
Mabini Extension, Cabanatuan City, Nueva Ecija
College of Nursing and Allied Medical Sciences

PART 1
 :

At the end of 48 Hours of lecture-discussion via simulation

activities, the Level 3 students will be able to formulate a
comprehensive nursing care plan in the care of clients with
problems in perception and coordination.

1. Appreciate the history and development in the field of

orthopaedic nursing.
2. Identify the different parts and functions of musculoskeletal
system.
3. Identify the different laboratory procedures and diagnostic
examinations in assessing clients with musculoskeletal
problems.
4. Recognize the various musculoskeletal problems with
corresponding signs and symptoms and nursing
management.
The challenge in caring for the orthopedic patient is in
carrying out basic nursing care procedures while
understanding and working with orthopedic devices used in
the treatment of musculoskeletal diseases and injuries. This
requires basic knowledge on the anatomy and physiology of
the Musculoskeletal System and other major body system. It
is also important that nursing students should know how to
avoid self - injury while caring for orthopedic patients by
understanding and applying principles of good body
mechanics. To avoid self-injury, those engaged in
orthopedic nursing must also understand and apply
principles of good body mechanics.

ORTHOPEDIC NURSING

The history of nursing began in London in the late 1800s

with the reform of unsanitary conditions by Florence
Nightingale. During the same period, the United States was
bitterly fighting the Civil War. Nursing had not developed as
a profession, and most of the duties performed by nurses
were conducted by men. Casualties of war required
rehabilitation and care. Crippled children were left to die
because they were considered a burden to society. Dr.
James Knight founded the Hospital for the Ruptured and
Crippled in his home on Second Avenue

The history of nursing and orthopaedic surgery dates back to

the late 1800s. Both developed out of societal need,
advances in medical science, and a will to help those
afflicted with disease. Crippling disorders have plagued
mankind since the beginning of time. These unfortunate
people had no recourse except begging for survival. The
same premise exists today in all disciplines of medicine.

1860- Florence Nightingale established the first school of

nursing at St. Thomas Hospital in London. She used her
knowledge of mathematics to interpret data collected
during her service in the Crimean War. Through statistical
analysis she proved that the incidence of preventable
deaths was caused by unsanitary conditions and that with
improvement in sanitary methods, the death rate would
decrease.
The Philippine Orthopedic Center (POC) was established on
February 9, 1945 as a special government hospital then
known as the Philippine Civilian Affairs Unit No.1 General
Hospital (PCAU 1). Major Francisco Roman- an army surgeon
and the first Hospital Chief. In May, it was renamed as the
Mandaluyong Emergency Hospital.

In August, the Bureau of Health took over its management

and reorganization measures were initiated reducing patient
bed capacity as well as manpower; such characteristics
shaped the true personality of the hospital as a Center of
orthopedics and trauma.

By 1947, Dr. Jose V. Delos Santos assumed and soon the

adoption of the name, National Orthopedic Hospital Two
years later, a four – year Residency Program in orthopedics
and anesthesia was started. Dr. Benjamin V. Tamesis
(3rd Hospital Chief) continued on the programs.

In 1956, a 5 – year residency program in orthopedics and

traumatology was instituted in 1963, the hospital site was
transferred to Maria Clara cor. Banawe St., Quezon City and
soon it was a pioneer in establishing a comprehensive
rehabilitation program (Physical Therapy, Occupational
Therapy, Artificial Limb and Brace Center.)

In 1982, pursuant to Batas Pambansa Blg. 301, it acquired a

new name, National Orthopedic Hospital and Rehabilitation
Center

In 1987, Dr. Rafael S. Recto was appointed as the 5th Medical

Director and in two (2) years’ time

NOH – RMC was renamed as Philippine Orthopedic Center

by virtue of RA 8766.

The musculoskeletal system provides form, stability, and

movement to the human body. It consists of the
body's bones (which make up the
skeleton), muscles, tendons, ligaments, joints, cartilage, and
other connective tissue. The term "connective tissue" is used
to describe the tissue that supports and binds tissues and
organs together. Its chief components are collagen and
elastic fibers, which are composed of different proteins.
Bone, although strong, is a constantly changing tissue that
has several functions. Bones serve as rigid structures to the
body and as shields to protect delicate internal organs. They
provide housing for the bone marrow, where the blood cells
are formed. Bones also maintain the body's reservoir of
calcium. In children, some bones have areas called growth
plates. Bones lengthen in these areas until the child reaches
full height, at which time the growth plates close. Thereafter,
bones grow in thickness rather than in length, based on the
body's need for additional bone strength in certain areas.

 Flat (such as the plates of the skull and the vertebrae)

 Tubular (such as the thighbones and arm bones, which
are called long bones)
 Classification of Bones by Shape

Some bones have combinations of these. All bones have

essentially the same structure. The hard outer part (cortical
bone) consists largely of proteins, such as collagen, and a
substance called hydroxyapatite, which is composed mainly
of calcium and other minerals. Hydroxyapatite is largely
responsible for the strength and density of bones. The inner
part of bones (trabecular bone)

is softer and less dense than the hard outer part but still
contributes significantly to bone strength. A reduction in the
amount or quality of trabecular bone increases the risk of
fractures (breaks). Bone marrow is the tissue that fills the
spaces in the trabecular bone. Bone marrow contains
specialized cells (including stem cells) that produce blood
cells. Blood vessels supply blood to the bone, and nerves
surround the bone.

Bones undergo a continuous process known as remodeling

In this process, old bone tissue is gradually replaced by new
bone tissue. Every bone in the body is completely reformed
about every 10 years. To maintain bone density and strength,
the body requires an adequate supply of calcium, other
minerals, and vitamin D and must produce the proper
amounts of several hormones, such as parathyroid hormone,
growth hormone, calcitonin, estrogen, and testosterone.
Activity (for example, weight-bearing exercises for the legs)
helps bones strengthen by remodeling. With activity and
optimal amounts of hormones, vitamins, and minerals,
trabecular bone develops into a complex lattice structure
that is lightweight but strong.

Bones are covered by a thin membrane called the

periosteum. Bone injuries are painful because of pain-sensing
nerves located mostly in the periosteum. Blood enters bones
through blood vessels that enter through the periosteum.

There are three types of muscles:

 Skeletal
 Smooth
 Cardiac (heart)

Two of these kinds—skeletal and smooth—are part of the

musculoskeletal system.

Skeletal muscle is what most people think of as muscle, the

type that can be contracted to move the various parts of the
body. Skeletal muscles are bundles of contractile fibers that
are organized in a regular pattern, so that under a
microscope they appear as stripes (hence, they are also
called striped or striated muscles). Skeletal muscles vary in
their speeds of contraction. Skeletal muscles, which are
responsible for posture and movement, are attached to
bones and arranged in opposing groups around joints. For
example, muscles that bend the elbow (biceps) are
countered by muscles that straighten it (triceps). These
countering movements are balanced. The balance makes

movements smooth, which helps prevent damage to the

musculoskeletal system. Skeletal muscles are controlled by
the brain and are considered voluntary muscles because
they operate with a person's conscious control. The size and
strength of skeletal muscles are maintained or increased by
regular exercise. In addition, growth hormone
and testosterone help muscles grow in childhood and
maintain their size in adulthood.

Musculoskeletal System
Muscles and Other Tissues of the Musculoskeletal System

Smooth muscles control certain bodily functions that are not

readily under a person's control. Smooth muscle surrounds
many arteries and contracts to adjust blood flow. It surrounds
the intestines and contracts to move food and feces along
the digestive tract. Smooth muscle also is controlled by the
brain but not voluntarily. The triggers for contracting and
relaxing smooth muscles are controlled by the body's needs,
so smooth muscles are considered involuntary muscle
because they operate without a person's conscious control.

Cardiac muscle forms the heart and is not part of the

musculoskeletal system. Like skeletal muscle, cardiac muscle
has a regular pattern of fibers that also appear as stripes
under a microscope. However, cardiac muscle contracts
and relaxes rhythmically without a person's awareness.

Tendons and Bursae

Tendons are tough bands of connective tissue made up

mostly of a rigid protein called collagen. Tendons firmly
attach each end of a muscle to a bone. They are often
located within sheaths, which are lubricated to allow the
tendons to move without friction.

Bursae are small fluid-filled sacs that can lie under a tendon,
cushioning the tendon and protecting it from injury. Bursae
also provide extra cushioning to adjacent structures that
otherwise might rub against each other, causing wear and
tear—for example, between a bone and a ligament or a
bony prominence and overlying skin (such as in the elbow,
kneecap, or shoulder area).

Ligaments

Ligaments are tough fibrous cords composed of connective

tissue that contains both collagen and elastic fibers. The
elastic fibers allow the ligaments to stretch to some extent.
Ligaments surround joints and bind them together. They help
strengthen and stabilize joints, permitting movement only in
certain directions. Ligaments also connect one bone to
another (such as inside the knee).

Joints

Joints are the junctions between two or more bones. Some

joints do not normally move, such as those located between
the plates of the skull. Other joints allow a large and complex
range of motion. The configuration of a joint determines the
degree and direction of possible motion. For example, the
shoulder joints, which have a ball-and-socket design, allow
inward and outward rotation as well as forward, backward,
and sideways motion of the arms. Hinge joints of the knees,
fingers, and toes allow only bending (flexion) and
straightening (extension).

The components of joints provide stability and reduce the risk

of damage from constant use. In a joint, the ends of the
bones are covered with cartilage. Cartilage is a smooth,
tough, resilient, and protective tissue composed of collagen,
water, and proteoglycans that reduces friction as joints
move. (Collagen is a tough fibrous tissue, and proteoglycans
are substances that help provide the cartilage's resilience.)
Joints also have a lining (synovial tissue) that encloses them
to form the joint capsule. Cells in the synovial tissue produce
a small amount of clear fluid (synovial fluid), which provides
nourishment to the cartilage and further reduces friction
while facilitating movement.

Fractures

A fracture is a break, usually in a bone. If the broken bone

punctures the skin, it is called an open or
compound fracture. Fractures commonly happen because
of car accidents, falls, or sports injuries. Other causes are low
bone density and osteoporosis, which cause weakening of
the bones.

Different Types of Fracture

1. Complete fracture – a break across the entire cross section

of the bone.

2. Open fracture- a fracture in which there is an open wound

or break in the skin near the site of the broken bone.

> exposed to the external environment

Note: Open fractures are graded according to the following

criteria:

a. Grade I is a clean wound less than 1 cm long

b. Grade II is a larger wound without extensive soft tissue

damage
c. Grade III is highly contaminated , has extensive soft tissue
damage and is the most severe

3. Incomplete fracture – occurs through only part of the cross-

section of the bone non exposure to the environment
4.Greenstick - Incomplete fracture. The broken bone is not
completely separated. Because greenstick fractures happen
in young, soft bones, they typically occur in children under 10
years old

5. Transverse - The break is in a straight line across the bone

6. Oblique - Diagonal break across the bone (Left) An oblique
fracture has an angled line across the shaft. (Right) A
comminuted fracture is broken into three or more pieces.

7. Spiral - The break spirals around the bone; common in a

twisting injury.

8. Compression - The bone is crushed, causing the broken

bone to be wider or flatter in appearance.
OTHER TYPES OF FRACTURE:

1. Avulsion – fracture which occurs when a fragment of bone

tears away from the main mass of bone
2. Depressed –a fracture in which fragments are driven
inward (seen frequently in fractures of skull and facial bones

3. Epiphyseal fracture – a fracture through the epiphysis

4. Pathologic fracture – it occurs through an area of diseased

bone (e.g. osteoporosis, bone cyst, bony metastasis, tumor)
Can occur without trauma or a fall.
 WESLEYAN UNIVERSITY-PHILIPPINES
Mabini Extension, Cabanatuan City, Nueva Ecija
College of Nursing and Allied Medical Sciences

PART 2

Paget’s disease of Bone:

A case study
Patient J is a 45yrs old lady presented to the OPD with the chief
complaints of Pain in the knee, low backache, pain in the thigh for the past
1yr. Breathlessness on & off for 6months. Patient was apparently alright
1yr ago following which patient developed pain in those areas, insidious
in onset, gradually progressive, no specific character attributed. No
specific aggravating / relieving factors. Patient has breathlessness for the
past 6months, while doing her household activity and increases more
during exertion & relieved by rest. Patient complains of occasional light
headedness.

 Attained menopause 2 yrs back,

cycles regular during premenstrual
period. No gynaec complaints in
the post-menopausal period
 Vegan by diet
 Patient has lost 10-15 cm of height
in the past 2- 3 yrs.

Examination

 Comfortable at rest
 Conscious, oriented, afebrile
 No pallor/ icterus/ cyanosis/
clubbing/ lymphadenopathy/ edema
  Pulse: 110/min;
 BP: 120/60 mm of hg, rt arm, supine position, SBP 130 mm
of hg in lower limb by palpatory method.
 JVP not elevated
 RR : 16/min
 Patient has fixed flexion deformity of hips
 She has kyphosis , no tenderness of spine There is Genu
varum / tibia vara .
 Other systems : normal

Problems:

 Bone pain
 Loss of height
 Breathlessness
 Limb deformities
 Probable High output state

Paget's disease of bone interferes with your body's normal

recycling process, in which new bone tissue gradually
replaces old bone tissue. Over time, bones can become
fragile and misshapen. The pelvis, skull, spine and legs are
most commonly affected.

The risk of Paget's

disease of bone
increases with age
and if family members
have the disorder.
However, for reasons
unknown to doctors,
the disease has
become less
common over the
past several years and is less severe when it does develop.
Complications can include broken bones, hearing loss and
pinched nerves in your spine.

Causes

 The cause of Paget's disease of bone is unknown.

Scientists suspect a combination of environmental and
genetic factors contribute to the disease. Several genes
appear to be linked to getting the disease.
Some scientists believe Paget's disease of bone is related to
a viral infection in your bone cells, but this theory is
controversial.

Risk factors

Factors that can increase your risk of Paget's disease of bone

include:

 Age. People older than 50 are most

likely to develop the disease.
 Sex. Men are more women.
 National origin. Paget's disease of
bone is more common in England,
Scotland, commonly affected than
are central Europe and Greece — as
well as countries settled by European
immigrants. It's uncommon in Scandinavia and Asia.
 Family history. If you have a relative who has Paget's
disease of bone, you're more likely to develop the
condition.

HOW COMMON IS PAGET’S DISEASE?

 Around 1 million people in the United States have

Paget’s disease.
  Paget’s disease tends to occur in older adults as well as
people from Northern Europe. The disorder occurs in
three men to every two women with Paget’s disease.

PATIENT DEMOGRAPHICS

Name: patient J
Age:45
Gender: female
Allergies: none
CHIEF COMPLAINTS: Pain in the
knee, low backache, pain in
the thigh for the past 1yr.

HISTORY

Breathlessness on & off for 6months. Patient was apparently

alright 1yr ago following which patient developed pain in
those areas, insidious in onset, gradually progressive, no
specific character attributed. No specific aggravating /
relieving factors. Patient has breathlessness for the past
6months, while doing her household activity and increases
more during exertion & relieved by rest. Patient complains of
occasional light headedness.
Examination

 Comfortable at rest
 Conscious, oriented, afebrile
 No pallor/ icterus/ cyanosis/
clubbing/ lymphadenopathy/
edema
 Pulse: 110/min;
 BP: 120/60 mm of hg, rt arm,
supine position, SBP 130 mm of
hg in lower limb by palpatory
method.
 JVP not elevated
 RR : 16/min
 Patient has fixed flexion deformity of hips
 She has kyphosis , no tenderness of spine There is Genu
varum / tibia vara .
  Other systems : normal

ANATOMY AND PHYSIOLOGY

The disease might affect only one or two areas of your

body or might be widespread.

 Pelvis. The pelvis is a

basin-shaped structure
that supports the spinal
column and protects the
abdominal organs. It
contains the following:
Sacrum. A spade-shaped
bone that is formed by
the fusion of 5 originally
 separate sacral vertebrae. Coccyx (also called the tail
bone).
 Skull. The skull is a bone structure
that forms the head in vertebrates.
It supports the structures of the
face and provides a protective
cavity for the brain. The skull is
composed of two parts: the
cranium and the mandible. ... In
humans these sensory structures
are part of the facial skeleton.

 Spine. The spine is our body's

central support structure. It
keeps us upright and connects
the different parts of our skeleton
to each other: our head, chest,
pelvis, shoulders, arms and legs.
Although the spine is made up of
a chain of bones, it is flexible due
to elastic ligaments
and spinal disks
  Leg. The bones of the leg
consist of the femur, tibia and
fibula, tarsals, metatarsals and
phalanges. A femur is the longest
and heaviest bone of the body.
Actually femur, tibia and fibula
bones together support the
shank of the leg.

PATHOPHYSIOLOGY OF PAGET'S DISEASE OF BONE

 Paget's disease of the

bone is a skeletal disorder
which results in increased
and disorganized bone
remodeling, leading to
dense but fragile and
expanding bones. The
identified genetic causes
of Paget's disease of bone
only explain why bone is
destroyed, but not why
the bone formed in its place is abnormal.
  Because this disease causes your body to generate new
bone faster than normal, the rapid remodeling produces
bone that's less organized and weaker than normal
bone, which can lead to bone pain, deformities and
fractures.

PAGET'S DISEASE

The genetic mutations found in Paget's disease currently

only account for about 15% of cases and are limited to
genes that affect osteoclast differentiation and function.
These mutations alone are insufficient to explain the full
phenotype, particularly hypervascularity and increased
bone formation. Through a series of basic science studies,
the investigators have recently found that preosteoclasts
secrete chemokines to promote migration of various stem
cells, which then differentiate into osteoblasts and
endothelial cells to support osteogenesis and
angiogenesis, respectively.

The investigators will perform a cross sectional study of

patients with active Paget's disease of bone compared to
similar people without Paget's disease of bone. The goal is
to enroll 10 patients with Paget's disease of the bone
(cases) and 10 healthy, age- and sex-matched people
(controls) whom meet similar exclusion criteria. Participants
who consent to the study will undergo a brief history and
physical exam, allow review of medical records relevant to
their disease, and have one blood (5 tablespoons) sample
drawn.

The investigators hypothesize that specific chemokine

concentrations are increased in people with Paget's
disease of the bone compared to controls. The
investigators also hypothesize that these levels correlate
with severity of disease. Therefore, the investigators primary
objective is to determine if serum chemokine levels are
increased in patients with Paget's disease of the bone. The
secondary objective is to evaluate if the serum chemokine
 concentrations correlate with various markers of disease
activity. Findings could aid in the clinical monitoring of
patients with Paget's disease of the bone and could
provide an additional therapeutic target to improve
treatment of this painful disease.

The disease might affect only one or two areas of your body
or might be widespread. Your signs and symptoms, if any, will
depend on the affected part of your body.

 Pelvis. Paget's disease of bone in the pelvis can cause

hip pain.
 Skull. An overgrowth of bone in the skull can cause
hearing loss or headaches.
 Spine. If your spine is affected, nerve roots can become
compressed. This can cause pain, tingling and
numbness in an arm or leg.
 Leg. As the bones weaken, they may bend — causing
you to become bowlegged. Enlarged and misshapen
bones in your legs can put extra stress on nearby joints,
which may cause osteoarthritis in your knee or hip.
SIGNS AND SYMPTOMS

Early symptoms of Paget's disease include bone pain, joint

pain (especially in the back, hips and knees), and headache.
Physical signs include enlargement and bowing of the thighs
(femurs) and lower legs (tibias), and enlargement of the skull
in the area of the forehead.

In patients who do have symptoms, bone pain is the most

common complaint. This pain can be related to active
Paget's disease or to its complications, which include:

 Fractures due to brittle bone.

 Deformity of bone, including bowing of the affected
bone.
 Advanced arthritis in joints near the affected bone.
  Compression on neighboring nerves from enlarged
bones, leading to a loss of sensation or movement.

Other Symptoms

Symptoms can also arise from the effect of the disease on

calcium levels in the blood
stream. When Paget's disease
is active in several bones,
overactive osteoclasts may
release enough calcium from
the bone as they break it down
to cause an elevated calcium
level in the blood. This rare
complication can lead to a
number of symptoms,
including:

 Fatigue
 Weakness
 Loss of appetite
 Abdominal pain
 Constipation
Very rarely, Paget’s disease can progress to a type of bone
cancer called Paget’s sarcoma. When this occurs, symptoms
may include severe and unrelenting pain in the area
affected by Paget’s disease. Paget's sarcoma occurs in only
about 1 percent of patients with Paget's disease. These
patients are usually older than 70 years of age. This type of
malignant bone tumor is very aggressive and has a poor
prognosis. None of the medical treatments for Paget's
disease are known to lower the risk for the development of
Paget's sarcoma.

TREATMENT

 There is no cure for Paget’s disease and no way to

reverse its effects on bone. Treatment focuses on
relieving symptoms and preventing future
complications.

NONSURGICAL TREATMENT

If you do not have pain or other symptoms, no treatment is

required. Your doctor may recommend simply monitoring
your condition with regular office visits and periodic x-rays to
watch for changes in the affected bone and to ensure that
complications do not develop.

If symptoms do occur, your doctor may recommend one or

more nonsurgical treatments.

 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS).

Medications such as ibuprofen, naproxen and aspirin
can help relieve mild bone pain that arises from Paget’s
disease or from arthritis that may be associated with the
disease.
 ASSISTIVE DEVICES. If your pelvis or leg is affected by the
disease, using a cane can help relieve pain by
decreasing the forces going through the bone. Using a
cane can also help prevent falls, so there is less risk of
fracture in the bone—a common complication of
Paget’s disease.
 Wearing a brace can help relieve pain by preventing
malalignment of the affected bones.
 BISPHOSPHONATE MEDICATIONS. When bone pain is
more significant, medications called bisphosphonates
are the treatment of choice. These drugs block
osteoclasts and can be very effective in treating Paget's
disease.
SURGICAL TREATMENT

In some cases, surgery may be needed to treat the

complications of Paget's disease, including:

 Bone fractures
 Malalignment or deformity of bone
 Severe arthritis

The surgical procedures used to treat fractures,

malalignment, or arthritis in patients with Paget's disease are
similar to those used to treat similar conditions in people with
normal bone.

These procedures may include:

 INTERNAL FIXATION. This procedure can be used to treat

fractures in bone affected by the disease. In internal
fixation, bone fragments are first repositioned into their
normal alignment, then held in place with screws, wires,
pins, or metal plates attached to the outside of the
bone.
 OSTEOTOMY. An osteotomy can help relieve pain and
restore alignment to weight-bearing joints that are
affected by Paget’s disease, especially the knee and
hip. During the procedure, your doctor will remove a
 wedge of bone near the damaged joint in order to shift
weight onto a healthier part of the joint.

 TOTAL JOINT
REPLACEMENT. In this
procedure, parts of an
arthritic or damaged joint
are removed and replaced
with a metal, plastic or
ceramic device called a
prosthesis. The prosthesis is
designed to replicate the
movement of a normal, healthy joint.

Surgery may also be needed if an enlarged bone begins

to compress nerves, especially in the spine or skull. In the
rare case of Paget's sarcoma, surgery is almost always
used to try to remove the tumor entirely. Chemotherapy
and radiation therapy may also be used.

Because Paget's disease increases the blood supply to

bones, your doctor may recommend taking
 bisphosphonates for a period of time before surgery to
help reduce potential blood loss.

Bones affected by Paget's disease may take longer to

heal than normal bones. A longer period of
rehabilitation may also be necessary.

DIAGNOSTIC TESTS

 X-RAYS. X-rays provide

images of dense structures,
such as bone. Paget’s
disease can usually be
diagnosed by looking at an
x-ray. A bone affected by
Paget’s usually appears
larger and denser than a
normal bone. It may also
have a deformed shape.
 LABORATORY TESTS. A blood test called serum alkaline
phosphatase may also be used to help confirm the
diagnosis. In patients with Paget’s disease, alkaline
 phosphatase levels are usually quite elevated—a
reflection of the high bone turnover rate.

 Paget's disease can also be detected with urine tests

that show rapid bone turnover.

 BONE SCAN. A bone scan may be used to help

determine which bones are affected. During this test, a
very small amount of radioactive dye is injected into a
vein. A special camera is then used to detect areas of
the skeleton with an increased uptake of the radioactive
material. These "hot spots" indicate areas where there is
more bone turnover than normal. Paget's disease almost
always looks "hot" on a bone scan, except when the
condition has been present for a long time and has
"burned out."

 Biopsy. A biopsy is sometimes necessary to confirm the

diagnosis of Paget's disease or to rule out other
conditions.
DISCHARGE PLANNING

 Your health care provider is the best source of

information for questions and concerns related to your

medical problem.

 To reduce your risk of complications associated with

Paget's disease of bone, try these tips:

 PREVENT FALLS. Paget's disease of bone puts you at high

risk of bone fractures. Ask your doctor for advice on

preventing falls. He or she may recommend that you use

a cane or a walker.

 FALL-PROOF YOUR HOME. Remove slippery floor

coverings, use nonskid mats in your bathtub or shower,

tuck away cords, and install handrails on stairways and

grab bars in your bathroom.

 EAT WELL. Be sure your diet includes adequate levels of

calcium and vitamin D, which helps bones absorb

 calcium. This is especially important if you're taking a

bisphosphonate. Review your diet with your doctor and

ask if you should take vitamin and calcium supplements.

 EXERCISE REGULARLY. Regular exercise is essential for

maintaining joint mobility and bone strength. Talk to your

doctor before beginning an exercise program to

determine the right type, duration and intensity of

exercise for you. Some activities may place too much

stress on your affected bones.

 NURSING CARE PLAN
ASSESSMEN NURSING NURSING GOAL INTERVENTIONS RATIONALE EVALUATION
T DIAGNOSIS

SUBJECTIVE: IMBALANCED SHORT TERM: INDEPENDENT: INDEPENDENT: SHORT TERM:

NUTRITION:
“I always LESS THAN After 8 hours of  Assess risk for  To provide After 8 hours of
experience BODY nursing injury. safety and nursing
REQUIREMENTS wellness
pain in my interventions the interventions the
RELATED TO
knee, a low INADEQUATE patient will be able  Provide a safe  To prevent patient will
back pain and CALCIUM AND to maintain and hazard- falls maintain
pain in my VITAMIN D AS functional mobility free functional
thigh area for EVIDENCED BY as long as possible environment, mobility as long as
the past 1 HIP within limitations and assist the possible within
DEFORMITY,
year. and then of disease process. client to limitations of
KYPHOSIS, AND
I was also identify disease process.
LOSS OF HEIGHT
breathlessness LONG TERM: hazards in the
on & off for the home LONG TERM:
past 6months. After several days environment.
And my diet is of nursing After several
vegan” As interventions the  Instruct  Premenopa days of nursing
verbalized by Patient will recommended usal women interventions the
demonstrate daily intake for (19-50 Patient will
the patient.
adequate intake of years old) demonstrate
calcium.
calcium and need 1,500 adequate intake
METHOD:
mg of
INTERVIEW vitamin D. of calcium and
calcium
daily. After vitamin D.
OBJECTIVE:  Patient will menopause
have a few, , the  Patient
 Bone
pain
if any, requiremen have a
 Loss of complicatio t is 1,200 few, if any,
height ns related mg daily. complicati
 Breathl to Getting ons
essness enough
immobility related to
 Limb vitamin D is
deformi as disease equally immobility
ties condition important as disease
 Kyphosi progresses as getting condition
s enough progresse
 Probabl  Patient will calcium
e High s
be able to because
accurately vitamin D
 output verbalize aids in the  Patient
state absorption
understandi can
of calcium
ng of accurately
METHOD: and
appropriate verbalize
improves
INSPECTION medication understan
muscle
DIAGNOSTIC administrati ding of
strength.
EXAMINATION  Instruct on the
on.  The patient appropriat
S importance of should be e
adequate outside 15 medicatio
exposure to minutes
n
sunlight to daily.
administra
prevent tion.
vitamin D
deficiency.

 If the patient
 Supplement
has limited ation will
exposure to ensure
sunlight, adequate
encourage vitamin D
vitamin D intake.
supplementati
on.

 Instruct  Exercise can

patient to help build
strong
perform gentle
bones and
exercises slow bone
loss.
Strength-
training
exercises
should be
combined
with
weight-
bearing
exercises.
Strength
training
helps in
bone and
 muscle
strength
 Provide a
 A diet high
balanced diet. in nutrients
that
support
skeletal
metabolism
: vitamin D,
calcium,
and
protein.

DEPENDENT:
 Administer DEPENDENT:
estrogen or • For
androgens to healthy
decrease the bones
rate of bone
resorption as
prescribed.
 Administer
calcium, • For
vitamin D, and bone
phosphorus as metabolism
.

 Administer
calcitonin as • To
prescribed inhibit bone
 Administer loss.
analgesics, • To
muscle help reduce
the pain.
relaxants, and
anti-
inflammatory
medications as
prescribed

COLLABORATIVE:

COLLABORATIVE:
 Refer client to
Nutrionist  This will
help the
client to
understand
more about
the
importance
of diet high
in protein,
calcium,
vitamins C,
D and iron.
 Refer client to
orthopedic  To help
client know
department
more about
her
condition.
 DRUG STUDY

MEDICATION GENERIC DOSAGE INDICATION/ SHAPE & COLOR NURSING

ACTION/CON
(BRAND NAME OF MEDICATION RESPONSIBLITY
TRADICTION
NAME)
Brand Name: Alendronate Alendronate Alendronate is used to CLINICAL
Fosamax, prevent and treat ALERT
40mg 1 tab
Binosto, Fosamax certain types of bone Name confusion has
Plus D OD PO loss (osteoporosis) in occurred
adults. Osteoporosis between Fosamax (al
Drug Class: causes bones to endronate)
Calcium become thinner and and Flomax (tamsulo
Metabolism break more easily. sin); use caution.
Modifiers; Your chance of Assessment
Bisphosphonate developing
osteoporosis increases  History: Allergy
Derivatives
as you age, after to bisphosphona
menopause, or if you tes, renal failure,
are taking upper GI
corticosteroid disease,
medications (such as lactation,
prednisone) for a long pregnancy
time.  Physical: Muscl
e tone, bone
Alendronate works by pain; bowel
slowing bone loss. sounds;
This effect helps urinalysis,
maintain strong bones serum calcium
and reduce the risk of Interventions
broken bones  WARNING: Gi
(fractures). ve in AM with
Alendronate belongs full glass of
to a class of drugs water at least 30
called min before the
bisphosphonates. first beverage,
food, or
INDICATION medication of
 Treatment and the day. Patient
prevention of must stay
osteoporosis in upright for 30
postmenopaus min.
al women  Monitor serum
calcium levels
before, during,
  Treatment of and after
men with therapy.
osteoporosis  Ensure 6-mo
 Treatment of rest period after
treatment
glucocorticoid-
for Paget’s dise
induced
ase
osteoporosis if retreatment is
 Treatment of required.
Paget’s disease  Ensure adequate
of bone in vitamin D and
patients with calcium intake.
alkaline  Provide comfort
phosphatase at measures if
least two times bone pain
upper limit of returns.
normal, those Teaching points
who are  Take drug in
symptomatic, morning with a
those at risk for full glass of
future plain water (not
complications mineral water),
at least 30 min
CONTRAINDICATI before any
ONS AND beverage, food,
CAUTIONS or medication,
Contraindicated with and stay upright
allergy to for 30 min and
biphosphonates; until after the
hypocalcemia. first food of the
day.
Use cautiously with  You may
renal dysfunction, experience these
side effects:
upper GI disease,
Nausea,
pregnancy, lactation. diarrhea; bone
pain, headache
(analgesic may
help).
 Report
twitching,
muscle spasms,
dark-colored
urine, severe dia
rrhea.
 WESLEYAN UNIVERSITY-PHILIPPINES
Mabini Extension, Cabanatuan City, Nueva Ecija
College of Nursing and Allied Medical Sciences

PART 3

Orthopedic Affiliation
A protective shell of fiberglass, plastic, or plaster, and
bandage that is molded to protect broken or fractured
limb(s) as it heals. A cast holds a broken bone (fracture) in
place and prevents the area around it from moving as it
heals. Casts also help prevent or decrease muscle
contractions and help keep the injured area immobile,
especially after surgery, which can also help decrease pain.

Casts and splints are orthopedic devices that are used to

protect and support fractured or injured bones and joints.
They help to immobilize the injured limb to keep the bone in
place until it fully heals. Casts are often made from fiberglass
or plaster.
After a bone is broken it needs rest and support to heal
properly. Orthopedic doctors use casts to support and
protect injured bones. A cast is a supportive bandage that is
solid and wraps all the way around the extremity.

Casts come in many shapes and sizes, but the two most
common types of cast material used are plaster and
fiberglass. While casts can be uncomfortable and
cumbersome, they are an effective and efficient method to
treat fractures.

While fiberglass material is newer, many casts used today are

still made from plaster. Plaster casts are most often used when
a fracture reduction (repositioning of the bone) is performed.

The reason plaster is used after repositioning the bone is that

plaster can be well molded to the patient, and therefore it
can support the bone more precisely. When a bone was out
of position and is manipulated back into position, plaster may
be used to help hold the bone in the proper position.

The problem with plaster is that it is heavy and must remain

dry. Plaster casts are a burden for the patient because of
their bulky and heavy material. Furthermore, water will distort
the cast shape and can cause problems for healing should
the cast get wet.

Fiberglass casts are usually fitted when the bone is not out of
position, or if the healing process has already
started. Fiberglass casts are lighter weight, longer wearing,
and more breathable than plaster. The fiberglass casts are
sturdier than the plaster and require less maintenance.

The vast majority of casts used today are fiberglass. The other
advantage of fiberglass that is appealing to many (not just
kids) is that it comes in many colors and is easy to 'dress up.'

Both plaster and fiberglass casts are wrapped over a few

layers of cotton that serve to protect the skin. Keeping this
cotton clean and dry will be of utmost importance for your
comfort. There is a special type of padding material that can
be used under fiberglass casts to allow the cast to get wet.
Ask your doctor if you are interested in a "waterproof" cast.

Casts can also be differentiated from splint materials. A splint

is often referred to by other names such as a soft cast or
temporary cast.

Splints are often used when more rigid immobilization is not

needed, or in the early stages after a fracture has occurred.
For example, seldom do patients leave a hospital emergency
room in a cast. Instead, after their fracture is diagnosed, they
are typically splinted. Splints can be made of many materials

The advantage of the splint in this setting is that there is more

room for swelling. A potentially devastating complication of
cast treatment after a fracture is compartment
syndrome. This condition occurs when too much pressure
builds up inside the body and can occur after a fracture
when swelling occurs in a space confined by a cast.

While compartment syndrome typically causes severe pain,

this can be difficult to distinguish from normal fracture pain
after a broken bone, and therefore most doctors don't want
to risk a complication and will, therefore, use a splint to ensure
there is adequate room for swelling.
 Evaluate the client’s pain, noting severity, nature, exact
location, source and alleviating and exacerbating
factors.
 Access neurovascular status.
 Inspect for and document any skin lesions, discoloration,
or no removable foreign material.
 Evaluate the client’s ability to learn essential procedures,
such as applying slings correctly, crutch walking, or using
a walker.

 Uses a pulling force to promote and maintain alignment

to an injured part of the body.
 Traction is used primarily as a short-term intervention until
other modalities, such as external or internal fixation, are
possible.
 Whenever traction is applied, counter traction must be
used to achieve effective results Traction is applied
 Reduce a fracture
 Reduce dislocation of a joint
The two main types of traction are skeletal traction and skin
traction. The type of traction used will depend on the
location and the nature of the problem.

Skeletal traction involves placing a pin, wire, or screw in the

fractured bone. After one of these devices has been
inserted, weights are attached to it so the bone can be
pulled into the correct position. This type of surgery may be
done using a general, spinal, or local anesthetic to keep you
from feeling pain during the procedure.

The amount of time needed to perform skeletal traction will

depend on whether it’s a preparation for a more definitive
procedure or the only surgery that’ll be done to allow the
bone to heal.

Skeletal traction is most commonly used to treat fractures of

the femur, or thighbone. It’s also the preferred method when
greater force needs to be applied to the affected area. The
force is directly applied to the bone, which means more
weight can be added with less risk of damaging the
surrounding soft tissues.

Skin traction is far less invasive than skeletal traction. It

involves applying splints, bandages, or adhesive tapes to the
skin directly below the fracture. Once the material has been
applied, weights are fastened to it. The affected body part is
then pulled into the right position using a pulley system
attached to the hospital bed.

Skin traction is used when the soft tissues, such as the muscles
and tendons, need to be repaired. Less force is applied
during skin traction to avoid irritating or damaging the skin
and other soft tissues. Skin traction is rarely the only treatment
needed. Instead, it’s usually used as a temporary way to
stabilize a broken bone until the definitive surgery is
performed.
 Avoid wrinkling and slipping of the traction bandage
and to maintain countertration.
 Proper positioning must be maintained.
 The patient should not turn from side to side.
 Check for signs of irritation or inflammation.
 Removes the foam boots to inspect the skin, ankle the
Achilles tendon 3x a day .
 Palpate the area of the traction tapes daily.
 Provide frequent repositioning to alleviate pressure and
discomfort.
 Use advance static mattresses or overlays.
 Questioning regularly about the sensation and ask the
patient to move toes/foot.
 Assess circulation of foot within 15-30 mins and then
every 1-2 hours .
 Encourage the patient to perform active foot exercises
every hour when awake.
Orthopaedic braces are objects made of rigid materials,
such as hard plastics, and soft materials such as spandex or
other tightly-knit fabrics designed to inhibit the movement of
a joint. The purpose of a brace is to ensure that a joint is
unable to move beyond a certain range of motion, or in
some cases at all. This ensures all connective tissues get the
chance to heal properly. Unlike a cast, a brace can be easily
worn or removed for bathing or physical therapy. In some
cases, a brace can even allow you to retain use of your
muscles for reasonable exercise. Orthopedic braces serve a
large number of purposes, depending on which body part
needs healing assistance.
Orthopaedics is the medical specialty that focuses on
injuries and diseases of your body's musculoskeletal system.
This complex system, which includes your bones, joints,
ligaments, tendons, muscles, and nerves, allows you to
move, work, and be active.Once devoted to the care of
children with spine and limb deformities, orthopaedists now
care for patients of all ages, from newborns with clubfeet
to young athletes requiring arthroscopic surgery to older
people with arthritis. And anybody can break a bone.

Bone regeneration strategies offer new and alternative

therapies for orthopedic applications including nonunion of
fractures, healing of critical-sized segmental defects, and
regeneration of articular cartilage in degenerative joint
diseases such as osteoarthritis. Although, to date, an
understanding of skeletal stem cell fate and
immunophenotype has proved a significant challenge, the
need for simple, safe, and efficacious protocols for the use of
skeletal stem cells in bone regeneration remains a central
issue. Ultimately, approaches will include (but not exclusively)
the development and integration of immuno-privileged
constructs containing an appropriate scaffold and
impregnated with sustained-release growth factors and
viable autogenous skeletal cells and,
ultimately, allogeneic skeletal populations.

The development of such a construct clearly requires close

coordination within a multidisciplinary framework, involving
cell scientist, biomedical engineer, mathematician, clinician,
and patient. Over the coming years, our understanding of
the continuum of skeletal cell development along the
osteogenic lineage and the role of the skeletal niche as well
as cell fate, plasticity, and the relevance of these
observations in vivo will be the key to clinical success. Current
avenues of research will undoubtedly focus on a phenotypic
fingerprint for the skeletal stem cell together with the
derivation of expansion protocols in defined media for
clinical application utilizing scaffolds that function as a
developmentally conducive extracellular niche.

Developmental paradigms in the context of musculoskeletal

tissue formation and in the adult context of injury and disease
will suggest, lead, and offer new insights into bone
regeneration. Thus, the development of protocols, tools, and
above all multidisciplinary approaches across the life science
and clinical science interface, for de novo tissue formation
using skeletal progenitor and stem cell populations, offers
exciting opportunities to improve the quality of life of many in
an increasing aging population.

During the process of researching orthopedic surgery I

thought it would be a mass variety of do's and don'ts with
all these big medical terms that only doctors would no and
has absolutely no value to a civilian. Of course that's what
it looked like when I started researching but when I started
searching for the definitions of words, looking and pictures
it all becomes very simple. Maybe not every little thing such
as a knee replacement but how they websites use their
vocabulary. Towards the middle of research I started to feel
like I was actually learning true things about orthopedic
surgery, for example, how certain things are said and done
such as explaining a surgery to a patient and seeing if they
are suitable. I know now that when you go into greater
detail and depth into something you might be interested in
you open your eyes into a new world of things I didn't even
know existed.

The occurence of an intrathoracic fracture dislocation of the

proximal humerus represents a true emergency despite the
initial clinical presentation being benign. Subtle clinical
indicators of an intrathoracic dislocation include
subcutaneous emphysema and the absence of a palpable
radial head in the anterior shoulder or axilla. Definitive
Management should include concurrent orthopaedic and
thoracic surgical consultation. Orthopaedic management
would generally consist of hemiarthroplasty, although
internal fixation may be attempted in a young patient. The
indications for thoracotomy and extraction of the humeral
head include progressive cardiopulmonary
compromise. Most importantly, awareness of this entity is
important as it can be easily overlooked as it was by our
trauma service.
 JORELLE I. CARBONELL
22 years old
Male
Single
Filipino
May 28, 1999
National Highway, Purok 2 Barangay Lipit Dipaculao, Aurora
3203

EDUCATIONAL BACKGROUND

ELEMENTARY
LIPIT ELEMENTARY SCHOOL
SECONDARY
FATHER JOHN KARASH MEMORIAL HIGH SCHOOL
TERTIARY
WESLEYAN UNIVERSITY - PHILPPINES
American Orthopedic Surgeon (November 2017), retrieved from:
https://orthoinfo.aaos.org/en/treatment/orthopaedics/

J.I. Dawson, ... R.O.C. Oreffo, in Comprehensive Biotechnology (Third Edition 2011), retrieved
from: https://www.sciencedirect.com/topics/earth-and-planetary-sciences/orthopedics