Disturbances in Visual and Auditory Function o Examine conjunctiva, sclera, iris, cornea,

chamber
Notes:
o Pupil’s equality, size and shape
Full visual function: o Usage of Snellen Chart
o Auricles if there are any lesions, nodules
o Intact retina o Auditory canal
o Clear lens o Weber tests, Rinne, Whispers test
o Normal intraocular pressure (IOP) ▪ Palpation
Hearing loss – common disability causes significant o Eyelids (swelling, pain, tenderness)
alteration o Lacrimal sac if there are any drainage
o Mastoid area of ears (if it is warm to touch)
Nursing History
Visual
▪ CC:
o Visual Floaters Cataract
o Visual loss ▪ A cataract is a lens opacity or cloudiness.
o Eye pain ▪ Opacity or cloudiness
o Diplopia ▪ Leading cause of blindness especially when (hindi
o Decreased visual acuity/clarity na operahan)
o Defects in color vision
o Diff seeing at night Signs and symptoms
▪ Present illness:
Clinical Manifestations
o Symptom
o Location (Right or Left eye) 1. Painless, blurry vision (characteristic of cataracts)
o Duration 2. Dim surroundings
o Radiation 3. Light scattering is common: reduced contrast
o Intensity sensitivity, sensitivity to glare, and reduced visual
o Frequency acuity
o Precipitating and alleviating factors 4. Myopic shift, astigmatism, monocular diplopia
o Ask if using glasses or contact lenses (if (double vision), color shift, brunescens, and
there is grado) reduced light transmission.
▪ Medical History:
Note: Na oobserve: Pupil (milky white)
o Allergies
o Hypertensive
o Diabetic
o CVA
o Multiple Sclerosis
o If patient did a corrective eye surgery
▪ Family History
o DM
o Hypertension
Physical Assessment
▪ Inspection
o Eye movement
o Ability to focus
o Appearance of eyelid, eyeball, lacrimal
apparatus if there are any discharges
Notes:
▪ Toxic – more on adverse effect of drugs
▪ Senile – about age
▪ Congenital – develops when pregnant
Risk Factors
1. Aging (40 y/o or older)
a. Loss of lens transparency
b. Clumping or aggregation of lens protein
c. Accumulation of a yellow-brown pigment due
to the breakdown of lens protein
d. Decreased oxygen uptake
e. Increase in sodium and calcium
f. Decrease in levels of vitamin C, protein, and
glutathione
2. Associated Ocular Conditions
a. Retinitis pigmentosa
b. Myopia
c. Retinal detachment and retinal surgery
d. Infection
3. Nutritional Factors
a. Reduced levels of antioxidants
b. Poor nutrition
c. Obesity
4. Toxic Factors
a. Corticosteroids, especially at high doses and
in long-term use
b. Alkaline chemical eye burns, poisoning
c. Cigarette smoking
d. Calcium, copper, iron, gold, silver, and
mercury, which tend to deposit in the pupillary
area of the lens
5. Physical Factors
a. Dehydration associated with chronic diarrhea,
use of purgatives in anorexia nervosa, and
use of hyperbaric oxygenation
b. Blunt trauma, perforation of the lens with a
sharp object or foreign body, electric shock
c. Ultraviolet radiation in sunlight and x-ray
6. Systemic Diseases and Syndromes
a. Diabetes mellitus
b. Down syndrome
c. Disorders related to lipid metabolism
d. Renal disorders
e. Musculoskeletal disorders
Pathophysiology
1. Cataracts can develop in one or both eyes at any
age as a result of a variety of causes. Cigarette
smoking, long-term use of corticosteroids,
especially at high doses, sunlight and ionizing
radiation, diabetes, obesity, and eye injuries can
increase the risk of cataracts.
2. The three most common types of senile (age-
related) cataracts:
a. Nuclear cataract - Caused by central opacity
in the lens and has a substantial genetic
component. It is associated with myopia
(nearsightedness), which worsens when the
cataract progresses. If dense, the cataract
severely blurs vision. Periodic changes in
prescription eyeglasses help manage this
condition.
b. Cortical cataract - Involves the anterior,
posterior, or equatorial cortex of the lens.
Cortical cataracts progress at a highly variable
rate. Vision is worse in very bright light.
People with the highest levels of sunlight
exposure have twice the risk of developing
cortical cataracts as those with low-level
sunlight exposure.
c. Posterior subcapsular cataracts- Occur in
front of the posterior capsule. This type
typically develops in younger people and, in
some cases, is associated with prolonged
corticosteroid use, diabetes, or ocular trauma.
Near vision is diminished, and the eye is
increasingly sensitive to glare from bright light
(sunlight, headlights).
Assessment and Diagnostic Findings
1. Decreased visual acuity
2. Snellen visual acuity test, Ophthalmoscopy, and Slit-
lamp biomicroscopic examination are used to establish the
degree of cataract formation.
Medical Management
✓ No nonsurgical (medications, eyedrops,
eyeglasses) treatment cures cataracts or prevents
age-related cataracts.
✓ Glasses, Contact lenses, Strong bifocals, or
Magnifying lenses
Surgical Management (treatment option of choice to age
related cataract)
1. Phacoemulsification
2. Lens Replacement
a. Aphakic eyeglasses
b. Contact lenses
c. IOL implants
Notes:
Can be prescribed 6-8 weeks before surgery (lenses)
Binibigyan corticosteroids after surgery pero minsan
sobrang corticosteroid can be a risk factor
Preoperative nursing interventions
▪ Explain the importance of compliance in a
preadmission interview
▪ Make sure that someone can drive the patient to
and from the day surgery center
▪ Tell the patient to tilt his head backward when
shampooing, to prevent jarring the eye and
increasing intraocular pressure
▪ Administer a preoperative laxative to prevent
straining during defecation, which increases
intraocular pressure
▪ Explain preoperative and postoperative care to
decrease the patient’s anxiety
▪ Answer questions and encourage the patient to
discuss concerns
Postoperative nursing interventions
▪ Review postoperative instructions to improve
compliance and prevent complications; the patient
may have difficulty reading instructions because of
impaired vision
▪ Tell the patient not to bend, strain, lift, cough,
sneeze, or rub the eye postoperatively; these
actions can increase intraocular pressure, which
can lead to complications, such as bleeding,
vitreous herniation, vision loss, pain, and wound
dehiscence; rubbing also increases the chance of
infection
▪ Tell the patient not to make quick movements or
read, which could irritate the patched eye or
dislodge an implanted lens
▪ Teach the patient or family member how to
administer eye medications properly
▪ Teach the patient how to clean the eye to prevent
infection
▪ Have the patient wear an eye shield and patch to
protect the eye from injury; tell him to keep the eye
patch dry and to wear an eye shield while sleeping
▪ Tell the patient to call the practitioner if any of
these signs or symptoms occur: eye pain that isn’t
relieved with analgesics, yellow or green
discharge, temperature above 100°F (37.8°C),
blurred vision, nausea and vomiting, and seeing
halos around lights
▪ Explain postoperative activity restrictions
▪ The patient may walk, climb stairs, watch
television, and perform daily activities but should
avoid engaging in strenuous physical activity and
lifting more than 10 lb (4.5 kg)
▪ The patient may bathe or shower but should avoid
getting water on the eye patch by tilting his head
back when shampooing
▪ The patient should avoid bending from the waist
and hanging the head forward; a long-handled
grabber may be used to pick up objects
▪ Make sure the patient is cared for by a family
member or friend after surgery
▪ Advise the patient to refrain from sexual activity
until he receives his practitioner’s approval
Promote Home and Community-Based Care
1. Teaching Patients Self-Care
a. Wear a protective eye patch for 24 hours after
surgery, followed by eyeglasses worn during the
day and a metal shield worn at night for 1 to 4
weeks.
b. Instruct the patient and family in applying and
caring for the eye shield.
c. Wear sunglasses while outdoors during the day
because the eye is sensitive to light.
d. Inform the patient that there may be slight morning
discharge, some redness, and a scratchy feeling
may be expected for a few days. A clean, damp
washcloth may be used to remove slight morning
eye discharge.
e. Notify the surgeon if new floaters (dots) in vision,
flashing lights, decrease in vision, pain, or
increase in redness occurs (because cataract
surgery increases the risk of retinal detachment,
pag matanda na yung floaters normal lang)
Continuing Care Glaucoma
1. Inform the patient: ▪ This group of disorders is characterized by high
intraocular pressure
a. Eye patch is removed after the first follow-
▪ (IOP) and optic nerve damage that affects
up appointment.
peripheral vision
b. May experience blurring of vision for
▪ Kada once in every 2 years magpa exam si patient
several days to weeks.
▪ For eye drop: 5 minutes interval for adequate
c. Sutures, if used, are left in the eye but
absorption
alter the curvature of the cornea, resulting
in temporary blurring and some
astigmatism.
d. Vision gradually improves as the eye
heals.
2. Patients with IOL implants:
a. Have functional vision on the first day
after surgery.
b. Vision is stabilized when the eye is
completely healed, usually within 6 to 12
weeks, when final corrective prescription
is completed.
Forms of glaucoma:
3. Patients who choose multifocal IOLs should be
aware that there may be increased night glare and contrast ▪ Open-angle (also known as chronic, simple, or
sensitivity. wide angle) glaucoma, which begins insidiously
and progresses slowly
Intraocular Lens Implant
▪ Angle-closure (also known as acute or narrow
1. Wear glasses or metal eye shield at all times angle) glaucoma, which occurs suddenly and can
following surgery as instructed by the physician. cause permanent vision loss in 48 to 72 hours
2. Always wash hands before touching or cleaning
Note:
the postoperative eye.
3. Clean postoperative eye with a clean tissue; wipe ▪ pilocarpine eyedrop – myotic drugs to treat
the closed eye with a single gesture from the glaucoma, nagkakaron ng blurred vision 1-2 hours
inner canthus outward. ▪ medications requires a lifelong treatment in
4. Bathe or shower; shampoo hair cautiously or glaucoma
seek assistance.
Signs and symptoms
5. Avoid lying on the side of the affected eye the
night after surgery. ▪ Open-angle glaucoma
6. Keep activity light (walking, reading, watching o possibly no symptoms, dull, morning
television). Resume the following activities only headache; mild aching in the eyes, loss of
as directed by the physician: driving, sexual peripheral vision; halos around lights; and
activity, unusually strenuous activity. reduced visual acuity (especially at night)
7. Avoid lifting, pushing, or pulling objects heavier that’s uncorrected by glasses
than 15 lb. ▪ Angle-closure
8. Avoid bending or stooping for an extended o rapid onset with pain and pressure over
period. the eye, blurred vision, decreased visual
9. Be careful when climbing or descending stairs. acuity, halos around lights, and nausea
10. Know when to contact the physician. and vomiting
Clinical Manifestation Signs and symptoms
✓ blurred vision or “halos” around lights ▪ may occur slowly or suddenly
✓ difficulty focusing ▪ include dark or irregular vitreous floaters, flashes
✓ difficulty adjusting eyes in low lighting of light, and progressive loss of vision in one area
✓ loss of peripheral vision
Note: walang eye pain, walang vision loss or halo around
✓ aching or discomfort around the eyes
the light
✓ headache
Diagnosis and treatment
Pathophysiology
▪ Ophthalmoscopy
1. The direct mechanical theory suggests that high
▪ Surgery
IOP damages the retinal layer as it passes through
▪ Diathermy
the optic nerve head.
▪ Laser photocoagulation
2. The indirect ischemic theory suggests that high
▪ Cryotherapy uses nitrous oxide
IOP compresses the microcirculation in the optic
▪ Scleral buckling
nerve head, resulting in cell injury and death.
▪ Treatment requires bed rest with the affected eye
Diagnosis and treatments patched and the patient’s head positioned
▪ Tonometry; perimetry or visual field tests Preoperative nursing interventions
▪ Ophthalmoscopy; gonioscopy
▪ Place the patient on bed rest, patch the eye as
▪ Other diagnostic tests: slit-lamp examination
prescribed, and position the patient’s head so that
and fundus photography
the retinal tear or hole is at the lowest point of the
▪ Drugs: topical adrenergic agonists, cholinergic
eye (if the detachment is toward the outer side of
agonists, beta-adrenergic blockers, and topical or
the head, have the patient lie on the affected side
oral carbonic anhydrase inhibitors (kasi
with the bed flat); these interventions help prevent
nakakapag increase ng fluid)
further detachment
▪ Surgery or laser treatments
▪ Provide emotional support to the patient who may
Nursing interventions be distraught at the potential loss of vision
▪ Prepare the patient for surgery by cleaning his
▪ Encourage patient compliance by teaching the
face and giving him antibiotics and eyedrops, as
patient about medications
ordered
▪ Postoperatively, give medications, as ordered, to
▪ Teach the patient about the role of the retina and
dilate the pupil and topical corticosteroids to rest
why floaters, flashes of light, and decreased vision
the pupil and protect the affected eye
occur
▪ Administer pain medication as ordered
▪ Allow the patient and family to discuss their
▪ Encourage the patient to be ambulatory
concerns
immediately after surgery
▪ Explain the preoperative routines and the surgical
Detachment of the Retina procedure

▪ is the separation of the sensory layers of the retina
from the underlying retinal pigment epithelium;
without treatment, the entire retina may detach,
causing severe vision impairment and possible
blindness
Postoperative nursing interventions
▪ Position the patient as directed; the position varies
according to the surgical procedure
▪ Tell the patient to avoid activities that increase
intraocular pressure, such as sneezing, coughing,
vomiting, lifting, straining during defecation,
bending from the waist, and rapidly moving the
head; increased intraocular pressure may cause
 more fluid to flow behind the retina before healing
is complete
▪ Administer eyedrops, antiemetics, analgesics,
and antibiotics, as ordered; to reduce corneal
edema and discomfort, apply ice packs as ordered
▪ Tell the patient to notify the practitioner if he
experiences floaters, flashes of light, blurred
vision, or pain that isn’t relieved with analgesics;
these symptoms indicate recurrence of
detachment
▪ Teach the patient to recognize and report the
signs and symptoms of infection, such as
temperature above 100° F (37.8° C), yellow or
green discharge, increased redness or pulling of
the eye or lid, and vision loss
▪ Show the patient how to administer eye
medications and change dressings using sterile
technique to decrease the risk of infection
▪ Tell the patient to wear the eye shield at night or
when napping to prevent accidental injury to the
eye
▪ Discuss when the patient can return to work,
resume activities of daily living, and drive or
perform strenuous activities
Common causes of blindness and visual impairment:
▪ Diabetic retinopathy
▪ Macular degeneration (pinaka risk factor for
blindness)
o Pag may nakitang lines si patient (amsler
grid, response kay patient – instruct to
visit ophthalmologist)
▪ Glaucoma
▪ Cataract
Meniere’s disease
▪ a blockage in the endolymphatic duct.
Endolymphatic hydrops, a dilation in the
endolymphatic space, develops, and either
increased pressure in the system or rupture of the
inner ear membrane occurs, producing symptoms
of Meniere’s disease.
Types
1. Cochlear
▪ Fluctuating, progressive sensorineural
hearing loss associated with tinnitus and aural
pressure in the absence of vestibular
symptoms or findings.
2. Vestibular
▪ Characterized as the occurrence of episodic
vertigo associated with aural pressure but no
cochlear symptoms.
Risk Factors
1. Positive family history
2. More common in adults (sa bata kasi nagsisismula
sa otitis media)
3. An average age of onset in the 40s, with
symptoms usually beginning between the ages of
20 and 60 years
4. Appears to be equally common in men and
women
Clinical Manifestations
1. Fluctuating, progressive sensorineural hearing
loss – hindi laging may hearing loss pero it may
worsen
2. Tinnitus or a roaring sound (kay cochlear)
3. Feeling of pressure or fullness in the ear
4. Episodic, incapacitating vertigo, often
accompanied by nausea and vomiting
Assessment and Diagnostic Findings
1. Careful history of the frequency, duration, severity,
and character of the vertigo attacks
2. Weber test - sounds may lateralize to the ear
opposite the hearing loss, the one affected
3. Audiogram - sensorineural hearing loss in the
affected ear progresses
4. Electronystagmogram - may be normal or may
show reduced vestibular response
Note:
- diagnostic procedure siya
- nurse may ask if the pt drinks tranquilizer (5
days before this procedure hindi dapat mag take
si patient because it may alter the result or mga
stimulants kasi it measures electrical potential
eye movement
Medical Management Notes:
Most patients with Meniere’s disease can be successfully Patient undergoes mastoidectomy, ang post op nursing
treated with diet and medication. mgt is to instruct patient that pt should protect ear for any
water na papasok sa ears nya to prevent infection
1. Low-sodium (1000 to 1500 mg/day or less) diet –
because the amount of sodium is one of the factors Hearing Impairment
regulates imbalance in fluids of the body kaya hindi
HEARING LOSS
pwedeng lumagpas sa 1500mg/day
Risk Factors
Note: foods rich in sugar, salty foods and canned foods
yung mga iiwasan 1. Genetic
2. Greater in men than in women
2. Pharmacologic Therapy
3. 55 years of age or older
a. Antihistamines: Meclizine (Antivert) 4. Occupations: carpentry, plumbing, and coal
mining
b. Tranquilizers: diazepam (Valium) – helps
5. Family history of sensorineural impairment
control vertigo
6. Congenital malformations of the cranial structure
c. Antiemetic: Promethazine (Phenergan) – (ear)
common; controls nausea, vomiting and vertigo 7. Low birth weight ((1500 g)
8. Use of ototoxic medications (gentamycin, loop
d. Diuretic therapy: Hydrochlorothiazide diuretics, aminoglycosides, aspirin, quinine)
[Dyazide], Triamterene [Dyrenium]) – relieve 9. Recurrent ear infections
symptoms in endolymphatic system 10. Bacterial meningitis
e. Methantheline bromide (Banthine) 11. Chronic exposure to loud noises
12. Perforation of the tympanic membrane
f. Intratympanic injection of Gentamicin
(Garamycin) Types

Surgical Management 1. Conductive hearing loss

1. Endolymphatic Sac Decompression
- Equalizes the pressure in the endolymphatic
space.
- First-line surgical approach to treat the vertigo of
Meniere’s disease because it is relatively simple
and safe and can be performed on an outpatient
basis.
2. Vestibular Nerve Sectioning
- Provides the greatest success rate
(approximately 98%) in eliminating the attacks of
vertigo.
- Cutting the nerve prevents the brain from
receiving input from the semicircular canals.
- Result from an external ear disorder
- For example, may middle ear disorder like
otitis media because it may disrupt the sound
- May nabuong seromin na Malaki at matigas
na
2. Sensorineural hearing loss
- Damage cochlear and vestibular nerve
3. Mixed hearing loss
- (Conductive and Sensorineural)
- Example si patient has been dx with chronic
otitis media, there is possibility na magkaron
ng cholesteatoma (tumor sa external ear
canal sa eardrums)
4. Functional hearing loss
- Non organic or unrelated to destructional
changes in hearing; manifestation of
emotional disturbance
Clinical Manifestations
1. Early: tinnitus, increasing inability to hear when in
a group, and a need to turn up the volume of the
television
2. Changes in attitude, the ability to communicate,
the awareness of surroundings, and even the
ability to protect oneself
3. Student may be uninterested and inattentive and
have failing grades
4. A person at home may feel isolated
5. May attempt to cross the street and fail to hear an
approaching car
Prevention
1. Noise level regulations: maximum legal amount to
noise over an average working day or week of 80
dB, with a peak sound pressure of 135 dB.
2. Workers should wear ear protection to prevent
noise-induced hearing loss when exposed to
noise above the legal limits. Ear protection against
noise is the most effective preventive measure
available. Hearing loss due to noise is permanent
because the hair cells in the organ of Corti are
destroyed.
Note:
if patient is exposed to too much loud noise magiging
severe yung hearing impairment
80-90 dB – noise induce hearing loss
Medical Management
▪ Permanent hearing loss: Aural rehabilitation
Nursing Management
A. For the Person Who is Hearing-impaired Whose
Speech is Difficult to Understand
1. Determine how the person prefers to
communicate with others. Do not assume that
writing, gestures, or other means are the best or
preferred technique.
2. Consider if the person uses sign language;
provide interpreters.
3. Devote full attention to what the person is saying.
Look and listen do not try to attend to another task
while listening.
4. Engage the speaker in conversation when it is
possible for you to anticipate the replies.
5. Determine the essential context of what is being
said.
6. Do not try to appear as if you understand if you do
not.
7. Have the person write the message rather than
risk misunderstanding. (pero kailangan pa din
natin i-assess if nakakapagsulat si patient)
8. Have the person repeat the message in speech,
after you know its content.
9. Provide written material written at a third-grade
level.
B. For the Person Who is Hearing-impaired Who
Speech Reads:
1. When speaking, always face the person as
directly as possible.
2. Make sure your face is as clearly visible as
possible. Locate yourself so that your face is well
lighted; avoid being silhouetted against strong
light. Do not obscure the person’s view of your
mouth in any way; avoid talking with any object
held in your mouth.
3. Be sure that the patient knows the topic or subject
before going ahead with what you plan to say.
4. Speak slowly and distinctly, pausing more
frequently than you would normally.
5. If you question whether some important direction
or instruction has been understood, check to be
certain that the patient has the full meaning of your
message.
6. If for any reason your mouth must be covered (as
with a mask) and you must direct or instruct the
patient, write the message.
Notes:
Whisper Test ang pwedeng gawin kay patient na may
hearing impairment
If patient is scheduled for MRI, kasi baka hindi
magkaintindihan ni patient dahil sa hearing loss
Additional Notes:
Rinne’s test – air conducted sound louder than the bone
conducted sound
If may hearing loss nurse should know if may trauma can be used to identify orbital tumors, retinal detachment,
vitreous hemorrhage, and changes in tissue composition
Pag long term or regular use of kinin medications, for mgt
with minimal discomfort for the patient.
of leg cramps and associated with hearing loss or hearing
acuity ▪ Ultrasonography
Pre op teaching for otosclerosis, after OR ma eexperience
ni patient na may hearing loss kasi yun yung effect at first
If patient has medications, he should be aware of regimen
kasi baka magkaron ng adverse effect na ototoxicity if too
much medications
If nagkaron si patient ng mastoid surgery, ang discharge
planning ay hindi pwede mag blow for 2-3 weeks dahil sa
pressure (lifting, nose blowing or sneezing kasi
magccause ng trauma)
Quiz:
What is the single most important diagnostic instrument in
detecting hearing loss?
▪ Audiometry
It can be used to evaluate if a person’s vertigo is becoming
worse or to evaluate the person’s response to treatment?
▪ Platform Post urography
First-line surgical approach to treat the vertigo of Ménière’s
disease because it is relatively simple and safe and can be
performed on an outpatient basis.
▪ Endolymphatic Sac Decompression
A detectable electrical potential from cranial nerve VIII and
the ascending auditory pathways of the brain stem in
response to sound stimulation.
▪ Auditory Brain Stem Response
IOL implantation is contraindicated in patients with,
except?
▪ Cataract
Which diagnostic enables the examiner to examine the eye
with magnification of 10 to 40 times the real image?
▪ Slit-Lamp Examination
Which detects retinal lesions?
▪ Color Fundus Photography
Responses to Altered Coordination Palpation:
Physical Assessment: -kung ano ininspect yun din ipapalpate
- masses, deformity, tenderness
Musculoskeletal:
- evaluate strength
- chief complaint - joints for any tenderness, crepitus, temperature
- pain (intensity, duration, frequency, precipitating - palpate arterial pulse and capillary refill
and alleviating factors) - NVS status (movement and sensation)
- daily activities are affected
- ask patient if using assistive devices (walkers,
1.Injuries
cane, etc.)
- ask patient taking OCT drugs to alleviate pain Fracture
A fracture is a complete or incomplete disruption in the
Medical history: other musculoskeletal disorder
continuity of bone structure. When the bone is broken,
Female: If using oral contraceptive/hormone therapy/ adjacent structures are also affected, resulting in soft
premenstrual or postmenstrual symptoms tissue edema, hemorrhage into the muscles and joints,
joint dislocations, ruptured tendons, severed nerves, and
Family history: musculoskeletal problems that runs in the
damaged blood vessels.
family
Notes: injured by falls, pwede maka damage yung mga
Social history:
fracture fragments, hindi lang bone affected, pati yung mga
- work surrounding parts
- exercise
Causes:
- diet
- hobbies ▪ direct blows
- drugs ▪ crushing forces
- alcohol ▪ sudden twisting motions
▪ extreme muscle contractions
Physical assessment: (Inspection and palpation only)
Types (may sinend syang pdf ng mga fractures na itsura
Inspection: dun daw tumingin para mas familiar)
-masses 1. Complete fracture - involves a break across the
- note for size, shape of bones, joints, body region entire cross- section of the bone and is frequently
or symmetry displaced (removed from its normal position)
- deformity 2. Incomplete fracture (green - stick fracture) -
- skin and tissues around joints, limbs and body involves a break through only part of the cross-
region section of the bone
- note color, swelling 3. Comminuted fracture - produces several bone
- observe how to stand, walks, move fragments. (durog durog)
- hand coordination 4. Closed fracture (simple fracture) - one that does
- curvature of spine not cause a break in the skin (seen in xray/mri,
- flexion, extension, etc ginagawa lang yung close reduction)
- ROM exercises 5. Open fracture (compound, or complex,
- major muscle groups (tone, strength, symmetry fracture) - one in which the skin or mucous
abnormalities, spasms, tics, tremors) membrane wound extends to the fractured bone
Specific Types of Fractures
1. Avulsion – a fracture in which a fragment of bone
has been pulled away by a tendon and its
attachment.
2. Comminuted – a fracture in which bone has
splintered into several fragments.
3. Compression – a fracture in which bone has
been compressed (seen in vertebral fractures).
4. Depressed – a fracture in which fragments are
driven inward (seen frequently in fractures of skull
and facial bones).
5. Epiphyseal – a fracture through the epiphysis.
6. Greenstick – a fracture in which one side of a
bone is broken and the other side is bent.
7. Impacted – a fracture in which a bone fragment is
driven into another bone fragment.
8. Oblique – a fracture occurring at an angle across
the bone (less stable than a transverse fracture).
9. Open – a fracture in which damage also involves
the skin or mucous membranes, also called a
compound fracture.
10. Pathologic – a fracture that occurs through an
area of diseased bone (osteoporosis, bone cyst,
Paget’s disease, bony metastasis, tumor); can
occur without trauma or fall.
11. Simple – a fracture that remains contained, with
no disruption of the skin integrity.
12. Spiral – a fracture that twists around the shaft of
the bone.
13. Stress – a fracture that results from repeated
loading of bone and muscle.
14. Transverse – a fracture that is straight across the
bone shaft
Notes: Open fracture - lumabas
Clinical Manifestations
1. Pain – di mo magagalaw basta basta kasi may
pain
2. Loss of Function
3. Deformity
4. Shortening of the extremity
5. Crepitus
6. Localized Edema and Ecchymosis
Assessment and Diagnostic Tests
1. MRI or arthroscopy – pag yung fracture hindi
open, dito makikita and confirms what type of
fracture
2. X-ray
Emergency Management
1. Immobilize the body part before the patient is moved.
a. Adequate splinting is essential.
b. Immobilization of the long bones of the lower extremities
may be accomplished by bandaging the legs together, with
the unaffected extremity serving as a splint for the injured
one.
c. In an upper extremity injury, the arm may be bandaged
to the chest, or an injured forearm may be placed in a sling.
d. The neurovascular status distal to the injury should be
assessed both before and after splinting.
2. Open fracture: the wound is covered with a sterile
dressing.
Medical Management
1. Reduction - restoration of the fracture fragments to
anatomic alignment and positioning.
a. Closed Reduction
- Accomplished by bringing the bone fragments into
anatomic alignment through manipulation and manual
traction.
- X-rays are obtained to verify that the bone fragments are
correctly aligned.
- Traction (skin or skeletal) may be used until the patient is
physiologically stable to undergo surgical fixation.
b. Open Reduction
- Through a surgical approach, the fracture fragments are
anatomically aligned.
- Internal fixation devices (metallic pins, wires, screws,
plates, nails, or rods) may be used to hold the bone
fragments in position until solid bone healing occurs.
- Internal fixation devices ensure firm approximation and
fixation of the bony fragments.
2. Immobilization
- After the fracture has been reduced, the bone fragments
must be immobilized and maintained in proper position and
alignment until union occurs.
- Immobilization may be accomplished by external or
internal fixation. Methods of external fixation include
bandages, casts, splints, continuous traction, and external
fixators.
3. Maintaining and Restoring Function
Reduction and immobilization are maintained as
prescribed to promote bone and soft tissue healing.
a. Control edema by elevating the injured extremity and
applying ice as prescribed.
b. Monitor neurovascular status (circulation, motion and
sensation).
c. Control restlessness, anxiety, and discomfort with
reassurance, position changes, and pain relief
strategies, including use of analgesics.
d. Encourage isometric and muscle-setting exercises to
minimize atrophy and to promote circulation.
e. Encourage participation in activities of daily living
(ADLs) to promote independent functioning and self-
esteem.
f. Promote gradual resumption of activities within the
therapeutic prescription.
Nursing Management
1. Patients with Closed Fractures
a. Elevate extremity to heart level.
b. Administer analgesics.
c. Exercise unaffected muscles.
d. Use mobility aids and assistive devices safely such as
crutches, walkers, and special utensils.
e. Remove floor rugs or anything that obstructs walking
paths throughout the house.
2. Patients with Open Fractures
a. Administer intravenous (IV) antibiotics immediately upon
the patient’s arrival in the hospital along with tetanus toxoid
if needed.
b. Initiate wound irrigation and debridement in the
operating room as soon as possible.
c. Reduce the fracture and stabilize by external fixation.
d. Leave wound open for 5 to 7 days for intermittent
irrigation and cleansing.
e. Elevate the extremity.
f. Assess neurovascular status frequently.
g. Monitor temperature at regular intervals
h. Observe for signs of infection.
Fracture Healing and Complications
Fracture healing and restoration of strength and mobility
may take an average maximum of 6 to 8 weeks, depending
on the quality of the patient’s bone tissue.
Factors That Enhance Fracture Healing
1. Immobilization of fracture fragments
2. Maximum bone fragment contact
3. Sufficient blood supply
4. Proper nutrition
5. Exercise: weight bearing for long bones
6. Hormones: growth hormone, thyroid, calcitonin, vitamin
D, anabolic steroids
7. Electric potential across fracture
Factors That Inhibit Fracture Healing
1. Inadequate fracture immobilization
2. Inadequate blood supply to the fracture site or adjacent
tissue
3. Displacement of fracture fragments or ends
4. Infection
5. Metabolic problems
6. Age (elderly persons heal more slowly)
7. Corticosteroids (inhibit the repair rate)
8. Malignancy
9. Weight bearing prior to approval
Early Complications
1. Hypovolemic Shock
2. Fat Embolism Syndrome
- After fracture of long bones or pelvic bones, or crush
injuries.
- At the time of fracture, fat globules may diffuse from the
marrow into the vascular compartment. The fat globules
(emboli) may occlude the small blood vessels that supply
the lungs, brain, kidneys, and other organs.
- The onset of symptoms is rapid, typically within 12 to 48
hours of injury, but may occur up to 10 days after injury.
Clinical Manifestations:
a. Presenting features - hypoxia, tachypnea, tachycardia,
and pyrexia
b. The respiratory distress response - tachypnea, dyspnea,
crackles, wheezes, precordial chest pain, cough,
large amounts of thick white sputum, and tachycardia
c. Arterial blood gas
d. Chest x-ray - shows a typical “snow- storm” infiltrate
e. Cerebral disturbances (due to hypoxia and the lodging
of fat emboli in the brain)
Prevention (immediate immobilization of fractures):
a. Early surgical fixation.
b. Minimal fracture manipulation.
c. Adequate support for fractured bones during turning and
positioning.
d. Maintenance of fluid and electrolyte balance
3. Compartment Syndrome
- Compartment syndrome in an extremity is a limb-
threatening condition that occurs when perfusion pressure
falls below tissue pressure within a closed anatomic
compartment.
- Acute compartment syndrome involves a sudden and
severe decrease in blood flow to the tissues distal to an
area of injury that results in ischemic.
Clinical Manifestations:
Five Ps: Pain, Paralysis, Paresthesias, Pallor, and
Pulselessness
Pain - a hallmark sign that occurs or intensifies with
passive ROM
- deep, throbbing, unrelenting pain, which continues to
increase despite the administration of opioids and seems
out of proportion to the injury
Management:
Maintaining the extremity at the heart level (not above
heart level), and opening and bivalving the cast or opening
the splint, if one or the other are present.
05/16/2022
1.Injuries
Sports Injury (may pdf dito)
Notes:
Clavicle Fracture:
- Clavicle can be open or close
Dislocated shoulder:
- Clinical man: Pain, lack of motion, may feel
empty shoulder socket, asymmetrical hindi
balance, affected arms appears longer
- Mgt: close reduction, immobilizer, splint or
pendulum exercises only after close reduction
(depende kung may internal or external
fixator)
Dislocated elbow:
- Clinical man: intense pain, edema, limited
motion, deformity, Ecchymosis, bluish
discoloration
- Mgt: immobilization, use of ice and ROM
exercises
Wrist sprain and fracture:
- Gentle ROM – 4-6 weeks for sprain only
 Knee sprain:
- Depende kung gaano ka severe yung injury
Knee strain:
- Strain – tendons and muscle are affected
- Sprain – ligaments are damaged
Menical tears:
- Medial tear - Meniscus tearing or damaged
- Mgt: rest, ice, compression and elevation
(RICE) medication, physical therapy,
arthoscopy pag super damaged
2.Joint Disorder
Osteoarthritis (OA)
- known as degenerative joint disease or
osteoarthrosis (even though inflammation may
be present), is the most common and most
frequently disabling of the joint disorders.
Notes:
kahit bata pwede pa din magkaroon regardless ng
risk factor na between 50-60
location san pwede magkaron: weight bearing
joints (knees, lumbar spine, proximal and distal
joints)
Classifications:
1. Primary (idiopathic) – walang prior disease related
to OA
2. Secondary – resulting from previous joint injury
Risk Factors:
1. Increased age
2. Between 50 to 60 years of age
3. Genetic – runs in the family
4. Previous joint damage (Secondary)
5. Congenital and developmental disorders of the
hip:
- congenital subluxation–dislocation of the hip,
acetabular dysplasia
- Legg-Calvé-Perthes disease
- Slipped capital femoral epiphysis
6. Obesity
7. Repetitive use of joints (occupational or
recreational) – sometimes because of weight na
naddamage na yung knees, cervical or lumbar na
hindi maayos yung body mechanics
Clinical Manifestations
1. Primary manifestations:
- Pain – inflamed ligaments or joint capsule or
irritation in nerve endings or muscle spasm
- Stiffness – most experienced in morning less
than 3-0 minutes and nawawala once moved
- Functional impairment – results from pain or
movement; limited motion
2. Painful bony nodes when inflamed
Assessment and Diagnostic Findings
1. Tender and enlarged joints
2. X-ray - progressive loss of the joint cartilage
Medical Management
1. Weight reduction
2. Prevention of injuries
3. Perinatal screening for congenital hip disease
4. Use of heat, joint rest and avoidance of joint
overuse, orthotic devices (splints, braces)
5. Isometric and postural exercises, and aerobic
exercise
6. Massage, yoga, or music therapy
7. Pulsed electromagnetic fields, or Transcutaneous
electrical nerve stimulation (TENS)
8. Occupational and physical therapy
9. Herbal and dietary supplements
10. Acupuncture, acupressure, wearing copper
bracelets or magnets, and participation in T’ai chi
11. Pharmacologic Therapy
a. Initial analgesic therapy: Acetaminophen (ex:
paracetamol)
b. Other analgesics: NSAIDs, COX-2 enzyme
blockers, Opioids, Intra-articular corticosteroids,
Topical analgesic agents such as Capsaicin
(Capsin, Zostrix), or Methylsalicylate
c. Glucosamine and Chondroitin – modify
cartilage structure
d. Intra-articular Viscosupplementation
(hyaluronates) – supplements the viscous
properties of synovial fluid
Surgical Management: Pathophysiology
1. Osteotomy 1. Hyperuricemia (serum concentration greater than 7
2. Arthroplasty mg/dL) can, but does not always, cause urate crystal
deposition.
Nursing Management: 2. When the urate crystals precipitate within a joint, an
inflammatory response occurs, and an attack of gout
Goal: pain management and functional ability of patient
begins.
1. Advise the patient to reduce weight and to exercise
3. With repeated attacks, accumulations of sodium urate
(walking).
crystals, called tophi, are deposited in peripheral areas of
2. Refer the patient for physical therapy or to an exercise
the body, such as the great toe, the hands, and the ear.
program.
3. Encourage the patient to use canes or other assistive Stages
devices for ambulation.
1. Asymptomatic hyperuricemia – di pa ramdam pero
4. Provide adequate pain management.
nagsisimula na mag accumulate
2. Acute gouty arthritis – for example: around 90% of
2.Joint Disorder
patient’s have gout’s affected part is metatarsophalangeal
Gout joint (big toe); affected din si knee; early attack: matatapos
within 3-10 days
Gout is a heterogeneous group of conditions related to a
genetic defect of purine metabolism that results in 3. Intercritical gout – symptom-free period
hyperuricemia.
4. Chronic tophaceous gout – presence of severe
Notes: inflammation; uric acids that deposits causes renal stones
that damage kidney
Kadalasan it’s with the food that we take (purine foods)
Clinical Manifestations
Nagkakaron ng purine metabolism defect
1. Early: acute arthritis
Risk Factors
At night: severe pain, redness, swelling, and warmth of
1. Primary hyperuricemia:
the affected joint
- severe dieting or starvation
2. Tophi formation – crystalline deposits accumulating in
- excessive intake of foods that are high in purines particular tissue, osseous tissue, soft tissue, and cartilage
(shellfish, organ meats), or heredity
Complications
2. Secondary hyperuricemia:
1. Renal urate lithiasis (uric acid urinary calculi/stones)
- increase in cell turnover (leukemia, multiple
2. Kidney damage/Gouty nephropathy (renal impairment)
myeloma, some types of anemias, psoriasis)
Assessment and Diagnostic Findings
- increase in cell breakdown, altered renal tubular
function, either as a major action or as an 1. Polarized light microscopy of the synovial fluid
unintended side effect of certain pharmacologic
2. Elevated serum uric acid - extensive tophus formation
agents (diuretics such as thiazides and
furosemide)
- low-dose salicylates, or ethanol, can contribute
to uric acid underexcretion
Medical Management Risk Factors
1. Acute attacks: 1. Women after menopause and in men later in life
- Colchicine (oral or parenteral) - lower deposition 2. Low testosterone in men
of uric acids
3. Advanced age
- NSAID (Indomethacin)
4. Family history
- Corticosteroid
5. Genetic
2. Uricosuric agents
6. Small frame, lack of weight and body mass index
- Drug/treatment of choice: Probenecid
7. Lifestyle (caffeine, alcohol, smoking)
(Benemid) corrects hyperuricemia and dissolves
deposited urate 8. Sedentary, immobility, lack of weight-bearing exercise
3. Allopurinol 9. Lack of exposure to sunlight
- breaking down of purines before forming into uric 10. Nutritional factors:
acids
- decreased calcitonin
4. Febuxostat (Uloric)
- low calcium intake
- treatment of gout that does not respond to usual
treatment - low vitamin D intake
- high phosphate intake (carbonated beverages),
inadequate calories
Nursing Management
11. Medications:
1. Encourage the patient to restrict consumption of foods
high in purines, especially organ meats, and to limit alcohol - Corticosteroids
intake. - Antiseizure medications
2. Encourage the patient to increase fluid intake. - Heparin
3. Advise the patient to maintain normal body weight. - Thyroid hormone
4. In an acute episode: administer analgesics and instruct 12. Diseases/Conditions:
the patient to avoid factors that increase pain and
inflammation, such as trauma, stress, and alcohol. - Anorexia nervosa
- Hyperthyroidism

3.Degenerative - Malabsorption syndrome

Osteoporosis - Renal failure

Osteoporosis is characterized by reduced bone mass, Prevention

deterioration of bone matrix, and diminished bone
architectural strength. The consequence of osteoporosis is
bone fracture.
1. Early identification of at-risk teenagers and young adults
2. Increased calcium and vitamin D intake
3. Participation in regular weight-bearing exercise
4. Modification of lifestyle (reduced use of caffeine,
cigarettes, carbonated soft drinks, and alcohol)
Pathophysiology 2. Laboratory studies:
1. Normal homeostatic bone turnover is altered; the rate of serum calcium
bone resorption that is maintained by osteoclasts is greater
serum phosphate
than the rate of bone formation that is maintained by
osteoblasts, resulting in a reduced total bone mass. serum alkaline phosphatase
2. The bones become progressively porous, brittle, and urine calcium excretion
fragile; they fracture easily under stresses that would not
break normal bone. urinary hydroxyproline excretion

3. These increase susceptibility to fracture, which occur hematocrit

most commonly as compression fractures of the thoracic
and lumbar spine, hip fractures, and Colles’ fractures of the
wrist. These fractures may be the first clinicalmanifestation
of osteoporosis
4. The gradual collapse of a vertebra may be
asymptomatic; it is observed as progressive kyphosis.
There is an associated loss of height, this results in
relaxation of the abdominal muscles and a protruding
abdomen, and pulmonary insufficiency.
5. Age-related loss begins soon after the peak bone mass
is achieved (in the fourth decade). Calcitonin, which
inhibits bone resorption and promotes bone formation, is
decreased. Estrogen, which inhibits bone breakdown,
decreases with aging.
6. The withdrawal of estrogens at menopause or with
oophorectomy causes an accelerated bone resorption that
continues during the postmenopausal years. Women
develop osteoporosis more frequently and more
extensively than men because of lower peak bone mass
and the effect of estrogen loss during menopause. More
than half of all women older than 50 years show evidence
of osteopenia.
Assessment and Diagnostic Tests
1 Dual-energy x-ray absorptiometry (DXA)
- Women older than 65 years old
- Men older than 70 years old
- Post-menopausal or older men 50 years old na
maerong osteoporosis risk factor
- pwede sa lahat ng tao due to osteoporosis
erythrocyte sedimentation rate (ESR)
3. X-ray studies
Complication: Bone fractures (kasi nag
bbrittle,naddamage)
Medical Management
1. A diet rich in calcium and vitamin D throughout life daily.
- best source of calcium and vitamin d – fortified
milk (ex: 3 glasses of milk)
2. Regular weight-bearing exercise
3. Pharmacologic Therapy
a. Calcium and vitamin D supplements
b. Bisphosphonates: Alendronate (Fosamax) or
Risedronate (Actonel), Ibandronate (Boniva), or
intravenous (IV) infusions of Zoledronic acid
(Reclast) – decrease bone loss and helps bone
mass
c. Calcitonin (Miacalcin)
d. Selective estrogen receptor modulators
(SERMs): Raloxifene (Evista) – prevent and
treatment if there is occurring osteoporosis
e. Teriparatide (Forteo)
4. Fracture Management
a. Joint replacement or by closed or open
reduction with internal fixation (hip pinning)
b. Percutaneous vertebroplasty or kyphoplasty –
parang cast din or bone cement na nilalagay sa
vertebra
Patient with Spontaneous Vertebral Fracture Related C. Improve Bowel Elimination
to Osteoporosis
1. High-fiber diet.
Nursing Diagnoses:
2. Increase fluid intake
1. Deficient knowledge about the osteoporotic
3. Use of prescribed stool softeners help prevent
process and treatment regimen
or minimize constipation (as ordered/prescribed)
2. Acute pain related to fracture and muscle
4. Monitor the patient’s intake, bowel sounds, and
spasm
bowel activity. (to check if there is constipation)
3. Risk for constipation related to immobility or
D. Prevent Injury
development of ileus (intestinal obstruction)
(madalas pag naka bed rest lang) 1. Encourage isometric exercises to strengthen
trunk muscles.
4. Risk for injury: additional fractures related to
osteoporosis 2. Encourage walking, good body mechanics, and
good posture.
Nursing Interventions
3. Encourage daily weight-bearing activity,
A. Promote Understanding of Osteoporosis and the
preferably outdoors in the sunshine to enhance
Treatment Regimen
the body’s ability to produce vitamin D.
1. Focus on teaching about factors influencing the
4. Avoid sudden bending, jarring, and strenuous
development of osteoporosis, interventions to
lifting.
arrest or slow the process, medication therapy,
and measures to relieve symptoms.
2. Emphasize that all people continue to need
sufficient calcium, vitamin D, and weight-bearing
exercise to slow the progression of osteoporosis.
B. Relieve Pain
1. Rest in bed in a supine or side-lying position
several times a day.
2. Perform knee flexion to increase comfort by
relaxing back muscles.
3. Apply intermittent local heat and back rubs to
promote muscle relaxation.
4. Instruct the patient to move the trunk as a unit
and to avoid twisting.
5. Encourage good posture and teach body
mechanics.
6. When assisting the patient out of bed: a trunk
orthosis may be worn for temporary support and
immobilization.
7. Instruct the patient to gradually resume
activities as pain diminishes
Activities Presented (05/06/2022): 3) Joint Replacement
- NVA
1) Total Hip Replacement
- Infection before OR (20-4 weeks)
- Artificial joint is replaced
- Skin Prep (1-2 days before OR)
- Prevent dislocation by:
- Prophylactic antibiotic (60 mins prior to
▪ Pillow
incision)
▪ Never cross legs
- After: Promote ambulation and use of walker
▪ Avoid bending forward to pick object
on floor
4) Skeletal Traction
▪ Affected legs don’t close to the
- 7-12 kg to achieve therapeutic effect
central body
- Prevent DVT
- Drain blood accumulation on first 24 hours
- Monitor NVA
(200-500ml)
- Hang Free (yung weight na ginagamit)
- If 24-48 hours, 30 ml or less per hour
Nursing Responsibility:
- Prevent deep vein thrombosis
▪ Monitor patient’s anxiety
▪ Use antiembolism or stockings
▪ Assist with self-cafre
- Monitor signs of DVT
▪ Monitor and Manage potential
▪ Pain
complication
▪ Swelling
▪ High fiber diet
▪ Tenderness
▪ Auscultate lungs (4-8 hours) to
- Medication:
prevent pneumonia
▪ Fondaparinux (Arixtia)
▪ Dalteparin (Fragmin)
5) Skin Traction
▪ Enoxaparin (Lovenox)
- 2-3 kg (weights)
- Avoid indwelling catheter
- Types:
- Prophylactic antibiotics
▪ Buck’s extension (lower leg)
- Use of walkers or canes
▪ Cervical head halter (neck pain)
- Resume ADL 3 months
▪ Pelvic belt (back pain)
- 3-6 months (stair, climbing, sexual interaction,
- 2-3.5 kg (extremities)
flat on back)
- 4.5-9 (pelvic)
- Excellent exercise
- Complications:
▪ Walking
▪ Circulatory impairment assessment
▪ Swimming
(15-30 mins every 1-2 hours)
▪ High rocking chair
▪ Check peripheral pulse
- Avoid low chair
6) External Fixator (OREF)
2) Total Knee Replacement
- Elevate extremities (to reduce swelling)
- Mostly because of osteoarthritis and severe
- Monitor NVA
traumatic injury
- Assess pin site
- Apply ice, as ordered\
▪ Redness
- NVA (6 P’s)
▪ Drainage
▪ Pain
▪ Tenderness
▪ Poikilothermia
▪ Pain
▪ Paresthesia
▪ Sore aching of pin
▪ Paralysis
- Active Exercise
▪ Pulselessness
▪ Pallor
- Active Flexion
 7) Cast
- Short leg (extending to knee)
- Cold therapy
- Elevate immobilized leg when seated
- Recumbent position several times/day
- Toe and ankle exercise
- Plaster of paris and fiber glass for cast type
8) Immobilize upper extremities
- Maintain body alignment
- If splint available or provided, ensure proper
use of splint and provide skin care
- Maintain muscle strength and joint mobility
- ROM exerfcise
- Control swelling, affected part must be
elevated
- Monitor circulation, movement and sensation
Clinical Manifestation:
▪ Bone pain and tenderness.
▪ Muscle weakness from calcium deficiency
▪ Dull, aching pain associated with
osteomalacia commonly affect the lower
back, pelvis hips, legs and ribs.
▪ Decreased muscle tone and leg
weakness
Diagnosis:
▪ Blood and urine test – help detect low
levels of vitamin d
▪ X-rays
▪ Bone biopsy – accurate in detecting
osteomalacia
Medical Management:

9) Types of Cast ▪ Vitamin D supplementation

- Plaster Cast (24-72 hours to dry) ▪ Calcium and phosphorus
- Fiberglass Cast supplementation
▪ Anti-epilectic drugs (phenobarbital,
Types of Splint: phenytoin and carbamazepine)
- Static ▪ Pain killers
- Dynamic Surgical Management:
- Serial static
- Static progressive ▪ Corrective osteotomy and fixation with
external factor – to disrupt the growth of
Types of Braces physis
- Cervical orthosis Nursing Diagnosis:
- Head
- Shoulder orthosis ▪ Acute pain r/t decrease process of
- Spinal orthosis osteomalacia
- Elbow wrist hand finger orthosis (EWHFO) ▪ Imbalanced nutrition less than body
requirements
▪ Impaired physical inactivity r/t joint
Activity Presented (05/17/2022): inflammation
▪ Risk for injury
1) Osteomalacia
▪ Osteomalacia is a metabolic bone Nursing Intervention:
disease characterized by inadequate ▪ Obtain dietary history to evaluate intake of
mineralization of bone. vitamin D foods
▪ The primary defect is a deficiency in ▪ Investigate degree of exposure to sunlight
activated vitamin D (calcitriol), which ▪ Provide diet high in vitamin D and calcium
promotes calcium absorption from the GI ▪ Encourage activity as tolerated
tract and facilitates mineralization of bone ▪ Provide appropriate fracture care
measures as indicated
2) Septic Arthritis
▪ Septic arthritis is an infection in the joint
(synovial) fluid and joint tissues.
▪ It occurs more often in children than in
adults. The infection usually reaches the
joints through the bloodstream.
▪ In some cases, joints may become
infected due to an injection, surgery, or
injury.
Signs and Symptoms:
The most common joints affected by septic
arthritis are the knee, hip, shoulder, elbow, wrist,
and finger. Most often, only one joint is affected.
Symptoms can occur a bit differently in each
person, but common symptoms include:
▪ Fever
▪ Joint pain
▪ Joint swelling
The types that can cause septic arthritis
include:
▪ Staphylococci. These are common
bacteria that often cause skin infections.
▪ Haemophilus influenzae. These are
bacteria that can infect the larynx,
trachea, and bronchi.
▪ Gram negative bacilli. This is a group of
bacteria that includes E. coli.
▪ Streptococci. This is a group of bacteria
that can lead to a wide variety of diseases.
▪ Gonococci. This is the bacterium that
causes gonorrhea.
▪ Viruses. Viruses such as HIV can infect
the joints of people of all ages
Risk factors for septic arthritis include:
▪ A systemic blood-borne infection
▪ IV drug use
▪ Osteoarthritis
▪ Past history of septic arthritis
▪ Rheumatoid arthritis
Treatment:
▪ include using a combination of powerful
antibiotics as well as draining the infected
synovial fluid from the joint. It's likely that
antibiotics will be administered
immediately to avoid the spread of the
infection
▪ Intravenous (IV) antibiotics are given,
usually requiring admission to the hospital
for initial treatment. The treatment,
however, may be continued on an
outpatient basis at home with the
assistance of a home health nursing
service.
Additional:
▪ Antibiotics can improve symptoms within
48 hours
▪ Some infection caused by fungi need
treatment with antifungal medicine
▪ May require joint aspiration and washout
(arthrocentesis)
▪ Arthrotomy – surgical exploration of joint
Nursing intervention
▪ Provide safety to prevent further
complication
▪ Encourage patient to maintain pillow
support, splints and braces to reduce pain
and maintain proper position
▪ Encourage use of stress management
technique such as progressive relaxation
▪ Avoid puncture wounds and damage to
skin to avoid infection
Medical Intervention:
▪ Administer antibiotics as needed to
prevent severity of infection
▪ Administer antipyretic as needed to
regulate temperature and control chills
3) Osteomyelitis Risk Factors:
▪ is an infection of the bone that results in
▪ Age (50 years old and older)
inflammation, necrosis and formation of
▪ Common in men
newborn
▪ Family history of Paget’s Disease
Classification:
▪ Hematogenous osteomyelitis Diagnostic Findings:
▪ Contiguous focus osteomyelitis
▪ Osteomyelitis with vascular insufficiency ▪ X-ray
▪ Blood test
Clinical Manifestation ▪ Urine test
▪ Bone scan
▪ Chills
▪ High fever
5) Amputation
▪ Rapid pulse
▪ Loss or removal of body part
▪ General malaise
▪ It can be traumatic or surgical
Assessment and Diagnostic Findings o Traumatic: Accidents/injuries
▪ Motor vehicle accidents
▪ X-ray
▪ Occupational
▪ Radioisotope bone scan
▪ Combat
▪ MRI
o Surgical:
▪ Wound and blood culture studies
▪ Blood vessel disease
▪ Bone scan
▪ Cancer
Medical Management: ▪ Infection
▪ Excessive tissue damage
Goal: to control and halt the infective process
Management:
▪ Intravenous antibiotic therapy is given
around-the-clock; continues for 3 to 6 ▪ Analgesics
weeks. ▪ Antibiotics
▪ Antibiotic medication is administered ▪ DVT prophylaxis
orally (on empty stomach) when infection ▪ Early physiotherapy
appears to be controlled; the medication ▪ Prosthetic ambulation
regimen is continued for up to 3 months. ▪ Removal of drain and stitches

Surgical Management: Rehabilitation Goals

▪ Sequestrectomy ▪ Medical stabilization

▪ Pain control
4) Paget’s Disease ▪ Psychological support
▪ Changes the bone remodeling process ▪ Initiation of functional rehab program
resulting in abnormally shaped, weak and
Medical Management
brittle bones.
▪ Post op limb elevation
Signs and Symptoms:
▪ Post op dressings and stump care
▪ Bone pain ▪ Drugs – pain control
▪ Joint pain, stiffness, swelling
▪ Nerve problems
▪ Enlargement and bowing of femurs and
lower legs
▪ Enlargement of skull around forehead
6) Bone Tumor
▪ An abnormal growth of cells within bone
that can form mass or lump
Types: (benign, malignant, metastatic)
Benign Bone Tumors
▪ Slow growing, well circumscribed, and
encapsulated.
▪ They produce few symptoms and do not
cause death
▪ Osteochondroma - the most common
benign bone tumor, may become
malignant.
▪ Enchondroma is a common tumor of the
hyaline cartilage of the hand, femur, tibia,
or humerus.
▪ Osteoid osteoma is a painful tumor that
occurs in children and young adults.
▪ Osteoclastomas (giant cell tumors) are
benign for long periods but may invade
local tissue and cause destruction
Malignant Bone Tumors
▪ Primary malignant musculoskeletal
tumors are relatively rare and arise from
connective and supportive tissue cells
(sarcomas) or bone marrow elements
(myelomas).
▪ Malignant primary musculoskeletal
tumors include osteosarcoma and
chondrosarcoma
▪ Osteogenic sarcoma (osteosarcoma)
is the most common and is often fatal
owing to metastasis to the lungs
▪ Chondrosarcoma, the second most
common primary malignant bone tumor,
is a large, bulky tumor that may grow and
metastasize slowly or very fast,
depending upon the characteristics of the
tumor cells involved.
Metastatic Bone Disease
▪ Metastatic bone disease (secondary bone
tumors) is more common than any
primary malignant bone tumor.
▪ The most common primary sites of tumors
that metastasize to bone are the kidney,
prostate, lung, breast, ovary, and thyroid.
Clinical Manifestations
Bone tumors present with a wide range of associated
problems:
▪ Asymptomatic or pain (mild, occasional to
constant, severe).
▪ Varying degrees of disability; at times, obvious
bone growth.
▪ Weight loss, malaise, and fever may be present.
▪ Spinal metastasis results in cord compression and
neurologic deficits
Assessment and Diagnostic Findings
▪ May be diagnosed incidentally after pathologic
fracture
▪ CT scan, bone scan, myelography, MRI,
arteriography, x-ray studies
▪ Biochemical assays of the blood and urine
(alkaline phosphatase levels are frequently
elevated with osteogenic sarcoma; serum acid
phosphatase levels are elevated with metastatic
carcinoma of the prostate)
▪ Surgical biopsy for histologic identification; staging
based on tumor size, grade, location, and
metastasis
Medical Management
Goal of treatment:
- to destroy or remove the tumor.
- This may be accomplished by surgical
excision (ranging from local excision to
amputation and disarticulation), radiation, or
chemotherapy.
▪ Limb-sparing (salvage) procedures are used to
remove the tumor and adjacent tissue; surgical
removal of the tumor may, however, require
amputation of the affected extremity.
▪ Chemotherapy is started before and continued
after surgery in an effort to eradicate
micrometastatic lesions.
▪ Soft tissue sarcomas are treated with radiation,
limb-sparing excision, and adjuvant
chemotherapy.
 ▪ Metastatic bone cancer treatment is palliative; the patient how to use assistive devices safely and
therapeutic goal is to relieve pain and discomfort how to strengthen unaffected extremities.
as much as possible while promoting quality of life. ▪ Encourage the patient and family to verbalize their
▪ Internal fixation of pathologic fractures, fears, concerns, and feelings; refer to psychiatric
arthroplasty, or methylmethacrylate (bone advanced practice nurse, psychologist, counselor,
cement) minimizes associated disability and pain or spiritual advisor if necessary.
in metastatic disease. ▪ Assist the patient in dealing with changes in body
image due to surgery and possible amputation
Nursing Management
▪ Encourage the patient to be as independent as
▪ Ask the patient about the onset and course of possible
symptoms
▪ Assess the patient’s understanding of the disease
process, how the patient and the family have been
coping, and how the patient has managed the
pain.
▪ Gently palpate the mass and note its size and
associated soft tissue swelling, pain, and
tenderness
▪ Assess patient’s neurovascular status and range
of motion of the extremity to provide baseline data
for future comparisons; evaluate the patient’s
mobility and ability to perform activities of daily
living (ADLs).
▪ Monitor vital signs; assess blood loss; observe
and assess for the development of complications
such as deep vein thrombosis (DVT)
▪ Teach patient and family about the disease
process and diagnostic and management
regimens; explain diagnostic tests, treatments (eg,
wound care), and expected results (eg, decreased
range of motion, numbness, change of body
contours) to help patient deal with the procedures
and changes and comply with the therapeutic
regimen.
▪ Assess pain and provide pharmacologic and
nonpharmacologic pain management techniques
to relieve pain and increase comfort level; work
with the patient to design the most effective pain
management regimen.
▪ Prescribe intravenous (IV) or epidural analgesics
to be used during the early postoperative period;
later, oral or transdermal opioid or nonopioid
analgesics are indicated to alleviate pain; external
radiation or systemic radioisotopes may be
prescribed.
▪ Ensure any prescribed weight-bearing restrictions
are followed; with help of physical therapist, teach