Mobility and Health
Musculoskeletal System - Skeletal System
and Assessment Review
- 206 bones and multiple joints, skeletal muscles, and supporting
structures
- The skeletal system is made up of bones, joints, skeletal
muscles, and supporting structures, such as ligaments, tendons,
etc.
- Growth and development of these structures occur primarily
during childhood and adolescence.
- Think back to Anatomy class and learning about bone
development and growth plates.
- Growth plate injuries are of concern in fractures during
childhood/adolescence.
- Function:
- Support
- Bones provide support for soft tissues
- Provides the framework for the body to allow
weight bearing
- Protection
- Bones protect vital organs
- Movement
- Bones serve to move body parts by providing
points of attachment for muscles
- Storage
- Bones store minerals and serve as a site for
hematopoiesis
- Bone Shapes
- Long Bones: longer than they are wide
- Consist of a mid-portion or diaphysis (di-af-a-this)
and end portions or epiphysis (e-pif-i-sis)
- Examples: bones of the arms, legs, fingers, and
toes. i.e. femur, tibia, fibula, humerus, radius,
ulnar, phalanges, etc.
- Short bones: smaller and bear little weight:
- Examples: wrist (carpal) and ankle (tarsal) bones.
- Flat bones: Thin, flat, and most are curved.
- Examples: Scapula, ribs, and sternum.
- These bones protect vital organs.
- Irregular bones: irregularly, uniquely shaped.
- Examples: vertebrae, sacrum, coccyx, ethmoid,
zygomatic, maxilla, mandible, palatine, inferior
nasal
- Bone Structure
- Compact Bone: (cortical bone)
- Smooth and dense outer layer
- Dense bone
- Bone in which the bony matrix is solidly filled with
organic ground substance and inorganic salts,
leaving only tiny spaces (lacunae) that contain
the osteocytes, or bone cells
- Spongy Bone: (cancellous bone or trabecular bone)
- Mesh like inner layer
- a very porous type of bone. It is highly
vascularized and contains yellow (contains fat
1
 cells – fat cells can become dislodged, enter the
bloodstream and cause fat embolism syndrome)
and red (location of hematopoiesis, production of
blood cells) bone marrow.
- usually located at the ends of the long bones (the
epiphyses), with the harder compact bone
surrounding it.
- Bone Cells
- Osteocytes: These are cells that maintain the bone
matrix
- Osteogenic cells: stem cells located in the bone that
play a prodigal role in bone repair and growth
- Osteoblasts: These are cells that form the bone
- Osteoclasts: These are cells that resorb the bone
- Bone also contains a matrix of mostly collagen,
polysaccharides, and lipids. The hardness of the bone
comes from the calcium salt deposits.
- Joints
- Also called articulation
- The region where 2 or more bones are joined.
- Provide movement and flexibility.
- There are 3 types of joints:
- Synarthrodial: completely immovable (cranium;
skull sutures)
- Amphiarthrodial: slightly moveable (pelvis and
vertebral joints)
- Diarthrodial or synovial: freely move (elbow,
knees, shoulders, hips).
- ***Most common
- Most commonly injured or diseased.
- Ligaments attach bone to bone
- These can limit or enhance movement, provide
joint stability, and enhance joint strength
- Tendons attach bone to muscle
- enables the bones to move when muscle
contracts
- when muscles contract, the increased pressure
causes the tendons to pull, push, or rotate the
bone to which it is connected.
- Muscular System/Skeletal Muscle
- Allows musculoskeletal function
- Attach to and cover the bones of the skeleton
- Promotes body movement
- Helps maintain posture
- Produces body heat
- Moved by conscious, voluntary control or reflex activity
- Approximately 600 muscles in the human body
- Three types
- Skeletal: a striated voluntary muscle controlled by the
central and peripheral nervous system
- Smooth: an involuntary muscle that is responsible for the
contraction of organs
- Cardiac: muscle is controlled by the autonomic nervous
system

2
 - Functions:
- Excitability: the ability to receive and respond to a
stimulus
- Contractibility: the ability to respond to a stimulus by
forcibly shortening
- Extensibility: the ability to respond to a stimulus by
extending and relaxing
- Elasticity: the ability to return to its resting length after
shortening or lengthening
- Changes related to Aging
- Bone structure changes (caused by expansion and resorption)
- Osteopenia – decreased bone density (can lead to
osteoporosis)
- Cartilage degeneration (can lead to arthritis)
- Atrophied muscle tissue (increased exercise can slow atrophy)
- Decreased coordination and ROM
- Loss of muscle strength
- Gait changes
- Slowed movement
- Increased fall risk
- Bone structure changes through bone expansion and resorption.
- As Bone density decreases (osteopenia) there are postural
changes that occur and increase the risk for fractures
- Caucasian women at highest risk
- As we age there is also less soft tissue to cushion the bony
prominences which then results in skin, this is why we must turn
and reposition our clients!
- Synovial joint cartilage degenerates due to repeated use of
joints, especially weight-bearing joints like hips and knees.
- This can lead to degenerative joint disease. Remember
that moist heat will help promote blood flow to the area
and aid in comfort.
- Muscle tissue will atrophy so we must teach exercise and
activity to slow the progression of muscle atrophy and to
increase muscle strength.
- Decreased range of motion (ROM) is caused by some of the
above issues as well as cartilage degeneration, muscle atrophy,
etc. Be sure to assess the ability to perform activities of daily
living (ADLS) and their mobility status.

Assessment - Health History

- Acute? Chronic? What kind of pain?
- Assess lifestyle factors that may affect physical condition- these
include, but are not limited to employment, activity level, and any
past or recent injuries.
- Family History: certain musculoskeletal disorders have familial
or genetic tendencies
- EX: Rheumatoid arthritis, osteoarthritis, gout, muscular
dystrophy
- Transcultural considerations:
- African Americans have shorter trunks and longer legs-
long bones are longer and narrower than Caucasians
- Male bones are more dense than women
- Caucasian women have the least amount of bone

3
 density than any group-more susceptible to fractures and
osteoporosis
- Meds:
- Steroids: negatively affect calcium metabolism and make
bones easier to break
- also ask about hx of meds taken for pain relief
- Diet: inadequate calcium intake or inadequate protein intake can
cause bone & muscle tone loss
- Low Vit C intake and inadequate protein inhibits bone
healing
- Obesity places strain on bones and joints, also inhibits
mobility
- Psychosocial: Anticipate psychosocial problems- prolonged
work absence, disability, multiple stressors, etc.
- Physical assessment
- Pain: different pain rating scales, quality, region, radiation, relief,
severity, time frame
- General inspection: assess bones and joints; palpate areas for
deformities and assess ROM. look at posture, gait, and mobility
for any deformities or impairments
- Gait:
- Normal gait has two phases; the stance phase and swing
phase.
- Observe balance, steadiness and length, and ease of
stride. Note any limps or asymmetry of gait
- Mobility: assess the use of assistive devices and transfer
techniques from bed to chair, etc., also check ability to perform
ADLS
- Diagnostics - Labs
- Nothing that is definitive for musculoskeletal issues but can lead
in the right direction
- Calcium: Ca
- Decreased with lack of calcium and vitamin D intake, and
malabsorption from the GI tract
- Hypocalcemia: osteoporosis and osteomalacia
- Increased with bone cancer, and multiple fractures.
- Hypercalcemia: metastatic bone cancer, Paget
disease, multiple bone fractures that are healing
- Phosphorus/Phosphate: P
- Increased with bone tumors and healing fractures
- Hyperphosphatemia: bone fractures healing,
bone tumors
- Hypophosphatemia: osteomalacia
- Alkaline Phosphatase: ALP
- Increased in Bone cancer, Paget’s disease, healing
fractures, rheumatoid arthritis, osteomalacia
- Creatinine Kinase: CK-MM
- to diagnose muscle trauma or disease.
- Increased in muscular dystrophy and traumatic injuries
(specifically, CPK-MM isoenzyme)
- Could indicate trauma/disease in cardiac muscles
- Lactic Dehydrogenase:
- Elevations may indicate skeletal muscle necrosis,
extensive cancer, progressive muscular dystrophy

4
 - Aspartate aminotransferase: AST
- Elevations may indicate skeletal muscle trauma;
progressive muscular dystrophy
- Aldolase: ALD
- Elevations may indicate polymyositis (uncommon
chronic rheumatic dx characterized by inflammation of
multiple muscles) and dermatomyositis (polymyositis
occurs with purplish skin rash), muscular dystrophy.
- Diagnostics - Imaging
- X-ray or radiography show skeletal and supporting structures
- Most commonly used
- DEXA Scan
- A bone density scan uses low dose X-rays to see how
dense (or strong) your bones are
- Used to diagnose or assess the risk of osteoporosis
- MRI - most appropriate for joints, soft tissue, and bony tumors
involving soft tissue.
- Joint replacements that are titanium or stainless steel are
OK for MRI
- Pacemakers or surgical clips are not OK!
- MRI can turn off pacemaker
- Knee replacement ok
- No metal!
- Pregnant pts are usually not scanned during the first
trimester….
- Enclosed area: assess for claustrophobia, may need an
antianxiety agent
- Newer MRIs are open
- Bone scan- a nuclear imaging test that shows how the bones
process an injected agent
- Used to detect tumors, arthritis, osteomyelitis,
osteoporosis, fractures of the vertebrae, or unexplained
bone pain.
- MRI is used more frequently today.
- Bone scan is very useful in detecting diffuse (not
concentrated) metastatic bone disease.
- Myelograms - may be done to assess the spinal cord,
subarachnoid space, or other structures for changes or
abnormalities.
- Contrast dye is injected into the spinal column.
- CSF can leak from the needle insertion site so
assess for headaches after the procedure.
- Must elevate bed 30-50 degrees after
- If there is a persistent leak the headache can be
severe.
- Bone biopsy - extracts part of bone for microscopic examination
- After biopsy, assess for bleeding, swelling, and
hematoma formation, and monitor pain level, affected
extremity is immobilized for 12-24 hours
- Assess temp- may rise 1-3 days after if infection sets in
- Mild analgesics used for pain
- Muscle biopsy- used to dx atrophy(MD) and inflammation
(polymyositis)
- Same procedure and follow-up as bone bx

5
 - Electromyogram(EMG) - used with nerve conduction studies to
determine the electrical potential in an individual muscle
- Temporary discomfort, may use mild sedation, no muscle
relaxants several days before test
- Performed bedside or in the neuro lab
- Follow up: Assess site for hematoma, may apply ice,
may c/o pain and anxiety after the test
- Arthroscopy: diagnostic test also a surgical repair procedure
- Fiberoptic tube inserted directly into joint for direct
visualization.
- Knee and shoulder most common sites.
- Usually given epidural anesthesia.
- Post-op procedure like any major surgery with a focus on
neuro assessment

Back Problems - Most common form of mobility and chronic pain issues
- Lower back (lumbar) most common area
- Posture - most common
- Lack of Workplace Ergonomics
- Ex: improper lifting technique
- Physical Condition
- Changes in support structures
- Spinal stenosis
- Hypertrophy of the intraspinal
Ligaments
- Osteoarthritis
- Osteoporosis
- Changes in vertebral support
- Malalignment with deformity
- Scoliosis
- Lordosis (inward abnormal curvature of the lumbar spinal area)
- Vascular changes
- Diminished blood supply to the spinal cord or cauda equina
causes by arteriosclerosis
- Blood dyscrasias
- Intervetebral disk degeneration
- Pregnancy
- Risk Factors
- Obesity
- Repetitive flexion/extension
- Occupational injury
- Smoking
- Congenital (ex. scoliosis)
- Degenerative changes
- Prior injuries
- Osteoarthritis
- Vascular changes
- Lifestyle
- Assessment
- Gait and spine flexion
- Stiff or flexed?
- Limping?
- Cant bend over or turn lumbar spine?
- Pain assessment

6
 - Visually inspect and palpate vertebral alignment and
tenderness
- Sensory perception
- Straight leg raising test
- Could indicate sciatica nerve pain
- Psychosocial
- Can cause depression
- Management
- Nonpharmalogical methods - recommend first over pharama
- Massage
- Spinal manipulation (chiropractic)
- Controversial
- Heat/Cold Therapy
- Acupuncture
- William’s position
- Helps bulging/herniated disk
- Semi-fowlers position with pillow under knees
- Relieves pressure, keeps spine flexed
- Stress reduction - distractions/music/etc
- Mindfulness
- Progressive muscle relaxation
- Yoga
- TENS unit
- Weight reduction
- Pharmacological Methods
- NSAIDs - 1st line
- Reduces inflammation
- ibuprofen/advil used more than tylenol because
tylenol doesnt help with inflammation as well
- Tramadol
- Weaker narcotic
- Try this before stronger narcotics/opiods
- Can cause nausea
- Duloxetine/Cymbalta
-
- Helps chronic back pain, FDA unsure why
- Skeletal muscle relaxants
- Not for older population
- Can cause dizziness, sedation
- OTC medications
- Ziconotide
- Ntype calcium channel blockers
- Block calcium channels on specific nerves that
relay pain signals
- Antiepileptics (Neurotin)
- Treats nerve root pain
- Steroids
- Given for pain crisis
- Should be short term treatment
- Long term can affect calcium absorption
which can lead to weakened bones
- Surgical Management
- Minimally Invasive Surgeries
- Not done if disk is pressing into spinal cord

7
 - Microdiskectomy
- 1inch incision - decreased risk for infection,
bleeding
- Remove small fragments of spine that are cause
compression/pain
- Laser-assisted laparoscopic surgery
- Goes through umbilicus to the back which helps
clean out any herniated discs
- Open Surgical Procedures
- higher risk for infection, dural tears, bleeding, recovery
time longer, higher pain
- Diskectomy
- Removal of entire herniated disk
- Laminectomy
- Most commonly performed back surgery
- Removing parts of the vertebral lamina - parts of
vertebra that is causing pressure, allows
everything to space out
- Spinal Fusion (ALIF, PLIF, LLIF, TLIF)
- Fusing two or more vertebra to cause
stabilization
- Can use donor bone, rods, plates, screws, ect
- Name is where the fusion is occurring
- Artificial disk replacement
- Postoperative Care
- Pain
- Bleeding - frequent vital signs, hypotension
- Wound/Drain Care - assess output, thickness, amount,
know what type of drain
- Mobility
- Ability to void - retention is common after surgery,
especially in nerve blocks. Back pain, feelings of
fullness. May need in/out cath
- DVT prevention
- Medications
- Mobility
- SCDs
- Neurovascular checks & VS q4(AT LEAST) for 1st
day
- Pulses
- Sensation
- Temperature
- Color
- ROM
- Neurological assessment
- Vital Signs Q-4hrs x 24hr
- Major complications
- Ileus
- Nerve injuries
- Diskitis
- Dural tears
- Prevention of Low Back Pain and Injury
- Proper posture
- Regular exercise - encourage low impact and back

8
 strengthening
- Swimming and walking
- Stretching/Yoga
- Household assistance
- Avoid high-heel shoes
- Avoid prolonged sitting or standing
- And have good posture when required
- Use footstool and ergonomic desks and chairs to lessen
strain
- Maintain ideal weight
- Adequate calcium intake
- Make sure vitamin D is adequate as well! Ca cannot be
absorbed without vit D
- Smoking cessation – stop or cut down
- Prevention in Pregnancy
- Education is key!
- Good posture
- Proper lifting technique
- With emphasis on bending and sitting
- Maintain wide-balance stance
- Exercise - start with walking if never exercised
- Can continue exercise plan if was established
prior to pregnancy

Osteoarthritis - Most commonly occurring arthritis in adults

- Also referred to as degenerative joint disease
- Problems include…
- Impaired mobility
- Persistent pain
- Disability
- Slow, progressive deterioration of joint cartilage
- Commonly affects hands and weight-bearing joints(knees, ankles)
- Breakdown of articular cartilage
- Usually limited to joints and surrounding tissue
- Fissures, calcifications, and ulcerations form as disease progresses
- Risk Factors
- Primary
- Age (after 50)
- Genetics
- Female
- Secondary (less common than primary)
- Obesity
- Trauma/repetitive injuries
- Athletes
- Mechanical stress
- Metabolic disease
- Blood disorders
- Smoking
- Assessment
- Pain Assessment
- What helps?
- How often?
- What kind?
- Crepitus - crunching

9
 - Heberden nodes - distal
- Bouchard nodes - approximal
- Joint effusions - fluid buildup, most common in knees, swelling,
warm to touch
- Decreased mobility
- Gait changes
- Spinal involvement
- Psychosocial
- Diagnostics
- Physical exam
- Labs (ESR, CRP)
- X-rays
- MRIs
- Hyaluronic Acid
- Lubricating substance in cartilage
- Determine, helps with synovial fluid levels
- Management
- Nonpharmalogical
- Nonpharmacological
- Exercise - movement is good, may need to push through
pain, reduce stiffness, strengthen muscles
- Maintain ideal body weight
- Heat/Cold therapy
- Swelling - ice
- Plan scheduled rest periods
- Assist with ADLs
- Walkers, canes, etc
- Complementary therapies
- Assistive Devices
- Physical Therapy
- Surgical (TJA)
- Pharmacological
- Acetaminophen (drug of choice)
- More helpful than NSAID’s
- NSAID/Cox-2 inhibitors
- Topical (lidocaine, salicylates, NSAIDs)
- Weaker opioids (tramadol)
- Corticosteroids
- Short term treatment injected into pain site
- 4-6 months used
- Long term complications if used longer
- Glucocorticoid injections
- Viscosupplementation (Hyaluronic Acid injections)
- Medical Marijuana
- OTC meds/supplements
- Glucosamine (monitor BS)
- Total Joint Arthroplasty - replacement
- Used to manage pain & increase mobility
- Most common: Hip, Knee, Shoulder
- Contraindications: active infection,
inflammation(seperate from expected at site),
uncontrolled medical conditions
- Preoperative Rehab - going to PT, doing exercise to
strengthen joint for more positive outcome postop

10
- Preop Care
- Dentist (dental abscess, infection)
- Labs
- Education class
- Donate blood in case of blood loss during surgery
- Anticoags held (coumadin, eliquis, plavex)
- Chlorhexidine bath
- 24 hr preop prophylactic abx
- Complications
- Hip dislocation, hypotension, bleeding, VTE,
infections, pneumonia, anemia, N/V, subluxation,
uncontrolledpain
- Postop Care
- Observe for complications
- VTE prophylaxis
- TCDB/IS use
- Pain Management
- Mobility
- Incisional Care
- Cannot be submerged in water until
incisions removed
- Hip Precautions (posterior approach)
- Frequent neurovascular checks
- Important for good blood flow
- Education
- Hip precautions
- Total knee: do not pivot
- Physical therapy
- THA:
- Acetabular and Femoral
- Last 10-15 yrs
- Type: Cemented (PMMA) or Noncemented
- Noncemented preferred, secured by new
bone growth in six weeks
- Approach: Anterior, Direct Lateral, or
Posterolateral
- Anterior: preferred, least likely of
dislocation, hip precautions
- Direct lateral, posterolateral: hip
precautions are important!
- Hip dislocation is common
- TKA:
- Unilateral vs Bilateral
- Type: Cemented or Noncemented joint
dislocation is not common
- CPM machine
- Joint failure more common in knee than hip, joint
dislocation is not common

11
 Mobility & Health, Fractures/Hip Fractures
Fractures - Fracture: break in the continuity of bone
- 2/3 of all injuries in the US
- Occur when bone can not withstand applied force
- Direct or secondary trauma
- Affects mobility and sensory perception
- Classification
- Complete - divides bone in 2 sections
- Incomplete - partial break through bone, does not divide into 2
sections
- Extent
- Closed (Simple) - no skin break, no visible wound or bone
- Open (Compound) - portion of bone breaks through the skin, or
damages the muscles, visible
- Increased risk of infection and delayed healing
- Cause
- Fragility (pathologic) - caused by weakened bone from disease
(osteo, brittle bone disease, ect)
- Fatigue (stress) - repetitive stress on bone (common runners
injury)
- Compression - caused by compression (falling and spine
compressing)
- Types
- Displaced (Dislocated): ends separated
- Nondisplaced: ends in alignment, break but stays aligned
easiest to treat
- Oblique: Longitudinal; forms an angle of about 45 degrees
relative to the long axis of the bone shaft
- Greenstick: Incomplete; compressed side bends and tension
side fails
- Spiral (Rotational): Long; encircling a bone shaft due to torsion
- Comminuted: Made up of several fragments,fragments are often
shattered, crushed or splintered
- Stages of Bone Healing

- Could take up to a year for the elderly to fully heal

- Bone Healing Problems
- Delayed Union – Does not heal within 6 mo
- Increase in pain

12
 - Nonunion – Never completely heals
- Bone cycle altered
- Common with multiple fractures
- Poor blood flow, infx, steroid use may be the cause
- Malunion – Heals in abnormal alignment
- Too soon of weight bearingmay be the cause
- Assessment
- Health History
- Injury/Event
- Physical Assessment
- Deformity
- Pain
- Pulses
- Pallor
- Paresthesia
- Paralysis/Paresis
- Psychosocial
- Lab and Radiographic (xrays, ct to see if tissue involvement)
- Emergency (Field) Care
- ABC’s first!
- Inspect for head/internal injuries
- Control bleeding - leave shoes on for injury in feet
- Prevent shock
- Neuro check
- Immobilize/splint - above and below
- Transport safely
- Prevention
- Use of seatbelts/MVA prevention
- Osteoporosis prevention, screening, andeducation
- Early screening
- Fall prevention
- Home safety
- Medication safety
- Older adults and driving
- Safety equipment
- Monitor diet – increase Vit D & Calcium
- Proper footwear
- Complications
- Acute Compartment Syndrome
- Serious, limb-threatening condition
- Could lead to amputation
- Increased pressure within one or more compartments
- Most common in leg or forearm
- Reduced perfusion leads to further edema and ischemia
- Can occur from internal or external source
- Can cause permanent muscle and nerve damage in as
little as 4-6 hours
- S/S:
- Edema
- 6 P’s:
- Pain - most common sign, severe, unable
to be treated, throbbing
- Paresthesia - vibration
- Pallor - shiny

13
 - Pulses
- Poikilothermia - unable to regulate
temperature, pt does not feel that
temprature is not regulated
- Paralysis - motor weakness or fail
- Interventions
- Determine cause and resolve if external(cast)
- Prevent chronic (recurring) compartment
syndrome by encouraging stretching, NSAID use,
proper footwear or diuretics
- Surgical Intervention: Fasciotomy to relieve
pressure
- Can lead to chronic compartment
syndrome
- Wound is severe and left open (48-72 hrs)
- May need skin graft
- Fat Embolism Syndrome (FES)
- Release of particles from yellow(fatty) bone marrow into
the bloodstream
- Occurs within 12 to 48 hours post-injury or post-op
- Obstruct blood vessels that supply vital organs
- Life threatening and is a priority - needs interventions
- Risk Factors:
- Usually results from fractures or fracture repair
- Age 70-80
- Male age 20-40
- Pancreatitis, osteomyelitis, sickle cell anemia, or
blunt trauma
- S/S:
- Hypoxemia, dyspnea, tachypnea, headaches,
lethargy, agitation, confusion, altered LOC,
seizures, vision changes,
- Petechiae over the neck, chest, or upper arms
- Diagnostics:
- Labs:
- ↓ PaO2
- ↑ ESR
- ↓ Ca
- ↓ RBC and plts
- ↑ lipids
- CXR
- MRI
- Chest CT
- Often misdiagnosed as a PE
- Look at the differences between fat
embolus and PE – Table 47.1pp. 1032
- Cannot see FE on doppler
- Treatment:
- If severe/life threatening may have
thromboembolectomy to remove fat embolus
- Bedrest
- Oxygenation
- Hydration (IV NS)
- Gentle handling

14
 - Possible steroids for inflammation
- Fracture immobilization
- Gentle handling with positioning
- No anticoags
- VTE/DVT/PE
- Clot in deep vein of lower extremity
- Can travel and get to lung becoming PE
- Risk Factors
- Elderly
- Cigarette smoking history
- Obesity
- Heart disease
- Oral contraceptives or HRT
- Previous history of DVT
- DVT
- Usually occurs 2-3 day post-op
- Redness
- Pain
- Tenderness
- Swelling
- PE - SUDDEN
- Dyspnea
- Respiratory distress
- Anxiety/Impending doom
- Coughing/Hemoptysis
- Tachycardia
- Sudden Chest pain
- Altered mental status
- Arrhythmia
- Diagnosed with an ultrasound and doppler
- Avascular Necrosis
- Blood supply gets cut off causes necrosis
- Delayed Bone Healing
- Chronic Regional Pain Syndrome
- Unrelenting, and unresolveable pain
- Infection/Osteomyelitis
- Hemorrhage, Shock, DIC

Osteomyelitis - Most common with open fracture

- MRSA
- May result in non-union of the fracture, chronic osteomyelitis and
possible amputation
- Prevent and/or treat ASAP
- Risk factors
- Diabetes
- Hemodialysis
- Weakened immune systems
- Sickle cell disease
- Intravenous drug abusers
- Elderly
- S/S
- Pain and/or tenderness in the infected area
- Swelling and warmth in the infected area
- Fever

15
 - Nausea, secondarily from being ill with infection
- General discomfort, uneasiness, or ill feeling
- Drainage of pus through the skin
- Excessive sweating
- Chills
- Lower back pain
- Swelling of the ankles, feet, and legs
- Changes in gait

Fracture Management - Nonsurgical

- 1) Reduction
- Manipulation and manual traction
- Restoration of fracture fragments into alignment
- Should be done immediately after receiving pt
- If break happened 12+ hours ago, may need
antiinflammatories before reduction
- Closed
- Traction
- 2) Immobilization
- Casts
- Immobilizes
- Promotes early mobility
- Reduces pain
- Provides support & protection
- Neurovascular checks*
- Types
- Plaster - traditional, heavy
- Warm at first, doesn’t dry until
24-72 hours, needs to be rotated
every 2 hours until dry
- Fiberglass - splash resistant, 15 minute
set time
- Liquid resin (NEW!) - waterproof, can
shower and bathe, 10 min set time
- Placement
- Arm
- Elevate above heart
- Ice first 24-48 hrs
- Leg
- Allows mobility
- Crutches or walker
- Elevate and ice for first 24 hrs
- Body Casts (Spica)
- Encircles trunk
- Placed in OR
- May or may not have a bar
- Complications
- Too loose: at risk for abrasions and
pressure ulcers
- Too tight: acute compartment syndrome
- Impaired skin integrity/ infection
- Circulatory impairment
- Peripheral nerve damage
- Immobility issues

16
 - Compartment Syndrome
- Cast Syndrome – Body cast
- anxiety
- Fracture blisters
- Nursing Interventions
- Monitor for compartment syndrome
- Monitor for infection
- Frequent neuro and circulation checks
- Monitor for drainage
- Assess for complications of immobility
- Keep extremity elevated
- Apply ice for first 24-48 hours
- Keep cast dry
- Never stick anything inside the cast
- Hair dryer on cool setting for
itching
- Assess stockinette underneath cast
- Patient/Family education
- Traction
- A system where a combination of pulleys, pins,
and weights are used to promote the healing of
fractured bones and realign
- Pulling force that is applied to part of an extremity
while a countertraction pulls in the opposite
direction
- Weights can never be on ground
- Purpose: Reduce fracture, immobilize, decrease
pain & muscle spasm,correct deformities, stretch
tight muscles
- Types
- Skin
- Buck’s traction (Velcro boots),
belt,or halter
- Assess skin q 8hr
- Neurovascular - every hour
for the first day, q4 for after
when in traction
- Decreases muscle spasms
- Stabilizes fracture
- 5-10 lbs
- Skeletal
- Screws directly into bone
- Correct & maintain position of
fracture
- Impairs mobility
- 15-30 lbs
- Pin site care
- Nursing Assessment
- Equipment
- Weights, pulley’s, ropes, Balkan
frame (overhead frame)
- Mobility - continuous or intermittent
- Need doctors order for changes
- Skin integrity - assess underneath every 8

17
 hours
- Pin site checks
- Relieve pressure and turn q4
- Use wedges, pillows
- Neurovascular - every hour for the first
day, q4 for after when in traction
- Gastrointestinal/Urinary
- Hip fracture bed pans
- Splints
- Bandages
-
- Surgical
- Open Reduction with Internal Fixation (ORIF)
- Most commonly used if not able to reduce it manually
- Promotes early mobility
- Pins used inside
- Externally fixate the bone
- Infection risk
- External Fixation
- Screwed in from the outside
- Closed reduction, pins on the outside
- Soft tissue injury
- Less risk of infection, sepsis, blood loss, complications
- Pre Op education
- Like other surgeries
- May receive a regional nerve block
- General Care
- Pain Management - high priority post-op
- Nerve Block
- Localized
- Lasts for a couple of days
- Educate: pain will worsen as nerve block wears
off
- May impact urinary retention
- IV Ketorolac (Toradol) - NSAID
- Harsh on kidneys - not for long term use(<5days)
- Opioids
- For severe pain
- Switch to NSAIDs once pain controlled
- Nonpharmacological Interventions
- Elevation
- Ice
- Distraction
- Post Op Assessment for Complications
- Infection
- Assess pin site frequently every 1-4 hours for first
24 hrs, then q 8hrs
- Inflammation, heat, odor
- Normal: clear drainage, crusting around
pin
- Call HCP: Drainage that lasts longer than
48 hrs, change in drainage color, odorous
- Acute Compartment Syndrome(ACS)
- Fat Embolism Syndrome(FES)

18
 - DVT
- Shock
- Acute Pain: most common diagnosis with fractures
- Planning: Expected outcomes
- Effective pain control through combination of
preventative measures, analgesic and non-analgesic
therapies
- Interventions
- Drug therapy
- Non-analgesic measures
- Complementary and Alternative Therapies
- Medications
- Analgesics - IV medications more potent
- Non-opioids
- Opioids
- Can develop a tolerance
- SE: Respiratory distress, confusion,
delirium, constipation
- Elderly: anesthesia can last up to 3 days
- Muscle Relaxants
- SE: drowsiness,dizziness, dry mouth, sedation,
ataxia, lightheadedness, urinary hesitancy or rtx,
hypotension, bradycardia
- Serious Side Effects: angioedema, anaphylaxis,
respiratory depression, coma, laryngospasm,
cardiovascular collapse, hallucinations
- Antianxiety Agents
- Sedation, resp depression
- Steroids
- Urinary rtx

Hip Fractures - Involves the upper third of the femur

- Most common injury in older adults
- Once one hip broken, more likely to break the other
- High mortality rate r/t complications
- Intracapsular: within joint capsule, no blood supply takes longer to heal
- Extracapsular: outsside of the joint capsule,
- larger blood supply: heals faster/More risk of bleeding
- Greatest risk factor is osteoporosis
- Prevention
- Medications
- Bisphosphonates: slow down bone loss, strengthen the
bone
- Calcium with Vitamin D: Ca cannot be absorbed without
Vit D
- Early Osteoporosis screening and education
- Physical Activity
- Smoking Cessation
- Fall Prevention: At home fall precautions are best defense
- S/S
- Pain – hip, thigh, or groin
- External rotation
- Shortening of affected leg
- Inability to move or bear weight, stiffness

19
 - Severe edema, bruising
- Management
- Must remain at bedrest at all times before surgery - no walking
- Premedicate before turning, bathroom
- Need extra hands, log roll
- Buck’s Traction - may have to be done before surgery
- Medications
- Surgical Repair
- ORIF
- Prosthetic implant - if femoral neck is fractured
- ORIF/THA postop mobility
- Bedrest day of surgery
- OOB 1st post-op day – ambulation
restrictions
- Physical therapy should be there
for first ambulation
- Prevention of dislocation/ subluxation
- Trochanter roll for hip alignment
- Pillow splint when turning (per
HCP)
- Higher risk for anterior surgery
- Avoid hip flexion
- HOB elevated only 35 - 40°
- Prevent adduction/ rotation
- Physical Therapy
- Do not sit in low sitting chairs or recliners
- Send home with bedside commode,
walker, etc
- ORIF/THA postop specifics
- Prevention of PE/DVT: SCD’s, TED hose
- Prevention of infection
- Assessment of bleeding
- Assessment of neurovascular status
- Management of pain
- Patient Education and Activity level
- Use of walker – crutches – cane
- Walker preferred
- Wound & drain assessment
- Managing medication side effects: urinary
rtx, confusion, etc
- Total Hip Replacement
- Precautions
- Avoid excessive trunk flexion in reaching
- Maintain hip in neutral position or
abduction
- No leg crossing at knee
- Use raised toilet seat
- Avoid hip flexion past 90°
- Avoid low, soft chairs
- Discharge Planning
- Home Care Preparation
- May require adaptive devices
- Assess barriers to care (physical,psychosocial,
emotional, etc.)

20
- Resources- family and community
- Patient and Family Education
- Someone should be with the patient when they go home
- Assess home support - home health/PT
- Referrals

21
 Parkinson’s Disease
- Progressive, degenerative neurological disease
- Most common among adult men
- Neurotransmitter Imbalance in brainstem
- Substanstia nigra: controls movement
- Dopamine vs ACH - vary inversely
- ACH gets higher because
Dopamine production lowers
- Loss of voluntary movement
- Symptoms similar to Huntingson’s disease
- Assessment
- Health History
- Physical Assessment
- Focus on neuro
- Gait assessment
- Romberg test
- Labs/Diagnostics
- None that can confirm diag.
- Can test CSF for dopamine but not definitive of
diagnosis
- Psychosocial Assessment
- Depression - dopamine decrease from disease process
- Knowledge Deficits
- For pt, caretakers, and family members
- Support groups
- Explain stages of progression so they know what to
expect
- S/S
- Four Cardinal Motor Symptoms:
- Non intentional tremor - usually in the hands
- Bradykinesia - slow movement
- Muscle rigidity - stiffness in arms/legs/neck
- Postural instability - loss of balance
- Non-Motor Symptoms: may have some or all
- Orthostatic hypotension
- Drooling/dysphagia: sit up while eating
- ConstNocturia
- Confusion/dementia
- Heat intolerance
- Anxiety/Depression
- Headache
- Stages
- Stage 1: Initial Stage
- Unilateral limb movement
- Minimal weakness
- Hand/arm trembling
- Stage 2: Mild Stage
- Bilateral limb involvement
- Mask like face: open mouth, gaze staring
- Slow, shuffling gait
- ADLs hard to complete independently
- Stage 3: Moderate Disease
- Postural instability
- Increased gait disturbances

22
 - Increased risk for falls!
- ADLs significantly difficult
- Stage 4: Severe Disability
- Akinesia
- Rigidity
- Cannot live alone
- May have no movement
- Need assistance with movement
- Stage 5
- Complete ADL Dependance
- Dysphagia - can occur at any stages
- Cognitive changes - majority do not have any but later
stages more likely
- Wheelchair bound
- Could be in nursing home at this point, completely
dependent

- Management: goal is to optimize the pt’s level of independence and

slow progression
- Prevent falls - safety is the largest concern!
- Encourage adequate nutrition
- Pharmacological
- Symptom management
- Rehabilitation
- Exercise: Promotes mobility & elevate mood
- Exercise regimen/PT
- Speech therapy
- Yoga/Tai Chi proven to help PD
- Sleep Patterns - sleep training
- Nutrition
- Consult dietician and speech therapy
- Consider appetite changes
- Dysphagia and aspiration precautions/diet
- Speech Pathologist: for dysphagia and speech
- Surgical: last resort
- Stereotactic Pallidotomy: go into the brain and destroy
part of basal ganglia to release muscle rigidity
- Deep Brain Stimulation: stimulates the brain to control

23
 involuntary movements using a pacemaker
- Fetal tissue and stem cell transplants
- Medications
- Dopamine Agonists: stimulate dopamine receptors in the brain
- Most effective in first 3-5 years, plateau after
- Adverse effects: orthostatic hypotension, hallucinations,
sleepiness/drowsiness
- Ropinorole (Requip)
- Pramipexole (Mirapex)
- Rotigotine
- Levodopa-Carbidopa: Sinemet
- Immediate natural precursor of dopamine
- Immediate release or controlled release
- Cannot stop using abruptly - will cause severe
parkinson’s symptoms
- Catechol O-methyltransferase Inhibitors: Inactivate dopamine
inactivators
- Entacapone (Comtan)
- Stalveo
- Can extend the amount of time levodopa works
- Monoamine Oxidase Inhibitor – Type B (MAOI-Bs)
- Rasagiline (Azilect)
- lows down dopamine breakdown
- Increase dopamine
- Multiple drug interactions, high risk for serotonin
syndrome
- Foods that have Tyramine: aged cheese/meat, beer/wine
- Anticholinergics: Inhibit acetylcholine
- Rarely drug of choice
- Can cause confusion in the elderly
- Urinary retention, dry mouth
- Antiviral: promotes synthesis of dopamine release
- Amantadine Hydrochloride (Symmetrel)
- Not a normal drug of choice
- Medical Marijuana
- Many positive symptom impacts
- Long-Term Medication Use
- “On-Off” phenomenon
- Toxicity
- Reduce/stop the dose
- Change medications
- Tolerance
- Increase drug dose
- Change medications
- Alter frequency of administration
- Take a drug holiday
- Specifically helpful for levodopa
carbodopa
- Patient & Caregiver Education
- Medication education - adherence!
- Familial education
- Schedule - same time every day
- Psychosocial changes r/t impaired mobility and cognition
- ADL completion

24
 - isolation
- Self-Management
- Encourage independence
- Preventative measures
- Fall prevention
- Prevent constipation
- Lots of lfuids, fiber, stool softener
- Supervise meals
- Offer smaller more frequent meals
- Ensure adequate nutrition with supplemental
nutrition products
- Health care resources
- Financial issues - access
- Social and state agencies
- Support groups
- Legal counsel - living will, update power of attorney, etc

25
 Sensory Perception/Eye Disorder
Glaucoma - Pathophysiology: a group of eye disorders characterized by
degeneration of retinal ganglion cells caused by increased IOP. Raised
pressure compresses and damages the optic nerve.
- Risk Factors
- Primary Glaucoma Causes
- Aging
- Heredity
- Associated Glaucoma Causes
- DM
- HTN
- Severe myopia
- Retinal detachment
- Secondary glaucoma
- Uveitis
- Iritis
- Neovascular disorders
- Trauma
- Ocular tumors
- Degenerative disease
- Eye surgery
- Central retinal vein occlusion
- Types:
- Acute/Angle Closure
- the most common form of glaucoma
- the eye’s drainage canals become clogged over time.
- This can damage the optic nerve.
- may be found early with regular eye exams and usually
responds well to treatment to preserve vision.
- Caused by slow drainage
- Decreased outflow: Asymptomatic vision damage
over time as IOP rises & stays elevated
- S/S: develops slowly, foggy vision, headaches.
- Late s/s: halos, loss of peripheral vision
- headache or brow pain(trigeminal/5th CN
pressure), N/V, abd pain, blurred vision, colored
halos around lights, bloodshot sclera, cloudy
cornea, difficulty concentrating
- Primary Open Angle (POAG)
- the angle in many or most areas between the iris and
cornea is closed, reducing fluid drainage and causing
increased eye pressure
- sudden onset
- medical emergency from sudden IOP rise
- often from meds used to dilate eyes
- S/S: Sudden severe pain around the eyes that radiates
over the face, quicker vision loss
- Secondary Open Angle
- Caused by increased fluid
- Results from ocular conditions like ocular tumors,
trauma, eye surgery, uveitis (iris, ciliary body & choroid).
Slow or abrupt onset.
- Slowly & asymptomatically over time
- Peripheral blind spots (crescent-shaped voids in

26
 peripheral vision) leading to “tunnel vision” if untreated
- No pain or pressure
- Diagnostics
- Tonometry: measures intraocular pressure using a tonometer
- Dilation & inspection
- Slit lamp microscope: POAG/normal angle, Angle
Closure/narrow/flat anterior chamber angle, edematous/frosty
cornea, moderately dilated pupil, cloudy aqueous
- Perimetry: assessing visual field. The patient presses a button
when a blinking light is seen
- Gonioscopy: painless, done w/slit lamp, better anterior chamber
angle visualization, the angle where the iris meets the cornea.
Distinguishes open & closed angle glaucoma
- Optic nerve imaging (scanning laser): done on a regular basis
for those w/ocular HTN or at risk
- Medications (Beta Blockers, Alpha 2 adrenergic antagonists, tr5
Prostaglandin agonists)
- Prostaglandin agonists, adrenergenic agonists, beta-andergenic
blockers
- Separate drops by 5-10 min to avoid “washing out”/dilution of
meds
- Hand washing
- No touching the tip to the eye
- Punctal occlusion: nasolacrimal duct to minimize systemic s/e
- Common s/e: mild burning, tearing & blurred vision, sclera
mildly red & itchy

Prostaglandin Agonsists:
Bimatoprost
Latanoprost
Travoprost

Andergenic Agonists:
Apraclonidine
Brimonidine tartrate

Beta-Andergenic Blockers:
Betaxolol HCl
Carteolol
Levobunolol
Timolol
Cholinergenic Agonists:
Carbachol
Echothiophate
Pilocarpine
Carbonic Anhydrase Inhib.
Brinzolamide
Dorzolamide

Combination Drug:
Brimonidine tartrate and
timolol maleate

27
 - Surgical Interventions
- Completed if medications do not control IOP
- *Laser Trabeculoplasty: POAG, burns the trabecular
meshwork, causing scarring, ↑ size between fibers, ↑ aqueous
humor outflow decreases IOP
- *Trabeculectomy: surgical procedure that creates a new
channel for fluid outflow.

Cataracts - Pathophysiology
- as people age, the lens gradually loses water and increases in
density. Causes clouding of the natural intraocular crystalline
lens that focuses the light entering the eye onto the retina.
- Etiology
- may be congenital (Down Syndrome), age-related, trauma,
exposure, or disorders (DM, hypoparathyroidism).
- Common causes: HTN, DM, Lupus, Thyroid issues, cardiac
disease, MS, pregnancy, HIV-III, sarcoidosis
- Some medications may impact vision
- Antihistamines
- Decongestants
- Antibiotics
- Opioids
- Antiocholinergenics
- Cholinerginic agonists
- Adrenergenic antagonists
- Beta blockers
- Oral contraceptives
- Chemo agents
- corticosteroids
- S/S
- Clouded, blurred, or dim vision
- Increasing difficulty with vision at night (from glare, less
definition of items in the dark)
- Sensitivity to light and glare
- Seeing "halos" around lights
- Need for brighter light for reading and other activities
- Frequent changes in eyeglass or contact lens prescription
- Fading or yellowing of colors
- Double vision in a single eye
- *No pain or eye redness is associated with age-related cataract
formation.
- Treatment
- Surgery is the only treatment. Perform ASAP once vision is
reduced and ADLs are affected.
- Nursing Interventions
- Preop
- Assess impact of condition on ADLs
- Teach about self examination required postop
- Eye drop instillation instruction
- If pt unable to manage several medications or
administration is hard, support is needed
- Ask about anticoagulant use
- drops given before surgery
- Dilation, lens paralysis, local anesthetic

28
 - Postop
- Abx and steroid drops given immeadiately after surgery
- Teach to wear dark glasses outdoors
- Teach pt AND support about medication schedule
- Written schedule
- Follow up appointments
- Mild itching is normal
- REPORT: significant swelling, bruising, pain early
after surgery, N/V → raises IOP!, yellow green
drainage
- Avoid strenuous activity
- Best vision not for 4-6 weeks

Eye Trauma - Diagnosis

- NO MRI if object contains or could contain metal.
- X-rays & CT scans done instead
- Analgesia as ordered, can be extremely painful
- Emotional support-reassure the patient
- Prevention
- Work: construction (nails etc.), mining, manufacturing,
thermal-welding torch burn, chemical-acid or alkaline, foreign
body, yard work/mowing grass,
- Hobbies: thermal injury-UV light from tanning beds, foreign
body-glass (stained glass)*, wood (carving) or metal work
- Sports: blunt or penetrating injury: racquetball, archery, gun
safety & fish hooks
- Violence: blunt injury-fist, penetrating-knife, stick, etc
- Random: car battery acid, drain cleaner, mace, pepper spray,
hair spray
- Nursing Interventions
- Determine mechanism of injury-chemical, blunt, thermal, foreign
body, penetrating
- ABC’s & other injuries: airway, breathing, circulation (ex: MVA),
other trauma?
- Protect the site- no pressure on the eye, pt should not blow their
nose
- Stabilize a foreign object but do not remove it (it may be holding
eye components together)
- Cover eye(s) w/ cup w/o putting pressure on it, sterile patch &
protective shield
- HOB up 45 degrees.
- Record time of injury & any 1st aid administered at the scene
- Symptoms
- visual acuity (gross), pain, photophobia, redness (diffuse or
local) or blood in the anterior chamber or draining blood, CSF or
aqueous humor, swelling, ecchymosis, tearing, visible foreign
body, prolapsed globe.
- Ocular irrigation
-

Corneal Abrasion - Pathophysiology

- Scrape or Scratch of the cornea.
- Painful can be caused by a small foreign body, trauma or
contact lens use. Dry eye

29
 - syndromes, malnutrition
- Corneal Infection – Abrasions allow organisms to enter leading
to corneal infections
- Corneal infections can lead to corneal ulceration which is a
deeper injury
- S/S
-
cloudy/hazy cornea
-
pain
-
reduced vision from hazing of image onto the retina (cloudy
cornea)
- photophobia (from irritation of cornea)
- Cloudy or purulent drainage noted on eyelids/lashes
- constant tearing/sensitivity (can be s/s of photophobia)
- Diagnosis
- visual acuity check –physical exam
- fluorescein stain is used (visualizes abrasions or ulcerations),
the patch areas will appear green color
- culture & ulcer scrapings- from ulcer center & edges w/sterile
spatula
- anesthetize eye first (no rubbing eyes)
- Treatment

Keratoconus - Pathophysiology
- - the degeneration of the corneal tissue resulting in an abnormal
corneal shape causing an uneven corneal surface. Caused by
inherited disorder or trauma
- Keratoplasty
- corneal transplant; requires local anesthesia, nerves around &
behind eye are numbed so pt cannot move eye or see
- Preop
- Ambulatory surgical setting
- -Assess for s/s of infection (Temp elevation, redness, drainage,
edema) and report these findings
- -Obtain IV access
- - Instill antibiotic eye drops Antimicrobials
- Postop/Education
- Same day surgery-home but return to MD the next day for a
check-up
- Usually the eye is covered with a patch/shield. It stays on until
the next MD visit usually the next day post op
- Teach to wear a patch at all times, even when sleeping at night
& especially when around pets/small children for a month.
- Teach hygiene
- Lie on the non-op side to IOP
- Avoid activities that IOP (cough, straining, jogging, dancing,
vacuuming, etc) for several weeks after surgery
- Abx eye ointment post op
- Eye drops (for 2-4wks after surgery) abx & steroid drops
- Can take up to 3-4 months but up to 1 yr for good vision to
return after surgery!
- Interventions
- Rejection
- Cornea has no blood supply but rejection is possible
- Rejection starts in donor cornea near graft edge & moves

30
 towards the center
- Rejection S/S:
- redness, photophobia, diminished vision, pain
- Steroid gtts used to hinder rejection
- If rejection continues: graft becomes opaque
-
- Donor Care
- HOB up 30
- ABX eye drops instilled
- Close eyes and apply Ice pack to eyes
- CDS-Carolina Donor Services

Macular Degeneration - Pathophysiology: when part of retina deteriorates (macula is part of

retina)
- Etiology
- *Leading cause of blindness in >55yoa
- *>10 million Americans affected
- Types:
- Dry/Atrophic/Age related
- macular cells start to atrophy, leading to slow
progressive & painless vision loss
- most common form (90% of all cases)
- age >60yoa
- c/o: close vision tasks becoming difficult
- may lead to wet in 10-15% of cts
- Wet/Exudative
- newly formed abnormal bld vessels form under center of
retina
- vessels: leak, bleed & scar: hurting sight
- starts in 1 eye, may affects other later
- 10% of people w/macular degen. But worse form to have
- c/o: more sudden/severe vision loss
- Risk Factors
- Age: most common type is dry/age related
- Caucasian
- Smoking
- Dietary-deficiency of beta carotene, vit E & C, zinc, antioxidants
lutein, & zeaxanthin
- HTN
- Farsightedness: eye to short, images focus behind retina
- Sun exposure
- S/S
- can be unilateral, distorted lines & images, scotomas-blind spots
- Diagnosis
- Amsler grid (grid if + see distortion), eye exam, angiography
- Treatment
- Dry/Age related:
- No curative treatment. Can slow/prevent w/proper diet,
avoid UV light & smoking, cholesterol control w/ diet &
statins
- Wet:
- Laser: seals leaking bld vessels w/wet form.
- OCULAR injections inhibits endothelial growth factor to
slow vision loss w/wet form.

31
 - *Avastin and Lucentis
- *Bevacizumab (Avastin)

Retinal Detachment - Pathophysiology

- emergency situation in which a thin layer of tissue (the retina) at
the back of the eye pulls away from its normal position;
Separates the retinal cells from the layer of blood vessels that
provides oxygen and nourishment.
- The longer retinal detachment goes untreated, the greater the
risk of permanent vision loss in the affected eye
- Risk factors
- Aging — retinal detachment is more common in people over age
50
- Previous retinal detachment
- Family history of retinal detachment
- Extreme nearsightedness (myopia)
- Previous eye surgery, such as cataract removal
- Previous severe eye injury
- Previous other eye disease or disorder
- Causes
- Posterior vitreous detachment
- Traction: from adhesions between vitreous gel & retina
- DM retinopathy, sickle cell dz, advanced ROP, penetrating
trauma
- *Exudates or serous fluid accumulates & causes detach w/o
break in retina.
- S/S
- The sudden appearance of many floaters — tiny specks that
seem to drift through your field of vision floating dark spots
- Flashes of light in one or both eyes (photopsia)
- Blurred vision
- Gradually reduced side (peripheral) vision
- A curtain-like shadow over your visual field
- Painless
- *The occasional fleeting floater that occurs as a spot or strand
and disappears after a few seconds is not something to worry
about
- Diagnosis
- Retinal examination - Fundoscopic eye exam w/dilated eyes
- Ultrasound imaging - Retina looks raised, gray, bloody folds in
retina; Orange peel look to retinal surface
- Treatment
- Scleral buckling - Silicone band indents the eye to approximate
the retina - usually stays in forever & commonly done due to
high success
- Pneumatic retinopexy - Gas bubble or silicone oil injected to
force the retina back in position –and- Laser/photocoagulation or
cold/cryotherapy or high-frequency current/diathermy used
- Vitrectomy - Eye fluid & scar tissue removed & fluid replaced
- Spontaneous reattachment is rare
- Nursing interventions
- Eye patch & shield post op or for trauma
- Post-gas pneumatic retinopexy: client remains surgery side up,
allows it to float up against retina in order to tamponade the RD,

32
 Positioning critical x 1-3 wks
- Ex: If break was on posterior eye, lie face down, If break was
on rt temporal retina, lie on left side
- Eye rest: no reading, writing, sewing or other “close work” (for
@7-10days)
- Teach s/s of infection & RD (sudden drop in acuity, eye pain,
eye pupil no reacting to light) to report

33