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1 Orthopedic System Alteration in Mobility Integumentary System Med/Surg I, Module 4 Part 1 of 4.

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Presentation on theme: "1 Orthopedic System Alteration in Mobility Integumentary System Med/Surg I, Module 4 Part 1 of 4."— Presentation transcript:

1 1 Orthopedic System Alteration in Mobility Integumentary System Med/Surg I, Module 4 Part 1 of 4

2 2 Chronic Musculoskeletal Conditions Curvature of the Spine Osteoporosis Osteomyelitis Osteoarthritis

3 3 Curvature of the Spine Kyphosis (left) and Lordosis (right) Kyphosis Source: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center. Lordosis Source: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center.

4 4 Scoliosis Source: Wikimedia Commons, Public Domain

5 5 Osteoporosis Increased Risk Family history Female Menopause-related low estrogen females, low testosterone males Medications Lifestyle

6 6 Osteoporosis Prevention Diet Calcium supplements Stop smoking Alcohol and caffeine intake weight-bearing exercise Sunlight

7 7 Osteoporosis Diagnosis Dual-energy x-ray absorptiometry (DEXA) scan Qualitative ultrasound (QUS) of heel or calcaneus

8 8 Osteoporosis Collaborative Management Replace estrogen or testosterone Raloxifene (Evista) Biphosphonates: Alendronate (Fosamax) and risedronate (Actonel) Teriparatide (Forteo) Ibandronate sodium (Boniva) Calcitonin (Miacalcin) Sodium fluoride

9 9 Osteoporosis Nursing Care Prevent falls Treat pain Orthotic devices Refer to physical therapy Range of motion exercises

10 10 Osteomyelitis Local swelling Redness Tenderness Pain Fever Bone pain Source: UCSD Catalog of Clinical Images, Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California, 92093-0611

11 11 Diagnosis Bone scan Biopsy MRI, CT or ultrasound: fluid collection, abscess, periosteal thickening Elevated WBC, positive blood cultures

12 12 Collaborative Care Surgical debridement is the primary treatment Postoperative care: wound irrigation with strict sterile technique; monitor site for signs of infection, monitor temperature and WBC Most cases caused by Staphylococcus aureus: Parenteral antibiotics based on wound, blood cultures for 4-6 weeks or Oral twice-daily ciprofloxacin if chronic Hyperbaric oxygen therapy to promote healing

13 13 Osteoarthritis Reprinted with permission: Charles J. Eaton, M.D. of The Hand Center Reprinted with permission: DePuy Orthopaedics, Inc.

14 14 Clinical Manifestations Crepitus Joint stiffness Pain with movement Heberdens nodes (distal joints) and Bouchards nodes (proximal joints) Knees: Joint effusions Muscle atrophy Spine: radiating pain, stiffness, muscle spasms in extremities Hips: pain referred to inguinal area, buttock, thigh or knee; loss of internal rotation

15 15 Collaborative Care Analgesics Rest Heat Weight control TENS

16 16 Total Joint Arthroplasty Source: Hughston Foundation Source: Hughston Foundation

17 17 Postoperative Care Abduction pillow, neutral position Prevent embolus Prevent infection Assess for bleeding Neurovascular compromise Manage pain Promote activity

18 18 Total Knee Arthroplasty Continuous passive motion (CPM) device Ice or hot/ice machine Keep knee in neutral, no rotation inward or outward Monitor: thromboembolism, infection, bleeding, CSM Teach: no hyperflexion or kneeling for 6 weeks

19 Acute Musculoskeletal conditions: FRACTURES Source: Wikimedia Commons/Creative Commons Licence Phote courtesy of Mexican 2000/Flickr

20 20 Open or Closed? Photo source: American Academy of Orthopaedic Surgeons,

21 21 Compound Fractures Grade I oSmall wound Grade II o~1 cm to 10 cm oskin & muscle contusions Grade III oLarge oDamaged skin, muscle, nerves, vessels

22 22 Assessment Can he move it? Does it hurt? Is it deformed?

23 23 Key Treatments Closed reduction Immobilization oSplint oCast Open reduction Open reduction; External Fixation National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center

24 24 Cast Care Prevent indentations when wet Elevate uniformly Air dry CSM – What am I looking for? No scratching implements!

25 25 Skin Traction To decrease muscle spasm Weight 5-7 pounds attached w/ adhesive tape Used before surgical repair Check sling, tape for placement Keep pulley, weights in place Photo Source:, Royal College of Surgeons of Ireland (RCSI), Creative Commons

26 26 Bucks Traction Hip fracture assessment What to do immediately? Bucks traction assessments What should be done later? What teaching is needed? Bucks Traction Source: DeRoyal Patient Care

27 27 Other Skin Traction Russells Cervical Thomas splint Bryants Cervical Pelvic

28 28 Skeletal Traction Weight 25-40 pounds Are the ropes on the pulleys? Are the weights hanging free? Where are the knots? Monitor CSM Pin care? Skin care

29 29 Balanced Suspension Counter-traction by weights Check ropes, knots, weights Are traction bars tightened? Is patient in alignment? How do pin sites look? When can I remove weights?

30 30 Spinal Traction Where are the knots? Are the weights hanging free? What do the pin sites look like? How do I turn the patient? How can I make the patient comfortable?

31 31 Complications Compartment syndrome Fat embolism DVT Osteomyelitis Aseptic necrosis

32 32 Compartment Syndrome Prevention oCheck CSM oIce, elevate oLoosen dressing, open cast Emergency care oFasciotomy:

33 33 Fat Embolism Long bones, multiple fractures Elderly: hip fractures Altered mental status Respiratory distress Petechiae on trunk Prevention: early immobilization of fracture

34 34 Deep Venous Thrombosis Most common complication Predisposing factors Common sites: leg, pelvic fx Pulmonary embolus prevention Deep Vein Thrombosis Source: National Heart & Blood Institute

35 35 Osteomyelitis Sources: open wounds, implanted hardware Staphylococcus aureus usually Rx: IV antibiotics

36 36 Aseptic Necrosis Death of bone tissue Hip fractures or bone displacement Hardware interferes with circulation

37 37 Amputation Diabetic, smoker, infected foot ulcer Trauma Grieving loss Altered self concept Coping Family response

38 38 Surgical Wounds Web Resource Click tab titled, Med-Surg 1 Drop down menu choose Wound Care

39 39 Wound Assessment Measure the wound in centimeters Assess phase of wound healing Reaction Regeneration Remodeling Wound location, color of wound bed, condition of wound margins, integrity of surrounding skin Signs and symptoms of infection Drainage: amount, color, consistency, odor

40 40 Wound Care Dressing The ideal dressing oKeeps wound moist oPrevents maceration oProtects from contamination oContains wound fluid oProtects granulation tissue

41 41 Traditional dry dressings oWounds exposed to air are more inflamed, painful, itchy and have thicker crusts than moist wounds oEpithelium migrates into wound bed: if must burrow between any eschar (crust or Wet to dry dressing significantly increase healing time oNonocclusive: increased risk of contamination and infection

42 42 Moist Wound Healing No eschar develops (crust, scab) Enhances autolytic debridement: promotes role of macrophages and leukocytes Bacterial barriers: prevent wound contamination Wound fluids kept at site: contain growth factors and enzymes that promote autolysis and healing

43 43 Potential for Infection Signs of infection –I-induration –F-fever –E-erythema –E-edema

44 44 Absorptive powders and pastes Used in heavily draining wounds: absorb up to 100x weight in fluid: may increase wound pH above physiological levels May require wrapping in gauze before inserting into wound bed Pastes easier to remove from wound

45 45 Wound Healing Normal healing (3R's) oReaction: inflammatory process (72 hours) oRegeneration: proliferation (up to three weeks) oRemodeling: (three weeks to two years)

46 46 Black Wound = Eschar Cellular debris will escape wound edges as necrotic tissue begins to separate from granulation tissue If eschar becomes contaminated: becomes excellent medium for infection wound remains in reaction or inflammatory stage systemic signs of infection Eschar delays regeneration phase by interfering with cell migration and wound closure Risk of wound infection increases as the amount of necrotic tissue increases Needs debridement

47 47 Yellow Wound Tissue not damaged enough to form an eschar so wound covered with thick yellow fibrous debris or viscous exudate oHigh risk of infection due to excellent medium for bacterial growth oNeeds continuing debridement Photo courtesy of Saddleback College, California,

48 48 Red Wound Red indicates presence of granulation tissue. oColor of granulation tissue affected by nutritional status and blood supply full thickness ulcer: crater with pale pink to beefy red granulation tissue crater slowly fills with granulation tissue from bottom upward oWound contraction and epithelialization continues. Epithelialization occurs from wound edges inward.

49 49 Wound Drainage Devices Decrease pressure in the wound by removing excess exudate thereby promoting healing from the inside (secondary healing). Examples: Penrose drain, Jackson- Pratt & Hemovac suction devices

50 50 Dehiscence/Evisceration Partial or complete separation of the outer wound layers. If the internal organs below the wound protrude out of it, the wound has eviscerated. Highest risk is in obese patients, diabetics or those receiving steroids.

51 51 Bacterial skin infections Folliculitis, furuncles, cellulitis: these infections are usually caused by Staphylococcus aureus. Folliculitis involves the hair follicle. Furuncles (boils) are deeper. Cellulitis is a general infection and involves deeper connective tissue. Topical antibiotics: Neomycin sulfate (Neosporin) Teach: wash area daily with antibacterial soap, allow skin to dry, prevent cross contamination

52 52 Herpes Simplex Virus Type 1 causes common cold sore, type 2 causes genital herpes. After first infection, recurrence is triggered by stress. Spreads by direct contact. Patient is contagious for the first 3-5 days. Topical acyclovir (Zovirax) shortens the period of infection

53 53 Herpes Zoster (Shingles) Caused by reactivation of varicella (chickenpox). Occurs in the dermatome corresponding to the infected nerve. Eruptions follow several days after pain in the area, last several weeks. Acyclovir (Zovirax), given topically and/or orally controls the severity of the lesions and decreases pain.

54 54 Acute Burns

55 55 Superficial Sunburn oEpidermis pink to red oMild edema oPainful oHealing time: 3-5 days oNo skin graft

56 56 Partial Thickness Burn Brief contact: scald, flames, grease, chemicals Epidermis and dermis damaged Blisters if mild burn, pale, mottled, waxy white with deeper Painful Healing time: 2-6 weeks No grafting unless healing prolonged

57 57 Full Thickness Burn Prolonged contact: scald, flame, tar, grease, chemical, electricity Epidermis, dermis & underlying tissues damaged Waxy white, dry, leathery, charred No pain Healing: Weeks to months Skin grafts required

58 58 Percentage of Burn Injury Source: Burn diagrams courtesy of BioTel Emergency Medical Service (EMS), Texas Department of Health,

59 59 Emergency Management Excessive leakage of plasma, especially in the first eight hours post-burn, causes hypovolemia, hypoproteinemia, hemoconcentration, electrolyte imbalances and acid base disturbances. In the absence of prompt fluid replacement, burn shock is imminent.

60 60 Fluid Resuscitation Initial 24 hours: Lactated ringer's 2-4 ml/kg/%burn/24 hours - given in the first 8 hours post- injury. Additional fluid required for inhalation injury. Maintain urine output of 30 ml/hr. 5% albumin – keep albumin >2.5 gm/dl

61 61 Monitoring Fluid shift lasts 24 to 72 hours. Hematocrit, electrolytes, osmolality, calcium, glucose, albumin Urine output >30 ml/hr Myoglobinuria and hemoglobinuria Pulse rate and pulse pressure Normal sensorium and adequate peripheral capillary refill

62 62 TypeCausePriority ThermalFlame, steam, liquidsSmother flames; Remove smoldering clothing & metal objects ChemicalAcids, strong alkalis, organic compounds Brush off dry chemicals Remove clothing; ascertain type of chemical ElectricalDirect or alternating current Lightning Separate patient from electrical current Smother any flames Start CPR; Obtain EKG RadiationSolar, X-rays Radioactive agents Remove from radiation source Remove clothing if contaminated using tongs or lead gloves Send to radiation decontamination center

63 63 Skin Care Hydrotherapy daily to debride eschar and cleanse wounds Topical enzyme such as collagenase (Santyl) or Accuzyme will debride more rapidly Silver coated anti-microbial dressing (Acticoat)

64 64 Grafting: Allograft (skin from a cadaver) Synthetic such as Biobrane Bioengineered skin substitute (Transcyte)

65 65 Prevention of Pressure Ulcers Patients at risk Inspect skin frequently Move at least every 2 hours Use life sheet or slide board Pad bony prominences Remove excess moisture Adequate nutrution Use protective barriers

66 66 Braden Scale 1 2 3 4 SensoryCompletely limited Very limitedSlightly limitedNo impairment MoistureConstantly moist Very moistOccasionally moist Rarely moist ActivityBedfastChairfastWalks occasionally Walks frequently MobilityCompletely immobile Very limitedSlightly limitedNo limitations NutritionVery poorProbably inadequate AdequateExcellent Friction/ Shear ProblemPotential problem No apparent problem

67 67 Pressure Ulcers Stage I: Redness only Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures

68 68 Stage 2 Pressure Ulcer Loss of epidermis and partial loss of dermis not extending into subcutaneous tissue Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures

69 69 Stage 3 Pressure Ulcer Full thickness wound. Includes loss of epidermis and dermis. Extends into subcutaneous tissue. Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures

70 70 Stage 4 Pressure Ulcer Deep penetrating wound. Includes loss of epidermis, dermis and subcutaneous tissue. Extends into muscle and/or bone. Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures

71 71 Basal Cell Carcinoma Malignancy of the basal cell layer of the epidermis. Genetic predisposition, chronic irritation, and ultra-violet exposure are risk factors. Photo Source: Wikimedia Commons

72 72 Squamous Cell Carcinoma Cancers of the epidermis Chronic irritation, skin damage risk factors Photo Source: Wikimedia Commons inoma.jpg

73 73 Malignant Melanoma Pigmented cancers in the melanin-producing epidermal cells. Risk factors: predisposition, excess ultra-violet exposure. Photo Source: Wikimedia Commons

74 74 Preventing Skin Cancer Avoid sun between 11:00 am and 3:00 pm Use sunscreen Wear a hat, opaque clothing, sunglasses in the sun Examine body monthly for lesions

75 75 Seek Medical Attention Changes color, especially darkening or spreading Changes in size Change in shape – sharp border becomes irregular or flat becomes raised Surrounding redness or edema Change in sensation, especially itching or tenderness Change in character: oozing, crusting, bleeding, scaling

76 76 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.

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