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Muscular-Skeletal Lecture 3. Amputation Pg 1080 Amputation “removal of a body part, often an extremity”

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Presentation on theme: "Muscular-Skeletal Lecture 3. Amputation Pg 1080 Amputation “removal of a body part, often an extremity”"— Presentation transcript:

1 Muscular-Skeletal Lecture 3

2 Amputation Pg 1080

3 Amputation “removal of a body part, often an extremity”

4 Amputation Common Causes – Peripheral Vascular Disease (PVD) – Trauma – Osteomyelitis – Tumor osteosarcoma

5 Which of the following type of amputation is the most common? A.Upper extremity B.Lower extremity

6 Amputation Reason – Relieve symptoms –  function –  quality of life

7 Which of the following is the preferred type of amputation A.AKA B.BKA

8 Amputation Most distal point

9 Amputation Nursing Assessment Pre-op – Neurovascular status CMS Doppler Ultrasound

10 Amputation Nursing Assessment Pre-op – Function – S&S of infection C&S Lymph nodes – Psych. status

11 Amputation Complications – Hemorrhage – Hematoma – Infection – Skin breakdown – Edema – Phantom limb pain – Contracture

12 Table Question What would you identify as the priority nursing diagnosis for a client who is post- op BKA?

13 Nrs Dx: for Amputation Acute pain Disturbed sensory perception Impaired skin integrity Grieving Self-care deficit Impaired physical mobility

14 Acute Pain

15 Nrs Dx: Acute Pain Opioid Evacuation Δ position Sandbag Distraction

16 Nrs Dx: Altered Sensory Perception  activity Rehab Distraction Rx – Analgesics – Tricyclic antidepressants – Anticonvulsants

17 Nrs Dx: Impaired skin integrity Gentle Aseptic tech. Diet –  protein – vitamins Residual limb shaping – Elastic dressing – Cast

18 Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site? A.Thoroughly irrigate the wound before collecting the specimen. B.Use a sterile swab and wipe the crusty area around the outside of the wound. C.Gently roll a sterile swab from the center of the wound outward to collect drainage. D.Use a sterile swab to collect drainage from the dressing.

19 NURSING ALERT If the cast or elastic dressing comes off, the residual limb must be immediately wrap with an elastic compression bandage. If not, excessive edema will develop leading to a delay in rehabilitation. Notify the surgeon so that another cast can be applied promptly

20 Nrs Dx: Impaired body image Nrs Dx: Grieving Relationship of trust Pt. care for limb Independence Realistic goals Support systems Referrals

21 Nrs Dx: Self Care Deficit Practice Nursing impact

22 Nrs Dx: Impaired physical mobility Prevent contractures Avoid – Abduction – External rotation – Flexion Prone* ROM Upper body exercises

23 Nursing Alert The residual limb should not be placed on a pillow because a flexion contracture of the hip may result.

24 A client hospitalized with MRSA (methicillin- resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? A.The client should be placed in a room with negative pressure. B.Infection requires close contact; therefore, the door may remain open. C.Transmission is highly likely, so the client should wear a mask at all times. D.Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.

25 A client who is admitted with an above-the- knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain? A."The pain will go away in a few days.“ B."The pain is due to peripheral nervous system interruptions. I will get you some pain medication." C."The pain is psychological because your foot is no longer there." D.“The pain and itching are due to the infection you had before the surgery."

26 The primary reason for rapid continuous rewarming of the area affected by frostbite is to: A.Lessen the amount of cellular damage B.Prevent the formation of blisters C.Promote movement D.Prevent pain and discomfort

27 You are assigned to care for a patient with a Below the Knee Amputation (BKA). Among the patient’s orders is one which states that the patient should be placed in the prone position twice daily. The nurse knows that the reason for this is: A.Changing the patient’s position will help to prevent skin breakdown B.To observe the stump for signs of infection C.To assist the patient in doing ROM (Range of Motion) exercises D.To stretch the flexor muscles and prevent flexion contractures

28 Small Group Questions 1.Look at the list of complications associated with an amputation. Identify ways to assess for each complication and treatment. 2.Describe the assessment of a patient going into surgery for a non-traumatic BKA.

29 What is the number one reason people go to their doctor? A.Respiratory infection B.Back pain C.Ear infection D.Head aches E.Complaint of symptoms assoc. with heart attacks

30 What is the number TWO reason people go to their doctor? A.Complaints of arthritis in the hands B.Back pain C.Ear infection D.Head aches E.Complaint of symptoms assoc. with heart attacks

31 Low Back Pain Pg 1117

32 Low Back Pain Multiple causes

33 Spinal Column Vertebrae Intervertebral disk

34 Intervertebral disks Youth – Cartilage – nucleus pulposus Age – Cartilage  Dense △ Shape

35 Term# vertebraeBody areaAbrv. Cervical7NeckC1 – C7 Thoracic12ChestT1 – T12 Lumbar5Low backL1 – L5 Sacrum5 (fused)PelvisS1 – S5 Coccyx3Tailbone

36 Spinal Column Facet joints Ligaments Muscles

37 Spinal Curves Shock Absorbers cal-spine-anatomy-animation

38 Disk degeneration Most common areas – L4 – L5 – L5 – S1

39 Disk protrusion AKA – Herniated nucleus pulposus – “Slipped disk”  pressure on the nerve  “Radiating” pain “Sciatica”

40 Low Back Pain S&S Acute – < 3 months Chronic – > 3 months

41 Low Back Pain S&S Muscle spasm  Lumbar curve

42 If a paravertebral muscle is in spasm, how would you describe the muscle tone? A.Atonic B.Flaccid C.Increased muscle tone D.Decreased muscle tone

43 Low Back Pain Assessment Hx & PE Reflexes CSM Pain.

44 Low Back Pain Medical Management If no serious problem  No additional testing for 4 weeks.

45 Low Back Pain Medical Management Self-limiting – 4 wks With – Rx – Rest – Relaxation

46 Medical Management: Rx Analgesics – Acetaminophen – NSAIDs Muscle Relaxants – Cyclobenzaprine (Flexeril) – S/E Drowsiness

47 Medical Management: Rx Tri-cyclic Antidepressants – Amitriptyline (Elavil)

48 Low Back Pain Medical Management Rest No – Twisting – Bending – Lifting – Reaching

49 Low Back Pain Medical Management Bed rest – 1-2 days Δ position frequently No sitting > 50 min. Gradual

50 Nonpharmacologic Interventions Relaxation – Heat – Spinal manipulation

51 Low Back Pain Nursing interventions Assess pain  –  analgesics Mattress – Firm – No sag Lumbar flexion

52 Low Back Pain Nursing interventions  activities gradually Low stress exercise 2 wks  abd. & trunk exercises Improve posture

53 Good body mechanics: Standing Short duration 1 foot on a stool ⌀ high hills ⌀ flexion Shift wt Stand on cushion ⌀ Lock knees

54 Good body mechanics: Sitting Short duration Chair – Straight back – Arm rests Knees  than hips Back support  extension Alt. sitting / walking

55 Good body mechanics: Lifting NEVER BEND AT THE WAIST! Bend knees Squat Hold item close Lift with your legs

56 No-No’s! Bending at the waist lifting without bending knees twisting and lifting Slouching Holding breath when lifting

57 Carpal Tunnel Syndrome Pg 1078

58 Carpal Tunnel Syndrome “Entrapment neuropathy” arpal-Tunnel-Syndrome.htm arpal-Tunnel-Syndrome.htm

59 Carpal Tunnel Syndrome Pathophysiology Median nerve Compressed

60 Carpal Tunnel Syndrome Etiology Men vs Women? – Women Age? – 30-60 Risk Factor – Repetitive movements

61 Carpal Tunnel Syndrome: S&S Pain – Night Paresthesia ? weakness

62 Carpal Tunnel Syndrome Assessment & Dx Tinel’s sign – Percussing over the median nerve  Tingling Numbness Pain – Test = +

63 Carpal Tunnel Syndrome Tx Corticosteroids Wrist splint

64 Carpal Tunnel Syndrome Surgery Open nerve release Endoscopic laser Local anesthetic Cut carpal ligament 

65 Small Group Questions 1.What medications are frequently prescribed to a clinic with acute low back pain? What are their actions 2.What are the 3-R’s of Low Back pain treatment? 3.Mr. Jones is suffering from acute back pain, what would you advice him to do? (What would your teaching plan include)? 4.Describe the pathophysiology of carpal tunnel syndrome. 5.Demonstrate how to perform the Tinel sign.

66 Osteoporosis: Pg. 1089

67 Osteoporosis: Pathophysiology Bone resorption Bone formation osteoclasts osteoblasts

68 Osteoporosis: Pathophysiology Bone Resorption > Bone formation =  bone mass

69 Osteoporosis: Pathophysiology / Hormones Age related changes  Calcitonin – Resorption  – Formation 

70 Osteoporosis: Pathophysiology / Hormones Age related changes  Estrogen – Resorption Inhibits

71 Osteoporosis: Pathophysiology / Hormones Age related changes  PTH – Resorption  – Formation 

72 Osteoporosis: Pathophysiology Porous Brittle Fragile Fx easily m/watch?v=rHyeZhcoZc Q m/watch?v=rHyeZhcoZc Q

73 Osteoporosis > 10 million Am. Have osteoporosis 33.6 million have osteopenia Men vs Women – Men < Women

74 Osteoporosis S&S Fractures may be the first clinical manifestation of osteoporosis

75 Osteoporosis Most Common Fx Compression – Thoracic spine – Lumbar spine Hip Colles – wrist

76 Osteoporosis S&S Collapsed vertebra Asymptomatic  Kyphosis   height  protruding abdomen  Pulm. insufficiency

77 Osteoporosis Risk Factors Age Men vs Women – WOMEN Small framed vs. large framed – Small framed Caucasian vs. Asian – Asian

78 Osteoporosis Risk Factors Nutritional factors – Adequate Cal. – Calcium – Vit. D

79 Osteoporosis Risk Factors Physical Activity stimulates bone formation & remodeling

80 Osteoporosis Risk Factors Immobility

81 Osteoporosis Assessment X-ray – Lumbar Biconcave – Thoracic Wedge shaped

82 Osteoporosis Assessment Bone densitometry – Detect bone mineral density (BMD) v=heTObdmOU8o v=heTObdmOU8o

83 Osteoporosis Medical management PREVENTION!!!!!! Diet – Calcium  – Vitamin D Exercise – Weight bearing

84 Osteoporosis Prevention Lifestyle – Alcohol – Smoking – Carbonated drinks? – Caffeine

85 Osteoporosis Medical Management Rx – Calcium 1,000 mg/day

86 Osteoporosis Medical Management Rx – Calcium 1,000 mg/day – Vit. D 600 IU/day – Vit. C 2,000 mg/day

87 Osteoporosis Medical Management: Rx Calcium Supplement Caltrate / Citracal Split dose S/E – Abd. distention – Constipation

88 Osteoporosis Medical Management: Rx Bisphosphonates Action –  bone resorption –  bone density Nrs implications – AM – Water – NPO ( ā & ṗ ) – Hold Ca+ – ⌀ lye down

89 Osteoporosis Medical Management: Rx Estrogen replacement

90 Osteoporosis Medical Management: FX Colles Fx Distal Radius D/T – Fall on open hand Reduced Active ROM

91 Osteoporosis Medical Management: FX Hip ORIF

92 Osteoporosis Medical Management: FX Compression Fx of vertebrae Conservative* If acute pain  – Vertebroplasty

93 Osteoporosis Nrs Process Acute Pain – D/T compression fx Rest – Supine – Side-lying – △ position frequently – Flex knees – No twisting  activity as pain 

94 Osteoporosis Nrs Process Risk for constipation D/T – Immobility – Meds Assess – Intake – BS – BM

95 Osteoporosis Nrs Process Risk for constipation Fiber –– Fluids –– Rx – Stool softeners

96 Paget’s Disease Page 1093

97 Paget’s disease Pathophysiology Rapid Bone Turnover  # of osteoclasts   bone resorption F/B  osteoblast activity  Bone replacement

98 Paget’s disease Pathophysiology Disorganized bone replacement Vascular Weak  Pathologic fractures  bowed legs  – Misalignment – Pain

99 Paget’s disease S&S Insidious Deformity – Skull – Pelvis – Femur/tibia Pain Warm Fx

100 Paget’s Disease Assessment & Dx Serum Ca+ – Normal X-ray Bone scan Bone biopsy

101 Paget’s Disease Medical Management Pain – Rx NSAIDs Gait – Assistive devices – Shoe lifts – PT Wt. control

102 Paget’s Disease Medical Management: Rx Calcitonin Action –  bone resorption –  osteoclasts Route – Sub q – Nasal

103 Paget’s Disease Medical Management: Rx Bisphosphonates Action –  bone turnover

104 Paget’s Disease: Nrs Management Teaching

105 Osteomalacia Page 1093

106 Osteomalacia AKA – Adult Rickets Deficit or impaired absorption of – Ca+ – Vit. D

107 Osteomalacia S&S Pain Difficulty △ positions* Weak* Waddle* Kyphosis Pathologic fx

108 Osteomalacia Medical Management Rx – Calcium – Vit. D – Bisphosphonate – Calcitonin

109 Small Group Questions 1.What is the pathophysiology of Osteoporosis? 2.What effect do the hormones calcitonin, estrogen and PTH have on bone remodeling? 3.What are Bisphosphonates? What advice would you give to a client with these? 4.What is a Colles’ fracture? What is a compression fx (of the vertebrae) 5.What is the pathophysiology of Paget’s Disease and Osteomalacia? 6.How are Paget’s Disease and Osteomalacia similar and how are they different?

110 During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate? A.Administer an antibiotic B.Contact the physician for an order for immune globulin C.Administer an antiviral D.Tell the client that he should remain in isolation for 2 weeks

111 A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to: A.Have a Protime done monthly B.Eat more fruits and vegetables C.Drink more liquids D.Avoid crowds

112 Following an amputation, the advantage to the client for an immediate prosthesis fitting is: A.Ability to ambulate sooner B.Less chance of phantom limb sensation C.Dressing changes are not necessary D.Less edema

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