Bones: anatomical changes mineral content mass Collagen formation > viscous synovial fluid > fibrotic synovial membranes joint cartilage water content & elasticity of cartilage
Muscles: anatomical changes mass tendon size – sclerosis elasticity of ligaments and tendons myosin adenosine triphosphatase (ATP) activity
Physiologic changes: Narrowing of joint spaces Bones make contact with bone muscle strength bone formation and bone reabsorption, leading to osteoporosis
flexion/extension of spine Posture & gait changes
mobility Joint stiffness & muscle strength Pain Disability, falls loss of independence, frailty
mobility MSK-related posture & gait changes Neuro-related gait & proprioception ( awareness of the position of one's body ) changes Environmental hazards fall risk Fractures Bone weakness
ROM limitations Mobility/walking difficulties Evidence of diffuse or localized joint pain Signs of motor or sensory dysfunction (weakness, spasticity, tremors, or rigidity) Gait changes caused by joint problems ( as opposed to those resulting from neurological problems) Change in level of functioning
Gait refers to the style or method of walking Problems with the gait may be due to: loss and recovery of balance the inability to maximize momentum the loss of use of gravity
Biological loss of flexibility, strength, posture, proprioception, sensory deficits neurological impairments such as Parkinson's disease Functional ill-fitting shoes or bony changes in the foot that influence the normal biomechanics of the foot Pathological prosthesis (the older person is at a higher risk for problems in association with a prosthesis)
Mobility includes: Transfer between objects or areas Walking Wheelchair and motorized transportation
To cause to decline from a condition of physical fitness, as through a prolonged period of inactivity, To lose physical fitness Predisposing risk factors: Prolonged bed rest because of an acute illness Disability that limits or temporarily eliminates mobility Chronic disease that causes a in activity Use of certain medications
Medical arthritis, cardiovascular, pulmonary disorders, deconditioning Psychological depression, cognitive impairment, poor motivation, fear of falling Sociological isolation, fear of crime, loss of friends Environmental multiple or uneven steps to maneuver or an unsafe home
Risk for noticeable decline in ROM within 48 hrs Daily loss of muscle strength
Joint contracture Decreased endurance Muscle weakness and atrophy Bone loss
Active or passive range of motion Regular repositioning of joints Neutral positioning of limbs Resting splints Therapeutic exercises Bed mobility training Standing or weight bearing
Supporting structure Arthralgias, myopathies: corticosteroids, lithium Osteoporosis, osteomalacia: corticosteroids, phenytoin, heparin Movement disorders EPS/tardive dyskinesia (are involuntary movements of the tongue, lips, face, trunk, and extremities that occur in patients treated with long-term dopaminergic antagonist medications) : neuroleptics, metoclopramide, amoxapine, methyldopa
Disorder of bone metabolism—loss of bone substance exceeds the rate of bone formation. The total bone mass is reduced, resulting in bones that become progressively porous, brittle, and fragile. Osteoporosis– number one cause of fractures in the elderly, >1.5 million per year
Primary Osteoporosis This is caused by osteopenia or thinning of the bone. This occurs when osteoclastic bone loss is faster than osteoblastic (bone building) activity. This is measured by BMD (bone mineral density Secondary Osteoporosis Caused by other disease mechanisms, or treatments, i.e. long term corticosteroids, methamphetamine or alcohol abuse, or prolonged immobility – can occur within 12 weeks Treatments are the same for both types
Post menopausal and low estrogen are a common cause Cushings disease, nutritional deficiency or malabsorption, long term steroids, prolonged immobility also cause osteoporosis Fractures common especially vertebral compressionHas visible deformity, loss of height, pain and constipation encourage regular, moderate exercise (walking), foods high in calcium and vitamin D, fiber and protein
Age Post-menopause (lack of estrogen stimulation) Thin lean body build Asian or thin Caucasian race Calcium and Vitamin D deficiency Lack of weight bearing exercise Alcohol abuse Tobacco use Excessive caffeine use (> 3 cups per day) Eating disorders Malabsorption disorders
DEXA Scan Screening annually of post- menopausal women DEXA Screening for hypothyroid and hyperthyroid patients Qualitative US – not used much Bone Scan is used for differential diagnostics, i.e. to rule out bone cancer Labs for Calcium, Magnesium, Phosphorus levels Urine for pyridinium levels
Educate – Calcium supplementation – new evidence is 1700 mg of calcium per day, or more for post-menopausal women not on hormone therapy. Fall prevention and safety Biphosphonates i.e. Fosamax, Actonel, Boniva– have to be taken 1 hour before any other foods or vitamins, with only water to be absorbed. Teach to maintain good posture and body mechanics Encourage regular, moderate exercise (walking), foods high in calcium and vitamin D, fiber and protein Vitamin D therapy –found in dairy and green leafy vegetables
Nursing’s primary concern is to assess and prevent neuro-vascular dysfunction. Neuro / circulation checks should be done of the affected limb every 15 minutes x 4, then every 30 minutes x2, then every hour. ( The book says every hour, but that is really too long, and your patient could go into shock) Immobilize the limb Control the pain Assess for shock
Other fracture interventions (with casting or immobilization/traction). Monitor for numbness, tingling, hyperesthesia, hypoesthesia Monitor for DVT’s – check pulses and color Instruct the client to examine the skin daily for any breakdown or alterations, call MD if oozing or redness occur Instruct client to avoid crossing their legs Instruct patient to completely abstain from tobacco Remove home safety hazards in the home Instruct patient not to scratch underneath the cast or around the pins/traction Give patient anticoagulants and analgesics if ordered Instruct patient to take vitamins, adequate amoaunts of magnesium, vitamin C, etc…for healing.
Neurovascular Components: “The 6 P’s” Early or Late Signs Assessment ParametersClient Teaching / Symptoms to Report Pain Early Assess area involved using 0 to 10 rating scale: 0 = no pain 10 = worst pain imaginable Increasing pain not relieved with elevation or pain medication Paresthesia Early Assess for numbness/tingling, pins or needles sensation: Should be absent. Numbness or tingling, pins or needles sensation Pallor Early Assess capillary refill. Brisk is < 3 seconds Increased capillary refill time > 3 seconds, blue fingers or toes Polar Late Assess skin temperature by touch: Warm Cool Cool/cold fingers or toes Paralysis Late Assess mobility: Moves fingers or toes Able to plantar dorsiflex the ankle area not involved or restricted by cast Unable to move fingers or toes Pulses Late Assess pulse(s) distal to injury: Pulse is palpable and strong Weak palpable pulses, unable to palpate pulses, pulse detected only with Doppler
Fractures- Pathological fractures occur when abnormal force is applied, or the bone is already weakened (osteoporosis, cancers, sarcomas, benign bone cysts, etc.). The type of fracture depends on the type of loading force and stress applied to the bone. See below. Closed - Greenstick -Spiral - Open (compound)
This is a photograph of 70 year old woman who first presented like this with a massive chondrosarcoma of her right upper humerus of 8 months duration. She refused all treatment, and she died of a massive haemorrhage when the tumour burst the following week.
Complications of fractures include: Fat emboli syndrome/CVA/Stroke Hematoma (leakage from the bone marrow usually), which can also be a hemmorhage Callus formation DVT- thromboembolism Infection – to Osteomyelitis Ischemic necrosis Fracture blisters Delayed union, nonunion, and malunion Osteoblastic proliferation…..
Perform/assist with relevant laboratory, diagnostic, and therapeutic procedures within the nursing role, including: Preparation of the client for the procedure. Client teaching (before and following the procedure). Accurate collection of specimens. Accurate interpretation of procedure results (compare to norms) and appropriate notification of the primary care provider. Assessment and evaluation of the client’s response (expected, unexpected adverse response, comparison to baseline) to the procedure. Planning and implementing body system specific interventions as appropriate. Monitoring and taking actions, including client education, to prevent or minimize the risk of complications. Recognizing signs of potential complications and reporting to the primary care provider. Recommending changes in the test/procedure as needed based on client findings. Protect the client from injury. Monitor therapeutic devices (drainage/irrigating devices, chest tubes), if inserted, for proper functioning. Identify the client’s prognosis based on knowledge of pathophysiology and understanding of the client’s pathology report.
Casts Casts are more effective than splints or immobilizers because they cannot be removed by the client. Types of casts include: Short and long arm casts. Short and long leg casts. Spica cast, which refers to a portion of the trunk and one or two extremities. Body cast, which encircles the trunk of the body. Splints and Immobilizers Splints are removable and allow for monitoring of skin swelling or integrity. Splints can be used to support fractured/injured areas or used for postparalysis injuries to avoid joint contracture. Immobilizers are prefabricated and are fastened with Velcro straps.
Traction Traction uses a pulling force to promote and maintain alignment to the injured area. In straight or running traction, the countertraction is provided by the client’s body. In balance suspension traction, the countertraction is produced by devices such as slings or splints. Goals of traction include: Realignment of bone fragments. Decreasing muscle spasms and pain. Correcting or preventing further deformities Types of Traction Manual Skin Skeletal Halo Traction
* Pin care is done frequently throughout immobilization (skeletal traction and external fixation methods) to prevent and to monitor for signs of infection including: --Drainage (color, amount, odor). --Loosening of pins. --Tenting of skin at pin site (skin rising up pin). Pin care protocols (use of hydrogen peroxide, povidone iodine) are based on provider preference and institution policy. A primary concept of pin care is that one cotton-tip swab is used per pin to avoid cross-contamination. Every 8 hr is a common parameter for pin care schedule.
External fixation involves fracture immobilization using percutaneous pins and wires that are attached to a rigid external frame. Used to treat: Comminuted fracture with extensive soft tissue. Leg length discrepancies from congenital defects. Bone loss related to tumors or osteomyelitis. Advantages include: Immediate fracture stabilization. Allows three plane correction of the injury. Minimal blood loss occurs in comparison with internal fixation. Allows for early mobilization and ambulation. Disadvantages include: Risk of pin tract infection. Potential overwhelming appearance to client.
Fractures- complications Acute Compartment Syndrome (ACS) A serious condition which can lead to a loss of life and limb, usually an arm or a leg. The swelling of an injury or trauma causes lack of innervations and compromised circulation to the affected part of the body, causing tissue death and necrosis. Edema causes this. Treatment is mandated by alleviating the pressure. The most common type of acute compartment syndrome in the hospital is infiltration of IV fluids, and in trauma victims.
Signs and Symptoms of ACS: Greater pain with passive movement than with active movement Swelling Pain not relieved with analgesics These are early signs and the physician needs to notified at once. ACS can lead to renal failure, shock, and loss of the limb or life.
Treatment Determine the cause of swelling, If the cast is too tight then it needs to be cut off. If the dressing is too tight, loosening the bandage will release the pressure Surgical release of tissue pressure is often required. (Fasciotomy)
Assessing fractures and trauma: Color or pallor of patient Color of the limb distal to the injury Movement Sensation Distal pulses Pain Skin temperature Capillary refil
Arthritis is a general condition characterized by inflammation and degeneration of a joint. Rheumatic disorders include more than 100 different types of recognized inflammatory disorders, making this collective group the most common orthopedic problem.
RA--Is a systemic inflammatiory disorder of connective tissue characterized by chronicity, remissions, and exacerbations. The potential for disability with rheumatoid arthritis is great and is related to the effects on joints, as well as the systemic problems.
Initially, the immune system produces antibodies, called rheumatoid factor (RF), that attack and destroy joint structures. In essence, when the restricting band of tissue calcifies, the joint no longer exists.
In most—onset is acute Joint involvement is usually bilateral and symmetrical. Localized s/s include: Joint pain, swelling, and warmth. Erythema Mobility limitation Spongy tissue on joint palpation Fluid aspirated from joint
Although dietary iron intake is adequate, clients characteristically have persistent anemia resulting from the effect of RA on the blood forming organs. Typically, the pain is more severe in the morning after a night’s rest. The pattern of remissions and exacerbations can continue for years.
Treatment regimen for severe rheumatoid arthritis is a balance between rest and exercise Drug of choice is aspirin Antiinflammatory drugs also given To avoid side effects give with food
Degenerative joint disease (arthritis) is a noninfectious progressive disorder of the weightbearing joints. The normal articular joint cartilage is smooth, white, and translucent. It is composed of cartilage cells (chondrocytes) imbedded in a sponge-like matrix made of collagen, protein polysaccharides, and water. With early primary arthritis, the cartilage becomes yellow and opaque with localized areas of softening and roughening of the surfaces. As degeneration progresses, the soft areas become cracked and worn, exposing bone under the cartilage. The bone then begins to remodel and increase in density while any remaining cartilage begins to fray. Eventually, osteophytes (spurs of new bone) covered by cartilage form at the edge of the joint. As mechanical wear increases, the cartilage needs repairing. The cartilage cells are unable to produce enough of the sponge-like matrix and therefore the damaged cartilage cannot repair itself. The cartilage has no blood supply to enhance healing.
Unlike RA, DJD has no remissions and no systemic symptoms, such as malaise and fever. It usually is limited to one or two joints that may start as early as the middle thirties, but is mainly associated with aging.
Brief joint stiffness and pain following a period of inactivity. The pain generally increase with heavy use and is relieved by rest. Eventually not relieved by rest The ROM of the affected joint becomes progressively limited, and stiffness and pain increase.
Clients with a knee of hip replacement may use a continuous passive motion (CPM) machine postoperatively. This machine promotes healing and flexibility within the knee or hip joint and increases circulation to the operative area. The md orders the amount of extension and flexion produced by the machine as well as the frequency of use.
The amount of flexion for clients with hip replacements should never exceed 30 degrees in a CPM machine.
Instruct on purpose of drug therapy, --- because aspirin and NSAIDs can cause gastric bleeding, instruct clients to take the med with food. Preoperatively withhold aspirin to reduce the risk for excessive bleeding. Monitor the CBC, Prothrombin time, and bleeding and clotting times to make sure that the client’s ability to control bleeding is not compromised.
Post-op keep the head of the bed at 45 degrees of less. Positioning the legs of clients with a hip replacement in abduction and extension because the opposite positions of adduction and flexion can dislocate the prosthetic head Make sure pt sits in an elevated chair or on a seat raised by pillows, so that the flexion is less than 90 degrees.
Inflammation of the bursa, a fluid- filled sac that cushions bone ends to enhance a gliding movement. The elbow, shoulder, and knee are common sites of bursitis. Trauma is the most common cause. Other causes include infection and secondary effects of gout and RA.
Painful movement of a joint, such as the elbow or shoulder, is the most common symptom. A distinct lump may be felt. If the bursa ruptures, tissue in the area may become edematous, warm, and tender.
Rest Salicylates or NSAIDs May inject with a corticosteroid preparation. Ongoing therapy involves mild ROM exercises
Severe bone infection Can result from trauma or secondary infection Acute localized osteomyelitis occurs when bone is contaminated directly by trauma, such as penetrating wounds or compound fractures.
Occasionally, surgical contamination or direct extension of bacteria from an infected area adjacent to the bone, such as the pin sites of skeletal traction, can cause osteomyelitis
Other complications of osteomyelitis include septicemia, thrombophlebitis, muscle contractures, pathologic fractures, and nonunion of fractures.
High fever, chills, rapid pulse, tenderness or pain over the affected area, redness, and swelling. Chronic infection may be characterized by a persistent draining sinus.
Handle the arm or leg or related area gently to prevent additional pain or fracture. Instruct the client to keep the area elevated and to bear weight only as indicated. Administer the prescribed antibiotics and pain medications
Changes with aging result from gradual loss Losses often begin in early adulthood Decline varies considerably from person to person Decrement does not become significant until the loss is fairly extensive Think in terms of thresholds: loss of function does not become significant until it crosses a given level (might be ok in normal situations, but unable to adapt under stress) Estrogen deficiency: Leading factor in osteoporosis
Adverse changes can be slowed or negated by engaging in regular exercise Beneficial effects on multiple systems What works relative to physical activity exercise programs: set goals, plan a program, address barriers, cross train
Nutritional Considerations Include dietary sources of proteins, fiber, omega-3 fatty acids, and fluids Avoid fasting, low-carbohydrate diets, and rapid weight loss Excess fiber and protein, caffeine, alcohol, and smoking promote calcium excretion
Pharmacologic Considerations Recommend oral calcium with vitamin D Teach about signs of salicylism Caution against discontinuing drugs and quick quack“cures” Caution against use of buffered aspirin or enteric-coated aspirin Provide detailed instructions about medical regimens Common adverse effects of NSAIDs are related to the GI tract
s-shaped vertebral column with four normal curvatures ◦ cervical ◦ thoracic ◦ lumbar ◦ pelvic primary curvatures – present at birth ◦ thoracic and pelvic secondary curvatures – develop later ◦ cervical and lumbar ◦ lifting head as it begins to crawl develops cervical curvature ◦ walking upright develops lumbar curvature Cervical curvature Thoracic curvature Lumbar curvature Pelvic curvature C7 T1 T12 L1 S1 L5 C1
from disease, paralysis of trunk muscles, poor posture, pregnancy, or congenital defect scoliosis – abnormal lateral curvature ◦ most common ◦ usually in thoracic region ◦ particularly of adolescent girls ◦ developmental abnormality in which the body and arch fail to develop on one side of the vertebrae kyphosis (hunchback) – exaggerated thoracic curvature ◦ usually from osteoporosis, also osteomalacia or spinal tuberculosis, or wrestling or weightlifting in young boys lordosis (swayback) – exaggerated lumbar curvature ◦ is from pregnancy or obesity Key Normal Pathological (b) Kyphosis (“hunchback”) (c) Lordosis (“hunchback”) (a) Scoliosis