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1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Musculoskeletal System Metro Community College NURS 1110 Nancy Pares,

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1 1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Musculoskeletal System Metro Community College NURS 1110 Nancy Pares, RN, MSN

2 2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of Connective Tissues  Bind structures together, providing support for individual organs and a framework for the body  Store fat, transport substances, provide protection, and play a role in repair of damaged tissue

3 3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of Connective Tissues  Types of connective tissue ◦ Loose (areolar, adipose, reticular) ◦ Dense (tendons, fascia, dermis, gastrointestinal tract submucosa, fibrous joint capsules) ◦ Elastic (aortic walls, vocal cords, parts of trachea and bronchi, some ligaments) ◦ Hematopoietic (blood) ◦ Strong supportive (cartilage, bone, ligaments)

4 4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of Connective Tissues  Bone ◦ Hard tissue: makes up most of skeletal system ◦ Functions: support, protection, movement, storage of calcium and other ions, and manufacture of blood cells

5 5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of Connective Tissues  Cartilage ◦ Specialized fibrous connective tissue ◦ Provides firm but flexible support for the embryonic skeleton and part of the adult skeleton ◦ Cartilage cells are called chondrocytes

6 6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of Connective Tissues  Ligaments ◦ Strong and flexible fibrous bands of connective tissue that connect bones and cartilage and support muscles ◦ Yellow ligaments, located in the vertebral column, are elastic and allow for stretching ◦ White ligaments, found in the knee, do not stretch but provide stability

7 7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of Connective Tissues  Tendons ◦ Composed of very strong and dense fibrous connective tissue ◦ They are in the shape of heavy cords and anchor muscles firmly to bones

8 8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Joint Structure and Function  Connective tissue disorders: manifested as joint disorders since joint mobility depends on functional connective tissue  Joint: site where two or more bones are joined; permit motion and flexibility of the rigid skeleton  Classification ◦ Synarthroses (fixed joints) ◦ Amphiarthroses (slightly movable joints) ◦ Diarthroses (freely movable joints)  Encased in a fibrous capsule made of strong cartilage and lined with synovial membrane

9 9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Age-Related Changes  Loss of bone mass and bone strength ◦ Osteoporosis common in women but affects men ◦ Put the older patient at risk for fractures  Cartilage gradually loses elasticity; becomes soft and frayed ◦ Water content decreases, and cartilage may ulcerate, leaving bony joint surfaces unprotected and promoting growth of osteophytes (bony spurs) ◦ Result in pain and limited mobility

10 10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chief Complaint and History of Present Illness  Complaints that suggest possible problems related to connective tissue disorders are aches, pain, joint swelling or stiffness, generalized weakness, a change in ability to work or to enjoy leisure activities, a change in appearance that is significant to the patient, and a change in ability to carry out activities of daily living

11 11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Past Medical History  Major childhood and adult illnesses, operations, and current medications and allergies  History of tuberculosis, poliomyelitis, diabetes mellitus, gout, arthritis, rickets, infection of bones or joints, autoimmune diseases, and neuromuscular disabilities  Accidents and injuries  Current medications

12 12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Family History  Osteoporosis, osteoarthritis, rheumatoid arthritis, gout, or scoliosis may have some genetic basis ◦ Autoimmune diseases, e.g., thyroid disorders  Review of systems ◦ General health status; determines patient’s perception of well-being ◦ Fatigue, malaise, anorexia, weight loss, pain, stiffness, dysphagia, or dyspnea

13 13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Examination  Vital signs, height, and weight  Skin color, rashes, lesions, scars, or any signs of injuries  Palpate skin for warmth, edema, and moisture  Palpate lymph nodes for enlargement and tenderness  Inspect joints for swelling and deformity, and palpate for warmth, swelling, and tenderness  Joint pain and range of motion  Measure limb length and muscle strength

14 14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures  Blood studies ◦ Complete blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein determination ◦ Venereal Disease Research Laboratory (VDRL), rheumatoid factor (RF), creatinine, and antinuclear antibody (ANA) tests  Urine studies ◦ Creatinine and uric acid levels

15 15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures  Radiologic imaging studies ◦ Radiography, ultrasonography, arthrography, nuclear scintigraphy, magnetic resonance imaging, diskography, tomography, and computed tomography ◦ No strenuous activity for hrs following procedure ◦ Joint aspiration: done at bedside

16 16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Therapeutic Measures  Drug therapy ◦ Glucocorticoids ◦ Nonsteroidal anti-inflammatory drugs (NSAIDs) ◦ Biologic response modifiers (BRMs) ◦ Disease-modifying antirheumatic drugs (DMARDs) ◦ Cyclooxygenase-2 (COX-2) inhibitors  Surgical treatment ◦ Indicated in some musculoskeletal disorders, such as degenerative joint disease and arthritis ◦ Continuous passive motion (CPM) machine

17 17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Disorders of Connective Tissue Structures

18 18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoarthritis  Pathophysiology ◦ Degeneration of articular cartilage with hypertrophy of the underlying and adjacent bone ◦ Normally, articular cartilage provides a smooth surface for one bone to glide over another ◦ Cartilage transfers the weight of one bone to another so the bones do not shatter ◦ Osteoarthritis: shock-absorbing protection lost ◦ New bone growth is stimulated by exposed bone surfaces, causing bone spurs

19 19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 41-1

20 20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoarthritis  Signs and symptoms ◦ Pain in affected joint, stiffness, limitation of movement, mild tenderness, swelling, and deformity or enlargement of the joint ◦ Heberden nodes and Bouchard nodes  Medical diagnosis ◦ Health history and radiographic studies ◦ Arthroscopy and MRI ◦ Synovial fluid aspiration

21 21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 41-2

22 22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoarthritis  Medical treatment ◦ Drug therapy  Acetaminophen, NSAIDs, DMARDs, COX-2 inhibitors, or low dose of salicylates (aspirin) ◦ Surgery  Arthroscopic surgery and arthroplasty ◦ Physical therapy  Improve range of motion; maintain muscle mass and strength ◦ Education

23 23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 41-3

24 24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoarthritis  Assessment ◦ Joint pain or tenderness ◦ Examine joints for crepitus, enlargement, deformity, and decreased range of motion ◦ Compare affected and unaffected joints to detect abnormalities ◦ Determine how the disease affects the patient’s mobility and ability to perform activities of daily living

25 25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoarthritis  Interventions ◦ Chronic Pain ◦ Impaired Physical Mobility ◦ Ineffective Coping ◦ Ineffective Therapeutic Regimen Management

26 26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoarthritis  Care following total joint replacement ◦ Assessment  Vital signs, level of consciousness, intake and output, respiratory and neurovascular status, urinary function, bowel elimination, wound condition, and comfort  Circulation and sensation in the affected extremity

27 27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoarthritis  Interventions ◦ Acute Pain ◦ Risk for Injury ◦ Impaired Physical Mobility ◦ Impaired Tissue Perfusion ◦ Risk for Infection ◦ Anxiety or Fear ◦ Deficient Knowledge

28 28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Rheumatoid Arthritis  Pathophysiology ◦ Chronic, progressive inflammatory disease ◦ Inflammation of the synovial tissue ◦ Synovium thickens; fluid accumulates in joint space ◦ Vascular granulation tissue (pannus) forms in the joint capsule and breaks down cartilage and bone ◦ Fibrous tissue invades pannus, converting it first to rigid scar tissue and finally to bony tissue ◦ These changes result in ankylosis

29 29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 41-6

30 30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Rheumatoid Arthritis  Signs and symptoms ◦ Pain in affected joints aggravated by movement ◦ Morning stiffness lasting more than 1 hour ◦ Weakness, easy fatigability, anorexia, weight loss, muscle aches and tenderness, and warmth and swelling of the affected joints ◦ Joint changes are usually symmetric ◦ Rheumatoid nodules (subcutaneous, over bony prominences) ◦ Any organ may be affected  Inflammation in tissues of heart, lungs, kidneys, eyes ◦ Clusters of symptoms  Sjögren’s, Felty’s, or Caplan’s syndromes

31 31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 41-7

32 32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Rheumatoid Arthritis  Medical diagnosis ◦ Health history and physical examination ◦ Laboratory studies  RF (rheumatoid factor), ESR (erythrocyte sedimentation rate), and CRP (C-reactive protein) ◦ MRI, bone scans, and DEXA scans

33 33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Rheumatoid Arthritis  Medical treatment ◦ Drug therapy  Aspirin and other NSAIDs for several months, with the addition of gold compounds, d-penicillamine, antimalarials, or sulfasalazine if needed ◦ Physical and occupational therapy ◦ Surgery  Arthroplasty, synovectomy, tenosynovectomy, and arthrodesis

34 34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 41-5

35 35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Rheumatoid Arthritis  Assessment ◦ Pain, joint swelling, tenderness, joint deformities and limitation of movement, fatigue, and decreased ability to perform activities of daily living  Interventions ◦ Chronic Pain ◦ Activity Intolerance ◦ Ineffective Coping ◦ Social Isolation ◦ Ineffective Therapeutic Regimen Management

36 36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoporosis  Pathophysiology ◦ Bone constantly formed and absorbed ◦ Until adolescence, bone formation exceeds bone absorption so that bones grow and strengthen ◦ Around age 30, bone absorption surpasses formation ◦ Loss of trabecular bone, innermost layer, occurs first ◦ Loss of cortical bone, hard outer shell, begins later  Begins earlier and progresses faster in women than in men ◦ Result is loss of bone mass

37 37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoporosis  Risk factors ◦ Older women who have small frames, who are white or of northern European heritage, and who have fair skin and blond or red hair ◦ Estrogen deficiency; physical inactivity; low body weight; inadequate calcium, protein, or vitamin D intake; corticosteroid therapy over more than 6 months; and excessive use of cigarettes, caffeine, and alcohol

38 38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoporosis  Signs and symptoms ◦ Back pain, fractures, loss of height due to vertebral compression, and kyphosis ◦ Bone deterioration in the jaw can cause dentures to fit poorly ◦ Collapsed vertebrae can cause chronic pain

39 39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoporosis  Medical diagnosis ◦ Absorptiometry ◦ Radiographs ◦ Bone specimen  Medical treatment ◦ Calcium supplementation and estrogen replacement ◦ Bisphosphonates and selective estrogen receptor modulators (SERMs) ◦ Regular exercise ◦ Percutaneous vertebroplasty

40 40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Osteoporosis  Assessment ◦ Diet, calcium intake, and exercise plan ◦ Note whether the patient is menopausal or has had an oophorectomy ◦ Compare height with previous measurements ◦ Posture; note the presence and degree of deformity  Interventions ◦ Risk for Trauma ◦ Chronic Pain ◦ Ineffective Therapeutic Regimen Management

41 41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Gout  Pathophysiology ◦ Characterized by hyperuricemia ◦ Related to excessive uric acid production or decreased uric acid excretion by the kidneys ◦ Four stages  Asymptomatic hyperuricemia  Acute gouty arthritis  Asymptomatic intercritical period  Chronic tophaceous gout

42 42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Gout  Signs and symptoms ◦ Asymptomatic hyperuricemia  Blood uric acid level is elevated, but no other symptoms  Many people with asymptomatic hyperuricemia never progress to the next stage

43 43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Gout  Signs and symptoms ◦ Acute gouty arthritis  Onset is abrupt, usually occurs at night  The patient is suddenly afflicted with severe, crushing pain and cannot bear even the light touch of bed sheets on the affected joint  Joint commonly affected is the great toe  Symptoms usually disappear within a few days

44 44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Gout  Signs and symptoms ◦ Asymptomatic intercritical period  No symptoms ◦ Chronic tophaceous gout  Advanced gout  Tophi: deposits of sodium urate crystals that are visible as small white nodules under the skin

45 45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 41-8

46 46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Gout  Medical diagnosis ◦ History and physical examination ◦ Urate crystals in synovial fluid ◦ Urinary uric acid ◦ Blood uric acid

47 47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Gout  Medical treatment ◦ Asymptomatic hyperuricemia requires no medical treatment ◦ NSAID alone or with colchicine for acute gouty arthritis ◦ For subsequent attacks: indomethacin, corticosteroids, and corticotrophin ◦ Avoid foods high in purines

48 48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Gout  Assessment ◦ Pain, joint swelling, tophi, uric acid stones, fever, and a history of trauma, injury, or surgery  Interventions ◦ Acute Pain ◦ Impaired Physical Mobility ◦ Altered Urinary Elimination ◦ Ineffective Therapeutic Regimen Management

49 49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fractures Metro Community College NURS 1110 Nancy Pares, RN, MSN

50 50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Classification of Fractures  Closed or simple fracture ◦ The bone does not break through the skin  Open or compound fracture ◦ Fragments of the broken bone break through skin ◦ Open fractures have three grades of severity  Grade I: least severe injury, with minimal skin damage  Grade II: moderately severe injury, with skin and muscle contusions (bruises)  Grade III: most severe injury (wound larger than 6 to 8 cm), with skin, muscle, blood vessel, and nerve damage

51 51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Classification of Fractures  Stress fracture ◦ Caused by either repeated or prolonged stress  Pathologic fracture ◦ Occurs because of a pathologic condition in the bone, such as a tumor or disease process, that causes a spontaneous break

52 52Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-1

53 53Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Etiology and Risk Factors  Commonly caused by trauma to the bone, especially as a result of automobile accidents and falls  Bone disease, e.g., bone cancer, can lead to a fracture  Hip fractures in older adults usually from falls  Risk factors for hip fractures: osteoporosis, advanced age, white race, use of psychotropic drugs, and female  In adults, ribs most commonly fractured  Fractures of the femur most common in young and middle- aged adults  Hip and wrist fractures are most common in older adults

54 54Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture Healing  A bone begins to heal as soon as an injury occurs  New bone tissue formed to repair the fracture, resulting in a sturdy union between the broken ends of the bone

55 55Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 55

56 56Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Complications

57 57Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infection  Osteomyelitis: from contamination of the open wound associated with a fracture or from contamination of indwelling hardware used to repair the broken bone  When infection is inadvertently brought by surgery or other treatment, it is known as iatrogenic  Any infection can interfere with normal healing  Common after an open fracture and surgical repair and may become chronic  In deep, grossly contaminated wounds, gas gangrene may develop

58 58Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Infection of the bone  Gas gangrene ◦ Foul smelling, watery drainage ◦ Significant swelling and redness  Treatment ◦ Aggressive IV antibiotics (4-8 wks) ◦ Wound care—irrigation, antibiotic surgical debridement, wound vac

59 59Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  16 year old male was admitted after a motocycle accident. He has a compound fracture of the thigh with a severe soft tissue injury. Following surgery, he has an external fixation device on the injured leg. A Jackson- Pratt drain is in place. Daily wound care is ordered.  List all the potential sources of bone infection.

60 60Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infection  Signs and symptoms ◦ Local pain, redness, purulent wound drainage, chills, and fever ◦ With gas gangrene, foul-smelling watery drainage with significant redness and swelling  Treatment ◦ IV antibiotics may be given for 4 to 8 weeks, followed by 4 to 8 weeks of oral drug therapy ◦ Wound care: irrigation, treatment with antibiotic beads, and surgical removal of dead bone tissue and/or hardware

61 61Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fat Embolism  Fat globules released from marrow of broken bone into bloodstream, then migrate to the lungs  They lodge in capillaries and obstruct blood flow  The fat particles break down into fatty acids, which inflame the pulmonary blood vessels, leading to pulmonary edema  Common with fractures of the long bones, multiple fractures, and severe trauma

62 62Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fat Embolism  Respiratory distress is the first sign of a fat embolism, followed by tachycardia, tachypnea, fever, confusion, and decreased level of consciousness  Treatment: bed rest, gentle handling, oxygen, ventilatory support, and fluid restriction and diuretics for pulmonary edema

63 63Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Deep Vein Thrombosis  Venous stasis, vessel damage, and altered clotting mechanisms contribute to formation of blood clots (thrombi), most commonly in deep veins of the legs  DVT increased with immobility often associated with a fracture  Thrombi can break off and travel to the lungs, causing a pulmonary embolism

64 64Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Compartment Syndrome  Serious complication from internal or external pressure on the affected area  Compartments: enclosed spaces made of muscle, bone, nerves, blood vessels wrapped by fibrous membrane  Internal pressure from bleeding/edema into a compartment; external pressure from a cast or tight dressing

65 65Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Compartment Syndrome  When bleeding or edema into a compartment, there is nowhere for drainage to go: it is trapped in the space  Increased fluid puts pressure on tissues, nerves, and blood vessels, so that blood flow is decreased, resulting in pain and tissue damage. External pressure also can decrease blood flow to the area

66 66Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Compartment Syndrome  Primary symptom is pain, especially with touch or movement, that can’t be relieved with opioids  Other signs and symptoms: edema, pallor, weak or unequal pulses, cyanosis, tingling, numbness, paresthesia, and finally, severe pain  The goal of treatment is to relieve pressure ◦ When internal pressure, a surgical fasciotomy, which entails making linear incisions in the fascia, may relieve pressure on the nerves and blood vessels ◦ For external pressure, cast or dressings are replaced

67 67Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Shock  After fracture, a risk of excessive blood loss  Trauma may rupture local blood vessels; internal organs may be punctured; results in internal bleeding  Loss of blood leads to shock, evidenced by tachycardia, anxiety, pallor, and cool, clammy skin  Immobilizing fractures reduces risk of hemorrhage  If severe external bleeding, external pressure should be applied and medical assistance summoned immediately

68 68Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Joint Stiffness and Contractures  Joint fractures or dislocations may be followed by stiffness or contractures, especially in older adults, due to immobility associated with fracture  Prevention requires appropriate positioning and progressive exercise programs  Treatment may employ splints, traction, casts, surgical manipulation, and aggressive physiotherapy

69 69Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Malunion  Expected healing time is appropriate but unsatisfactory alignment of bone results in external deformity and dysfunction

70 70Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Delayed Union  Failure of a fracture to heal in the expected time  The bone usually heals eventually; it may just be slower

71 71Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nonunion  Occurs when a fracture never heals  Treatment ◦ Osteogenic method: implantation of bone grafts ◦ Osteoconductive methods: synthetic materials to provide a matrix for bone growth ◦ Osteoinduction: substances such as platelet-derived growth factor ◦ Electric stimulation  Internal or external; up to 10 hours a day for 3-6 months  Time consuming but can prevent further surgery and bone grafts

72 72Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Signs and Symptoms  Depend on type and location of the break  Some fractures have so few manifestations that they can be detected only with x-ray  Signs and symptoms are swelling, bruising, pain, tenderness, loss of normal function, abnormal position, and decreased mobility  See Box 42-1, p. 918

73 73Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures  Standard radiographs ◦ Reveal bone disruption, deformity, or malignancy  Computed tomography (CT) ◦ Detect fractures of complex structures, such as the hip and pelvis, or compression fractures of the spine  Bone scan ◦ Detect small bone fractures or fractures caused by stress or disease

74 74Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Five ‘P’s ◦ Pain ◦ Pulses ◦ Pallor ◦ Paresthesis ◦ Paralysis

75 75Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment

76 76Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Reduction  The process of bringing the ends of the broken bone into proper alignment

77 77Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Closed Reduction or Manipulation  Nonsurgical realignment that returns bones to their previous anatomic position  No surgical incision is made; however, general or local anesthesia is given  By using traction, manual pressure, or a combination  After reduction of a fracture, x-ray taken and a cast usually applied

78 78Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-3

79 79Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Open Reduction  A surgical procedure in which an incision is made at the fracture site  Usually for open (compound) or comminuted fractures to clean the area of fragments and debris

80 80Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Immobilization  Necessary for healing to occur  Prevents movement and increases union  Accomplished in many ways, such as fixation, casts, splints, and traction

81 81Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fixation  An attempt to attach the fragments of the broken bone together when reduction alone is not feasible because of the type and extent of the break

82 82Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Internal Fixation  Done during open reduction surgical procedure  Rods, pins, nails, screws, or metal plates used to align bone fragments and keep them in place for healing  Promotes early mobilization; preferred for older adults who have brittle bones that may not heal properly, or who may suffer the consequences of immobility

83 83Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-4

84 84Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. External Fixation  Pins are inserted into the bone, above and below fracture  Pins are then attached to an external frame and adjusted to align the bone  If there is soft tissue damage or infection, external fixation allows access to the site and facilitates wound care  Pin care is extremely important to prevent the migration of organisms along the pin from the skin to the bone  Patients should be taught to do their own pin care and to recognize signs of infection

85 85Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-5

86 86Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-6

87 87Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Therapeutic Measures

88 88Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Casts, Splints, and Immobilizers  Hold the bone in alignment while allowing movement of other parts of the body  Types of cast materials: plaster of Paris, fiberglass, thermoplastic resins, thermolabile plastic, and polyester-cotton knit impregnated with polyurethane  Variety of materials used for splints/immobilizers  Four main groups of casts: (1) upper extremity, (2) lower extremity, (3) cast brace, and (4) body or spica cast

89 89Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Traction  Exerts a pulling force on a fractured extremity to align bone fragments  Prevents or corrects deformity, decreases muscle spasm, promotes rest, and maintains the position of the injured part  May be applied directly to the skin (skin traction) or attached directly to a bone (skeletal traction) with a metal pin or wire

90 90Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Traction  Skin traction ◦ Buck’s traction  For hip and knee contractures, muscle spasms, and alignment of hip fractures  Weight used during skin traction should not be more than 5 to 10 pounds to prevent injury to the skin  Skeletal traction ◦ Provides a strong, steady, continuous pull and can be used for prolonged periods ◦ Examples of skeletal traction are Gardner-Wells, Crutchfield, and Vinke tongs and a halo vest, in which pins are inserted into the skull on either side

91 91Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-7

92 92Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-8

93 93Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Traction  Complications ◦ Impaired circulation, inadequate fracture alignment, skin breakdown, and soft tissue injury ◦ Pin track infection and osteomyelitis can occur with skeletal traction

94 94Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 94

95 95Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assistive Devices

96 96Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Crutches  Increase mobility and assist with ambulation  Physical therapist measures patient for proper fit and instructs in crutch-walking techniques  Nurse reinforces the instructions and evaluates whether the crutches are being used properly  A properly fitted crutch should reach to three fingerbreadths below the axilla to avoid pressure on the axilla and nerves when walking

97 97Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-8

98 98Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Crutches: Gait Patterns  Two-point gait ◦ The crutch on one side and the opposite foot are advanced at the same time ◦ Used with partial weight-bearing limitations and with bilateral lower extremity prostheses  Three-point gait ◦ Both crutches and the foot of the affected extremity are advanced together, followed by the foot of the unaffected extremity ◦ This gait requires strength and balance ◦ Used for partial or no weight bearing on affected leg

99 99Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Crutches: Gait Patterns  Four-point gait ◦ The right crutch is advanced, then the left foot, then the left crutch, then the right foot ◦ Used if weight bearing is allowed and one foot can be placed in front of the other  Swing-to gait ◦ Both crutches are advanced together, then both legs are lifted and placed down again on a spot behind the crutches ◦ The feet and crutches form a tripod

100 100Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Crutches: Gait Patterns  Swing-through gait ◦ Both crutches are advanced together, then both legs are lifted through and beyond the crutches and placed down again at a point in front of the crutches ◦ Used when adequate muscle power and balance in the arms and legs

101 101Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-9

102 102Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Walker  Used for support and balance, usually by older adults

103 103Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Canes  Provide minimal support and balance, and relieve pressure on weight-bearing joints  Placed on the unaffected side with the top even with the patient’s greater trochanter

104 104Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Electrical Stimulation  Electrical stimulation may be used to promote bone healing by promoting bone growth  An electrical current is delivered through one of three methods ◦ A surgically implanted device ◦ Device with pins that are inserted through the skin to the fracture site ◦ Pack of electrical coils applied to skin around fracture  Electrical bone stimulators successful in 80% of cases, with an average healing time of 16 weeks

105 105Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment  Health history ◦ The cause, type, and extent of the injury ◦ Symptoms associated with the injury ◦ Other medical problems that may have been related to the cause of the fracture

106 106Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment  Physical examination ◦ Deviations in bone alignment ◦ Inspect the skin over the fracture for lacerations, bruising, or swelling ◦ Neurovascular checks (pulse, skin color, capillary refill time, sensation) in the areas distal to the wound to compare circulation and sensation. Assess pulse rate and volume, as well as capillary refill time in the nails distal to the injury

107 107Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Interventions  Acute Pain  Ineffective Tissue Perfusion  Risk for Infection  Impaired Physical Mobility  Risk for Impaired Skin Integrity  Activity Intolerance

108 108Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Management of Specific Fractures

109 109Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture of the Hip  Medical diagnosis ◦ Radiography  Medical treatment ◦ Traction and surgical repair (internal fixation, femoral head replacement, or total hip replacement) ◦ Patients may begin physical therapy as early as 1 day after surgery, depending on the type of repair; begin by sitting in a chair and then progress to a walker

110 110Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 41-4

111 111Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-10

112 112Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture of the Hip  Assessment ◦ Pain, impaired peripheral circulation on the affected side, complications of immobility, skin breakdown, and ability to carry out activities of daily living

113 113Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture of the Hip  Interventions ◦ Relieving pain, promoting mobility and independence, and preventing complications ◦ Proper body alignment is extremely important in preventing injury to the fracture area ◦ Turn patients from side to side as ordered ◦ Affected hip must not be adducted or flexed more than 90 degrees because excessive flexion/adduction can dislocate the prosthesis

114 114Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 114

115 115Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Colles’ Fracture  A break in the distal radius (wrist area)  Medical diagnosis ◦ Radiography  Medical treatment ◦ Closed reduction or manipulation of the bone and immobilization in either a splint or a cast

116 116Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Colles’ Fracture  Assessment ◦ Pain and swelling following treatment of the fracture  Interventions ◦ Extremity should be supported and protected and can be elevated on a pillow during the first few days ◦ Encourage patients to move their fingers and thumb to promote circulation and reduce swelling, and to move their shoulders to prevent stiffness and contracture ◦ Teach proper cast care

117 117Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture of the Pelvis  Medical diagnosis ◦ Radiography

118 118Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture of the Pelvis  Medical treatment ◦ A less severe non–weight-bearing fracture treated with bed rest on a firm mattress or bed board for a few days to 6 weeks ◦ Severe weight-bearing fracture may require a pelvic sling, skeletal traction, double hip spica cast, or external fixation ◦ Monitor patient so injuries can be treated immediately ◦ Check for presence of blood in urine and stool, and watch abdomen for signs of rigidity or swelling

119 119Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture of the Pelvis  Assessment ◦ Signs of bleeding, swelling, infection, thromboembolism, and pain ◦ Assess urine output because the absence of urine may indicate a perforated bladder

120 120Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture of the Pelvis  Interventions ◦ When handling patients, take extreme care to prevent displacement of the fracture fragments ◦ Turn patient only on the order of a physician ◦ Provide back care when patient raised from the bed using the trapeze or with adequate assistance from others ◦ Ambulation may be encouraged even though painful; follow physician’s orders

121 121Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Most common of malignant bone tumors  Primary ◦ Rare in adults ◦ Most often in adolescents  Secondary ◦ Resulting from metastasis:  Prostate, breast, kidney, thyroid, lung

122 122Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Diagnosis ◦ s/s vague ◦ X-ray, MRI, CT, CBC, biopsy, serum alkaline phosphatase, serum calcium levels  Treatment ◦ Chemotherapy ◦ Radiation ◦ surgery

123 123Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Amputations,Soft tissue injury and Nutritional Needs Metro Community College NURS 1110 Nancy Pares, RN, MSN

124 124Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Amputation  Can occur through a joint (between the bones) or through a bone itself  Disarticulation: term used for an amputation through the joint  The general site of the amputation is described by the joint nearest to it

125 125Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 43-1

126 126Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 126

127 127Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 127

128 128Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 128

129 129Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 129

130 130Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Indications and Incidence  Trauma ◦ Common types of accidents and injuries leading to amputation include those involving motorcycles and automobiles, farm machinery, firearms and explosives, electrical equipment, power tools, and frostbite  Disease ◦ Peripheral vascular disease, diabetes mellitus, arteriosclerosis, and chronic osteomyelitis

131 131Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Indications and Incidence  Tumors ◦ Bone tumors that are very large and invasive  Congenital defects ◦ Convert a deformed limb into a more functional one that can be fitted with a prosthetic device

132 132Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures  Vascular studies  Pulse volume recording  Thermography  Doppler ultrasound  Biopsy

133 133Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment  Must include appropriate treatment and control of underlying diseases or injuries ◦ Diet, medication, and exercise help patients with diabetes and poor peripheral circulation ◦ If peripheral vascular disease, encourage to stop smoking; nicotine causes vasoconstriction ◦ Trauma patient may have to be stabilized to maintain normal heart rate and blood pressure

134 134Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Surgical Treatment  Amputation at the lowest level that will preserve healthy tissue and favor wound healing  Surgeon chooses one of two procedures, depending on condition of the extremity and the reason for the surgery ◦ Closed amputations  Create a weight-bearing residual limb, important for lower extremity amputations ◦ Open amputations  The severed bone or joint is left uncovered by a skin flap  Required when an actual or potential infection exists, as may occur with gangrene or trauma

135 135Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Prostheses  Artificial substitutes for missing body parts  Prosthetist creates and supervises use of prosthesis  A limb prosthesis may be placed while the patient is still in the operating room  With lower extremity amputations, older or debilitated patients, and infection, prosthesis fitting delayed until residual limb heals  Can usually bear full weight on permanent prosthesis about 3 months after amputation

136 136Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 43-2

137 137Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 43-3

138 138Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Complications  Hemorrhage and hematoma  Necrosis  Wound dehiscence  Gangrene  Edema  Contracture  Pain  Infection  Phantom limb sensation  Phantom limb pain

139 139Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment  Record conditions that resulted in need for amputation  Preexisting cardiovascular problems  Family history of diabetes, hypertension, and vascular diseases  Signs and symptoms that relate to the vascular condition or other chronic and acute problems  Diet and fluid intake, intake of salt and alcohol, and use of tobacco  Exercise and rest and sleep habits as well as the effects of the current symptoms on the patient’s usual activities  Patient’s psychosocial background may offer insight into how the patient will tolerate treatments and procedures

140 140Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Examination  Height, weight, and vital signs  Assess neurovascular status  Skin color, texture, temperature, and turgor  Palpate peripheral pulses for quality, symmetry  Assess capillary refill  Sensation; ask patient to identify touch on extremities  Mental and emotional status and general cognitive abilities; determines patient’s understanding of the illness and its implications

141 141Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Interventions  Anxiety  Anticipatory grieving

142 142Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Postoperative Nursing Care  Assessment ◦ Monitor vital signs frequently in the first 48 hours ◦ Inspect the dressing frequently for bleeding ◦ If drain receptacle, note color and amount of drainage ◦ Monitor patient’s temperature for elevations that may indicate infection ◦ Note any foul odor from the dressing ◦ After the dressing is removed, inspect the residual limb for edema ◦ Document patient’s pain, including type, location, severity, and response to treatment

143 143Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Postoperative Nursing Care  Interventions ◦ Decreased Cardiac Output ◦ Pain ◦ Risk for Infection ◦ Impaired Skin Integrity and Risk for Impaired Skin Integrity ◦ Disturbed Sensory Perception ◦ Risk for Injury ◦ Impaired Physical Mobility ◦ Activity Intolerance ◦ Self-Care Deficit ◦ Anxiety, Fear, and Ineffective Coping ◦ Disturbed Body Image

144 144Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. The Older Adult Amputee  May have needs that should be taken into consideration when planning and providing care  Completely capable of learning but often requires smaller units of information, more repetition, more time  During teaching process patients with glasses or hearing aids should have them in place  Remind that phantom sensations are not uncommon or bizarre; this can reduce fear or anxiety of these sensations  Many have one or more chronic health problems  The loss of a limb can be especially difficult; it is important to provide psychological support

145 145Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Replantation  Involves the use of a microscope and highly specialized instruments to reanastomose (reconnect) blood vessels and nerve fibers in a severed limb  Limb sutured into its correct anatomic position  Advances in microsurgical techniques and preservation of severed limbs have made this technique increasingly successful

146 146Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Indications  For amputations through the hand or wrist  Amputated thumbs are reattached whenever possible because of their importance in hand function  In severely injured hand in which two or more fingers are detached, surgeon restores as many fingers as possible  Amputations above the wrist do not lend themselves as readily to replantation because of the extensive tissue, muscle, and bone damage accompanying the injury  In general, the greater the muscle mass injury, the less likely replantation is possible

147 147Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Emergency Care  Wrap amputated parts in a clean cloth saturated with normal saline or Ringer’s lactate  Put in a sealed plastic bag that is placed in ice water  Direct contact between the amputated part and the ice can lead to further tissue damage and cell death  Partially amputated parts should remain attached to the patient and be kept cool if possible  Extra care to avoid detaching any parts since even small connections increase the chances for successful repair  Patient may require treatment for shock due to blood loss  Tourniquets should not be used unless absolutely necessary

148 148Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment  Assess circulatory status  Closely monitor vital signs  Inspect the residual limb (or dressing) for bleeding  Assess pain at the site of the injury and at other locations  Measure and record fluid intake and output  Note patient’s emotional status, and assess understanding of the preoperative activities and postoperative routines  Identify sources of support

149 149Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Preoperative Nursing Care  Interventions ◦ Administer intravenous fluids and blood as ordered ◦ If the dressing becomes saturated with blood, reinforce the dressing ◦ Report continued or excessive bleeding to the physician ◦ Even though preparations for replantation are hurried, be sensitive to the patient’s fear and anxiety ◦ Accept the patient’s feelings ◦ Provide brief, simple explanations ◦ Administer analgesics as ordered for pain

150 150Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Postoperative Nursing Care: Assessment  Monitor vital signs, intake and output, and level of consciousness  Hourly neurovascular assessment of limb  Doppler device or pulse oximeter to evaluate circulation  Note and record the limb’s color, capillary refill, turgor, temperature, and sensation  Assess limb for edema because massive edema often accompanies replantation

151 151Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Postoperative Nursing Care: Interventions  Elevate the limb  Abstain from nicotine- and caffeine-containing products for 7 to 10 days postoperatively  Enforce a strict ban on cigarette smoking  Room at 80° F to prevent compensatory vasoconstriction of peripheral tissues  Loosen tight or restrictive gowns or pajamas  Administer ordered drugs; monitor effects  Discuss thoughts and feelings about the replantation, disfigurement, and loss of function

152 152Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Strain ◦ Injuries to muscles or tendons that cause over stretching  Sprain ◦ Injuries to ligaments-pain (torn ligaments) ◦ Emergency treatment  Immobilize, elevate, cold

153 153Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  R—rest  I----ice  C---compression  E---elevation

154 154Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Disclocation ◦ A severe injury of the ligamentous structures that surround a joint ◦ Complete displacement or separation of the articular surfaces of the joint ◦ Treatment  ASAP (may lead to avascular necrosis  Closed reduction  immobilization

155 155Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Subluxation ◦ Partial or incomplete displacement of joint surface ◦ s/s similar to dislocation; less severe ◦ Treatment  Same as for dislocation  Less time to heal

156 156Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  CBC  UA  CMP  EKG  Chest x-ray

157 157Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Should always be individualized to client  Osteoarthritis ◦ Low calorie diet ◦ No use of glucosamine or chondroitan if allergic to shellfish  RA ◦ Easily fatigued ◦ Omega-3 fatty acids ◦ Corticosteroids: requires low salt diet

158 158Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Gout ◦ No ETOH ◦ Limit purine (sardines, herring, mussels very high) ◦ Moderate : chicken, salmon, crab, veal, mutton, bacon, pork, beef and ham ◦ Mild: milk, cheese, ice cream, chocolate ◦ Limit oxalate: spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, instant coffee, tea

159 159Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.  Fractures ◦ Need protein intake of 1 g/kg of body wt ◦ Vitamins: esp B&C, calcium ◦ Fluid intake: ml/day ◦ High fiber


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