1. Musculoskeletal Stressors
NUR240
JBorrero 10/08

2. Arthritis Degenerative Joint Disease Arthritis= joint inflammation.
Arthralgia= joint pain
Different types of arthritis:
Osteoarthritis
Rheumatoid arthritis
Gouty arthritis
Arthritis and other rheumatoid disorders (various conditions that affect the musculoskeletal system) are widespread, affecting more than 33 million people in the U.S.

3. Osteoarthritis
Most common form of arthritis, noninflammatory, nonsystemic disease
One or many joints undergo degenerative and progressive changes, mainly wt. bearing joints.
Stiffness, tenderness, crepitus and enlargement develop.
Deformity, incomplete dislocation and synovial effusion may eventually occur.
Treatment: rest, heat, ice, anti inflammatory drugs, decrease wt. if indicated, injectable corticosteroids, surgery.
Degenerative changes including: subchondral bony sclerosis, loss of articular cartilage, proliferation of bony spurs and cartilage in the joint. Inflammation of synovial membrane of the joint is late in the disease.
Osteoarthritis also known as degenerative joint disease.
X-ray- osteophytes (spurs) reactive changes occur at the joint margins and on the subchondral bone in the form of spurs.

4. Osteoarthritis- Risk Factors
Age
Decreased muscle strength
Obesity
Possible genetic risk
Early in disease process, OA is difficult to dx from RA
Hx of Trauma to joint

5. OA- Signs and Symptoms
Joint pain and stiffness that resolves with rest or inactivity
Pain with joint palpation or ROJM
Crepitus in one or more joints
Enlarged joints
Heberden’s nodes enlarged at distal IP joints
Bouchard’s nodes located at proximal IP joints

6. What to assess for: ESR, Xrays, CT acans Pain
Degree of functional limitation
Levels of pain/fatigue after activity
Range of motion
Proper function/joint alignment
Home barriers and ability to perform ADLs

7. Osteoarthritis- Tx
Pharmacotherapy- tylenol, NSAIDS, ASA, Cox-2 inhibitors
Intra-articular injections of corticosteroids
Glucosamine- acts as a lubricant and shock absorbing fluid in joint, helps rebuild cartilage
Balance rest with activity
Use bracing or splints
Apply thermal therapies
Arthroplasty- joint replacement can relieve pain and restore loss of function for patients with advanced disease.
Hyalgan- given weekly, 5-6x, lasts 6 months.

8. Auto-Immune Disease
Inflammatory and immune response are normally helpful
BUT these responses can fail to recognize self cells and attack normal body tissues.
Called an auto-immune response
Can severly damage cells, tissues and organs
EG. RA, SLE, Progressive systemic sclerosis, connective tissue disorders and other organ specific disorders

9. Rheumatoid Arthritis
Chronic, systemic, progressive inflammatory disease of the synovial tissue, bilateral, involving numerous joints.
Synovitis-warm, red, swollen joints resulting from accumulation of fluid and inflammatory cells.
Classified as autoimmune process
Exacerbations and remissions
Can cause severe deformities that restrict function

10. RA- Risk Factors Female gender Age 20-50 years Genetic predisposition
Epstein Barr virus
Stress

11. Rheumatoid Arthritis- Dx
Rheumatoid Factor antibody- High titers correlate with severe disease, 80% pts.
Antinuclear Antibody (ANA) Titer- positive titer is associated with RA.
C- reactive protein- 90% pts.
ESR: Elevated, moderate to severe elevation
Arthocentesis- synovial fluid aspirated by needle
RA- chronic, progressive, systemic disease of unknown etiology. The clinical manifestetions are primarily inflammation of synovial tissue in the joints. The inflammatory response may affect any area of the body in which connective tissue is present (blood vessels, heart, skin, etc).

12. RA – Signs and Symptoms
Joints- bilateral and symmetric stiffness, tenderness, swelling and temp. changes in joint.
Pain at rest and with movement
Pulses- check peripheral pulses, use doppler if necessary, check capillary refill.
Edema- observe, report and record amt. and location of edema.
ROM, muscle strength, mobility, atrophy
Anorexia, weight loss
Fever- generally low grade
Inspect joints for size, shape, skin color and general appearance. Size and shape are altered by fluid accumulation, hypertrophied synovium, or bony overgrowth. Redness indicates inflammation. Pallor or cyanosis indicates lack of blood supply.

13. RA- Sign and Symptoms
1. Fatigue- unusual fatigue, generalized weakness
2. Morning stiffness lasting longer than 30 minutes after rising, subsides with activity.
3. Red, warm, swollen, painful joints
4. Systemic S&S
5. Pain- at rest and with movement
What should we monitor?
5. Involvement from vasculitis or direct immune complex invasion of the organs.
Diagnostic testing-

14. Rheumatoid Arthritis- Tx
Rest, during day- decrease wt. bearing stress.
ROM- maintain joint function, exercise –water.
Medication- analgesic and anti-inflammatory (NSAIDS), steroids,Gold therapy, topical meds. Immunosuppressive drugs- Imuran, Cytoxan, methotrexate. Monitor for toxic effects
Biological response modifiers (BRM):Inhibit action of tumor necrosis factor (Humira, Enbrel, Remicade)
Ultrasound, diathermy, hot and cold applications
Surgical- Synovectomy, Arthroplasty, Total hip replacement.
Meds- indomethacin, phenylbutazone,gold salts, some antineoplastic drugs. Corticosteroids
Diathermy= use of elevated temp. via electric current, ultrasound or microwave.
Surgery- Synovectomy- part or all of the synovial membrane is removed to prevent recurrent inflammation. Result is pain relief and improvement in wt. bearing and in the ability to move joints.
Arthroplasty- attempts to recreate a joint as nearly like the original as possible.
Total hip- artificial joint
Drugs described in more detail in pharm book.

15. Nursing Interventions
Assist with/encourage physical activity
Provide a safe environment
Utilize progressive muscle relaxation
Refer to support groups
Emotional support

16. Complications Sjogrens’s syndrome Joint deformity Vasculitis
Cervical subluxation

17. Gouty Arthritis Very painful joint inflammation, swollen and reddened
Primary-Inborn error of uric acid metabolism- increases production and interferes with excretion of uric acid
Secondary- Hyperuricemia caused by another disease
Excess uric acid – converted to sodium urate crystals and precipitate from blood and become deposited in joints- tophi or in kidneys, renal calculi
Treatment:
Meds- colchicine, NSAIDS, Indocin (indomethacin), glucocorticoid drugs,
Allopurinol, Probenecid-reduce uric acid levels
Diet- excludes purine rich foods, such as organ meats, anchovies, sardines, lentils, sweetbreads,red wine
Avoid ASA and diuretics- may precipitate attacks
Meds- more detail in pharm book

18. Systemic Lupus Erythematosus
SLE- Chronic Inflammatory disease affecting many systems.
Women between 18-40, black>white, child bearing years
Autoimmune process- antibodies react with DNA, immune complexes form- damage organs and blood vessels.
Includes: vasculitis; renal involvement; lesions of skin and nervous system.
Initial manifestation- arthritis, butterfly rash, weakness, fatigue, wt. loss
Symptoms and tx. depend on systems involved.
Systemic Lupus is discussed along with arthritis because like rheumatoid arthritis it has an autoimmune component and it is a chronic inflammatory disease.

19. Systemic Lupus Erythematosus
Pathologic changes-Autoimmune process
1. Vasculitis in arterioles and small arteries
2. Granulomatous growths on heart valves- non bacterial endocarditis.
3. Fibrosis of the spleen, lymph node adenopathy
4. Thickening of the basement membrane of glomerular capillaries.
5. 90% swelling and inflammatory infiltrates of synovial membrane.
There is no characteristic pattern to S.L.E. The onset is often gradual, mild and vague, therefore may go undiagnosed for years. The symptoms are variable and depend upon the systems involved.
Incidence- 9:1 female, average age at onset- 30.

20. SLE 6. Renal- Lupus nephritis 7. Pleural effusion or PN
8. Raynaud’s phenomenon- about 15% cases
9. Neuro- psychosis, paresis, migraines, and seizures

21. SLE Dx ANA- hallmark test, + in 98% pts. Medications- NSAIDS
Antimalarial meds- hydroxychloroquine (Plaquenil) Immunosuppressive agents- pt teaching corticosteroids, methotrexate, cyclophosphamide
Antidepressants
Resources:
ANA test- detects antibodies produced to DNA and other material. These antibodies can cause tissue damage characteristic of autoimmune disorders. The client’s serum is combined with nuclear material and tagged antihuman antibody to detect ANA – antihuman antibody complexes. It is not specific for SLE (may be present in rheumatoid arthritis) but 95% of clients have a positive ANA titer.
LE cell test is also used to detect SLE and monitor its treatment, Neutrophils that contain large masses of phagocytized DNA from the nuclei of PMN (polymorphonuclear cells) are called LE cells. Like the ANA, the LE cell prep is non specific for SLE. A positive result may also be seen in rheumatoid arthritis or with meds such as isoniazid, Pcn, phenytoin…
Antirheumatic drugs are slower acting.
Teaching the patient and family about the disorder and its management is a key component of nursing care.

22. Systemic Lupus- Education
Encourage to avoid undue emotional/ physical stress and to get enough rest
Alternate exercise + planned rest periods.
Teach how to recognize the symptoms of a flare
Teach how to prevent and recognize infection
Avoid sunlight, use sunscreen
Eat a well balanced diet,vitamins and iron.
Establish short term goals
Teach re: meds.
Meds avoid- Pronestyl, Hydralazine.
Sunlight- precipitating factor, also stress and certain meds- pronestyl and hydralazine.
A transient lupus like syndrome may occur with these drugs, resolves after meds are dc’d

23. Charting Chuckles
On the second day, the knee was better, and on the third day, it had completely disappeared.
While in the emergency department, she was examined, X-rated, and sent home
The patient will need disposition, and therefore, we will get Dr. Blank to dispose of him.
Patient was admitted through the emergency department. I examined her on the floor.

24. Joint Replacement Indications
Rheumatoid arthritis
Trauma
Congenital deformity
Avascular necrosis
Replacement of a total joint with a prosthesis provides stabliity and range motion and eliminates pain.
This greatly improves functional ability and quality of life. Many pt’s wait years in pain before deciding to have joint replaced.
Avascular necrosis- disruption of blood supply.
Joints frequently replaced are: hip, knee and fingerjoints.

25. Total Hip Replacement Indications for surgery: Arthritis
Femoral neck fractures
Congenital hip disease
Failed prosthesis
Osteotomy= The operation for cutting through a bone.
Arthritis- degenerative joint disease, rheumatoid arthitis.
Improved prosthetic devices and operative techniques, prosthesis last much longer.
Pt. teaching:
Pneumatic compression stockings
Use of trapeze and that physical therapy will begin in 1-2 days post-op.

26. Pre-op management Assess medication history.
Assess Respiratory, neurovascular, nutritional and integumentary status.
Presence of other diseases- COPD, CAD, Hx. Of DVT or pulmonary embolism.
Discuss surgical procedure, informed consent.
Prepare for autologous blood donation.
Be certain that antiinflammatories and corticosteroids were discontinued at least 10 days prior to admission, or according to Dr. or hosp. policy.
Meds being taken currently, including iron supplements.
Discussion of these assessments- baseline, underlying conditions esp. resp. to tolerate surgery, nv. Any compromising condition? How are the pulses? How is the skin? This is very important because a skin lesion may be covered by bandage or casting material post-op.
Clarify that the patient fully understands the surgery he/she is about to undergo, did the pat. Receive true informed consent.
Autologous blood donation would have to have been arranged prior to surgery, clarify status of the situation.

27. Pre-op teaching Presence of drains and hemovac postoperatively.
Pain management (epidural/PCA).
Coughing and deep breathing.
Use of incentive spirometer
ROM exercises to unaffected extremities.
Post-op restrictions:
Need to avoid bending beyond 90 degrees
Importance of leg abduction post-op.
If pt’s know what to expect it will greatly decrease their anxiety and you will gain their cooperation.
Years ago, Pt’s came into the hosp. the night before surgery, and one would have an opportunity for a large amt of pt. teaching, at least, in theory. Now, pt’s come in on the morning of surgery, so it is very limited, but we’ll discuss the ideal.
What kind of pain management will be used and instruct the pt. on how it works and their role in pain management. They need to tell the nurse if pain management is not working sufficiently etc.. They will not get hooked on pain relief medicine.
We need to prevent atelectasis
Need to prevent complications of bedrest, including atrophy of muscles, skin breakdown and contractures.
The specific restrictions depend on Dr.

28. Post-op Management of THR
Assess neurovascular status of involved extremity.
Incision site, wound drains, hemovac.
Note excessive bleeding or drainage
Respiratory status- elderly population.
Position of affected joint and extremity
Mental alertness
Assess Hgb and Hct
Pain management
Peripheral pulse, pallor, cyanosis, edema, sensation, temperature, mobility.
Measures to prevent DVT ankle and foot exercises hourlywhile awake, compression stockings, pneumatic devices, OOB ambulate with assistance first post-op day. Low dose heparin also used.
Wound drainage ml in first 24 hrs. is expected, by 48 hrs., the total drainage in 8 hours usually decrease to 30 ml or less
If greater, notify surgeon. Autotransfusion may be used post-op drained blood is filtered and reinfused into pt. in immediate post-op period.
Mental alertness- are they able to cooperate? Are they getting confused? Disoriented? Is pt. hypoxic? Lyte imbalance? Threw a clot?

29. Total hip replacement-Complications
Dislocation of hip prosthesis
Thromboembolism
Infection
Avascular necrosis
Loosening of the prosthesis
Keep femoral head in acetabular cup, Teach re: abduction, use of abduction splint, wedge pillow. Pt. has to be log rolled, kept in alignment. Pt’s hip never flexed more than 90degrees, Do not raise HOB greater than 60 degrees. Fracture pan and use trapeze
Have pt. pivot on unaffected leg.
Heterotrophic ossification= formation of bone in periprosthetic space.
Avascular necrosis= bone death caused by lack of blood supply.

30. Dislocation of prosthesis
Increased pain, swelling
Acute groin pain
Shortening of the leg
Abnormal internal or external rotation
Restricted ability or inability to move leg
Reported popping sensation in hip.
If becomes dislocated, notify surgeon immediately, OR quickly so that there is no circulatory or neruologic damage to the leg.
As the hip heals, there is less chance of dislocation, however, stressed to the new hip joint should be minimal.

31. Impaired physical mobility r/t joint replacement and pain
Maintain bed rest with affected joint abducted with wedge pillow.
Perform passive and teach active ROM to unaffected joints, quad, isometric, gluteal exercises.
Ambulate with assistance, WB restrictions
Turn pt. as ordered, monitor skin for breakdown
According to surgeon, some have weight bearing restrictions, some don’t want pt. turned onto affected side, etc.
Expected outcomes; Maintains proper body alignment in bed and while ambulating. Increases weight bearing as prescribed, understands and participates in rehabilitation regimen, progresses toward self care.

32. Altered Tissue perfusion r/t reduced flow and immobilization
Administer parenteral fluids with electrolytes to increase tissue perfusion.
Monitor VS q4h and prn, I and O.
Assess NV status q1h for first 12 hrs., then q4h. Color, temp., pulse, sensation.
Ambulation and exercises
Monitor CBC, electrolytes, PT/INR
Administer anticoagulants - phlebitis
NV status- observe for signs of thrombosis, compartment syndrome= any condition in which a structure such as a nerve or tendon is being constricted in a space,
Expected outcomes- VS stable and within normal limits
Lab values are within normal limits. Extremities are warm and normal color, pulses are palpable.

33. Pain r/t surgical intervention and impaired mobility
Assess location, intensity, quality pain.
Administer analgesics, sedatives, anti-inflammatories, assess effectiveness,
Monitor PCA or continuous epidural
Change position frequently, back rubs.
Provide diversional activities- reduce attention on pain.
Monitor - severe chest, affected joint pain.
Use pain scale
Monitor for severe chest pain- indicate emboli, joint pain could indicate displacement.
Expected outcomes- Displays more relaxed affect
States pain is at a tolerable level
Participates in diversional activities.

34. Knowlwdge deficit R/T…
Stress importance of rehab program and exercises, no flexion greater than 90 degrees.
Discuss and demonstrate incision care
Medication teaching- especially anticoagulants, instruct pt to be checked, observe for bleeding, etc.
High protein, high fiber and increased fluid to prevent constipation.
Pain Management
Incision care- depend on surgeons preference, discuss sign and symptoms of wound infection.
Encourage follow up visits with Dr.
Discuss signs and symptoms of dislodgment-( fever- infection), inflammation, pain, immobility

35. Discharge/home care
Safety: stairs with hand rails, no scatter rugs, grab bars tub and toilet, good light.
Height of bed and chair for easy transfer.
Elevated toilet seat, fracture pan, urinal
Ability to care for wound, correct supplies and hand washing technique.
Correct transfer techniques, ability to follow rehab plan and exercises.
Elevated toilet seat to avoid displacement of prosthesis

36. Arthroscopy Pre-op: lab work- Hgb, Hct, Pt/PTT, urine, PT,exercises
History of underlying problem, meds.
Post-op- N/V assessment, pulses distal to Joint.
Teach: ROM to unaffected extremities, limitations post-op, crutch walking prn, pain management, reinforce explanation of procedure.
Arthroscopy is examination of interior of a joint with a small fiberoptic tube called an arthroscope, allows for means of diagnosing and performing needed surgery, frequently scoped joints are- knee, elbow and shoulder.
These joints are frequently scoped to clean out debris from trauma and/ or arthritis.
Usually same day surgery.
Potential complications- edema, hemorrhage, thrombophlebitis, infection, DVT, compartment syndroms.
Partial weight bearing or crutched hrs. post-op
Physical therapy out pt. muscle strength training.

37. Total Knee Replacement
Indications:Osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, bleeding into joint.
Post-op compression bandage and ice.
Assess N/V status of leg, active flexion q1h. While awake, CPM machine.
Wound suction drain
OOB within24 hrs., knee immobilizer and elevated while sitting.
Pt.’s have severe pain and functional disabilities.
Bleeding into joint from hemophilia.
Drain ml first 24hrs., then 25 ml by 48 hrs. after surgery.
CPM continuous passive motion machine- in recovery room, Usually starts 10 degrees extension and 50 degrees flexion then it is a advanced.
Complications- infection, loosening and wear of prosthetic device.

38. Care of the patient undergoing an amputation
Pre-op monitor N/V status both extremities
Observe for ulceration, edema, necrosis.
Baseline VS and lab data, doppler studies, angiography, ECG, chest x-ray.
Time for verbalization fears, anxieties.
Teach re; overhead trapeze, C and DB, incentive spirometer.
Surgical removal of part of the leg because of trauma, disease, tumors, or congenital anomalies, a skin flap is generally constructed to facilitate healing and use of prosthetic equipment.

39. Post-op: amputation
Stump dressing, amt. and color of drainage, hemovac drain.
Respiratory status and VS.
Presence of phantom limb pain.
Monitor for complications; infection, hemorrhage, phantom pain, contractures, scar formation, abduction deformity.
PT, diet, rest, activity, wound care
Pain management
Phantom limb pain
Immobility complications
Exercise to strengthen triceps muscles for crutch walking.

40. Body image disturbance r/t loss body part
Allow time for pt. to grieve, assess need for counseling.
Encourage pt. to discuss and view stump
Assist in identifying positive coping strategies, praise strengths observed.
Provide a supportive environment.
Demonstrate positive regard for pt. and acceptance of personal appearance.
Assess religious beliefs re: care of amputated limb
Verbalize feelings re: change in role, job, family, sexual perosn
Expected outcomes- Begins using positive coping skills in dealing with loss of body part.
Begins to express feelings of acceptance of altered self.
Participates in self care activities, ADL’s and stump care.

41. Discharge/ Home care planning
Environmental/safety status:
Hand rails- tub toilet, stairs, no scatter rugs.
Wide doorway to accommodate wheelchair, walker, Ht. of bed, chair ok.
Ability to care for wound and has correct supplies.
Ability and desire to follow prescribed rehab plan and exercises.
Prosthesis fitting with orthotist

42. Osteoporosis Primary or Secondary
Metabolic bone disorder- progressively porous, brittle, fragile bones, low bone density, susceptible to fractures
Occurs in postmenopausal women
Bone resorption (osteoclast) > bone formation (osteoblast) activity
Dowager’s hump – progressive kyphosis – gradual collapse of vertebrae.
Post menopausal lose height, c/o fatigue.
Osteopenia, precursor to osteoporosis
Dx tests: Radiographs, Dexa scans
Osteoporosis affects 28 million americans.
Reduction in total bone mass and a change in bone structure, increases susceptibility to fracture.
Life style mod.- reduce use of caffeine, cigarettes, alcohol.
Three glasses of skim milk or equivalent each day
If take calcium, take with vitamin C to promote absorption.
HRT very conrtoversial now, most people are not taking hormones.

43. Osteoporosis- Risk Factors
Gerontologic- over 80 yrs. old, 84% have osteoporosis.
Family hx, thin, lean body build
Postmenopausal estrogen deficiency
Hyperparathyroidism – increases bone resorption
Hx of low Ca intake and low levels of Vit D
Long tem corticosteroid use
Lack of physical activity/ prolonged immobility
Hx of smoking, high alcohol intake
Calcitonin inhibits bone resorption and promotes bone formation.Calcitonin (from thyroid gland) increase deposit of calcium in bone.
Circulation- if decreased blood supply then decreased osteogenesis, if deprived of blood then necrosis can occur.
Estrogen- inhibits bone breakdown.
From these hormonal changes- net bone loss over time.
Small framed non obese white women greatest risk, less bone mass.
Unmodifiable risk factors: Age, gender, race, genetic factors, endocrine disorders.
Modifiable risk factors: Calcium and Estrogen deficiency, smoking, high alcohol intake, sedentary lifestyle, medications.

44. Osteoporosis
Diagnosis:
Physical assessment:
Psychosocial assessment:

45. Pt. teaching- osteoporosis
Adequate dietary calcium- 1200mg/day with fluids
Exercise, wt. bearing beneficial.
Walking outdoors- vitamin D absorption.
Good body mechanics
Safe home environment, fall prevention
Balanced diet- protein, Mg, Vit K & D, Ca
Modify lifestyle choices- smoking, alcohol and caffeine intake and sedentary lifestyle.

46. Patient teaching- Meds
HRT-Raloxifene (Evista)
PTH- Forteo Subcut
Bisphosphonates- Fosamax,Boniva, Actonal
Reclast, Zometia
Calcitonin, Vit D
NSAIDs

47. Osteomyelitis Infection of the bone Endogenous:
Extension of soft tissue infection- infected pressure ulcers or incision.
Blood borne (spread from other body sites)
At risk- poorly nourished, elderly, obese, impaired immune systems, corticosteroid therapy, chronic illnesses.
Prevention- proper tx. of infections, aseptic post op wound care
Exogenous:
Organism enters from outside the body. Eg. Open fx
Most common, staph aureus, also proteus, pseudomonas, e coli
May reach bone directly via compound fx, blood stream or by direct extension from infections in adjacent structures.
Extension- infected pressure ulcer, infection incision
Direct- open fracture, bone surgery, penetrating trauma
Blood borne- spread other sites- tonsils, boils, teeth.
Bone exposed and necrotic tissue removed.
Most common organism- staph aureus
Can be acute or chronic
S/S- high fever, chills, increased HR, general malaise, swelling, tenderness, over the bone, heat and redness over the site, painful movement.
Dx- increased leukocytes, elevated ESR, blood cultures, x-rays, Bone scan, MRI

48. Osteomyelitis Signs and symptoms-
High fever, chills, increased HR, general malaise, swelling, tenderness, heat and erythema, painful movement.
Draining ulcers, bone pain
Dx- increased WBCs, elevated ESR, positive blood cultures, X-rays, bone scan, MRI.
X-ray- blackened area
Warm soaks helpful

49. Osteomyelitis Tx Long term IV antibiotics
Hickman or other CVAD catheter
Strict sterile technique for tx
Hyperbaric oxygen tx
Surgery- bone exposed and necrotic tissue removed, debridement, bone grafts, amputation

50. Contusions, Strains, Sprains
Contusion-soft tissue injury, hematoma, ecchymosis.
Strain- “muscle pull” over use over stretching.
Sprain – an injury to ligaments surrounding joint, caused by twisting.
Management- RICE = rest, ice, compression, elevation.
Contusion- injury in which the skin is not broken. Pain, swelling and discoloration.
Strain- microscopic, incomplete muscle tear with some bleeding into the tissue.
Sprain- ligaments maintain stability and allow movement, torn ligament loses is stabilizing function. Blood vessels rupture,edema occurs, avulsion fracture may occur (bone fragment is pulled away by ligament or tendon) may be assoc. with a sprain.
After acute inflammatory phase hrs., then heat.

51. Orthopedic Injuries
Joint dislocation- out of joint. If not treated promptly, avascular necrosis can occur.
Reduced- put back in place = closed reduction. Neurovascular status- check.
Rotator cuff injury/tear
Tennis elbow
Ligament injuries
Analgesia, muscle relaxants, joint immobilized by bandages, splints, casts, traction, maintained stable position.
Gentle, passive ROM progress to active ROM
Other injuries- Rest, ice elevation.

52. Fractures (Fx)
Complete- a break across the entire cross- section and is frequently displaced.
Incomplete (Greenstick)-break occurs through only part of the cross-section of the bone.
Closed Fracture (simple)- doesn’t break through the skin.
Open fracture (compound) - extends through the skin
Comminuted- splintered into fragments
Depressed- fragment(s) is(are) indriven
Pathologic- through an area of diseased bone
Fracture- a disruption or break in continuity of the bone – traumatic or pathologic.

53. Fractures- Signs and Symptoms
Pain- continuous and increases in severity after injury.
Swelling- usually over affected area, but can also occur in adjacent structures.
Reduction- open or closed
Treatment- Casting and/or traction
Pain- may be due to muscle spasms, overriding of fractured bone ends and /or damage to adjacent structures.
Shock- bone very vascular, treatment- restore blood volume, and circulation, relieve pain, provide adequate splinting, protect from further injury.

54. Fracture complications
Shock
Fat embolism
Compartment syndrome
DVT, thromboembolism or pulmonary embolism.
DIC
Infection
Avascular necrosis
Fat embolism- particularly of long bones or pelvis, multiple fractures or crush injuries. Fat globules combine with platelets and form emboli. Then block small blood vessels- brain, lungs, kidney onset rapid usually hrs. may occur up to one week after injury.
Clinical manifestations- hypoxia, tachypnea, tachycardia, cerebral dist. Due to hypoxia, low blood gas.
Treatment – resp. support, adequate fluids, MS pain., steroids, anticoagulants, encourage coughing and deep breathing.
Compartment syndrome Compression of structures within the defined ares formed by fascial walls and is a result of secondary edema. Compartment syndrome requires immediate action.
The swelling obstructs venous/arterial circulation resulting in inadequate circulation and ishemia,
If the ischemia continues – may result in contracture, loss of function, amputation, or death.
Symptoms: Progressive pain distal to injury
Numbness or tingling
Loss of sensation
Loss of function
Pallor, coolness of extremity
Diminished or absent peripheral pulses.
Treatment- Elevate extremity
Ice- enhance venous return and decrease edema
May need to remove cast or decrease traction weight
May need fasciotomy.( structure such as nerve or tendon is being constricted in a space.)Tissue perfusion is reduced, pt. c/o pain, deep throbbing unrelenting pain- can lead to muscle anoxia- frequent assessment of nv function. Treatment- release dressing or cast elevate extremity above heart.
DVT- TEDS, heparin, lovenox, PE- resp. support, heparin. Veins of lower extremities and pelvis, most susceptible.
DIC- bleeding disorder- ecchymosis, unexpected bleeding after surgery,
Infection- open fractures- contaminated, surgery- risk look for signs of infection.
Avascular necrosis- loss of blood supply, pain and limited movement, treatment bone grafts, prosthetic devices, fusion of joints.

55. Casts
Used to immobilize a body part so that a fracture of a bone or dislocation can heal.
Pressure from hard casting materials can produce complications such as:
Pain
Decreased sensation
Skin breakdown
Casting materials- plaster or fiberglass.

56. Casts-Indications Provide protection and healing of fractures
Maintain therapeutic alignment- body parts
Protect soft tissue injuries
Provide support after orthopedic surgery
Correct skeletal malformations.

57. Casts
While cast is drying, check C/M/S or NV status hourly and then q4-8h
Circulation/ vascular checks- Warmth, color, pulses, capillary refill, swelling.
Motion checks- ask pt. to wiggle fingers or toes.
Sensation checks- can pt. feel pressure, ask about pain, this may detects if cast is too tight.
Check for odor and drainage
Circulation- check for warmth of toes or fingers
Check color of nailbeds
Compare pulse rates and quality of extremities bilaterally
Check apillary filling
Check for swelling.

58. Electrical Bone Stimulation
Application of electrical current at fracture site, invasive or non-invasive.
Stimulates osteogenesis to fracture site.
Invasive- inserts cathode to site.
Non-invasive- Coil encircles cast or skin, attached to external generator, used 3-10 hrs. per day.
Contraindicated in presence of infection.
Used for fractures that are not healing properly.

59. Factors inhibit fracture healing
Extensive local trauma
Bone loss- demineralization, osteoporosis
Inadequate immobilzation
Space/tissue between bone fragment
Infection, malignancy, bone disease
Irradiated bone (radiation necrosis)
Avascular necrosis
Age- impaired healing process
Corticosteroids inhibit repair rate

60. Traction- Indications
Used to minimize muscle spasm
Used to reduce, align, and immobilize fractures
Used to correct/prevent deformity
Tx of dislocated, degenerated, rutured intravetebral discs and sc compression
Nursing goals:
Maintain line of pull.
Pt. is in center of bed, with good alignment
Weights hanging freely.
Prevent complications
Traction is applied, must have countertraction-= pt’s body weight

61. Types of traction
Skin traction (straight) - Buck’s, Bryant’s, pelvic girdle. The pull is transmitted to muscle structure, indirect traction.
Skeletal traction – pins or wires inserted in bone and attached to traction, may be used to treat fractures of humerus, tibia, fibula
Continuous- for fractures
Intermittent- for back muscle sprains
Traction is the application of a straightening or pulling force to return or maintain the fractured bones in normal anatomic position. Weights are applied to maintain the necessary force.
Balanced suspension- Supports the extremity off the bed and allows for some patient mobility without disruption of pull. Ropes are attached to one end of the extremity and at the other end are free falling weights. An example is Balanced suspension with Thomas splint and pearson Attachment.
Continuous- fracture, intermittent- back sprain.
Skin traction is indirect traction on underlying skeletal system.
Skeletal traction- accepts lb. of weight. Some examples are; Steinman pin, Kirschner wire, Halo traction.

62. Traction Ropes unobstructed and in straight alignment.
Skin care- check skin traction for intact skin, pin care for skeletal traction.
Circulation- fat emboli, thromboembolism.
Respiratory- pneumonia, exercise, ROM.
GI- high fiber diet, increased fluids.
Renal- to prevent stones- increase fluids.
MS- isometric exercises
Pain management
Diversion activities
Check ropes for knots and check knots at footplate, should not touch pulley or bed.
Resultant line of pull in line with long axis of bone.
Help pt. maintain countertraction, often need help to move up in bed, keep feet from foot of bed.

63. 5P’s Assessment for Orthopedic Patients
Symmetric comparison:
Pain- location, severity
Pulse- distal to injury, check bilaterally.
Parasthesias- numbness, tingling, compare bilaterally. Sensaton check
Pallor- check skin color and temp.
Paralysis- Assess mobility, watch for foot drop, compartment syndrome.
Assess skin frequently for pressure, friction, injury at least q 2 h Need to support limb.

64. Documentation Amt traction, type, weight, changes in tx
Pt tolerance and pain
Pt assessment of NV checks, skin condition, respiratory status, elimination pattern
Note condition of any pin sites and any care given

65. Hip fractures
High incidence in elderly due to risk for falls, osteoporosis.
Intracapsular- fx. Neck of femur, may damage blood supply, aseptic necrosis.
Extracapsular- base of neck and lesser tronchanter of femur- heals more easily.
ORIF- open reduction with internal fixation.
ORIF- rods, pins, prosthesis, fixed sliding plate. If femoral neck or head is fractures, prosthesis is placed.
Intracapsular- in joint capsule
Extracapsular- outside the joint capsule.
Nonsurgical options- Buck’s traction and skeletal traction.

66. Symptoms of Fractures Deformity Swelling Bruising Muscle spasms
Tenderness
Pain
Impaired sensation
Loss of normal function
Abnormal mobility
Crepitus
Shock
Abnormal Xrays
Consolidation and remodeling may take 6 weeks to 1 year

67. Nursing Diagnoses Risk for injury r/t subluxation or dislocation
Pain related to surgical incision
Risk for infection r/t impaired skin integrity
Impaired physical mobility
Risk for Peripheral Neurovascular Dysfunction
Adduction of the affected leg beyond the body’ midline can cause dislocation of the hip.
Turn to either side abduction pillow in place, check with surgeon orders.
Abduction pillow between legs.
Turn client carefully, maintaining alignment, preventing adduction.
Do not flex operative hip beyond 90 degrees- can cause dislocation.
Use an elevated toilet seat.
Sit upright in supporting chair
Teach client not to cross legs.
Crossing legs can cause adduction.
Give pain medication as needed, PCA.
Use non drug pain relief, relaxation exercises, back rub, distraction.
Position for function and comfort- proper alignment.
Frequent changes of position.
ROM exercises, OOB as ordered, usually next day. Reinforce transfer and ambulation techniques (walker or crutches).
Have trapeze on bed and teach its use.
Teach to weight bear as tolerated, as instructed by physician.
Assess need for assistance with ADL and make appropriate arrangements for home.
Prevent complications of immobility.
Ankle and foot exercises
OOB ASAP PT will work with pt.
5. Inspect fx site, palpate lightly for temp,sensation, pulses, cap refill and assess motor function
Assess the 5Ps- may be indicative of compartment syndrome
Pain unrelieved by narcotis, notify physician immediately

68. Back Pain Review of anatomy Cervical Disc Low back pain
Signs and Symptoms
Etiology
Intevetebral disc is made up of cartilage in a plate that forms a cushion between vertebral bodies (nucleus pulposus)
In herniation, nucleus protrudes into the fibrous ring around the disc with resultant nerve compression.
Protrusion or rupture is usually preceded by degenerative changes that occur with aging, spondylosis
C- usually occurs in C5, C6, C7 interspaces
LBP can be caused by muscle spasm, strain, disk degeneration or herniation.Msot common between L4 and L5, and L5 and sacrum
Back pain- herniation of the lumbar IV disc is the most common cause of pain of sciatic distribution
Severe burning, stabbingpain down the leg of the foot.
Pressure on SC, leg weakness and bowel and bladder dysfunction
Muscle spasms can be aggravated by sneezing, coughing, or straining
LBP >3mos or with repeated episodes is considered chronic back pain
Etiology- trauma, obesity, smoking,. Prevention is a priority

69. Back Pain- Assessment and Dx Evaluation
Posture and gait
Cervical Disc Pain and stiffness
Loss of muscle strength
Assess bowel and bladder control
MRI, CT scan, Neuro exam
Electromyelography and Nerve conduction studies
Check leg weakness, flexion of spine, alignment, swelling and muscle spasm. Pain that radiates down the leg and buttocks, thigh and calf pain
Stiffness in neck, top of shoulders and region of scapula Pain may also occur in upper extremities and head with paraesthesias and numbness of UE

70. Back Pain Conservative Management
Positioning
Firm mattress and back board
Exercise and physical therapy
Pharmacology
Heat and Ice
Diet Therapy
PT with manipulation, shoes insoles, back braces
Complementary and alternative therapies
Semifowlers with knees flexed to relax muscles of lower back
PT with plan to strenghten back
Meds:
Muscle relaxants: Cyclobenzapine HCl ( Flexeril)
NSAIDS- ASA, Motrin, Vioxx
Oral steroids
Epidural or local cortisone shots
Botox
Heat or Ice Heat 20-30min for minutes 4x day and some ice Ice 10-15min q1-2h
Diet- weigh loss
CAM- chiropractic tx, distraction, imagery, accupuncture, music therapy

71. Operative Procedures Conventional open Procedures: Diskectomy
Laminectomy
Diskectomy with fusion
Minimally Invasive Surgeries:
Percutaneous lumbar diskectomy
Microdiskectomy
Laser assisted laparoscopic lumbar diskectomy
Interbody cage fusion
Direct current stimulation for bone fusion
Discectomy- removal of herniated or extruded fragments of intevertebral disc
Laminectomy- removal of lamin (flat part of either side of arch of vertebra) to expose the neural elements in the spian;l canal, Identify anf remove pathology and relieve compression to the cord and roots.
Disc with fusion- a bone graft (ileac crest/bone bank) is used to fuse the vertebral spinous process to stabilize the spine and reduce the rate of recurrence.

72. Postoperative Care Body mechanics Neurovascular assessment CSF leakage
Fluid volume deficit
Acute urinary retention
Paralytic ileus
Fat embolism
Infection
Persistant or progressive lumbar radiculopathy
Prevent these complications that may occur in the first 24-48hrs.

73. Back Surgery- Patient Education
Takes 6 weeks for ligaments to heal
Schedule rest periods
Avoid heavy labor 2-3mos postop
Back exercises
Activity increased gradually
Back brace or corset if pain oersists

74. Cervical Disc Herniation or Rupture
Usually occurs at C5, C6, or C7 interspaces
Surgical tx is MIS cervical diskectomy with or without fusion using an anterior or posterior approach
Complications:
Due to degenerative changes
Pain also a/r/o bony outgrowths, osteophytes

75. Postop Care- Cervical Diskectomy
ABC
Check dsg for CSF
Check for hoarseness and inability to cough
Check for swallowing ability
Assess pt ability to void
Assist with ambulation
Manage pain
Assess for complications