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ORTHOPEDIC NURSING
04/08/23 RON R.N.,M.D. 1
Review of Anatomy and Physiology• The musculo-skeletal system consists of
the muscles, tendons, bones and cartilage together with the joints
• The primary function of which is to produce skeletal movements
04/08/23 RON R.N.,M.D. 2
Muscles
Three types of muscles exist in the body• 1. Skeletal Muscles
• Voluntary and striated• 2. Cardiac muscles
• Involuntary and striated• 3. Smooth/Visceral muscles
• Involuntary and NON-striated
04/08/23 RON R.N.,M.D. 3
TENDONS
• Bands of fibrous connective tissue that tie bones to muscles
04/08/23 RON R.N.,M.D. 4
LIGAMENTS
• Strong, dense and flexible bands of fibrous tissue connecting bones to another bone
04/08/23 RON R.N.,M.D. 5
BONES
• Variously classified according to shape, location and size
• Functions
1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition
04/08/23 RON R.N.,M.D. 6
JOINTS
• The part of the Skeleton where two or more bones are connected
04/08/23 RON R.N.,M.D. 7
CARTILAGES
• A dense connective tissue that consists of fibers embedded in a strong gel-like substance
04/08/23 RON R.N.,M.D. 8
BURSAE
• Sac containing fluid that are located around the joints to prevent friction
04/08/23 RON R.N.,M.D. 9
ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM
• The nurse usually evaluates this small part of the over-all assessment and concentrates on the patient’s posture, body symmetry, gait and muscle and joint function
04/08/23 RON R.N.,M.D. 10
ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM• 1. HISTORY• 2. Physical Examination
• Perform a head to toe assessment• Nurses need to inspect and palpate • The special procedure is the
assessment of joint and muscle movement
• Usually, a tape measure and a protractor are the only instruments
04/08/23 RON R.N.,M.D. 11
ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM• Gait• Posture• Muscular palpation• Joint palpation• Range of motion• Muscle strength
04/08/23 RON R.N.,M.D. 12
ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES• 1. BONE MARROW ASPIRATION
• Usually involves aspiration of the marrow to diagnose diseases like leukemia, aplastic anemia
• Usual site is the sternum and iliac crest
• Pre-test: Consent• Intratest: Needle puncture may be
painful• Post-test: maintain pressure
dressing and watch out for bleeding04/08/23 RON R.N.,M.D. 13
ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES• 2. Arthroscopy
• A direct visualization of the joint cavity• Pre-test: consent, explanation of procedure,
NPO• Intra-test: Sedative, Anesthesia, incision will
be made• Post-test: maintain dressing, ambulation as
soon as awake, mild soreness of joint for 2 days, joint rest for a few days, ice application to relieve discomfort
04/08/23 RON R.N.,M.D. 14
ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES3. BONE SCAN• Imaging study with the use of a contrast
radioactive material• Pre-test: Painless procedure, IV
radioisotope is used, no special preparation, pregnancy is contraindicated
• Intra-test: IV injection, Waiting period of 2 hours before X-ray, Fluids allowed, Supine position for scanning
• Post-test: Increase fluid intake to flush out radioactive material
04/08/23 RON R.N.,M.D. 15
ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES
4. DXA- Dual-energy XRAY absorptiometry
• Assesses bone density to diagnose osteoporosis
• Uses LOW dose radiation to measure bone density
• Painless procedure, non-invasive, no special preparation
• Advise to remove jewelry
04/08/23 RON R.N.,M.D. 16
04/08/23 RON R.N.,M.D. 17
Common musculoskeletal problems
The Nursing Management
04/08/23 RON R.N.,M.D. 18
Nursing Management of common musculo-skeletal problems
PAIN• These can be related to joint
inflammation, traction, surgical intervention
• 1. Assess patient’s perception of pain
• 2. Instruct patient alternative pain management like meditation, heat and cold application, TENS and guided imagery
04/08/23 RON R.N.,M.D. 19
Nursing Management
PAIN• 3. Administer analgesics as prescribed
• Usually NSAIDS• Meperidine can be given for severe
pain• 4. Assess the effectiveness of pain
measures
04/08/23 RON R.N.,M.D. 20
Nursing Management
IMPAIRED PHYSICAL MOBILITY• 1. Instruct patient to perform range of
motion exercises, either passive or active
• 2. Provide support in ambulation with assistive devices
• 3. Turn and change position every 2 hours
• 4. Encourage mobility for a short period and provide positive reinforcements for small accomplishments
04/08/23 RON R.N.,M.D. 21
Nursing Management
SELF-CARE DEFICITS• 1. Assess functional levels of the patient• 2. Provide support for feeding problems
• Place patient in Fowler’s position• Provide assistive device and supervise mealtime• Offer finger foods that can be handled by patient• Keep suction equipment ready
04/08/23 RON R.N.,M.D. 22
Nursing Management
SELF-CARE DEFICITS• 3. Assist patient with difficulty bathing and
hygiene• Assist with bath only when patient has
difficulty• Provide ample time for patient to finish
activity
04/08/23 RON R.N.,M.D. 23
Musculoskeletal Modalities
• Traction
• Cast
04/08/23 RON R.N.,M.D. 24
Nursing Management
Traction• A method of fracture immobilization by
applying equipments to align bone fragments
• Used for immobilization, bone alignment and relief of muscle spasm
04/08/23 RON R.N.,M.D. 25
Traction
• Skin traction- Buck, Bryant
• Skeletal traction
04/08/23 RON R.N.,M.D. 26
Traction
• Balanced Suspension traction
• Running/Straight traction
04/08/23 RON R.N.,M.D. 27
Traction
• Pulling force exerted on bones to reduce or immobilize fractures, reduce muscle spasm, correct or prevent deformities
04/08/23 RON R.N.,M.D. 28
Traction
• TO decrease muscle spasms• TO reduce, align and immobilize
fractures• To correct deformities
04/08/23 RON R.N.,M.D. 29
04/08/23 RON R.N.,M.D. 30
04/08/23 RON R.N.,M.D. 31
Nursing Management
Traction: General principles• 1. ALWAYS ensure that the
weights hang freely and do not touch the floor
• 2. NEVER remove the weights• 3. Maintain proper body alignment• 4. Ensure that the pulleys and ropes
are properly functioning and fastened by tying square knot
04/08/23 RON R.N.,M.D. 32
Nursing Management
Traction: General principles• 5. Observe and prevent foot drop
• Provide foot plate• 6. Observe for DVT, skin irritation and
breakdown• 7. Provide pin care for clients in skeletal
traction- use of hydrogen peroxide
04/08/23 RON R.N.,M.D. 33
Nursing Management
Traction: General principles
8. Promote skin integrity• Use special mattress if possible• Provide frequent skin care• Assess pin entrance and cleanse the pin with
hydrogen peroxide solution• Turn and reposition within the limits of traction• Use the trapeze
04/08/23 RON R.N.,M.D. 34
Nursing Management
CAST• Immobilizing tool made of plaster of Paris
or fiberglass• Provides immobilization of the fracture
04/08/23 RON R.N.,M.D. 35
Nursing Management
CAST: types
1. Long arm
2. Short arm
3. Short leg
4. Long leg
5. Spica
6. Body cast
04/08/23 RON R.N.,M.D. 36
Casting Materials
• Plaster of Paris• Drying takes 1-3 days• If dry, it is SHINY, WHITE, hard and
resistant• Fiberglass
• Lightweight and dries in 20-30 minutes• Water resistant
04/08/23 RON R.N.,M.D. 37
Cast application
1. TO immobilize a body part in a specific position2. TO exert uniform compression to the tissue3. TO provide early mobilization of UNAFFECTED
body part4. TO correct deformities5. TO stabilize and support unstable joints
04/08/23 RON R.N.,M.D. 38
Nursing Management
CAST: General Nursing Care• 1. Allow the cast to air dry (usually 24-72 hours)• 2. Handle a wet cast with the PALMS not the
fingertips
04/08/23 RON R.N.,M.D. 39
Nursing Management
CAST: General Nursing Care• 3. Keep the casted extremity ELEVATED using a
pillow• 4. Turn the extremity for equal drying. DO NOT
USE DRYER for plaster cast• Encourage mobility and range of motion
exercises
04/08/23 RON R.N.,M.D. 40
Nursing Management
CAST: General Nursing Care
• 5. Petal the edges of the cast to prevent crumbling of the edges
• 6. Examine the skin for pressure areas and Regularly check the pulses and skin
04/08/23 RON R.N.,M.D. 41
Nursing Management
CAST: General Nursing Care
• 7. Instruct the patient not to place sticks or small objects inside the cast
• 8. Monitor for the following: pain, swelling, discoloration, coolness, tingling or lack of sensation and diminished pulses04/08/23 RON R.N.,M.D. 42
Nursing Management
CAST: General Nursing Care• Hot spots occurring along the cast
may indicate infection under the cast
04/08/23 RON R.N.,M.D. 43
Common Musculoskeletal conditions
Nursing management
04/08/23 RON R.N.,M.D. 44
METABOLIC BONE DISORDERSOsteoporosis• A disease of the bone characterized by a
decrease in the bone mass and density with a change in bone structure
04/08/23 RON R.N.,M.D. 45
METABOLIC BONE DISORDERSOsteoporosis: Pathophysiology• Normal homeostatic bone turnover is
altered rate of bone RESORPTION is greater than bone FORMATION reduction in total bone mass reduction in bone mineral density prone to FRACTURE
04/08/23 RON R.N.,M.D. 46
METABOLIC BONE DISORDERS
Osteoporosis: TYPES• 1. Primary Osteoporosis- advanced age, post-
menopausal• 2. Secondary osteoporosis- Steroid overuse, Renal
failure
04/08/23 RON R.N.,M.D. 47
METABOLIC BONE DISORDERS
RISK factors for the development of Osteoporosis
• 1. Sedentary lifestyle• 2. Age• 3. Diet- caffeine, alcohol, low Ca and
Vit D• 4. Post-menopausal• 5. Genetics- caucasian and asian• 6. Immobility
04/08/23 RON R.N.,M.D. 48
METABOLIC DISORDER
ASSESSMENT FINDINGS• 1. Low stature• 2. Fracture
• Femur• 3. Bone pain
04/08/23 RON R.N.,M.D. 49
METABOLIC DISORDER
LABORATORY FINDINGS• 1. DEXA-scan
• Provides information about bone mineral density
• T-score is at least 2.5 SD below the young adult mean value
• 2. X-ray studies
04/08/23 RON R.N.,M.D. 50
METABOLIC DISORDER
Medical management of Osteoporosis• 1. Diet therapy with calcium and
Vitamin D • 2. Hormone replacement therapy• 3. Biphosphonates- Alendronate,
risedronate produce increased bone mass by inhibiting the OSTEOCLAST
• 4. Moderate weight bearing exercises• 5. Management of fractures
04/08/23 RON R.N.,M.D. 51
METABOLIC DISORDER
Osteoporosis Nursing Interventions1. Promote understanding of
osteoporosis and the treatment regimen
• Provide adequate dietary supplement of calcium and vitamin D
• Instruct to employ a regular program of moderate exercises and physical activity
• Manage the constipating side-effect of calcium supplements
04/08/23 RON R.N.,M.D. 52
METABOLIC DISORDER
Osteoporosis Nursing Interventions• Take calcium supplements with meals• Take alendronate with an EMPTY stomach
with water• Instruct on intake of Hormonal
replacement
04/08/23 RON R.N.,M.D. 53
METABOLIC DISORDER
Osteoporosis Nursing Interventions
2. Relieve the pain• Instruct the patient to rest on a firm
mattress• Suggest that knee flexion will cause
relaxation of back muscles• Heat application may provide comfort• Encourage good posture and body
mechanics• Instruct to avoid twisting and heavy lifting04/08/23 RON R.N.,M.D. 54
METABOLIC DISORDER
Osteoporosis Nursing Interventions• 3. Improve bowel elimination• Constipation is a problem of calcium
supplements and immobility• Advise intake of HIGH fiber diet and
increased fluids
04/08/23 RON R.N.,M.D. 55
METABOLIC DISORDER
Osteoporosis Nursing Interventions• 4. Prevent injury• Instruct to use isometric exercise to
strengthen the trunk muscles• AVOID sudden jarring, bending and
strenuous lifting• Provide a safe environment
04/08/23 RON R.N.,M.D. 56
Juvenile rheumatoid Arthritis
• Definition:• AUTO-IMMUNE inflammatory joint
disorder of UNKNOWN cause• SYSTEMIC chronic disorder of
connective tissue
• Diagnosed BEFORE age 16 years old
04/08/23 RON R.N.,M.D. 57
Juvenile rheumatoid Arthritis
• PATHOPHYSIOLOGY : unknown
• Affected by stress, climate and genetics
• Common in girls 2-5 and 9-12 y.o.
04/08/23 RON R.N.,M.D. 58
Juvenile rheumatoid Arthritis
Systemic JRA Pauci-articular Polyarticular
FEVER MILD joint pain and swelling
Morning joint stiffness and fever
Salmon-pink rash
IRIDOCYCLITIS Weight Bearing joints
Five or more joints
Less than 4 joints
Five or more joints
Anorexia, anemia, fatigue
Very Good prognosis
Poor prognosis
04/08/23 RON R.N.,M.D. 59
JRA
• Symptoms may decrease as child enters adulthood
• With periods of remissions and exacerbations
04/08/23 RON R.N.,M.D. 60
JRA
Medical Management
1. ASPIRIN and NSAIDs- mainstay treatment
2. Slow-acting anti-rheumatic drugs
3. Corticosteroids
04/08/23 RON R.N.,M.D. 61
JRA
Nursing Management
1. Encourage normal performance of daily activities
2. Assist child in ROM exercises
3. Administer medications
4. Encourage social and emotional development
04/08/23 RON R.N.,M.D. 62
JRA
Nursing Management
During acute attack:• SPLINT the joints• NEUTRAL positioning• Warm or cold packs
04/08/23 RON R.N.,M.D. 63
DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS• The most common form of degenerative
joint disorder
04/08/23 RON R.N.,M.D. 64
DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS• Chronic, NON-systemic disorder of joints
04/08/23 RON R.N.,M.D. 65
DEGENERATIVE JOINT DISEASE
OSTEOARTHRITIS: Pathophysiology• Injury, genetic, Previous joint damage, Obesity,
Advanced age Stimulate the chondrocytes to release chemicals chemicals will cause cartilage degeneration, reactive inflammation of the synovial lining and bone stiffening
04/08/23 RON R.N.,M.D. 66
DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Risk factors• 1. Increased age• 2. Obesity• 3. Repetitive use of joints with previous
joint damage• 4. Anatomical deformity• 5. genetic susceptibility
04/08/23 RON R.N.,M.D. 67
DEGENERATIVE JOINT DISEASE
OSTEOARTHRITIS: Assessment findings• 1. Joint pain• 2. Joint stiffness• 3. Functional joint impairment limitation• The joint involvement is ASYMMETRICAL• This is not systemic, there is no FEVER, no
severe swelling• Atrophy of unused muscles• Usual joint are the WEIGHT bearing joints
04/08/23 RON R.N.,M.D. 68
DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Assessment findings
1. Joint pain• Caused by
• Inflamed cartilage and synovium• Stretching of the joint capsule• Irritation of nerve endings
04/08/23 RON R.N.,M.D. 69
DEGENERATIVE JOINT DISEASE
OSTEOARTHRITIS: Assessment findings2. Stiffness commonly occurs in the morning after commonly occurs in the morning after
awakeningawakening Lasts only for less than 30 minutes DECREASES with movement, but worsens after
increased weight bearing activitry Crepitation may be elicited
04/08/23 RON R.N.,M.D. 70
DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Diagnostic findings1. X-ray• Narrowing of joint space• Loss of cartilage• Osteophytes2. Blood tests will show no evidenceno evidence of
systemic inflammation and are not useful
04/08/23 RON R.N.,M.D. 71
DEGENERATIVE JOINT DISEASE
OSTEOARTHRITIS: Medical management• 1. Weight reduction• 2. Use of splinting devices to support joints• 3. Occupational and physical therapy• 4. Pharmacologic management
• Use of PARACETAMOL, NSAIDS• Use of Glucosamine and chondroitin• Topical analgesics• Intra-articular steroids to decrease inflam
04/08/23 RON R.N.,M.D. 72
DEGENERATIVE JOINT DISEASE
OSTEOARTHRITIS: Nursing Interventions1. Provide relief of PAIN
• Administer prescribed analgesics• Application of heat modalities. ICE PACKS may
be used in the early acute stage!!!• Plan daily activities when pain is less severe• Pain meds before exercising
04/08/23 RON R.N.,M.D. 73
DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Nursing Interventions
2. Advise patient to reduce weight• Aerobic exercise• Walking
3. Administer prescribed medications• NSAIDS
04/08/23 RON R.N.,M.D. 74
DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Nursing Interventions
4. Position the client to prevent flexion deformity • Use of foot board, splints, wedges and
pillows
04/08/23 RON R.N.,M.D. 75
Rheumatoid arthritis
• A type of chronic systemic inflammatory arthritis and connective tissue disorder affecting more women (ages 35-45) than men
04/08/23 RON R.N.,M.D. 76
Rheumatoid arthritis
FACTORS:
Genetic
Auto-immune connective tissue disorders
Fatigue, emotional stress, cold, infection
04/08/23 RON R.N.,M.D. 77
Rheumatoid arthritis
Pathophysiology• Immune reaction in the synovium attracts
neutrophils releases enzymes breakdown of collagen irritates the synovial liningcausing synovial inflammation edema and pannus formation and joint erosions and swelling
04/08/23 RON R.N.,M.D. 78
Rheumatoid arthritis
ASSESSMENT FINDINGS
• 1. PAIN
• 2. Joint swelling and stiffness-SYMMETRICAL, Bilateral
• 3. Warmth, erythema and lack of function
• 4. Fever, weight loss, anemia, fatigue
• 5. Palpation of join reveals spongy tissue
• 6. Hesitancy in joint movement04/08/23 RON R.N.,M.D. 79
Rheumatoid arthritis
ASSESSMENT FINDINGS• Joint involvement is SYMMETRICAL and
BILATERAL• Characteristically beginning in the hands, wrist and
feet• Joint STIFFNESS occurs early morning, lasts MORE
than 30 minutes, not relieved by movement, diminishes as the day progresses
04/08/23 RON R.N.,M.D. 80
Rheumatoid arthritis
ASSESSMENT FINDINGS• Joints are swollen and warm• Painful when moved• Deformities are common in the hands and feet
causing misalignment • Rheumatoid nodules may be found in the
subcutaneous tissues
04/08/23 RON R.N.,M.D. 81
Rheumatoid arthritis
Diagnostic test• 1. X-ray
• Shows bony erosion• 2. Blood studies reveal (+) rheumatoid factor,
elevated ESR and CRP and ANTI-nuclear antibody• 3. Arthrocentesis shows synovial fluid that is cloudy,
milky or dark yellow containing numerous WBC and inflammatory proteins
04/08/23 RON R.N.,M.D. 82
Rheumatoid arthritis
MEDICAL MANAGEMENT• 1. Therapeutic dose of NSAIDS and Aspirin to
reduce inflammation• 2. Chemotherapy with methotrexate, antimalarials,
gold therapy and steroid• 3. For advanced cases- arthroplasty, synovectomy• 4. Nutritional therapy
04/08/23 RON R.N.,M.D. 83
Rheumatoid arthritis
MEDICAL MANAGEMENT
GOLD THERAPY:• IM or Oral preparation• Takes several months (3-6) before effects can be
seen• Can damage the kidney and causes bone marrow
depression• May NOT work for all individuals
04/08/23 RON R.N.,M.D. 84
Rheumatoid arthritis
Nursing MANAGEMENT
1. Relieve pain and discomfort• USE splints to immobilize the affected
extremity during acute stage of the disease and inflammation to REDUCE DEFORMITY
• Administer prescribed medications• Suggest application of COLD packs during
the acute phase of pain, then HEAT application as the inflammation subsides
04/08/23 RON R.N.,M.D. 85
Rheumatoid arthritis
Nursing MANAGEMENT2. Decrease patient fatigue• Schedule activity when
pain is less severe• Provide adequate periods
of rests3. Promote restorative sleep
04/08/23 RON R.N.,M.D. 86
Rheumatoid arthritis
Nursing Management4. Increase patient mobility• Advise proper posture and
body mechanics• Support joint in functional
position• Advise ACTIVE ROME• Avoid direct pressure over the
joint 04/08/23 RON R.N.,M.D. 87
Rheumatoid arthritis
Nursing Management5. Provide Diet therapy• Patients experience anorexia,
nausea and weight loss• Regular diet with caloric
restrictions because steroids may increase appetite
• Supplements of vitamins, iron and PROTEIN
04/08/23 RON R.N.,M.D. 88
Rheumatoid arthritis
6. Increase Mobility and prevent deformity:
• Lie FLAT on a firm mattress• Lie PRONE several times to
prevent HIP FLEXION contracture• Use one pillow under the head
because of risk of dorsal kyphosis• NO Pillow under the joints because
this promotes flexion contractures
04/08/23 RON R.N.,M.D. 89
Rheumatoid arthritis
• Capsaicin• Unknown mechanism, probably
Inhibits substance “P”• Reduces pain• Applied over the affected area• Do NOT bandage the area• Side effect: burning sensation• Wash hands after application
04/08/23 RON R.N.,M.D. 90
Hot versus Cold
HOT Cold
Use to RELIEVE joint stiffness, pain and muscle spasm
Use to control inflammation and pain
After acute attack ACUTE ATTACK
04/08/23 RON R.N.,M.D. 91
OA versus RA
RA OA
Onset is early Onset is late
Chronic systemic disease
Degenerative disease
Involves the synovium Involves the cartilages
Involved joints are symmetrical- fingers, cervical spine
Involved joints are unilateral- weight bearing knee, hips spine
Malaise, fever, anemia No other S/SX systemic04/08/23 RON R.N.,M.D. 92
OA versus RA
RA OA
Joint tenderness, swelling, warmth and redness
Subcutaneous nodules
Stiffness that dimishes
Crepitus, stiffness in the morning decreases after activity
Rest the joint, cold and heat modalities, ASA, NSAIDS, DMARDS
Rest the joints, Avoid overactivity, Weight reduction, cold and warm modalities, ASA
04/08/23 RON R.N.,M.D. 93
Gouty arthritis
• A systemic disease caused by deposition of uric acid crystals in the joint and body tissues
• CAUSES:• 1. Primary gout- disorder of Purine metabolism• 2. Secondary gout- excessive uric acid in the
blood like leukemia
04/08/23 RON R.N.,M.D. 94
04/08/23 RON R.N.,M.D. 95
04/08/23 RON R.N.,M.D. 96
Gouty arthritis
• ASSESSMENT FINDINGS• 1. Severe pain in the involved joints, initially the big
toe• 2. Swelling and inflammation of the joint• 3. TOPHI- yellowish-whitish, irregular deposits in
the skin that break open and reveal a gritty appearance
• 4. PODAGRA-big toe
04/08/23 RON R.N.,M.D. 97
Gouty arthritis
ASSESSMENT FINDINGS• 5. Fever, malaise• 6. Body weakness and headache• 7. Renal stones
04/08/23 RON R.N.,M.D. 98
Gouty arthritis
DIAGNOSTIC TEST• Elevated levels of uric acid in the blood• Uric acid stones in the kidney• (+) urate crystals in the synovial fluid
04/08/23 RON R.N.,M.D. 99
Gouty arthritis
• Medical management• 1. Allupurinol- take it WITH FOOD
• Rash signifies allergic reaction
• 2. Colchicine• For acute attack
• 3. Probenecid• For uric acid excretion
in the kidney
04/08/23 RON R.N.,M.D. 100
Gouty arthritis
Nursing Intervention
1. Provide a diet with LOW purine• Avoid Organ meats, aged and processed foods• STRICT dietary restriction is NOT necessary
2. Encourage an increased fluid intake (2-3L/day) to prevent stone formation
3. Instruct the patient to avoid alcohol
4. Provide alkaline ash diet to increase urinary pH
5. Provide bed rest during early attack of gout04/08/23 RON R.N.,M.D. 101
Gouty arthritis
Nursing Intervention
6. Position the affected extremity in mild flexion
7. Administer anti-gout medication and analgesics
04/08/23 RON R.N.,M.D. 102
Fracture
• A break in the continuity of the bone and is defined according to its type and extent
04/08/23 RON R.N.,M.D. 103
Fracture
• Severe mechanical Stress to bone bone fracture
• Direct Blows• Crushing forces• Sudden twisting motion• Extreme muscle contraction
04/08/23 RON R.N.,M.D. 104
Fracture
TYPES OF FRACTURE• 1. Complete fracture
• Involves a break across the entire cross-section
• 2. Incomplete fracture• The break occurs through only a part of
the cross-section
04/08/23 RON R.N.,M.D. 105
04/08/23 RON R.N.,M.D. 106
Fracture
TYPES OF FRACTURE• 1. Closed fracture
• The fracture that does not cause a break in the skin
• 2. Open fracture• The fracture that involves a break in the
skin
04/08/23 RON R.N.,M.D. 107
04/08/23 RON R.N.,M.D. 108
Fracture
TYPES OF FRACTURE• 1. Comminuted fracture
• A fracture that involves production of several bone fragments
• 2. Simple fracture• A fracture that involves break of bone
into two parts or one
04/08/23 RON R.N.,M.D. 109
Fracture
ASSESSMENT FINDINGS• 1. Pain or tenderness over the
involved area• 2. Loss of function• 3. Deformity• 4. Shortening• 5. Crepitus• 6. Swelling and discoloration
04/08/23 RON R.N.,M.D. 110
Fracture
ASSESSMENT FINDINGS
1. Pain• Continuous and increases in severity • Muscles spasm accompanies the fracture
is a reaction of the body to immobilize the fractured bone
04/08/23 RON R.N.,M.D. 111
Fracture
ASSESSMENT FINDINGS
2. Loss of function• Abnormal movement and pain can result
to this manifestation
04/08/23 RON R.N.,M.D. 112
Fracture
ASSESSMENT FINDINGS
3. Deformity• Displacement, angulations or rotation of
the fragments Causes deformity
04/08/23 RON R.N.,M.D. 113
Fracture
ASSESSMENT FINDINGS
4. Crepitus• A grating sensation produced when the
bone fragments rub each other
04/08/23 RON R.N.,M.D. 114
Fracture
• DIAGNOSTIC TEST• X-ray
04/08/23 RON R.N.,M.D. 115
Fracture
EMERGENCY MANAGEMENT OF FRACTURE• 1. Immobilize any suspected fracture• 2. Support the extremity above and below
when moving the affected part from a vehicle • 3. Suggested temporary splints- hard board,
stick, rolled sheets• 4. Apply sling if forearm fracture is suspected
or the suspected fractured arm maybe bandaged to the chest
04/08/23 RON R.N.,M.D. 116
Fracture
EMERGENCY MANAGEMENT OF FRACTURE
• 5. Open fracture is managed by covering a clean/sterile gauze to prevent contamination
• 6. DO NOT attempt to reduce the facture
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Fracture
MEDICAL MANAGEMENT • 1. Reduction of fracture either open or
closed, Immobilization and Restoration of function
• 2. Antibiotics, Muscle relaxants such as METHOCARBAMOL and Pain medications
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Fracture
General Nursing MANAGEMENT
For CLOSED FRACTURE• 1. Assist in reduction and immobilization• 2. Administer pain medication and muscle
relaxants• 3. teach patient to care for the cast• 4. Teach patient about potential complication
of fracture and to report infection, poor alignment and continuous pain
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FractureGeneral Nursing MANAGEMENT For OPEN FRACTURE• 1. Prevent wound and bone infection• Administer prescribed antibiotics• Administer tetanus prophylaxis• Assist in serial wound debridement• 2. Elevate the extremity to prevent edema formation• 3. Administer care of traction and cast
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Fracture• FRACTURE COMPLICATIONS• Early• 1. Shock• 2. Fat embolism• 3. Compartment syndrome• 4. Infection • 5. DVT
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Fracture• FRACTURE COMPLICATIONS• Late• 1. Delayed union• 2. Avascular necrosis• 3. Delayed reaction to fixation devices• 4. Complex regional syndrome
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Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Occurs usually in fractures of the long bones• Fat globules may move into the blood stream because
the marrow pressure is greater than capillary pressure• Fat globules occlude the small blood vessels of the
lungs, brain kidneys and other organs
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Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Onset is rapid, within 24-72 hours• ASSESSMENT FINDINGS• 1. Sudden dyspnea and respiratory distress• 2. tachycardia• 3. Chest pain• 4. Crackles, wheezes and cough• 5. Petechial rashes over the chest, axilla and hard palate
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Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Nursing Management• 1. Support the respiratory function• Respiratory failure is the most common cause of
death• Administer O2 in high concentration• Prepare for possible intubation and ventilator support
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Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Nursing Management• 2. Administer drugs• Corticosteroids• Dopamine• Morphine
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Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Nursing Management• 3. Institute preventive measures• Immediate immobilization of fracture• Minimal fracture manipulation• Adequate support for fractured bone during
turning and positioning• Maintain adequate hydration and electrolyte
balance
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Fracture• Early complication: Compartment syndrome• A complication that develops when tissue perfusion in
the muscles is less than required for tissue viability
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Fracture
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Fracture
• Early complication: Compartment syndrome• ASSESSMENT FINDINGS1. Pain- Deep, throbbing and UNRELIEVED pain by opiods• Pain is due to reduction in the size of the muscle
compartment by tight cast• Pain is due to increased mass in the compartment by edema,
swelling or hemorrhage
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Fracture
• Early complication: Compartment syndrome• ASSESSMENT FINDINGS• 2. Paresthesia- burning or tingling sensation• 3. Numbness • 4. Motor weakness• 5. Pulselessness, impaired capillary refill time and
cyanotic skin
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Fracture
• Early complication: Compartment syndrome• Medical and Nursing management• 1. Assess frequently the neurovascular status of the
casted extremity• 2. Elevate the extremity above the level of the
heart• 3. Assist in cast removal and FASCIOTOMY
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Strains
• Excessive stretching of a muscle or tendon
• Nursing management• 1. Immobilize affected part• 2. Apply cold packs initially, then heat
packs• 3. Limit joint activity• 4. Administer NSAIDs and muscle
relaxants04/08/23 RON R.N.,M.D. 133
Sprains
• Excessive stretching of the LIGAMENTS• Nursing management• 1. Immobilize extremity and advise rest• 2. Apply cold packs initially then heat packs• 3. Compression bandage may be applied to
relieve edema• 4. Assist in cast application• 5. Administer NSAIDS
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Herniated disk
• Occurs when all or part of the nucleus pulposus forces through the weakened or torn outer ring (annulus pulposus
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Herniated disk
• Impingement on the spinal nerves will result to BACK PAIN
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Herniated disk
• Causes
1. Trauma
2. Strain
3. Joint degeneration
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Herniated disk
ASSESSMENT findings
1. Severe lower BACK PAIN that may radiate to the buttocks or legs and feet
2. Motor and sensory loss in the area supplied by the compressed nerves
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Herniated disk
DIAGNOSIS of Herniated disk
1. Straight leg raising test• (+) leg pain
2. LeSegue’s test• 90 degrees knee and thigh (-) DTR
3. XR
4. CT
5. MRI
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Herniated disk
Nursing Implementation
1. Provide complete BED rest for several days
2. Advise heat application over the area to lessen pain and muscle spasm
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Herniated disk
Nursing Implementation
3. Provide exercise on bed
4. Assist in pelvic traction application
5. Provide the drugs as ordered
Aspirin
Diazepam
Muscle relaxant
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Herniated disk
Nursing Implementation
6. Provide care for laminectomy
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Laminectomy
• Removal of the spinal lamina to stabilize the vertebral joint and
Removal of the protruding disk
• Usually accompanied by insertion of metal plates
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Laminectomy
• Pre-operatively• Routine pre-operative care• Remind the patient that he should lie
non his BACK after the operation• Monitor for worsening of symptoms• Use anti-embolic stocking• Encourage ROME• Coordinate with the PT
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Laminectomy
• Pre-operatively• Fluids to prevent renal stones• Incentive spirometry• Maintain on BED rest
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Laminectomy
• POST-operatively• Maintain BED rest• VERY IMPORTANT : LOG ROLLING TECHNIQUE
to turn• Never lie on PRONE• HEMOVAC drainage system= check tubing for
kinks, record amount, report colorless moisture in dressing
• Provide straight BACKED chair for LIMITED sitting ONLY
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Laminectomy
• HOME CARE• AVOID sitting for a prolonged period of time• AVOID twisting, bending at the waist• Sleep on BACK• Proper weight to PREVENT lordosis
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Amputation
Nursing InterventionsPost-operative care: after amputation• Elevate stump for the FIRST 24
HOURS to minimize edema and promote venous return
• Place patient on PRONE position after 24 hours
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Amputation
Nursing Interventions
Post-operative care: after amputation
• Assess skin for bleeding and hematoma
• Wrap the extremity with elastic bandage
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