Skeleton Classification of Bones

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    Review of Anatomy and

    Physiology Skeleton

    Classification of bones Compact (dense)

    Cancellous (spongy) Bone marrow

    Axial section

    Appendicular section

    Joint articulations Muscles

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    Diagnostic Tests andAssessments

    Radiologic tests Are diagnostic studies performed using x-

    rays, with or without injection of contrastmedia, to detect musculoskeletal problemsand monitor effectiveness of treatment

    X-ray (radiograph): most common and

    widely used radiologic test for assessmentof musculoskeletal problems andeffectiveness of treatment

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    Diagnostic Tests and

    Assessments EMG (electromyogram or myogram):

    records and evaluates the electricalactivity of muscles during contraction

    Detects abnormal electrical activity inmuscle

    There are two different types of EMG:intramuscular (IM) EMG (more commonly

    used) and surface EMG (SEMG)

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    Diagnostic Tests and

    Assessments Long, small-gauge needles are inserted through

    the skin into muscle

    Needles detect electrical activity of the muscle

    and transmit information into electromyogrammachine; electrical activity is displayed visuallyon an oscilloscope or heard audibly through anaudiotransmitter (microphone)

    (SEMG): electrodes are placed above muscle to

    detect electrical activity

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    Diagnostic Tests and

    Assessments Arthroscopy: a surgical procedure used

    to examine the internal structure of a jointusing an arthroscope il-sized device with

    optical fibers and lenses), which is insertedinto very small skin incisions; device isconnected to a video camera to allow forvisualization of the interior of the joint

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    Diagnostic Tests and

    Assessments Procedure may be used for diagnosis or

    treatment of musculoskeletal disorders suchas osteoarthritis, rheumatoid arthritis,

    infectious types of arthritis, and internal jointinjuries like meniscus tears, ligament strainsor tears and cartilage deterioration

    Arthroscopic surgery can be done during

    procedure to repair joint tissues;arthroscopic surgery creates less tissuetrauma, less pain, and allows for a rapidrecovery

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    Diagnostic Tests and

    Assessments Client education: postprocedure Encourage client to take analgesics for comfort

    and limit activity as directed

    Instruct client to observe site for hematoma orbleeding

    Teach client how to perform neurovascularassessment (temperature, color, capillary refill,movement, and sensation) on affectedextremity

    Teach client about signs and symptoms ofinfection to report; elevated temperature,warmth at injection site, purulent discharge,

    and redness

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    Diagnostic Tests and

    Assessments Arthrogram: contrast media or air

    is injected into the joint cavity toallow for visualization of jointstructures; client moves jointthrough a series of movements whilea series of x-rays are taken; assess

    for allergy to contrast media

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    Diagnostic Tests and

    Assessments

    Client education preprocedure: if injectedcontrast dye is used, inform client that once thedye is injected there may be a feeling of warmth,nausea, headache, salty taste in the mouth,itching, hives, and rash throughout the body(symptoms are usually temporary and will betreated if necessary

    Client education postprocedure

    Inform client that temporary discoloration of theskin and urine is normal after injection of dye

    Teach client to perform neurovascular assessmenton affected extremity

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    Diagnostic Tests and

    Assessments CT scan (computerized axial

    tomography): combines x-rays withcomputer technology to produce ahighly detailed, cross-sectionalimage of internal organs andstructures of the body; also known as

    CAT scan

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    Diagnostic Tests and

    Assessments Body is visualized from skin to central part

    of the body being examined; recordedimage is called a tomogram

    Client education If ingested contrast dye is used, instruct client

    to increase fluid intake to assist in eliminationof dye

    Monitor for evacuation of contrast media and

    possible constipation Initial stools may be white in color, which is

    normal until all contrast media is evacuated

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    Diagnostic Tests and

    Assessments MRI (magnetic resonance imaging):

    radiologic technique (without radiation)that uses magnetism, radio waves, and a

    computer to produce cross-sectionalimages of the body structures

    Machine is extremely noisy and may cause orexacerbate a claustrophobic sensation

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    Diagnostic Tests and

    Assessments Client education Explain procedure to the client; a mild sedative may

    be given preprocedure to help decrease any anxietyassociated with a claustrophobic feeling

    Instruct client to notify healthcare providers of anymetallic body parts such as implants, pacemakers,artificial joints, metallic bone plates, prostheticdevices, surgical clips, bullet fragments, metallicclips, or other al objects within the body that can

    distort the MRI image or affect the magnetic field

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    Diagnostic Tests and

    Assessments

    Bone scan: technique used to create images ofbones on a computer screen or on a film using asmall amount of radioactive material that travelsthrough the bloodstream Radioactive material is especially absorbed in

    abnormal areas of a bone; degree of dye absorption isrelated to the amount of blood flow to the bone

    A camera scans the entire body and a recording ismade on a special film

    Increased dye absorption is seen with osteomyelitis,

    osteoporosis, fractures, Pagets disease and cancer ofthe bone

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    Diagnostic Tests and

    AssessmentsArthrocentesis (joint aspiration)

    and analysis: fluid is removed fromjoint to reduce swelling and pain

    and/or obtain fluid for examinationusing a sterile needle and syringe Post-procedure complications are

    uncommon but may include localizedbruising, minor bleeding into the jointcavity, and loss of pigment at injectionsite (septic arthritis is a rare butserious complication)

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    Diagnostic Tests and

    Assessments Client education

    If cortisone medication was injected into the joint,teach client to monitor for inflammation of the

    injected area, atrophy or loss of pigment at theinjection site, and increased blood glucose

    Instruct client to follow post-procedure activityrestrictions as directed by healthcare provider

    Instruct client to monitor for post-procedurecomplications and check dressing for excessivebleeding

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    Laboratory Studies

    Antinuclear antibodies (ANA): sensitivescreening blood test used to detectautoimmune disease

    ANAs destroy the nucleus (innermost core of thecell that contains the DNA) of the cells

    Test not definitive but suggests presence ofauto-antibodies (antibodies directed against thebodys own tissue)

    Present in clients with a number of autoimmunediseases such as rheumatoid arthritis, systemiclupus erythematosus, scleroderma, and others

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    Laboratory Studies

    Calcium (Ca++): one of the most abundantelectrolytes in the body that causesneuromuscular irritability and contractions; adultnormal reference value is 9 to 11 mg/dL Stored in bone and gives bone stability

    Blood specimen is obtained to monitor calcium level Normal ranges vary slightly among healthcare

    institutions Decreased calcium levels may be found in

    osteomalacia, inadequate dietary intake of calcium,renal disease, and hypoparathroidism

    Increased calcium levels may be seen in boneneoplasm, multiple fractures, immobilization, renalcalculi, and hyperparathyroidism

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    Laboratory Studies

    Phosphorus (2.5 to 4.5 mg/dL is normalreference range): blood sample is obtained tomonitor level and compare phosphorus level withother electrolytes in the body (such as calcium) A high percentage of total phosphorus in the body is

    combined with calcium in teeth and bones Decreased levels can be seen with hypercalcemia,

    starvation, malabsorption syndrome, osteomalacia, andvitamin D deficiency

    Increased levels can be seen with healing fractures,metastatic bone tumors, and hypocalcemia

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    Laboratory Studies

    Rheumatoid factor (RF) (Normal-negative or

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    Laboratory Studies

    Erythrocytes sedimentation rate(ESR); normal is

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    Laboratory Studies Uric acid(Normal male 4.5 to 6.5 mg/dL,

    female 2.5 to 5.5 mg/dL): test generally used tomonitor serum uric acid levels during thetreatment of gout and may be used to diagnoseother health problems

    Uric acid is the end product of purine metabolism;the kidneys normally excrete excess uric acid

    Hyperuricemia (elevated urine or serum uric acidlevels) occurs because of poor renal function,excessive purine metabolism, and/or excessive

    dietary intake of purine foods Elevated uric acid level is seen in gout

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    Common Nursing

    Techniques andProcedures

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    Common Nursing Techniques

    and Procedures Instructing the client on the use of

    crutches

    Crutch gaits: safe method of walkingusing crutches, alternating bodyweight on one or both legs and thecrutches;

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    Instruction for the Client on

    the Use of Crutches Four-Point Gait

    Slow gait

    Require good coordination Weight bearing is on both legs

    Move each foot and crutch forward

    separately (right crutch, left foot;left crutch, right foot)

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    Instruction for the Client onthe Use of Crutches

    Two-point gait

    Faster than four-point gait

    Requires more balance

    There is partial weight-bearing on eachfoot

    Arm movement simulate arm movementwhen walking

    Move left crutch and right foot forwardtogether; move right crutch and left footforward together

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    Instruction for the Client on

    the Use of Crutches Three-point gait

    Fast gait

    Two crutches and unaffected legbear weight alternately

    Weaker leg and both crutchesmove together followed bystronger leg

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    Instruction for the Client on

    the Use of Crutches Swing-to gait

    Fast gait

    Used by clients with paralysis oflegs and hips

    Prolonged use may lead to atrophyand unused muscles

    Advance crutches forward together,lift body using arms, then swing tomeet crutches

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    Common Nursing Techniquesand Procedures

    Traction: direct pulling forceapplied to a fractured extremity

    that results in realignment of bone Reduces fracture, lessens muscle

    spasms, relieves pain, correctsdeformities, promotes rest, and

    allows for exercise

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    Common Nursing Techniquesand Procedures

    Skin and skeletal traction are mostcommonly used; manual traction is onlyused briefly under physician direction

    Skin traction (using tape, boots, splints) Assists in reduction of a fracture (does notprimarily achieve reduction) and helpsdecrease muscle spasms

    Generally used for short-term treatment (48 to72 hours) and is applied directly to the skin

    Weights range from 5 to 10 pounds

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    Common Nursing Techniquesand Procedures

    Balanced suspension (traction that is ahanging support to immobilized body partin a desired position)

    Used with skeletal traction to improvemobility while maintaining alignment offracture

    Body part is suspended using splints, ropes,

    and weights

    Client able to perform activities such astoileting and personal hygiene; bed linen canbe changed without disturbing tractionalignment

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    Common Nursing Techniquesand Procedures

    Countertraction: pulling forceexerted in the opposite direction toprevent the client from sliding to theend of the bed; examples ofcountertraction include the clientsweight, elevating the foot of the bed

    (Trendelenburg), and elevating thehead of the bed with cervicaltraction

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    Nursing Care for the Client in

    Traction

    Ensure that all ropes, weights, and pulleys arehanging freely, not shredded or torn, in astraight line

    Bed linen should be kept off traction ropes

    Teach client that weights should not be lifted forany reason (lifting weights alters the line of pulland could potentially interfere with bone healing)

    Ensure that the ordered amount of weight ismaintained at all times

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    Nursing Care for the Client in

    Traction Teach client how to perform skin

    assessment to monitor and prevent skinbreakdown on bony prominence and

    pressure areas Ensure that body is always kept in proper

    alignment to prevent complications such asexternal rotation of the joint, increase pain,

    and poor healing of the fracture Teach client how to monitor for infection at

    pin sites

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    Nursing Care for the Client in

    Traction

    Inform client to avoid massaging calves orreddened areas to prevent clotdislodgement caused by venous stasis

    Encourage client to increase fluid intake

    (2,500 mL per day unless contraindicated)and roughage in diet to preventconstipation, UTI, and renal calculi

    Teach client how to perform deep-breathing

    and coughing exercises to preventrespiratory complication

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    Nursing Care for the Client in

    Traction Encourage client to use the overhead trapeze

    (and unaffected leg if possible) to reposition forcomfort, shift weight to prevent skin breakdown,perform exercises, and assist with personal care,toileting and bed linen changes

    Encourage client to adhere to exercise regimento maintain muscle tone, endurance, andprevent bone demineralization

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    Nursing Care for the Client in

    Traction Provide diversional activities and

    encourage social interaction withfamily and friends to preventpotential isolation

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    Common Nursing Techniquesand Procedures

    Cast care: a cast is applied forimmobilization to ensure stability ofa fracture

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    Nursing Care of the Client in

    a Cast

    Instruct the client to avoid covering a new castwith blanket or plastic for extended periods

    Turn client from side to side (using palms notfingertips) every 2 hrs to facilitate to drying forthe first 24 to 72 hrs

    Instruct client to apply ice for the first 24 hrsover fracture side to control edema, ensuringthat ice is securely contained so cast does notbecome wet

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    Nursing Care of the Client in

    a Cast Instruct the client to elevate the extremity above

    the level of the heart to promote venous return forthe first 24 hrs after application

    Instruct client to perform active ROM to jointsabove and below immobilized extremity

    Teach client about signs and symptoms to reportto healthcare provider: increasing pain inimmobilized extremity, excessive swelling anddiscoloration of exposed limb, burning or tinglingunder cast, sores, or foul odor under cast

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    Common Nursing Techniquesand Procedures

    Splinting and immobilization: likecasts, splints are used to immobilizea fractured extremity to ensure

    stability after closed reduction andexternal fixation; teach client how toperform neurovascular assessment

    (color, temperature, capillary refill,and pulses)

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Laminectomy: surgical incision of the lamina doneprimarily to relieve symptoms related to herniatedintervertebral disc

    Assess effectiveness of pain management

    Perform neurological and neurovascular assessment;monitor bowel and bladder function

    Assess client for complaints of severe headache orleakage of cerebrospinal fluid (CSF), nausea, abdominaldiscomfort, incontinence, amount and character ofdrainage on dressing

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Use the logroll technique (turning a client as aunit) to turn and reposition client; maintainproper alignment of the spine at all times

    Inform client that bed rest may be maintained

    for the first 24 to 48 hours after procedure;pillows may be used for comfort under thethighs in the supine position and between thelegs in the side-lying position

    Assist client to rise as a unit when getting

    out of bed (especially for the first time) Instruct client that paresthesias (numbness

    and tingling of extremities) may not berelieved immediately after procedure

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Internal fixation: fracture immobilizationwith a metal device (made of screws, pins,and/or plates) that is surgically inserted torealign and maintain a fracture

    Inform client that x-rays will be taken atregular intervals to ensure proper alignmentof the fixation device

    Instruct client about signs and symptoms toreport related to infection; elevated

    temperature, localized pain and warmth,tenderness, chills, malaise, and changes inneurovascular status of affected extremity

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Joint replacement, total hip replacement(THR) THR is frequently performed for client with

    conditions such as rheumatoid arthritis,malignant bone tumors, arthriris associatedwith Pagets disease, juvenile rheumatoidarthritis, and hip fracture

    Advantages of THR: substantial relief of pain,improved function and quality of life

    Teach client about plan for effective painmanagement and side effects/adverse effectsof pain medications

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Teach client about dislocation precautions Avoid extremes of internal rotation, adduction,

    and 90-degree flexion of affected hip for at least4 to 6 weeks after procedure

    Prevent adduction: use an abduction pillow, avoidcrossing the legs, avoid twisting to reach forobjects behind, and avoid driving a car and takingtub baths for at least 4 to 6 weeks

    Modify equipment to avoid 90-degree hip flexion(raised toilet seats, platform under chair, use ofreaches, long-handled shoe horns, and sockpullers)

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Teach client about signs and symptoms to reportto healthcare provider Infection-redness, swelling, abnormal drainage, foul

    odor, and elevated temperature

    Deep vein thrombosis (pain, sudden swelling in

    affected extremity, enlargement of superficial veins,skin discoloration, and localized warmth)

    Inform client that physical therapy exercises will beginon the first postoperative day to restore and maintainrange of motion, muscle strength, and mobility, and toprevent complications such as DVT

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Instruct client that homecaremanagement program will include: Ongoing nursing assessment of pain

    management

    Periodic dressing changes and monitoring forinfection Monitoring and adjustment of coagulation

    status weekly if taking warfarin (Coumadin)and less often if taking enoxaparin (Lovenox), alow-molecular-weight heparin

    An exercise program assisted by a physicaltherapist to assess and restore musclestrength and range of motion

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Instruct client to inform all healthcareproviders (dentists, etc.) of history of joint

    replacement surgery so that prophylacticantibiotics can be prescribed as necessary

    Inform client that periodic x-rays will berequired as follow-up throughout lifetime

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Amputation Provide client teaching about

    effective pain managementtechniques; signs and symptoms toreport: redness, elevatedtemperature, and/or unusual, foul

    smelling drainage; abrasions; and anyother signs of skin breakdown

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Teach client how to care for residual limb:wash daily using warm water andbacteriostatic soap, rinse and gently pat

    dry thoroughly, expose to air for at least20 minutes after washing; avoid use oflotions, alcohol, powder, or oils unlessprescribed by healthcare provider; change

    limb sock daily, wash sock using mild soapand dry flat and discard sock that is inpoor condition

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    Nursing Management of ClientUndergoing Musculoskeletal Surgery

    Instruct client to perform upper extremity activerange of motion (AROM) exercise daily

    Instruct client to lay prone for 30 minutes 3 to 4times/day (if client is able and if part of standard ofcare) and avoid elevat6ing or sitting with residuallimb on pillows to prevent flexion contractures

    Tell client that pain mat persist in the amputatedextremity and that this is normal and real; thediscomfort will be treated with analgesics or otherinterventions

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    Disorders of theMusculoskeletal System

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    Osteoporosis (porous

    bone) Osteoporosis (porous bone)Disease characterized by low bone

    mass and structural deterioration of

    bone tissue, causing the bone(especially weight-bearing bonessuch as the hip, spine, and wrist) tobecome fragile and more susceptibleto fractures

    Affects both women and men;however, women are at greater risk

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    Osteoporosis (porous

    bone) Etiology and pathophysiologyAs people age, bone resorption happens

    faster than bone formation, which causes the

    bone to lose Ca++ and bone density; sincemost of the bodys calcium is stored in bonesand teeth, this rapid bone resorption leads toporous bone or osteoporosis

    When serum Ca++ decreases, the bodytakes stored Ca++ from bone

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    Osteoporosis (porous

    bone) AssessmentRisk factors include female gender,

    increasing age; thin, small body frame

    Caucasian or Asian-American ethnicity;family history; inadequate dietary intake ofcalcium; sedentary lifestyle; smoking;excessive alcohol intake; steroidmedications; postmenopausal state; chronic

    liver disease; anorexia; and malabsorption

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    Osteoporosis (porous

    bone) Females are at higher risk for osteoporosis than men Women have smaller body frames, which contribute to

    less bone density

    Bone resorption begins at an earlier age in women and

    is accelerated in menopause

    Breast-feeding and pregnancy deplete skeletal reservesunless calcium intake is increased to match demands

    Since currently women often live longer than men,longevity increases the likelihood of osteoporosis

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    Osteoporosis (porous

    bone)

    Planning and implementation Provide client teaching about prevention:

    take adequate amounts of Ca++ throughoutlifetime to decrease the incidence ofosteoporosis;

    proper nutrition for adequate calcium intake;

    weight-bearing exercises to force Ca++ backinto the bone;

    safety measures to prevent falls that can resultin fractures;

    bone mineral density (BMD) tests to measurebone mass in clients at risk for developingosteoporosis

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    Osteoporosis (porous

    bone)Provide clients with informationabout recommended daily dietaryintake of calcium: Ca++ 1,000

    mg/day for premenopausal andpostmenopausal women takingestrogen replacement therapy(ERT), and 1,500 mg/day forpostmenopausal women who arenot taking ERT

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    Osteoporosis (porous

    bone)Provide information about foods high in Ca++ and the importance of calcium intake withvitamin D: dark, green leafy vegetables (suchas broccoli, bok choy,collard greens,spinach), sardines, salmon with the bone,dairy products (such as milk, cottage cheese,cheese, yogurt, and ice cream); Ca++supplements can also be used to supplement

    dietary intake

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    Osteoporosis (porous

    bone) Medication therapy Estrogen replacement therapy (ERT) is generally

    used for prevention of osteoporosis after menopause Usually given in the form of a pill or skin patchDecreases bone demineralization and symptoms

    of menopause

    Can increase risk for endometrial cancer(progesterone may be given with estrogen, calledhormone replacement therapy or HRT, to decrease

    risk)Client is at risk for developing deep vein

    thrombosis (DVT)

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    Osteoporosis (porous

    bone)Alendronate (Fosamax): prevents boneresorption; used to treat both men andwomen with glucocorticoid-induced

    osteoporosisReloxifene (Evista): used for prevention

    and treatment of osteoporosis; selectivereceptor modulator (SERM) thatprevents bone loss; side effects are rarebut may include hot flashes or DVT

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    Osteoporosis (porous

    bone) Risedronate sodium (Actonel): biphosphonate, used forprevention and treatment of osteoporosis inpostmenopausal women and for prevention and treatmentof glucocorticoid-induced osteoporosis in both men and

    women Slows and stops bone loss, increases mineral densityand reduces the risk of fractures

    Instruct client to take drug with a glass of water at least30 minutes before the first food or beverage of the day

    and avoid eating for at least 30 minutes after taking themedication

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    Osteoporosis (porous

    bone) Client educationReinforce the importance of weight-

    bearing exercises (jogging, walking,

    hiking, stair climbing, tennis, dancing,and weight training

    Encourage client to stop smoking

    Encourage client to avoid excessiveintake of alcohol

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    Osteoporosis (porous

    bone)

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    Osteomyelitis

    Osteomyelitis

    Acute or chronic infection of the

    bone usually caused by thestaphylococcus aureus organism

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    Osteomyelitis

    Etiology and pathophysiology

    Infection can occur from direct orindirect invasion of infectious

    organisms

    Direct invasion generally occurs frominvasive procedures such as surgery

    (joint prosthesis, arthroplasty) andinjuries such as fractures

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    Osteomyelitis

    Infection can also be caused by indirectinvasion (also referred to ashematogenous dissemination), where the

    infection of the bone tissue or joint iscaused by spread of the infectiousorganism, through the bloodstream from apreexisting infectious focus; course and

    virulence of infection is influenced byblood circulation to the affected bone

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    Osteomyelitis

    Long bones are common sites of infection inchildren, and spine, hip, and foot are commonsites of infection in adults

    At-risk populations include children, elderly, andindividuals with weakened immune systems

    Osteomyelitis warrants aggressive immediatetreatment with antibiotics or surgery (wounddebridement) if infection of bone is extensive

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    Osteomyelitis

    li i

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    Osteomyelitis

    AssessmentObserve for symptoms of local and/or systemic

    infection: elevated temperature, chills,restlessness, severe bone pain unrelieved by

    analgesics or rest and aggravated bymovement, swelling, redness, and warmth atthe infection site

    Wound culture, bone scan, CT scan, and MRIprovide information for diagnosis andassessment of the extent of infection

    O li i

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    Osteomyelitis

    Planning and implementation Explain all therapies and interventions to client

    and family to decrease anxiety and enhancecooperation with plan of care

    Use a rating scale to assess pain and evaluateeffectiveness of pain management measures

    Provide ongoing education and emotionalsupport since the seriousness of the infectious

    process duration and uncertainty surroundingtime for recuperation, potential complications,and associated risk can be a very fearfulexperience for client and family

    O li i

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    Osteomyelitis

    Teach client about risk factors forosteomyelitis, which include previous jointreplacement surgery and implants

    Use sterile technique for all dressingchanges and manipulation of affected limb;handle extremity very gently

    Avoid activities that increase circulation toaffected area or cause edema, pain, and

    pathologic fractures, such as exercise,application of heat, or keeping extremity independent position

    O t liti

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    Osteomyelitis

    Immobilize affected extremity as prescribed byphysician and keep body in proper alignment

    Monitor temperature at least every 2 hours

    Provide cool environment, light clothing, antipyretic

    medication, antibiotics, and other therapies asprescribed and/or appropriate to keep temperaturewithin the clients baseline

    Keep client well hydrated to prevent dehydrationfrom insensible water loss

    O t liti

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    Osteomyelitis

    If long-term management is required,provide client with instructions aboutwound care using sterile technique,

    medication regimen (includinginstruction on venous access devices ifneeded), antibiotic administration,proper diet, rest, followup visits, and

    laboratory tests

    O t liti

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    Osteomyelitis

    Provide information about adverse effectsof antibiotic therapy such as ototoxicityand nephrotoxicity (aminoglycosides) and

    hepatotoxicity cephalosporins) Instruct and assist client with interventions

    to prevent complications associated withimmobility (turn and reposition every two

    hours, coughing and deep breathingexercises, etc.)

    O t liti

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    Osteomyelitis

    Medication therapy

    Indicated with or without surgicalintervention

    Generally includes antibiotics andanalgesics

    Reinforce information about adverse

    effects of antibiotic therapy asoutlined in previous section

    O t liti

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    Osteomyelitis Client education

    Teach client about the importance of takingantibiotic medications as prescribed (for thefull duration) and to report adverse effectsof the medication to prescriber

    Review medication regimen and have clientverbalize an understanding of teaching

    Reinforce the importance of rest and proper

    diet to facilitate healing, and preventconstipation and dehydration

    Reinforce the importance of limbimmobilization during treatment

    O t liti

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    Osteomyelitis

    M l d t h (MD)

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    Muscular dystrophy (MD)

    Muscular dystrophy (MD)

    Group of genetic childhood disorderscharacterized by progressive muscleweakness, muscle wasting ofsymmetrical groups of muscles, andincreasing disability and deformity

    Types of muscular dystrophy includeduchenne, myotonic, Beckers,facioscapulohumeral, and limb girdle

    Most common form is Duchenne

    muscular dystrophy

    M l d t h (MD)

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    Muscular dystrophy (MD)

    Etiology and pathophysiology

    Inherited sex-linked group of disorders

    Significant risk factor is family history

    Each type differs in regard to musclegroups affected, age at onset, rate ofprogression, and pattern of inheritance

    Each type of MD affects specific musclegroups

    M sc lar d stroph (MD)

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    Muscular dystrophy (MD)

    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)

    AssessmentMuscle biopsy is the primary test to confirm

    diagnosis (test show degeneration of musclefibers)

    EMG is also used as a diagnostic test thatidentifies origin of muscle weakness(destruction of muscle or nerve damage)

    Progressive muscle weakness, hypotonia (lossof muscle mass), and delayed development of

    motor skills such as walking may be observedand reported by parent or caregiver

    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)

    Planning and implementation

    Provide support and assist family withdecision-making process surrounding

    Development of a homecare plan to supportas much independence as possibleModifications in home environment to

    support the clients maximal functional

    abilityEncourage family to actively involve client in

    care

    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)

    Family members may experience a myriad ofemotions including fear, guilt, anger and blame;support family to enhance coping with clientsprogressively worsening disease; refer to local

    support groups including the MuscularDystrophy Association of America

    Assist client and family to cope with theprogressive, incapacitating, and fatal nature of

    the disease

    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)Encourage family to interact with the familybased on developmental and not chronologicalage

    Teach family strategies to prevent skinbreakdown (frequent skin care and linen

    changes if incontinent, turn and reposition atleast 2 hours, use of protective barrierointments, and adequate fluid intake)

    Perform passive range of motion exercises tomaintain function in unaffected extremities

    and prevent/delay contractures in affectedextremities

    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)

    Medication therapy

    There is no effectivepharmacological or other treatment

    Corticosteroids are often used toincrease muscle strength

    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)

    Client education

    Provide information about healthcareteam members and roles, including

    those involved in homecare programfor client

    Instruct family to offer client soft foods

    and to cut into small pieces to preventaspiration and choking

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    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)

    Muscular dystrophy (MD)

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    Muscular dystrophy (MD)

    Pagets disease (osteitis

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    Paget s disease (osteitisdeformans)

    Pagets disease (osteitis deformans)

    Description

    Chronic skeletal bone disease with insidious

    onsetDiagnosed around the fourth decade of life

    Results in enlarged, deformed bones butdoes not affect normal bones

    Generally affects skull, long bones, spine,and ribs

    Pagets disease (osteitis

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    Paget s disease (osteitisdeformans)

    Etiology and pathophysiology

    Cause of disease unknown; however,viral infection has been hypothesized

    as a probable etiologyHereditary factor: may be seen in

    more than one family member

    Early diagnosis and treatment isimportant to prevent diseaseprogression and deformity

    Pagets disease (osteitis

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    Paget s disease (osteitisdeformans)

    Excessive bone resorption followed bybone formation leads to weakenedbone, bone pain, arthritis, deformity,

    and potential pathologic fracturesNormal bone marrow is replaced by

    vascular, fibrous, connective tissue thatleads to formation of larger,

    disorganized, and weaker bone tissue

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    Pagets disease (osteitis

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    Paget s disease (osteitisdeformans)

    Symptoms include bone pain (most commoncomplaint) and other symptoms depending onwhich bones are affected with the disease

    for example, if the skull is affected, headacheand hearing loss may be reported as well as

    increasing head size

    Hip pain may be present if the pelvis or femuris involved

    Bowing of the lower extremities producing a

    waddling gait and curvature of the spine may beseen in advanced stages of the disease

    Pagets disease (osteitis

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    Paget s disease (osteitisdeformans)

    Planning and implementation

    Prognosis is good especially if treatmentis started before major deformity occurs

    Provide analgesics and muscle relaxantsfor comfort

    Administer medications as directed tocontrol progression of disease (seemedication section)

    Pagets disease (osteitis

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    Paget s disease (osteitisdeformans)

    Encourage client to take medication as directed byhealthcare provider since deformity and loss of bonestrength will continue without prescribed medications

    If skull is affected, assists with diet modification,dentures, and eating utensils since teeth may

    become weak from the diseaseHearing aid may be recommended if hearing lossresults from the disease

    Refer client and family to support group

    Pagets disease (osteitis

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    Paget s disease (osteitisdeformans)

    Medication therapyThe goal of treatment is to control progression

    of the disease

    The following medications are approved by the

    Federal Drug Administration (FDA):biophosphonates, etidronate disodium(Didronel), pamidronate disodium (Aredia),alandronate sodium (Fosamax), tiludronatedisodium (Skelid), residronate sodium

    (Actonel), and calcitonin (Miacalcin)

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    Pagets disease (osteitis

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    Paget s disease (osteitisdeformans) Encourage client to participate in an exercise

    program to maintain skeletal muscle health, idealbody weight, and joint mobility

    Instruct client to sleep on a firm mattress if backdiscomfort is present; if back brace is needed,instruct client on the prevention of skin breakdown

    under brace (undershirt) and safety measures (nodriving with brace)

    Encourage client to modify environment at home toprevent falls that may lead to subsequent fractures

    Encourage client to participate in community supportgroup

    Pagets disease (osteitis

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    Paget s disease (osteitisdeformans)

    Musculoskeletal trauma

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    Musculoskeletal trauma

    FracturesDescription A fracture is a break in the continuity of the

    bone

    Fractures may be classified as:Closed (simple fracture): the bone breaksbut the skin remains intact

    Open (compound fracture): broken endsof the bone penetrate the skin

    Musculoskeletal trauma

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    Musculoskeletal trauma

    Fractures may also be classified as: Avulsion: a fracture resulting fromthe tearing of the supporting tendonsand ligaments

    Comminuted: the broken bonefragments into more then two pieces

    Compressed: the bone is crushed

    Impacted: ends of the broken aredriven into each other

    Musculoskeletal trauma

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    Musculoskeletal trauma

    Depressed such as in skull fracture,where the bone structure is broken andpressed inward

    Spiral: the break spreads in a spiral

    fashion along the bone shaft; is usuallycaused by sports injuries

    Greenstick: an incomplete break in thebone where one side splinters leavingthe other side bent or intact; morecommon in children

    Musculoskeletal trauma

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    Musculoskeletal trauma

    Musculoskeletal trauma

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    Etiology and pathophysiology

    Fractures occur in all age group,although the elderly are more proneto fractures resulting from falls

    When a bone breaks, the healing

    process occurs in three phasesA fracture initiates an inflammatoryresponse (inflammatory phase)

    Calcium eventually is deposited in the

    area osteoblasts promote new boneformation (resparative phase)

    Eventually the ends of the fracturereunite (remodeling phase)

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    Musculoskeletal trauma

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    Musculoskeletal trauma

    Crepitus may also be present in palpation;

    crepitation is a popping or grating soundcreated by the movement of broken bonefragments

    Muscle spasms may be noted near the

    fractured boneEcchymosis or a bluish discoloration of the

    area caused by blood extravasation intothe surrounding subcutaneous tissues

    Pain that may be intense and possiblyshock if blood loss is severe

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    Musculoskeletal trauma

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    Musculoskeletal trauma

    Elevate the fractured extremity to reduceswelling and pain

    Apply ice to the affected extremity

    Assist in fracture reduction

    Closed: involves external manipulation torealign the bones

    Open: involves a surgical procedure torealign the bones

    Maintain traction as prescribed; see sectionon nursing care of the client in traction

    Musculoskeletal trauma

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    uscu os e e a au a Monitor for complications compartment syndrome:impairment of circulation within inelastic fasciacaused by external pressure (> 30 mmHg) thatresults in tissue death and nerve injury;

    external pressure can be created by casts,splints, or dressings;

    manifestations include unrelieved pain,extremity, tingling, or diminished sensation(paresthesia), loss of sensation, pallor, coolness ofthe extremity, and weakness; bivalving may benecessary if the cast is too tight

    Musculoskeletal trauma

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    Infection: wound drainage, fever, painand odor

    Fat embolism: chest pain, dyspnea,

    tachycardia, decreased O2 saturation,apprehension, changes in l;evel ofconciousness, petechiae on upper trunkand axilla

    Deep vein thrombosis: calf pain andtenderness, swelling or edema

    Musculoskeletal trauma

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    Medication therapy: includes analgesics and

    antibioticsClient education

    teach the client to exercise the extremities notimmobilized to prevent muscle atrophy

    teach client regarding cast care, splint, and/ortraction (see previous discussions)

    teach the client about neurovascular assessmentsthat need to be done

    teach client regarding pin care procedure andmethods of preventing wound infection

    Hip fracture

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    p

    Musculoskeletal trauma

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    Hip fracture

    Description: the hip can be fractured atdifferent sites, namely, the head, neck,

    and trochanteric areas;Pathophysiology: incidence of hip

    fracture increases with age; 90 percentof hip fractures are caused by falls

    Musculoskeletal trauma

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    Assessment a hip fracture is a medical emergencyhip fractures are generally sustained from

    falls; monitor level of consciousness and

    assess for other injuriesperform neurovascular assessment on

    affected extremity

    extremity of affected hip will be shorter than

    unaffected extremityfractured hip will generally externally rotate

    Musculoskeletal traumal i d i l i

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    Planning and implementation

    Prepare client for surgical intervention (verifyallergies, informed consent, etc.)

    Instruct client that an abductor pillow or splintmay be necessary to prevent disarticulation ofthe femur

    Inform client that sandbags may be usedalong the external border of the affected limbto prevent external rotation

    Inform client that pain medication will beavailable for comfort postoperatively(generally patient controlled analgesia [PCA] isused)

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    Musculoskeletal trauma

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    Teach client about the pain rating scale to beused postoperatively and encourage client toreport any discomfort

    Teach client deep-breathing and coughingexercises preoperatively

    Use aseptic technique for dressing changes andwound drainage

    Provide information on therapies and equipmentto expect postoperatively (indwelling urinaycatheter, PCA, IV therapy, possible traction, etc.)

    Monitor preoperative use of skin traction toimmobilize the limb until surgery is ordered

    Musculoskeletal trauma

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    Client education

    Reinforce deep-breathing and coughingexercises postoperatively

    Preoperatively teach client about

    postoperative precautions to prevent hipdislocation (no hip flexion greater than 90degrees, internal rotation of affected hip, oradduction of affected hip); these include such

    activities as avoiding low chairs, using raisedtoilet seat, no excessive bending

    Reinforce teaching about postoperativecourse

    Sprains and strains

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    p

    Musculoskeletal trauma

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    Sprains and strainsDescription

    A sprain is a stretch and/or tear ofa ligamentA strain is a twist, pull, and/ortear that may involve bothmuscles and tendons

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    Musculoskeletal trauma

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    Medication therapy: analgesicsmuscle relaxants, and anti-inflammatory agents as necessary

    Client education: reinforceinformation covered above inplanning and implementation section

    Gout

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    Gout

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    Primary form of disease is hereditary;secondary form is acquired

    Laboratory findings show elevated

    serum uric acid (hyperuricemia)Characterize by recurring attacks of

    acute joint inflammation

    Gout

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    Etiology and Pathophysiology

    Inherited abnormality in the bodys abilityto process uric acid

    Hyperuricemia is caused by increasedpurine synthesis and/or decreased renalexcretion of uric acid

    Elevated serum uric acid level can also be

    caused by prolonged fasting andexcessive alcohol intake

    Gout

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    AssessmentRisk factors:

    Obesity, excessive weight gain,

    excessive alcohol intake, impaired renalfunction, hypertension,

    chemotheraphy for leukemia andcertain lymphomas, certain thiazide

    diuretics, aspirin, and tuberculosismedications

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    Gout

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    Gout Planning and implementation

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    Planning and implementation

    Prevent any bed linen from touching affected

    extremity because of extreme tenderness (bedcradle and/or footboard can be used)

    Instruct client to adhere to activity restriction suchas bed rest and immobilization of affected extremity

    during periods of exacerbationMonitor uric acid levels to prevent exacerbation and

    evaluate effectiveness of treatment

    Instruct client about precipitating factors for the

    diseaseEncourage diet low in purines

    Gout

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    Medication theraphy:

    anti-inflammatory agents, (such ascolchicines, NSAIDs or

    corticosteroids),

    antihyperuricemic (such as allop-urinol [Zyloprim]) and uricosurics

    (such as prebenecid [Probalan])

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    Degenerative Joint Disease(DJD) O h i i (OA)

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    (DJD) or Osteoarthritis (OA)

    Osteoarthritis (OA)

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    Slowly progressive disorder of articulatingjoints especially weight-bearing joints

    Commonly affects hand and weight-bearingjoints (knees, hips, feet, and back)

    Breakdown of articular cartilage occurs

    Injury is usually limited to joint andsurrounding tissue

    Disease ranges from very mild to very severe

    Osteoarthritis (OA)

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    Osteoarthritis (OA)

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    Etiology and pathophysiology

    Cartilage degeneration causes bones to rubagainst each other, causing pain and decreasingfunction of the joint

    Risk factors

    Age (most significant): primarily affectsmiddle-age to older adults

    Obesity (generally causes arthritis of theknees)

    Repetitive joint injuries caused by sports,accidents, or work-related injuries

    Osteoarthritis (OA)

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    Genetics (especially seen with OA ofthe hands): client may be born withdefective cartilage or slight defect in

    the way the joint fits together, and asthe client ages, the joint cartilagecontinues to progressively, degenerateand enzymes (hyaluronidase) are

    released, which cause furtherbreakdown

    Osteoarthritis (OA)

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    Assessment

    Disease is diagnosed with physical examand a history of symptoms

    X-ray confirms the diseaseJoint pain is present with movement and

    weight-bearing and is relieved by rest

    There is limited range of motion with

    progressive loss of function

    Osteoarthritis (OA)

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    There is joint stiffness after rest

    Crepitation (grating sensation caused by roughjoint surfaces rubbing together) occurs

    Heberdens nodes (raised bony growths over the

    distal interphalangeal joints) are presentBouchards nodes (raised bony growths over the

    proximal interphalangeal joint of the hand) arenoted

    Osteoarthritis (OA)

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    Osteoarthritis (OA)

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    Instruct client to apply heat/cold therapyto affected joint temporary pain relief

    Assist client in planning scheduled restperiods to relieve stress on joints

    Assist client with activities of daily living(ADL) as needed

    Provide information aboutcomplementary therapies such as visualimagery and relaxation techniques forpain control

    Osteoarthritis (OA)

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    Medication therapy

    Acetaminophen is generally used to controlmild pain without inflammation

    Therapy also includes anti-inflammatoryagents such as NSAIDs and corticosteroids

    If NSAIDs are ineffective in controllinginflammation and pain, glucocorticosteroidsmay be injected directly into the joint

    Osteoarthritis (OA)

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    Client education

    Teach client about the nature of and treatment of disease

    Teach client principles of good body mechanics

    Instruct client about the correct use of assistive devicesand encourage use as needed

    Assist client in planning daily activities and tasks thatallow for schedule rest periods

    Teach client to avoid activities that put excessive stresson joints and caused pain

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    Low Back Pain

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    Low Back PainP i b lt f t t d t

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    Pain may be a result of acute or repeated stress on

    the lower back over a period of yearsPain occurs because of degeneration and/or acute

    injury to the tissue of the lower back

    Caused by sprain or strain of ligaments andmuscles

    Pain may be felt at the site of the injury or referred

    Overall health of muscles of the lower backdetermines the degree of risk for injury as well asthe speed of recovery

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    Low Back Pain

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    Assessment

    Risk factors include but are not limitedto: degenerative disc disease, poormuscle tone of the lower back,

    sedentary lifestyle, obesity, poor bodymechanics, smoking, and stress

    Client will report pain caused by a shiftof one vertebra on another or pinching

    and irritation of the nerve rootMuscle spasms are a common symptom

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    Low Back Pain

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    Planning and implementationThe goal of treatment is to improve

    symptoms and slow progression of

    the degenerative process Include client and family in plan of

    care

    Provide emotional support

    Low Back Pain

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    Medication therapyMedication therapy includes but is not

    limited to analgesics, NSAIDs, and

    muscle relaxantsEpidural corticosteroid injections may

    be used if conservative treatment isineffective

    Low Back PainClient education

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    Client education

    Teach client about expected therapeuticeffects, side/adverse effects, andcontraindications with medication use

    Teach client about the pain rating scale

    Teach client the importance of adhering toactivity restrictions such as bed rest asindicated

    Teach client the importance of adhering to

    gradual to activity restrictions such asadherence with exercise plan

    Low Back Pain

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    Teach client the importance ofmaintaining ideal body weight

    Inform client that physical therapy will

    be part of the rehabilitation process toassist in maintaining muscle strengthand flexibility as well as improvingmuscle tone

    Teach client the use of heat/cold forcomfort

    Low Back Pain

    Teach client about the importance of adhering to the principles of

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    p g p pbody mechanics to avoid excessive strain on the lower back

    Encourage client to sleep on a firm mattress

    Have client demonstrate correct sleeping position using the principlesof body mechanics (side lying or supine with knees and hips flexed)

    Encourage client to avoid or stop smoking

    Teach client about use of prescribed brace or corset (if needed) to

    prevent flexion and extension motions of lower back

    Low Back Pain

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