Background of Anatomy and Physiology Human skeleton made up of 206 bones Human skeleton made up of 206 bones 1. 1. Axial skeleton includes Axial skeleton includes a. a. Bones of skull Bones of skull b. b. Ribs and sternum Ribs and sternum c. c. Vertebral column Vertebral column 2. 2. Appendicular skeleton includes Appendicular skeleton includes a. a. Bones of limbs Bones of limbs b. b. Shoulder girdles Shoulder girdles c. c. Pelvic girdle Pelvic girdle

Background of Anatomy and Physiology Human skeleton made up of 206 bones 1.Axial skeleton includes a.Bones of skull a.Bones of skull b.Ribs and sternum

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Background of Anatomy and Physiology

Human skeleton made up of 206 bonesHuman skeleton made up of 206 bones1.1. Axial skeleton includesAxial skeleton includes a.a. Bones of skullBones of skull b.b. Ribs and sternumRibs and sternum c.c. Vertebral columnVertebral column

2.2. Appendicular skeleton includesAppendicular skeleton includes a.a. Bones of limbsBones of limbs b.b. Shoulder girdlesShoulder girdles c.c. Pelvic girdlePelvic girdle

Classification of bones by shape

Functions of bones

1. Form structure and provide support for soft tissues

2. Protect vital organs from injury 3. Serve to move body parts by providing

points of attachment for muscles 4. Store minerals 5. Serve as site for hematopoiesisBone cells include 1. Osteoblasts: cells that form bone 2. Osteocytes: cells that maintain bone

matrix 3. Osteoclasts: cells that resorb bone

Clients with Musculoskeletal Disorders

Background 1. Normal bone remodeling process

involves sequence of bone reabsorption and formation

2. Adults replace about 25% of trabecular bone (the porous type of bone found in the spine and all articulating joints) every 4 months through reabsorption of old bone by osteoclasts and formation of new bone by osteoblasts

Client with osteoporosis

Definition a. Disorder characterized by loss of bone

mass, increased bone fragility, increased risk for fractures

b. Imbalance of processes that influence bone growth and maintenance; associated with aging, but may result from endocrine disorder or malignancy

c. Significant health threat for Americans: estimated 28 million persons; more common in aging women: half of women over 50 experience osteoporosis-related fracture in lifetime (hip, wrist, vertebrae)

Client with osteoporosisRisk Factors a. Risk of developing osteoporosis depends on

amount of bone mass achieved between ages 25 – 35

b. Unmodifiable risk factors1. Aging: decrease in osteoblastic and osteoclastic

activity related to decreasing levels of hormones (estrogen in females; testosterone in males)

2. Gender: women have 10 – 15% less peak bone mass than men; bone loss begins earlier (30’s) and proceeds more rapidly (before menopause)

3. European Americans and Asians have less bone density than African Americans

4. Endocrine disorders affecting metabolism: hyperthyroidism, hyperparathyroidism, Cushing’s syndrome, diabetes mellitus

Client with osteoporosis

Modifiable risk factors 1. Calcium deficiency: insufficient calcium in diet results in

body removing calcium from bones; diets high in protein lead to acidosis, and high in diet soda are high in phosphate

2. Menopause, decreasing estrogen levels: estrogen replacement therapy can reverse bone changes but may increase risk for other diseases

3. Cigarette smoking: decreased blood supply to bones 4. Excessive alcohol intake: toxic effect on osteoblastic

activity; high alcohol intake frequently associated with nutritional deficiencies

5. Sedentary life style: weight-bearing exercise such as walking positively influences bone metabolism

6. Use of specific medications: aluminum-containing antacids, corticosteroids, anticonvulsants, prolonged heparin therapy, antiretroviral

A normal spine at 40 years, and the osteoporotic changes at ages 60 and 70 years

Client with osteoporosis

Pathophysiology a. Diameter of bone increases, thinning outer

supportive cortex b. Trabeculae (spongy tissue) lost and outer

cortex thins c. Minimal stress leads to fracture

4. Manifestations (“silent disease”: bone loss occurs without symptoms)

a. Loss of height b. Progressive curvature of spine (dorsal

kyphosis, cervical lordosis, accounting for “dowager’s hump”)

c. Low back pain d. Fractures of forearm, spine or hip

Client with osteoporosis

Complications a. Fractures (> 1.5 million fractures

yearly), many spontaneous or resulting from everyday activities

b. Persistent pain and associated posture changes restrict client activities and ability to perform ADL

6.Collaborative Care a. Stopping or slowing osteoporosis b. Alleviating symptoms c. Preventing complications

Client with osteoporosis

Diagnostic Tests a. Xrays: picture of skeletal structures but

osteoporotic changes not seen until> 30% of bone mass lost

b. Quantitative computed tomography (QCT) of spine: measures trabecular bone within vertebral bodies

c. Dual-energy Xray absorptiometry (DEXA): measures bone density in lumbar spine or hip; highly accurate

d. Alkaline phosphatase (AST): elevated post fracture

e. Serum bone Gla-protein (osteocalcin) marker of osteoclastic activity and is indicator of rate of bone turnover; used to evaluate effects of treatment

Client with osteoporosisMedicationsa. Estrogen replacement therapy reduces bone loss, increases bone density in

spine and hip, reducing risk of fractures in postmenopausal women. 1. Recommended for women who have undergone surgical menopause

before age 50 2. Associated risk for estrogen therapy alone is increased risk of

endometrial cancer 3. Hormone replacement therapy (estrogen and progestin) associated

with increased risk for cardiovascular disease and breast cancerb. Raloxifene (Evista): selective estrogen receptor modulator (SERM) that

prevents bone loss by mimicking estrogen effects on bone density; side effects are hot flashes; contraindicated for women with history of blood clots

c. Biphosphonates: potent inhibitors of bone resorption used to prevent and treat osteoporosis

1.Alendronate (Fosamax) 2.Risedronate (Actonel) 3.Etidronate (Didronel)d. Calcitonin (Miacalcin): hormone increases bone formation and decreases bone

resorption; available as nasal spray or parenterale. Sodium fluoride: stimulates osteoblast activity, decreases risk of spinal

fractures but associated with increased risk of other fractures including hip

Client with osteoporosisNursing Care a. Emphasis is prevention and education of clients under

age of 35 b. Prevention of complications in those with osteoporosis

Health Promotiona. Calcium intake1. Maintain daily intake of calcium at recommended levels, in

divided doses a. Age 19 – 50: 1000mg b. Age 51-64: 1200 mg c. Age 65 and >: 1500 mg)2. Optimal intake before age 30 – 35 increases peak bone mass3. Foods high in calcium include milk, milk products, salmon,

sardines, clams, oysters, dark green leafy vegetables4. Supplementation:calcium carbonate (Tums); calcium combined

with Vitamin D for older adults

Client with osteoporosis

Exercise 1. Physical activity that is weight-bearing 2. Walking 20 minutes, 4 or > times per week

Health-related behaviors 1. Include not smoking 2. Avoid excessive alcohol 3. Limit caffeine to 2 – 3 cups of coffee daily 4. Limit diet soda

Client with osteoporosis

Nursing Diagnosesa. Health Seeking Behaviorsb. Risk for Injuryc. Imbalanced Nutrition: Less than

body requirementsd. Acute PainHome Care: Focus is on education

including safety and fall prevention inside and outside the home

Client with Paget’s Disease (osteitis deformans)

Description a. Progressive skeletal disorder with

excessive metabolic bone activity leading to affected bones becoming larger and softer

b. Affects femur, pelvis, vertebrae, sacrum, sternum, skull

c. Relatively rare d. Occurs more often in whites e. Slightly more common in males f. Familial tendency

Client with Paget’s Disease (osteitis deformans)


a.Bones are initially soft and bowing occurs; then become hard and brittle leading to fractures

b.Slow progression with 2-stage process1. Excessive osteoclastic bone resorption2. Excessive osteoblasticbone formation

Client with Paget’s Disease (osteitis deformans)

Manifestations a. Most are asymptomatic b. Localized pain of long bones, spine,

pelvis, cranium; pain is mild to moderate deep ache which is aggravated by pressure and weight-bearing noticed at night and when resting

c. Flushing and warmth over areas of bone involvement

Client with Paget’s Disease (osteitis deformans)

Complicationsa. Degenerative osteoarthritisb. Pathological fracturesc. Nerve palsy syndromes from

involvement of upper extremitiesd. Compression of spinal cord

causing tetraplegiae. Mental deterioration from skull

involvement and brain compression

Client with Paget’s Disease (osteitis deformans)

Collaborative Care a. Pain relief b. Suppression of bone cell activity c. Complication prevention

Diagnostic Test a. Xray (often incidental) slow localized

areas of demineralization in early phase; later enlargement of bones with tiny cracks in long bones or bowing in weight-bearing bones

b. Bone scan: active Paget’s disease

Client with Paget’s Disease (osteitis deformans)

c. CT scans and MRI: show degenerative problems, spinal stenosis, nerve root impingement

d. Serum alkaline phosphatase: steady rise as disease progresses

e. Urinary collagen pyridinoline testing: indicator of rate of bone resorption

Client with Paget’s Disease (osteitis deformans)

Medications a. Mild symptoms relieved by aspirin or

NSAIDs b. Bone resorption retarded by 1.Biphosphonates: calcium supplements are

prescribed in addition a. Alendronate (Fosamax) b. Pamidronate (Aredia) c. Tiludronate (Skelid)2.Calcitonic: works as analgesic for bone pain a. Salmon calcitonin (Calcimar) b. Human calcitonin (Cibacalcin)

Client with Paget’s Disease (osteitis deformans)

Surgery a. Total hip or knee replacement is usually

required when client with Paget’s disease develops degenerative arthritis of hip or knee

b. May require surgery for spinal stenosis, nerve root compression

Nursing Diagnoses a. Chronic Pain 1. May involve wearing a back brace for relief of

back pain 2. Heat therapy and massage b. Impaired Physical MobilityHome Care: manifestations often relieved by treatment

Client with osteomalacia (adult rickets)

Metabolic bone disorder characterized by inadequate or delayed mineralization of bone matrix leading to marked deformities of weight bearing bone and pathologic fractures

Pathophysiology a. Primary causes are vitamin D deficiency and hypophosphatemia 1. Vitamin D deficiencya. Present in 1. Older adults 2. Very-low-birth weight infants 3. Strict vegetariansb. Caused by 1. Diet low in vitamin D 2. Impaired intestinal absorption of fats 3. Inadequate sun exposure 4. Some types of renal failure 2. Hypophosphatemia: most commonly caused by alcohol abuse

Process of vitamin D metabolism in the body

Client with osteomalacia (adult rickets)

Other causes 1. Insufficient calcium absorption in intestines,

due to lack of calcium or resistance to action of Vitamin D

2. Increase loss of phosphorus through urineManifestations a. Bone pain and tenderness b. Common fractures are distal radius and

proximal femurCollaborative Care: requires differential

diagnosis from osteoporosis

Client with osteomalacia (adult rickets)

Diagnostic Tests a. Xray demonstrates generalized bone

demineralization b. Serum calcium levels are normal or low c. Serum parathyroid hormone is

frequently elevated as compensatory response

d. Alkaline phosphatase level usually elevated

Client with osteomalacia (adult rickets)

Medicationsa. Treatment of underlying conditionb. Vitamin D therapy with calcium

and phosphate supplementsc. Radiologic evidence of healing

apparent within weeks of therapy

Client with osteomalacia (adult rickets)

Nursing Care a. Assessment of dietary intake of Vitamin D,

calcium, phosphorus, exposure to ultraviolet light b. Management of client responses to bone pain

and tenderness, fractures, muscle weakness c. Vitamin D sources include dairy products

fortified with Vitamin D and cod liver oil d. If client takes supplements, must be aware of

potential for toxicity with fat soluble vitamins e. Fall prevention

Client with osteomyelitis1. Infection of the bone, may occur as acute, subacute, or chronic2. Consequence of bacteremia, invasion from contiguous focus of

infection, skin breakdown; more prevalent in adults over age of 50

3. Pathophysiologya. Usually bacterial in nature: most commonly Staphylococcus

aureusb. Sources of infection 1. Direct contamination of bone from open wounds

(trauma) 2. Complication of surgery 3. Extension of chronic ulcers including venous, arterial,

diabeticc. Infection develops in bone, which may interfere with vascular

supply to bone, and necrosis occurs; difficult for antibiotics to reach the bacteria within the bone



Client with osteomyelitis

Collaborative Carea. Pain reliefb. Infection elimination or prevention c. Early diagnosis to prevent bone

necrosis by early antibiotic therapyd. Often requires bone debridement and

long course of antibiotics

Client with osteomyelitis

Diagnostic Tests a. MRI and CT scans: show abscesses

and soft tissue changes b. Radionucleotides bone scans:

determine whether infectious or inflammatory changes in bone

c. CBC and ESR: WBC and ESR are elevated

d. Blood and tissue cultures: identify infectious organism and determine appropriate antibiotic therapy

Client with osteomyelitis

Medications a. Antibiotics mandatory to prevent acute

case from becoming chronic osteomyelitis b. Initially treated as staph infection until

results of culture are obtained c. Definitive antibiotics prescribed

according to culture results d. Continued at least 4 – 6 weeks with

intravenous or oral antibiotics

Client with osteomyelitis

Surgery a. Needle aspiration or percutaneous

needle biopsy performed to obtain specimen; specimen may also be obtained during debridement procedure

b. Surgical debridement is primary treatment for chronic cases: wound is opened, irrigated; drainage tubes may be inserted for irrigation, suction, and antibiotic instillation

Client with osteomyelitis

Nursing Care a. Persons with chronic osteomyelitis face

frequent and lengthy treatments b. Client needs to be aware of

manifestations of recurrent infection (inflammation in area, temperature elevation)

c. Prognosis is uncertain and client must be maintained under care to prevent amputation or functional deficits

Client with osteomyelitis

Nursing Diagnoses a. Risk for Infection b. Hyperthermia: interventions include

maintenance of adequate fluid intake c. Acute Pain: splinting or use of immobilizer

may limit swelling and improve pain d. AnxietyHome Care a. Often vital part of treatment of osteomyelitis b. Referral to home care agency for support with

wound treatment, antibiotic administration, obtaining supplies, nutritional teaching

Neoplastic Disorders: Bone Tumors


1.Tumors may be malignant or benign a. Benign tumors grow slowly and do not

invade surrounding tissues b. Malignant tumors grow rapidly and


2.Tumors can be primary (rare) or metastatic lesions originating from primary tumors of prostate, breast, kidney, thyroid, lung

Neoplastic Disorders: Bone Tumors

Pathophysiology1. Cause unknown, but connection

exists between bone activity and development of primary bone tumors

2. Primary tumors cause osteolysis, bone breakdown, which weakens bone and leads to bone fractures

3. Malignant bone tumors invade and destroy adjacent bone tissue

Neoplastic Disorders: Bone Tumors

Manifestations: often history of fall or blow to extremity brings mass to attention

1. Pain2. Mass3. Impaired function

Neoplastic Disorders: Bone Tumors

Diagnostic Tests 1. Xray: shows location of tumors and extent of bone

involvement a. Benign tumors show sharp margins separating from

normal bones b. Metastatic bone destruction: characteristic “moth-

eaten” pattern 2. CT scan: evaluation of extent of tumor invasion into

bone, soft tissues, neurovascular structures 3. MRI: determine extent of tumor invasion, response of

bone tumors to radiation and chemotherapy, recurrent disease 4. Needle biopsy to determine exact type of bone tumor 5. Serum alkaline phosphatase: elevated with malignant

bone tumors 6. RBC count elevation 7. Serum calcium: elevated with massive bone destruction

Neoplastic Disorders: Bone Tumors

Treatments 1. Chemotherapy a. Used to shrink tumor before surgery b. Control reoccurrence c. Treat metastasis 2. Radiation a. Often combined with chemotherapy b. Used for pain control with metastatic carcinomas c. Eliminate tumor remains after surgery 3. Surgery a. Eliminate primary bone tumors to eliminate tumors

completely; may involve excise tumor or amputate affected limb

b. With some surgeries, cadaver allografts or metal prostheses used to replace missing bone to avoid amputation

Neoplastic Disorders: Bone Tumors

Nursing Diagnoses 1. Risk for Injury (pathologic fractures) 2. Acute and Chronic Pain 3. Impaired Physical Mobility 4. Decisional Conflict: assist client in gaining

information for informed decisions regarding treatment options

Home Care 1. Client education regarding treatment plan,

wound care, activity and weight bearing restrictions 2. Support with referral to prosthetic specialist

or hospice as case indicates

Client with a Fracture

Fracture: any break in continuity of bone1.Occurs when bone is subjected to more

kinetic energy than the bone can absorb

2.Mechanisms producing fracturea. Direct: energy applied at or near

site of fractureb. Indirect: transmitted from point of

impact to site where bone is weaker

Client with a Fracture

Classifications of fracturesa. Simple (closed) skin intact over fracture or

compound (open) where skin is interrupted over injury and there is increased risk for infection

b. Fracture line may be 1. Oblique: at 45o angle to bone 2. Spiral: curves around the bone 3. Avulsed: occurs when fracture pulls bone and

other tissues away from point of attachment 4. Comminuted: bone breaks in many small

pieces 5. Compressed: bone is crushed 6. Impacted: broken bone ends are forced into

each other 7. Depressed: broken bone is forced inward

Common types of fractures

Open fracture

Closed fracture

Client with a Fracture

c. Complete fracture involves entire width of bone; incomplete fracture does not involve the entire width of bone

d. Stable (nondisplaced) fracture is fracture in which bones maintain their anatomic alignment; unstable (displaced) fracture: fracture in which bones move out of correct anatomic alignment

e. Description according to point of reference i.e. midshaft, intrarticular

Client with a Fracture

Manifestationsa. May be accompanied by soft

tissue injuries involving muscles, arteries, veins, nerves, skin

b. May be alteration in circulation, sensation, swelling, pain

c. May be obvious deformity or fracture

d. May have felt the breakage of bone during the injury event

Client with a Fracture

Fracture healinga. Phases include1. Inflammatory phase a. Bleeding and inflammation develop at site of

fracture b. Hematoma forms around the bone surface c. Necrosis of osteocytes leads to vasodilation

and edema d. Collagen forms and allows calcium to be

deposited2. Reparative phase a. Callus begins to form b. Osteoblasts promote formation of new bone c. Osteoclasts destroy dead bone and assist in

synthesis of new bone

Client with a Fracture

Remodeling phase a. Excess callus is removed b. New bone is laid down along the fracture line c. Eventually fracture site is calcified and bone is

reunitedb. Healing of fracture influenced by 1. Age and physical condition of client 2. Type of fracturec. Time 1. Uncomplicated fracture of arm or foot heals in

6 – 8 weeks 2. Fractured hip heals in 12 – 16 weeks

The stages of bone healing

Client with a Fracture

Emergency care involvesa. Immobilization of fracture 1. Immobilize above and below the deformity 2. Splint to maintain normal anatomical

alignment and prevent further dislocation or damage 3. Use air splint or splint to bodyb. Maintenance of tissue perfusion 1. Control obvious bleeding with pressure

dressing 2. Assessment of pulses, movement, sensation;

any alteration requires prompt medical evaluation c. Prevention of infection: Cover open wounds

with sterile dressing

Client with a Fracture

Diagnostic Tests a. History of incident and initial assessment b. Xray of bones involved in fracture c. Additional tests as indicated: CBC, blood chemistries,

coagulation studies to assess for blood loss, renal function, muscle breakdown, excessive bleeding or clotting

8. Medications a. Pain relief according to degree of injury and client’s

assessment of pain (may require narcotics) b. NSAIDs for anti-inflammatory affect as well as analgesia c. Medications to guard against ulcers d. Stool softeners to prevent constipation e. Antibiotics especially with open fractures f. Anticoagulants, if client considered at risk for deep vein


Client with a Fracture

Treatmentsa.Surgery1.Indicationsa. Requires direct visualization and

repairb. Fracture associated with long-term

complicationsc. Severely comminuted fracture,

which threatens vascular supply

Client with a Fracture

Types a. External fixation: external fixator (frame

connected to pins inserted into long axis of bone) maintains immobilization of fracture but increases independence of client

b. Internal fixation: surgical procedure open reduction internal fixation (ORIF); involves reducing fracture and applying hardware (pins, nails, screws, or plates) to hold bones in place

External fixation of a fracture

Internal fixation hardware

Internal fixation hardware

Client with a Fracture

Traction: application of straightening or pulling force to maintain or return fractured bones in normal alignment; prevent muscle spasms

1. Weights are used to maintain necessary force2. Types of traction a. Manual: by hand b. Straight: pulling force in straight line; Buck’s

traction: straight skin traction often used with fractured hip

c. Balanced suspension: involves more than one force of pull

d. Skeletal: application of pulling force through placement of pins into the bone; allows use of more weight to maintain alignment; increased risk of infection

Client with a Fracture

Casting: rigid device applied to immobilize bones and promote healing

1. Extends above and below the fractured bone which must be relatively stable

2. Types include a. Plaster: 48 hours needed to dry b. Fiberglass: dries within one hour d. Electrical bone stimulation: application of

electrical current at the fracture site; used to treat fractures that are not healing properly 1.Increases migration of osteoblasts and osteoclasts to fracture

site 2.May be accomplished invasively or noninvasively 3.Contraindicated in presence of infection

Client with a Fracture

Complicationsa. Compartment syndrome: excess pressure in limited

space, constricting structures within and reducing circulation to muscles and nerves; normal pressure is 10 – 20 mm Hg

1. Results from hemorrhage and edema following a fracture or crush injury or external compression of limb, if cast is too tight

2. May result in cyclic ischemia and edema increasing risk for loss of limb or sepsis

3. Usually develops within first 48 hours of injury 4. Manifestations include progressive pain often

distal to injury not responsive to analgesia, decreased sensation, loss of movement; pulses may remain normal

Client with a Fracture

Fat Embolism Syndrome (FES) 1. Fat globules lodge in pulmonary vascular bed

or peripheral circulation: occurs with long bone fracture, pressure within bone marrow rises, exceeds capillary pressure and fat globules leave bone marrow and enter circulation

2. Manifestations: characterized by neurologic dysfunction, pulmonary insufficiency, petechial rash on chest, axilla, and upper arms within few hours or week after injury

3. May result in pulmonary edema, atelectasis, ARDS

4. Prevention: early stabilization of long-bone fractures

Client with a Fracture

Deep vein thrombosis (DVT): blood clot forms in lining of large vein; can lead to pulmonary embolism

1. Prevention: early immobilization of fracture and early ambulation

2. Prophylactic anticoagulation, antiembolism stocking and compression boots

3. Prompt diagnosis of DVT and adequate treatment

Infection: any complication decreasing blood supply increases risk; may result from contamination at time of injury or during surgery

1. Organisms include Pseudomonas, Staphylococcus or Clostridium

2. May lead to osteomyelitis, infection within the bone

Client with a Fracture

Delayed union: prolonged healing of bones beyond usual time period

1.Risk Factors include a. Poor nutrition b. Inadequate immobilization c. Prolonged reduction time d. Infection, necrosis, age e. Immunosuppression f. Severe bone trauma2.Detected by serial xrays (xray findings lag 1

– 2 weeks behind the healing process)

Client with a Fracture

Nonunion 1. Persistent pain and movement at fracture site 2. Treatments a. Surgery: internal fixation, bone grafting b. Debridement if infection present c. Electrical stimulation

Reflex Sympathetic Dystrophy 1. Poorly understood post-traumatic condition 2. Manifestations of persistent pain,

hyperesthesias, swelling, changes in skin color, texture, temperature, and decreased motion

3. Treatment includes sympathetic nerve block

Client with a Fracture

Nursing Care involved with fractures includes management of

1. Pain 2. Impaired physical mobility 3. Impaired tissue perfusion 4. Neurovascular compromise 5. Assessment of client’s response to traumaHealth Promotion 1. Emphasis is trauma prevention 2. Maintain good bone health including weight-

bearing exercise, avoiding obesity, adequate calcium intake

Client with a Fracture

Nursing Diagnoses 1. Acute Pain 2. Risk for Peripheral Neurovascular Dysfunction 3. Risk for Infection 4. Impaired Physical Mobility 5. Risk for Disturbed Sensory Perception: Tactile

Home Care: Client and family teaching focuses on individualized needs

1. Cast care 2. Following physician’s directions regarding weight

bearing 3. Home physical therapy referral 4. Obtaining needed equipment

Client with an Amputation

Partial or total removal of body part resulting from traumatic event or chronic condition

B. Causes of amputation 1. PVD is major cause 2. Trauma is major cause of upper

extremity amputation 3. Other traumatic events resulting in

amputation include frostbite, burns, electrocution

C. Underlying cause of amputation is interruption in blood flow either acute or chronic

Client with an Amputation

Levels of amputation1. Determined by local (ischemia and gangrene) and system

factors (cardiovascular status, renal function, severity of diabetes mellitus)

2. Goals a. Alleviate symptoms b. Maintain health tissue c. Increase functional outcome: joints are preserved

whenever possible to allow for greater function

Types of amputation 1. Open (guillotine): performed when infection is

present and remains open to drain 2. Closed (flap): wound is closed with flap of skin

sutured in place over stump

Common sites of amputation

Client with an Amputation

Amputation site healing 1. Immediate post-operative: assess

circulation to stump 2. Rigid or compression dressing is

applied to prevent infection and minimize edema

3. Stump is wrapped in Ace bandage to allow a conical shape to form and prevent edema applied from distal to the proximal extremity

Client with an Amputation

Complications1. Infection: a. Local 1. Drainage or odor 2. Redness 3. Positive wound culture 4. Increased discomfort at suture lineb. System 1. Fever, chills 2. Increased heart rate or decreased blood

pressure 3. Positive wound or blood cultures

Client with an AmputationDelayed healinga. Slower rate of healing than normal b. Factors include 1. Poor or inadequate nutrition 2. Poor blood flow, possibly related to smoking 3. Decreased cardiac output limits circulationChronic stump paina. Results from neuroma formation causing severe

burning painb. Treatments include 1. Medications 2. Nerve blocks 3. Transcutaneous electrical nerve stimulation

(TENS) 4. Surgical stump reconstruction

Client with an Amputation

Phantom limb pain/ phantom limb sensation a. Majority of amputees have sensations

such as tingling, numbness, cramping or itching in the phantom foot or hand, often self-limited

b. Phantom limb pain is pain often difficult to treat; may be referred to pain clinic for comprehensive pain management

Client with an Amputation


a.Abnormal flexion and fixation of joint caused by muscle atrophy and shortening

b.Common complication associated with above the knee amputation

c. Interventions include 1. Lying prone for periods throughout day 2. Active and passive range of motion 3. Avoid prolonged sitting

Client with an Amputation

Prosthesis a. Type depends on level of amputation,

client’s occupation and life style b. Client with lower extremity amputation

often fitted with early walking aids: pneumatic device that fits over stump and allows early ambulation, decreased postoperative swelling

Client with an Amputation

Nursing Diagnoses a. Acute Pain b. Risk for Infection c. Impaired Skin Integrity d. Risk for Dysfunctional Grieving e. Disturbed Body Image f. Impaired Physical MobilityHome Care: Education and information for

client and family regarding stump care, prosthesis fitting and care, assistive devices, exercises, rehabilitation, safety issues

Stump dressing