exam 3 Flashcards
(235 cards)
1
Q
Two Types of Bone Tissue
A
cancellous
corticol
2
Q
Cancellous:
A
spongey bone found on interior of the bone. Lattice like pattern
3
Q
Cortical:
A
outer shell of bone
4
Q
Four Categories of Bones
A
long
short
flat
irregular
5
Q
long bones
A
like the femur
6
Q
short bones
A
like the metacarpals
7
Q
flat bones
A
like the skapula or sternum
8
Q
irregular bones
A
like the vertibrae
9
Q
three bone cell types
A
osteoclasts
osteoblasts
osteocytes
10
Q
osteoblasts
A
secretes matrix of bone formation
11
Q
osteoclasts
A
break down bone
12
Q
osteocytes
A
maintain function of the bone. a bone cell, formed when an osteoblast becomes embedded in the matrix it has secreted.
13
Q
Bone Maintenance
A
process of remodeling and resorption (osteoclasts)
14
Q
Remodeling
A
maintains bone structure: continuous process
15
Q
Resorption
A
removes bone tissue
16
Q
Hormones involved in bone system
A
calcitrol parathormone/calcitonin growth hormone thyroid hormone and cortisol estrogen
17
Q
calcitrol
A
active form on vitamin D. Functions to increase amount of calcium to the blood from the GI tract. Facilitates bone mineralization.
18
Q
parathormone/calcitonin
A
regulators of calcium homeostasis. Promotes movement of calcium from the bone. When there are low levels of Ca in the blood, there is an increased level of parathormone. Calcitonin increases deposit of calcium in the bone
19
Q
Growth hormone
A
direct and indirect effects on skeletal growth and remodeling. Stimulates skeletal growth, especially in children.
20
Q
Thyroid hormone and cortisol
A
Increases bone mass and mineralization
21
Q
estrogen
A
stimulates osteoblasts and inhibits osteoclasts
22
Q
six phases of bone healing page 1079 in book
A
- hematoma formation/inflammation
- fibrocartilage formation
- cartilage calcification
- cartilage removal
- bone formation
- remodeling
23
Q
Three kinds of joints
A
synathrosis (immovable)-skull
amphiarthrosis (limited motion)-vertabrae
diarthrosis (freely movable)-hip/elbow
24
Q
tendons
A
attach muscle to bone
25
ligaments
attach bone to bone
26
Types of musculoskeletal pain
```
Bone pain: boring pain
Muscular pain: cramping
Fracture pain: intense and sharp
Sprain or strain: hurts with moving
Radiating: hard to identify where it's coming from
```
27
Altered sensation
Parasthesia: pins and needles/numbness
28
Past, Family, and Social History
```
Past History:
Broken bones
Hx of musculoskeletal disease
Family History:
Limitations
Musculoskeletal diseases
Social History:
Activity level of patient
Exercises (frequently exercising, or new regimen)
High-risk activities or sports
```
29
Physical Assessment Components
Posture
Gait: have them walk ahead of you and note changes
Bone integrity: xrays and alignment/symmatry
Joint function: passive and active range of motion
Muscle strength and size: assess bilaterally
Skin: look for breakdown, edema, turgor
Neurovascular status
30
Posture assessment
normal curvature is convex in thoracic and concave in other parts
31
kyphosis:
Hunchback
32
Scoliosis
crooked spine
33
lordosis
exaggerated curvature of the lumbar spine
34
Neurovascular status
capillary refill-less than 3 seconds
sensation-paresthesia, numbness, burning
ROM (passive and active)
35
symptoms of decreased neurovascular status
```
decreased ROM
numbness
cold extremity
Compartment syndrome:
swelling
severe pain esp with passive movement
```
36
imaging options
xray
compound tomography
magnetic resonance imaging
arthography
37
xray
val for people with possible fracture. Shows texture and erosion. Widening or narrowing of bone. Any irregularities. Downside, multiples might be needed to assess the structure you’re looking at. Serial xrays to find degenerative diseases or healing of bone.
38
Compound Tomography
CT. Shows detail of specific plane of soft tissues. Can ID location and extent of fracture that's difficult to evaluate
39
Magnetic resonance imaging:
MRI-magnetic field help us see abnormalities like tumors or tissues in bones. Soft tissues and bone
checklist to determine if there's a metal implant.
Ink from tattoos might have an effect on MRI.
40
Arthrography:
in combo with CT or MRI. Finds acute or chronic tears and joints. Inject a contrast into the joint they want to look at, then perform range of motion. When there is a tear in the joint, contrast leaks out of the joint capsule. Metformin/kidney functions in high risk patients.
41
Bone Densitometry
xrays or ultrasound to find osteoporosis
42
Bone scan
detects metastasis or primary bone tumors (not common) Most often there is a malignancy elsewhere that metastasizes in the bone.
Isotope injected, scanned, and lights up where the tumors might be.
43
arthroscopy
Allows you to visualize joints.
| arthroscope goes into the joint to find tears of tendons or ligaments
44
arthrocintesis
joint aspiration-removing fluid from a joint. Most likely has a joint effusion due to infection.
45
electromyography
EMG: gives us information on muscles and nerves. Assesses muscle weakness.
Can be painful
46
biopsy
determines structure and composition of marrow, bone, and muscle to diagnose specific diseases.
47
Blood tests related to musculature
```
CBC: Hgb level: especially in fracture cases
WBC count:
Coagulation studies:
Serum calcium levels-
Serum phosphorus levels-
Vitamin D levels:
Serum enzyme
Serum myoglobin,
Calcium in the urine:
```
48
CBC
common blood study (complete blood count): fractures cause a lot of blood loss
49
WBC
infection (osteomylitis or infection after surgery)
50
Coagulation studies
to be certain bleeding time (stop warfarin, aspirin, lovanox a week before surgery)
51
Serum calcium levels
inversely related to phosphorus
52
Serum phosphorus levels
dx parathyroid function. Acid phosphatase in paget's disease or metastatic cancer.
53
Vitamin D levels
Assesses bone metabolism
54
Serum enzyme
levels of creatin kinase elevate with injury
55
Serum myoglobin
especially with severe muscle trauma
56
Calcium in the urine
bone destruction (breakdown of bone)
57
Aging on the Musculoskeletal System :
all affect ability to do ADLs. 40-1 on 1082
58
Effects on bone due to aging
- Gradual progressive loss of bone mass: reduced height, posture height, loss of flexibility, back pain, inflesion of hips and knees, decreased ROM.
- Bones fragile and prone to fracture: assess their activity levels. Light weight bearing and stretching to increase bone mass. fall prevention: hip and wrist
59
Effects on muscle due to aging
Diminish in size: atrophy. Decreased collagen
Loss of strength and flexibility: tendons become less elastic. Diminished agility. Decreased response time and loss of balance.
60
Effects on joints due to aging
Progressive cartilage deterioration: increased pain.
| Stiffness, reduced flexibility and pain in joints.
61
Effects on ligaments due to aging
Lax ligaments
| Weakness
62
Common reason for PCP visit
| Caused by many musculoskeletal problems
```
Acute lumbosacral strain
Unstable lumbosacral ligaments & weak muscles
OA of the spine
Spinal stenosis
Intervertebral disk problems (herniated disk/bulging disk)
Unequal leg length
Osteoporosis
Metastasis
Obesity
```
63
Diagnostic Procedures for lower back pain
X-ray of spine
Bone scan & blood studies for presence of infection or biomarkers
CT, MRI, EMG
64
Pain associated to lower back pain
Radiating down the leg (radiculopathy)
Sciatica: low back down thigh then down below the knee. There is usually an impingement on the nerve.
Muscle spasm
65
Nursing Diagnosis related to lower back pain
Acute Pain
Activity Intolerance
Risk of falls
Ineffective coping
66
Outcomes related to nursing plans for lower back pain
```
Management of causes
Body mechanics
pain management: tens unit, massage, acupuncture, heat or ice, rest, inversion tables.
Increased activity
Decrease pain
```
67
Intervention plans around lower back pain
Weight loss: walking 30 minutes 3-4 times a week
Physical therapy: teaches the patient strengthening exersizes
Pain control (pharmacological and non-pharmacological)
Teach them how to properly get out of bed. (log roll then have them sit up with arms. Takes practice.)
After surgery, no twisting or 90 degree bending. Walking is best. might get a back brace.
68
Upper Extremity Problems
```
Bursitis and Tendinitis
Carpal Tunnel Syndrome
Impingement Syndrome
Ganglion
Dupuytren’s Disease
```
69
Bursa
little sack in the joint that is filled with fluid
70
Tendonitis
inflammation of the tendon
71
Treatments for burstitis and tendonitits
Rest
Ice and heat
NSAID’s: (nursing considerations GI bleeds and kidneys)
Arthroscopy if pain & weakness continue: synovectomy to remove the inflamed portion of the joint. Surgery doesn't help.
72
Impingement Syndrome
Caused by overuse of shoulder. Untreated can cause a rotator cuff tear.
73
s/s of impingement syndrome
Pain
Shoulder tenderness
Limited movement and spasm
Atrophy
74
treatment of impingement syndrome
```
Rest
NSAIDs
Joint injections of corticosteroid
Physical therapy
Arthroscopic debridement to get impingement out of the joint.
```
75
Carpal Tunnel Syndrome
Neuropathy of median nerve in the wrist. Compressed by band that wraps around the nerve. Commonly caused by repetitive wrist movements.
76
Tinel's sign:
purcuss on inner aspect of the wrist. Numbness/tingling=positive sign.
77
s/s of carpal tunnel syndrome
Pain
Numbness & paresthesias
Weakness along median nerve (thumb, index and middle fingers)
78
Treatment/Management of carpal tunnel syndrome
```
Wrist splints useful in preventing hyperextension. Decrease of repetitive motions.
Yoga, acupuncture, OT
NSAIDs and cortisone injections
Surgery
traditional open nerve release
endoscopic nerve release
Conservative first
```
79
Ganglion cyst
Collection of gelatinous material near tendon sheaths and joints.
May be asymptomatic
Occurring between the 2nd and 3rd decade of life
80
Treatment of ganglion
```
Aspiration
Corticosteroid injection
Surgical excision
compression dressing
immobilization splint
```
81
Dupuytren’s Disease
Slow, progressive contracture of palmar fascia.
| Flexion of fourth and fifth fingers and sometimes the middle finger.
82
Treatment of dupuytren's disease
Finger stretching to prevent contracture
| Palmar and digital fasciotomies
83
dupuytren's disease is caused by:
Autosomal recessive trait
Most frequently in men older than 50
Drug therapy for epilepsy, diabetes
Alcoholism
84
Common Foot Problems
Plantar Fasciitis
| Bunion
85
diseases related to common foot problems
Diabetes
| Peripheral vascular disease
86
Plantar Fasciitis
Inflammation of foot supporting fascia
87
Acute onset of heel pain r/t plantar fasciitis
First steps in the morning
| Anterior medial aspect of heel
88
management of plantar fasciitis
Stretching exercises should help the pain. Long stretch of the calf muscle.
Supportive shoes and cushioning
Orthotic devices: spend the money on good shoes.
NSAIDs
89
Hallux Valgus (Bunion)
Great toe deviates laterally
90
risk factors for hallux valgus
Heredity
Ill-fitting shoes
Aging
Osteoarthritis
91
Treatment for hallux valgus
Depends on pt. age, severity of deformity, and severity of symptoms. If its not complicated, you can just get shoes... corticosteroid therapy, surgery.
Complications: limited ROM after surgery. Lots of pain post-op=pain medications initially. Elevate foot to level of the heart.
Toe flexion and extension after surgery.
Get proper shoes
92
Education for disease related foot problems
```
Peripheral neuropathy with decreased sensation
Skin ulcers
Education:
don't clip your own nails
assess feet every day
```
93
Nursing Interventions: Upper & Lower Extremity Conditions
```
Promote tissue perfusion
relieve pain
increase activity
Prevent infection
Promote home and community based care
```
94
Promoting tissue perfusion in the patient with upper/lower extremity conditions
Neurovascular assessment: circulation, sensation, movement every 1-2 hours post operatively.
Temperature, color, capillary refill, peripheral pulses
95
Pain management options
Pharmacologic (analgesics) vs nonpharmacologic methods (ice, tens unit, elevation, drinking uncontrollably)
96
Activity assistance in the patient with upper/lower extremity conditions
Assist with ADL’s following surgery and have them gradually increase activities on their own
What is the weight bearing status of the limb? Non weight bearing=no pressure at all. Time will vary and might change after the healing continues
97
Preventing infection in the patient with upper or lower extremity conditions
```
Dressing care, education on symptoms of infection
s/s:
warm/red/tender
increased pain
fever/chills
```
98
Osteoporosis Characteristics
Reduction of bone density and change in bone structure
- Bones become progressively porous, brittle, and fragile
- Fracture easily under stresses that would not break normal bone
- Fractures are often first manifestation of osteoporosis: hip and compression fractures in the spine. Wrists too.
99
Patho of osteoperosis
Increased bone breakdown
Decreased bone formation leads to porous, brittle bones that lead to fractures.
Reduced total bone mass
100
Manifestations of osteoperosis
- Kyphosis: result of the compression of vertebrae. -Abdominals begin to stick out and lead to pulmonary issues- fatigue r/t compression of the lungs if hunched over.
- Loss of height
- DEXA scan: used to diagnose osteoporosis. 2.5 SDs or more from the normal range is a diagnosis of osteoporosis. Measures the bone density that's been lost.
101
Risk factors for osteoperosis
Genetics
Age: post menopause. Decreased calcitonin in men and women. Hormone replacement therapy is no longer first line defense
Nutrition: vitamin D and calcium. Inadequate calorie intake.
Physical Exercise: sedentary lifestyle with no weight bearing exercises. Bones need the stress of being active for remodeling.
Lifestyle Choices: caffeine and alcohol. Smoking. Lack of sunlight. all these reduce osteogenesis
Medications: corticosteroids can reduce bone mass. Anti seizure medication can inhibit calcium.
Comorbidity: anorexia, renal failure, parathyroid or thyroid issues.
102
Pharmacological therapy for osteoperosis
- Bisphosphates
| - Calcitonin
103
Education r/t bisphosphates for osteoperosis
reduce spine and hip fractures by inhibiting osteoclast activity. Adequate vit D and calcium is needed for these medications to work. (fosomax with vit D or actinel with calcium) Could have GI adverse effects (nausea, flatulence/diarrhea, ulcer formation) take in the morning with an empty stomach with a full glass of water and then sit upright for 30-60 minutes after taking.
104
Education r/t calcitonin for osteoperosis
inhibits osteoclasts to reduce bone loss. increased activity of osteoblasts. Regulate calcium and increase absorption in the bone. Nasal spray (might cause nasal irritation or flushing of the face) or sub-q or IM injection. Can cause GI problems or urinary frequency.
105
Preventing injury for patients with osteoperosis
Regular weight bearing exercises-strengthen muscles and improves balance which decreases falls.
20-30 minutes of aerobic exercise like walking 3-4 days a week.
106
Fracture management for patients with osteoperosis
```
Conservative treatment or surgery
Hip fractures: hip pinning.
Compression fractures of the vertebrae: conservative treatment
bone cement
Fall prevention
```
107
Patient education r/t nutrition for osteperosis patients
- Calcium
- Vitamin D
From the book:
Three glasses of skim or whole vitamin D milk/calcium enriched orange juice/cheese and other dairy/steamed broccoli/canned salmon with the bones
1300 mg daily thru adolescence then 1000 mg a day in adulthood
108
Paget’s Disease
| Pathophysiology
Proliferation of osteoclasts-primary=bone resorption.
localized, rapid bone turnover
Compensatory increase of osteoblasts
Blasts are more increased to compensate for the osteoclast overactivity
Results in disorganized bone
109
Manifestations of paget's disease
Most patients never experience symptoms but have skeletal deformity
Skeletal deformity involves skull and long bones
Pain, tenderness, and warmth over bones
110
pain relief for paget's disease
NSAIDs -monitor for GI adverse effects and kidney functions
Gait problems monitored with orthopedic devices and supportive devices
111
Education for those with paget's disease
Adequate calcium and vitamin D
| Maintain healthy weight to limit pressure on the bones
112
Pharmacologic therapy for Paget's disease
Calcitonin
bisphosphates
cytotoxic antibiotics antineoplastic medications. Plicamyacin
113
Cytotoxic antibiotics for paget's disease
can be used to help control paget's. Reserved for people who are severely affected: thickened skulls causing nerual problems.
antineoplastic medications: Plicamyacin
114
bisphosphates
produce rapid reduction of bone turn over. Educate about GI side effects.
115
calcitonin
slows down the breakdown of bone. Gets everything at a more normal rate of adsorption and build up. decreases number of osteoclasts. Effect may not be evident until 3-6 months.
116
Osteomyelitis:
infection in the bone. Hard to treat because bone is not very vascular
117
Three ways bone can become infected
- Extension of soft tissue infection (infected pressure or vascular ulcer, incisional infection).
- Direct bone contamination from bone surgery, open fracture, or traumatic injury (gunshot wound): always considered contaminated. Risk is huge. Usually within 30 days after surgery.
- Hematogenous (bloodborne) spread form other sites of infection (infected tonsils, boils, infected teeth, upper respiratory infection)
118
Patients at risk for osteomyelitis
elderly
immunocompromised
corticosteroid therapy
disease or conditions that affect wound healing
119
Manifestations and Assessment of bloodborn osteomyelitis
Sudden onset
Clinical & lab manifestations resembling sepsis
high fever
rapid pulse
area of bone becomes tender and very painful with movement
120
Manifestations and assessment of acute osteomyelitis
Soft tissue swelling on x-ray
within 12 weeks: calcification
Leukocytosis and elevated ESR
Pain, but not as severe as blood borne.
121
Manifestations and assessment of chronic osteomyelitis
Large irregular cavities on bone from prolonged infection. Abscesses in the area as well.
Anemia associated with chronic infection
Development of abscess
122
Assessment of patient with osteomyelitis
Acute onset of s/s of localized pain, erythema, fever or recurrent drainage of an infected sinus tract with associated pain, edema, and low-grade fever
Physical exam: inflamed, edematous, warm, tender area with potential purulent drainage and elevated temperature
123
Diagnosis of patient with osteomyelitis
```
Acute pain
Impaired physical mobility
Risk for extension of infection
Deficient knowledge
Risk for falls
Ineffective coping as a result of amputation
```
124
Planning for the patient with osteomyelitis
Pain relief,
improved physical mobility as soon as possible
control & eradication of infection
knowledge of treatment regimen
Long term antibiotics:
superinfections: c diff, yeast infections
125
Interventions for patients with osteomyelitis
```
Relieving pain
-immobilize affected extremity
-elevate to reduce the swelling
-pain meds
Improving physical mobility
-there might be mobility restrictions (usually non weight bearing in the affected limb)
-Use limbs that can be used.
Controlling the infectious process
-Treat with broad spectrum antibiotics
have good coverage across wide variety of infections
-Culture the infection to get a more specific antibiotic
-Teach about superinfections
Teaching patients self-care
-Education about infusions
-Monitor for healing
-no increased pain
-persistent fever
-decreased pain and drainage, increased ROM are signs of healing.
```
126
Evaluation of patients with osteomyelitis
Experiences pain relief
- Reports decreased pain
- No tenderness at site & no discomfort with movement
Increases physical mobility
-Participates in ADL’s as much as possible
Shows absence of infection****most important.
- Takes antibiotics as prescribed
- Normal temperature
- Negative wound cultures
Adheres to therapeutic plan
- Takes medications as prescribed
- Wound care
- No recurrence of symptoms
127
Medical management of bone tumors
Primary bone tumor: goal is to destroy or remove the tumor in some way. Usually in benign bone tumors, you would just monitor them. Most common in teens.
Secondary bone tumor: patient has cancer that started some other place, so goal is palliative.
128
Nursing management for a patient with bone tumors
Patient education
- explain what the goals of treatment are
- explain any diagnostic tests that the patient will have.
Relieving pain
- bone tumors are very painful.
- analgesics/nonpharm treatment
Prevent pathologic fracture
-teach about fall prevention
Promote coping skills & self-care
- helps the patient and their family
- we want them to do as much as they can
Managing complications
129
Levels of amputation
Below-knee amputation (BKA)
| Above-knee amputation (AKA)
130
Complications from amputations
- hemorrhage
- skin breakdown
- phantom limb pain
- contracture
131
phantom limb pain
some patients have no difficulty with this, but other patients have a hard time with it. Might feel like numbness, tingling, cramping
- medications might be used to help manage the pain
- acupuncture
- Do not "elevate" the amputated extremity (don't elevate the nub)
132
contracture due to amputation
nurse should educate them to not sit for prolonged periods of time
after first 24 hours, reposition to laying prone
133
Management /interventions for new amputees
Promoting rehabilitation: the way they move is forever changed, get PT involved early, get prosthetics involved early. It might take time to find a prosthetic they like. Encourage them to do as many of their ADLs that they can do. Get family involved in encouraging them to move as much as possible.
Minimizing altered sensory perceptions
Helping achieve physical mobility
134
Total Hip Replacement
Surgical replacement of the hip joint with artificial prosthesis
135
Indications for total hip replacement
Indicated for OA, acetabular dysplasia, RA, AVN, traumatic injury (fracture)
136
Post-op hip precautions
elective will be weight bearing as tolerated.
Don't bend past 90 degrees: raise toilet seat, pillows in chairs
No crossing legs when sitting
no internal rotating
137
Post-op knee replacements
Surgical replacement of the knee joint with artificial prosthesis
Indicated for pt. with severe pain and functional disabilities such as arthritis
138
Preop assessment for total joint replacements
respiratory, renal, history of DVT or increase risks: pts with varicose veins, neurovascular status
139
Pre-op interventions for total joint replacements
Cleanse skin before surgery to prevent infection
IV antibiotic right before surgery. At least two more doses post operatively.
Educate about mobility: educate them many times esp. before surgery before sedation or anesthesia
140
Positioning for total joint replacements
hip replacements: no bending past 90 degrees, don’t internally rotate, don't cross midline
Knee replacement: no pillows under the knee.
Continuous passive motion device: some patients will have these while in bed. It extends and bends the knee for them while they are laying down.
141
Preventing infections in total joint replacements
Pre-op assessment for infections
Pre-op skin prep
Prophylactic antibiotics: once before and at least twice after
142
Intraoperative management for total joint replacements
Blood loss management
- Reinfusion devices
- Monitor EBL closely: estimated blood loss
Adherence to sterile procedures
-Prevent infection
Culture of joint during surgery
-May be helpful in identifying subsequent infections
143
Postoperative management for total joint replacements: repositioning
no pillows under knee if total knee replacement. If they want it elevated, slant the bed up. Teach about flexion and extension exercises. Teach about transferring
144
Postoperative management for total joint replacements: promoting ambulation
Get out of bed as soon as possible. Even just stand the day of surgery to know what it feels like to walk or stand with their new knee.
145
Postoperative management for total joint replacements: monitoring for complications/preventing DVT
DVT is a big complication (SED, Ted hose, foot flexion and extension) monitor drainage from surgical site, pressure ulcer precautions (especially on their heels), a vascular necrosis, heterotrophic _________
146
Postoperative management for total joint replacements: Monitoring Wound Drainage
we expect 200-500 mls of blood drainage in the first 24 hours. By 48 hours, that number significantly decreases. 50 Mls every 8 hours or less. More than that and you should tell the physician.
147
Postoperative management for total joint replacements: preventing infection
dressing changes, signs and symptoms of an infection. Home health may include physical therapy with a nurse who can change a dressing. The ones with total hip surgery are the ones who really need the extra help with dressing changes. Post op infection can occur 4-24 months after surgery.
148
Patients with a cast: quad setting exercises
position patient supine with leg extended. Instruct patient to push knee back onto the mattress by contracting the anterior thigh muscles. Encourage pt to hold the position for 5-10 seconds then relax. Repeat 10x
149
Patients with a cast: gluteal setting exercises
Position the patient supine with legs extended, if possible. Instruct the patient to contract the muscles of the buttocks. Encourage the patient to hold the contraction for 5-10 seconds then let them relax. Repeat 10x
150
Monitoring & Managing Potential Complications in patients with casts
- Compartment syndrome
- Pressure ulcers: pain and tightness in the affected area. Warmth over the area. Drainage might occur.
treatment: cut a window from the cast to release pressure
- Disuse syndrome: when muscles are left inactive for a long period of time. Strengthening exercises of flexion and resistance
151
Patient teaching about casts from book
Cast care:
- move about as normal
- Use a sling if it's on an upper extremity
- Perform Rx exercises regularly
- Don't attempt to scratch the skin under the cast
- cushion he rough edges of the cast with tape
- Keep the cast dry, but don't cover it with plastic or rubber because it causes condensation
- report persistant pain, swellng that doesn't respond to elevation, changes in sensation, decreased ability to move exposed fingers or toes, changes in cap refill, skin color, and temperature.
- note odors around the cast, stained areas, warm spots, and pressure areas
- don't try to fix a broken cast yourself
152
Cast materials
Fiberglass: lighter weight and water resistant
Plaster: can't get this wet
153
Heterotropic Ossification
Abnormal formation of bone in response to trauma
Will resolve over time, but it might have to be excised
Management:
- Early mobilization
- NSAIDs
154
Internal Fixation Devices
Pain and decreased function indicate problem
Problems include mechanical failure, material failure (device ends up getting recalled then needs to be replaced), corrosion, allergic response to the metal of the implant
155
External Fixation Devices : considerations
Infection
- purulent drainage
- redness and warmth
- increased pain
Pin care
-to prevent infection. There will be physicians orders on it
156
Avascular Necrosis (AVN)
Occurs when bone loses blood supply
Common in femoral neck fractures and dislocation
Bone may collapse or reabsorb
Management:
Attempts to revitalize bone with bone grafts
Prosthetic replacement
Arthrodesis (joint fusion)
157
Disseminated Intravascular Coagulation (DIC)
Systemic disorder resulting in widespread hemorrhage
Manifestations:
- Unexpected bleeding after surgery particularly bleeding from mucus membranes, IV sites, GI tract
- Bleeding from mucous membranes, venipuncture sites and GI and urinary tracts
158
Management of DIC
Treatment discussed in Chapter 20
Watch for early signs of bleeding
Notify provider immediately
159
Venous Thromboembolism risk factors
Include Deep Vein Thrombosis and Pulmonary embolism
Risk factors
Bedrest/immobilization
Fractures of lower extremities or pelvis
160
Manifestations of thromboembolism
Vary with size and location of emboli
Most frequent are: sudden shortness of breath, restlessness, increased Respirations, tachycardia, chest pain, low grade fever in PE
Swelling, warmth, and pain in the affected extremity in a DVT
161
Management of thromboembolism
Preventions:
-foot flexion and extension
-Lovenox (don't massage after administration, change sites, watch for signs of bleeding) or warfarin
compression devices (Ted hose, SEDs)
-Encourage them to get out of bed as much as possible and as soon as possible
-Incentive spirometer (10 times every hour)
Educate about not ambulating
162
Delayed union
Prolonged healing of fracture
| usually in patients who smoke, have diabetes, or take long term corticosteroids
163
Malunion
Flawed allignment/union of fractured bone
| Pt might have persistent pain at the fracture site with decreased ROM
164
Nonunion
Failure of fractured bone to unite in normal alignment
Nurse and physician can recognize discomfort/pain might be pointing to this or malunion (pain would be relieved with something, otherwise its compartment syndrome)
165
Treatment for nonunion
internal fixations with plates and pins and screws
bone grafts
electrical bone stimulation to help stimulate the bone to grow
Go back to being immobilized and non weight bearing to facilitate bone healing
166
Management of delayed union, malunion, or nonunion
- Avoid things that delay healing like NSAIDS, smoking, corticosteroids
- Assess risk factors for delayed healing
- Internal fixation, bone grafting, electrical bone stimulation, immobilization, non-weight bearing exericses
167
Management/prevention of fat embolism syndrome
- The sooner we recognize it, the better
- Immobilization
- early surgical fixation with minimal manipulation
- Adequate support during turning/positioning
- Maintenance of fluid and electrolyte balance
- *****Prompt respiratory support *priority measure. In acute respiratory distress, you administer O2 then call physician. Continuously monitor O2 saturation.
- Oxygen therapy, mechanical ventilation,
- IV corticosteroids for inflammation, vasopressor medications IV for prevention and treatment of shock and hypotension
- Fluid replacement therapy
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Manifestations of a fat embolism
Change in behavior (disoriented and restless), disorientation, respiratory compromise are presenting features (tachypnia, hypoxia)
Hypoxia, axillary, subconjunctival or anterior chest wall petechiae, tachypnea, tachycardia and fever (> 39.5)
FIRST would be change of behavior and change in respiraty status
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Fat embolism syndrome
Often in pts with pelvic, long bone, or particularly traumatic fractures
Fat globules released when bone fractures and act like a clot
Occlude small blood vessels
Rapid onset
24-72 hrs. after injury
170
Risk factors for fat embolism
Trauma, fracture of long bones or pelvic bones
Multiple fractures
Crush injuries
Young adults 20-30 years & elderly over 65 (usually result of a hip fracture)
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Complications of Fractures
- Fat embolism syndrome
- Delayed union, malunion, & nonunion
- Venous thromboemboli
- Disseminated intravascular coagulation (DIC)
- Avascular necrosis (AVN)
- Reaction to devices
- Heterotropic ossification
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Nursing Management of the Patient with a Fracture: varies with type of fracture
varies with type of fracture
| presence of infection
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Relieving pain from a fracture
- analgesics-opioids
- Cold or ice packs to the site
- sometimes muscle relaxants
- If pain doesn't get better with meds=compartment syndrome
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Improving mobility after fracture
might take several months to regain function and mobiliity
That limb may atrophy
Do full range of motion exercises to regain function. We want to facilitate them to do as much as they can while maintaining non weight bearing orders.
Focus on early mobility to ward off DVT
flexion and extension exercises every hour. Compression machines are ok, but they still need to do flexion and extension
175
Evaluating neurovascular status after a fracture
assess every hour for 8-12 hours or 24 hours if there's a great need.. Assess every 4 hours after that.
176
Maintaining and Restoring Function after fracture
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exercises with PT or rehab. Most are strengthening exercises.
Transferring exercises (bed to chair) especially if they have orders for no weight bearing
Don't rush into weight bearing. Follow physicians orders re weight bearing status.
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Open fractures considerations
Open fractures have a very high risk of osteomyelitis. Prompt cleaning and infection prevention. Usually done in OR under anesthesia.
Fixation with internal (screws and rods inside) or external fixation devices (screws and rods on the outside. Pin care is the care for where the screws go into the skin.) All open fractures are considered contaminated.
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Treatment of contamination for open fractures
broad spectrum, systemic antibiotic started within 3 hours of injury
if infection starts, culture it and adjust antibiotics appropriately
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Goals in managing a patient with open fractures
prevent infection
- follow strict orders for dressing changes using sterile techniques (aseptic later down the road)
- If the wound has to remain open, you'll have a wound care consult for a wound vac. Once risk is gone, close the wound
educate the family on what to watch for
- purulent drainage
- redness and increased temp
- report any of these signs to the physician immediately
180
Wound debridement
Remove foreign bodies, debris, & bacteria
181
Infection prevention in open fractures
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Sterile dressing changes
Antibiotics
Wound debridement
Monitor temperature
Report s/s of infection promptly
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Closed reduction
Closed reduction: mostly done without anesthesia
Accomplished through manipulation & manual traction
Cast or splint applied
Anesthesia with percutaneous pinning
Might be done without surgery
Retraction: skeletal (pins go into the bone) or skin (weights placed on a boot to realign hip fractures)
After closed reduction, you get an immobilizing device
Lots of xrays used. Series of xrays to make sure reduction was successful
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Open reduction
ORIF (open reduction internal fixation) surgical procedure to surgically allign the fracture fragments using plates and rods to help maintain alignment of the bone. Depends on the severity of the fracture to determine how much hardware is used.
Surgical intervention to align bone fragments
Placement of internal fixation devices (pins, wires, screws,
plates, nails, or rods)
Educate that these hardware are not designed to carry full body weight.
Bone graft: from patient or cadaver
Done when there's an open fracture (when the bone comes through the skin)
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Neurovascular Status
| 5 P’s
Warning signs that something is wrong with perfusion
pain
poikilothermia- cold limb
pallor-paleness
parethesia- numbness to burning/pain/itching/tingling
pulselessness or weak pulse with delayed cap refill
If they have all 5 Ps, it might be too late to save that limb
185
Blood Loss r/t fractures
Large amount of blood may be lost d/t trauma to the surrounding tissue. There are arteries around bones.
Femur fracture 1000-1500 mls-risk of hypovolemic shock
186
Hypovolemic Shock manifestations
Thirst, anxiety & restlessness, elevated HR, weak pulse, decreased BP (Box 42-2) decreased LOC, anxiety and restlessness, decreased urine output (regular is 30 mls)
187
Nursing considerations for shock:
slow the blood loss if you can
monitor closely
get to help as soon as possible
188
Clinical manifestations of fractures
- pain
- loss of function
- shortening and deformity
- crepitus: Grating sensation on palpation
- swelling
- discoloration: ecchymosis
189
pain r/t fractures
Immediate, continuous, increasing severity the longer they go without immobilization and treatment
initial 20 minutes after the fracture, there might be no pain.
spasms usually accompany a fracture
Might have crepitus, swelling, discoloration around the site
shortening and deformity in the affected bone (internal rotation in a hip)
sometimes the deformity is visible, sometimes only palpable
190
Contusions
Soft tissue injury caused by blunt force-falling, kicking, hitting something
Hematoma
191
Strain
“pulled muscle”
Injury to muscle/tendon unit
Caused by repetitive movements, stress, new exercise regiment
192
Sprain
Injury to ligaments and supporting muscle fibers
| Ligaments connect muscle to bone
193
Dislocation
Articular surfaces no longer in alignment
| Avascular necrosis
194
Nursing Interventions for musculoskeletal trauma
resting and elevating the extremity, ice, compression, assess neurovascular function
195
immobilization after musculoskeletal trauma
Until definite diagnosis is determined
Rediction of dislocation=putting the thing back in place. Pt will receive some pain medication and muscle relaxants
respiratory status
fall risk
About a week after reduction: ROM exercises will begin with a PT, adhering to exercises
196
RICE for musculoskeletal trauma
Rest
Ice
Compression
Elevation
197
Chronic illness
medical illnesses or health problems with associated symptoms or disabilities that require long-term management (3 months or longer). Disease with a nonreversible pathology. Could be a gradual onset, or acute. Pts are individual and progress goes at their own rate. Unlikelihood of cure and require long term surveillance, maintenance, and might lead to disability.
198
Prevalence & Causes of Chronic Illnesses
| Lifestyle factors:
Obesity
Chronic stress & sedentary lifestyle
Smoking, excessive drinking, & poor nutrition
Longer lifespan
199
Causes for increased chronic illness:
people are living longer
Better advances in technology, nutrition, pharmacology, safer working conditions, and greater access to healthcare
Improved screening and diagnostic procedures
start treatment earlier, so disease progresses slower
200
Characteristics of Chronic Illnesses in the acute setting
chances are you won't be addressing the chronic illness directly. This means it must be integrated into the care of the acute disease process.
201
Characteristics of chronic illness
Chronic illnesses impact the social and psychological aspects of life in the patient and family. Altars body image and self esteem.
202
Phases of Chronic illness
- Acute
- Stable
- Unstable
- Remission
- Exacerbation
Pts can travel through these phases in any order. See table in book that includes nursing implications for each phase.
203
Comorbidities
Potential for development of other chronic disease
| Diabetes leads to neurovascular changes or kidney disease
204
Trajectory Model of Chronic Illness
```
Pretragectory
Trajectory onset
Stable
Unstable
Acute
Crisis
Comeback
Downward
Dying
```
205
Pre-trajectory phase of chronic illness
Lifestyle risk factors habits that place the person at risk for a chronic disease (genetic predisposition, cardiac disease risk factors)
206
Trajectory onset of chronic illness
appearance of manifestations. Onset of disease. Time of diagnostic work up.
207
stable phase of chronic illness
When the illness course and symptoms are under control. Everyday life activities can be completed in light of the illness. Family and caregiver are "humming along smoothly"
208
Unstable phase of chronic illness
development of complication or exacerbation of symptoms
|
209
Acute phase of chronic illness
severe presentation of symptoms. May enter hospitalization, may be put on bedrest, disruption of daily life
210
Crisis phase of chronic illness
critical or life threatening situation that requires emergency intervention
211
Comeback of chronic illness
gradual return to the way of life prior to complication, may have new things to adapt to after last complication
212
Downward phase of chronic illness
rapid or gradual decline of a condition.Physical decline with disability results in worsening of management of everyday life.
213
Dying phase of chronic illness
X P
214
Chronic Illness & Nursing Practice
| Direct Care
Physical, clinic, hospital
Patient’s home
Depends on status of illness. Could be home care, wound care, education
215
Chronic Illness & Nursing Practice
| Supportive Care
Monitoring & education
Counseling,
advocacy for the patient and the family, especially for primary care giver
make sure their needs are met
referring to case management, support groups
Referral or case management
Ongoing monitoring/counseling about stages
216
Chronic Illness & Nursing Practice
| Holistic Care
Mind, body and soul
Make sure you aren't treating them as just the illness they came it with. Make sure you are caring for their entire beings.
217
Chronic illness and nursing practice
| Acceptance
Accept negative personal choices (i.e. smoking, drinking, poor diet, no exercise)
non judgemental communication
be accepting of how they choose to deal with their diagnosis
218
Communication toward patients with chronic illness
Inform the patient and family in layman's terms with supportive team: case workers, chaplains, etc. Goal is to let them know there is support around them.
Best time to talk- let the family guide this. Sometimes it's not the best time for you.
Presence- active listening. You may be super busy, but it is important to slow down and let them talk to you.
Safe setting with no inturruptions
Allow pt. and family to set agenda-allow them to determine the duration, ask questions, and where the conversation leads.
219
Hospice Care
Patient’s illness is deemed life-limiting
PCP states that death is expected in 6 months:
---usually a requirement for insurance
A service that is team centered:
-Focus on dying person’s needs (i.e. physical, psychological, social, spiritual) Preparation.
Keep them as pain and symptom free as possible
With insurance, there are specific regulations that are required in order to approve hospice care.
Usually done in the home, but sometimes it doesn't work out.
220
Medicare vs Medicaid hospice:
physician determination that death is within 6 months
| diagnosis of terminal illness
221
Palliative Care
- Provide relief from pain & other symptoms
- Can be applicable early in an illness
- Does not need physician's word saying they will die within 6 months
- Affirms life and regards dying as a natural process
- Neither hastens nor postpones death of patient
- Sometimes is done a little late because of projection of feelings onto a situation
- be the patient's advocate to get them a palliative care counsel
- Rely heavily on advance directives and offer supportive care.
- Integrates psychological & spiritual aspects of care
- Provides support for patient & family
- Team approach to address needs
- Influences QOL & may positively influence illness trajectory
- Applicable early in course of illness, in conjunction with other therapies
222
People with terminal illnesses need these three things
know what's happening to them and be able to talk about the reality of it with someone who will listen
allowed to experience the pain of feeling bad
be able to participate in the plans for how they will spend their final days
223
Predeath period
|
Primary responsibility of the nurse is to establish a relationship with the dying person
gain trust
help them come up with a plan to meet their goals
224
Death event
Anticipate problems such as distressing symptoms
| Be present when patient dies if possible. Can be hard if the person wants to be alone when they pass.
225
Bereavement
|
Time after death
Help family to relive the death event
Support family
226
Methods of Stating End-of-Life Preferences
- advance directives
- Durable power of attorney
- living will
227
advance directives
Written documents, individual of sound mind
Document preferences regarding EOL care to be followed when individual cannot communicate their wishes
Always get a copy and document it
make sure everyone knows about it (physicians, etc)
Advocate for this
228
living will
Individual documents treatment preferences
| Provides instructions for care when individual cannot communicate wishes
229
Durable power of attorney
Legal document
| Signer appoints another to make medical decisions on his/her behalf
230
Nursing Tasks at End-of-Life
Pain & symptom management
Communicate effectively with dying patients and their families
Educate patients and families about EOL decision making: we can usually prevent a situation of fighting from happening, but education will hopefully diminish the risk of there being conflict. Assess the feelings of the family members so you can address things directly.
Help other professional caregivers develop plan of care that coheres with the wishes of patients and families
Provide care to patients who are close to death
Are present at the time of death
After death, attend to families’ loss, grief, and bereavement
Achieve quality of life care at the end of life by providing culturally sensitive care during entire hospice-care experience
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Loss, Grief, & Bereavement
|
Loss: losing a loved one
Grief: personal feelings that accompany an anticipated or actual loss
Stage of grief (Kubler-Ross)
Mourning: individual, family, group & cultural expressions of grief and associated behaviors
Bereavement: period of time in which mourning takes place
Professional caregivers are not immune to grief!
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Stages of Grief
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Denial
Sadness
Anger
Bargaining
Fear
Acceptance
```
233
Type of sinoarthosis joint
skull
234
Type of amphiarthosis joint
vertabral joints
235
Types of diarthosis joints
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Ball and socket (hip and shoulder)
Hinge (elbow and knee)
Saddle (thumb)
Pivot (radius and ulna)
Gliding (wrist)
```
