Musculoskeletal Flashcards
(150 cards)
1
Q
Osteoblast
A
Function in bone formation, and it contains collagen and living cells
2
Q
Osteocytes
A
Mature bone cells that function in bone maintenance
Located in the lacunae
3
Q
Osteoclast
A
Function in destroying, demineralizing, and remodeling bone
Located in Howship lacunae (In bone, osteoclasts found in pits in the bone surface which are called resorption bays, or Howship’s lacunae).
4
Q
List the Primary risks on Osteoporosis
A
1. Genetics: • Age (older than 50 and postmenopausal) • Gender (females greater than males) • Race (Caucasian or Asian) • Family history • Smaller body frame (< 58 kg) 2. Nutrition (Modifiable) • Low calcium intake • Low vitamin D intake • High potassium intake • Inadequate calories 3. Lifestyle (Modifiable) • Sedentary lifestyle • Cigarette smoking • Excessive alcohol consumption (more than three glasses per day)
5
Q
List the Secondary Risk factors on Osteoporosis
A
1. Medications • Corticosteroid therapy for more than 3 months • Anticonvulsants • Heparin therapy • Thyroid hormones 2. Disease pathology • Cushing’s disease • Hypogonadism or premature menopause • Malabsorptive issues (Crohn’s, celiac disease, gastric surgery, etc.) • Chronic liver disease • Inflammatory bowel disease • Rheumatoid arthritis • Hyperthyroidism • Hyperparathyroidism • Previous fracture 3. Other • Parental history of hip fracture • Recurrent falls • Prolonged immobilization
6
Q
Sesamoid bones
A
patella or “knee cap”
7
Q
Joints
A
Non-synovial joints and Synovial joints
8
Q
What is bone resorption?
A
Same thing as Osteoclastic activity
9
Q
Osteogenesis
A
Process of short and long bone formation. Cartilage is present during process.
- Bone in constant state of turnover.
- Bone remodeling throughout lifespan.
- Role of menopause, loss of estrogen and race.
10
Q
Ossification
A
Process of formation of bone matrix/mineral deposition.
11
Q
Hormonal influences in bone formation and maintenance.
A
- )Estrogen.
- )Thyroid-stimulating hormone and calcitonin.
- )Parathyroid hormone.
- )Growth hormones.
- )Calcium
12
Q
What are the changes in aging bones and Muscles ?
A
- Changes in bone density, posture & gait occur over time.
- After age 30, bone density diminishes.
- Menopause accelerates bone density loss in women.
- With age, joints become stiffer.
- Joint calcification occurs.
- Dowager’s hump.
- Sarcopenia – Loss of skeletal muscle.
13
Q
What is Osteopenia?
A
Bone Loss
14
Q
What is the normal Standard Deviation on a BMD measurement?
A
Normal: 1 SD
Osteoporosis: 2.5 SD
Osteopenia: 1-2.5 SD
15
Q
How can a patient prevent Osteoporosis?
A
- Balanced diet high in calcium and vitamin D throughout life
- Use of calcium supplements
- Regular weight-bearing
- Weight training stimulates bone mineral density (BMD)
- Healthy lifestyle includes avoidance of smoking/excessive alcohol intake
16
Q
List the pharmacological Interventions to treat osteoporosis.
A
- Calcium 1,200mg/day and vitamin D 800-1,000 IU
- Bisphosphonates (Prevent Loss of bone density): Must be taken on empty stomach and sit upright for at least 30 mins and never give in conjunction with calcium
- Calcitonin: To decrease osteoclastic activity
- Estrogen agonist/anatgonist
- Parathyroid hormone
- Teriparatide
17
Q
What are some complications of Osteoporosis?
A
Risk for falls, which incurs a greater risk for fractures, specifically vertebral compression fractures and hip fractures.
18
Q
List the findings you will see while doing an assessment on a patient with Osteoporosis.
A
- “Dowager’s hump” (kyphosis of the dorsal spine)
- Loss of height (loss as great as 2 to 3 in. [5–7.5 cm])
- Back pain (sharp or acute)
- Pain increased with activity and relieved with rest
- Restriction of movement, especially in the thoracic and lumbar regions
- Fear of falling (known as “fallophobia”) and/or history of previous falls
- Previous fractures
- constipation, abdominal distention, and reflux esophagitis
- potential respiratory complications are due to curvature of the spinal column and decreased chest excursion.
19
Q
What would you assess for a patient with Osteoporosis?
A
- Fall Risk
- Pain: pain decreases mobility and optimal functioning.
- Nutritional status : Adequate ingestion of protein, magnesium, vitamin K, calcium, vitamin D, and trace elements essential for bone formation/remodeling
- Assess level of activity/exercise
- Body image disturbance
20
Q
As a nurse, what would you do/implement to treat someone with Osteoporosis?
A
- Administer Meds (Bisphosphonates & Vitamins), Give Calcitonin, Estrogen therapy, Parathyroid hormone.
- Dual-Acting bone agent: Decreases osteoclastic activity
- Monoclonal activity - Inhibits osteoclastic function
- Support exercise program/Implement
- Provide training for safe movement with activities of daily living
- Contact home health agency for a home environmental safety
21
Q
What is osteocytes ?
A
Mature bone cells that function in bone maintenance
Located in the lacunae
22
Q
What is osteoclast ?
A
Function in destroying, demineralizing, and remodeling bone
Located in Howship lacunae (In bone, osteoclasts found in pits in the bone surface which are called resorption bays, or Howship’s lacunae).
23
Q
Flat bones
A
protective bones of the chest and sternum.
24
Q
Irregular bones
A
vertebral body
25
sesamoid bones
patella or "knee cap"
26
joints
Non-synovial joints and Synovial joints
27
Type of muscles
Three types of muscles (skeletal muscle, smooth muscle, and cardiac muscle)
28
Osteogenesis
Process of bone formation
29
Ossification
Process of formation of bone matrix/mineral deposition.
- Bone in constant state of turnover.
- Bone remodeling throughout lifespan.
- Role of menopause, loss of estrogen and race.
30
Aging bones and Muscles
Changes in bone density, posture & gait occur over time
After age 30, bone density diminishes
Menopause accelerates bone density loss in women
With age, joints become stiffer
Joint calcification occurs
Dowager’s hump
Sarcopenia – Loss of skeletal muscle
31
Sarcopenia
Gradual muscle loss after the 4th decade of life (>30 years old).
- Loss through inactivity comprises 1 % per year,in males after the age of 50.
- Loss of muscle mass is permanent affecting ADls and bone mass later in life.
- Loss of muscle protein will affect the immune system as well as affect insulin absorption; increasing the risk for type 2 diabetes.
- Metabolic syndrome may be ameliorated (improved) through the maintenance of muscle mass through life.
32
Physical assessment for the musculoskeletal function includes assessment of which of the following ?
A-) ROM, posture and symmetry.
33
A client arrives to the emergency room with a suspected orthopedic injury. Which question should the nurse ask?
B-) Describe the location and quality of the pain.
34
Musculoskeletal overview.
Musculoskeletal conditions and injuries are not conditions of older age but relevant across life span.
- 60% and 77% of unintentional injuries reported United States due to musculoskeletal trauma.
- About 27 million musculoskeletal injuries occur annually in the United States with strains, sprains, and most prevalent is fractures.
- These injuries effects patients’ mobility, sensation etc.
35
Bone fractures
- Incidence of fractures are on the rise in the U. S. with about six million fractures annually and occur in young/older population with porous and weakness.
- Fragility fractures in older adults result of progressive decrease in bone density/strength, frequently suffer chronic bone disorders that increase risk of pathologic fractures.
36
Examples of Chronic bone disorders.
1. Cushing’s syndrome.
2. Osteoporosis.
3. Osteogenesis imperfecta.
4. Neoplasms.
5. Anorexia. 6.Paget’s disease.
* These diseases significantly weaken bones, decrease load-carrying capacity and tolerance to force, increase the patient’s susceptibility to fractures, and further prolong the healing process.
37
High-energy trauma
Fractures in young people between the ages of 12 and 21 are typically the result of high-energy trauma.
Fractures in people 65 years or older are usually caused by low-energy trauma, for example, fractures from falling
38
Examples of high-energy trauma include:
.Motor vehicle collisions
.Contact sports.
.Bicycle accidents.
39
Bone
Classified as dense, irregular connective tissue made up of osteoblasts and osteocytes.
Provide support/structure, assist body in movement, and protect vital organs.
40
Fracture
A disruption, or break in the continuity of a bone.
| There are numerous classifications of fractures that can occur throughout the body.
41
What is a Complete fracture?
The disruption spans across the width of the bone, causing bone fragments.
- Types:
1. Transverse ( In-place fragments after closed reduction).
2. Oblique(the fracture line occurs usually at 45-degree angle across cortex of the bone
3. Spiral (fracture wraps around shaft of the bone).
4. Impacted (Jammed fragments with indistinct line,Segments of bone are wedged into each other at the fracture line).
5. Comminuted ( Fracture has several disruptions producing shattered bone fragments within fracture site, >2 fragments).
42
What is an Incomplete fracture ?
The disruption occurs through part of the bone cortex; however, there is no displacement of bone fragments.
Types:
1.Greenstick
( Buckled/bent bone, happens in children)
2.Compression( Crumpled cancellous bone, happens in adults).
43
What is a Closed (simple) fracture ?
Fracture that is contained within the skin
44
What is an Open (compound) fracture ?
Disruption in which pieces of bone protrude through the skin, creating an external wound that exposes the fracture site. Open fractures are graded on the basis of their severity.
45
Open wounds Grade I
Presence of a puncture wound, minimal injury to the soft tissues, and vasculature remains intact
46
Open wound Grade II
Puncture wound, fragments of broken bone, moderate skin and muscle contusions, and significant wound contamination
47
Open wound Grade III
Severe damage to soft tissues, nerves, muscles, and blood vessels. The open fracture site is considered extremely contaminated and contains numerous comminuted fractures.
48
What is an Avulsion fracture?
Caused by overstretching/tearing of tendon/ligament, separating small segment of bone at insertion site
49
What is a Compression fracture?
Fracture caused by excessive force along axis of cancellous (spongy internal layer of bone) bone, leads to bone collapsing on itself, in vertebral compression fractures from falls of significant heights
50
What is a depressed fracture ?
Disruptions in which bone fragments are forced inward; in facial/skull fractures of blunt trauma
51
What is a Displaced fracture ?
Malalignment of bone fragments at the fracture site.
52
Clinical Manifestations
1. )Pain:
- Continuous pain and increases in severity until bone fragments are immobilized.
- After a fracture, injured area becomes numb and surrounding muscles flaccid.
- Muscle spasms occur within few to 30 minutes, and result more intense pain than at time of injury.
- Muscle spasms minimize movement and results in further bony fragmentation or malalignment.
```
2.) Loss of function:
After fracture, extremity cannot function due to normal function of muscles depends on integrity of bones they are attached.
Pain contributes to loss of function.
Abnormal movement (false motion) may be present.
```
3. ) Deformity:
- Displacement, angulation, or rotation of fragments fracture of the arm or leg causes deformity that is detectable when the limb is compared with the uninjured extremity.
```
4.) 5Ps:
Pain
Pallor
Pulseless
Paresthesia
Paralysis
```
5. ) Edema
6. ) Ecchymosis ( swelling, purple-blue color.)
7. ) Point tenderness over fracture site.
8. ) Crepitus
9. ) Shortening of extremity.
53
Diagnostic Findings
Diagnosis of fractures based on thorough history of how the injury occurred, a physical assessment, and confirmed by radiography or computed tomography (CT).
During patient’s history is obtained, important to note specific mechanism of force that caused injury.
Other imperative information includes patient’s medical history and any chronic illnesses, medications, and potential substance abuse.
Medications and substance abuse can impair mental judgment and function and contribute to motor vehicle accidents and falls, thus producing bone fractures and other traumatic injuries.
Chronic illness suspected as having major role in injury, a bone scan and MRI may be needed to confirm the diagnosis.
54
Medical Treatment
-Definitive treatment highly dependent on their type and location and may require either surgical or nonsurgical intervention.
Table 54.1 describes various fractures and their treatment.
-Open fractures with contaminated wounds, antibiotics are implemented to prevent osteomyelitis and other wound infections.
-Effective pain management is an important aspect in treating fractures.
-Narcotics and anti-inflammatory medications are effective in controlling pain and inflammation.
-Medications allow patient to gradually regain movement and function of the injured area.
-After definitive treatment, movement and function are key in preventing muscle atrophy and contractures.
55
Emergency Management.
-Immediately after injury, body part is immobilized before patient is moved.
Adequate splinting is essential.
-Joints proximal/distal to fracture must be immobilized to prevent movement of fracture fragments.
-*Immobilization of the long bones of the lower extremities accomplished by bandaging the legs together, with the unaffected extremity serving as a splint for the injured one.
-Upper extremity injury, arm may be bandaged to chest, or an injured forearm may be placed in a sling.
*Assess neurovascular status distal to injury before/after splinting to determine adequacy of peripheral tissue perfusion/nerve function.
*Open fracture wound is covered with sterile dressing to prevent contamination of deeper tissues.
No attempt made to reduce fracture, even if one of the bone fragments is protruding through the wound.
Splints are applied for immobilization.
Clothes are gently removed from uninjured side of body and then from the injured side.
Fractured extremity is moved as little as possible to avoid more damage.
Open fractures with contaminated wounds, antibiotics are implemented to prevent osteomyelitis and other wound infections.
Pain management in important aspect in treating fractures.
Narcotics and anti-inflammatory medications are effective in controlling pain and inflammation.
56
Medical Managment
Reduction:
*Nonsurgical treatment of a fracture or a closed reduction.
Refers to restoration of fracture fragments to anatomic alignment/positioning.
Physician reduces fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage.
Fracture reduction becomes more difficult as injury begins to heal.
Before fracture reduction/immobilization, patient is prepared for procedure; consent for procedure is obtained, and an analgesic agent is given as prescribed.
Anesthesia may be given.
*Surgical repair of fractures includes: Open reduction with Internal fixation or External fixation.
57
*Open Reduction
Surgical repair of fractures includes: Open reduction with Internal fixation or External fixation.
58
*Internal Fixation (surgery)
Requires use of plates, screws, rods, and other hardware to realign fractured bone segments.
Irrigation and debridement might be needed for open fractures contaminated with dirt/foreign matter.
59
*External Fixation (casts)
Application of series of rods/pins to area surrounding fracture, creating an external frame to stabilize/align displaced fragments.
External fixators are frequently used when there is significant soft-tissue damage at fracture site.
60
Nursing Management Preoperative.
Nurse should inform patients of:
.Immobilization
.Assistive devices
.Expected activity limitations after surgery.
61
Nursing Management Postoperative.
.Monitor vital signs
.Apply general principles of nursing care
.Perform frequent neurovascular assessment of affected extremity
.Minimize pain and discomfort through proper alignment and positioning
62
Nursing Assessment for Close Fractures.
Assessed for absence of opening in the skin at fracture site.
63
Nursing Assessment for Open Fractures.
Assessed for risk for osteomyelitis, tetanus, gas gangrene, signs of infection.
64
Assessment and Analysis
```
Swelling
Ecchymosis
Deformity
Hemorrhage
Pain
```
65
Nursing Interventions
Vital signs.
Physical assessment of injury (inspection/palpation).
Palpate injured extremity noting six Ps: pain, pressure, paralysis, pallor, paresthesia, and pulselessness.
Complete neurovascular assessment - checking movement/sensation.
Verify proper positioning, application, and stability of traction/splinting/immobilization devices.
Laboratory tests (myoglobin, Creatine phosphokinase (CPK), Complete blood count (CBC), metabolic profile, and renal studies)
Urine appearance
Intake and output
66
Nursing Actions
Maintain pulmonary hygiene (Incentive spirometry exercises/coughing/deep breathing expands alveoli, helping maintain adequate alveolar gas exchange)
Administer analgesia/antibiotics/anticoagulants as ordered.
Wound/Pin care and Elevation.
Apply ice and Repositioning.
Range-of-motion exercises and ambulation using available assistive devices.
Provide hydration and nutrition
Positive feedback and encouragement
67
Nursing Teaching
Treatment process and treatments.
Overview of healing process.
Consume adequate calories and vitamins to promote healing.
Appropriate use of analgesia.
Wound care via aseptic technique.
Exercise and ambulation using assistive devices.
Proper use of slings, splints, casts, and traction devices.
*Self-care activities
Free from infection
Uses analgesic intervention as prescribed.
Exhibit no neurovascular compromise (compartment syndrome or VTE).
Complies/actively participates in nutrition, activity, and exercise protocols.
Maintains stable vital signs, intake and output, and perfusion.
68
Early complications of Fractures
```
Unstable reduction.
Medial or ulnar nerve stretched.
Shock.
Fat embolism.
Deep vein thrombosis.
Disseminated intravascular coagulopathy.
Infection.
Septicemia.
Post reduction swelling.
Anesthesia problems.
Injury to proximal segment of bone during reduction
```
69
Late complications of fractures
```
Malunion
Compartment syndrome.
Rupture of extensor pollicis tendon.
Frozen shoulder.
Carpel tunnel syndrome.
Nonunion.
Sudeck's osteodystrophy
```
70
* Neurovascular compromise
- Complication due to any source of decreased blood flow and oxygenation to the tissues.
One cause is severing of blood vessels/nerves surrounding bone by sharp bone fragments from a fracture.
Use of traction and immediate fracture reduction is vital in preventing further damage to the neuro-vasculature.
71
*Joint dislocation
Displaced bones compress nerves/vessels cause of neurovascular compromise.
Joint should be realigned as soon as possible.
72
*Other possible sources of edema
Iclude hemorrhage from initial injury, burns, venous thrombosis, and excessive exercise.
Increased swelling compresses the blood vessels, restricting blood flow and oxygenation of the muscles and nerves, leading to tissue hypoxia.
Resulting effect of neurovascular compression can progress to permanent damage/eventual loss of the extremity.
73
*Compartment syndrome -
Rare but serious complication which, when undetected, can cause permanent loss of affected limb due to neurovascular compromise caused by increased pressure in the extremity.
Occurs with increased edema/hemorrhage within compartment space under the fascia.
Can be caused by extended compression from casts and splints.
Most common symptoms are the “six Ps”:
*Passive Pain at rest, with Pressure, Paresthesia, Pallor, Paralysis, and Pulselessness.
Six Ps of compartment syndrome, pallor, paralysis, and pulselessness *considered to be late findings.
Once compartment syndrome is suspected, nurse should immediately notify provider to relieve pressure on the extremity If caused by pressure from a cast, the provider will remove the cast immediately.
Immediate fasciotomy is indicated in the case of internal pressure from edema.
*Fasciotomy - procedure where the surgeon makes incisions on both medial and lateral aspects of the extremity down through the fascia, relieving the compartment pressure.
74
*Venous Thromboembolism (VTE) -
- Develop in large vessels of the extremities, caused by extended periods of immobility, traumatic injuries, cardiac disease, long surgeries, obesity, smoking, and use of oral contraceptives.
Clots can develop in large vessels, hinder circulation/break apart, and travel to pulmonary arteries and become pulmonary emboli.
*Pulmonary emboli clog pulmonary vasculature hindering gas exchange, impairing oxygenation, and potentially leading to respiratory failure and patient death.
*Patients experience pulmonary embolism exhibit dyspnea, tachycardia, abnormal breath sounds, pleuritic chest pain, cyanosis, anxiety, and altered mentation.
75
*Fat Embolism Syndrome -
- Rare complication after orthopedic injury and surgery.
Frequently manifest in long bone fractures where particles of the exposed fatty bone marrow have migrated into the systemic circulation.
Particles mobilize throughout the body and clog smaller blood vessels, producing generalized petechiae: small or pinpoint round spots that appear red or purple on the skin.
Like VTE, fat emboli can travel/lodge in the pulmonary artery and become pulmonary emboli.
As a result, patients experience symptoms of respiratory distress, acute confusion, and restlessness potentially leading to respiratory failure and patient death.
76
*Traumatic rhabdomyolysis -
Result from injuries of compression and tissue ischemia, such as crush injuries.
Crush injuries produce continued compression of muscle tissue that restricts blood flow and precipitates tissue ischemia.
Tissue ischemia catalyzes vicious cycle of inflammation, increased capillary permeability, release of more fluid/intracellular contents into the compartment and circulatory system.
*Myoglobin is an intracellular oxygen-binding protein found in skeletal muscle that pills out dead muscle cells. In the circulatory system, myoglobin travels to the kidneys and lodge in the nephrons.
Kidneys are unable to effectively filter the proteins and cause acute tubular necrosis and renal failure.
*Symptoms of rhabdomyolysis include severe flank plan and dark tea-colored urine.
Patients who have experienced crush injuries must have regular monitoring of serum myoglobin/renal function levels.
If rhabdomyolysis is present, fluid resuscitation is indicated to help “flush” myoglobin through the kidney.
*Rhabdomyolysis - complicated by multiple electrolyte disorders including hyperkalemia, hypophosphatemia, and hypo/hypercalcemia.
77
Rhabdomyolysis
Symptoms: Pain, weakness, swelling, tenderness, possible kidney failure.
Types: Exertion, Crush Syndrome, Blood supply, Metabolism, Body temperature, Infection.
Treatments: IV fluids, Urinary alkalizations, and blood transfusion.
Prevention: Minimize chances of traumatic injuries, keep workout levels moderate, do ot over do it.
78
*Malunion
Complication that occurs when fractures fail to heal in the correct anatomical alignment.
Result from inadequate fracture reduction/immobilization, misalignment during fracture reduction, or premature removal of splints and casts.
79
*Nonunion
Rfers to fracture that failed to heal.
* Septic nonunion is precipitated by infection
* Aseptic nonunion due to older age, anemia, tobacco/nicotine, diabetes, and medications that suppress healing such as NSAIDs, steroids, and aspirin.
80
*Surgical treatment of malunion/nonunion
- bone grafting (from patient or by using cadaver and donor bone) and/or application of bone growth stimulators.
81
*Infection
All open fractures are deemed contaminated and can cause a bone infection called *osteomyelitis.
If undetected, bacterial infections can develop into gas gangrene/tetanus.
Other potential sources of infection are external fixators, internal hardware from surgical repair, and hospital-acquired nosocomial infections.
Patients with wound/bone infection can exhibit delayed wound healing, purulent drainage, erythema, fever, and elevated white blood cell counts.
Infection can be prevented through strict aseptic wound care and frequent assessments.
82
*Hypovolemia
- Due to loss of blood may occur with fracture.
Blood loss from open
Internal hemorrhage from closed fractures must be rapidly assessed and treated.
Presence of large hematomas at site of injury can signify internal bleeding.
Close monitoring of vital signs is essential.
Pelvis is highly vascular and potential fracture site where patients can quickly hemorrhage/decompensate into hypovolemic shock.
83
What is Osteomyelitis and what does it lead to?
Infection of the bone
| Leads to inflammation, necrosis and new bone formation
84
What are the 2 ways one can acquire Osteomyelitis?
1.Exogenous- Direct bone contamination
2.Endogenous- Bloodborne spread from another site of infection or extension of soft tissue infection
Typically occurs in area of bone that is traumatized or has lowered resistance
85
Name the causative organism for Osteomyelitis.
Methicillin-resistant Staphylococcus aureus...More than 50% caused by Staph aureus
Other: Proteus and Pseudomonas spp., Escherichia coli
86
Hip Fractures Diagnosis.
```
Examination:
-Undisplaced fracture
.limited findings
.painful range of motion
of the hip.
```
```
-Displaced femoral neck fractures
.the affected leg is typic
ally shortened and
externally rotated.
.All motions of the hip
are painful.
```
87
Risk Factors for Hip Fractures.
```
Old age.
Female.
History of Osteoporosis.
Low Estrogen levels.
TIA's, anemia, medications and Cardiovascular Diseases that can put the patient at risk for falls.
```
88
Nursing Priorities for Hip Fractures.
```
Hydration.
Respiratory support.
Circulation checks.
Pain control.
Prevention of immobility
complications.
History of Chronic conditions and Medications.
```
89
Explain the pathophisiology of Osteomyelitis.
-Pathophysiology for acute/chronic osteomyelitis is complex and NOT CLEARLY understood;
-Both acute/chronic osteomyelitis, process begins with an INVASION OF THE BONE and surrounding tissue by one or multiple BACTERIAL PATHOGENS,
-Leads to INFLAMMATION/an increase in vascularity to the region that ultimately RESUTS IN EDEMA.
Within days to weeks, a THROMBUS occurs in the vessel, which LEADS TO ISCHEMIA and SLOW NECROSIS of the affected area and bone.
-Once necrotic bone is present, healing is delayed, a superimposed infection/abscess is highly probable.
-Results in a cycle of more inflammation and infection.
-Ultimate clinical hallmark is bone necrosis/development of sinus tracts between bone and skin
90
Who's at risk for Osteomyelitis?
1. Poorly nourished
2. Elderly
3. Obese
4. Impaired immune system
5. Chronic illnesses
6. Receiving long-term corticosteroid therapy/immunosuppressive agents
91
Nursing Management.
```
Immediate postoperative care for a patient with a hip fracture similar to other patients undergoing major surgery.
. Attention given to pain
management.
.Prevention of second
ary medical problem.
.Early mobilization of
the patient so that in
dependent functioning
can be restored.
```
First 24 to 48 hours, relief of pain and prevention of complications, and continuous neurovascular assessment.
Nurse encourages deep breathing and dorsiflexion and plantar flexion exercises every 1 to 2 hours.
Thigh-high anti-embolism stockings or pneumatic compression devices are used, and anticoagulants are given as prescribed to prevent the formation of VTE.
Nurse administers prescribed analgesic medications and monitors patient’s hydration, nutritional status, and urine output.
92
What are the clinical manifestations of chronic Osteomyelitis?
Constant bone pain
Swelling
Tenderness & warmth
NON-HEALING ULCER (diff. from acute)
-Infected area becomes warm, painful, swollen, and extremely tender.
-Patient may describe a constant, pulsating pain that intensifies with movement
93
* Nursing Management
-Repositioning Patient:
Most comfortable and safest way to turn the patient is to turn to the uninjured side.
Standard method involves placing a pillow between the patient’s legs to keep the affected leg in an abducted position.
Proper alignment and supported abduction are maintained while turning.
-Promoting Exercise:
Patient encouraged to exercise as much as possible by means of the over-bed trapeze.
Device helps strengthen arms and shoulders in preparation for protected ambulation (toe touch, partial weight bearing).
First postoperative day, patient transfers to chair with assistance and begins assisted ambulation.
Amount of weight bearing permitted depends on stability of the fracture reduction.
Primary provider prescribes degree of weight bearing.
Physical therapists work with the patient on transfers, ambulation, and safe use of assistive devices.
Anticipate discharge to home/extended-care facility with use of assistive devices.
Modifications in the home may be needed (elevated toilet seats and grab bars).
-Neurovascular complications may occur from direct injury or edema in the area that causes compression of nerves and blood vessels.
With hip fracture, bleeding into the tissues and edema are expected.
Monitoring/documenting neurovascular status of affected leg are vital.
-Prevent Venous Thrombus Embolism.
Encourages intake of fluids/ankle/foot exercises.
Anti-embolism stockings, pneumatic compression devices, and prophylactic anticoagulant therapy are indicated and should be prescribed.
Patient/patient’s caregiver should be educated on signs, symptoms, and risks of VTE, and how to administer anticoagulant prophylaxis as prescribed (see Chart 42-4).
Intermittent assessment of patient’s legs for signs of DVT (unilateral calf tenderness, warmth, redness, and swelling).
Assess legs every 4 hours (at least) for signs of DVT
Unilateral calf tenderness, warmth, redness, and swelling.
-Pulmonary complications (e.g., atelectasis, pneumonia) are a threat to older patients undergoing hip surgery.
Coughing and deep-breathing exercises, intermittent changes of position, and use of an incentive spirometer may help prevent respiratory complications.
Pain treated with analgesic agents, typically opioids; otherwise, patient not able to cough, deep breathe, or engage in prescribed activities.
Nurse assesses breath sounds to detect
adventitious or diminished sounds.
-Skin breakdown - seen in older patients with hip fracture.
Patients tend to remain in one position and may develop pressure ulcers.
Proper skin care, especially on the bony prominences, helps to relieve pressure.
High-density foam mattress overlays may provide protection by distributing pressure evenly.
-Loss of bladder control (incontinence/retention) may occur.
Use of an indwelling catheter is avoided due to high risk of urinary tract infection.
If a catheter is inserted at time of surgery, it usually removed on first postoperative day followed by a trial to void
Ensure proper urinary tract function, nurse encourages liberal fluid intake if no pre-existing cardiac disease.
-Watch patient for Severe Pain, Inability to move leg, and shortening and External rotation of the leg.
94
Nursing postoperative care for hip fractures ?
Cough/Deep breath q2h.
Stockings and Compression Devices to decrease DVT, Venous Stasis.
Circulation and Neuro Status checks of affected leg
Pain control.
Mobilize ASAP.
Check under patient for drainage.
95
What are the surgical treatments for Osteomyelitis?
1. Surgical debridement
2. Surgical removal of hardware as needed
3. Surgical amputation
96
List the complications of Osteomyelitis?
1. Sepsis
2. Potential amputations
3. Squamous cell carcinoma
4. Tumors (Fibrosarcoma, Myeloma, Lymphoma, Plasmacytoma, Angiosarcoma)
97
What clinical findings would a nurse assess for with a patient who has osteomyelitis?
- Fever
- Pain
- Irritability, general malaise, lethargy
- Difficulty moving joints near affected area
- Difficulty bearing weight on affected area
- Poor perfusion to area as evidences by venous stasis ulcers
- Stiff back
98
What interventions should a nurse take for a patient with osteomyelitis?
1. ASSESS
- Pain
- Temp, BP, Pulse
- Wound
- Neurovascular status
- Lab studies
- Blood & wound cultures
2. ACTIONS
- Administer IV Antibiotics
- Administer analgesics
- Apply thermal therapy as prescribed
- Apply ROM below affected site
- Assist with ADLs
- Provide nutritional support
- Contact home health agency for IV ABX --infusion
3. TEACH
- Analgesic medication instructions
- ABX (Antibiotics) compliance
- Incorporation of high protein diet for healing..
99
What is Gout?
OVERSECRETION OF URIC ACID or a renal defect resulting in decreased excretion of uric acid, or a combination of both, occurs.
100
Complications of Amputations.
-Hemorrhage in traumatic amputations is caused by the destruction of large blood vessels within the extremity, leading to severe bleeding and consequent hypo perfusion.
Bleeding if not controlled with a pressure dressing/tourniquet, patient further decompensates into hypovolemic shock and death.
-Infection in older patients with peripheral vascular disease undergoing elective amputations with increased risk for developing infections of tissue/bone.
Osteomyelitis - infection of the bone can quickly progress to sepsis in geriatric patients
-Contractures may occur in the residual limb due to loss of bone, nerves, and muscle.
Seen in lower-extremity amputations and manifested by lack of movement/exercise in the residual limb.
Encourage patient to perform active ROM exercises and participate in physical therapy.
-Phantom limb pain common complication of amputations which produces numbness, tingling, sharp burning pain, muscle cramps, feeling extremity is present.
May experience soon after surgery or 2 – 3 months after amputation
Phantom sensations diminish over time.
Keeping patient active helps decrease occurrence of phantom limb pain
Administration of antidepressant/anticonvulsant medications such as gabapentin has demonstrated effectiveness in treating phantom limb pain.
-Neuromas are clumps of nerve axons in the distal end of residual limb that have regenerated after surgical amputation.
Mostly occur in upper-extremity amputations but can develop in any residual limb.
Development of neuromas often inevitable/interferes with proper fit/use of prosthetic devices, frequently requiring additional surgery for removal.
```
Joint contractures.
Hematomas.
Necrosis.
Stump pain.
Hyperesthesia of stump.
Stump edema.
Bone overgrowth.
Causalgia.
```
101
*Nursing Interventions.
Nursing Interventions:
-Assessments
Vital signs
Hypotension/tachycardia may occur secondary to hemorrhage and sepsis.
Increased temperature - indication of infection.
Decreased SpO2 indicates problems with oxygenation.
CBC
Hemorrhage in traumatic amputation causes loss of red blood cells (RBCs), and low hemoglobin and hematocrit.
Pulses, temperature, color, movement, and sensation of affected extremity
Weak pulses, pale color, cool temperature, limited movement/sensation indicate inadequate blood flow/tissue perfusion in affected limb that may indicate potential need for elective amputation.
Pain
Phantom limb pain - common side effect due to remapping of impulses from the amputated extremity to the spinal cord, causing continued pain sensations.
Wound/incision site
Warm, red tissue with purulent drainage is sign of wound infection.
102
*Nursing Actions.
- Insert large bore IV –
Massive blood loss necessitates IV blood and fluid resuscitation.
Transfusion of IV fluids and blood products as ordered
Replace fluid and blood lost in traumatic amputation.
-Administer analgesia as ordered - Improved pain control promotes movement, function, increase ability to participate in rehabilitation.
Alternative pain management techniques - TENS unit or CAM therapies are synergistic in conjunction with analgesic medications.
-Refrain from using a pillow under remaining portion of the lower extremity
Prevents the development of flexion contractures that can occur if a pillow is left under the extremity.
- Application of ice for no longer than 15 to 20 minutes - Promotes vasoconstriction and decreases painful edema.
- Nutrition: maintain adequate intake and output - increased metabolic demands of healing require additional protein and carbohydrates.
- Range of motion - Strengthens muscles and prevents contractures in the residual limb fostering improved self-care
- Application of rigid splint - Minimizes edema by compressing residual limb for a better fit into the prosthesis
103
What are the secondary causes of gout?
- Caused by another disease (CKF, excessive diuretic use)
- Treatment based on underlying cause
- Affects people of any age
104
List the risk factors for developing gout.
- Obesity
- Hypertension
- Eating large amounts of meat and seafood
- Using thiazide diuretics: increases the net urate reabsorption in the renal tulles, therefore, increasing the serum uric acid level
- Consuming large quantities of alcohol.
105
How do we diagnose gout?
1. History, PHYSICAL ASSESSMENT
2. LABS
- SERUM ACID LEVEL > 6.5mg/dL
- Elevated ESR
- Elevated urinary uric acid
- Elevated BUN & serum creatinine= Kidney and live not working properly.
3. RADIOGRAPHICAL
- Plain radio-graphical findings are usually normal in early gout.
- Erosions and soft tissue nodules may be present in chronic gout.
106
What are some subjective findings a patient may say while experiencing gout?
I have severe joint pain (usually great toe or knee).
I think my joint is swollen.
I cannot move my joint.
My joint feels hot when I touch it.
107
What are some objective findings for gout?
Tenderness on palpation
Soft tissue swelling on examination accompanied by warmth and redness
Presence of tophi in the chronic gout patient
108
How can we treat gout, nonpharmacological?
- Weight management - obesity is a modifiable risk factor for gout
- Reduction in alcohol consumption
- Splinting of affected extremity/joint
- Low purine diet
- Medication adherence
109
How can we pharmacologically treat gout?
1. Acute phase Management
Goal is pain relief/reduction of inflammation
-INDOCIN/COLCHICINE (decrease buildup of uric acid crystals in the joint)
-GLUCOCORTICOIDS (to reduce inflammation and provide pain relief)
2. Chronic phase Management
Goal is to lower uric-acid levels
ALLOPURINOLl(Zyloprim)/febuxostat (Uloric) -reduce serum uric acid by inhibiting production of uric acid
110
What is a complication gout patients can have?
Urate crystals can aggregate to form a STONE, making gout patients more likely to experience kidney stones than the general population.
111
What should a nurse assess of a patient who has gout?
```
Intense joint pain
Tenderness on palpation
Swelling
Redness
Warmth
Decreased range of motion
Presence of tophi
```
112
What interventions should a nurse take for a patient who has gout?
1. ASSESS
-Monitor uric acid levels
-Presence of tophi, lumps or hard nodules
-Assess for red, swollen, and painful joints
-Assess pain levels
2. ACTIONS
-Administer uric acid-lowering agents as directed
-Administer analgesics and anti-inflammatory medications as ordered
-Administer glucocorticoid therapy as directed
3. TEACHING
-Avoid alcoholic beverages, especially beer
T-ake uric acid-lowering agents as directed
-Report gout flares promptly
-Proper nutrition
113
Define Osteoarthritis.
non-inflammatory degenerative disorder of the joints
114
What is the most common form of Arthritis in theUSA?
Osteoarthritis
115
How do we classify Osteoarthritis?
OA classified as either PRIMARY (idiopathic, with no prior event or disease related to the OA, or SECONDARY, resulting from previous joint injury or inflammatory disease, similar to RA
116
What type of joints are involved in Osteoarthritis?
WEIGHT-BEARING joints (knees, hips, feet, lumbar spine, cervical spine, proximal interphalangeal joints, and distal interphalangeal joints of the hands.
-Involvement of shoulders and elbows usually occurs after trauma, inflammation, or overuse.
117
Why does Osteoarthritis occur?
"Occurs due to breaks down of cartilage & loss of functionality"
118
Explain the pathophysiology of Osteoarthritis.
1. OSTEOPHYTES - projections of NEW CARTILAGE and BONE GROWTH forms along joint lines, contributing to PAIN in the joint and decreased range of motion.
-New bone growth may break off as bone spurs/contribute to further cartilage loss.
-CARTILAGE LOSS is a clinical feature of osteoarthritis, causing the BONE to be UNPROTECTED, which LEADS to the DETERIORATION of JOINT function.
2. SYNOVIUM produces synovial fluid, serves to lubricate the joints.
In osteoarthritis, synovial membrane become THICKENED and OVERPRODUCE synovial fluid, causing MORE PAIN and even greater
119
What is Bouchard's node?
Osteophyte formations on PROXIMAL interphalangeal joints.. This happens in Osteoarthritis
120
What is Heberden's nodes?
Osteophyte formations on DISTAL interphalangeal joints.. This happens in Osteoarthritis
121
List the risk factor for Osteoarthritis
- OLDER AGE: one of the most prevalent risk factors for developing osteoarthritis
- FEMALE
- OBESITY: correlates most with development of knee/hand osteoarthritis
- "Osteoarthritis of knees more common in AFRICAN AMERICAN WOMEN than in Caucasian women."
- "Osteoarthritis of the hands most prevalent in WOMEN."
- Sport activities
- Hx of previous injuries
- Genetic predisposition
- Muscle weakness
- History of inflammatory arthritis, other bone and joint disorders.
- Certain occupations whose job entails repetitive knee bending or who perform physical labor are at an increased risk for developing hand and hip osteoarthritis.
122
Which clinical manifestations are present in Osteoarthritis?
- PAIN, STIFFNESS, functional impairment, deformity, MUSCLE SPASM, localized INFLAMMATION, IMMOBILITY
- Joint pain aggravated by movement or exercise and RELIEVED BY REST
- If morning stiffness is present it usually lasts less than 30 minutes
- Examination: affected joint may be enlarged with a decreased ROM
- Crepitus may be palpated especially over the knee
- DIP (Heberden’s nodes) & PIP (Bouchard’s nodes)
- TENDERNESS over /around joint, bony swelling, soft tissue swelling, and instability.
- Joint effusion
123
How is Osteoarthritis diagnosed?
1. X-RAY: confirmed need for joint replacement; MRI
124
What are three ways we can treat Osteoarthritis?
1. NONPHARMACOLOGIC
Weight loss if indicated
Aerobic exercise
Physical therapy
Appropriate footwear
Protective footwear
Energy conservation
2. PHARMACOLOGIC
Tylenol for mild-moderate pain
NSAIDs for mod-severe pain
Intra-articular steroid injections
Combination tx appropriate: Tylenol, NSAIDs & intra-articular injections
Opioid analgesics used sparingly, habit forming risk
3. SURGICAL: May be necessary for severe cases of OA causing disability
-ARTHROSCOPIC DEBRIDEMENT: joint is IRRIGATED and EXPANDED in order to visualize the joint and REMOVE DEBRIS that could be promoting joint inflammation.
-ARTHROSCOPIC SYNOVECTOMY: REMOVE excessive growth of the synovial MEMBRANE in order to reduce joint inflammation.
-SURGICAL FUSION: fuse together the joint surfaces to ELIMINATE ANY MOVEMENT of the joint.
-TOTAL JOINT REPLACEMENT: eplacing the joint surface with a prosthesis.
125
What are some complications associated with Osteoarthritis?
- Bleeding
- Hypertension
- Hypovolemia
- Wound site infection
- Dislocation/subluxation (partial dislocation)
- Deep Vein Thrombosis
- Pulmonary Embolism
126
What assessment findings would a nurse look for on a patient with Osteoarthritis?
-Unsteady gait
-Bony enlargement or swelling of affected joints
-Fatigue
P-ainful range of motion of affected joints
-Elevated serum creatinine secondary to NSAID use
-Elevated liver enzymes related to multiple medication use
- Constipation secondary to decreased physical activity and/or use of narcotic analgesics
127
What should a nurse assess pre-operative for a Patient with Osteoarthritis?
Pre-surgical screening, ECG, metabolic profile, coagulation studies, CBC, pain management
128
What should a nurse assess post-operative for a Patient with Osteoarthritis?
```
Pain management, pain level
Vital Sign Assessment.
Temperature
Laboratory assessment
Neurovascular assessment
Monitor wound drainage
```
129
What should a nurse implement post-operative for a Patient with Osteoarthritis?
- Administer PAIN MED as ordered
- WOUND CARE
- MOBILIZATION=early movement from bed to chair=facilitates recovery
- ANTI-EMBOLIC stocking or compression stocking=reduces venous stasis
- Administer ANTICOAGULANT therapy as ordered
- Continuous passive motion (CPM) machine
- Maintain proper POSITIONING and turning schedule: abduction pillow prevent dislocation & internal rotation of the affected extremity
- FREQUENT TURN=prevent pressure on heels & other prominences
130
What interventions should a nurse take for a patient experiencing osteoarthritis?
1. Assess
- Vital signs
- Weight
- Skin integrity
- Serum creatinine
2. Actions
- Administer analgesics & anti-inflammatory medications
- Provide cold pack for painful joints
- Provide heat pads for painful muscles
3. Teaching
- Medication administration & compliance
- Report adverse effects of medications: chest pain, abdominal pain, abnormal bleeding, -bloody stool/emesis
- Regular physical activity
- Assist with OT & PT referral
- Assist with orthopedic surgery referral
- Assist with home health referral
131
Hip Fracture Etiology
Annually, more than 250,000 adults older than 65 years of age sustain a hip fracture requiring hospitalization.
Weak quadriceps muscles, slowed reflexes, decreased bone tensile strength, general frailty due to age, and conditions that produce decreased cerebral arterial perfusion (transient ischemic attacks, anemia, emboli, cardiovascular disease, effects of medications) contribute to the incidence of falls, which are the major cause of hip fracture.
Older adults (particularly women) who have low bone density from osteoporosis and who tend to fall frequently have a high incidence of hip fracture.
132
What are the three major types of hip fracture ?
1.) Extracapsular fractures - fractures of trochanteric region (between base of the neck and the lesser trochanter of the femur) and of sub trochanteric region.
2.) Intracapsular fractures - fractures of the neck of the femur.
Damage vascular system that supplies blood to the head/neck of the femur, and bone may become ischemic.
3.)Periprosthetic fractures are fractures to the regions surrounding prosthetics joints.
133
Clinical Manifestations of Hip Fractures
1.)Intracapsular femoral neck fractures:
Leg is shortened, adducted, and externally rotated.
Pain in the hip and groin or in medial side of the knee.
Cannot move the leg without a significant increase in pain.
Patient most comfortable with leg slightly flexed in external rotation.
Impacted intracapsular - moderate discomfort (even with movement), may allow patient to bear weight, and may not demonstrate obvious shortening or rotational changes. Diagnosis confirmed by x-ray.
2.)Extracapsular femoral fractures of the trochanteric/sub trochanteric regions:
-Extremity significantly shortened,
Externally rotated to greater degree than intracapsular fractures,
Patient exhibits muscle spasm that resists positioning of the extremity in a neutral position.
Associated area of ecchymosis.
Diagnosis confirmed by x-ray.
134
Diagnosis
```
Examination:
-Undisplaced fracture
.limited findings
.painful range of motion
of the hip.
```
```
-Displaced femoral neck fractures
.the affected leg is typic
ally shortened and
externally rotated.
.All motions of the hip
are painful.
```
135
Hip Fractures Risk Factors.
```
Old age.
Female.
History of Osteoporosis.
Low Estrogen levels.
TIA's, anemia, medications and Cardiovascular Diseases that can put the patient at risk for falls.
```
136
Medical Management.
Buck’s extension traction
Type of temporary skin traction,
Traditionally applied/believed to reduce muscle spasm, immobilize extremity, and relieve pain.
Surgical treatment consists of
Open or closed reduction of the fracture and internal fixation,
Replacement of the femoral head with a prosthesis (hemiarthroplasty),
Closed reduction with percutaneous stabilization for an intracapsular fracture.
Surgical intervention is carried out as soon as possible after injury.
Preoperative objective to ensure patient is in favorable condition as possible for the surgery.
Displaced femoral neck fractures are treated as emergencies, with reduction and internal fixation performed within 24 hours after fracture.
Femoral head often replaced with prosthesis if there is complete disruption of blood flow to the femoral head.
137
Types of Hip Surgeries.
Internal fixation.
Hip compression screw.
Partial hip replacement.
Total hip replacement.
138
Nursing Management.
Immediate postoperative care for a patient with a hip fracture similar to other patients undergoing major surgery.
Attention given to pain management
Prevention of secondary medical problems
Early mobilization of the patient so that independent functioning can be restored.
First 24 to 48 hours, relief of pain and prevention of complications, and continuous neurovascular assessment.
Nurse encourages deep breathing and dorsiflexion and plantar flexion exercises every 1 to 2 hours.
Thigh-high anti-embolism stockings or pneumatic compression devices are used, and anticoagulants are given as prescribed to prevent the formation of VTE.
Nurse administers prescribed analgesic medications and monitors patient’s hydration, nutritional status, and urine output.
139
Abduction pillow.
Prevents adduction and internal rotation which could cause dislocation of hip prothesis. Should be used when patient is sleeping and lying in bed. Typically worn for 6-12 weeks, this allows a pseudo-capsule to form around the joint and muscle strengthening. Patients who have had previous hip surgery are more likely to dislocate the hip prothesis and are always given the abduction pillow.
140
Nursing Management.
-Repositioning Patient:
Most comfortable and safest way to turn the patient is to turn to the uninjured side.
Standard method involves placing a pillow between the patient’s legs to keep the affected leg in an abducted position.
Proper alignment and supported abduction are maintained while turning.
-Promoting Exercise:
Patient encouraged to exercise as much as possible by means of the over-bed trapeze.
Device helps strengthen arms and shoulders in preparation for protected ambulation (toe touch, partial weight bearing).
First postoperative day, patient transfers to chair with assistance and begins assisted ambulation.
Amount of weight bearing permitted depends on stability of the fracture reduction.
Primary provider prescribes degree of weight bearing.
Physical therapists work with the patient on transfers, ambulation, and safe use of assistive devices.
Anticipate discharge to home/extended-care facility with use of assistive devices.
Modifications in the home may be needed (elevated toilet seats and grab bars).
-Neurovascular complications may occur from direct injury or edema in the area that causes compression of nerves and blood vessels.
With hip fracture, bleeding into the tissues and edema are expected.
Monitoring/documenting neurovascular status of affected leg are vital.
-Prevent Venous Thrombus Embolism
Encourages intake of fluids/ankle/foot exercises.
Anti-embolism stockings, pneumatic compression devices, and prophylactic anticoagulant therapy are indicated and should be prescribed.
Patient/patient’s caregiver should be educated on signs, symptoms, and risks of VTE, and how to administer anticoagulant prophylaxis as prescribed (see Chart 42-4).
Intermittent assessment of patient’s legs for signs of DVT (unilateral calf tenderness, warmth, redness, and swelling).
Assess legs every 4 hours (at least) for signs of DVT
Unilateral calf tenderness, warmth, redness, and swelling.
141
What are amputations ?
-Amputation is the severing, or removal, of part of the body, generally involving the extremities.
-Traumatic amputations - high-energy trauma mutilates/destroys soft tissues, blood vessels, nerves, and bones of the extremities. (blunt force trauma in motor vehicle crashes, motorcycle crashes, pedestrian versus vehicle injuries, gunshot wounds,) industrial jobs requiring use of power tools (lawn mowers and snow blowers).
Conflicts in Iraq and Afghanistan precipitated thousands of traumatic amputations among military professionals because of improvised explosive devices. Amputations of upper extremities frequently seen in motor vehicle crashes,
Amputations of lower extremity occur in motorcycle crashes/pedestrian injuries.
142
Elective amputations
- typically due to vascular compromise secondary to chronic illnesses (peripheral vascular disease, diabetes, neoplasms, and infections).
Risk factors for elective amputations include noncompliance with diabetic treatment regimen, smoking, and venous stasis ulcers.
Amputation is used to relieve symptoms, improve function, and improve quality of life.
Below-knee amputation (BKA) is preferred to above-knee amputation (AKA) because of the importance of the knee joint and the energy requirements for walking.
143
Causes of amputations?
- Progressive peripheral vascular disease ( often complication of diabetes Mellitus: "Diabetic Foot").
- Trauma: crush injury, burn injury including electrical, frostbite.
- Chronic osteomyelitis.
- Gas gangrene
- Malignant tumor.
- Congenital deformity.
144
Traumatic amputation Medical Management ?
Control bleeding & replace blood loss from injury.
Apply tourniquet to remaining limb- tourniquet can remain in place for up to 6 hours before tissue necrosis
Coagulation panel/CBC - establish need for immediate blood transfusion.
Serum lactate level - indicator of anaerobic metabolism, helps determine level of hypoxemia gauge success of resuscitative efforts.
To preserve life/maintain limb function - salvage surgery may be required to control hemorrhage, reattach limbs (Box 54.5), or remove/reconstruct the damaged.
145
Elective Amputation Medical Management?
Done after all medical interventions to reestablish perfusion are utilized. Ex: hyperbaric therapy, anticoagulant therapy.
Radiography - to determine the extent of bone damage or infection
Venograms/arteriograms – to assess the level of peripheral circulation.
Cultures and sensitivities isolate infective organisms in the wound and allow for accurate implementation of antibiotics.
Percutaneous transluminal angioplasty - (insertion of a balloon-tipped catheter into the affected artery that can be expanded to open the artery and restore blood flow), and anticoagulant therapy.
Neoplasms of the bone, resection of the tumor and bone grafting can often eliminate the need for surgical amputation.
Patients are often fitted and sized for a prosthesis before their elective amputation surgery.
Once all efforts have been exhausted elective amputations are performed to salvage remaining function of viable tissue.
146
Complications of Amputations.
-Hemorrhage in traumatic amputations is caused by the destruction of large blood vessels within the extremity, leading to severe bleeding and consequent hypo perfusion.
Bleeding if not controlled with a pressure dressing/tourniquet, patient further decompensates into hypovolemic shock and death.
-Infection in older patients with peripheral vascular disease undergoing elective amputations with increased risk for developing infections of tissue/bone.
Osteomyelitis - infection of the bone can quickly progress to sepsis in geriatric patients
-Contractures may occur in the residual limb due to loss of bone, nerves, and muscle.
Seen in lower-extremity amputations and manifested by lack of movement/exercise in the residual limb.
Encourage patient to perform active ROM exercises and participate in physical therapy.
147
*Nursing Managament
Nursing Interventions:
-Assessments
Vital signs
Hypotension/tachycardia may occur secondary to hemorrhage and sepsis.
Increased temperature - indication of infection.
Decreased SpO2 indicates problems with oxygenation.
CBC
Hemorrhage in traumatic amputation causes loss of red blood cells (RBCs), and low hemoglobin and hematocrit.
Pulses, temperature, color, movement, and sensation of affected extremity
Weak pulses, pale color, cool temperature, limited movement/sensation indicate inadequate blood flow/tissue perfusion in affected limb that may indicate potential need for elective amputation.
Pain
Phantom limb pain - common side effect due to remapping of impulses from the amputated extremity to the spinal cord, causing continued pain sensations.
Wound/incision site
Warm, red tissue with purulent drainage is sign of wound infection.
148
*Nursing Actions.
- Insert large bore IV –
Massive blood loss necessitates IV blood and fluid resuscitation.
Transfusion of IV fluids and blood products as ordered
Replace fluid and blood lost in traumatic amputation.
-Administer analgesia as ordered - Improved pain control promotes movement, function, increase ability to participate in rehabilitation.
Alternative pain management techniques - TENS unit or CAM therapies are synergistic in conjunction with analgesic medications.
-Refrain from using a pillow under remaining portion of the lower extremity
Prevents the development of flexion contractures that can occur if a pillow is left under the extremity.
- Application of ice for no longer than 15 to 20 minutes - Promotes vasoconstriction and decreases painful edema.
- Nutrition: maintain adequate intake and output - increased metabolic demands of healing require additional protein and carbohydrates.
- Range of motion - Strengthens muscles and prevents contractures in the residual limb fostering improved self-care
- Application of rigid splint - Minimizes edema by compressing residual limb for a better fit into the prosthesis
149
*Nursing Teaching
- Medication regimen (Pain control for ambulation/self care, antibiotics for wound healing/decreases risk of superinfection/antibiotic-resistant organisms).
- Nutrition and hydration (proteins/carbohydrates - healing of bone, muscle, and skin, Increasing dietary fiber and maintaining hydration prevents narcotic-associated constipation).
- Wound care - continues after discharge, teach using aseptic technique minimizes risk of infection.
- Signs and symptoms of infection – Teach how to identify early signs of infection (increased or purulent drainage, redness, warmth, increased temperature, and seek medical attention as necessary).
- ROM exercises - Prevent contractures/strengthen muscles for movement/function
- Community support resources – Involve case manager/social worker coordinate resources to allow patient to resume rehabilitation and self-care activities at home with the use of various assistive devices. Organizations composed of other amputee patients can offer additional encouragement and emotional support.
- Collaborate with physical therapist and prosthetist-orthoptist - Professionals promote adaptation to new lifestyle and help ensure prosthesis fit. They can also serve as a resource for any prosthesis-related issues.
150
*Nursing Management.
Wrap limb with compression dressing (Fig. 54.9)
Figure-eight technique
Start 1 to 3 days postoperatively
Wrap from distal to proximal position
Start with minimal tension, then increase gradually
Rewrap two to three times per day
Keep wrapped unless bathing
If pain occurs, the wrapping is probably too tight
Limb wrapping decreases edema/aids in correct fitting of prosthesis on the residual limb.
