(ncm 104)ortho sir pat lao 2
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Preoperative
Offer support/encouragement Discuss:
Rehabilitation program & use of prosthesis
Upper extremity exercise such as push ups in bed
Crutch walking
Amputation dressing/cast Phantom limb sensation as a normal occurrence
Observe stump dressing for signs of hemorrhageand mark outside of dressing so rate of bleedingcan be assessed (tourniquet at bedside)
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Prevent edema
Raise extremity with pillow support for first 24 h Prevent hip/knee contractures
Avoid letting patient sit in chair with hips flexedfor long periods of time
Have patient assume prone position several timesa day and position hip on extension Avoid elevation of stump after 24 hrs For BKA: hip & knee exercises For AKA: hip exercises
Pain medication as ordered (phantom limbpain)
Ensure that stump bandages fit tightly andare applied properly to enhance prosthesisfitting
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Rheumatoid arthritis chronic systemic
inflammatory disease
destruction of connectivetissue and synovial
membrane within thejoints
weakens and leads todislocation of the jointand permanent deformity
Risk Factors exposure to infectious
agents
fatigue
stress
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Signs and Symptoms Morning stiffness Fatigue Weight loss Joints are warm,
tender, and swollen
Swan neckdeformity-lateDiagnostic Studies X-ray Elevated WBC,
platelet count, ESR*,and positive RFTreatmentNo cure for RA
Swan neck deformity
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Aspirin- mainstay of treatment, has bothanalgesic and anti-inflammatory effects
Nonsteroidal anti-inflammatory drugs(NSAIDs): Indomethacin (Indocin) Phenylbutazone (Butazoldin) Ibuprofen (Motrin) Fenoprofen (Nalfon) Naproxen (Naprosyn) Sulindac (Clinoril)
Immunosuppressives: Methotrexate Gold Standard for RA treatment Teratogenic
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Gold compounds
Injectable form: sodium thiomalate,aurothioglucose; given IM once a week;
takes 3-6 months to become effective Oral form: auranofin- smaller doses are
effective; diarrhea is a common sideeffect
Corticosteroids
Intra-articular injections
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Treatment Surgical Procedures: synovectomy,
arthrotomy, arthrodesis, arthroplasty
Nursing Management Advised bed rest during acute pain Passive ROM exercise of joints Splint painful joints Heat & Cold application Advised warm bath in the morning Protect from infection Advised well-balanced diet
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Arthrotomy
Arthrodesis Arthroplasty
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Progressivedegeneration of thejoints as a result ofwear and tear affects weight-bearing joints andjoints that receive the
greatest stress, suchas the knees, toes,and lower spine.
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Risk Factors aging (>50 yr) rheumatoid arthritis arteriosclerosis obesity trauma family historySigns and Symptoms Dull, aching pain,* tenderjoints fatigability, malaise crepitus cold intolerance* joint enlargement presence of Heberdensnodes or Bouchardsnodes weight loss
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Aspirin inhibits cyclooxygenase enzyme, diminishes the formation
of prostaglandins anti-inflammatory, analgesic, antipyretic action inhibit platelet aggregation in cardiac disordersAdverse effects Epigastric distress, nausea, and vomiting In toxic doses, can cause respiratory depression Hypersensitivity Reyes syndrome
Ibuprofen use for chronic treatment of rheumatoid and osteoarthritis less GI effects than aspirinAdverse effects dyspepsia to bleeding headache, tinnitus and dizziness
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Indomethacin inhibits cyclooxygenase enzyme
more potent than aspirin as an anti-inflammatory agent
Adverse effects: nausea, vomiting, anorexia, diarrhea
headache, dizziness, vertigo, light-headedness, and mental confusion
Hypersensitivity reaction
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Nursing Intervention Promote comfort: reduce pain, spasms,
inflammation, swelling Heat to reduce muscle spasm Cold to reduce swelling and pain
Prevent contractures: exercise, bed rest on
firm mattress, splints to maintain properalignment Weight reduction Isometric and postural exercisesNursing Diagnosis Pain related to friction of bones in joints Risk for injury related to fatigue Impaired physical mobility related to stiff,
limited movement
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Metabolic disorder that
develops as a result ofprolonged hyperuricemia
Caused by problems insynthesizing purines or bypoor renal excretion of uricacid.
Acute onset, typicallynocturnal and usuallymonarticular, often involving
the first metatarsophalangealjointRisk Factors Men
Age (>50 years)
Genetic/familial tendency
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Signs and Symptoms extreme pain swelling erythema of the
involved joints fever
TophiLaboratory Findings elevated serum uric
acid (>7.0 mg/dl)* urinary uric acid elevated ESR and WBC crystals of sodium
urate aspirated from atophus confirms thediagnosis*
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Allopurinol- a purine analog
- reduces the production of uric acid by competitively inhibiting uricacid biosynthesis which are catalyzed by xanthine oxidase.
Effective in the treatment of primary hyperuricemia of gout andhyperuricemia secondary to other conditions (malignancies).
Adverse effects: hypersensitivity reactions, nausea and diarrhea
Colchicine Effective for acute attacks Anti-inflammatory activity alleviating pain within 12 hours Adverse effects: nausea, vomiting, abdominal pain, diarrhea,
agranulocytosis, aplastic anemia, alopecia
Probenecid/Sulfinpyrazone uricosuric agents increases the renal excretion of uric acid Sulfinpyrazone used as a preventive agent. Adverse effects: nausea, rash & constipation
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Maintain a fluid intake of at least 2000 to 3000 ml a day to avoidkidney stone. Avoid foods high in purine such as wine, alcohol, organ meats,sardines, salmon, anchovies, shellfish and gravy. Take medication with food. Have a yearly eye examination because visual changes can occurfrom prolonged use of allopurinol Caution client not to take aspirin with these medication because itmay trigger a gout attack and may cause an elevated uric acidlevels. Encourage rest and immobilize the inflamed joints during acuteattacks Avoid excessive alcohol intake Notify physician if rash, sore throat, fever or bleeding develops.
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COMPARING ARTHRITIS
Rheumatoid Osteoarthritis Gouty
Etiology Autoimmune
+ Rh factor
Degenerative
senescence
Metabolic orfamilialpurinemetabolism
Incidence 35-45 women Men or more inwomen
Men over 40
Signs andsymptoms
Subcutaneaousnodules
Morning stiffness
Swan neckdeformity
Heberdens nodule Tophi
Areasaffected
Joints of hands Weight bearingjoint
Great toe
Management
Aspirin, NSAIDs
Paraffin bath
Symptomatic Colchicine
Avoid purine
dietAllopuyrinol
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Bacterial Infection ofthe bone and softtissue
Staphylococcus aureus
is the most commonpathogen. Hemolytic
streptococcus
Other organismsinclude Proteus,Pseudomonas and E.Coli
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Risk Factors
poorly nourished, elderly orobese
impaired immune systems
chronic illnesses
long term corticosteroid therapy
Open wound
infection
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Organism reaches the bone throughan open wound
Infection causes bone destruction
Bone fragment necrose -sequestra
New bone cells form over thesequestrum during healing
resulting in nonunion
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Clinical Manifestation area appears warm, swollen and
extremely painful ( localized edema)
systemic manifestations (fever,chills, tachycardia) Bone pain Muscle spasm
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Diagnostic Studies X-ray
Bone Scan Blood and wound culture
Bone Biopsy
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1. Antibiotics : Cefazolin and Clindamycin
2. Analgesic : Oxycodone,
1. 1015 mg of oxycodone produces ananalgesic effect similar to 10 mg of morphine
3. Vital Signs and Neurovascular status
4. Diet : High calorie, vitamin C and DCalcium
5. Activity : bed rest6. Heat therapy
7. Antipyrectic : aspirin, acetaminophen
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1. Monitors the neurovascular status of the affectedextremity
2. Elevation reduces swelling and associateddiscomfort
3. Pain is controlled with prescribed analgesics andother pain-reducing techniques
4. Must be protected by immobilization devices andavoidance of stress on the bone
5. The patient must understand the rationale of forthe activity of restriction
6. Encourage patient to have a full participation inADLs within the physical limitations to promotegeneral well-being
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Monitor the patients response to antibiotic therapy
Observes the IV access for evidence of phlebitis, infection, orinfiltration,
With long term intensive antibiotic therapy (monitors thepatient for sign of infection like oral or vaginal candidiasis,loose or fouling-smelling stool
If surgery is necessary (take measures to ensure adequatecirculation to the affected area (wound suction to prevent
accumulation, elevation of the area to promote venousdrainage, avoidance of pressure on the grafted area) tomaintain needed immobility, and to ensure the patientsadherence of to weight bearing restrictions.
Changes dressings using aseptic technique (to promote
healing and to prevent cross-contamination
Diet high in protein and Vitamin C (promotes a positivenitrogen balance and healing
Encourage adequate hydration as well
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Promote comfort
Immobilized affected bone by maintainingsplinting. Elevate affected leg Administer analgesics as needed.Control infectious process Apply warm, wet soaks 20 min. several
times a day. Administer antibiotics as prescribed. Use aseptic technique when dressing the
wound.Encourage participation in ADL within thephysical limitations of the patient.
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a reduction in bone density and a change inbone structures
bones become previously porous, brittle and
fragile
bones fracture easily under stresses thatwould not break in normal bone
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Incidence- women older than 80 years old of age is 84%.
The average 75 years-old woman has lost 25%of her cortical bone and 40% of her trabecular
bone.
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Age1. Post-menopause
2. Advance age
3. Low testosterone in men
4. Decreased calcitonin
Nutrition1. Low calcium intake
2. Low vitamin D3. High phosphate intake
4. Inadequate calories
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Physical exercise Sedentary
Lack of weight-bearing exercise Low weight and body mass index
Lifestyle choices Caffeine
Alcohol Smoking
Lack of exposure to sunlight
Medications
Corticosteroids
Antiseizure medications Heparin
Thyroid Hormone
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Back pain.
Loss of height and stooped posture.
A Curved upper back (dowager's hump). Fracture : hip, spine and wrist.
Compression fractures
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1. Primary Osteoporosis : women after menopause (usually after 45 and 55
years) later in men.
2. Secondary Osteoporosis medications or other conditions and disease that
affect bone metabolism.
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Predisposes to low bone
mass
Genetics-Caucasian or Asian-Females
-Family history-Small frameAge-Post-menopause-Advance age-Low testosterone in men-Decreased calcitoninNutrition-Low calcium intake-Low vitamin D-High phosphate intake-Inadequate calories
Hormones
(estrogen, calcitonin,and testosterone)inhibit bone loss.
Reduces nutrients
needed for the boneremodeling
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Physical Exercise-Sedentary-Lack of weight-bearing exercise-Low weight and body mass indexLifestyle Choices-Caffeine-Alcohol-Smoking-Lack of exposure to sunlightMedications-Corticosteroids-Antiseizure medications-Heparin-Thyroid Hormone
Reducesosteogenesis inbone remodeling
Affects calciumabsorption andmetabolism
Bones needed
stress for bone
maintenance.
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Dual-energy X-ray Absorptiometry (DEXA)-Means of measuring bone mineral densities
(BMD)
Two xray beams with differing energy levels are
aimed at the patient bones.X ray. Serum calcium Serum phosphataseUrine calcium excretion
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1. Hormone replacement therapy (HRT)1. Raloxifene (Evista) preserving BMD w/o
estrogenic effect on the uterus ( prevention and
treatment for osteoporosis
2. Bishosphonates
3. Alendronate - inc. bone mass by inhibiting
osteoclast function.
4. Calcitonin
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Nursing Diagnosis
1. Deficient knowledge about the osteoporotic
process and treatment regimen
2. Acute pain related to fracture and musclespasm
3. Risk for constipation related to immobility or
development of ileus
4. Risk for injury:additional fractures related to
osteoporosis
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Nursing Inteventions
Promoting and Understanding of Osteoporosis and the
Treatment Regimen
1. Adequate dietary or supplemental calcium (1200-
1500 mg/day) and vitamin D
2. Regular weight-bearing exercise
3. Modification of lifestyle like cessation of smoking,
reduce the use of caffeine and alcohol4. Help to maintain bone mass
5. Instruct to take the calcium supplements with meals
6. Teach patient to drink adequate fluids to reduce the
risk of renal calculi7. For Alendronate users, it must be taken on an empty
stomach with water and the patient must not
consume foods or liquids for 30-60 minutes.
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Relieving Pain1. Rest in bed in a supine position or side-
lying position several times a day. Themattress should be firm and non-sagging.
2. Intermittent local heat and back rubspromote muscle tension
3. Instruct to move the trunk as a unit andavoid twisting.
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primary malignant neoplasm of bones
Also known as Osteogenicsarcom
Occurs between 10-25 years of age, with Paget's
disease and exposure to radiation.
Exhibits a moth-eaten pattern of bone destruction.
Most common sites: metaphysis of long bones
especially the distal femur, proximal tibia andproximal humerus.
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Risk Factors
Cause is unknown. family history / inherited cancers :
Li-Fraumeni SyndromeRetinoblastoma
being tall for specific agePrevious treatment with radiation for another cancer
That usually occurs in children younger than 4 yrs.
P h h i
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1.Osteosarcoma occurs mainly in the metaphyses oflong bones, sites of active epiphyseal growth.Distal femurProximal tibiaProximal humerus1.As a tumor of mesenchymal cells, osteosarcoma
demonstrates production of osteoid cells.2.It is a bulky tumorthat extends beyond the bone the
bone into a soft tissue.3.This may encircle the bone and destroy the
trabeculae of affected area.4.Osteosarcoma disseminates through bloodstream,usually to the lung.
5.Other sites of metastatic spread include otherbones and visceral organs
Pathophysiology:
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High grade mesenchymaltumorDistal femurProximal tibia
Proximal humerusFormation of
osteoid
Lungs, bones,visceral organs
Metastasize throughblood streams
Bulky tumor thatdestroys trabeculaeof diseased area
Predisposing Factors
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Clinical Manifestation local signs pain ( dull,
aching and intermittent innature), swelling, limitationof motion
palpable mass near the endof a long bone
systemic symptoms:
malaise, anorexia, andweight loss
Diagnostic Findings Biopsy- confirms the
diagnosis
X-ray MRI Bone Scan Increase alkaline
phosphatase
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Radiation Chemotherapy (methotrexate(leucovorin/Adriamycin) Cytoxan, Ifosfamide Surgical management
amputation limb salvage procedures
Prognosis: poor prognosis (rapid growth rate)
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Promote understanding of the diseaseprocess and treatment regimen
Promote pain relief Prevent pathologic fracture Assess for potential complications(infection, complications of immobility). Encourage exercise as soon as possible(1st or 2nd post-op day)
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a plastic surgery
that involvesremoval of thehead of the femurfollowed by
placement of aprosthetic implant
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Teach client how to use crutches
Teach client mechanics of transferring.
Discuss importance of turning and positioning post-op.
Place affected leg in an abducted position and straightalignment following surgery
Prevent hip flexion of more than 90 degrees.
Apply support stockings
Advise client to avoid external/internal rotation of affectedextremity for 6 months to 1 year after surgery
Instruct client to avoid excessive bending, heavy lifting,jogging, jumping
Encourage intake of foods rich in Vitamin C, protein, and
iron. Administer prescribed medications.
Metallic implant
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Infection Hemorrhage Thrombophlebitis Pulmonary embolism Prosthesis dislocation Prosthesis loosening
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condition in which
the head of thefemur is
improperly seatedin the acetabulum,or hip socket, ofthe pelvis.
Congenital ordevelop after birth
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Neonates: laxity of theligaments around thehip, allowing thefemoral head to bedisplaced from theacetabulum uponmanipulation.
Implementation: Splinting of the hipswith Pavlik harness tomaintain flexion andabduction and externalrotation (neonatalperiod) Pavlik harness
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Infants Asymmetry of the gluteal and
thigh skin folds when thechild is placed prone and thelegs are extended against theexamining table. Limited range of motion inthe affected hip. Asymmetric abduction of theaffected hip when the child isplaced supine with the kneesand hips flexed. apparent short femur on theaffected side
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Implementation Traction and/or
surgery to releasemuscles andtendons
Following surgery,positioning and
immobilization in aspica cast untilhealing is achieved.
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The walking child minimal to
pronouncedvariation in gait with
lurching toward theaffected side;positiveTrendelenburg sign
Positive Barlow orOrtolanis maneuverOrtolanis maneuver Barlow maneuver
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Caring forPatient with
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Osteomalaciainvolves softeningof
the bones caused bya deficiency of vitamin Dor problems with themetabolism of this
vitamin.
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In children, the
condition is calledrickets and isusually caused by adeficiency of
vitamin D .
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In adult, the conditionis usually caused by:
1. Inadequate dietaryintake of vitamin D
2. Inadequate exposureto sunlight (ultravioletradiation)
3. Malabsorption ofvitamin D
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Other conditions:1. Hereditary or acquired disorders
of vitamin D metabolism
2. Kidney failure and acidosis ,3. PO4 depletion associated with
low dietary intake or kidneydisease
4. Side effects ofmedications usedto treat seizures .
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Risk factors are related tothe causes.
In the elderly, there is anincreased risk for those whotend to remain indoors andwho avoid milk because oflactose intolerance
The incidence is 1 in 1000people.
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Deficiency of activated VITAMIN D
(Calcitriol)
Decreased absorption, malabsorption or excessive loss ofCALCIUM
Inadequate
MINERALIZATION of bone
SOFTENING of the
BONE
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diffuse bone pain , especially in the hips muscle weakness
symptoms associated with low calcium1. numbness around the mouth & of
extremities2. Carpopedal spasms3. Bowing of legs4. Waddling or limping GAIT5. Decrease in height/ Spinal Deformities (i.e.
KYPHOSIS)
k
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In children, symptoms ofricketsinclude:
delayed sitting, crawling, and walking; pain whenwalking; and the development ofbowlegs orknock-
knees.
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1. Bone biopsy: (+) increase in osteoid
2. Bone X-ray or CT scan of lumbosacral spineshows demineralization.
3. Studies of the vertebrae: (+) compression fx
4. Low serum vitamin D level
5. Low serum calcium &phosphate levels
6. Elevated ALP (Alkaline Phosphatase)
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1. Adequate dietaryintake of dairy
products that arefortified withvitamin D
2. Adequate exposure
of the body tosunlight
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Oral supplementsof vitamin D ,calcium, and
phosphorus
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Large doses of Vitamin Dwith exposure to sunlightmay be indicated inpeople with intestinal
malabsorption .
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Monitoring of blood levelsofphosphorus andcalcium may be indicatedwith some underlying
conditions. Braces or surgery to
correct deformities
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Protrusion of the nucleus of the disk into thefibrous ring of the disk with subsequent nervecompression
May occur in any portion of the vertebralcolumn
Signs & Symptoms1. Pain
2. Sensory changes3. Loss of reflex
4. Muscle weakness
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1. Cervical Pain/ Stiffness head, neck & upper extremities Paresthesia, numbness
Weakness
2. Lumbar Low back pain radiating to the buttocks and leg Postural deformity of the spine
(+) Straight-Leg Raise test
Weakness & Asymmetric reflexes
Sensory loss
Nursing Alert: Perform repeated assessments ofsensorimotor
functions/ reflexes to determine progression of condition80
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Alleviating pain1. Anti-inflammatory drugs, muscle
relaxants, and narcotic analgesics2. Use ofbed boards under the mattress3. Bed restsupine or low fowlers or side
lying position with slight knee flexion andpillows between knees.
4. Moist heat application5. Relaxation techniques
Nursing Interventions
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Surgical incision of part of posterior arch ofvertebrae and removal of protruded disc Nursing InterventionPreoperative
Teach patient log rolling and use of bedpanPostoperative Position as ordered Lower spinal surgery- flat Cervical spine surgery: slight elevation of
head of bed Proper body alignment- cervical spinal
surgery: avoid flexion of neck and applycervical collar
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Avoid: Acute hip flexion (bending, stooping, crossing the
legs
Prolonged sitting/standing
Running, jogging, horseback riding Back- strengthening exercises
Prone position
Walk in seawater
Lie in side- lying with hip flexion
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Patient teaching and Discharge Planning Wound care
Good posture and proper body mechanics
Activity level as ordered
Recognition and reporting of complications such aswound infection, sensory or motor deficits
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