musculoskeletal lecture
TRANSCRIPT
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Prepared by:Edwin Jonathan A. Manlapas, DDM, R.N
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“ Great Minds have purposes, others have wishes.”
Washington Irving
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“ A winner has a plan, a loser has an excuse.”
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Musculoskeletal system2nd largest body systemBones, joints & skeletal muscles
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Anatomy & Physiology
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Skeletal System206 bonesMultiple joints
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Classification of bones by shape:
Long bones – cylindrical with rounded ends; often bear weight
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Short bones – phalanges, small & bear little or no weight
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Flat bones – scapulaProtect vital organs; often contain blood forming cells
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Irregular bones – unique shapes; carpal bones of the wrist, bones in the inner ear
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Classification of bone by structure:
Cortex – outer dense, compact bone tissue
Medulla – composed of spongy cancellous bone
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Epiphyses – 2 knob-like ends
Diaphysis – bone shaftPlays a role in growth & development
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Haversian system – structural unit of cortical, compact bone
Cancellous tissue – with trabecula; filled with red & yellow marrow
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Hematopoiesis – production of blood cells; happen in the red bone marrow
Yellow marrow – contains fat cells
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Osteoblasts – bone forming cellsOsteoclasts – bone destroying cells
Osteon – bone matrix; consists of collagen, mucopolysaccharides & lipids
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Function of the skeletal system:
Provides a framework for the body.
Supports the surrounding tissues
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Assists in movement (muscles, tendons)
Protect vital organs (heart, lungs)
Production of red blood cellsProvides storage for mineral salts (Ca & PO4)
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Calcium & Phosphorus99% Calcium90% Phosphorus
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Serum concentration of Ca & Phosphorus maintain an inverse relationship
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Calcitonin Decreases the serum Ca concentration if increased above normal levels
Inhibits bone resorption
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Increases renal excretion of Ca & Phosphorus
Vitamin D – promotes absorption of Ca & Phosphorus from the small intestine; enhance PTH activity
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A decreased in Vitamin D can result in Osteomalacia among adults & Rickets in children
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Parathyroid hormone (Parathormone, PTH) – stimulates bone’s osteoclastic activity & release calcium to the blood
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Growth hormone – increase bone length; determines the amount of bone matrix formed before puberty
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Glucocorticoids – regulate protein metabolism; regulate intestinal Ca & Phosphorus absorption
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Estrogens & Androgens Estrogen stimulates osteoblastic activities & inhibit parathormone
Testosterone – increase bone mass by promoting anabolism
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Thyroxine – increase the rate of protein synthesis
Insulin works with growth hormones to build & maintain healthy bone tissue
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Joint – a space in which 2 or more bones come together
Provide movement & flexibility in the body
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Types of joint:Synarthrodial – completely immovable joints (Ex. Joints in the cranium)
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Ampiarthrodial – slightly movable joints (Ex. Pelvis)
Diarthrodial (Synovial) – freely movable joint (Ex.Elbow & knee)
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Synovial joints are the only joints lined by synovium; a membrane that secretes synovial fluid for lubrication & shock absorption
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consists of elongated cells called muscle fibers that utilizes ATP to generate force
produces heat, body movements & maintains posture
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1. Skeletal muscle – attached to the bones of the skeleton; fibers with striations, voluntary controlled by CNS & PNS
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2. Cardiac muscle – forms most of the wall of the heart; striated; involuntary, controlled by ANS
intercalated discs – unique structure of cardiac muscle
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3. Smooth muscle – non-striated, involuntary, located in walls of hollow internal structures like blood vessels, airways of the lungs, stomach, intestine & gall bladder
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Contraction helps constrict the lumen of blood vessels
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CARTILAGECostal Cartilage – connects sternum to rib cage
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Yellow Cartilage – external ear, epiglottis
Hyaline Cartilage – septum of nose, larynx, trachea
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TENDONS – bands of tough, fibrous tissue that attach muscles to bones
LIGAMENTS – attach bones to other bones at joints
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Decreased bone densityIncreased bone prominence
Kyphotic posture : widened gait, shift in the center of gravity
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Cartilage degenerationDecreased ROMMuscle atrophy , decreased strength
Slowed movement
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HistoryDemographic data:Young men – risk for trauma R/T motor vehicle crashes
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Older adults – risk for falls fracture, soft tissue injury
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Family history and genetic risk :
Osteoporosis – age related bone loss
Bone cancerOsteoarthritis
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Personal History :Accidents, illnesses, lifestyle, medication
Level of physical activityTraumatic injuriesParticipation in sports/sports injuries
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Diet History :Determine risk of inadequate nutrition
Lactose intolerance → affect Ca intake
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Insufficient Vitamin C or D → inhibits healing of bone and tissue
Obesity→ places excess stress and strain on bones and joints
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Socioeconomic Status:Computer related jobs→
carpal tunnel syndrome ( entrapment of median nerve in the wrist )
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Construction worker, Health care workers → back injury
Athletes → joint dislocation, fractures
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Current Health Problems:PAIN – most common complaint
- acute or chronic - best if client describes the pain in his/her own words
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PQRST Model P rovoking incidentQ uality of painR egion, radiation and reliefS everity of painT ime
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General InspectionPosture – body build and alignment when standing and walking
Gait – two phases of normal, automatic gait
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1. Stance phaseAntalgic gait – abnormality in
the stance phase of gait Part of one leg is painful, the
person shortens the stance phase on the affected side
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2. Swing phaseLurch – abnormality in the swing phase
Occur when muscles in the buttocks and/or legs are too weak to allow the person to change weight from one foot to the other
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MobilityGoniometer – a tool use to provide an exact measurement of ROM
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Assessment of the Head & Neck
- inspect, palpate the skull (shape, symmetry, tenderness and masses)
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Common abnormal findings:1. tenderness and pain2. crepitus ( grating sound )
3. spongy swelling
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Assessment of the spineBoth hands are placed over the lumbosacral area, apply pressure with thumb
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Lordosis – in pregnancy , in abdominal obesity
Scoliosis – client flexes forward from the hip, inspect lateral curve
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Assessment of the Upper Extremity
Assessment of the Lower Extremity
genu valgum ( “knock knee “)
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genu varum ( “bow-legged )
Neurovascular Assessment
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Lovett’s Scale for Grading Muscle Strength
5 Normal : ROM unimpaired against gravity with full resistance
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4 Good : can complete ROM against gravity with some resistance
3 Fair : can complete ROM against gravity
2 Poor : can complete ROM with gravity eliminated
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1 Trace : no joint motion and slight evidence of muscle contractility
0 Zero : no evidence of muscle contractility
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LABORATORY PROFILESerum Calcium( 9-10.5 mg/dL )Hypercalcemia :• Metastatic cancers of the bone• Paget’s Disease• Bone fractures in healing stage
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Hypocalcemia:• Osteoporosis• Osteomalacia
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Serum Phosphorus ( 3–4.5 mg/dL )
Hyperphosphatemia:• Bone fracture in healing stage• Bone tumors• Acromegaly
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Hypophosphatemia:• Osteomalacia
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Alkaline Phosphatase, ALP (30-120 units/L)Elevations may indicate :• Metastatic cancers of the bone
• Paget’s Disease • Osteomalacia
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Serum muscle enzymesCreatinine kinase ,CK Men : 55-170 units/L Women : 30-135 units/L
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Elevations may indicate :Muscle trauma ; Effects of EMG
Progressive muscular dystrophy
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Lactate dehydrogenase, LDH Total LDH: 100-190 units/LElevations may indicate:• Skeletal muscle necrosis• Extensive cancer• Progressive muscular dystrophy
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Aspartate aminotransferase, AST
( 0-35 units/L )Elevations may indicate:• Skeletal muscle trauma• Progressive muscular dystrophy
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Aldolase, ALD ( 3-8.2 units/dL )
Elevations may indicate:• Polymyositis and dermatomyositis
• Muscular dystrophy
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RADIOGRAPHIC EXAMINATIONS
Standard Radiography ; CT Scan
Tomography – produces planes or slices , for focus and blurs the image of other structures
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Xeroradiography – highlights the contrast between structures
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Myelography – involves injection of contrast medium or dye into the subarachnoid space of the spine usually by spinal puncture
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Arthrography – x-ray study of the joint after contrast medium (air or solution ) has been injected to enhance its visualization
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Other Diagnostic Tests:Bone biopsy – the doctor extracts a specimen of
bone for microscopic exam
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Muscle biopsy – done for the diagnosis of atrophy and inflammation
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Electromyography (EMG) – accompanied by nerve conduction studies for determining the electrical potential generated in individual muscle
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Diagnosis of neuromuscular, lower motor neuron and peripheral nerve disorder
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Client Prep: skeletal muscle relaxant is d/c by the doctor
Procedure: at bedside or EMG laboratory
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Nerve conduction tested 1st – flat electrodes placed along the nerves
muscle potential – multiple needle electrodes , ½ -3 inches
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Follow up care:• inspect needle site for hemato- ma formation→ apply ice• check complain of inc. pain and
anxiety
![Page 105: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/105.jpg)
Arthroscopy – for diagnostic test or surgical procedure
Arthroscope – a fiberoptic tube inserted into a joint for direct visualization
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Client Prep: client must be able to flex knee at least 40 degrees
- CI if client have joint infection - ambulatory basis/same day surgery
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Procedure: - local, light general or epidural anesthesia
- knee flexed at 40 degrees, irrigated
- less than ¼ inch incision, insert arthroscope
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Follow up care:1. evaluate neurovascular status of affected limb
2. monitor distal pulses, warmth, color, capillary refill, movement, pain, sensation of affected limb
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3. Encourage client to perform appropriate exercises
4. Ice – used for 24 hrs5. Elevate extremity for 24-48 hrs
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6. Monitor/ observe for:Swelling, HypothermiaIncrease joint pain due to mechanical injury
Thrombophlebitis, Infection
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Bone scan – radionuclide test in which radioactive material is injected for visualization of the entire skeleton
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- detect tumors, osteomyelitis,
arthritis,vertebral compression fracture, osteoporosis, unexplained bone pain
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Gallium/Thallium Scan – similar to bone scan but more specific and sensitive in detecting bone problem
![Page 117: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/117.jpg)
Radioisotopes used:Gallium citrate - most common
Thallium - osteosarcoma
![Page 118: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/118.jpg)
Client prep: Doctor/technician administer isotope 1-2 days before scanning
Procedure: 30-60 minutes, mild sedation for older clients or in severe pain, lie still
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Follow up care: encourage to push fluids
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Magnetic Resonance Imaging – image produced through the interaction of magnetic fields, radio waves and atomic nuclei showing hydrogen density
- more accurate than CT scan and Myelography
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- Gadolinium-DTPA (diethylenetriamine-pentacetid acid ) – contrast agent
- remove all metal objects, check clothing zippers and metal fasteners, surgical clip
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Ultrasonography – sound waves produce an image of the tissue
Visualizes:• Soft tissue disorder • Traumatic joint injuries• Osteomyelitis• Surgical hardware placement
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Common Health Problems of the Neonate & Infant:
Congenital Hip Displacement
![Page 124: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/124.jpg)
Head of the femur is improperly seated in the acetabulum, or hip socket of the pelvis
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Acetabulum of the pelvis is shallow.
Occurs most often among children of Mediterranean ancestry
6 times more frequently among girls than boys
![Page 126: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/126.jpg)
Can be congenital or develop after birth
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I. Dysplasia of the Hip
![Page 129: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/129.jpg)
AssessmentNeonates: laxity of the ligaments around the hip
Infants beyond the newborn period
![Page 130: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/130.jpg)
Affected leg appears shorter than the normal leg
Unequal number of skin folds on the posterior thigh
![Page 131: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/131.jpg)
Asymmetry of the gluteal & thigh skin folds
Limited range of motion (ROM) in the affected hip
![Page 132: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/132.jpg)
Asymmetric abduction of the affected hip
Apparent short femur on the affected side (Galeazzi sign, Allis sign)
![Page 133: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/133.jpg)
Galeazzi sign – apparent shortening of the femur; as shown with the difference of knee levels with the knees & hips flexed at right angle when patient is lying on a flat table
![Page 134: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/134.jpg)
The walking child: minimal to pronounced variations in gait w/ lurching toward the affected side; positive Trendelenburg sign
![Page 135: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/135.jpg)
Positive Barlow or Ortolani’s maneuver
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Barlow’s maneuver – performed by adducting the hip (bringing the thigh towards the midline) while applying a light pressure on the knees with the force directed posteriorly
![Page 137: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/137.jpg)
Positive Barlow test – if the hip can popped out from the socket
![Page 138: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/138.jpg)
Ortolani’s test or maneuver – physical exam for hip dysplasia
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Performed by gently abducting the infant’s leg with the examiner’s thumb while placing an anterior pressure on the greater trochanter (index & forefinger)
![Page 140: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/140.jpg)
Positive sign is a distinctive “clunk” which can be felt or heard as the femoral head relocates anteriorly into the acetabulum
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Diagnotic tests:X-ray (shows shallow acetabulum)
SonogramMagnetic Resonance Imaging
![Page 144: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/144.jpg)
ImplementationIn the neonatal period, splinting of the hips w/ Pavlik harness to maintain flexion & abduction & external rotation
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Multiple diapers – effectively separates the legs
Frejka splint – parents must keep the splint at all times except when bathing or changing diapers
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Following the neonatal period, traction &/or surgery to release muscles & tendons
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Bryant’s skin traction
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Following surgery, positioning & immobilization in a Spica cast
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Osteotomy following traction in profoundly affected children
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Pavlik Harness – an adjustable chest halter that abducts the legs
Method of choice for long term therapy; reduces therapy to 3-4 weeks, simplifies care
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The defect may be unilateral or bilateral
Long-term interval follow-up is required
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“Talus” – ankle“Pes” – foot1 in every 1000 children born with the defect
Boys are affected than girls
![Page 158: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/158.jpg)
Congenital Clubfoot
![Page 159: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/159.jpg)
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AssessmentThe foot is plantar flexed w/ an inverted heel & adducted forefoot
![Page 162: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/162.jpg)
ImplementationTreatment begins as soon after birth as possible
![Page 163: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/163.jpg)
Serial manipulation & casting are performed weekly, if correction is not achieved in 3 to 6 months, surgery is indicated
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Monitor neurovascular status of the toes
![Page 166: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/166.jpg)
Instruct parents in cast care & the signs of neurovascular impairment that requires physician
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Dennis Browne SplintFor clubfoot/congenital Talipes Equinovarus
Tendon is short – complete soft tissue release
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Torticollis (wry neck) – head is tilted/turned to 1 side; chin is elevated & turned to the opposite side
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Head position should be corrected before adulthood
Affects 2% of newborn
![Page 173: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/173.jpg)
Diagnosis:History taking – determine circumstances surrounding birth, trauma or associated symptoms
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Physical examination – shows decreased rotation & bending to the side opposite the muscle affected
Neck muscles/areas between
![Page 175: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/175.jpg)
the neck & shoulder are tense & tender
Management:Medications (muscle relaxants/NSAIDs)
Physical devices
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Botulinum toxinSurgery
![Page 177: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/177.jpg)
Radiographic examination – radiographs of the cervical spine
MRI – for structural problems
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Common health Problem of Young Adolescent
Scoliosis
![Page 179: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/179.jpg)
Scoliosis A lateral curvature
of the spine
![Page 180: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/180.jpg)
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AssessmentVisible curve fails to straighten when the child, bends forward & hangs down toward feet
![Page 183: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/183.jpg)
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Hips, ribs, & shoulders are asymmetrical
Apparent leg length discrepancy
![Page 185: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/185.jpg)
Assessment
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ImplementationPrepare the child & parents for the use of a brace if prescribed
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Prepare the child & parents for surgery (spinal fusion; placement of internal instrumentation rods) if prescribed
![Page 188: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/188.jpg)
BracesUsually worn from 16 to 23 hours a day
![Page 189: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/189.jpg)
Keep the skin clean & dry, avoiding lotions & powders
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Advise the child to wear soft nonirritating clothing under the brace
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Common Health Problem of the Young Adult:
Osteogenic Osteosarcoma
![Page 192: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/192.jpg)
Osteosarcoma/Osteogenic sarcoma
Most common type of primary malignant tumor
50% occur in distal femur
![Page 193: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/193.jpg)
Primary – those that originate in bone
Secondary – those that originate in other tissues & metastasize to bone
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Clinical Manifestations:PainSwellingLarge lesionSclerotic central massSunburst appearance
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Inward bony expansionIncidence:Occurs more often in males than females (2:1); 10-20 y/o
Older clients with Pagets disease
![Page 196: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/196.jpg)
Primary tumors (breast, prostate, kidneys, thyroid, lungs) bone seeking tumor cells carried to bone (blood stream) pathologic fracture
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Laboratory Assessment:Elevated serum alkaline phosphatase
Elevated serum Ca levelElevated ESR
![Page 198: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/198.jpg)
Radiographic Assessment:Bone destructionIrregular periosteal new boneCortical breakthroughIncrease/decrease bone density
![Page 199: Musculoskeletal Lecture](https://reader037.vdocument.in/reader037/viewer/2022102922/5473e71db4af9f8c408b462a/html5/thumbnails/199.jpg)
MRIBone scan
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Nursing diagnoses:Acute/Chronic Pain r/t physical injury
Anticipatory grieving r/t change in body image
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Disturbed body image r/t effects of illness, treatment including surgery
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Interventions:Treatment is aimed at reducing the size/removing tumor
Drug therapy – analgesics, chemotherapeutic agents
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Radiation therapy – reduce tumor size & pain
Surgery
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Common Health Problems of the Adult:
Adult Rheumatoid Arthritis
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Rheumatology – study of rheumatic disease
Rheumatic disease – disease/condition affecting the musculoskeletal system
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Arthritis – inflammation of one or more joints
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Rheumatoid Arthritis (RA)Most common connective tissue disease
Most destructive to the joints
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Chronic, progressive, systemic inflammatory autoimmune disease affecting the synovial joints
characterized by remissions & exacerbations
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Autoantibodies (rheumatoid factors RF’s) are formed attack healthy tissues (synovium) inflammation of synovial membrane synovium thickens fluid accumulates in joint space pannus formation erosion of cartillage bone erosion
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Pannus – vascular granulation tissue composed of inflammatory cells; erodes the cartillage & eventually destroys bone
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Etiology of RA is unclear; research suggests a combination of genetic & environmental factors
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Some researchers suspect female reproductive hormones
Epstein Barr virusPhysical/emotional stress
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Clinical Manifestations:Joint stiffnessSwelling Painfatigue
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Generalized weaknessMorning stiffnessUpper extremity joints affected (proximal interphalangeal/metacarpophalangeal joints)
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Bilateral/symmetric joint affectation; number of joints affected increases
Gel phenomenon – morning stiffness that lasts 45 minutes to several hours upon awakening
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Swan neckUlnar deviation
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Laboratory Assessment:No single test that confirms the disease
Rheumatoid factor – measures the presence of unusual antibodies IgM, IgG types
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Antinuclear Antibody TiterErythrocyte Sedimentation Rate (ESR) – diagnosis of inflammatory CT disease
C Reactive Protein test
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Standard X-ray – visualize joint changes & deformities
CT Scan – determines cervical spine involvement
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Arthrocentesis – synovial fluid is analyzed for inflammatory cells & immune complexes; RF included
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Nursing responsibility:Monitor insertion site for bleeding/leakage of synovial fluid
Teach the client to use ice & rest affected joint for 24 hrs.
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Management:NSAID’sDisease-Modifying Anti-Rheumatic Drugs – hydroxychloroquine (Plaquenil)
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Sulfasalazine (Azulfidine)Minocycline (Minocin)Methotrexate (Rheumatrex) – immuno suppressive medication
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Gold therapyGold sodium thiomalate (Myochrysine)
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Nonpharmacologic modalities:
Adequate restProper positioningIce & heat applications
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Gouty Arthritis (Gout) – systemic disease in which urate crystals deposit in joints causing inflammation.
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2 types of gout:1.Primary gout – most common type; results from 1 of several inborn errors of purine metabolism
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Production of uric acid exceeds the excretion capability of the kidneys
Sodium urate is deposited in synovium causing inflammation
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2. Secondary gout – involves hyperuricemia (excessive UA in blood) caused by another disease
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Renal insufficiency, diuretic therapy, chemotherapeutic agents; multiple myeloma
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4 phases of the primary disease:
1.Asymptomatic hyperuricemic phase – serum level elevated; no overt signs of disease
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2. Acute phase – 1st attack of gouty arthritis; excruciating pain in 1 or more small joints (metatarsophalangeal joint of the great toe)
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Podagra – 75% experience inflammation of this joint as the initial manifestation
Elevated ESR & WBC
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3. Intercritical/Intercurrent state of the disease – attack occurs after months or years; asymptomatic; no abnormalities found in joints
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4. Chronic tophaceous gout – deposits of urate crystals develop under the skin & major organs
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Gout affects more men than women
Clinical Manifestations:Acute gout – Painful inflamed joints
Chronic gout – inspect for tophi
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Tophi – deposits of Na urate crystals; commonly appear on the outer ear
Arms & fingers near the joints
Renal calculi
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Diagnostic tests:Serum uric acid – more than 8 mg./100 ml.
Urinary uric acid levels – more than 600 mg./24 hr after a 5 day restriction of purine intake
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Synovial fluid aspiration (arthrocentesis) – detect the presence of needle-like crystals
Drug therapy:Colchicine (Colsalide) – works within 12 hrs.
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Repeated acute gout/chronic gout – Allopurinol (Zyloprim) – promotes uric acid excretion
Nurse monitors serum uric acid levels to check the effectiveness of medications
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Diet therapy: Strict low-purine diet; avoid foods such as organ meats, shellfish, oily fish with bones (sardines)
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Avoid aspirin & diureticsAvoid excessive physical/emotional stress
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Force fluidsIntake of Alkaline ash foods – citrus foods & juices, milk
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Carpal Tunnel SyndromeCarpal tunnel – rigid canal between the carpal bones and flexor retinaculum
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Compressed median nerve in the wrist
Pain and numbnessParesthesia ( painful tingling )
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Etiology and Genetic risk:Excessive hand exerciseEdema or hemorrhage into CT
Thrombosis of the median artery
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CTS – most common repetitive strain injury (RSI)
- fastest growing type of occupational injury : factory worker, computer operators etc; sports activities ( golf, tennis )
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Incidence and prevalence :Adults – bet 30-60 yrs oldWomenDominant handChildren and adolescent – computer use
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Clinical Manifestation: Phalen’s maneuver/testRelax the wrist into flexion Place back of hands together and flex both wrist
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(+) – paresthesia palmar side of thumb, index and middle finger, radial half of ring finger
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Tinel’s signLightly tapping area of median nerve in the wrist
(+) – paresthesia
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BP cuff placed on the upper arm , inflated to the client’s systolic pressure
(+) – pain and tingling
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Diagnostic Assessment :Xray – bone changes, lesions, synovitis
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EMG- nerve dysfunctionMRI ,UTZFinding : Enlarged median nerve within the carpal tunnel
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Interventions: NonsurgicalDrug – NSAIDS Immobilization - splint
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SurgicalOpen carpal tunnel release (OCTR)
Endoscopic carpal tunnel release ( ECTR )
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Synovectomy – for rheumatoid arthritis , complication of CTS
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Post Operative Care:Elevate hand and arm above heart level
Check neurovascular status
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Move fingers of affected hand
Restrict hand movements, lifting heavy objects – 4 to 6 wks after surgery
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Musculoskeletal disorders:Metabolic bone diseases (osteoporosis, Paget’s disease)
Bone tumors Bone deformities
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Osteoporosis Metabolic diseasebone demineralizationDecreased bone densityFractures
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“silent disease”Mostly affected are wrists, hip & vertebral column
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Osteoclastic (bone resorption) activity exceeds osteoblastic (bone building) activity decreased bone mineral density (BMD) loss of spongy bone/cortical bone
fragile bone tissue Fracture
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Diagnosis is based on BMD values using T-scores
T-score – the number of standard deviations above or below the average BMD for young, healthy white women
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Osteopenia – T-score between 1 & 2.5
Osteoporosis among postmenopausal women BMD T-score more than 2.5 standard deviations below normal
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2 theories in osteoporosis:May result from decreased osteoblastic activity
Increased osteoclastic (bone resorption) activity
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Classification of osteoporosis:
1.Generalized osteoporosis:Involves many structures in the skeleton
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Primary osteoporosis – occurs among postmenopausal women/men in 6th or 7th decade of life
Decrease estrogen/testosterone
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Secondary osteoporosis – results from associated medical conditions (hyperparathyroidism, long term corticosteroid use, prolonged immobility)
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2. Regional osteoporosis – occurs when limb is immobilized r/t fracture, injury, paralysis or joint inflammation
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Immobilization greater than 8-12 weeks
Exact cause of osteoporosis is unknown
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About 98% of peak bone mass achieved by 20 years of age
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Building strong bone as a young person – best defense against osteoporosis in later adulthood
(National Osteoporosis Foundation 2003)
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Most health care providers focus on the risk of osteoporosis in women older than 50 years old & do not assess risk as often in women 49 years of age & younger (Berarducci et.al 2000)
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Risk factors:Postmenopausal womenBreast Ca survivorsGenetics – Hx of fracture among a 1st degree relative
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Thin, lean built White, Asian women
Protein deficiencyAlcohol consumption/Cigarette smoking
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IncidenceWomen are affected than men 80%
1.5 million fractures/year300,000 are hip fractures
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Clinical Manifestations:“dowager’s hump” or kyphosis of the dorsal spine
Client verbalized that height has been shortened (2-3 inches)
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Backpain occurs after lifting, bending or stooping
Pain is worsened by activity & relieved by rest
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Laboratory Assessment:No definite laboratory test that confirm a diagnosis of primary osteoporosis
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uPYR Crosslinks assay – measures urinary concentrations of pyridinium; a collagen substance found in bone & cartilage
Increased urinary levels indicate bone resorption
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Radiographic AssessmentX-rays of the spine & long bones show loss of bone density & fractures
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Bone density changes are evident if 25-40% of bone loss has occurred
Dual-energy x-ray absorptiometry (DEXA) – painless scan that measures
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bone mineral density (BMD)
Physicians recommend that women in their 40’s have a baseline DEXA
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Nursing diagnoses:Impaired physical mobility r/t decreased muscle strength, pain
Acute/Chronic pain r/t effects of acute physical illness
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Interventions:MedicationsNutritional therapyExercise
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Drug therapy:HRTCa supplementsVitamin D
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BiphosphonatesSelective estrogen receptor moduloators (SERM’s)
Calcitonin
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Hormone Replacement Therapy (HRT)
Used as primary prevention strategy for reducing bone loss among post menopausal woman
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Long term effects of HRT include breast’s CA, CV disease & stroke
Parathyroid hormone – teriparatide (Forteo), SQ injection
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Calcium – not a treatment for osteoporosis; it is an important part of the prevention program in promoting bone health
Ca carbonate (Tums, OsCal)
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Teach clients to take Ca with food & 6-8 ounces of H20
Instruct clients to take foods rich in Ca (Milk & dairy products, green leafy vegetables)
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Vitamin D for optimal Ca absorption in the small intestines
Bisphosphonates – inhibit bone resorption by binding with crystal elements in bone
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alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel)
Nursing Alert:Instruct clients to take the drug early in the morning with 8 oz.
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of H2O & wait 30 minutes before eating. Must remain upright during the 30 minutes before eating
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Selective Estrogen Receptor Modulators (SERM’s)
Designed to mimic estrogen in some parts of the body & blocking its effect elsewhere
Raloxifene (Evista)
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Calcitonin – inhibits osteoclastic activity
Diet therapy – Ca & Vitamin D intake must be increased; alcohol & caffeine consumption must be discouraged
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Fall prevention – a hazard free environment is necessary
“Falling star protocol”Exercise – PT’s prescribed exercises that strengthen the
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Abdominal & back muscles; active ROM exercises
Walking 30 minutes 3X a week, swimming & bicycling are recommended
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Bowling & horseback riding are avoided – may cause vertebral compression
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Orthotic devices or dorsolumbar orthoses – immobilize the spine during acute pain phase & provide spinal column support
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Osteomalacia – softening of the bone tissue; characterized by inadequate mineralization of osteoid
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EtiologyPrimary Vitamin D deficiency – lack of sunlight exposure, poor dietary intake, malabsorption of Vitamin D
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HypophosphatemiaIntake of barbiturates, anticonvulsants & fluoride
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Incidence:Common among non industrialized nations
Strict vegetarians without adequate supplement of Vitamin D
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Muscle weaknessJoint painWaddling & unsteady gait (due to muscle weakness)
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Diagnostic Assessment:X-ray – reveal a decrease in the trabeculae of cancellous bone & lack of osteoid sharpness
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Classic diagnostic finding – presence of radiolucent bands (Looser’s lines/zones)
Looser’s zones – stress fractures that have not mineralized.
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Bone biopsy will confirm the diagnosis
Interventions:Major treatment is Vitamin D
RDA – 400 IU
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Meeting the RDA for Vitamin DAdvise clients to get sun exposure for at least 5 minutes weekly
Eat food high in Ca to promote Vitamin D absorption
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Eat foods high in Vitamin D including milk & dairy products, ice cream, yogurt & cheese
Egg, swordfish, chicken, liver & cereals
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Characteristic
Osteoporosis Osteomalacia
Definition Decreased bone mass
Demineralized bone
Pathophysiology
Lack of Ca Lack of Vitamin D
Radiographic Findings
Osteopenia/fractures
Pseudofractures, Looser’s zone, fractures
Calcium level Normal Low or Normal
Phosphate level
Normal Low or Normal
Parathyroid hormone
Normal High or Normal
Alkaline Phosphatase
Normal High
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Osteoarthritis (Degenerative Joint Disease DGD)
most common arthritis2nd most common cause of disability among adults in U.S.
Common cause of disability worldwide
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Progressive deterioration & loss of cartilage in 1 or more joints
Affects weight bearing joints (hips, knees, vertebral column)
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Cartilage becomes soft fissures/pitting develop cartilage thins joint space narrows bone spurs formed
inflammatory enzymes enhance tissue deterioration
repair process fails
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Causative mechanism of primary Osteoarthritis at the cellular level has not yet identified
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Predisposing factors:DevelopmentalGeneticMetabolicTrauma
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Age – strongest risk factorAbout ¾ of people older than 55 y/o has joint changes seen in X-rays
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Health promotion/ Illness prevention:
Keep weight within normal limits
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Avoid/limit activities that promote stress on joints (jogging)
Limit participation in recreational sports, risk seeking activities to prevent trauma
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Assessment: Ask questions about the course of the disease
Collect information specific for OA (nature/location of joint pain)
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Ask clients about their occupation, nature of work, Hx of trauma, weight history & exercise
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Physical Assessment:Middle-aged/older women who complains of chronic joint pain or stiffness
Pain during palpation/ROM
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CrepitusEnlarged jointsHeberden’s nodes – (distal interphalangeal joint)
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Bouchard’s nodes – (proximal interphalangeal joint)
Atrophy of skeletal musclesHip/knee pain cause the client to limp
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Laboratory assessment:Elevated erythrocyte sedimentation rate (ESR)
High-sensitivity C-Reactive Protein
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Radiographic assessment:Structural joint changesCT scan MRI
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Nursing Diagnoses:Chronic pain r/t muscle spasm, cartilage degeneration & joint inflammation
Impaired physical mobility r/t pain & muscle atrophy
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Major concern is pain controlNon-surgical management:AnalgesicsRestPositioningThermal modalities
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Acetaminophen (Tylenol) – drug of choice
NSAID’sDirect injection with cortisone
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RestLocal rest – immobilizing a joint with a splint or brace
Systemic rest – immobilizing the whole body – nap
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Psychological rest – relief from daily stress
Positioning – joint in functional position; small pillow under the neck or head
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Elevate the legs (8-12 inches)Thermal modalities:Heat application (hot showers, baths, hot packs, compresses & moist heating pads)
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Weight controlTranscutaneous Electrical Nerve Stimulation (TENS)
Stem cell therapy
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Surgical Management:Total joint arthroplasty – surgical creation of a joint
Arthroscopy- less invasive procedure to remove damage cartilage
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Total hip arthroplasty – performed among clients greater than 60 y/o
Common complication - subluxation
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Position client in supine position with the head slightly elevated with abduction pillow in between the legs to prevent adduction
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Life threatening complication – Deep Venous thrombosis (DVT) & pulmonary embolism
Use thigh high stockings & sequential compression devices
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Anticoagulant:Low molecular weight heparin
Aspirin
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Client getting out of bed – stand on the side of affected leg; client assumes sitting position, client stands on the unaffected leg & pivot to the chair with assistance
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Client must not flex the hips more than 90 degrees
Partial weight bearing allowed for the 1st few weeks/x-ray evidence of bony growth
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Characteristic Rheumatoid Arthritis (RA)
Osteoarthritis (OA)
Age of onset 35-45 y/o > 60 y/o
Gender Affected
Female (3:1) Female (2:1)
Risk factors/cause
Autoimmune (Genetic)
Aging, genetic factor, obesity, trauma, occupation
Disease process
Inflammatory Degenerative
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Disease pattern
Bilateral, symmetric, multiple joints, usually affects upper extremities firstDistal interphalangeal joints of hands sparedSystemic
Unilateral, single joint, affects weight bearing joints & hands,spineMetacarpophalangeal joint sparedNon-systemic
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Lab findings Elevated rheumatoid factor, antinuclear antibody, ESR
Normal or slightly elevated ESR
Dug therapy NSAID’s, Corticosteroids, Methotrexate, Leflunomide (Arava
NSAID’s, Acetaminophen
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Osteomyelitis – inflammation/Infection of bone tissue
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Exogenous osteomyelitis – infectious organisms enter from outside of the body (from open fracture)
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Endogenous osteomyelitis (hematogenous osteomyelitis)– organisms are carried by the blood stream from other areas of infection
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Contiguous bone infection results from skin infection of adjacent tissues
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2 Major types of Osteomyelitis:Acute hematogenous infection – results from bacteremia, underlying disease or non- penetrating trauma
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Subchronic/chronic osteomyelitis – due to inadequate treatment.
About 50% of cases due to gram negative bacteria
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IncidenceHematogenous osteomyelitis is the most common type
More common among children; increasingly common in adults
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Men experience osteomyelitis more frequently than women
Bone tissue in vertebrae & long bones are common sites of infection
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AssessmentBone pain – common complaint of client’s with bone infection
Constant, localized, pulsating sensation that intensifies with movement
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Fever (> 38° C)Area of infected bone swells; tender to palpation
ErythemaDraining ulcers
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Elevated WBC countElevated ESR valueBone scan using technetium or gallium is helpful in the diagnosis
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Definitive diagnosis – bone biopsy
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Nursing Diagnoses:Acute/Chronic Pain r/t inflammation
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Hyperthermia r/t pathogenic invasion of the bone
Ineffective tissue perfusion (peripheral) r/t tissue swelling
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Interventions:IV antibiotics Hyperbaric Oxygen Therapy – affected area is exposed to a
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high concentration of O2 that diffuses in the tissues to promote healing
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Sequestrectomy – to debride the infected bone; allow revascularization of tissues
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Common Health Problems Across the Life Span:FracturesTraction
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Fracture – break or disruption in the continuity of bone
Caused by direct blow, crushing force, sudden twisting motion or extreme muscle contraction
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Classification of fractures:According to the extent of the break:
Complete fracture – break is across the entire width; bone is divided into 2 distinct sections
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Incomplete fracture – partial break in the bone; break is confined through only part of the bone
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According to the extent of associated soft tissue damage:
Open (Compound) – skin over broken bone is disrupted; soft tissue injury & infection are common
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These are graded to define the extent of tissue damage:
Grade 1 – least severe injury; skin damage is minimal
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Grade 2 – accompanied by skin & muscle contusions
Grade 3 – damage to the skin, muscle, nerve tissue & blood vessels
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Wound is more than 6-8 cms.
Closed (simple) fracture – skin over the fractured area remains intact
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Pathologic ( spontaneous) – occurs after minimal trauma to a bone that has been weakened by a disease
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Greenstick fracture – one side of bone is broken, the other is bent, most commonly seen in children
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Classification According to pattern:
Transverse fracture – bone is broken straight across
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Oblique fracture – the break extends in an oblique direction; slanting direction
Spiral fracture – the break partially encircles the bone
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Classification as to appearance:
Comminuted – bone is splintered or crushed with 3 or more fragments
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Impacted – when fractured end of bones are pushed into each other
Compression fracture – produced by a loading force applied to the long axis of cancellous bone
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Depressed – usually occurs in the skull; broken bone driven inward
Longitudinal – break runs parallel with bone
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Fracture dislocation – fracture is accompanied by a bone out of joint
Fatigue or stress fracture results from excessive strain or stress on the bone
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Fractures
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Classification in relation to the joint:
Intracapsular within the jointExtracapsular – outside the capsule
Intra-articular – within the joint
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Classification as to Location:
ProximalDistalMid-shaft
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Clinical Manifestations:Pain or tenderness over the involved area
SwellingLoss of function
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Obvious deformityCrepitus – grating sensation either heard or felt
Erythema, EdemaMuscle spasm/impaired sensation
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Bleeding from an open wound with protrusion of fractured bone
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Principles of fracture treatment:
Reduction of bone fragments to normal position & immobilization
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Maintenance of reduction until healing is sufficient to prevent displacement
Preservation & restoration of musculoskeletal function
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Stages of bone healing: 1. Hematoma formation – blood accumulates into the area between & around the fragments. The clot begins 24 hrs after the fracture occurs
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2. Cellular proliferation – (within 5 days) hematoma undergoes organization. Fibrin strand form with the clot creating a network for revascularization & invasion of fibroblast & osteoblast.
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Beginning of external cartilaginous callus formation.(osteoid tissue)
3. Callus formation – (2-3 weeks) minerals are being deposited in the osteoids forming a large
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mass of differentiated tissue bridging the fractured bone.
4. Ossification – mineral deposition continues & produces a firmly reunited bone. Final ossification takes
3-4 months.
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5. Consolidation & remodeling – final stage of fracture repair consists of removal of any remaining devitalized tissue & reorganization of new bone
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Interventions for Fracture:ReductionFixationTractionCasts
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Reduction – restoring the bone to proper alignment
Closed Reduction – performed by manual manipulation
Maybe performed under local/general anesthesia
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Open Reduction – involves surgical intervention
Treated with internal fixation devices
Client may be placed in traction or cast following the procedure
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Fixation Internal fixation – follows open reduction
Involves the application of screws, plates, pins, nails to hold the bone fragments in alignment
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May involved the removal of damaged bone & replacement with a prosthesis
Provides immediate bone strength
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Risk of infection is associated with this procedure
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External fixation – an external frame is utilized with multiple pins applied through the bone
Provides more freedom of movement than with traction
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Roger Anderson External Fixator (RAEF)
For fracture of the tibia, radius, ulna done under anesthesia
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Ilizarov fixator – for severe comminuted fracture, bone lengthening
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Plaster cast – a temporary immobilization device which is made up of gypsum sulfate
Undergoes unhydrous calcinations when mixed with water, swells & forms into a hard cement
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Made of rolls of plaster bandage, wet in cool water & applied to the body
Cools after 15 minutesRequires 24-72 hrs to dry completely
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Non-plaster cast –(fiberglass cast)
Lighter in weight, stronger, water resistant & durable
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Impregnated with cool water-activated hardeners & reach full rigidity in minutes
Diminish skin problems
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Functions:To immobilizeTo prevent or correct deformity
To support, maintain & protect realigned bone
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To promote healing & early weight bearing
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Materials for casting:StockinetteWadding sheetPlaster of Paris
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Complications of cast:1.Neurovascular compromise
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Watch out for 6 P’s:PainPulselessnessPallor
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ParesthesiaParalysisPoikilothermia
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2. Incorrect alignment3. Cast syndrome – (Superior
mesenteric artery syndrome) occurs with body casts; any cast that involves the abdomen
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Decreases the blood supply to the bowel
Signs/Symptoms:Abdominal pain, nausea & vomiting
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4. Compartment syndrome –increased pressure within a limited space, compromises the function & circulation in the area
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Long arm posterior moldFracture of radius/ulna with open wound, swelling or infection
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Mechanical Aids for Walking:Canes:Standard straight-legged caneTripod or crab caneQuad cane – provides the best support
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Standard cane – 36 inches in length
The length should permit the elbow to be slightly flexed
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Health Teachings:Hold the cane with the hand on the stronger side of the body
Position the standard cane 6 inches to the side & 6 inches in front of the near foot.
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When Maximum Support is Required:
Move the cane forward 1 foot while the body weight is borne by both legs
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Move the weak leg forward to the cane while weight is borne by the cane & stronger leg
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Move the stronger leg forward ahead of the cane & weak leg while the weight is borne by the cane & weak leg.
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Walkers – for ambulatory clients needing more support than a cane provides.
Client needs to bear at least partial weight on both legs
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Hand bar below the client’s waist & client’s elbow slightly flexed
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Crutches Axillary crutch with hand bars
Loftstrand bar – extends only to the forearm; substitute to cane
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Canadian or Elbow Extensor Crutch – made of single tube of aluminum with lateral attachments, a hand bar, cuff for the forearm & has a cuff for the upper arm
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Nursing Alert:The weight of the body must be borne by the arms rather than the axillae (can injure the radial nerve, eventually can cause crutch palsy)
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Crutch Palsy – weakness of the muscles of the forearm, wrist & hand
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Measuring Clients for Crutches:
To obtain the correct length for the crutches & the correct placement of the handpieces
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2 ways to measure the crutch length:
Client in supine position, the nurse measures from the anterior axillary fold to the heel of the foot & add 1 inch.
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The client stands erect. The shoulder rest of the crutch is at least 3 finger widths, that is 1-2 inches below the axilla.
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The angle of the elbow flexion must be 30 degrees.
Tip of the crutch is 6 inches from the side & 4 inches from the front of the foot.
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Crutch stance (Tripod Position) –proper standing position with crutches.
Crutches are placed 6 inches in front of the feet & 6 inches laterally.
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Crutch gait – gait a person assumes on crutches by alternating body weight on one or both legs & the crutches.
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5 Standard Crutch Gaits:Four Point GaitThree Point Gait2 Point GaitSwing toSwing through
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Four Point- Alternate Gait – most elementary, safest gait; client needs to bear weight on both legs
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The nurse ask the client to:Move the right crutch ahead 4-6 inches.
Move the left front foot forward, to the level of the left crutch
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Move the left crutch forward
Move the right foot forward
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3 Point GaitClient bears entire body weight on the unaffected leg
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Both crutches & affected leg advances
Unaffected leg advances
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Two-Point Alternate Gait Partial weight bearing on each foot
Faster than 4 point gait
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Move the left crutch & the right foot together
Move the right crutch & the left foot ahead together
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Swing – To Gait – paralysis of the legs & hips
Move both crutches ahead together
Lift body weight by the arms & swing to the crutches
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Swing –Through Gait Move both crutches forward together
Lift body weight by the arms & swing through beyond the crutches
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Going up the StairsNurse stands behind the client
Placing weight on crutches while moving the unaffected leg onto the step
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Going down the StairsThe nurse stands 1 step below
Moving the crutches & affected leg to the next step
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Traction – is the act of pulling and drawing which is usually associated with counter traction
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Provides proper bone alignment & reduces muscle spasm
For support, reduce bone fracture
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Nursing responsibility:Maintain proper body alignment
Ensure that the weights are hanging freely
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Ensure that pulleys are not obstructed; pulleys move freely
Place knots in the ropes to prevent slipping
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Types of traction:Manual traction – done with the use of the hands of the operator
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Skeletal traction – pin is driven across the bone to provide an excellent hold while a weight is attached
Use of pins, tongs & wires
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Crutchfield tongsFor fracture of cervical spineC1-C5 cervical spine tensionUse for 4 weeks
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Vinke’s skull caliperC1-C5 cervical spine tension
Use for 4 weeks
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Nursing responsibility:Monitor color, motion & sensation of affected extremity
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Monitor the insertion site for redness, swelling or infection
Provide insertion site care as prescribed
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Skin traction – applied by the use of elastic bandages or adhesive straps to the skin while a pull is applied by a weight
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2 Types:Non-adhesive type – uses laces, buckles, leather & canvas
Ex. Head halter strap
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Adhesive type – uses adhesive tape or elastic bandages
Ex. Dunlop skin traction
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Cervical skin traction – relieved muscle spasm & compression in the upper extremities & neck
Uses a head halter & chin pad
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For cervical spine affectation
For Pott’s disease
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Principles of traction:1.Patient must be in dorsal recumbent position
2.Line of pull should be in line with the deformity. Consider the position of diagonal bar & positioning of pulley.
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1st pulley in line with the thigh, 2nd pulley in line with the knee or screw, 3rd pulley in line with the 2nd & 3rd pulleys
Weight bag must be at the level of the bed frame
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3.Traction must be continuous. Emphasized the importance of manual traction.
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4. Avoid friction – rope should be running along the groove of the pulley, knots away from the pulley. Weights should be hanging freely. Observe for wear & tear of ropes.
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5. Provide counter traction. For every traction there must be a counter traction (Patient’s body weight)
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Nursing Care of Patients with Traction:
1. AssessmentAssess patient as to level of understanding/consciousness
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2. Provision of general comfort
Skin care – head to toe; focus on the sponging of affected extremity
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3. Potential Complications:Upper respiratory – Pneumonia – back tapping & deep breathing
Bed sore – good perineal care; proper skin care, turning, lift buttocks once in a while
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Urinary & kidney problem – good perineal care, increase fluid intake
Bowel complication – fear of apparatus, no privacy, lack of fluids/perineal care
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Pin site infection – observe for signs & symptoms of infection; loosening pin tract, pus coming out from insertion site, foul smelling odor, fever
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Deformity – contracted knees, atrophy of muscles, foot drop, joint contractures
4. Provision of Exercises:ROM exercises with the use of trapeze
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Deep breathing exercisesStatic quadriceps exercise – alternate contraction & relaxation of quadriceps muscles
Toe pedal exercises
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5. Nutritional status6. Psychological aspectFear of the unknown, fear of death, fear of apparatus, fear of losing a job, financial fear
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7. Provision of supportive therapy
Offer books to read, listen to radio or TV, discover interest
8. Spiritual aspect
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Know patient’s religion, encourage relatives to give spiritual communication, visiting chaplain
Divertional activities – divert attention for any pain
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Knee Injuries Medial/lateral meniscus – act as shock absorbers; can tear.
Tearing – result of twisting the leg when the knee is flexed & foot is placed firmly on the ground.
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Medial meniscus tear – due to internal rotation
Lateral meniscus tear – due to external rotation
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“Bucket handle injury” – causes the knee to lock; torn cartilage jams between the femur & tibia thus preventing the extension of knees.
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Diagnostic tests:McMurray test – examiner flexes & rotates the knee & then presses on the medial aspect while slowly extending the leg.
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Positive test – if clicking is palpated or heard
Clinical manifestations:PainSwelling
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Tenderness in the kneeClicking/snapping sound
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Management:Locked knee – manipulation; casting for 3-6 weeks
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Meniscectomy – Partial/total
Open meniscectomy – requires a surgical incision
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for the removal of all or the part of the meniscus
Closed meniscectomy – accomplished through an arthroscope
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Client begins leg exercises immediately after the procedure to strengthen the leg, prevent thrombophlebitis & reduce swelling.
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Elevate the affected leg to 1 or 2 pillows
Apply ice to reduce swellingFull weight bearing restricted for several weeks
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Dislocations/Subluxations Occurs when articulating surfaces are no longer in proximity
Common in shoulder, hip, knee & fingers
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Etiology:TraumaCongenital/pathologic - arthritis
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Clinical manifestations:PainImmobilityAlteration in contour of jointDeviation in length of extremityRotation of extremity
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Management:Closed manipulation/reduction
Cast – immobilized the joint until healing
Traction/splint
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Strain (muscle pull) – excessive stretching of a muscle or tendon when weak or unstable
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Etiology:FallsLifting of heavy itemsExercise
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Classification according to severity:
1.1st degree (mild) strain – mild inflammation, little bleeding, swelling, ecchymosis & tenderness
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2. 2nd degree (moderate) strain – tearing of muscle or tendon fibers without complete disruption; muscle function might be impaired
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3. 3rd degree (severe) strain – ruptured muscle or tendon, involving separation of muscle to muscle, muscle to tendon or tendon from bone
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ManagementCold & heat applicationsExerciseActivity limitationsNSAIDs
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Muscle relaxantSurgical repair
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Sprains – excessive stretching of a ligament
Etiology : twisting motion from falls; sports activity
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Classification according to severity:
1.1st degree (mild) sprain – involves tearing of a few fibers of a ligament; joint function not affected
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2. 2nd degree (moderate) sprain – more fibers are torn; stability of joint remains intact
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3. 3rd degree (severe) sprain – marked instability of joint
Clinical manifestations: Pain Swelling
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Management:1st degree sprain:RestIce (24-48 hrs.)
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Application of compression bandage (reduce swelling; provide support)
Elevation
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2. 2nd degree sprain – immobilization (elastic bandage, splint or cast), partial weight bearing until ligament heals
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3. 3rd degree (severe) sprain – immobilization (4-6 weeks); surgery
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Amputation – removal of the part of the body
Note: The nurse recognizes that the psychosocial effect of the procedure is more devastating than the physical impairment
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Loss experienced is complete & permanent causing a change in body image & self esteem
Amputation – ranges from removal of part of a digit to removal of nearly half of the entire body.
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1. Open (guillotine) method – for clients with infection, for those who most likely to develop infection
Wound remains open, drains allow exudates to escape until infection clears
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Surgeon suture the skin flaps over the wound at a later time
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2. Closed (flap) method – surgeon pulls the skin flaps over the bone end & sutures them in place. 1 or more drains are inserted.
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Traumatic amputation – occurs when body a part is severed unexpectedly; attempt of replantation is possible
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Levels of amputation:Lower extremity amputation performed frequently
Syme amputation – most of the foot removed; ankle preserved
for peripheral vascular disease
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Advantage – weight bearing can be achieved without the use of prosthesis & without pain
Below knee amputation (BKA) – preserve the knee joints
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Above knee amputations – cause of amputation extends beyond the knee
The higher the level of amputation more energy is required for ambulation
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Complications of amputations:
HemorrhageInfection
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Phantom limb painNeuroma – sensitive tumor found in severed nerve endings
Flexion contractures
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Phantom limb pain – frequent complication of amputation
More often after AKAFelt during the early post op period
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Common among clients who experienced chronic limb pain before the surgery
Client complains of pain (intense crushing/burning) in the removed body part most often shortly after surgery
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Incidence/Prevalence:More than 100,000 amputations yearly in US
Half of these among clients with DM
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Middle aged or older man with DM & a lengthy history of smoking
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2nd largest group affected young men involved in vehicular accidents (Motorcycle)
Injury at work (industrial equipment)
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Diagnostic assessment:Measurement of segmental limb BP – Ankle-brachial index – Ankle systolic pressure/Brachial systolic pressure
Normal ABI=1 or greater
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Doppler ultrasonographyLaser Doppler flowmetryTranscutaneous Oxygen Pressure
Angiography
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Ultrasonography – measures the velocity of blood flow in the limbs
TcPO2 – measures the oxygen pressure to indicate blood flow in the limb
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Nurse’s Primary Focus:Monitor for signs that there is sufficient tissue perfusion but no hemorrhage
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Pain Management:Phantom limb pain – recognize that pain is real; It is not therapeutic that the limb can’t hurt because it is missing.
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Drug therapy:IV Infusion of Calcitonin (Calcimar) – during the week of amputation
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Alternative treatment:Transcutaneous Electrical Nerve Stimulation (TENS)
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MassageDistraction therapyPrevention of Infection:Initial pressure dressings/drains usually removed in 48-72 hrs after surgery.
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Promotion of ambulation:Start muscle-strengthening exercises before the surgery
Arrange for a client to see a certified prosthetist-orthotist (CPO)
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Older clients with PVD – fitted after the residual limb has healed
Wrapping with elastic bandages – to reduce the edema, shrink the limb & hold the wound dressing in place
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Reapply the bandages every 4-6 hrs when loose
Figure 8 wrapping prevents restriction of blood flow
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Common Health Problems of the Young Adult
Multiple SclerosisMyasthenia Gravis
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Chronic, progressive neurologic disease of the CNS
Unknown etiology
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Progressive demyelinization of the white matter of the CNS
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Occurs between ages 20-40Affects women twice as often as men
Whites are affected compared to Hispanics, Blacks or Asians
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Etiology: UnknownImmunogenetic viral disease
Inmmune mediated demyelination triggered by viral infection
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15-20 times more common in primary relatives of affected patients
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InfectionPhysical injuryEmotional stressPregnancyFatigue
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Formation of plaque along myelin sheath
Inflammatory reaction; Edema
Scarring/destruction of myelin sheath
Primary demyelination
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Death of oligodndrocyte
Incomplete remyelination of nerves
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Optic nervesCerebrumCervical SC
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WeaknessParesthesia of 1 or more extremities
Vision loss (optic neuritis)Incoordination
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Bowel/bladder dysfunction (SC involvement)
Fatigue common symptom that worsens as the day progresses
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History/ Clinical findings2 episodes of neurologic dysfunction in different locations in the CNS
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Spinal fluid evaluationMRI- brain, SC – presence of MS plaques
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Relieve symptomsHelp the patient to function
Corticosteroids
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Chronic autoimmune disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body.
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Antibody mediated attack against the acetylcholine receptors in the neuromuscular junction
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Cardinal features:Muscle weakness/ fatigue
Worsens with exercise; improves with rest
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Etiology: unknownOnset: early onset 20-30 yrs old
Predilection to womenLate onset: after age 50 men are more susceptible
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Increasing weakness with sustained muscle contraction – primary feature
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Depletion of Acetylcholine receptors (NMJ)
Elevated antibody titers
Muscle weakness
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Clinical presentation – testing the response of anticholinergic drugs
Endrophonium – Tensilon test
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Neostigmine methylsulfate (Prostigmin) longer duration of effect (1-2 hrs)
EMG – confirm the diagnosis
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Muscle weaknessPtosisDiplopiaExpressionless face
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Drooping eyelidsOpen mouthSevere cases respiratory muscle arrest
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No treatment availableShort acting anticholinesterase compounds – achieved maximum muscle strength & endurance
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Corticosteroids – prednisone – decrease levels of serum Ach receptor antibodies
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Complications:Myasthenic crisis experience worsening condition
Increase dose on anticholinergic drugs
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Cholinergic crisis – overmedication
Abdominal cramps, diarrhea, excessive pulmonary secretions
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PlasmaphereisThymectomy – alter immunologic control mechanism that affect production of antibody to ACH receptor
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Common Health Problems of the Older Adult:
Parkinson’s DiseaseAlzheimer’s disease
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Parkinson’s disease- is a progressive neurological disorders that results from degeneration of neurons in a region of the brain that controls movement
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Parkinson Disease (Paralysis agitans)
3rd most common neurologic disorder of older adult
Debilitating disease affecting motor ability
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4 Cardinal Symptoms:TremorRigidityAkinesia (slow movement)Postural instability
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Pathophysiology:Degeneration of Substantia Nigra
Decrease dopamine production
Decrease ability to refine voluntary movement
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Organ/ System affected- Brain
( substantia nigra & basal ganglia)
- Neuromuscular system
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Neuromuscular system- combination of the
nervous system & muscles.
- work together to permit movement.
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Basal gangliaintegrates feeling and movement
shifts and smoothens fine motor behavior
suppression of unwanted motor behaviors
sets the body's idle or anxiety level
enhances motivation
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CaudatePutamen
Globus pallidusSubstantia nigra
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Substantia nigra- controls voluntary movement, regulates mood, and produces the neurotransmitter dopamine
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Causative:ToxinsHead traumaCerebral anoxiaDrug-induced
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Predisposing factor:- Age- Heredity- Sex- Exposure to toxins
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Tremor] Rapid shaking of the hands, arms or legs
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Arms and legs become stiff and hard to move
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Difficulty starting or completing movements
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Lack of balance or difficulty adjusting to sudden changes in position
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is a nuclear medicine imaging technique which produces a three-dimensional image or map of functional processes in the body.
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is a noninvasive transthoracic graphic produced by an electrocardiograph, which records the electrical activity of the heart over time.
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High risk for injury related to postural, instability & muscular rigidity
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Impaired verbal communication related slowness of movement
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Altered nutrition: less than body req. related to poor or pharyngeal muscle control & coordination
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Knowledge deficit related to the complexity of & fluctuations in the treatment regimen.
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LevodopaDopamine agonistsAmantadineCOMT inhibitorAnticholinergicBromocriptine
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Levodopa- a dopamine precursor, increases the dopamine supply in neurons making more availabale to stimulate dopaminergic receptors.
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Dopamine agonists- directly stimulate nerves in the brain that are not naturally being stimulated by dopamine.
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Amantadine- blocks acetylcholine receptors and promotes release of dopamine
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Anticholinergic- block acetylcholine
receptors that help control the muscles of the arms, legs, and body.
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Ablative surgerythis procedure locates, targets and then ablates or destroys a targeted area of the brain affected by Parkinson's.
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Deep brain stimulation- treats the tremors and slowness associated with Parkinson's disease. This therapy has been shown to provide greater relief of symptoms with fewer side effects than other treatments.
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Pallidotomy In this procedure, a surgeon selectively destroys a portion of the brain called the globus pallidus.
can improve gait and balance.
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Thalamotomy a related procedure that involves surgically destroying part of the brain's thalamus.
is useful primarily to reduce tremor.
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Transplantationcalled restorative surgery
dopamine-producing cells are implanted into a certain part of the brain.
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Most common form of dementia
Progressive impairment in memory, cognitive function, language, judgment & ADL
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Incidence:10-15% people older than age 65
19% older than 7547% older than 85
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Etiology- unknownRisk factors:GeneticsIncreasing age
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Female genderViruses, toxins & previous head injury
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Changes in CHON of the nerve cells of
cerebral cortex
Accumulation of neurofibrillary tangles & neuritic plaques
Degenerating nerve terminals
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Changes in CHON of the nerve cells of cerebral cortex
Neurotransmitter changes
Decrease in cholinergic neurons in basal nucleus
Loss of choline acetyltransferase
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Cognitive decline(Learning, reasoning, memory , recall,
language recall)
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Onset is subtle/insidiousGradual decline of cognitive functioning
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Short term memory impairment
Impairment in decision making
Decrease cognition
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ApraxiaHyperorality – desire to take everything in the mouth
Loss of self care abilities
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•Patient history•EEG•CT Scan (Non contrast)•MRI•Neuropsychological evaluation
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Maximize functional abilities
Improve quality of lifeCholinesterase inhibitors Tacrine(Cognex)
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Donepezil (Aricept)Reminiscence therapyArt/recreational therapy
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Common Health Problems Across the Life Span
Guillain-Barre Syndrome
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PolyradiculoneuritisInflammatory disease of unknown cause/involves degeneration of myelin sheath of peripheral nerves
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Affects people of all ages & races
Most common cause of acute general paralysis
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.75 – 2 cases/ 100000 population
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Predisposing factors:Respiratory/GI infectionsViral infectionsImmune reactionsvaccination
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Viral infection
Autoimmune reactions
Damage to myelin sheath (Peripheral Nerves)
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ParesthesiaSymmetric progressive muscle weakness
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Loss of DTRAutonomic dysfunction (Increase HR/postural hypotension)
Deep aching muscle pain in shoulder girdle
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Respiratory muscle weakness – cause of death
85-90 % recover completely
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History/Physical ExamCSF analysisElectrophysiologic studies
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PlasmapheresisSupportive care
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