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common disorders and diseases of musculoskeletal system. includes assessment findings, treatment, diagnostic tests, etc.. Great for study!
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MUSCULOSKELETAL SYSTEMDISORDERS
PYRAMID POINTS
Assessment findings in a fracture Initial care of a fracture Various types of traction Nursing care of the client in traction Client education for the use of a halo device Client education related to crutch walking Client education related to the use of a cane
or walker
PYRAMID POINTS
Assessment findings and interventions for complications of a fracture
Care of the client following hip pinning and hip prosthesis
Care of the client following total knee replacement
Treatment measures for the client with a herniated intervertebral disc
Care of the client following disc surgery
PYRAMID POINTS
Interventions following amputation Treatment modalities for the client with
rheumatoid arthritis Client education related to osteoporosis Client education related to gout
INJURIES
STRAINS An excessive stretching of a muscle or tendon Management involves cold and heat
applications, exercise with activity limitations, antiinflammatory medications, and muscle relaxants
Surgical repair may be required for a severe strain (ruptured muscle or tendon)
INJURIES
SPRAINS An excessive stretching of a ligament usually
caused by a twisting motion Characterized by pain and swelling Management involves rest, ice, and a
compression bandage to reduce swelling and provide joint support
Casting may be required for moderate sprains to allow the tear to heal
Surgery may be necessary for severe ligament damage
INJURIES
ROTATOR CUFF INJURIES Musculotendinous or rotator cuff of the shoulder
sustains a tear usually as a result of trauma Characterized by shoulder pain and the inability to
maintain abduction of the arm at the shoulder (drop arm test)
Management involves nonsteroidal antiinflammatory drugs (NSAIDs), physical therapy, sling support, and ice/heat applications
Surgery may be required if medical management is unsuccessful or for those who have a complete tear
FRACTURES
DESCRIPTION A break in the continuity of the bone caused
by trauma, twisting as a result of muscle spasm or indirect loss of leverage, or bone decalcification and disease that result in osteopenia
TYPES OF FRACTURES
CLOSED OR SIMPLE Skin over the fractured area remains intact
GREENSTICK One side of the bone is broken and the other is
bent; most commonly seen in children
TRANSVERSE The bone is fractured straight across
OBLIQUE The break extends in an oblique direction
TYPES OF FRACTURES
SPIRAL The break partially encircles bone
COMMINUTED The bone is splintered or crushed, with three or
more fragments COMPLETE
The bone is completely separated by a break into two parts
INCOMPLETE A partial break in the bone
TYPES OF FRACTURES
OPEN-COMPOUND The bone is exposed to air through a break in
the skin, and soft tissue injury and infection are common
IMPACTED A part of the fractured bone is driven into
another bone DEPRESSED
Bone fragments are driven inward
TYPES OF FRACTURES
COMPRESSION A fractured bone compressed by other bone
PATHOLOGICAL A fracture due to weakening of the bone
structure by pathological processes, such as neoplasia or osteomalacia; also called spontaneous fracture
TYPES OF FRACTURES
From Ignativicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia: W.B. Saunders.
FRACTURE OF AN EXTREMITY ASSESSMENT
Pain or tenderness over the involved area Loss of function Obvious deformity Crepitation Erythema, edema, ecchymosis Muscle spasm and impaired sensation
FRACTURE OF AN EXTREMITY INITIAL CARE
Immobilize affected extremity If a compound fracture exists, splint the
extremity and cover the wound with a sterile dressing
INTERVENTIONS FOR A FRACTURE Reduction Fixation Traction Casts
REDUCTION
DESCRIPTION Restoring the bone to proper alignment
REDUCTION
CLOSED REDUCTION Performed by manual manipulation May be performed under local or general
anesthesia A cast may be applied following reduction
CLOSED REDUCTION
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.
REDUCTION
OPEN REDUCTION Involves a surgical intervention May be treated with internal fixation devices The client may be placed in traction or a cast
following the procedure
FIXATION INTERNAL FIXATION
Follows open reduction Involves the application of screws, plates,
pins, or nails to hold the fragments in alignment
May involve the removal of damaged bone and replacement with a prosthesis
Provides immediate bone strength Risk of infection is associated with the
procedure
INTERNAL FIXATION
From Browner BB et al (1992) Skeletal trauma. Philadelphia: W.B. Saunders.
FIXATION EXTERNAL FIXATION
An external frame is utilized with multiple pins applied through the bone
Provides more freedom of movement than with traction
EXTERNAL FIXATION
From Ignatavicius, D., Workman, M. (2002). Medical-surgical nursing, ed 3, Philadelphia: W.B. Saunders. Courtesy of Smith and Nephew, Inc., Orthopedics Division, Memphis, TN.
TRACTION
DESCRIPTION The exertion of a pulling force applied in two
directions to reduce and immobilize a fracture Provides proper bone alignment and reduces
muscle spasms
TRACTION
IMPLEMENTATION Maintain proper body alignment Ensure that the weights hang freely and do not
touch the floor Do not remove or lift the weights without a
physician’s order Ensure that pulleys are not obstructed and
that ropes in the pulleys move freely Place knots in the ropes to prevent slipping Check the ropes for fraying
SKELETAL TRACTION DESCRIPTION
Mechanically applied to the bone using pins, wires, or tongs
IMPLEMENTATION Monitor color, motion, and sensation (CMS) of
the affected extremity Monitor the insertion sites for redness,
swelling, or drainage Provide insertion site care as prescribed
SKELETAL TRACTION
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.
CERVICAL TONGS AND HALO FIXATION DEVICE
Head and Spinal Cord Injuries
SKIN TRACTION
DESCRIPTION Traction applied by the use of elastic
bandages or adhesive
SKIN TRACTION: SIDE ARM
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.
TYPES OF SKIN TRACTION
Cervical traction Buck’s traction Bryant’s traction Pelvic traction Russell’s traction
CERVICAL SKIN TRACTION Relieves muscle spasms and compression in
the upper extremities and neck Uses a head halter and a chin pad to attach
the traction Use powder to protect the ears from friction
rub Position the client with the head of the bed
elevated 30 to 40 degrees and attach the weights to a pulley system over the head of the bed
CERVICAL SKIN TRACTION
From James, S. Ashwill, R., & Droske, S. (2002). Nursing care of children, ed 2, Philadelphia: W.B. Saunders.
HEAD HALTER TRACTION
From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BUCK’S SKIN TRACTION Used to alleviate muscle spasms; immobilizes a
lower limb by maintaining a straight pull on the limb with the use of weights
A boot appliance is applied to attach to the traction
Weight is attached to a pulley; allow the weights to hang freely over the edge of bed
Not more than 5 pounds of weight should be applied
Elevate the foot of the bed to provide the traction
BUCK’S SKIN TRACTION
From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BRYANT’S AND RUSSELL’S SKIN TRACTION Refer to the module entitled Pediatric
Nursing, Musculoskeletal Disorders for information related to these types of traction
PELVIC SKIN TRACTION
Used to relieve low back, hip, or leg pain and to reduce muscle spasm
Apply the traction snugly over the pelvis and iliac crest and attach to the weights
Use measures as prescribed to prevent the client from slipping down in bed
PELVIC SKIN TRACTION
From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BALANCED SUSPENSION DESCRIPTION
Used with skin or skeletal traction Used to approximate fractures of the femur,
tibia, or fibula Produced by a counterforce other than client
BALANCED SUSPENSION
From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BALANCED SUSPENSION IMPLEMENTATION
Position the client in low Fowler’s, either on the side or back
Maintain a 20-degree angle from the thigh to the bed
Protect the skin from breakdown Provide pin care if pins are used with the
skeletal traction Clean the pin sites with sterile normal saline
and hydrogen peroxide or Betadine as prescribed or per agency procedure
DUNLOP’S SKIN TRACTION
DESCRIPTION Horizontal traction to align fractures of the
humerus; vertical traction maintains the forearm in proper alignment
IMPLEMENTATION Nursing care is similar to Buck’s traction
DUNLOP’S SKIN TRACTION
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
CASTS DESCRIPTION
Made of plaster or fiberglass to provide immobilization of bone and joints after a fracture or injury
CASTS
From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.
CASTS
IMPLEMENTATION Keep the cast and extremity elevated Allow a wet cast 24 to 48 hours to dry
(synthetic casts dry in 20 minutes) Handle a wet cast with the palms of the hand
until dry Turn the extremity unless contraindicated, so
that all sides of the wet cast will dry Heat can be used to dry the cast
CASTS
IMPLEMENTATION The cast will change from a dull to a shiny
substance when dry Examine the skin and cast for pressure areas Monitor the extremity for circulatory impairment
such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse
Notify the physician immediately if circulatory compromise occurs
Prepare for bivalving or cutting the cast if circulatory impairment occurs
CASTS
IMPLEMENTATION Petal the cast; maintain smooth edges around
the cast to prevent crumbling of the cast material
Monitor the client’s temperature Monitor for the presence of a foul odor, which
may indicate infection Monitor drainage and circle the area of
drainage on the cast Monitor for warmth on the cast
CASTS
IMPLEMENTATION Monitor for wet spots, which may indicate a need
for drying, or the presence of drainage under the cast
If an open draining area exists on the affected extremity, a cut-out portion of the cast or a window will be made by the physician
Instruct the client not to stick objects inside the cast
Teach the client to keep the cast clean and dry Instruct the client on isometric exercises to
prevent muscle atrophy
COMPLICATIONS OF FRACTURES Fat embolism Compartment syndrome Infection and osteomyelitis Avascular necrosis Pulmonary emboli
FAT EMBOLISM DESCRIPTION
An embolism originating in the bone marrow that occurs after a fracture
Clients with long bone fractures are at the greatest risk for the development of fat embolism
Usually occurs within 48 hours following the injury
FAT EMBOLISM ASSESSMENT
Restlessness Mental status changes Tachycardia, tachypnea, and hypotension Dyspnea Petechial rash over the upper chest and neck
IMPLEMENTATION Notify the physician immediately Treat symptoms as prescribed to prevent
respiratory failure and death
COMPARTMENT SYNDROME DESCRIPTION
Increased pressure within one or more compartments causing massive compromise of circulation to an area
Leads to decreased perfusion and tissue anoxia
Within 4 to 6 hours after the onset of compartment syndrome, neuromuscular damage is irreversible
ANTERIOR COMPARTMENT SYNDROME
From Black JM, Hawks JH, Keene AM (2001): Medical-surgical nursing: clinical management for positive outcomes 6th ed., Philadelphia, W.B. Saunders.
COMPARTMENT SYNDROME ASSESSMENT
Increased pain and swelling Pain with passive motion Inability to move joints Loss of sensation (paresthesia) Pulselessness
IMPLEMENTATION Notify the physician immediately
INFECTION AND OSTEOMYELITIS DESCRIPTION
Can be caused by the interruption of the integrity of the skin
The infection invades bone tissue
INFECTION AND OSTEOMYELITIS ASSESSMENT
Fever Pain Erythema in the area surrounding the fracture Tachycardia Elevated white blood cell (WBC) count
IMPLEMENTATION Notify the physician Prepare to initiate aggressive IV antibiotic
therapy
AVASCULAR NECROSIS
DESCRIPTION An interruption in the blood supply to the bony
tissue, which results in the death of the bone ASSESSMENT
Pain Decreased sensation
IMPLEMENTATION Notify the physician if pain or decreased
sensation occurs Prepare the client for removal of necrotic tissue
because it serves as a focus for infection
PULMONARY EMBOLISM DESCRIPTION
Caused by immobility precipitated by a fracture
PULMONARY EMBOLISM
ASSESSMENT Restlessness and apprehension Dyspnea Diaphoresis Arterial blood gas changes
IMPLEMENTATION Notify the physician if signs of emboli are
present Prepare to administer anticoagulant therapy
CRUTCH WALKING
DESCRIPTION An accurate measurement of the client for
crutches is important because an incorrect measurement could damage the brachial plexus
The distance between the axilla and the arm pieces on the crutches should be two fingerwidths in the axilla space
The elbows should be slightly flexed 20 to 30 degrees when walking
BRACHIAL PLEXUS
From Crossman AR, Neary D (1995). Neuroanatomy: an illustrated color text. Edinburgh: Churchill Livingstone.
CRUTCH WALKING
DESCRIPTION When ambulating with the client, stand on the
affected side Instruct the client never to rest the axilla on the
axillary bars Instruct the client to look up and outward when
ambulating Instruct the client to stop ambulation if
numbness or tingling in the hands or arms occurs
CRUTCH WALKING
From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2, St. Louis, 2000, Mosby.
CRUTCH GAITS
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
CANES
DESCRIPTION Made of a lightweight material with a rubber tip
at the bottom
SINGLE- AND QUAD-FOOT CANES
From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
CANES
IMPLEMENTATION Stand at the affected side of the client when
ambulating The handle should be at the level of the
client’s greater trochanter The client’s elbow should be flexed at a 25- to
30-degree angle
CANES
CLIENT EDUCATION Hold the cane close to the body Hold the cane in the hand on the unaffected
side so that the cane and weaker leg can work together with each step
Move the cane at the same time as the affected leg
Inspect the rubber tips regularly for worn places
HEMICANES OR QUAD-FOOT CANES Used for clients who have the use of only one
upper extremity Hemicanes provide more security than a quad-
foot cane; however, both types provide more security than a single-tipped cane
Position the cane at the client’s unaffected side with the straight nonangled side adjacent to the body
Position the cane 6 inches from client’s side with the handgrips level with the greater trochanter
WALKERS
Stand adjacent to the client on the affected side
Instruct the client to put all four points of the walker flat on the floor before putting weight on the hand pieces
Instruct the client to move the walker forward and to walk into it
TYPES OF HIP FRACTURES
Intracapsular Extracapsular
INTRACAPSULAR HIP FRACTURE Bone is broken inside the joint Skin traction is applied preoperatively to
immobilize and prevent pain Treatment includes a total hip replacement or
internal fixation with replacement of the femoral head with a prosthesis
Avoid hip flexion to prevent displacement
EXTRACAPSULAR HIP FRACTURE Fracture can occur at the greater trochanter
or can be an intertrochanteric fracture Trochanteric fracture is outside the joint Preoperative treatment includes balanced
suspension traction Avoid hip flexion to prevent displacement Surgical treatment includes internal fixation
with nail plate, screws, or wires
INTERNAL FIXATION
From Black JM, Matassarin-Jacobs E (1997): Medical-surgical nursing: clinical management for continuity of care 5th ed., Philadelphia, W.B. Saunders.
HIP REPLACEMENTS
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby. Courtesy of Zimmer, Inc., Warsaw, IN.
TOTAL HIP REPLACEMENT
From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
HIP FRACTURE
POSTOPERATIVE Maintain leg and hip in proper alignment Prevent flexion or external or internal rotation Turn the client from back to unaffected side Do not position to the affected side unless
prescribed by the physician Maintain leg abduction to prevent internal or
external rotation
HIP FRACTURE
POSTOPERATIVE Use a trochanter roll to prevent external
rotation Ensure that the hip flexion angle does not
exceed 60 to 80 degrees Elevate the head of the bed 30 to 45 degrees
for meals only Ambulate as prescribed by the physician Avoid weight bearing on the affected leg as
prescribed; instruct the client in the use of a walker to avoid weight bearing
HIP FRACTURE
POSTOPERATIVE Keep the operative leg extended, supported,
and elevated when getting client out of bed Avoid hip flexion greater than 90 degrees and
avoid low chairs when out of bed Monitor the wound for infection or hemorrhage Monitor circulation and sensation of the
affected side
HIP FRACTURE
POSTOPERATIVE Maintain the Hemovac or Jackson-Pratt drain
if in place; maintain compression to facilitate drainage and monitor and record output of drainage
Drainage should continuously decrease in amount, and by 48 hours postoperatively, drainage should be approximately 30 ml in an 8-hour period
HIP FRACTURE
POSTOPERATIVE Maintain the use of antiembolism stockings
and encourage the client to flex and extend the feet and ankles
Instruct the client to avoid crossing the legs and bending over
Physical therapy will begin postoperatively as prescribed by the physician
TOTAL KNEE REPLACEMENT
DESCRIPTION Implantation of a device to substitute for the
femoral condyles and the tibial joint surfaces
KNEE PROSTHESIS
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.
TOTAL KNEE REPLACEMENT
POSTOPERATIVE Monitor the incision for drainage and infection Maintain the Hemovac or Jackson-Pratt drain
if in place Begin continuous passive motion (CPM) 24 to
48 hours as prescribed to exercise the knee and provide moderate flexion and extension
Administer analgesics before CPM to decrease pain
CONTINUOUS PASSIVE MOTION
From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, St. Louis, 1996, Mosby.
TOTAL KNEE REPLACEMENT
POSTOPERATIVE The leg should not be dangled to prevent
dislocation Prepare the client for out-of-bed activities as
prescribed Avoid weight bearing and instruct the client in
crutch walking
HERNIATION: INTERVERTEBRAL DISC DESCRIPTION
Nucleus of the disc protrudes into the annulus causing nerve compression
TYPES Cervical Lumbar
DISC HERNIATION
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.
CERVICAL DISC DECRIPTION
Occurs at C5 to C6 and C6 to C7 interspaces Causes pain and stiffness in the neck, top of
the shoulders, scapula, upper extremities, and head
Produces paresthesia and numbness of the upper extremities
CERVICAL DISC
IMPLEMENTATION Provide bed rest to relieve pressure and
reduce inflammation and edema Provide immobilization as prescribed via
cervical collar, traction, or brace Apply hot, moist compresses as prescribed to
increase the blood flow and relax spasms Instruct the client to avoid flexing, extending,
or rotating the neck Instruct the client to avoid long periods of
sitting
CERVICAL DISC
IMPLEMENTATION Instruct the client that while sleeping, to avoid
the prone position and keep the head, spine, and hip in alignment
Instruct the client in the use of analgesics, sedatives, antiinflammatory agents, and corticosteroids as prescribed
Prepare the client for a corticosteroid injection into the epidural space if prescribed
Assist the client with the application of a cervical collar or cervical traction as prescribed
CERVICAL COLLAR Used for cervical disc herniation Holds the head in a neutral or slightly flexed
position The client may have to wear a cervical collar
24 hours a day Inspect the skin under the collar for irritation When the pain subsides, the client is taught
cervical isometric exercises to strengthen the muscles
CERVICAL COLLAR
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders. Courtesy of Zimmer, Inc., Dover, OH.
LUMBAR DISC DESCRIPTION
Most often occurs at L4 to L5 or L5 to S1 interspaces
Postural deformity occurs Produces muscle weakness, sensory loss, and
alteration of the tendon reflexes The client experiences low back pain and
muscle spasms with radiation of the pain into one hip and down the leg (sciatica)
Pain is aggravated by bending, lifting, straining, sneezing, and coughing, and is relieved by bed rest
LUMBAR DISC IMPLEMENTATION
Provide bed rest as prescribed Apply moist heat and massage as prescribed Instruct the client to sleep on the side with the
knees and hips in a position of flexion and with a pillow between the legs
Apply pelvic traction as prescribed to relieve muscle spasms
LUMBAR DISC IMPLEMENTATION
Begin ambulation gradually as the inflammation and edema subsides
Instruct the client in the use of muscle relaxants, antiinflammatory medications, and corticosteroids as prescribed
Instruct the client in the use of a corset or brace as prescribed
Instruct the client regarding correct posture while sitting, standing, walking, and working
LUMBAR DISC IMPLEMENTATION
Instruct the client to lift objects by bending the knees and keeping the back straight, avoiding lifting anything above the elbows
Instruct the client regarding a weight-control program as prescribed
Instruct the client in an exercise program as prescribed to strengthen abdominal and back muscles
DORSOLUMBAR ORTHOSIS
From Mosby’s medical, nursing, and allied health dictionary, ed 6, (2002). St. Louis: Mosby. Courtesy of Truform Orthotics and Prosthetics, Cincinnati, OH.
LOW BACK CARE
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.
TYPES OF DISC SURGERY
CHEMOLYSIS Injections to dissolve affected disc
DISCECTOMY Removal of herniated disc tissue and related
matter DISCECTOMY WITH FUSION
Fusion of vertebrae with bone graft LAMINOTOMY
Division of the lamina of a vertebrae LAMINECTOMY
Removal of the lamina
DISC SURGERY
PREOPERATIVE Reassure the client that surgery will not
weaken the back Instruct the client regarding coughing and
deep-breathing exercises Instruct the client about logrolling and range-
of-motion exercises
DISC SURGERY: CERVICAL DISC POSTOPERATIVE
Monitor for respiratory difficulty Encourage coughing and deep breathing Monitor for hoarseness and inability to cough
effectively because this may indicate laryngeal nerve damage
Use throat sprays or lozenges for sore throat and do not use those that may numb the throat to avoid choking
DISC SURGERY: CERVICAL DISC POSTOPERATIVE
Monitor the wound for drainage Provide a soft diet if the client complains of
dysphagia Monitor for sudden return of radicular pain,
which may indicate that the cervical spine has become unstable
DISC SURGERY: LUMBAR DISC POSTOPERATIVE
Monitor for wound hemorrhage Monitor sensation and motor ability of the
lower extremities as well as color, temperature, and sensation of toes
Monitor for urinary retention, paralytic ileus, and constipation
Initiate measures to prevent constipation such as a high-fiber diet, increased fluids, and stool softeners as prescribed
DISC SURGERY: LUMBAR DISC POSTOPERATIVE
When turning and repositioning the client, place the bed in a flat position and a pillow between the legs; turn the client as a unit (logroll) without twisting the client’s back
When positioning the client, a pillow is placed under the head with the knees slightly flexed
Avoid extreme knee flexion when the client is lying on the side
DISC SURGERY: LUMBAR DISC POSTOPERATIVE
To assist the client out of bed, raise the head of the bed while the client lies on the side; the client's head and shoulders are supported by the first nurse, the client pushes self to a sitting position, and the second nurse eases the legs over the side of the bed
Instruct the client to avoid sitting because it places a strain on the surgical site
DISC SURGERY: LUMBAR DISC POSTOPERATIVE
Administer narcotics and sedatives as prescribed to relieve pain and anxiety
Encourage early ambulation Assist the client with the use of a back brace
or corset if prescribed
AMPUTATION OF A LOWER EXTREMITY DESCRIPTION
The surgical removal of a lower limb or part of the limb
LEVELS OF LOWER EXTREMITY AMPUTATION
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia: W.B. Saunders.
AMPUTATION FLAPS
From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
AMPUTATION OF A LOWER EXTREMITY POSTOPERATIVE
Monitor vital signs Monitor for infection and hemorrhage Mark bleeding and drainage on the dressing if
it occurs Keep a tourniquet at the bedside Monitor for pulmonary emboli
AMPUTATION OF A LOWER EXTREMITY POSTOPERATIVE
Observe for and prevent contractures Monitor for signs of necrosis and neuroma Evaluate for phantom limb sensation and pain;
explain sensation and pain to the client, and medicate the client as prescribed
Check the physician’s orders regarding positioning
AMPUTATION OF A LOWER EXTREMITY POSTOPERATIVE
If prescribed, during the first 24 hours, elevate the foot of the bed to reduce edema, then keep the bed flat to prevent hip flexion contractures
Do not elevate the stump itself because elevation can cause flexion contracture of the hip joint
After 24 and 48 hours postoperatively, position the client prone if prescribed to stretch the muscles and prevent flexion contractures of hip
AMPUTATION OF A LOWER EXTREMITY POSTOPERATIVE
In the prone position, place a pillow under the abdomen and stump and keep the legs close together to prevent abduction
Maintain application of an Ace wrap or elastic stump shrinker as prescribed to provide stump shrinkage
Remove and rewrap the Ace bandage or elastic stump shrinker three to four times daily as prescribed
AMPUTATION OF A LOWER EXTREMITY POSTOPERATIVE
Wash the stump with mild soap or water and apply lanolin to the skin if prescribed
Massage the skin toward the suture line to increase circulation
Prepare for a cast application if prescribed to prepare the stump for prosthesis
Encourage the client to look at the stump Encourage verbalization regarding loss of the
body part and assist the client to identify coping mechanisms to deal with the loss
STUMP WRAPPING
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.
BELOW-THE-KNEE AMPUTATION POSTOPERATIVE
Prevent edema Do not allow the stump to hang over the edge
of the bed Do not allow the client to sit for long periods of
time to prevent contractures
ABOVE-THE-KNEE AMPUTATION POSTOPERATIVE
Prevent internal or external rotation of the limb Place a sandbag or rolled towel along the
outside of the thigh to prevent rotation
AMPUTATION OF A LOWER EXTREMITY REHABILITATION
Instruct the client in crutch walking Prepare the stump for prosthesis Prepare the client for the fitting of the stump
for prosthesis Instruct the client in exercises to maintain
range of motion Provide psychosocial support to the client
RHEUMATOID ARTHRITIS (RA) DESCRIPTION
Chronic systemic inflammatory disease; the etiology may be related to a combination of environmental and genetic factors
Leads to destruction of connective tissue and synovial membrane within the joints
Weakens and leads to dislocation of the joint and permanent deformity
Formation of pannus occurs at the junction of synovial tissue and articular cartilage projecting into the joint cavity and causing necrosis
RHEUMATOID ARTHRITIS (RA) DESCRIPTION
Exacerbations are increased by physical or emotional stress
Risk factors include exposure to infectious agents; fatigue and stress can exacerbate the condition
Vasculitis can cause malfunction and eventual failure of an organ or system
RHEUMATOID ARTHRITIS (RA) ASSESSMENT
Inflammation, tenderness, and stiffness of the joints
Moderate to severe pain and morning stiffness lasting longer than 30 minutes
Joint deformities, muscle atrophy, and decreased range of motion
Spongy, soft feeling in the joints
RHEUMATOID ARTHRITIS (RA) ASSESSMENT
Low-grade temperature, fatigue, and weakness
Anorexia, weight loss, and anemia Elevated sedimentation rate and positive
rheumatoid factor X-ray showing joint deterioration Synovial tissue biopsy presents inflammation
RHEUMATOID ARTHRITISEARLY, MODERATE, AND ADVANCED STAGE
From Monahan FD, Neighbers M: Medical-surgical nursing: foundations for clinical practice, ed. 2, Philadelphia, 1998, W.B. Saunders.
RHEUMATOID ARTHRITISMUSCLE ATROPHY
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.
RHEUMATOID NODULE
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.
BOUTONNIERE DEFORMITY
From Zitelli BJ, Davis HW: Atlas of Pediatric Physical Diagnosis, ed. 3, St. Louis, 1997, Mosby.
SWAN NECK DEFORMITY
From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts and clinical practice, ed. 6, St. Louis, 1999, Mosby.
RHEUMATOID (RA) FACTOR DESCRIPTION
A blood test used to diagnose rheumatoid arthritis
VALUES Nonreactive: 0 to 39 IU/ml Weakly reactive: 40 to 79 IU/ml Reactive: greater than 80 IU/ml
RHEUMATOID ARTHRITIS (RA) PAIN
Salicylates (acetylsalicylic acid [aspirin]) Monitor for side effects including tinnitus,
gastrointestinal (GI) upset, or prolonged bleeding time
Administer with meals or a snack Monitor for abnormal bleeding or bruising
RHEUMATOID ARTHRITIS (RA) NONSTEROIDAL ANTIINFLAMMATORY
DRUGS (NSAIDs) May be prescribed in combination with
salicylates if pain and inflammation has not decreased within 6 to 12 weeks following salicylate therapy
Monitor for side effects such as GI upset, CNS manifestations, skin rash, hypertension, fluid retention, and changes in renal function
RHEUMATOID ARTHRITIS (RA) CORTICOSTEROIDS
Administer as prescribed during exacerbations or when commonly used agents are ineffective
ANTINEOPLASTIC MEDICATIONS Administer as prescribed in clients with life-
threatening RA GOLD SALTS
Administer as prescribed in combination with salicylates and NSAIDs to induce remission and decrease pain and inflammation
RHEUMATOID ARTHRITIS (RA) PHYSICAL MOBILITY
Preserve joint function Provide ROM exercises to maintain joint
motion and muscle strengthening Balance rest and activity Splints during acute inflammation to prevent
deformity Prevent flexion contractures
RHEUMATOID ARTHRITIS (RA) PHYSICAL MOBILITY
Apply heat or cold therapy as prescribed to joints
Apply paraffin baths and massage as prescribed
Encourage consistency with exercise program Instruct the client to stop exercise if pain
increases Exercise only to the point of pain Avoid weight bearing on inflamed joints
RHEUMATOID ARTHRITIS (RA) SELF-CARE
Assess the need for assistive devices such as higher toilet seats, chairs, and wheelchairs to facilitate mobility
Collaborate with occupational therapy to obtain assistive adaptive devices
Instruct the client in alternative strategies for providing activities of daily living
RHEUMATOID ARTHRITIS (RA) FATIGUE
Identify factors that may contribute to fatigue Monitor for signs of anemia Administer iron, folic acid, and vitamin
supplements as prescribed Monitor for drug-related blood loss by testing
the stool for occult blood Instruct the client in measures to conserve
energy such as pacing activities and obtaining assistance when possible
RHEUMATOID ARTHRITIS (RA) BODY IMAGE DISTURBANCE
Assess the client’s reaction to the body change
Encourage the client to verbalize feelings Assist the client with self-care activities and
grooming Encourage the client to wear street clothes
RHEUMATOID ARTHRITIS (RA) SURGICAL INTERVENTIONS SYNOVECTOMY
Removal of the synovia to help maintain joint function
ARTHRODESIS Bony fusion of a joint to regain some mobility
JOINT REPLACEMENT (ARTHROPLASTY) Replacement of diseased joints with artificial
joints Performed to restore motion to a joint and
function to the muscles, ligaments, and other soft tissue structures that control a joint
OSTEOARTHRITIS
DESCRIPTION Also known as degenerative joint disease
(DJD) Cause is unknown but may be caused by
trauma, fractures, infections, or obesity Progressive degeneration of the joints caused
by wear and tear
OSTEOARTHRITIS
DESCRIPTION Causes the formation of bony build-up and the
loss of articular cartilage in peripheral and axial joints
Affects the weight-bearing joints and joints that receive the greatest stress such as the knees, toes, and lower spine
JOINT CHANGES IN OSTEOARTHRITIS
From Ignatavicius DD, Workman ML, Mishler MA, Medical-surgical nursing across the healthcare continuum, ed. 3, Philadelphia, 1999, W.B.Saunders.
OSTEOARTHRITIS
ASSESSMENT Joint pain that early in the disease process
diminishes after rest and intensifies after activity
As the disease progresses, pain occurs with slight motion or even at rest
Symptoms are aggravated by temperature change and humidity
Crepitus
OSTEOARTHRITIS
ASSESSMENT Joint enlargement Presence of Heberden’s nodes or Bouchard’s
nodes Limited ROM Difficulty getting up after prolonged sitting Skeletal muscle atrophy Inability to perform activities of daily living Compression of the spine as manifested by
radiating pain, stiffness, and muscle spasms in one or both extremities
SEVERE OSTEOARTHRITIS
From Kamal A, Brockelhurst J: Color atlas of geriatric medicine, ed. 2, St. Louis, 1991, Mosby.
HEBERDEN’S NODES
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.
BOUCHARD’S NODES
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.
OSTEOARTHRITIS
PAIN Administer NSAIDs, salicylates, and muscle
relaxants as prescribed Prepare the client for corticosteroid injections
into joints as prescribed Place affected joint in a functional position Immobilize the affected joint with a splint or
brace Avoid large pillows under the head or knees Provide a bed or foot cradle
OSTEOARTHRITIS
PAIN Position the client prone twice a day Instruct the client on the importance of moist
heat, hot packs or compresses, and paraffin dips as prescribed
Apply cold applications as prescribed when the joint is acutely inflamed
Encourage adequate rest recommending 10 hours of sleep at night and a 1- to 2-hour nap in the afternoon
OSTEOARTHRITIS
NUTRITION Encourage a well-balanced diet Encourage weight loss if necessary
OSTEOARTHRITIS
PHYSICAL MOBILITY Reinforce the exercise program and the
importance of participating in the program Instruct the client that exercises should be
active rather than passive and to exercise only to the point of pain
Instruct the client to stop exercise if pain is increased with exercising
Instruct the client to decrease the number of repetitions in an exercise when the inflammation is severe
OSTEOARTHRITISSURGICAL INTERVENTIONS OSTEOTOMY
The bone is cut to correct joint deformity and promote realignment
TOTAL JOINT REPLACEMENT (TJR) Performed when all measures of pain relief
have failed Hips and knees are most commonly replaced Contraindicated in the presence of infection,
advanced osteoporosis, and severe inflammation
RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS CLIENT EDUCATION
Assist the client to identify and correct hazards in the home
Instruct the client in the correct use of assistive adaptive devices
Instruct in energy conservation measures Review prescribed exercise program Instruct the client to sit in a chair with a high,
straight back
RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS CLIENT EDUCATION Instruct the client to use a small pillow, only
when lying down Instruct the client in measures to protect the
joints Instruct the client regarding the prescribed
medications Stress the importance of follow-up visits with
the health care provider
OSTEOPOROSIS
DESCRIPTION An age-related metabolic disease Bone demineralization results in the loss of
bone mass, leading to fragile and porous bones and subsequent fractures
Greater bone resorption than bone formation occurs
Occurs most commonly in the wrist, hip, and vertebral column
Can occur postmenopausal or as a result of a metabolic disorder or calcium deficiency
OSTEOPOROTIC CHANGES
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.
OSTEOPOROSIS
ASSESSMENT Back pain after lifting, bending, or stooping Back pain that increases with palpation Pelvic or hip pain, especially with weight
bearing Problems with balance Decline in height from vertebrae compression
OSTEOPOROSIS
ASSESSMENT Kyphosis of the dorsal spine Constipation, abdominal distention, and
respiratory impairment as a result of movement restriction and spinal deformity
Pathological fractures Appearance of thin, porous bone on x-ray
DOWAGER’S HUMP
From Seidel HM et al: Mosby’s guide to physical examination, ed. 4, St. Louis, 1999, Mosby.
SEVERE OSTEOPOROSIS
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.
OSTEOPOROSIS
IMPLEMENTATION Assess risk for injury Provide a safe and hazard-free environment
and assist the client to identify hazards in the home environment
Use side rails to prevent falls Move the client gently when turning and
repositioning
OSTEOPOROSIS
IMPLEMENTATION Encourage ambulation; assist with ambulation if
the client is unsteady Instruct in the use of assistive devices such as a
cane or walker Provide ROM exercises Instruct in the use of good body mechanics and
exercises to strengthen abdominal and back muscles in order to improve posture and provide support for the spine
Instruct the client to avoid activities that can cause vertebral compression
OSTEOPOROSIS
IMPLEMENTATION Apply a back brace as prescribed during an
acute phase to immobilize the spine and provide spinal column support
Encourage the use of a firm mattress Provide a diet high in protein, calcium, vitamin
C and D, and iron Encourage adequate fluid intake to prevent
renal calculi Instruct the client to avoid alcohol and coffee
MILWAUKEE BRACE
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
OSTEOPOROSIS
IMPLEMENTATION Administer estrogen or androgens to decrease
the rate of bone resorption as prescribed Administer calcium, vitamin D, and
phosphorus as prescribed for bone metabolism
Administer calcitonin as prescribed to inhibit bone loss
Administer analgesics, muscle relaxants, and antiinflammatory medications as prescribed
GOUT
DESCRIPTION A systemic disease in which urate crystals
deposit in joints and other body tissues Leads to abnormal amounts of uric acid in the
body Primary gout results from a disorder of purine
metabolism Secondary gout involves excessive uric acid in
the blood that is caused by another disease
GOUTY JOINT
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.
PHASES OF GOUT
ASYMPTOMATIC No symptoms Serum uric acid is elevated
ACUTE Excruciating pain and inflammation of one or
more small joints, especially the great toe
PHASES OF GOUT
INTERMITTENT Asymptomatic period between acute attacks
CHRONIC Results from repeated episodes of acute gout Results in deposits of urate crystals under the
skin and within the major organs, especially the renal system
GOUT
ASSESSMENT Excruciating pain in the involved joints Swelling and inflammation of the joints Tophi (hard, fairly large, and irregularly
shaped deposits in the skin) that may break open and discharge a yellow, gritty substance
Low-grade fever Malaise and headache Pruritus Presence of renal stones Elevated uric acid levels
GOUT
From Clinical Slide Collection of the Rheumatic Diseases, © 1991,1995,1997. Used with permission of the American College of Rheumatology.
GOUT
IMPLEMENTATION Provide a low-purine diet as prescribed Instruct the client to avoid foods such as organ
meats, wines, and aged cheese Encourage a high fluid intake of 2000 ml to
prevent stone formation Encourage weight-reduction diet if required Instruct the client to avoid alcohol and
starvation diets because they may precipitate a gout attack
GOUT
IMPLEMENTATION Increase urinary pH (above 6) by eating
alkaline-ash foods such as citrus fruits and juices, milk, and other dairy products
Provide bed rest during the acute attacks Monitor joint ROM ability and appearance of
joints Position the joint in a mild flexion position
during acute attack
GOUT
IMPLEMENTATION Elevate the affected extremity Protect the affected joint from excessive
movement or direct contact with sheets or blankets
Provide heat or cold for local treatments to affected joint as prescribed
Administer NSAIDs and antigout medications as prescribed
Recommended