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Orthopedic SystemAlteration in MobilityIntegumentary System

Med/Surg I, Module 4Part 1 of 4

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Chronic Musculoskeletal Conditions

Curvature of the Spine Osteoporosis Osteomyelitis Osteoarthritis

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Curvature of the SpineKyphosis (left) and Lordosis (right)

KyphosisSource: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center.http://medicine.ucsd.edu/clinicalimg/thorax-kyphosis.html

LordosisSource: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center.http://medicine.ucsd.edu/clinicalimg/thorax-kyphosis.html

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Scoliosis

Source: Wikimedia Commons, Public Domainhttp://commons.wikimedia.org/wiki/Category:Orthosis

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Osteoporosis

Increased Risk Family history Female Menopause-related low

estrogen females, low testosterone males

Medications Lifestyle

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Osteoporosis

Prevention Diet Calcium supplements Stop smoking Alcohol and caffeine intake weight-bearing exercise Sunlight

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Osteoporosis

Diagnosis Dual-energy x-ray

absorptiometry (DEXA) scan Qualitative ultrasound (QUS)

of heel or calcaneus

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OsteoporosisCollaborative Management Replace estrogen or testosterone Raloxifene (Evista) Biphosphonates: Alendronate

(Fosamax) and risedronate (Actonel) Teriparatide (Forteo) Ibandronate sodium (Boniva) Calcitonin (Miacalcin) Sodium fluoride

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Osteoporosis

Nursing Care Prevent falls Treat pain Orthotic devices Refer to physical therapy Range of motion exercises

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Osteomyelitis

Local swelling Redness Tenderness Pain Fever Bone pain Source: UCSD Catalog of Clinical Images, Photographs by Charlie

Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California, 92093-0611http://medicine.ucsd.edu/clinicalimg/extremities-Toe-Osteo.htmlhttp://medicine.ucsd.edu/clinicalimg/extremities-osteomyelitis.html

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Diagnosis

Bone scan Biopsy MRI, CT or ultrasound: fluid

collection, abscess, periosteal thickening

Elevated WBC, positive blood cultures

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Collaborative Care Surgical debridement is the primary treatment Postoperative care: wound irrigation with

strict sterile technique; monitor site for signs of infection, monitor temperature and WBC

Most cases caused by Staphylococcus aureus: Parenteral antibiotics based on wound, blood

cultures for 4-6 weeks or Oral twice-daily ciprofloxacin if chronic Hyperbaric oxygen therapy to promote healing

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Osteoarthritis

Reprinted with permission: Charles J. Eaton, M.D. of The Hand Centerhttp://www.eatonhand.com/

Reprinted with permission: DePuy Orthopaedics, Inc.http://www.depuyorthopaedics.com/

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Clinical Manifestations Crepitus Joint stiffness Pain with movement Heberden’s nodes (distal joints) and

Bouchard’s nodes (proximal joints) Knees: Joint effusions Muscle atrophy Spine: radiating pain, stiffness,

muscle spasms in extremities Hips: pain referred to inguinal area,

buttock, thigh or knee; loss of internal rotation

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Collaborative Care

Analgesics Rest Heat Weight control TENS

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Total Joint Arthroplasty

Source: Hughston Foundationhttp://www.hughston.com/hha/a.11.2.1.htm

Source: Hughston Foundationhttp://www.hughston.com/hha/a.11.2.1.htm

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Postoperative Care

Abduction pillow, neutral position

Prevent embolus Prevent infection Assess for bleeding Neurovascular compromise Manage pain Promote activity

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Total Knee Arthroplasty Continuous passive motion (CPM)

device Ice or hot/ice machine Keep knee in neutral, no rotation

inward or outward Monitor: thromboembolism,

infection, bleeding, CSM Teach: no hyperflexion or

kneeling for 6 weeks

Acute Musculoskeletal

conditions: FRACTURES

Source: Wikimedia Commons/Creative Commons LicencePhote courtesy of “Mexican 2000”/Flickrhttp://commons.wikimedia.org/wiki/Image:Clavicle_fracture.jpg

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Open or Closed?

Photo source: American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=A00139

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Compound Fractures Grade I

o Small wound

Grade IIo ~1 cm to 10 cmo skin & muscle contusions

Grade IIIo Largeo Damaged skin, muscle, nerves,

vessels

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Assessment

Can he move it? Does it hurt? Is it deformed?

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Key Treatments

Closed reduction Immobilization

o Splinto Cast

Open reduction

Open reduction; External FixationNational Institutes of Health Osteoporosisand Related Bone Diseases National ResourceCenter http://jama.ama-assn.org/cgi/reprint/291/17/2160.pdf

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Cast Care

Prevent indentations when wet

Elevate uniformly Air dry CSM – What am I looking

for? No scratching implements!

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Skin Traction To decrease muscle spasm Weight 5-7 pounds attached

w/ adhesive tape Used before surgical repair Check sling, tape for

placement Keep pulley, weights in place

Photo Source: www.HealCentral.org, Royal College of Surgeons of Ireland (RCSI), Creative Commons

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Buck’s Traction

Hip fracture assessment What to do immediately? Buck’s traction assessments What should be done later? What teaching is needed?

Buck’s TractionSource: DeRoyal Patient Care http://www.deroyal.com/PDFCatalogs/orthopedicCatalog.aspx

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Other Skin Traction

Russell’s Cervical Thomas splint Bryant’s Cervical Pelvic

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Skeletal Traction

Weight 25-40 pounds Are the ropes on the pulleys? Are the weights hanging free? Where are the knots? Monitor CSM Pin care? Skin care

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Balanced Suspension

Counter-traction by weights Check ropes, knots, weights Are traction bars tightened? Is patient in alignment? How do pin sites look? When can I remove weights?

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Spinal Traction

Where are the knots? Are the weights hanging free? What do the pin sites look

like? How do I turn the patient? How can I make the patient

comfortable?

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Complications

Compartment syndrome Fat embolism DVT Osteomyelitis Aseptic necrosis

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Compartment Syndrome

Preventiono Check CSMo Ice, elevateo Loosen dressing, open cast

Emergency careo Fasciotomy:

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Fat Embolism

Long bones, multiple fractures Elderly: hip fractures Altered mental status Respiratory distress Petechiae on trunk Prevention: early

immobilization of fracture

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Deep Venous Thrombosis Most common

complication Predisposing factors Common sites: leg,

pelvic fx Pulmonary embolus

preventionDeep Vein ThrombosisSource: National Heart & Blood Institute http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt/DVT_WhatIs.html

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Osteomyelitis

Sources: open wounds, implanted hardware

Staphylococcus aureus usually

Rx: IV antibiotics

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Aseptic Necrosis

Death of bone tissue Hip fractures or bone

displacement Hardware interferes with

circulation

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Amputation

Diabetic, smoker, infected foot ulcer

Trauma Grieving loss Altered self concept Coping Family response

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Surgical WoundsWeb Resource

http://alfa.saddleback.edu Click tab titled, “Med-

Surg 1” Drop down menu choose

“Wound Care”

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Wound AssessmentMeasure the wound in centimetersAssess phase of wound healing

• Reaction • Regeneration • Remodeling

Wound location, color of wound bed, condition of wound margins, integrity of surrounding skin

Signs and symptoms of infection Drainage: amount, color, consistency, odor

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Wound Care Dressing

The ideal dressingo Keeps wound moisto Prevents macerationo Protects from contaminationo Contains wound fluido Protects granulation tissue

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Traditional dry dressings

o Wounds exposed to air are more inflamed, painful, itchy and have thicker crusts than moist wounds

o Epithelium migrates into wound bed: if must burrow between any eschar (crust or Wet to dry dressing significantly increase healing time

o Nonocclusive: increased risk of contamination and infection

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Moist Wound Healing

•No eschar develops (crust, scab) •Enhances autolytic debridement: promotes role of macrophages and leukocytes

•Bacterial barriers: prevent wound contamination

•Wound fluids kept at site: contain growth factors and enzymes that promote autolysis and healing

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Potential for Infection

Signs of infection–I-induration –F-fever –E-erythema –E-edema

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Absorptive powders and pastes

Used in heavily draining wounds: absorb up to 100x weight in fluid: may increase wound pH above physiological levels May require wrapping in gauze before inserting into wound bed Pastes easier to remove from wound

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Wound Healing

Normal healing (3R's)oReaction: inflammatory

process (72 hours) oRegeneration: proliferation (up

to three weeks) oRemodeling: (three weeks to

two years)

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Black Wound = EscharCellular debris will escape wound edges as

necrotic tissue begins to separate from granulation tissue

If eschar becomes contaminated:• becomes excellent medium for infection • wound remains in reaction or

inflammatory stage • systemic signs of infection

Eschar delays regeneration phase by interfering with cell migration and wound closure

Risk of wound infection increases as the amount of necrotic tissue increases

Needs debridement

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Yellow Wound

Tissue not damaged enough to form an eschar so wound covered with thick yellow fibrous debris or viscous exudateo High risk of infection due to

excellent medium for bacterial growth

o Needs continuing debridement Photo courtesy of Saddleback College, California, http://www.saddleback.edu/alfa/N170/woundclassification.aspx

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Red Wound

Red indicates presence of granulation tissue.o Color of granulation tissue affected

by nutritional status and blood supply• full thickness ulcer: crater with pale pink

to beefy red granulation tissue • crater slowly fills with granulation tissue

from bottom upward

o Wound contraction and epithelialization continues. Epithelialization occurs from wound edges inward.

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Wound Drainage Devices

Decrease pressure in the wound by removing excess exudate thereby promoting healing from the inside (secondary healing).

Examples: Penrose drain, Jackson-Pratt & Hemovac suction devices

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Dehiscence/Evisceration

Partial or complete separation of the outer wound layers. If the internal organs below the wound protrude out of it, the wound has eviscerated. Highest risk is in obese patients, diabetics or those receiving steroids.

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Bacterial skin infections Folliculitis, furuncles, cellulitis:

these infections are usually caused by Staphylococcus aureus. Folliculitis involves the hair follicle. Furuncles (boils) are deeper.

Cellulitis is a general infection and involves deeper connective tissue.

Topical antibiotics: Neomycin sulfate (Neosporin)

Teach: wash area daily with antibacterial soap, allow skin to dry, prevent cross contamination

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Herpes Simplex Virus

Type 1 causes common cold sore, type 2 causes genital herpes. After first infection, recurrence is triggered by stress. Spreads by direct contact. Patient is contagious for the first 3-5 days.

Topical acyclovir (Zovirax) shortens the period of infection

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Herpes Zoster (Shingles)

Caused by reactivation of varicella (chickenpox). Occurs in the dermatome corresponding to the infected nerve. Eruptions follow several days after pain in the area, last several weeks.

Acyclovir (Zovirax), given topically and/or orally controls the severity of the lesions and decreases pain.

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Acute Burns

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Superficial Sunburn

oEpidermis pink to redoMild edemaoPainfuloHealing time: 3-5 daysoNo skin graft

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Partial Thickness Burn

Brief contact: scald, flames, grease, chemicals

Epidermis and dermis damaged Blisters if mild burn, pale,

mottled, waxy white with deeper Painful Healing time: 2-6 weeks No grafting unless healing

prolonged

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Full Thickness Burn

Prolonged contact: scald, flame, tar, grease, chemical, electricity

Epidermis, dermis & underlying tissues damaged

Waxy white, dry, leathery, charredNo painHealing: Weeks to monthsSkin grafts required

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Percentage of Burn Injury

Source: Burn diagrams courtesy of BioTel Emergency Medical Service (EMS), Texas Department of Health, http://www.biotel.ws/protocolsHTML/Protocols2004/BurnDiagramBurnFormula.asp

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Emergency Management

Excessive leakage of plasma, especially in the first eight hours post-burn, causes hypovolemia, hypoproteinemia, hemoconcentration, electrolyte imbalances and acid base disturbances. 

In the absence of prompt fluid replacement, burn shock is imminent.

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Fluid ResuscitationInitial 24 hours:

Lactated ringer's 2-4 ml/kg/%burn/24 hours - given in the first 8 hours post-injury.

Additional fluid required for inhalation injury.

Maintain urine output of 30 ml/hr.5% albumin – keep albumin >2.5

gm/dl

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Monitoring Fluid shift lasts 24 to 72 hours.  Hematocrit, electrolytes,

osmolality, calcium, glucose, albumin  

Urine output >30 ml/hr Myoglobinuria and hemoglobinuria Pulse rate and pulse pressure Normal sensorium and adequate

peripheral capillary refill

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Type Cause Priority

Thermal Flame, steam, liquids

Smother flames; Remove smoldering clothing & metal objects

Chemical Acids, strong alkalis, organic compounds

Brush off dry chemicals Remove clothing; ascertain type of chemical

Electrical Direct or alternating currentLightning

Separate patient from electrical currentSmother any flamesStart CPR; Obtain EKG

Radiation Solar, X-raysRadioactive agents

Remove from radiation sourceRemove clothing if contaminated using tongs or lead glovesSend to radiation decontamination center

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Skin Care

Hydrotherapy daily to debride eschar and cleanse wounds

Topical enzyme such as collagenase (Santyl) or Accuzyme will debride more rapidly

Silver coated anti-microbial dressing (Acticoat)

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Grafting: Allograft (skin from a

cadaver) Synthetic such as

Biobrane Bioengineered skin

substitute (Transcyte)

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Prevention of Pressure Ulcers

Patients at risk Inspect skin frequently Move at least every 2 hours Use life sheet or slide board Pad bony prominences Remove excess moisture Adequate nutrution Use protective barriers

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Braden Scale 1 2 3

4Sensory Completely

limitedVery limited

Slightly limited

No impairment

Moisture Constantly moist

Very moist Occasionally moist

Rarely moist

Activity Bedfast Chairfast Walks occasionally

Walks frequently

Mobility Completely immobile

Very limited

Slightly limited

No limitations

Nutrition

Very poor Probably inadequate

Adequate Excellent

Friction/Shear

Problem Potential problem

No apparent problem

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Pressure UlcersStage I: Redness only

Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures http://www.saddleback.edu/alfa/

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Stage 2 Pressure UlcerLoss of epidermis and partial

loss of dermis not extending into subcutaneous tissue

Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures http://www.saddleback.edu/alfa/

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Stage 3 Pressure UlcerFull thickness wound. Includes loss of epidermis and dermis.

Extends into subcutaneous tissue.

Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures http://www.saddleback.edu/alfa/

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Stage 4 Pressure UlcerDeep penetrating wound. Includes

loss of epidermis, dermis and subcutaneous tissue. Extends into

muscle and/or bone.

Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures http://www.saddleback.edu/alfa/

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Basal Cell Carcinoma

Malignancy of the basal cell layer of the epidermis.

Genetic predisposition, chronic irritation, and ultra-violet exposure are risk factors.

Photo Source: Wikimedia Commonshttp://commons.wikimedia.org/wiki/Image:Basaliom2.jpg

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Squamous Cell Carcinoma

Cancers of the epidermis Chronic irritation, skin

damage risk factors

Photo Source: Wikimedia Commonshttp://commons.wikimedia.org/wiki/Image:Squamous_Cell_Carcinoma.jpg

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Malignant Melanoma

Pigmented cancers in the melanin-producing epidermal cells.

Risk factors: predisposition, excess ultra-violet exposure.

Photo Source: Wikimedia Commonshttp://en.wikipedia.org/wiki/Image:Malignant_melanoma.jpg

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Preventing Skin Cancer

Avoid sun between 11:00 am and 3:00 pm

Use sunscreen Wear a hat, opaque clothing,

sunglasses in the sun Examine body monthly for

lesions

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Seek Medical Attention Changes color, especially darkening or

spreading Changes in size Change in shape – sharp border becomes

irregular or flat becomes raised Surrounding redness or edema Change in sensation, especially itching

or tenderness Change in character: oozing, crusting,

bleeding, scaling

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Photo Acknowledgement:All unmarked photos and clip

art contained in this module were obtained from the

2003 Microsoft Office Clip Art Gallery.