Fracture and Casts Updated 2011

8/7/2019 Fracture and Casts Updated 2011

1/171

Fractures


2/171

What is a fracture?

A fracture is a break in the continuity of a

bone.

Other structures may be involved.

There might be soft tissue edema,

hemorrhage into muscles and joints, joint

dislocations, ruptured tendons , severed

nerves, damaged blood vessels and injury

to body organs.


3/171

Classifications of Fractures

Complete - fracture involving the entire

cross section of the bone; usually

displaced.


4/171

Incompletefracture involving only a

portion of the cross section of bone;

usually undisplaced.


5/171

Open break in the skin and underlying

soft tissue leading directly into fracture or

its hematoma.


6/171

Closed Fracture does not

communicated with outside area.


7/171

Specific Types of Fractures

Greenstick one side of a bone is

broken, and the other side is bent.


8/171

Transverse fracture straight across the

bone.


9/171

Oblique fracture occurring at an angle

across the bone.


10/171

Comminuted bone has splintered into

several fragments.


11/171

Clinical Manifestations Pain

Loss of function; inability to use the part

Localized swelling and discoloration of the

skin

Deformity (visible or palplable)

False motion; abdominal mobility atfracture site

Crepitation (grating sensation)

Bone might be visible through skin


12/171

Fracture

TYPES OF FRACTURE

1. Complete fracture

Involves a break across the entire

cross-section 2. Incomplete fracture

The break occurs through only a part of

the cross-section

4/28/2011 RON R.N.,M.D. 12


13/171

4/28/2011 RON R.N.,M.D. 13


14/171

Fracture

TYPES OF FRACTURE

1. Closed fracture

The fracture that does not cause a

break in the skin 2. Open fracture

The fracture that involves a break in the

skin

4/28/2011 RON R.N.,M.D. 14


15/171

4/28/2011 RON R.N.,M.D. 15


16/171

Fracture

TYPES OF FRACTURE

1. Comminuted fracture

A fracture that involves production of

several bone fragments 2. Simple fracture

A fracture that involves break of bone

into two parts or one

4/28/2011 RON R.N.,M.D. 16


17/171

Fracture

ASSESSMENT FINDINGS

1. Pain or tenderness over the

involved area

2. Loss of function

3. Deformity

4. Shortening

5. Crepitus

6. Swelling and discoloration

4/28/2011 RON R.N.,M.D. 17


18/171

Fracture

ASSESSMENT FINDINGS

1. Pain

Continuous and increases in severity

Muscles spasm accompanies the fractureis a reaction of the body to immobilize the

fractured bone

4/28/2011 RON R.N.,M.D. 18


19/171

Fracture

ASSESSMENT FINDINGS

2. Loss of function

Abnormal movement and pain can result

to this manifestation

4/28/2011 RON R.N.,M.D. 19


20/171

Fracture

ASSESSMENT FINDINGS

3. Deformity

Displacement, angulations or rotation of

the fragments Causes deformity

4/28/2011 RON R.N.,M.D. 20


21/171

Fracture

ASSESSMENT FINDINGS

4. Crepitus

A grating sensation produced when the

bone fragments rub each other

4/28/2011 RON R.N.,M.D. 21


22/171

Fracture

DIAGNOSTIC TEST

X-ray

4/28/2011 RON R.N.,M.D. 22


23/171

Fracture

EMERGENCY MANAGEMENT OF FRACTURE

1. Immobilize any suspected fracture

2.S

upport the extremity above and belowwhen moving the affected part from a vehicle

3. Suggested temporary splints- hard board,

stick, rolled sheets

4. Apply sling if forearm fracture is suspectedor the suspected fractured arm maybe

bandaged to the chest

4/28/2011 RON R.N.,M.D. 23


24/171

Fracture

EMERGENCY MANAGEMENT OF

FRACTURE

5. Open fracture is managed by covering a

clean/sterile gauze to preventcontamination

6. DO NOT attempt to reduce the facture

4/28/2011 RON R.N.,M.D. 24


25/171

Fracture

MEDICAL MANAGEMENT

1. Reduction of fracture either open or

closed, Immobilization and Restoration of

function 2. Antibiotics, Muscle relaxants such as

METHOCARBAMOL and Pain

medications

4/28/2011 RON R.N.,M.D. 25


26/171

Fracture

General Nursing MANAGEMENT

ForCLOSED FRACTURE

1. Assist in reduction and immobilization 2. Administer pain medication and muscle

relaxants

3. teach patient to care for the cast

4. Teach patient about potential complicationof fracture and to report infection, poor

alignment and continuous pain

4/28/2011 RON R.N.,M.D. 26


27/171

Fracture

General Nursing MANAGEMENTFor OPEN FRACTURE

1. Prevent wound and bone infection

Administer prescribed antibiotics

Administer tetanus prophylaxis Assist in serial wound debridement

2. Elevate the extremity to prevent edema formation

3. Administer care of traction and cast

4/28/2011 RON R.N.,M.D. 27


28/171

Fracture FRACTURE COMPLICATIONS Early

1. Shock

2. Fat embolism

3. Compartment syndrome

4. Infection

5. DVT

4/28/2011 RON R.N.,M.D. 28


29/171

Fracture FRACTURE COMPLICATIONS Late

1. Delayed union

2. Avascular necrosis

3. Delayed reaction to fixation devices

4. Complex regional syndrome

4/28/2011 RON R.N.,M.D. 29


30/171

Fracture FRACTURE COMPLICATIONS:FatEmbolism Occurs usually in fractures of the long bones

Fat globules may move into the blood stream becausethe marrow pressure is greater than capillary pressure

Fat globules occlude the small blood vessels of thelungs, brain kidneys and other organs

4/28/2011 RON R.N.,M.D. 30


31/171

Fracture FRACTURE COMPLICATIONS: Fat Embolism

Onset is rapid, within 24-72 hours

ASSESSMENT FINDINGS

1. Sudden dyspnea and respiratory distress

2. tachycardia

3. Chest pain 4. Crackles, wheezes and cough

5. Petechial rashes over the chest, axilla and hard palate

4/28/2011 RON R.N.,M.D. 31


32/171

Fracture FRACTURE COMPLICATIONS: Fat Embolism Nursing Management

1. Support the respiratory function

Respiratory failure is the most common cause ofdeath

Administer O2 in high concentration

Prepare for possible intubation and ventilator support

4/28/2011 RON R.N.,M.D. 32


33/171

Fracture FRACTURE COMPLICATIONS: Fat Embolism Nursing Management

2. Administer drugs

Corticosteroids

Dopamine

Morphine

4/28/2011 RON R.N.,M.D. 33


34/171

Fracture FRACTURE COMPLICATIONS: Fat Embolism NursingManagement

3. Institute preventive measures

Immediate immob

ilizationoffracture Minimalfracture manipulation

Adequate support forfractured bone during

turning and positioning

Maintain adequate hydration and electrolyte

balance

4/28/2011 RON R.N.,M.D. 34


35/171

Fracture Early complication:Compartment syndrome

This results from fractures of arms or legs whereclosed compartment are present.

Compartment contains blood vessels, nerves,

muscles which are enclosed by fascia.

A complication that develops when tissue perfusion inthe muscles is less than required for tissue viability

4/28/2011 RON R.N.,M.D. 35


36/171

Fracture

Tight dressing

Tight cast

Edema of contents of the compartment

Increase pressure within closed compartment

5 Ps

Pain

Pallor

Pulselessness

Paresthesia

paralysis

Contractures

e.g. Volkmanns contractures

(Irreversible wrist drop)

Function disability


37/171

Fracture

4/28/2011 RON R.N.,M.D. 37


38/171

Fracture

Early complication:Compartment syndrome

ASSESSMENT FINDINGS

1. Pain- Deep, throbbing and UNRELIEVED pain by opiods

Pain is due to reduction in the size of the musclecompartment by tight cast

Pain is due to increased mass in the compartment by edema,swelling or hemorrhage

4/28/2011 RON R.N.,M.D. 38


39/171

Fracture


ASSESSMENT FINDINGS

2. Paresthesia- burning or tingling sensation

3. Numbness 4. Motor weakness

5. Pulselessness, impaired capillary refill time and

cyanotic skin

4/28/2011 RON R.N.,M.D. 39


40/171

Fracture


Medical and Nursing management

1. Assess frequently the neurovascular status of the

casted extremity 2. Elevate the extremity above the level of theheart

3. Assist in cast removal and FASCIOTOMY

4/28/2011 RON R.N.,M.D. 40


41/171

Open Reduction Internal Fixation

(ORIF)

- Surgical insertion of internal fixation devices like metal pins, wires or

screws to keep bone fragment in position.

PRE-OPERATIVE CARE:

1. Immobilize the affected bone

2. Handle the affected bone gently

3. Cover open fractures with sterile gauze.

POST-OPERATIVE CARE

1. Monitor neuromascular status

2. Monitor for signs of nerve damage 5Ps

3. Monitor for complications: DVT (Homans sign), thromboplebitis,

infection


42/171

CARPAL TUNNEL SYNDROME:

Compressionofthe mediannerve ofthe wrist.

Most common in women 30-50 years ofage.

Usually associated with job-related tasks (typists,computeroperators, assembly line workers,

truck drivers, carpenters)

Initialmanifestations:paresthesia, clumsinesswhwn using the hands

Othermanifestations;

NumbnessPain

Paresthesia

Pain radiating toforearm, shoulder and chest

Loss offine motormovement ofthe hand.


43/171

LABORATORY DATA:

(+) Tinels Sign tapping the mediannerve at the wristproduces the symptoms

(+) Phalens test holding the wrist in acute flexionfor

60 s produces the symptoms

Splint the wrist

Administered steroid as ordered

Prepare the client for surgical intervention:

(decompressionofthe mediannerve)

Prepare the client foroccupation and jo

bcounselling

Post-operatively, elevate the hand and arm 24h

Encourage the client to handle normal activities ofdaily

living, 2-3 days following surgery


44/171

Strains

Excessive stretchingofa muscle or

tendon

Nursingmanagement

1. Immobilize affected part

2. Apply cold packs initially, then heat

packs 3. Limit joint activity

4. AdministerNSAIDs and muscle

relaxants4/28/2011 RON R.N.,M.D. 44


45/171

Sprains

Excessive stretching of the LIGAMENTS

Nursing management

1. Immobilize extremity and advise rest 2. Apply cold packs initially then heat packs

3. Compression bandage may be applied to

relieve edema

4. Assist in cast application

5. Administer NSAIDS

4/28/2011 RON R.N.,M.D. 45


46/171

Herniated disk

Occurs when allorpart ofthe nucleus

pulposus forces through the weakened

or tornouter ring (annulus pulposus

4/28/2011 RON R.N.,M.D. 46


47/171

Herniated disk

Impingement on the spinalnerves will

result to BACKPAIN

4/28/2011 RON R.N.,M.D. 47


48/171

Treatment

Reduction setting the bone; restoration

of fracture fragments into anatomical

position and alignment.


49/171

Methods

Closed reduction

Traction

Open reduction


50/171


51/171


52/171

Open Reduction

Operative intervention to achieve fracture

reduction

Bone fragments are repositioned under

direct visualization

Internal fixation devices(metallic pins,

wires, screws, plates, nails, rods) may be

used to hold bone fragments in position

After closure of wound, cast may be

applied


53/171


54/171


55/171

Musculoskeletal Modalities

Traction

Cast

4/28/2011 RON R.N.,M.D. 55


56/171

Nursing Management

Traction

A method of fracture immobilization by

applying equipments to align bone

fragments Used for immobilization, bone alignment

and relief of muscle spasm

4/28/2011 RON R.N.,M.D. 56


57/171

Traction

Skin traction- Buck, Bryant

Skeletal traction

4/28/2011 RON R.N.,M.D. 57


58/171


59/171


60/171

Traction

Pullingforce exerted onbones to

reduce or immobilize fractures, reduce

muscle spasm, correct orprevent

deformities

4/28/2011 RON R.N.,M.D. 60


61/171


62/171

4/28/2011 RON R.N.,M.D. 62

Balance suspension traction (skeletal)


63/171

4/28/2011 RON R.N.,M.D. 63

Bucks traction (Skin)


64/171

Nursing Management

Traction:General principles

1. ALWAYS ensure that the

weights hang freely and do not

touch the floor 2. NEVERremove the weights

3. Maintain proper body alignment

4. Ensure that the pulleys and ropesare properly functioning and

fastened by tying square knot

4/28/2011 RON R.N.,M.D. 64


65/171

Nursing Management


5. Observe and prevent foot drop

Provide foot plate

6. Observe for DVT, skin irritation andbreakdown

7. Provide pin care for clients in skeletal

traction- use of hydrogen peroxide

4/28/2011 RON R.N.,M.D. 65


66/171

Nursing Management


8. Promote skin integrity

Use special mattress if possible

Provide frequent skin care Assess pin entrance and cleanse the pin

with hydrogen peroxide solution

Turn and reposition within the limits of

traction Use the trapeze

4/28/2011 RON R.N.,M.D. 66


67/171

Nursing Management

CAST

Immobilizing tool made of plaster of Paris

or fiberglass

Provides immobilization of the fracture

4/28/2011 RON R.N.,M.D. 67


68/171


69/171

Casting Materials

Plaster of Paris

Drying takes 1-3 days

If dry, it is SHINY, WHITE, hard and

resistant Fiberglass

Lightweight and dries in 20-30 minutes

Water resistant

4/28/2011 RON R.N.,M.D. 69


70/171

Cast application

1. TO immobilize a body part in a specificposition

2. TO exert uniform compression to thetissue

3. TOprovide early mobilizationofUNAFFECTED body part

4. TO correct deformities

5. TO stabilize and support unstable

joints

4/28/2011 RON R.N.,M.D. 70


71/171


72/171

Nursing Management

CAST:GeneralNursingCare

3. Keep the casted extremity

ELEVATED using a pillow

4. Turn the extremity for equal drying.DONOTUSEDRYER forplaster cast

Encourage mobility and range of

motion exercises

4/28/2011 RON R.N.,M.D. 72


73/171

Nursing Management


5. Petal the edges ofthe cast to

prevent crumblingofthe edges

6. Examine the skinforpressureareas and Regularly check the

pulses and skin

4/28/2011 RON R.N.,M.D. 73


74/171

Nursing Management


7. Instruct the patient not to

place sticks or smallobjects

inside the cast

8. Monitorfor the following:

pain, swelling, discoloration,

coolness, tingling or lack ofsensation and diminished

pulses4/28/2011 RON R.N.,M.D. 74


75/171

Nursing Management


Hot spots occurring along the cast

may indicate in

fecti

on under the cast

4/28/2011 RON R.N.,M.D. 75


76/171

Common

Musculoskeletal

conditions

Nursing management

4/28/2011 RON R.N.,M.D. 76


77/171

What is a cast?

A cast holds a broken bone in place as it

heals. Casts also help to prevent or decrease

muscle contractions, and are effective at

providing immobilization, especially after

surgery.

Casts immobilize the joint above and the joint

below the area that is to be kept straight and

without motion. For example, a child with a

forearm fracture will have a long arm cast to

immobilize the wrist and elbow joints.


78/171

What are casts made of?

The outside, or hard part of the cast, is made from two

different kinds of casting materials.

plaster- white in color.

fiberglass - comes in a variety of colors, patterns, and

designs.

Cotton and other synthetic materials are used to line the

inside of the cast to make it soft and to provide padding

around bony areas, such as the wrist or elbow.

Special waterproof cast liners may be used under a

fiberglass cast, allowing the child to get the cast wet.

Consult your child's physician for special cast care

instructions for this type of cast.

Wh t th diff t t f


79/171

What are the different types of

casts?

Short arm cast: Applied below the elbow to

the hand.

Use: Forearm or wrist fractures. Also

used to hold the forearm or wrist muscles

and tendons in place after surgery.


80/171


81/171

Long arm cast: Applied from the upper arm to

the hand.

Use: Upper arm, elbow, or forearm

fractures. Also used to hold the arm or

elbow muscles and tendons in place after

surgery.


82/171


83/171


84/171


85/171

Shoulder spica cast: Applied around the

trunk of the body to the shoulder, arm, and

hand.

Use:Shoulder dislocations or after

surgery on the shoulder area


86/171


87/171

Minerva cast: Applied around the neck and

trunk of the body.

Use: After surgery on the neck or upper

back area.


88/171


89/171

Short leg cast: Applied to the area below the

knee to the foot.

Use: Lower leg fractures, severe ankle

sprains/strains, or fractures. Also used to

hold the leg or foot muscles and tendons

in place after surgery to allow healing.


90/171


91/171

Leg cylinder cast: Applied from the upper

thigh to the ankle.

Use: Knee, or lower leg fractures, knee

dislocations, or after surgery on the leg or

knee area.


92/171


93/171


94/171


95/171

One and one-halfhip spica cast: Applied

from the chest to the foot on one leg to the

knee of the other leg. A bar is placed between

both legs to keep the hips and legs

immobilized.

Use: Thigh fracture. Also used to hold the

hip or thigh muscles and tendons in place

after surgery to allow healing.


96/171

Bilaterallongleg hip spica cast: Applied

from the chest to the feet. A bar is placed

between both legs to keep the hips and legs

immobilized.

Use: Pelvis, hip, or thigh fractures. Also

used to hold the hip or thigh muscles and

tendons in place after surgery to allow

healing.


97/171


98/171


99/171


100/171

Abductionboot cast: Applied from the upper

thighs to the feet. A bar is placed between

both legs to keep the hips and legs

immobilized.

Use: To hold the hip muscles and tendons

in place after surgery to allow healing.


101/171

How canmy child move around


102/171

y

while in a cast?

Assistive devices for children with casts

include:

crutches

walkers

wagons

wheelchairs

reclining wheelchairs


103/171


104/171


105/171

Older children with body casts may need to use a

bedpan or urinal in order to go to the bathroom.

Tips to keep body casts clean and dry and prevent

skin irritation around the genital area include the

following:

Use a diaper or sanitary napkin around the

genital area to prevent leakage or splashing of

urine.

Place toilet paper inside the bedpan to prevent

urine from splashing onto the cast or bed.

Keep the genital area as clean and dry as

possible to prevent skin irritation.

When to call your child's

physician:


106/171

physician:

Contact your child's physician or healthcareprovider if your child develops one or more of

the following symptoms:

fever greater than 101 F

increased pain

increased swelling above or below the cast

complaints of numbness or tingling

drainage or foul odor from the cast

cool or cold fingers or toes


107/171

METABOLIC BONE


108/171

DISORDERS

Osteoporosis: Pathophysiology

Normal homeostatic bone turnover is

altered rate of bone RESORPTION is

greater than bone FORMATION

reduction in total bone mass reduction inbone mineral density prone to

FRACTURE

4/28/2011 RON R.N.,M.D. 108

METABOLIC BONE


109/171

DISORDERS

Osteoporosis: TYPES

1. Primary Osteoporosis- advanced age,

post-menopausal

2.S

econdary osteoporosis-S

teroidoveruse, Renal failure

4/28/2011 RON R.N.,M.D. 109

METABOLIC BONE


110/171

DISORDERS

RISK factors for the development of

Osteoporosis

1. Sedentary lifestyle

2. Age 3. Diet- caffeine, alcohol, low Ca

and Vit D

4. Post-menopausal

5. Genetics- caucasian and asian

6. Immobility

4/28/2011 RON R.N.,M.D. 110


111/171

METABOLIC DISORDER

ASSESSMENT FINDINGS

1. Low stature

2. Fracture

F

emur 3. Bone pain

4/28/2011 RON R.N.,M.D. 111


112/171

T-score and World Health Organization


113/171

T-score and World Health Organization

Diagnosis of Bone Density:

T-score Diagnosis

0 to -0.99 SD Norma BMD

-1.0 to -2.49 SD Low Bone density

(osteopenia)


114/171

METABOLIC DISORDER

Medical management of Osteoporosis

1. Diet therapy with calcium and

Vitamin D

2. Hormone replacement therapy 3. Biphosphonates- Alendronate,

risedronate produce increased bone

mass by inhibiting the

OSTEOCLAST

4. Moderate weight bearing

exercises

5. Management of fractures

4/28/2011 RON R.N.,M.D. 114


115/171

METABOLIC DISORDER

Osteoporosis Nursing Interventions

1. Promote understanding ofosteoporosis and the treatmentregimen

Provide adequate dietarysupplement of calcium and vitaminD

Instruct to employ a regular programof moderate exercises and physicalactivity

Manage the constipating side-effectof calcium supplements4/28/2011 RON R.N.,M.D. 115


116/171

METABOLIC DISORDER


Take calcium supplements with meals

Take alendronate with an EMPTY stomach

with water

Instruct on intake of Hormonal

replacement

4/28/2011 RON R.N.,M.D. 116


117/171

METABOLIC DISORDER


2. Relieve the pain

Instruct the patient to rest on a firm

mattress

Suggest that knee flexion will cause

relaxation of back muscles

Heat application may provide comfort

Encourage good posture and body

mechanics

Instruct to avoid twisting and heavy lifting

4/28/2011 RON R.N.,M.D. 117


118/171

METABOLIC DISORDER


3. Improve bowel elimination

Constipation is a problem of calcium

supplements and immobility

Advise intake of HIGH fiber diet and

increased fluids

4/28/2011 RON R.N.,M.D. 118


119/171

METABOLIC DISORDER


4. Prevent injury

Instruct to use isometric exercise to

strengthen the trunk muscles

AVOID sudden jarring, bending and

strenuous lifting

Provide a safe environment

4/28/2011 RON R.N.,M.D. 119


120/171

Juvenile rheumatoid Arthritis

Definition:

AUTO-IMMUNE inflammatory joint

disorder of UNKNOWN cause

SYSTEMIC chronic disorder of

connective tissue

Diagnosed BEFORE age 16 years old

4/28/2011 RON R.N.,M.D. 120


121/171

Juvenile rheumatoid Arthritis

PATHOPHYSIOLOGY : unknown

Affected by stress, climate and genetics

Common in girls 2-5 and 9-12 y.o.

4/28/2011 RON R.N.,M.D. 121

Systemic JRA Pauci-articular Polyarticular


122/171

FEVER MILD joint pain

and swelling

Morning joint

stiffness andfever

Salmon-pink

rash

IRIDOCYCLITIS Weight

Bearing joints

Five or more

joints

Less than 4

joints

Five or more

joints

Anorexia,

anemia, fatigue

Very Good

prognosisPoor prognosis

4/28/2011 RON R.N.,M.D. 122


123/171

JRA

Symptoms may decrease as child enters

adulthood

With periods of remissions and

exacerbations

4/28/2011 RON R.N.,M.D. 123


124/171


125/171

JRA

Nursing Management

1. Encourage normal performance of daily

activities

2. Assist child in ROM exercises

3. Administer medications

4. Encourage social and emotional

development

4/28/2011 RON R.N.,M.D. 125


126/171

JRA

NursingManagement

During acute attack:

SPLINT the joints

NEUTRAL positioning

Warm or cold packs

4/28/2011 RON R.N.,M.D. 126


127/171

DEGENERATIVE JOINT DISEASES

Types of Arthritis


128/171

Rheumatoid Arthritis Gouty Arthritis Osteoarthritis

Main Problem Recurrentinflammation of the

synovial lining of the

joints, usually the

upper extremities. It

is more common in

women

Metabolic disorderof uric acid

formation and

excretion. It is

more common in

men

Degeneration ofthe articular

cartilage in the

joints. It affects

both men and

women ( more

common inmen)

Initial

manifestation

Morning stiffness

relieved by warm

bath or soaks

Initially

asymptomatic. A

common sign is

dusky red hotswollen joints,

usually of the

great big toe

Pain and swelling

in a weight-

bearing joint,

usuallyaggravated by

activity

Types of ArthritisRheumatoid arthritis Gouty Arthritis Osteoarthritis


129/171

y

Other

manifestations

-joint instability

-ulnar deviation offingers (ulnar drift)

-swan-neck deformity

of the hands

-ankylosis

* Boutonnieredeformity

-joint pain

-redness andswelling in joints

-tophi

accumulation of

urate crystals

-Malaise-fever

-joint stiffness

-crepitus-Heberdens

(DIP)nodes-distal

joints of the

fingers

-Bouchardsnodes-(PIP)

proximal joints of

the fingers

-Increased pain in

cold weather

-Decreased range

of motion

Laboratory data Elevated ESR Elevated urate

crystals synovial

fluids

X-ray

Rheumatoid Arhritis Gouty Arthritis Osteoarthritis

Priorit Pain related to Joint Pain related to Joint Pain related to


130/171

Priorit

y

Nursi

ng

Diagn

osis

Pain related to Joint

Inflammation

Pain related to Joint

Inflammation

Pain related to

bone

degenerations in

the joints

Interv

entio

ns

Teach the patient to take

aspirin regularly as ordered

even in the absence ofsymptoms.

-Instruct the client that

tinnitus is a side effect of

aspirin

-Apply moist heat for 15-30min to reduce muscle

spasm

-Use ice packs during

acute phase to decrease

the pain

Teach the client to

maintain purine-

restricted diet (avoidorgan meats,alcohol,

beans, sardines)

-inc. oral fluid intake

-Avoid aspirin and

diuretics as theseinterfere with uric acid

secretion

-complication

kidney stone

Priority: minimize

discomfort

Implement WHAT:

W weight control

H hot compress

or icepacks

A aspirin use

T trunk assistive

devices (canes)

DEGENERATIVE JOINT

DISEASE


131/171

DISEASE

OSTEOARTHRITIS The most common form of degenerative

joint disorder

4/28/2011 RON R.N.,M.D. 131


132/171

DEGENERATIVE JOINT

DISEASE


133/171

DISEASE

OSTEOARTHRITIS:Pathophysiology Injury, genetic, Previous joint damage,

Obesity, Advanced age

Stimulate the chondrocytes to releasechemicals

chemicals will cause cartilage

degeneration, reactive inflammation of

the synovial lining and bone stiffening

4/28/2011 RON R.N.,M.D. 133


134/171


135/171

This process may affect any joint in the

body, though the knees and hands are

most commonly affected, followed by thespine, hips, ankles and shoulders. Elbows

and wrists aren't usually affected. Usually

between one and four separate joints are

involved

DEGENERATIVE JOINT

DISEASE


136/171

DISEASE

OSTEOARTHRITIS: Risk factors

1. Increased age

2. Obesity

3. Repetitive use of joints with previous

joint damage

4. Anatomical deformity

5. genetic susceptibility

4/28/2011 RON R.N.,M.D. 136

OSTEOARTHRITIS: Assessment findings

1 Joint pain


137/171

1. Joint pain

2. Joint stiffness 3. Functional joint impairment

limitation

The joint involvement is

ASYMMETRICAL This is not systemic, there is no FEVER,

no severe swelling

Atrophy of unused muscles

Usual joint are the WEIGHTbearing

joints

4/28/2011 RON R.N.,M.D. 137

DEGENERATIVE JOINT

DISEASE


138/171

DISEASE


1. Joint pain

Caused by

Inflamed cartilage and synovium

Stretching of the joint capsule

Irritation of nerve endings

4/28/2011 RON R.N.,M.D. 138

DEGENERATIVE JOINT

DISEASE


139/171

DISEASE


2. Stiffness

commonly occurs in the morning aftercommonly occurs in the morning afterawakeningawakening

Lasts only forless than 30 minutes DECREASES with movement, but worsens

after increased weight bearing activitry

Crepitation may be elicited

4/28/2011 RON R.N.,M.D. 139

DEGENERATIVE JOINT

DISEASE


140/171

DISEASE

OSTEOARTHRITIS: Diagnostic findings

1. X-ray

Narrowing of joint space

Loss of cartilage

Osteophytes2. Blood tests will show no evidenceno evidence of

systemic inflammation and are not useful

4/28/2011 RON R.N.,M.D. 140

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS: Medical


141/171

OSTEOARTHRITIS:Medical

management

1. Weight reduction

2. Use of splinting devices to support

joints

3. Occupational and physical therapy 4. Pharmacologic management

Use of PARACETAMOL, NSAIDS

Use of Glucosamine and chondroitin

Topical analgesics

Intra-articular steroids to decrease inflam

4/28/2011 RON R.N.,M.D. 141


142/171

DEGENERATIVE JOINT

DISEASE


143/171

DISEASE

OSTEOARTHRITIS: Nursing Interventions

2. Advise patient to reduce weight

Aerobic exercise

Walking

3. Administer prescribed medications

NSAIDS

4/28/2011 RON R.N.,M.D. 143

DEGENERATIVE JOINT

DISEASE


144/171

DISEASE

OSTEOARTHRITIS: Nursing Interventions

4. Position the client to prevent flexion

deformity

Use of foot board, splints, wedges and

pillows

4/28/2011 RON R.N.,M.D. 144

Rh t id th iti


145/171

Rheumatoid arthritis

A type of chronic systemic inflammatory

arthritis and connective tissue disorder

affecting more women (ages 35-45) than

men

4/28/2011 RON R.N.,M.D. 145

Rhe matoid arthritis


146/171


FACTORS:

Genetic

Auto-immune connective tissue disorders

Fatigue, emotional stress, cold, infection

4/28/2011 RON R.N.,M.D. 146


147/171


ASSESSMENT FINDINGS


148/171

ASSESSMENT FINDINGS

1. PAIN 2. Joint swelling and stiffness-

SYMMETRICAL, Bilateral

3.W

armth, erythema and lack offunction

4. Fever, weight loss, anemia,

fatigue

5. Palpation of join reveals spongy

tissue

6. Hesitancy in joint movement4/28/2011 RON R.N.,M.D. 148



149/171


ASSESSMENT FINDINGS

Joint involvement is SYMMETRICAL andBILATERAL

Characteristically beginning in the hands, wrist

and feet Joint STIFFNESS occurs early morning, lasts

MORE than 30 minutes, not relieved bymovement, diminishes as the day progresses

4/28/2011 RON R.N.,M.D. 149



150/171


ASSESSMENT FINDINGS

Joints are swollen and warm

Painful when moved

Deformities are common in the hands and

feet causing misalignment

Rheumatoid nodules may be found in

the subcutaneous tissues

4/28/2011 RON R.N.,M.D. 150


151/171


152/171


153/171


Nursing MANAGEMENT


154/171

Nursing MANAGEMENT

1. Relieve pain and discomfort USEsplints to immobilize the affected

extremity during acute stage of the

disease and inflammation to REDUCE

DEFORMITY Administer prescribed medications

Suggest application ofCOLD packs

during the acute phase of pain, then

HEATapplication as the inflammation

subsides

4/28/2011 RON R.N.,M.D. 154



155/171


Nursing MANAGEMENT

2. Decrease patient fatigue

S

chedule activity whenpain is less severe

Provide adequate periods

of rests3. Promote restorative sleep

4/28/2011 RON R.N.,M.D. 155



156/171

Nursing Management4. Increase patient mobility

Advise proper posture and

body mechanics Support joint in functionalposition

Advise AC

TIVE ROME Avoid direct pressure over

the joint4/28/2011 RON R.N.,M.D. 156


N i M t


157/171

Nursing Management

5. Provide Diet therapy

Patients experience anorexia,nausea and weight loss

Regular diet with caloricrestrictions becausesteroids may increase

appetite Supplements of vitamins,

iron andPROTEIN4/28/2011 RON R.N.,M.D. 157


6 Increase Mobility and prevent


158/171

6. Increase Mobility and prevent

deformity:

Lie FLATon a firm mattress

Lie PRONEseveral times topreventHIPFLEXION contracture

Use one pillow under the headbecause of risk of dorsalkyphosis

NOPillow under the jointsbecause this promotes flexioncontractures

4/28/2011 RON R.N.,M.D. 158



159/171


Capsaicin Unknown mechanism, probably

Inhibits substance P

Reduces pain Applied over the affected area

Do NOTbandage the area

Side effect: burning sensation

Wash hands after application

4/28/2011 RON R.N.,M.D. 159

Hot versus Cold

HOT Cold


160/171

HOT Cold

Use to RELIEVE

joint stiffness, pain

and muscle spasm

Use to control

inflammation and

pain

After acute attack ACUTE ATTACK

4/28/2011 RON R.N.,M.D. 160


161/171

OA versus RA


162/171

OA versus RA

RA OA

Joint tenderness,

swelling, warmth and

redness

Subcutaneous nodules

Stiffness that

diminishes

Crepitus, stiffness in

the morning decreases

after activity

Rest the joint, cold andheat modalities, ASA,

NSAIDS, DMARDS

Rest the joints, Avoidoveractivity, Weight

reduction, cold and

warmmodalities, ASA4/28/2011 RON R.N.,M.D. 162

Gouty arthritis


163/171

Gouty arthritis

A systemic disease caused by depositionof

uric acid crystals in the joint and body

tissues

CAUSES:

1. Primary gout- disorder ofPurinemetabolism

2. Secondary gout- excessive uric acid in

the blood like leukemia

4/28/2011 RON R.N.,M.D. 163


164/171

4/28/2011 RON R.N.,M.D. 164


165/171

4/28/2011 RON R.N.,M.D. 165

Gouty arthritis


166/171

Gouty arthritis

ASSESSMENT FINDINGS

1. Severe pain in the involved joints, initiallythe big toe

2. Swelling and inflammation of the joint

3. TOPHI- yellowish-whitish, irregulardeposits in the skin that break open andreveal a gritty appearance

4. PODAGRA-big toe

4/28/2011 RON R.N.,M.D. 166

Gouty arthritis


167/171

Gouty arthritis

ASSESSMENT FINDINGS

5. Fever, malaise

6. Body weakness and headache

7. Renal stones

4/28/2011 RON R.N.,M.D. 167


168/171

Gouty arthritis


169/171

Gou y a s

Medical management

1. Allupurinol- take it WITH FOOD

Rash signifies allergic

reaction

2. Colchicine

For acute attack

3. Probenecid

For uric acid excretion

in the kidney

4/28/2011 RON R.N.,M.D. 169

Gouty arthritis

Nursing Intervention

1 Provide a diet with LOW purine


170/171

1. Provide a diet with LOWpurine

Avoid Organ meats, aged and processedfoods

STRICTdietary restriction is NOT

necessary

2. Encourage an increased fluid intake (2-

3L/day) to prevent stone formation

3. Instruct the patient to avoid alcohol

4. Provide alkaline ash diet to increaseurinary pH

5. Provide bed rest during early attack of gout4/28/2011 RON R.N.,M.D. 170

Gouty arthritis


171/171

y

Nursing Intervention

6. Position the affected extremity in mild

flexion

7. Administer anti-gout medication and

analgesics

Documents

Fracture and Casts Updated 2011