OsteoporosisFracturesDegenerative Joint Disease/OsteoarthritisTotal Hip and Knee Prostheses Bone Infections / OsteomyelitisGoutMusculoskeletal DisordersPart I
Emergency & Ortho Nursing ..is Not for the Faint of Heart !
Fractured femur 2* Gun Shot Wound
Oblique fracture / spiral fracture / torsion fracture
Green stick fracture
Concept Map: Selected Topics in Musculo-Skeletal NursingPATHOPHYSIOLOGY
FractureOsteoporosisDegenerative Joint DiseaseOsteoarthritisOsteomyelitisGout
AmputationTotal Joint Replacement
ASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation
Neuro / Circ Checks--The 6 Ps
Care PlanningPlan for client adls, Monitoring, med admin.,Patient education, morebasedOn Nursing Process: A_D_O_P_I_E
NURSING DIAGNOSES THAT APPLY.
Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary
Nursing Diagnoses That (Might) ApplyPain, acuteComfort, impairedMobility, alteredSelf-care deficit feeding, grooming; bathing, hygeine; toiletingFalls, risk forSkin breakdown, risk forConstipation, risk forDiversional activity, risk forMobility, Physical, impairedMobility, bed, risk forWalking, impaired,
Tissue perfusion, impaired peripheralPeripheral neurovascular dysfunction, risk forKnowledge, deficientBody image, disturbedGrievingMore
Musculoskeletal DisordersObjectivesSee the Study Guide for Complete List of Objectives
Compare and contrast different types of fracturesDiscuss the usual healing processes for boneIdentify complications of fracturesDescribe the nursing care of the client with casts or traction, including client educationPrioritize nursing care for patients who are at risk for osteopeniaDescribe the role of drug therapy, diet, and exercise in management of osteoporosis.
Musculoskeletal DisordersObjectivesSee the Study Guide for Complete List of Objectives Describe the pain management of client with bone disordersPrioritize nursing care for a patient who has had a hip ORIF or knee replacementIdentify common types of amputationsIdentify appropriate nursing care for patients with degenerative joint disease (DJD)Prioritize nursing care for patients who are at risk for osteomylitis (bone infection)Describe the role of drug therapy in prevention and management of degenerative joint diseaseDescribe the causes of gout and appropriate treatments.
Musculoskeletal DisordersReview of Bone physiology this is a picture of normal bone, with osteoblasts rebuilding injured or old bone, faster than osteoclasts can break it down
Musculoskeletal DisordersThis is one osteoclast dissolving boneAs part of the normal healing process
Healthy bone provides structure and support for the human body.The marrow makes stem cells which produce our red and white cells when theymature.
Osteoporosis number one cause of fractures in the elderly, >1.5 million per yearPrimary Osteoporosis is caused by osteopenia or thinning of the bone. This occurs when osteoclastic bone loss is faster than osteoblastic (bone building) activity.This is measured by BMD (bone mineral density)Osteopenia = T-score of less than- 1.0Treatment starts here, new guidelines 2008Osteoporosis = T-score of > -2.5
Musculoskeletal Disorders- -----OsteoporosisSecondary OsteoporosisCaused by other disease mechanisms, or treatments, i.e. long term corticosteroids, methamphetamine or alcohol abuse, or prolonged immobility can occur within 12 weeksTreatments are the same for both types and osteoclastic activity is the same
Low-power scanning electron microscope image of normal bonearchitecture in the 3rd lumbar vertebra of a 30 year old womanmarrow and other cells have been removed to reveal thick, interconnected plates of boneSlides courtesy of the Bone Research Society BRS, UK
Low-power scanning electron microscope image of osteoporoticbone architecture in the 3rd lumbar vertebra of a 71 year old womanmarrow and other cells have been removed to reveal eroded, fragile rods of bone
Detail of a trabicular bone element perforated by osteoclast action-- note pitting of the bone stalagmite
Musculoskeletal diseasesOsteoporosis Risk FactorsAgePost-menopause (lack of estrogen stimulation)Thin lean body buildAsian or thin Caucasian raceCalcium and Vitamin D deficiencyLack of weight bearing exerciseAlcohol abuseTobacco useExcessive caffeine use (> 3 cups per day)Eating disordersMalabsorption disorders
Musculoskeletal diseasesOsteoporosisDiagnostics:DEXA Scan Screening annually of post-menopausal women DEXA Screening for hypothyroid and hyperthyroid patients Qualitative US not used muchBone Scan is used for differential diagnostics, i.e. to rule out bone cancerLabs for Calcium, Magnesium, Phosphorus levelsUrine for pyridinium levels
DXA ScanThis is a typical bone densitometry study. A low dose x-ray is performed of the lumbar spine, hip (shown here) or wrist. From the resulting image /measurement, calculations can be made to determine the density of the patient's bone (T-score) and compare it to the reference standard of a healthy thirty-year-old of the same sex and ethnicity to determine future risk of fracture.
Musculoskeletal diseasesOsteoporosis Treatments and Nursing Interventions Educate Side effects of meds Calcium supplementation new evidence is 1700 mg of calcium per day, or more for post-menopausal women not on hormone therapy. May use TUMS if stomach is upset with supplementsExercisesFall prevention and safetyBiphosphonates i.e. Fosamax, Actonel, Boniva have to be taken 1 hour before any other foods or vitamins, with only water to be absorbed.Vitamin D therapy not usually needed in the sunny desert, found in dairy and green leefy vegetables
Musculoskeletal DisordersFracture treatmentNursing primary concern is to assess and prevent neuro-vascular dysfunction. Neuro / circulation checks should be done of the affected limb every 15 minutes x 4, then every 30 minutes x2, then every hour. ( The book says every hour, but that is really too long, and your patient could go into shock)Immobilize the limbControl the painAssess for shock
Risk for Peripheral Neurovascular deficitOther fracture interventions (with casting or immobilization/traction).Monitor for numbness, tingling, hyperesthesia, hypoesthesiaMonitor for DVTs check pulses and colorInstruct the client to examine the skin daily for any breakdown or alterations, call MD if oozing or redness occurInstruct client to avoid crossing their legsInstruct patient to completely abstain from tobacco Remove home safety hazards in the homeInstruct patient not to scratch underneath the cast or around the pins/tractionGive patient anticoagulants and analgesics if orderedInstruct patient to take vitamins, adequate amoaunts of magnesium, vitamin C, etcfor healing.
The 6 PsEarly orLate SignsAssessment ParametersClient Teaching /Symptoms to ReportPainEarlyAssess area involved using 0 to 10 rating scale: 0 = no pain 10 = worst pain imaginableIncreasing pain not relieved with elevation or pain medicationParesthesiaEarlyAssess for numbness/tingling, pins or needlessensation: Should be absent.Numbness or tingling, pins or needles sensationPallorEarlyAssess capillary refill.
Brisk is < 3 secondsIncreased capillary refill time > 3 seconds, blue fingers or toesPolarLateAssess skin temperature bytouch:
Warm CoolCool/cold fingers or toesParalysisLateAssess mobility: Moves fingers or toes Able to plantar dorsiflex the ankle area not involved or restricted by castUnable to move fingers or toesPulsesLateAssess pulse(s) distal toinjury: Pulse is palpable and strongWeak palpable pulses, unable to palpate pulses, pulse detected only with Doppler
Musculoskeletal DisordersFractures- Pathological fracturesoccur when abnormal force is applied, or the bone is already weakened (osteoporosis, cancers, sarcomas, benign bone cysts, etc.). The type of fracture depends on the type of loading force and stress applied to the bone. See below.Closed - Greenstick -Spiral - Open (compound)
This is a photograph of 70 year old woman who first presented like this with a massive chondrosarcoma of her right upper humerus of 8 months duration. She refused all treatment, and she died of a massive haemorrhage when the tumour burst the following week.
Musculoskeletal Disorders Fractures- Complications of fractures include:Fat emboli syndrome/CVA/Stroke Hematoma (leakage from the bone marrow usually), which can also be a hemmorhageCallus formation DVT- thromboembolismInfection to OsteomyelitisIschemic necrosisFracture blistersDelayed union, nonunion, and malunionOsteoblastic proliferation..
i.e. Osgoods Schlatters
Osgood Schlatters is