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Page 1: Musculoskeletal Disorders

MUSCULOSKELETAL SYSTEMDISORDERS

Page 2: Musculoskeletal Disorders

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

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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

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PYRAMID POINTS

Interventions following amputation Treatment modalities for the client with

rheumatoid arthritis Client education related to osteoporosis Client education related to gout

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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)

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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

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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

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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

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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

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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

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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

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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

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TYPES OF FRACTURES

From Ignativicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia: W.B. Saunders.

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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

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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

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INTERVENTIONS FOR A FRACTURE Reduction Fixation Traction Casts

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REDUCTION

DESCRIPTION Restoring the bone to proper alignment

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REDUCTION

CLOSED REDUCTION Performed by manual manipulation May be performed under local or general

anesthesia A cast may be applied following reduction

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CLOSED REDUCTION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

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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

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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

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INTERNAL FIXATION

From Browner BB et al (1992) Skeletal trauma. Philadelphia: W.B. Saunders.

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FIXATION EXTERNAL FIXATION

An external frame is utilized with multiple pins applied through the bone

Provides more freedom of movement than with traction

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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.

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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

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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

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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

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SKELETAL TRACTION

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

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CERVICAL TONGS AND HALO FIXATION DEVICE

Head and Spinal Cord Injuries

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SKIN TRACTION

DESCRIPTION Traction applied by the use of elastic

bandages or adhesive

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SKIN TRACTION: SIDE ARM

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

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TYPES OF SKIN TRACTION

Cervical traction Buck’s traction Bryant’s traction Pelvic traction Russell’s traction

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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

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CERVICAL SKIN TRACTION

From James, S. Ashwill, R., & Droske, S. (2002). Nursing care of children, ed 2, Philadelphia: W.B. Saunders.

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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.

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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

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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.

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BRYANT’S AND RUSSELL’S SKIN TRACTION Refer to the module entitled Pediatric

Nursing, Musculoskeletal Disorders for information related to these types of traction

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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

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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.

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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

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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.

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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

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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

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DUNLOP’S SKIN TRACTION

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

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CASTS DESCRIPTION

Made of plaster or fiberglass to provide immobilization of bone and joints after a fracture or injury

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CASTS

From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.

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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

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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

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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

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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

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COMPLICATIONS OF FRACTURES Fat embolism Compartment syndrome Infection and osteomyelitis Avascular necrosis Pulmonary emboli

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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

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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

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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

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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.

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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

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INFECTION AND OSTEOMYELITIS DESCRIPTION

Can be caused by the interruption of the integrity of the skin

The infection invades bone tissue

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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

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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

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PULMONARY EMBOLISM DESCRIPTION

Caused by immobility precipitated by a fracture

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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

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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

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BRACHIAL PLEXUS

From Crossman AR, Neary D (1995). Neuroanatomy: an illustrated color text. Edinburgh: Churchill Livingstone.

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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

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CRUTCH WALKING

From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2, St. Louis, 2000, Mosby.

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CRUTCH GAITS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

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CANES

DESCRIPTION Made of a lightweight material with a rubber tip

at the bottom

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SINGLE- AND QUAD-FOOT CANES

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

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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

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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

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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

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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

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TYPES OF HIP FRACTURES

Intracapsular Extracapsular

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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

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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

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INTERNAL FIXATION

From Black JM, Matassarin-Jacobs E (1997): Medical-surgical nursing: clinical management for continuity of care 5th ed., Philadelphia, W.B. Saunders.

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HIP REPLACEMENTS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby. Courtesy of Zimmer, Inc., Warsaw, IN.

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TOTAL HIP REPLACEMENT

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

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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

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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

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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

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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

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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

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TOTAL KNEE REPLACEMENT

DESCRIPTION Implantation of a device to substitute for the

femoral condyles and the tibial joint surfaces

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KNEE PROSTHESIS

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

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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

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CONTINUOUS PASSIVE MOTION

From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, St. Louis, 1996, Mosby.

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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

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HERNIATION: INTERVERTEBRAL DISC DESCRIPTION

Nucleus of the disc protrudes into the annulus causing nerve compression

TYPES Cervical Lumbar

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DISC HERNIATION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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.

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LOW BACK CARE

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

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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

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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

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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

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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

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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

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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

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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

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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

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AMPUTATION OF A LOWER EXTREMITY DESCRIPTION

The surgical removal of a lower limb or part of the limb

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LEVELS OF LOWER EXTREMITY AMPUTATION

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia: W.B. Saunders.

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AMPUTATION FLAPS

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

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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

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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

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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

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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

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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

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STUMP WRAPPING

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

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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

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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

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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

Page 123: Musculoskeletal Disorders

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

Page 124: Musculoskeletal Disorders

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

Page 125: Musculoskeletal Disorders

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

Page 126: Musculoskeletal Disorders

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

Page 127: Musculoskeletal Disorders

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.

Page 128: Musculoskeletal Disorders

RHEUMATOID ARTHRITISMUSCLE ATROPHY

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

Page 129: Musculoskeletal Disorders

RHEUMATOID NODULE

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

Page 130: Musculoskeletal Disorders

BOUTONNIERE DEFORMITY

From Zitelli BJ, Davis HW: Atlas of Pediatric Physical Diagnosis, ed. 3, St. Louis, 1997, Mosby.

Page 131: Musculoskeletal Disorders

SWAN NECK DEFORMITY

From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts and clinical practice, ed. 6, St. Louis, 1999, Mosby.

Page 132: Musculoskeletal Disorders

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

Page 133: Musculoskeletal Disorders

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

Page 134: Musculoskeletal Disorders

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

Page 135: Musculoskeletal Disorders

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

Page 136: Musculoskeletal Disorders

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

Page 137: Musculoskeletal Disorders

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

Page 138: Musculoskeletal Disorders

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

Page 139: Musculoskeletal Disorders

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

Page 140: Musculoskeletal Disorders

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

Page 141: Musculoskeletal Disorders

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

Page 142: Musculoskeletal Disorders

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

Page 143: Musculoskeletal Disorders

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

Page 144: Musculoskeletal Disorders

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.

Page 145: Musculoskeletal Disorders

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

Page 146: Musculoskeletal Disorders

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

Page 147: Musculoskeletal Disorders

SEVERE OSTEOARTHRITIS

From Kamal A, Brockelhurst J: Color atlas of geriatric medicine, ed. 2, St. Louis, 1991, Mosby.

Page 148: Musculoskeletal Disorders

HEBERDEN’S NODES

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

Page 149: Musculoskeletal Disorders

BOUCHARD’S NODES

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

Page 150: Musculoskeletal Disorders

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

Page 151: Musculoskeletal Disorders

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

Page 152: Musculoskeletal Disorders

OSTEOARTHRITIS

NUTRITION Encourage a well-balanced diet Encourage weight loss if necessary

Page 153: Musculoskeletal Disorders

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

Page 154: Musculoskeletal Disorders

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

Page 155: Musculoskeletal Disorders

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

Page 156: Musculoskeletal Disorders

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

Page 157: Musculoskeletal Disorders

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

Page 158: Musculoskeletal Disorders

OSTEOPOROTIC CHANGES

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

Page 159: Musculoskeletal Disorders

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

Page 160: Musculoskeletal Disorders

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

Page 161: Musculoskeletal Disorders

DOWAGER’S HUMP

From Seidel HM et al: Mosby’s guide to physical examination, ed. 4, St. Louis, 1999, Mosby.

Page 162: Musculoskeletal Disorders

SEVERE OSTEOPOROSIS

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

Page 163: Musculoskeletal Disorders

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

Page 164: Musculoskeletal Disorders

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

Page 165: Musculoskeletal Disorders

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

Page 166: Musculoskeletal Disorders

MILWAUKEE BRACE

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

Page 167: Musculoskeletal Disorders

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

Page 168: Musculoskeletal Disorders

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

Page 169: Musculoskeletal Disorders

GOUTY JOINT

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders.

Page 170: Musculoskeletal Disorders

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

Page 171: Musculoskeletal Disorders

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

Page 172: Musculoskeletal Disorders

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

Page 173: Musculoskeletal Disorders

GOUT

From Clinical Slide Collection of the Rheumatic Diseases, © 1991,1995,1997. Used with permission of the American College of Rheumatology.

Page 174: Musculoskeletal Disorders

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

Page 175: Musculoskeletal Disorders

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

Page 176: Musculoskeletal Disorders

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