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Chapter 33
Care of Patients with Musculoskeletal
and Connective Tissue Disorders
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Theory Objectives




State the factors to be assessed for the
patient who has a connective tissue injury.
Compare the assessment findings of a
connective tissue injury with those of a
fracture.
State the care that is needed for the patient
who has an external fixator in place.
Identify the “do’s and don’ts” of cast care.
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Theory Objectives (cont.)



Discuss the potential complications related to
fractures.
Identify the special problems of patients with
arthritis and specific nursing interventions that
can be helpful.
Compare the preoperative and postoperative
care of a patient with a total knee replacement
with that of a patient with a total hip
replacement.
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Theory Objectives (cont.)



Explain the process by which osteoporosis
occurs, ways to slow the process, and how
the disorder is treated.
Describe the care of the patient with a
metastatic bone tumor.
Identify important postoperative observations
and nursing interventions in the care of the
patient who has undergone an amputation.
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Sprain



A sprain is a partial or complete tearing of the
ligaments that hold various bones together to
form a joint
A sprain occurs when a joint may be forced,
during trauma, past its normal range of
motion, or there may be twisting
The ankle, knee, and wrist are most
commonly sprained
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Signs and Symptoms



Grade I (mild): Tenderness at site; minimal
swelling and loss of function; no abnormal
motion
Grade II (moderate): More severe pain,
especially with weight-bearing; swelling and
bleeding into joint; some loss of function
Grade III (severe, complete tearing of fibers):
Pain may be less severe, but swelling, loss of
function, and bleeding into joint are more
marked
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Diagnosis


Physical examination
X-ray to rule out a fracture or other pathology
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Treatment and Management

RICE



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Rest
Ice after injury and for 24-72 hours
Compression—snug elastic bandage, careful to
not to cut off circulation
Elevation
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Sprains

The Goal is to protect the ligament until it
heals by scarring. Ligaments do not grow
back together.

If a joint is immobile too long, and muscles
are not exercised muscle atrophy can begin
within a matter of days- can cause permanent
disability.
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Treatment and Management
(cont.)

Grade II or III



Rest the joint
Crutches for lower extremity sprain
NSAIDs around the clock for first couple of days
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Etiology and Pathophysiology


A strain is a pulling or tearing of a muscle, a
tendon, or both
A strain occurs by trauma, overuse, or
overextension of a joint
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Etiology and Pathophysiology
(cont.)


The most common muscle strain occurs in
the back muscles (back problems are
discussed in Chapter 23, because they often
have a neurologic component)
Muscle strains do occur in other skeletal
muscles—the most common sites are the
hamstrings, quadriceps, and calf muscles
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Strain

Signs, symptoms, and diagnosis
 History of overexertion
 Soft tissue swelling
 Pain
 Bleeding if muscle is torn
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Complementary and Alternative
Therapies

Soothing sore muscles



Arnica purchased and applied topically as an
essential oil is supposed to soothe sore, tired
muscles after a long day’s work
Valerian or kava brewed as a tea is also said to
relax muscles
Honey or apple juice will make the teas more
palatable
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Treatment and Nursing
Management



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Ice and compression should be immediately
applied and the part should be rested
The patient is taught to use ice for 20 minutes
out of the hour only
When compression is used, the distal parts of
the extremity must be checked for sensation
and adequate circulation. Pallor (color) Pain
Parasthesia (numbness or tingling) Pulse
(Capillary Refill) Pressure (Swelling) Edema
Paralysis (Movement)
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Treatment and Nursing
Management (cont.)


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Heat can be applied after 48 hours
Anti-inflammatory medications are used for
discomfort and, when spasm is present, a
muscle relaxant may be prescribed
Time is the greatest healer
The patient is cautioned against reinjury and
is taught proper ways to lift and move
Surgical repair may be necessary
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Dislocation and Subluxation
Dislocation is the stretching and tearing of
ligaments around a joint with complete
displacement of a bone.
Subluxation is a partial dislocation.
Most common sites are the shoulder, knee,
ankle, and temporomandibular joint.
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Dislocation cont.
Dislocation often includes:
 History of an outside force pushing from a
certain direction
 Severe pain, aggravated by motion of the
joint, muscle spasm, or abnormal appearance
of the joint.
Diagnosis
 Physical Exam
 X-ray
 Example dislocated shoulder.

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Dislocation and Subluxation
(cont.)

Treatment


Reduction of displacement under anesthesia
Nursing management
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

Rest the joint
Pain control
Heat or cold applications (Ice first 48 hours then
heat.)
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Rotator Cuff Tear
Usually results from repetitive activity.
Example: Throwing or making overhead
motions with the arm.
 Basketball, baseball players
Signs and Symptoms
 Pain
 The patient will not be able to externally
rotate the shoulder, or perform abduction

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Rotator Cuff Injury
Treatment
 Rest
 Sling will be applied to the affected shoulder
 Anti-inflammatory medications
 When acute episode is over:
 Gentle progressive exercise is ordered. PT
 Prior to exercise Heat is recommended
before the joint is exercised.
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Rotator Cuff Tear



If the tear does not heal:
Surgical repair usually by arthroscopy is
indicated.
Shoulder is immobilized
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Bursitis

Etiology and pathophysiology


Injury or overuse Usually repetitive motion
Signs, symptoms, and diagnosis




Mild to moderate aching pain
Swelling
History of injury
Physical examination
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Bursitis (cont.)
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Treatment
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
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Rest, ice, and massage
Anti-inflammatory agents
Compression wrap
Bursa cortisone injection
Nursing management



Assess pain and perfusion
Assist with mobilization
Activity limitations
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ACL Tear
ACL (Anterior Cruciate Ligament
 Most commonly occurs from athletic injuries
 Falls and motor vehicle accidents may also
cause injury
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ACL Tear cont

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The ligament may be torn from the femur
or tibia.
Often the patient will tell you that they heard a
loud “pop” the time of injury.
Swelling will occur within hours
The knee may feel unstable and feel like it
can “give way”.
Full extension of the leg is difficult
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ACL Tear cont.
Diagnosis
 Physical Exam and data collection how injury
occurred
 MRI
 Arthroscopy is performed at which time the
repair may be done. Grafting may be done if
there is complete tearing.
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ACL Tear



According to the text some physicians order
(CPM) continuous passive range of motion to
promote full range of motion.
Not so common today.
Isometric exercises are prescribed in the
recovery period including quadriceps bent
knee exercises and foot exercises.
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Meniscal Injury
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
The meniscus is the shock absorber of the
knee and lies on top of the tibia, between tibia
and the femur.
A meniscus injury may accompany an ACL
injury.
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Mensical Injury


Often occurs from a fixed foot rotation in
weight bearing with the knees flexed, during
sports activities such as basketball or skiing.
Hear either a “Popping”, described like they
feel like the knee is catching or buckling on
them
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Meniscal Injury cont




Diagnosis
Physical exam patient history. May hear a
click with localized pain with movement of the
joint. How did it happen, what activity was the
patient doing?
MRI is order to confirm
Surgical repair is done arthroscopically
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ACL Tear





After injury the knee is:
immobilized usually with a long brace with
fixed flexion
Measures are instituted to decrease pain and
reduce swelling.
Ice dependent upon doctor
Pain Management initial opiods, anti
inflammatory medications
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Achilles Tendon Rupture




The Achilles attaches to the calcaneus (heel
bone)
If overstretched it can rupture.
Sports injuries or a fall from a height are the
usual ways that this injury occurs.
Injury most often occurs with bursts of
jumping, pivoting, and running such as tennis,
and basketball.
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Achilles Tendon Rupture




Some predisposing factors that can
increase risk include
Diabetes
Arthritis
Some antibiotic use ( Cipro) Side effect can
cause tendonitis.
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Achilles Tendon Rupture
Symptoms
 Sudden pain in the back of the ankle
 May hear a “ popping” sound or a snapping
sound
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Achilles Tendon Rupture







Physical Exam
May see a depression 2 inches above the
back of the heel
Pain
Swelling
Stiffness
Inability to point toes, or stand on tiptoe
Bruising
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Achilles Tendon Rupture

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Treatment Achilles Tendon Rupture
Splinting
Surgery followed by casting
Recovery
6-8 weeks followed by PT
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Meniscal Injury


Pain Management is a priority
PT is prescribed for muscle strengthening
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Carpal Tunnel Syndrome

Etiology and pathophysiology


Compression of the median nerve
Signs and symptoms




Pain
Numbness
Tingling of the hand, particularly at night
Repetitive movements of hands and wrists
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Carpal Tunnel Syndrome (cont.)
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Diagnosis
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Treatment

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
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Physical examination
Compression test
Electromyography
Rest and splinting
Changing the angle of the wrist during repetitive
movements
Steroid injections
Surgery
Nursing management
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Bunion
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
A bunion is the most common foot
problem. It is a painful swelling of the
bursa that occurs when the great toe, at
the metatarsal joint.
It may hereditary, or from ill fitting shoes
More common in females than males
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Bunion

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

Wearing open toed shoes made of soft
leather or athletic shoes that are wider in the
toes area helps to reduce the pain.
Shoes that have give.
Properly fitting shoes.
Metatarsal pads may provide some relief or
pressure.
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Bunion
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Corticosteroid injections are given into the
joint if there is active bursitis and pain.
Analgesics and anti-inflammatory
medications may be prescribed.
Surgical Intervention
Bone realignment or bunionectomy may be
done if becomes too painful. The key is too
painful.
Hammertoes often accompany bunions and
they may be repaired at the same time.
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Fractures
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
Etiology and pathophysiology
Definition
Trauma
Osteoporosis and metabolic problems
Mechanism of injury
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Fractures (cont.)

Signs and symptoms
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

Minimal to severe pain depending on the type of
fracture, the bone(s) involved, and the amount of
displacement
Swelling and/or bleeding
Tenderness, deformity of the bone, ecchymoses,
crepitation with any movement, and loss of
function
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Fractures (cont.)

Diagnosis


Physical examination
X-ray
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Types of Fractures

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
Complete
Incomplete
Comminuted
Closed (simple)
Open (compound)
Greenstick
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Types of Fractures (cont.)
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Types of Fractures (cont.)
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Types of Fractures (cont.)
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Elder Care Points



The elderly are more at risk for fractures
because of decreased reaction time, failing
vision, lessened agility, alterations in balance,
and decreased muscle tone
Proton pump inhibitors (PPIs) increase the risk
for fracture of the hip, wrist, and spine
In epidemiologic studies, the risk was highest for
people over age 50, who had used PPIs for
more than a year
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Treatment of Fracture

Emergency care



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

Prevent shock and hemorrhage
“Splint as it lies”
Tetanus immunization
Prophylactic antibiotics
Primary aim of treatment
Establish union between broken ends to
restore bone continuity
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Five Stages of Bone Healing and
Repair
1.
Blood oozes from the torn blood vessels in
the area of the fracture; the blood clots and
begins to form a hematoma between the two
broken ends of bone (1 to 3 days)
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Five Stages of Bone Healing and
Repair (cont.)
2.
Other tissue cells enter the clot, and
granulation tissue is formed. This tissue is
interlaced with capillaries, and it gradually
becomes firm and forms a bridge between
the two ends of broken bone (3 days to 2
weeks)
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Five Stages of Bone Healing and
Repair (cont.)
3.
Young bone cells enter the area and form a
tissue called “callus.” At this stage, the ends
of the broken bone are beginning to “knit”
together (2 to 6 weeks)
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Five Stages of Bone Healing and
Repair (cont.)
4.
The immature bone cells are gradually
replaced by mature bone cells (ossification),
and the tissue takes on the characteristics of
typical bone structure (3 weeks to 6 months)
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Five Stages of Bone Healing and
Repair (cont.)
5.
Bone is resorbed and deposited, depending
on the lines of stress. The medullary canal is
reconstructed during consolidation and
remodeling (6 weeks to 1 year)
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Reduction of Fractures
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Closed reduction
Open reduction
Stabilization

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

Internal fixation
External fixation
Casts, splints, and braces
Traction
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Internal Fixation





Pins, nails, or metal plates
Open reduction and internal fixation
Prosthesis and autotransfusion
IV antibiotics and risk for infection
Nursing care



Maintain good alignment of the affected leg
Prevent complications of immobility
Control pain
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Examples of Internal Fixation
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External Fixation

Indications



Massive open fractures with extensive soft-tissue
damage
Infected fractures that do not heal properly
Multiple trauma such as burns, chest injury, or
head injury
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External Fixation (cont.)
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Nursing Management



Pin site care and premedicate for pain
Showering
Physical therapy and ADLs
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Casts and Fractures


Materials including plaster and synthetic
casts
Long-leg and short-leg casts, slings, and
spicas
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Synthetic Limb Cast
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Braces and Splints


Fracture boot, hinged brace, and slab
Patient teaching



Explain the procedure—feel warmth as cast sets
and dries
Never put a fresh cast on plastic
Never cover a fresh plaster cast with a blanket
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Walking Boot
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Skeletal Traction


Pins, wires, or tongs directly through the bone
at a point distal to the fracture so that the
force of pull from the weights is exerted
directly on the bone
Skeletal traction uses 10 or more pounds of
weight and the body acts as the
countertraction
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Skin Traction



Bandage (moleskin or foam traction boot) is
applied to the limb below the site of fracture
and then pull is exerted on the limb
No more than 7 to 10 lb of weight are used
Continuous or intermittent
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Common Types of Traction
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Common Types of Traction
(cont.)
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Points of Care for the Patient in
Traction


Traction devices must be assessed to see
that they are in correct position and that the
weights are hanging free
The patient’s body position should be
assessed for proper alignment
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Complications of Fractures



The sooner a fracture is fixed, the less likely
the chance for complications.
Healing can be impeded by improper
alignment and inadequate immobilization
Continued twisting, shearing, and abnormal
stresses prohibit a strong, bony union.
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Fractures and Infection




Open comminuted fractures and surgery
Antibiotics
Inadequate calcium and phosphorus, vitamin
deficiency, and atherosclerosis
Temperature, white blood cells, and wound
appearance (redness, swelling, heat, and
purulent drainage)
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Osteomyelitis

Osteomyelitis is a bacterial infection of the
bone


Staphylococcus aureus
Sudden onset with severe pain and marked
tenderness at the site, high fever with chills,
swelling of adjacent soft parts, headache, and
malaise
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Diagnosis

The earlier osteomyelitis is diagnosed and
treated, the better the prognosis

History of injury to the part, open fracture, boils,
furuncles, or other infections
 Sedimentation rate and WBC count
 X-rays
 Biopsy, in which the bone sample exhibits signs of
necrosis
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Treatment




Antibiotics are prescribed for 4 to 6 weeks,
and the abscess is incised and drained
Dead bone and debris are débrided from the
site
The affected limb is immobilized for complete
rest
Sometimes amputation is the only cure
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Nonunion of Fractures


Electrical bone growth–stimulating device
Surgery and bone grafting
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Fat Embolism

Signs and symptoms



Change in mental status
Respiratory distress, tachypnea, crackles and
wheezes
Rapid pulse, fever, and petechiae (a measles-like
rash over the chest, neck, upper arms, or
abdomen)
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Nursing Management







Stay with the patient
High Fowler’s position
Use a non-rebreather mask
Establish a peripheral IV
Summon the physician immediately
Anticipate hydration with IV fluids and correction
of acidosis
Intubation and mechanical ventilation
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Venous Thrombosis



The veins of the pelvis and lower extremities are
very vulnerable to thrombus formation after
fracture, especially hip fracture
Immobility, traction, and casts may contribute to
venous stasis
Compression stockings, sequential compression
devices, range-of-motion (ROM) exercises on
the unaffected lower extremities are used to help
prevent the problem
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Compartment Syndrome



External or internal pressure that restricts
circulation in one or more muscle
compartments of the extremities
Severe, unrelenting pain unrelieved by
narcotics
Assess for 6 “Ps”: pain, pallor, paresthesia,
pulselessness, paralysis, and poikilothermia
(cold to the touch)
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Treatment and Nursing
Management



Recognition and immediate notification of the
physician can prevent permanent loss of
function
If a cast is in place, the cast can be bivalved
(split through all layers of the material)
Dressings will be cut or replaced
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Treatment and Nursing
Management (cont.)


Surgical fasciotomy (linear incisions in the fascia
down the extremity) may be necessary to relieve
the pressure on the nerves and blood vessels if
other measures do not relieve the problem
Elevation is the key to preventing compartment
syndrome; toes and fingers should be higher
than the trunk
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Fascial Compartments of the Calf
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84
Fasciotomy
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Nursing Management of
Fractures

Assessment (data collection)





Initial assessment (pretreatment)
• Mechanism of injury
• Physical assessment
• Special consideration of open fractures
Daily assessment (posttreatment)
Physical assessment of neurovascular status
Thorough assessment of a patient in a cast
Nutrition for immobile musculoskeletal patients
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Nursing Management of
Fractures (cont.)

Implementation




Cast care—fiberglass and polyester cotton knit
casts and plaster casts
Comfort measures
Positioning and repositioning
Itching and skin care
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Nursing Management of
Fractures (cont.)

Evaluation





Pain should be under control
Progress toward independent ADLs
No problems with immobility (skin breakdown,
constipation, atelectasis, or DVT)
No complications (infection, compartment
syndrome)
If the goals are not being met, the plan should be
revised
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Inflammatory Disorders of the
Musculoskeletal System







Lyme disease
Osteoarthritis
Rheumatoid arthritis
Gout
Osteoporosis
Paget’s disease
Bone tumors
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Lyme Disease

Cause


Transmitted by the bite of a deer tick. A systemic
infection occurs from a bacteria called Spirochete,
Borrelia burgdorferi.
Signs and symptoms 1-2 weeks

Flu-like symptoms
 Bull’s-eye rash
 Pain and stiffness in joints and muscles
 Progresses to Stage II if untreated 2-12 weeks
 Carditis
 Meningitis, peripheral neuritis, or facial paralysis
similar to Bells Palsy
 Fatigue, cognition problems, and arthralgias
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Lyme Disease Rash
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Deer Tick
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Lyme Disease cont.




Treatment
Oral antibiotics such as doxicycline,
amoxicillin by mouth for 10-21 days.
Later stages are treated with IV antibiotics
Steps to prevent Lyme disease include using
insect repellent, wearing long sleeve clothing
when in woods. Removing ticks promptly from
clothing.
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Osteoarthritis

Etiology and pathophysiology





A non inflammatory degenerative joint disease
that can affect any weight-bearing joint
The exact cause is not known
Risk factors: Heredity, aging, female gender,
obesity, previous joint injury, and
recreational/occupational usage
People with osteoarthritis seem to produce less
collagen to strengthen and protect the joints
With time joints become thickened and withstand
weight poorly causing more damage to cartilage.
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Osteoarthritis




Signs, symptoms, and diagnosis
Usually occurs Asymmetrically
Typically affects only one or two joints
Chief symptoms


Aching pain with joint movement and stiffness and
limitation of mobility
Joints may be deformed and nodules may be
present
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Treatment of Osteoarthritis





Pain management—including salicylates,
acetaminophen, or NSAIDs
Strengthening and aerobic exercise,
Weight reduction if the patient is overweight
Maintenance of joint function
Complementary and alternative therapies
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Nursing Management of
Osteoarthritis





Balance exercise and rest,
Walking, knitting, and swimming improve
mobility
Moist heat application
Encourage to maintain weight within normal
limits decreases stress on the joints.
Imagery, relaxation, and diversion


Quadriceps strengthening exercises may relieve
pain and disability of the knee
Yoga and massage may help to manage the pain
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Rheumatoid Arthritis

Etiology and pathophysiology





Is an Inflammatory Disease of the joints
Rheumatoid factor will appear in the blood and in
the synovial fluid of the joints.
Remissions and exacerbations
As the disease progresses Pannus is formed
which is granulated tissue this can lead to
ankylosis, and damage/atrophy of muscles
Subcutaneous nodules may form in the pleura,
heart valves, or eyes
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Rheumatoid cont.





Cause is unknown
Can occur at any age.
More common in older women
Maybe hormonal, genetic, environmental
An infectious agent may trigger an
autoimmune response
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Rheumatoid Arthritis (cont.)

Signs and symptoms





Joint pain, warmth, edema, limitation of motion,
and multiple joint stiffness lasting more than 1
hour, worse in the morning.
Symmetrical—affects joints of the hands, wrists,
and feet. Nodules may form on the joints.
Limitations of ADLs due to joint deformity, and
pain.
Systemic symptoms
Low grade fever, anorexia, weight loss, anemia
resistant to iron.
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Comparison of Rheumatoid
Arthritis and Osteoarthritis





Definition
Pathology
Etiology
Rheumatoid factors
(autoantibodies)
Age at onset





Weight
General state of
health
Appearance of joints
Muscles
Other
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Rheumatoid Arthritis

Diagnosis




History of morning stiffness that lasts more than
one hour or arthritis pain in 3 or more joints that
lasts more than 6 weeks for greater than 1 hour
Blood tests for RF, C-reactive protein, and
erythrocyte sedimentation rate, synovial fluid will
be positive for RA
X-rays confirm the cartilage destruction and bone
deformities
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Treatment of Rheumatoid
Arthritis






Aimed at Relieving pain
Minimizing joint destruction
Promote joint function Rest exercise, and
medication.
Preserve ability to perform self-care
Immobilization and use of splints and other
supportive devices during periods of severe
inflammation
Hot and Cold Treatments
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Medications for Rheumatoid
Arthritis



NSAIDs (i.e., ibuprofen) are the first-line agents
used for arthritis pain
Other medications include salicylates,
corticosteroids, antimalarial drugs, methotrexate,
gold compounds, sulfasalazine, d-penicillamine,
and disease-modifying antirheumatic drugs
(DMARDs)
Tumor necrosis factor drugs (TNF inhibitors)
Humeria, Prolia
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Rheumatoid Treatment cont.



Systemic corticosteroids (Once thought to be
miracle drugs) Long term affects diminish
over time requiring and increase in the dose
to obtain the same results.
Long term steroids increase the risk for
diabetes mellitus, osteoporosis, hypertension,
acne, cataracts, and weight gain.
Reserved for patient who do not get relief
with the other drugs.
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Medications for Rheumatoid
Arthritis (cont.)


The injection of steroids directly into a joint
(intra-articular administration) has been used
successfully in treating painful flare-ups,
shortening the period of inflammation, and
relieving pain and other symptoms
When intra-articular steroid therapy is used, it is
recommended that not more than two or three
doses be injected into any joint within 1 year’s
time
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Clinical Cues





Monitor patients taking NSAIDs for GI
intolerance
Assess liver, kidney, and central nervous system
function frequently
Watch for signs of blood dyscrasias and check
for tinnitus and hearing loss regularly
The side effects of NSAIDs can be serious and
sometimes permanent
If early signs of toxicity appear, they should be
reported promptly to the physician
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Elder Care Points




Elderly arthritic patients must be taught to watch
for side effects and promptly report to the
physician or nurse
Dizziness, which predisposes to falls, can occur
with analgesics for arthritis pain, particularly if
the medication contains codeine
Advise patients to arise slowly, hold on to
furniture until steady, and to wait until dizziness
passes before trying to walk
Assistive devices for ambulation can also
prevent falls
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Surgical Intervention and
Orthopedic Devices


Casts/braces and splints may be used to
immobilize an affected part so that it can rest
during an active phase of the arthritic disease
Surgery




Synovectomy -Excision of synovial membrane.
Osteotomy - Excision of a wedge of bone to allow
realignment
Tendon reconstruction
Joint replacement
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Nursing Management of
Rheumatoid Arthritis

Expected outcomes



Patient’s pain will be controlled with medications,
heat, and exercise within 2 weeks
Patient’s mobility will improve with the use of
assistive devices and physical therapy within 3
weeks
Patient will demonstrate less disturbance of body
image by partaking in more social activities within
1 month
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Implementation and Evaluation of
Rheumatoid Arthritis

Rest and exercise


Instructions for joint protection
Applications of heat and cold

Safety considerations
 Patient teaching



Diet
Psychosocial care
Resources for patient and family education
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Total Joint Replacement





May be done for a knee, shoulder, hip, elbow
or finger
Hip and Knee the most common
Non cemented press fit prosthesis usually
used for a younger, heavier, or active patient.
Cement used in the prosthetic usually lasts
about 10 years
Primary purpose is the relieve pain
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Joint Replacement cont.





Most joints are elective surgery
Patient will come in for PAT work
Data collection will begin
An appointment will be scheduled for pre op
teaching usually 3 weeks ahead of time
Many centers coordinating all the above on
one day
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Joint Replacement







Expectations discussed
Pain management
Routine and expectations foley, IV activity
Rehab and PT
Pre op exercises, Isometric
Blood collection post op
Patient will receive instructions to complete
chlorahexidine showers pre op or scrubs to
the affected leg
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Joint Replacement cont






Patient transported to OR in bed
Returned in bed
Ice for pain
Abductor pillows for Hip prosthesis to prevent
dislocation
Pillow needs to be in place when turning the
patient from side to side
Dislocation is the concern.
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Joint Replacement cont.




Post Op
Patient may have a blood salvage unit . It is
then filtered and retuned to the patient
Drain in surgical site, DVT prophalxsis
important. Heparin, lovenox or counmadin
Weight bearing staus PT
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Total Hip Replacement
Discharge Teaching






It is OK to lay on operated side
For 3 months, you should not cross your legs
Put a pillow between legs when rolling over or lie
on your side in bed
It is OK to bend your hip but not beyond a right
(90-degree) angle
Avoid sitting in low chairs
Continue daily exercise program at home
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Gout

Etiology and pathophysiology
 Arthritis
of a joint caused by high Uric acid
levels
 Possible factors
• Genetic increase in purine metabolism
• More common in patient populations that
consume increase protein and high purine
diets.
 Big
toe most common but can occur in
other joints.
 Diuretic therapy and secondary gout
because of the loss of fluids
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Gout (cont.)

Signs and symptoms



Tight reddened skin over an inflamed, edematous
joint accompanied by elevated temperature and
extreme pain in the joint
Elevated serum uric acid
Diagnosis


History and physical examination
Serum uric acid
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Gout’
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Gout (cont.)

Treatment

NSAIDs for 2-5 days
 Colchicine, allopurinol, and probenecid (Benemid)
given orally with drastic relief within 24-48 hours
 Febuxostat (Uloric)

Nursing management



Patient teaching and medications
Diet management—weight control and restriction of
high-purine foods
Fluid intake Increase to 2000-3000cc per day to
protect the kidney from crystal formation and stones.
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Gout cont.




Alcohol should be restricted
Patients who are placed on allopurinol require
periodic liver function tests
Dietary restriction high purine diets.
Examples: Red meat, organ meat, sardines,
anchovies, sweetbreads.
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Elder Care Points


Elderly patients with decrease creatine
clearance should not take allopurinol.
If patient has elevate BP Cozar is a good
choice. ARB controls BP and promotes
dieresis
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Audience Response Question 1
Dietary management of gout includes which
measure(s)? (Select all that apply.)
1.
Weight reduction
2.
Salt restriction
3.
High caloric intake
4.
Avoiding foods high in purine
5.
High-carbohydrate diet
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Osteoporosis



Etiology and pathophysiology
Makes the patient more prone to fractures
Decrease in bone mass


Risk factors: Age, chronic disease (i.e., liver, lung,
kidney), medications (i.e., steroids,
anticonvulsants, anticoagulants, proton pump
inhibitors, selective serotonin inhibitors), long-term
calcium deficiency, vitamin D deficiency, smoking,
excessive caffeine or alcohol intake, and
sedentary lifestyle
Premenopausal age of 35 women loose 1% bone
mass a year. Post menopausal 2% per year
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Osteoporosis (cont.)

Signs and symptoms



No early signs and symptoms
Height loss, kyphosis, and compression of the
spine
Diagnosis

Bone x-rays Bones appear porous
 Dual energy x-ray absorptiometry (DXA or DEXA);
reported as a T score
 1.5 to 2.0 standard deviations = osteopenia
 2.5 to 3.0 standard deviations = osteoporosis
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Treatment

Goals







Stop bone density loss
Increase bone formation
Prevent fractures
Estrogen replacement therapy
Adequate dietary and supplemental calcium and
vitamin D
Weight-bearing exercise
Bisphosphonates (Fosamax, Actinol)
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Treatment of Osteoporosis and
Vertebral Fracture





Vertebral fractures are common in patients
with osteoporosis.
This are two new minimally invasive spine
procedures for those who do not repond to
tradtional therapy
Vertebroplasty
Kyphoplasty
These are often treated with pain medication,
activity limitation, physical therapy, and
bracing
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Osteoporosis



Parathyroid hormones are alternative
treatment for post menopausal women who
can’t take estrogen. Miacalcin or Fortical
Contains calcitonin.
Diary Products are the best source of
calcium; cheese, yogurt, are better choices.
Sardines and anchovies are also sources of
calcium
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Nursing Management



Promote screening for osteoporosis
Teach the benefits of healthy lifestyle, need
for calcium supplement, and weight-bearing
exercise
Medications, cautions, and side effects

Upright position for 1 hour after taking
bisphosphonate-type drugs to prevent esophageal
irritation and erosion
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Paget’s Disease



Etiology
More common in men
Cause unknown



Abnormal weak bones
Problem with bone reabsorbtion followed by
replacement of normal marrow with fibrous
connective tissue. Prone to fracture
Signs and symptoms

Pain main problem
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Paget’s Disease (cont.)

Diagnosis




X-Ray Usually diagnosed at time of fracture
24 hour urine presence of hydroxyproline
presence indicates osteoclasic activity
Serum alkaline phospatase is elevated in disease
Nursing management



Firm mattress may relieve back pain
Light brace or corset
Avoid lifting and twisting proper body mechanics
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Bone Tumors

Etiology and pathophysiology




Bone is subject to both benign and malignant
tumors
Bone tumors are often seen in people 10-25 years
of age ( Osteosarcoma)
Primary and secondary tumors
Arise from several types of tissues including
cartilage, bone, and fibrous tissue
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Bone Tumors (cont.)

Signs and Symptoms


Diagnosis




Pain, warmth, and swelling
X-ray, bone scan, and biopsy
Metastatic Disease is seen more than a primary
bone cancer
Malignancies of the prostate, kidney, breast,
thyroid, and lung spread to the bone. Vertebrae,
pelvis, and femur
Treatment

Surgery, radiation, and chemotherapy
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Amputation


Lower-limb amputations are related to peripheral
vascular disease, diabetes mellitus and resultant
gangrene, severe trauma, malignancy,
congenital defects, and military injuries from
shrapnel and land mines
Upper-extremity amputations are brought on by
crushing blows, thermal and electric burns,
severe lacerations, vasospastic disease,
malignancy, and infection
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Amputation:
Preoperative Care





Patient participation in decision-making
May have preference of how to dispose of
limb.
Stages of loss and grieving (Denial, anger,
grieving)
Phantom sensations Patient remembers pain
before surgery, brain still receiving signals
Physical preparation

Muscle strengthening exercises to prepare for
post op rehabilitaion
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Amputation:
Postoperative Care


Two most important post op concerns
Hemorrhage and edema of residual limb

Elevation for 24 hours after 24 hours hip
contractures may develop
 Monitoring for excessive bleeding
 VS
 IV fluids
 Dressing care The initial dressing is usually
removed by the surgeon 48 to 72 hours later.
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Amputation Post Op Care






Assess the skin for inflammation or
breakdown , warmth, drainage
Assess pain
Phantom limb sensations
Miacalcin IV infusion during the week after
surgery.
Transcutaneous electrical nerve stimulator
Stump stocking
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Amputation:
Postoperative Care (cont.)

Alternative modes for managing stump after
amputation



Soft dressing with delayed prosthetic fitting
Rigid plaster dressing and early prosthetic fitting
Rigid plaster dressing and immediate prosthetic
fitting
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Amputation:
Postoperative Care (cont.)

Adequate healing and weight-bearing






Below-the-knee amputation is better to begin walking
and weight-bearing than above-the-knee amputation
Abduction contractures and proper positioning
Adjusting to the new center of gravity
Patient teaching: stump care, activity and
weight-bearing, and exercise
Rehabilitation
Community care
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C-Leg Prosthesis in Action
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Care After Accidental Amputation




Rinse the detached part only enough to
remove visible debris
Wrap the part in a clean, damp cloth
Place the part in a sealed plastic bag or in a
dry water-tight container
Immerse the bag or container in a mixture of
water and ice (3 parts water to 1 part ice). Do
not let the part get wet or freeze
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Care After Accidental Amputation
(cont.)



Alternatively, place the container in an
insulated cooler filled with ice
If no ice is available, keep the part cool; do
not expose it to heat
Tag the bag or container with the person’s
name and the name of the body part and take
it to the hospital with the person
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