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Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Chapter 46
Nursing Care of Patients with
Musculoskeletal and
Connective Tissue
Disorders
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Bone and Soft Tissue
Disorders
 Strain – A soft tissue injury that occurs when a muscle or
tendon is excessively stretched
 Sprain- Excessive stretching of one or more ligaments
during a sports activity, exercise or fall
 Dislocation- Ends of the bones are forced from the normal
position
 Bursitis- shoulder, hip, knee, ankle common sites
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Carpal Tunnel Syndrome
 Median Nerve Compression in Wrist’s
Carpal Tunnel
 Occurs with Swelling in Tunnel
 Finger, Hand, Arm Pain/Numbness can be
caused by trauma, arthritis, repetitive hand
movements, as with typing and cash
register operations.
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Linda S. Williams / Paula D. Hopper
Carpal Tunnel Syndrome (cont’d)
 Relieve Inflammation and Rest Wrist
 Splint
 Anti-inflammatory
 Surgery- Median nerve is released from its
compression during the surgery, thus
correcting the problem
 Teach Prevention – frequent short breaks from
work, using ergonomically appropriate devices to
minimize the pressure placed on the area of the wrist
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Fractures
 Break in a Bone
 Cause
 Trauma
 Pathological (From Disease )
 Open – Breaks Skin
 Closed – Does Not Break Skin
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Linda S. Williams / Paula D. Hopper
Types of Fractures
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Signs and Symptoms
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Pain
Decreased ROM
Limb Rotation
Deformity, Shortening of Limb
Swelling
Bruising
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Etiology and Risk Factors
 Commonly caused by trauma to the bone, especially as a result of
automobile accidents and falls
 Bone disease, e.g., bone cancer, can lead to a fracture
 Hip fractures in older adults usually from falls
 Risk factors for hip fractures: osteoporosis, advanced age, white
race, use of psychotropic drugs, and female
 In adults, ribs most commonly fractured
 Fractures of the femur most common in young and middle-aged
adults
 Hip and wrist fractures are most common in older adults
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Shock
 After fracture, a risk of excessive blood loss
 Trauma may rupture local blood vessels; internal
organs may be punctured; results in internal bleeding
 Loss of blood leads to shock, evidenced by tachycardia,
anxiety, pallor, and cool, clammy skin
 Immobilizing fractures reduces risk of hemorrhage
 If severe external bleeding, external pressure should
be applied and medical assistance summoned
immediately
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnostic Tests
 X-Ray
 CT scan
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Emergency Treatment
 Splint It As It Lies!
 Seek Medical Treatment
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Fracture Management
 Goals
 Realignment of Bone Ends
 Immobilization
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Fracture Healing Phases
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Fracture Healing
 Healing affected by location and severity of the fracture,
type of bone, other bone pathology, blood supply to the
area, infection, and the adequacy of immobilization
 Also age, endocrine disorders, and some drugs affect
healing
 Healing time increases with age; it may take six times
as long for the same type of fracture to heal in an older
adult as in an infant
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Joint Stiffness and
Contractures
 Joint fractures or dislocations may be followed by
stiffness or contractures, especially in older adults, due
to immobility associated with fracture
 Prevention requires appropriate positioning and
progressive exercise programs
 Treatment may employ splints, traction, casts, surgical
manipulation, and aggressive physiotherapy
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Closed Reduction
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Manual Realignment
Bandages/Splints
Casts
Traction
 Skin
 Skeletal
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Types of Skin Traction
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Balanced Suspension and
Skeletal Traction
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Fracture Management (cont’d)
 Open Reduction with Internal Fixation
 External Fixation
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External Fixation
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Complications of Fractures
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Nonunion
Neurovascular compromise
Hemorrhage
Infection
Thromboembolitic Complications
Acute Compartment Syndrome
Fat Embolism Syndrome
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Compartment Syndrome
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Nursing Diagnoses
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Acute Pain
Impaired Physical Mobility
Impaired Walking
Ineffective Health Maintenance
Risk for Peripheral Neurovascular
Dysfunction
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Nursing Diagnoses (cont’d)
 Risk for Ineffective Tissue Perfusion
 Risk for Ineffective Skin Integrity
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Palming the Cast
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Nursing Care
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Cast Care- pg 1069
Traction Care pg 1069
Pain Control
Neurovascular Checks
Skin Care
Nutrition
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Patient Education
 Cast Care
 Pin Care
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Osteomyelitis
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Infection of Bone
Prevention is Key!
Fever, Redness, Heat, Pain, Swelling, Pain
Long-term Antibiotic Therapy
Incision and Drainage
Amputation
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Osteomyelitis (cont’d)
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Osteomyelitis (cont’d)
 Nursing Care
 Medication Teaching
 Hand Hygiene
 Sterile Dressing Changes
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Avascular Necrosis
 A variety of factors can interfere with
blood supply after a bone injury
 Once bone cells are deprived of oxygen
and nutrients, they die and their cell walls
collapse
 Signs and symptoms
 Pain, instability, and decreased function in
the affected area
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Avascular Necrosis
 Treatment
 Relief of weight bearing and removal of part
of the bone to decrease pressure
 If conservative measures fail, surgical
procedures may be recommended
 Sometimes amputation is necessary
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Linda S. Williams / Paula D. Hopper
Osteoporosis
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Low Bone Mass as Bone Loses Density
Prone to Fractures Occur
Spine, Wrist, Hip Most Common
All Bones Affected
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Osteoporosis Prevalence
 Over10 Million People
 8 Million Females
 2 Million Males
 Over Age 50 Fractures
 1 in 2 Women
 1 in 4 Men
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Osteoporosis Fracture Effects
 Hip/Vertebral Fractures
 Reduced Quality of Life
 Increased Disability
 Risk of Death
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Osteoporosis Prevention
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Build Bone Through Age 30
Obtain Adequate Calcium and Vitamin D
Exercise (Especially Childhood )
Avoid Alcohol and Smoking
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Osteoporosis Risk Factors
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Aging
Female
Caucasian/Asian
Fracture History
Family History
Petite Body Build
Postmenopausal Women
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Osteoporosis Risk Factors (cont’d)
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Low Testosterone and Estrogen
Low Calcium Intake
Low Vitamin D
Excessive Caffeine, Protein, Sodium
Sedentary Lifestyle
Excessive Alcohol Use
Cigarette Smoking
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Osteoporosis (cont’d)
 Signs and Symptoms
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Dowager’s Hump
Kyphosis
Height Decreases
Back Pain
Fracture
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Osteoporosis (cont’d)
 Body System Effects- decreased
respiratory capacity
 Functional Effects – limited causing
dependence
 Emotional effects- body image changes,
depression, anxiety
 Socialization- decreased due to limitations
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Osteoporosis
 Medical diagnosis
 Absorptiometry
 Radiographs
 Bone specimen
 Medical treatment
 Calcium supplementation and estrogen replacement
 Bisphosphonates and selective estrogen receptor modulators
(SERMs)
 Regular exercise
 Percutaneous vertebroplasty
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Osteoporosis Diagnostic
Tests
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Dual-energy X-Ray Absorptiometry
Serum Calcium, Vitamin D Decreased
Serum Phosphorus Increased
Serum Alkaline Phosphatase Increased
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Osteoporosis Therapeutic
Interventions
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Reduce Risk Factors
Calcium Supplements
Vitamin D Supplements
Medications
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Antiresorptive Medications
 Bisphosphonates
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Alendronate (Fosamax)
Ibandronate (Boniva)
Risedronate (Actonel)
Zoledronic acid (Reclast)
 Calcitonin (Fortical, Miacalcin)
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Antiresorptive Medications
(cont’d)
 Selective Estrogen Receptor Modulator
 Raloxifene (Evista)
 Estrogen Therapy
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Anabolic (Bone Forming)
 Teriparatide (Forteo)
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Osteoporosis Nursing Care
 Pain Relief
 Symptom Management
 Education
 Diet: Increase Calcium, Vitamin D
 Exercise
 Medication
 Fall Prevention
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Paget's Disease
 Metabolic bone disease affecting normal bone remodeling
 Cause-unknown affects mainly older adults and men
 Increased breakdown and formation of bone that results in enlarged,
abnormally formed and brittle bone, can weaken the bone causing
deformities
 Disorganized Bone Deposits
 No Obvious Symptoms Usually if confined to one bone- Pain major
symptom in many, limping, stiffness
 X-Ray, Bone Scan
 Relieve Pain, Teach, Promote Life Quality
 Treatment- Bisphosphantes, Fosamax, Actonel
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Bone Cancer
 Primary Malignant Tumors
 Osteosarcoma or osteogenic sarcoma
 Most Common primary malignant as well as the
most fatal bone tumor
 50% Occur in Distal Femur in Young Men
 Typically metastasizes to Lung Within 2 Years
 Symptoms pain and swelling in an arm or leg that
worsens with exercise or at night
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Bone Cancer (cont’d)
 Primary Malignant Tumors
 Ewing’s Sarcoma
 Most Malignant bone tumor.
 Pelvis and legs are most often affected in children
and young men
 Chrondrosarcoma
 Cancer of Cartilaginous Cells
 Better Prognosis
 Usually occurs in middle aged and older people
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Primary Bone Cancer
 Therapeutic Interventions
 Surgery, Chemotherapy, Radiation
 Nursing Care
 Postoperative Care
 Supportive
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Metastatic Bone Disease
 Bone-seeking Cancers
 Prostate, Breast, Lung, Thyroid
 Pathological Fractures
 Severe Pain
 Therapeutic Interventions
 Radiation
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Metastatic Bone Disease (cont’d)
 Nursing Care
 Supportive Care as with Other Cancers
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Gout
 Pathophysiology
 Systemic Connective Tissue Disorder
 Uric Acid Build Up
 Urate Crystals Deposited in Joints/Connective
Tissues
 Severe Inflammation
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Causes and Types
 Primary – Inherited Problem with Purine
Metabolism
 Uric acid production is greater than the kidneys
ability to excrete it.
 Secondary – Another Health Problem i.e.
renal insufficiency
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Signs and Symptoms
 Acute
 Swollen, Red, Hot, Painful Inflamed Joints
 Great Toe
 Chronic Gout
 Urate Deposits Under Skin
 Renal Stones
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Figure 41-8
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Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams
/ Paulajoint
D. Hopper
Chronic
involvement with crystal
Neglected chronic gout with tophi
accumulation - tophus
Early crystal accumulation at the
Acute gout - swelling redness and heat in the joint
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elbow - tophus
Understanding Medical Surgical Nursing, 4th Edition
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Diagnostic Tests
 Serum Uric Acid
 Joint Fluid – Uric Acid Crystals
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Medical diagnosis
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
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
History and physical examination
Urate crystals in synovial fluid
Urinary uric acid
Blood uric acid
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Gout
 Assessment
 Pain, joint swelling, tophi, uric acid stones,
fever, and a history of trauma, injury, or
surgery
 Acute Pain
 Impaired Physical Mobility
 Altered Urinary Elimination
 Ineffective Therapeutic Regimen
Management
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Understanding Medical Surgical Nursing, 4th Edition
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Gout
 Nursing interventions
 Decrease discomfort; elevate extremity, avoid pressure
on the extremity (bed cradle), encourage rest,
analgesics, hot or cold packs
 Assist with ADLs as needed
 Protect extremity from injury (clear walking area, firm
soled shoes, etc)
 Encourage PO fluids
 Monitor I/Os
 Assess for signs of renal colic
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Gout
 Medical treatment
 Asymptomatic hyperuricemia requires no medical
treatment
 NSAID alone or with colchicine for acute gouty arthritis
 For subsequent attacks: indomethacin, corticosteroids,
and corticotrophin
 Allopurinol (inhibits synthesis of uric acid)
 Avoid foods high in purines
 Drugs to alkalinize urine (uric acid precipitates in
acidic urine)
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Therapeutic Interventions
 Medication
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Colchicine
NSAIDs
Allopurinol (Zyloprim)
Probenecid (Benemid)
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Nursing Care
 Teaching
 Diet: Avoid Foods High in Purines
 Avoid Aspirin, Diuretics, Alcohol
 Increase Fluids
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Systemic Lupus
Erythematosus
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Autoimmune Disease
Genetic Link
Remissions and Exacerbations
Systemic Type
Skin Type – Discoid Lupus Erythematosus
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Pathophysiology
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Abnormal Antibodies
Immune Complex Formation
Complement System Activation
Affects Connective Tissue
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Signs and Symptoms
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Butterfly Rash
Photosensitive
Fever
Fatigue, Malaise
Arthralgia, Myalgia
Weight Loss
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Signs and Symptoms (cont’d)
 Mucosal Ulcers
 Alopecia
 Skin Lesions
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Diagnostic Tests
 Biopsy
 Erythrocyte Sedimentation Rate
 Immunological Tests
 Antinuclear Antibody Titers
 Antibodies Against SR Proteins
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Therapeutic Interventions
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NSAIDs
Corticosteroids
Antimalarials
Immunomodulating Drugs
Topical Cortisone
Chloroquine (Aralen)
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Nursing Diagnoses
 Acute Pain
 Ineffective Coping
 Risk for impaired skin integrity
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Patient Education
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Skin Care
Avoid Prolonged Exposure to Sunlight
Exercise
Immunization
Stress Reduction
Community Support Groups
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Progressive Systemic
Scleroderma
 Pathophysiology
 Primary vessel injury/dysfunction of immune system
 Manifestations: from inflammation to degeneration of tissues, that
results in decreased elasticity, stenosis, and occlusion of vessels
 Signs and symptoms
 Raynaud’s phenomenon, symmetric painless swelling or
thickening of the skin, taut and shiny skin, morning stiffness,
frequent reflux of gastric acid, difficulty swallowing, weight loss,
dyspnea, pericarditis, and renal insufficiency
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Figure 41-9
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Progressive Systemic
Scleroderma
 Medical diagnosis
 History and physical examination may lead the
physician to suspect fibrotic changes typical of
PSS in the skin, lungs, heart, or esophagus
 Positive ANA assay result, elevated ESR, and
increased serum muscle enzyme levels
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Progressive Systemic
Scleroderma
 Medical treatment
 No cure
 High doses of steroids or other
immunosuppressants may bring about
remission
 Physical therapy
 Antihypertensives, ACE, CCB
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Progressive Systemic
Scleroderma
 Assessment
 Pain and stiffness in the fingers; intolerance for cold
 Signs and symptoms suggestive of cardiovascular, respiratory,
renal, and gastrointestinal problems
 Skin rash, loss of wrinkles on the face, limitations of joint range of
motion, muscle weakness, and dry mucous membranes
 Examine the hands for contractures of the fingers and for color
changes or lesions on the fingertips
 Palpate the fingers to determine warmth
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Progressive Systemic
Scleroderma
 Nursing Interventions
 Meticulous skin care, protective clothing, cool baths
and mild soaps & lotions
 Avoid vasospasm triggers- cold, smoking, etc
 Encourage activity, permit independence
 Manage chronic pain (similar to rheumatoid arthritis)
 Demonstrate social acceptance with therapeutic touch
 If dysphagia is present, manage appropriately (small,
frequent meals, avoid caffeine, spicy food)
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Scleroderma
 Inflammation Develops into Fibrosis and
Sclerosis of Tissues
 Autoimmune Response
 Progress Very Rapidly
 Remissions and Exacerbations
 Poor Prognosis
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Signs and Symptoms
 Arthritis, Fatigue
 Scleroderma
 Pitting Edema, Tightening, Hardening,
Thickening of Skin Tissue
 Loss of ROM
 Contractures
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Diagnosis
 History
 Physical
 Patients with CREST thought to have
worse prognosis, a group of sign
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

Calcinosis
Raynauds phenomenon
Esophageal dysmotility
Sclerodactyl
Telangiectasia- spider like lesions
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Linda S. Williams / Paula D. Hopper
Osteogenesis Imperfecta
 Congenital Abnormality Characterized by
Skeletal Bone Fragility
 Brittle Bones Disease
 Pathological Fractures
 Collagen Synthesized Abnormally
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Osteogenesis Imperfecta (cont’d)
 Signs and Symptoms





Fragile Bones
Triangular Shaped Face
Potential Hearing Loss
Scoliosis
Loose Joints
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Osteogenesis Imperfecta (cont’d)
 Signs and Symptoms (cont’d)




Alterations in Muscle Tone or Development
Blue, Purple, Grey Tint to Sclera
Brittle or Discolored Teeth
Smooth, Thin Skin
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Osteogenesis Imperfecta (cont’d)
 Diagnosis
 History of frequent Fractures
 Physical
 Skin Biopsy- assess the collagen fibershowever not definitive
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Osteogenesis Imperfecta (cont’d)
 Therapeutic Interventions
 No Treatment
 Fracture Care
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Osteogenesis Imperfecta (cont’d)
 Nursing Care
 Careful Handling
 Teaching
 Support Groups
 Osteogensis Imperfecta Foundation
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Polymyositis







Un known cause
Diffuse Inflammation of Skeletal Muscle
Dermatomyositis – with Rash
Progressive
Remissions and Exacerbations
Women Greater Than Men
Treatment: Prednisone
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Muscular Dystrophy




Group of Nine Disorders
Loss of Muscle Tissue
Progressive Muscle Weakness
Genetic
 Duchenne’s MD most common in children
 Mytonic MD most common in adults
 Skeletal Muscle Fibers Degenerate, Atrophy
 Symptoms include: difficulty walking, and muscle
weakness in the arms, legs, and trunk, developmental
delays
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Therapeutic Interventions
 Supportive Care
 Prevention of Complications
 Physical therapy, surgery to correct
deformities, exercise programs
 Gene therapy is currently under
investigation
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Nursing Diagnoses




Impaired Physical Mobility
Ineffective Breathing Pattern
Self-care Deficits
Deficient Knowledge
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Osteoarthritis
 Also known as Degenerative Joint Disease
(DJD)
 Common
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Pathophysiology
 Articular Cartilage/Joints Bone Ends
Deteriorate
 Joint Space Narrows, Bone Spurs Develop,
Joint Inflamed
 Joint Deformities, Pain, Immobility
 Weight-bearing Joints
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Joints Affected by Osteoarthritis
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Causes
 Unknown
 Risk Factors
 Aging
 Obesity
 Excessive “Wear and Tear” on Synovial Joints
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Signs and Symptoms
 Joint Pain
 Intensifies After Physical Activity
 Stiffness
 Heberden’s and Bouchard’s Nodes
 Bony Nodes on Joints of Fingers
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Diagnostic Tests




X-Rays
CT scan
MRI
Synovial Fluid Analysis
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Osteoarthritis of the knee
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Severe osteoarthritis with formation of Heberden and
Bouchard nodes
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Therapeutic Interventions
 No Cure
 Medication
 NSAIDs
 Rest and Exercise
 Heat or Cold
 Weight Control
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Therapeutic Interventions (cont’d)
 Complementary Therapies
 Imagery, Music Therapy, Acupressure,
Acupuncture
 Surgery
 Total Joint Replacement
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Rheumatoid Arthritis
 Chronic, Progressive, Systemic
Inflammatory Disease
 Destroys Synovial Joints and Other
Connective Tissues
 Includes Major Organs
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Rheumatoid Arthritis (cont’d)
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Pathophysiology
 Synovitis
 Synovium Thickens, Fluid Accumulates
 Destructive Pannus Erodes Joint Cartilage,
Destroys Joint Bone
 Pannus Converted to Bony Tissue
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Pathophysiology (cont’d)
 Joint Deformity
 Other Connective Tissue Affected: blood
vessels, nerves, kidneys, pericardium, and
lungs- malfunction or failure can occur.
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Figure 41-6
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Severe ulnar deviation and deformity in RA
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Etiology




Unknown
Genetic Predisposition
Environmental
Autoimmune Response – Antibodies
(Rheumatoid Factor)
 Local and Systemic Inflammation
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Signs and Symptoms
 Remissions and Exacerbations
 Varies by Individual
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Signs and Symptoms (cont’d)
 Early Symptoms





Bilateral, Symmetrical Joint Inflammation
Reddened, Warm, Swollen, Stiff, Painful
Stiffness After Resting
Activity Decreases Pain and Stiffness
Low Grade Fever, Weakness, Fatigue,
Anorexia
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Signs and Symptoms (cont’d)
 Late Symptoms
 Joint Deformity
 Secondary Osteoporosis
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Rheumatoid Arthritis
 Rheumatoid nodules (subcutaneous, over
bony prominences)
 Any organ may be affected
 Inflammation in tissues of heart, lungs,
kidneys, eyes
 Clusters of symptoms
 Sjögren’s (autoimmune disorder affecting
moisture producing glands), Felty’s, or
Caplan’s syndromes
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Joint Abnormalities in
Rheumatoid Arthritis
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Linda S. Williams / Paula D. Hopper
Diagnosis






Rheumatoid Factor (RF)
Red Blood Cell (RBC)
C4 Complement Decreased
Erythrocyte Sedimentation Rate (ESR)
Antinuclear Antibody (ANA)
C-reactive Protein (CRP)
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Therapeutic Interventions
 Medication
 Disease-modifying Antirheumatic Drugs
 Leflunomide (Arava)
 Etanercept (Enbrel)
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Therapeutic Interventions (cont’d)
 Medication (cont’d)
 Methotrexate
 Prednisone
 NSAIDs
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Therapeutic Interventions (cont’d)
 Heat/Cold
 Balanced Rest and Activity
 Surgery – Total Joint Replacement
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Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Nursing Diagnoses






Acute Pain
Disturbed Body Image
Fatigue
Self-care Deficit
Impaired Physical Mobility
Deficient Knowledge
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Hip Replacement
 Acetabular Cup Inserted Into Pelvic
Acetabulum
 Femoral Component Inserted Into Femur
 Total hip replacement video
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Total Hip Replacement (cont’d)
 Preoperative Care
 Elective procedure
 Autologous Blood Donation
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Total Hip Replacement (cont’d)
 Postoperative Care to Prevent
Complications
 Hip Dislocation
 Prevent Adduction or Hyperflexion
 Skin Breakdown
 Prevent Pressure Ulcers
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Figure 41-3
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Abductor Pillow
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Hip Flexion After Total Hip
Replacement
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Total Joint Replacement
 Care following total joint replacement
 Assessment
 Vital signs, level of consciousness, intake and
output, respiratory and neurovascular status, urinary
function, bowel elimination, wound condition, and
comfort
 Circulation and sensation in the affected extremity
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Total Joint Replacement
 Potential complications from surgery
 Dislocation of prosthesis
 Pulmonary embolism
 Fat embolism (hip)
 Urinary retention
 Constipation
 Deep vein thrombosis
 Bleeding
 Infection
 Pneumonia
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Total Hip Replacement (cont’d)
 Pain
 Provide Pain Relief
 Infection
 Prophylactic Antibiotics
 Coughing and Deep Breathing
 Incisional Care
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Total Hip Replacement (cont’d)
 Bleeding
 Monitor Incision/Drainage from Drain
 Neurovascular Compromise
 Neurovascular Checks
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Total Hip Replacement (cont’d)
 Ambulation
 Physical Therapy
 Use Walker/Crutches
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Total Hip Replacement (cont’d)
 Thromboembolitic Complications
 Compression Devices
 Leg Exercises
 Enoxaparin (Lovenox)
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Total Hip Replacement (cont’d)
 Self-care
 Assistive Dressing Devices
 Raised Toilet Seat
 Rehabilitation
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Total Knee Replacement
 Femoral Component, Tibial Component,
Patellar Button
 Dislocation Not a Concern
 Care like Total Hip Replacement
 Continuous Passive Motion Machine (CPM)
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Continuous Passive Motion
Machine
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Amputation
Removal of a body part
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Amputation (cont’d)
 Surgical Amputations
 Ischemia from Peripheral Vascular Disease
 Bone Tumor, Frostbite, Congenital Problems,
Infections
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Amputation (cont’d)
 Traumatic Amputations
 Accidents
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Amputation (cont’d)
 Replantation
 Wrap Severed Body Part in Cool, Slightly Moist
Cloth
 Place in Sealed Plastic Bag Submerged in
Cold Water
 Transported to Hospital
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Amputation (cont’d)
 Levels of Amputation




Below-the-knee (BKA)
Above-the-knee (AKA)
Below-the-elbow (BEA)
Above-the-elbow (AEA)
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Figure 43-1
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Amputation Nursing Care
 Preoperative Nursing Diagnoses
 Deficient Knowledge
 Teach Preoperative Procedures
 Disturbed Body Image
 Begin Support Services
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Indications and Incidence
 Trauma
 Common types of accidents and injuries
leading to amputation include those involving
motorcycles and automobiles, farm machinery,
firearms and explosives, electrical equipment,
power tools, and frostbite
 Disease
 Peripheral vascular disease, diabetes mellitus,
arteriosclerosis, and chronic osteomyelitis
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Indications and Incidence
 Tumors
 Bone tumors that are very large and invasive
 Congenital defects
 Convert a deformed limb into a more functional
one that can be fitted with a prosthetic device
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Amputation Nursing Care
(cont’d)
 Postoperative
 Hemorrhage Prevention
 Infection
 Pain Control
 Phantom Pain
 Mobility and Ambulation
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Bandaging for Above-theKnee Amputation
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Amputation Nursing Care
(cont’d)
 Postoperative Nursing Diagnoses
 Prosthesis- pg 1104
 Lifestyle Adaptation
 Supportive family
 Self care
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Diagnostic Tests and
Procedures





Vascular studies
Pulse volume recording
Thermography
Doppler ultrasound
Biopsy
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Medical Treatment
 Must include appropriate treatment and
control of underlying diseases or injuries
 Diet, medication, and exercise help patients
with diabetes and poor peripheral circulation
 If peripheral vascular disease, encourage to
stop smoking; nicotine causes vasoconstriction
 Trauma patient may have to be stabilized to
maintain normal heart rate and blood pressure
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Surgical Treatment
 Amputation at the lowest level that will preserve healthy
tissue and favor wound healing
 Surgeon chooses one of two procedures, depending on
condition of the extremity and the reason for the surgery
 Closed amputations
 Create a weight-bearing residual limb, important for lower extremity
amputations
 Open amputations
 The severed bone or joint is left uncovered by a skin flap
 Required when an actual or potential infection exists, as may occur
with gangrene or trauma
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Prostheses
 Artificial substitutes for missing body parts
 Prosthetist creates and supervises use of prosthesis
 A limb prosthesis may be placed while the patient is still in
the operating room
 With lower extremity amputations, older or debilitated
patients, and infection, prosthesis fitting delayed until
residual limb heals
 Can usually bear full weight on permanent prosthesis
about 3 months after amputation
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Figure 43-2
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Figure 43-3
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Complications










Hemorrhage and hematoma
Necrosis
Wound dehiscence
Gangrene
Edema
Contracture
Pain
Infection
Phantom limb sensation
Phantom limb pain
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Assessment




Record conditions that resulted in need for amputation
Preexisting cardiovascular problems
Family history of diabetes, hypertension, and vascular diseases
Signs and symptoms that relate to the vascular condition or other
chronic and acute problems
 Diet and fluid intake, intake of salt and alcohol, and use of tobacco
 Exercise and rest and sleep habits as well as the effects of the
current symptoms on the patient’s usual activities
 Patient’s psychosocial background may offer insight into how the
patient will tolerate treatments and procedures
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Physical Examination







Height, weight, and vital signs
Assess neurovascular status
Skin color, texture, temperature, and turgor
Palpate peripheral pulses for quality, symmetry
Assess capillary refill
Sensation; ask patient to identify touch on extremities
Mental and emotional status and general cognitive
abilities; determines patient’s understanding of the illness
and its implications
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Postoperative Nursing Care
 Assessment




Monitor vital signs frequently in the first 48 hours
Inspect the dressing frequently for bleeding
If drain receptacle, note color and amount of drainage
Monitor patient’s temperature for elevations that may indicate
infection
 Note any foul odor from the dressing
 After the dressing is removed, inspect the residual limb for edema
 Document patient’s pain, including type, location, severity, and
response to treatment
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Postoperative Nursing Care
 Nursing Diagnoses











Decreased Cardiac Output
Pain
Risk for Infection
Impaired Skin Integrity and Risk for Impaired Skin Integrity
Disturbed Sensory Perception
Risk for Injury
Impaired Physical Mobility
Activity Intolerance
Self-Care Deficit
Anxiety, Fear, and Ineffective Coping
Disturbed Body Image
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The Older Adult Amputee
 May have needs that should be taken into consideration when
planning and providing care
 Completely capable of learning but often requires smaller units of
information, more repetition, more time
 During teaching process patients with glasses or hearing aids should
have them in place
 Remind that phantom sensations are not uncommon or bizarre; this
can reduce fear or anxiety of these sensations
 Many have one or more chronic health problems
 The loss of a limb can be especially difficult; it is important to provide
psychological support
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