Download Metro Community College NURS 1110 Nancy Pares, RN, MSN 1

Metro Community College
NURS 1110
Nancy Pares, RN, MSN
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Bind structures together, providing support
for individual organs and a framework for
the body
Store fat, transport substances, provide
protection, and play a role in repair of
damaged tissue
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Types of connective tissue
◦ Loose (areolar, adipose, reticular)
◦ Dense (tendons, fascia, dermis, gastrointestinal
tract submucosa, fibrous joint capsules)
◦ Elastic (aortic walls, vocal cords, parts of trachea
and bronchi, some ligaments)
◦ Hematopoietic (blood)
◦ Strong supportive (cartilage, bone, ligaments)
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Bone
◦ Hard tissue: makes up most of skeletal system
◦ Functions: support, protection, movement,
storage of calcium and other ions, and
manufacture of blood cells
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Cartilage
◦ Specialized fibrous connective tissue
◦ Provides firm but flexible support for the
embryonic skeleton and part of the adult skeleton
◦ Cartilage cells are called chondrocytes
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Ligaments
◦ Strong and flexible fibrous bands of connective
tissue that connect bones and cartilage and
support muscles
◦ Yellow ligaments, located in the vertebral column,
are elastic and allow for stretching
◦ White ligaments, found in the knee, do not stretch
but provide stability
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Tendons
◦ Composed of very strong and dense fibrous
connective tissue
◦ They are in the shape of heavy cords and anchor
muscles firmly to bones
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Connective tissue disorders: manifested as joint
disorders since joint mobility depends on
functional connective tissue
Joint: site where two or more bones are joined;
permit motion and flexibility of the rigid skeleton
Classification
◦ Synarthroses (fixed joints)
◦ Amphiarthroses (slightly movable joints)
◦ Diarthroses (freely movable joints)
Encased in a fibrous capsule made of strong
cartilage and lined with synovial membrane
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Loss of bone mass and bone strength
◦ Osteoporosis common in women but affects men
◦ Put the older patient at risk for fractures

Cartilage gradually loses elasticity; becomes soft
and frayed
◦ Water content decreases, and cartilage may ulcerate,
leaving bony joint surfaces unprotected and promoting
growth of osteophytes (bony spurs)
◦ Result in pain and limited mobility
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Complaints that suggest possible problems
related to connective tissue disorders are
aches, pain, joint swelling or stiffness,
generalized weakness, a change in ability to
work or to enjoy leisure activities, a change
in appearance that is significant to the
patient, and a change in ability to carry out
activities of daily living
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Major childhood and adult illnesses,
operations, and current medications and
allergies
History of tuberculosis, poliomyelitis,
diabetes mellitus, gout, arthritis, rickets,
infection of bones or joints, autoimmune
diseases, and neuromuscular disabilities
Accidents and injuries
Current medications
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Osteoporosis, osteoarthritis, rheumatoid
arthritis, gout, or scoliosis may have some
genetic basis
◦ Autoimmune diseases, e.g., thyroid disorders
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Review of systems
◦ General health status; determines patient’s
perception of well-being
◦ Fatigue, malaise, anorexia, weight loss, pain,
stiffness, dysphagia, or dyspnea
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Vital signs, height, and weight
Skin color, rashes, lesions, scars, or any signs of
injuries
Palpate skin for warmth, edema, and moisture
Palpate lymph nodes for enlargement and
tenderness
Inspect joints for swelling and deformity, and
palpate for warmth, swelling, and tenderness
Joint pain and range of motion
Measure limb length and muscle strength
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Blood studies
◦ Complete blood cell count, erythrocyte
sedimentation rate (ESR), and C-reactive protein
determination
◦ Venereal Disease Research Laboratory (VDRL),
rheumatoid factor (RF), creatinine, and antinuclear
antibody (ANA) tests
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Urine studies
◦ Creatinine and uric acid levels
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Radiologic imaging studies
◦ Radiography, ultrasonography, arthrography,
nuclear scintigraphy, magnetic resonance imaging,
diskography, tomography, and computed
tomography
◦ No strenuous activity for 12-24 hrs following
procedure
◦ Joint aspiration: done at bedside
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Drug therapy
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Glucocorticoids
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Biologic response modifiers (BRMs)
Disease-modifying antirheumatic drugs (DMARDs)
Cyclooxygenase-2 (COX-2) inhibitors
Surgical treatment
◦ Indicated in some musculoskeletal disorders, such as
degenerative joint disease and arthritis
◦ Continuous passive motion (CPM) machine
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Pathophysiology
◦ Degeneration of articular cartilage with hypertrophy of
the underlying and adjacent bone
◦ Normally, articular cartilage provides a smooth surface for
one bone to glide over another
◦ Cartilage transfers the weight of one bone to another so
the bones do not shatter
◦ Osteoarthritis: shock-absorbing protection lost
◦ New bone growth is stimulated by exposed bone surfaces,
causing bone spurs
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Figure 41-1
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Signs and symptoms
◦ Pain in affected joint, stiffness, limitation of
movement, mild tenderness, swelling, and
deformity or enlargement of the joint
◦ Heberden nodes and Bouchard nodes
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Medical diagnosis
◦ Health history and radiographic studies
◦ Arthroscopy and MRI
◦ Synovial fluid aspiration
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Figure 41-2
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Medical treatment
◦ Drug therapy
 Acetaminophen, NSAIDs, DMARDs, COX-2 inhibitors,
or low dose of salicylates (aspirin)
◦ Surgery
 Arthroscopic surgery and arthroplasty
◦ Physical therapy
 Improve range of motion; maintain muscle mass and
strength
◦ Education
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Figure 41-3
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Assessment
◦ Joint pain or tenderness
◦ Examine joints for crepitus, enlargement,
deformity, and decreased range of motion
◦ Compare affected and unaffected joints to detect
abnormalities
◦ Determine how the disease affects the patient’s
mobility and ability to perform activities of daily
living
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Interventions
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Chronic Pain
Impaired Physical Mobility
Ineffective Coping
Ineffective Therapeutic Regimen Management
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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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Interventions
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Acute Pain
Risk for Injury
Impaired Physical Mobility
Impaired Tissue Perfusion
Risk for Infection
Anxiety or Fear
Deficient Knowledge
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Pathophysiology
Chronic, progressive inflammatory disease
Inflammation of the synovial tissue
Synovium thickens; fluid accumulates in joint space
Vascular granulation tissue (pannus) forms in the joint
capsule and breaks down cartilage and bone
◦ Fibrous tissue invades pannus, converting it first to rigid
scar tissue and finally to bony tissue
◦ These changes result in ankylosis
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Figure 41-6
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Signs and symptoms
◦ Pain in affected joints aggravated by movement
◦ Morning stiffness lasting more than 1 hour
◦ Weakness, easy fatigability, anorexia, weight loss, muscle aches
and tenderness, and warmth and swelling of the affected joints
◦ Joint changes are usually symmetric
◦ Rheumatoid nodules (subcutaneous, over bony prominences)
◦ Any organ may be affected
 Inflammation in tissues of heart, lungs, kidneys, eyes
◦ Clusters of symptoms
 Sjögren’s, Felty’s, or Caplan’s syndromes
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Figure 41-7
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Medical diagnosis
◦ Health history and physical examination
◦ Laboratory studies
 RF (rheumatoid factor), ESR (erythrocyte
sedimentation rate), and CRP (C-reactive protein)
◦ MRI, bone scans, and DEXA scans
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Medical treatment
◦ Drug therapy
 Aspirin and other NSAIDs for several months, with
the addition of gold compounds, d-penicillamine,
antimalarials, or sulfasalazine if needed
◦ Physical and occupational therapy
◦ Surgery
 Arthroplasty, synovectomy, tenosynovectomy, and
arthrodesis
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Figure 41-5
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Assessment
◦ Pain, joint swelling, tenderness, joint deformities and
limitation of movement, fatigue, and decreased ability to
perform activities of daily living
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Interventions
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Chronic Pain
Activity Intolerance
Ineffective Coping
Social Isolation
Ineffective Therapeutic Regimen Management
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Pathophysiology
◦ Bone constantly formed and absorbed
◦ Until adolescence, bone formation exceeds bone
absorption so that bones grow and strengthen
◦ Around age 30, bone absorption surpasses formation
◦ Loss of trabecular bone, innermost layer, occurs first
◦ Loss of cortical bone, hard outer shell, begins later
 Begins earlier and progresses faster in women than in men
◦ Result is loss of bone mass
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Risk factors
◦ Older women who have small frames, who are white
or of northern European heritage, and who have fair
skin and blond or red hair
◦ Estrogen deficiency; physical inactivity; low body
weight; inadequate calcium, protein, or vitamin D
intake; corticosteroid therapy over more than 6
months; and excessive use of cigarettes, caffeine,
and alcohol
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Signs and symptoms
◦ Back pain, fractures, loss of height due to
vertebral compression, and kyphosis
◦ Bone deterioration in the jaw can cause dentures
to fit poorly
◦ Collapsed vertebrae can cause chronic pain
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Medical diagnosis
◦ Absorptiometry
◦ Radiographs
◦ Bone specimen
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Medical treatment
◦ Calcium supplementation and estrogen replacement
◦ Bisphosphonates and selective estrogen receptor
modulators (SERMs)
◦ Regular exercise
◦ Percutaneous vertebroplasty
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Assessment
◦ Diet, calcium intake, and exercise plan
◦ Note whether the patient is menopausal or has had an
oophorectomy
◦ Compare height with previous measurements
◦ Posture; note the presence and degree of deformity
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Interventions
◦ Risk for Trauma
◦ Chronic Pain
◦ Ineffective Therapeutic Regimen Management
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Pathophysiology
◦ Characterized by hyperuricemia
◦ Related to excessive uric acid production or
decreased uric acid excretion by the kidneys
◦ Four stages
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Asymptomatic hyperuricemia
Acute gouty arthritis
Asymptomatic intercritical period
Chronic tophaceous gout
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Signs and symptoms
◦ Asymptomatic hyperuricemia
 Blood uric acid level is elevated, but no other
symptoms
 Many people with asymptomatic hyperuricemia never
progress to the next stage
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Signs and symptoms
◦ Acute gouty arthritis
 Onset is abrupt, usually occurs at night
 The patient is suddenly afflicted with severe,
crushing pain and cannot bear even the light touch
of bed sheets on the affected joint
 Joint commonly affected is the great toe
 Symptoms usually disappear within a few days
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Signs and symptoms
◦ Asymptomatic intercritical period
 No symptoms
◦ Chronic tophaceous gout
 Advanced gout
 Tophi: deposits of sodium urate crystals that are
visible as small white nodules under the skin
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Figure 41-8
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Medical diagnosis
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History and physical examination
Urate crystals in synovial fluid
Urinary uric acid
Blood uric acid
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Medical treatment
◦ Asymptomatic hyperuricemia requires no medical
treatment
◦ NSAID alone or with colchicine for acute gouty
arthritis
◦ For subsequent attacks: indomethacin,
corticosteroids, and corticotrophin
◦ Avoid foods high in purines
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Assessment
◦ Pain, joint swelling, tophi, uric acid stones, fever,
and a history of trauma, injury, or surgery
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Interventions
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Acute Pain
Impaired Physical Mobility
Altered Urinary Elimination
Ineffective Therapeutic Regimen Management
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Metro Community College
NURS 1110
Nancy Pares, RN, MSN
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Closed or simple fracture
◦ The bone does not break through the skin
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Open or compound fracture
◦ Fragments of the broken bone break through skin
◦ Open fractures have three grades of severity
 Grade I: least severe injury, with minimal skin damage
 Grade II: moderately severe injury, with skin and muscle
contusions (bruises)
 Grade III: most severe injury (wound larger than 6 to 8 cm),
with skin, muscle, blood vessel, and nerve damage
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Stress fracture
◦ Caused by either repeated or prolonged stress
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Pathologic fracture
◦ Occurs because of a pathologic condition in the
bone, such as a tumor or disease process, that
causes a spontaneous break
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Figure 42-1
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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 middleaged adults
Hip and wrist fractures are most common in older adults
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A bone begins to heal as soon as an injury
occurs
New bone tissue formed to repair the
fracture, resulting in a sturdy union between
the broken ends of the bone
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Osteomyelitis: from contamination of the open
wound associated with a fracture or from
contamination of indwelling hardware used to
repair the broken bone
When infection is inadvertently brought by
surgery or other treatment, it is known as
iatrogenic
Any infection can interfere with normal healing
Common after an open fracture and surgical
repair and may become chronic
In deep, grossly contaminated wounds, gas
gangrene may develop
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Infection of the bone
Gas gangrene
◦ Foul smelling, watery drainage
◦ Significant swelling and redness
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Treatment
◦ Aggressive IV antibiotics (4-8 wks)
◦ Wound care—irrigation, antibiotic surgical
debridement, wound vac
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16 year old male was admitted after a
motocycle accident. He has a compound
fracture of the thigh with a severe soft tissue
injury. Following surgery, he has an external
fixation device on the injured leg. A JacksonPratt drain is in place. Daily wound care is
ordered.
List all the potential sources of bone
infection.
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Signs and symptoms
◦ Local pain, redness, purulent wound drainage, chills, and
fever
◦ With gas gangrene, foul-smelling watery drainage with
significant redness and swelling
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Treatment
◦ IV antibiotics may be given for 4 to 8 weeks, followed by
4 to 8 weeks of oral drug therapy
◦ Wound care: irrigation, treatment with antibiotic beads,
and surgical removal of dead bone tissue and/or
hardware
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Fat globules released from marrow of broken
bone into bloodstream, then migrate to the lungs
They lodge in capillaries and obstruct blood flow
The fat particles break down into fatty acids,
which inflame the pulmonary blood vessels,
leading to pulmonary edema
Common with fractures of the long bones,
multiple fractures, and severe trauma
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Respiratory distress is the first sign of a fat
embolism, followed by tachycardia,
tachypnea, fever, confusion, and decreased
level of consciousness
Treatment: bed rest, gentle handling,
oxygen, ventilatory support, and fluid
restriction and diuretics for pulmonary
edema
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Venous stasis, vessel damage, and altered
clotting mechanisms contribute to
formation of blood clots (thrombi), most
commonly in deep veins of the legs
DVT increased with immobility often
associated with a fracture
Thrombi can break off and travel to the
lungs, causing a pulmonary embolism
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Serious complication from internal or
external pressure on the affected area
Compartments: enclosed spaces made of
muscle, bone, nerves, blood vessels
wrapped by fibrous membrane
Internal pressure from bleeding/edema into
a compartment; external pressure from a
cast or tight dressing
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When bleeding or edema into a
compartment, there is nowhere for drainage
to go: it is trapped in the space
Increased fluid puts pressure on tissues,
nerves, and blood vessels, so that blood
flow is decreased, resulting in pain and
tissue damage. External pressure also can
decrease blood flow to the area
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Primary symptom is pain, especially with touch or
movement, that can’t be relieved with opioids
Other signs and symptoms: edema, pallor, weak
or unequal pulses, cyanosis, tingling, numbness,
paresthesia, and finally, severe pain
The goal of treatment is to relieve pressure
◦ When internal pressure, a surgical fasciotomy, which
entails making linear incisions in the fascia, may relieve
pressure on the nerves and blood vessels
◦ For external pressure, cast or dressings are replaced
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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
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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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Expected healing time is appropriate but
unsatisfactory alignment of bone results in
external deformity and dysfunction
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Failure of a fracture to heal in the expected
time
The bone usually heals eventually; it may
just be slower
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Occurs when a fracture never heals
Treatment
◦ Osteogenic method: implantation of bone grafts
◦ Osteoconductive methods: synthetic materials to provide
a matrix for bone growth
◦ Osteoinduction: substances such as platelet-derived
growth factor
◦ Electric stimulation
 Internal or external; up to 10 hours a day for 3-6 months
 Time consuming but can prevent further surgery and bone
grafts
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Depend on type and location of the break
Some fractures have so few manifestations
that they can be detected only with x-ray
Signs and symptoms are swelling, bruising,
pain, tenderness, loss of normal function,
abnormal position, and decreased mobility
See Box 42-1, p. 918
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Standard radiographs
◦ Reveal bone disruption, deformity, or malignancy
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Computed tomography (CT)
◦ Detect fractures of complex structures, such as the hip
and pelvis, or compression fractures of the spine
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Bone scan
◦ Detect small bone fractures or fractures caused by stress
or disease
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Five ‘P’s
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Pain
Pulses
Pallor
Paresthesis
Paralysis
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The process of bringing the ends of the broken
bone into proper alignment
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Nonsurgical realignment that returns bones
to their previous anatomic position
No surgical incision is made; however,
general or local anesthesia is given
By using traction, manual pressure, or a
combination
After reduction of a fracture, x-ray taken
and a cast usually applied
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Figure 42-3
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A surgical procedure in which an incision is
made at the fracture site
Usually for open (compound) or
comminuted fractures to clean the area of
fragments and debris
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Necessary for healing to occur
Prevents movement and increases union
Accomplished in many ways, such as
fixation, casts, splints, and traction
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An attempt to attach the fragments of the
broken bone together when reduction alone
is not feasible because of the type and
extent of the break
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Done during open reduction surgical
procedure
Rods, pins, nails, screws, or metal plates
used to align bone fragments and keep
them in place for healing
Promotes early mobilization; preferred for
older adults who have brittle bones that may
not heal properly, or who may suffer the
consequences of immobility
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Figure 42-4
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


Pins are inserted into the bone, above and below fracture
Pins are then attached to an external frame and adjusted to
align the bone
If there is soft tissue damage or infection, external fixation
allows access to the site and facilitates wound care
Pin care is extremely important to prevent the migration of
organisms along the pin from the skin to the bone
Patients should be taught to do their own pin care and to
recognize signs of infection
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Figure 42-5
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Figure 42-6
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



Hold the bone in alignment while allowing
movement of other parts of the body
Types of cast materials: plaster of Paris,
fiberglass, thermoplastic resins, thermolabile
plastic, and polyester-cotton knit impregnated
with polyurethane
Variety of materials used for splints/immobilizers
Four main groups of casts: (1) upper extremity,
(2) lower extremity, (3) cast brace, and (4) body
or spica cast
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


Exerts a pulling force on a fractured
extremity to align bone fragments
Prevents or corrects deformity, decreases
muscle spasm, promotes rest, and
maintains the position of the injured part
May be applied directly to the skin (skin
traction) or attached directly to a bone
(skeletal traction) with a metal pin or wire
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
Skin traction
◦ Buck’s traction
 For hip and knee contractures, muscle spasms, and alignment
of hip fractures
 Weight used during skin traction should not be more than
5 to 10 pounds to prevent injury to the skin

Skeletal traction
◦ Provides a strong, steady, continuous pull and can be
used for prolonged periods
◦ Examples of skeletal traction are Gardner-Wells,
Crutchfield, and Vinke tongs and a halo vest, in which
pins are inserted into the skull on either side
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Figure 42-7
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Figure 29-8
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
Complications
◦ Impaired circulation, inadequate fracture
alignment, skin breakdown, and soft tissue injury
◦ Pin track infection and osteomyelitis can occur
with skeletal traction
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



Increase mobility and assist with ambulation
Physical therapist measures patient for proper fit
and instructs in crutch-walking techniques
Nurse reinforces the instructions and evaluates
whether the crutches are being used properly
A properly fitted crutch should reach to three
fingerbreadths below the axilla to avoid pressure
on the axilla and nerves when walking
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Figure 42-8
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
Two-point gait
◦ The crutch on one side and the opposite foot are
advanced at the same time
◦ Used with partial weight-bearing limitations and with
bilateral lower extremity prostheses

Three-point gait
◦ Both crutches and the foot of the affected extremity are
advanced together, followed by the foot of the unaffected
extremity
◦ This gait requires strength and balance
◦ Used for partial or no weight bearing on affected leg
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
Four-point gait
◦ The right crutch is advanced, then the left foot,
then the left crutch, then the right foot
◦ Used if weight bearing is allowed and one foot can
be placed in front of the other

Swing-to gait
◦ Both crutches are advanced together, then both
legs are lifted and placed down again on a spot
behind the crutches
◦ The feet and crutches form a tripod
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
Swing-through gait
◦ Both crutches are advanced together, then both
legs are lifted through and beyond the crutches
and placed down again at a point in front of the
crutches
◦ Used when adequate muscle power and balance in
the arms and legs
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Figure 42-9
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
Used for support and balance, usually by
older adults
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

Provide minimal support and balance, and
relieve pressure on weight-bearing joints
Placed on the unaffected side with the top
even with the patient’s greater trochanter
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

Electrical stimulation may be used to promote
bone healing by promoting bone growth
An electrical current is delivered through one of
three methods
◦ A surgically implanted device
◦ Device with pins that are inserted through the skin to the
fracture site
◦ Pack of electrical coils applied to skin around fracture

Electrical bone stimulators successful in 80% of
cases, with an average healing time of 16 weeks
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
Health history
◦ The cause, type, and extent of the injury
◦ Symptoms associated with the injury
◦ Other medical problems that may have been
related to the cause of the fracture
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
Physical examination
◦ Deviations in bone alignment
◦ Inspect the skin over the fracture for lacerations,
bruising, or swelling
◦ Neurovascular checks (pulse, skin color, capillary
refill time, sensation) in the areas distal to the
wound to compare circulation and sensation.
Assess pulse rate and volume, as well as capillary
refill time in the nails distal to the injury
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





Acute Pain
Ineffective Tissue Perfusion
Risk for Infection
Impaired Physical Mobility
Risk for Impaired Skin Integrity
Activity Intolerance
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
Medical diagnosis
◦ Radiography

Medical treatment
◦ Traction and surgical repair (internal fixation,
femoral head replacement, or total hip
replacement)
◦ Patients may begin physical therapy as early as 1
day after surgery, depending on the type of
repair; begin by sitting in a chair and then
progress to a walker
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Figure 41-4
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Figure 42-10
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
Assessment
◦ Pain, impaired peripheral circulation on the
affected side, complications of immobility, skin
breakdown, and ability to carry out activities of
daily living
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
Interventions
◦ Relieving pain, promoting mobility and
independence, and preventing complications
◦ Proper body alignment is extremely important in
preventing injury to the fracture area
◦ Turn patients from side to side as ordered
◦ Affected hip must not be adducted or flexed more
than 90 degrees because excessive
flexion/adduction can dislocate the prosthesis
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4
114


A break in the distal radius (wrist area)
Medical diagnosis
◦ Radiography

Medical treatment
◦ Closed reduction or manipulation of the bone and
immobilization in either a splint or a cast
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
Assessment
◦ Pain and swelling following treatment of the fracture

Interventions
◦ Extremity should be supported and protected and can be
elevated on a pillow during the first few days
◦ Encourage patients to move their fingers and thumb to
promote circulation and reduce swelling, and to move
their shoulders to prevent stiffness and contracture
◦ Teach proper cast care
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
Medical diagnosis
◦ Radiography
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
Medical treatment
◦ A less severe non–weight-bearing fracture treated with
bed rest on a firm mattress or bed board for a few days to
6 weeks
◦ Severe weight-bearing fracture may require a pelvic sling,
skeletal traction, double hip spica cast, or external
fixation
◦ Monitor patient so injuries can be treated immediately
◦ Check for presence of blood in urine and stool, and watch
abdomen for signs of rigidity or swelling
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
Assessment
◦ Signs of bleeding, swelling, infection,
thromboembolism, and pain
◦ Assess urine output because the absence of urine
may indicate a perforated bladder
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
Interventions
◦ When handling patients, take extreme care to
prevent displacement of the fracture fragments
◦ Turn patient only on the order of a physician
◦ Provide back care when patient raised from the
bed using the trapeze or with adequate assistance
from others
◦ Ambulation may be encouraged even though
painful; follow physician’s orders
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
Most common of malignant bone tumors
Primary
◦ Rare in adults
◦ Most often in adolescents

Secondary
◦ Resulting from metastasis:
 Prostate, breast, kidney, thyroid, lung
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Diagnosis
◦ s/s vague
◦ X-ray, MRI, CT, CBC, biopsy, serum alkaline
phosphatase, serum calcium levels

Treatment
◦ Chemotherapy
◦ Radiation
◦ surgery
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Metro Community College
NURS 1110
Nancy Pares, RN, MSN
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

Can occur through a joint (between the
bones) or through a bone itself
Disarticulation: term used for an amputation
through the joint
The general site of the amputation is
described by the joint nearest to it
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Figure 43-1
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6
126
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7
127
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8
128
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9
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
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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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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




Vascular studies
Pulse volume recording
Thermography
Doppler ultrasound
Biopsy
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
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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

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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



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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



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




Hemorrhage and hematoma
Necrosis
Wound dehiscence
Gangrene
Edema
Contracture
Pain
Infection
Phantom limb sensation
Phantom limb pain
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






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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



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
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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

Anxiety
Anticipatory grieving
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
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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
Interventions
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
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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




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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


Involves the use of a microscope and highly
specialized instruments to reanastomose
(reconnect) blood vessels and nerve fibers in
a severed limb
Limb sutured into its correct anatomic
position
Advances in microsurgical techniques and
preservation of severed limbs have made
this technique increasingly successful
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




For amputations through the hand or wrist
Amputated thumbs are reattached whenever possible
because of their importance in hand function
In severely injured hand in which two or more fingers are
detached, surgeon restores as many fingers as possible
Amputations above the wrist do not lend themselves as
readily to replantation because of the extensive tissue,
muscle, and bone damage accompanying the injury
In general, the greater the muscle mass injury, the less
likely replantation is possible
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





Wrap amputated parts in a clean cloth saturated with
normal saline or Ringer’s lactate
Put in a sealed plastic bag that is placed in ice water
Direct contact between the amputated part and the ice can
lead to further tissue damage and cell death
Partially amputated parts should remain attached to the
patient and be kept cool if possible
Extra care to avoid detaching any parts since even small
connections increase the chances for successful repair
Patient may require treatment for shock due to blood loss
Tourniquets should not be used unless absolutely necessary
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





Assess circulatory status
Closely monitor vital signs
Inspect the residual limb (or dressing) for
bleeding
Assess pain at the site of the injury and at other
locations
Measure and record fluid intake and output
Note patient’s emotional status, and assess
understanding of the preoperative activities and
postoperative routines
Identify sources of support
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
Interventions
◦ Administer intravenous fluids and blood as ordered
◦ If the dressing becomes saturated with blood, reinforce
the dressing
◦ Report continued or excessive bleeding to the physician
◦ Even though preparations for replantation are hurried, be
sensitive to the patient’s fear and anxiety
◦ Accept the patient’s feelings
◦ Provide brief, simple explanations
◦ Administer analgesics as ordered for pain
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




Monitor vital signs, intake and output, and
level of consciousness
Hourly neurovascular assessment of limb
Doppler device or pulse oximeter to
evaluate circulation
Note and record the limb’s color, capillary
refill, turgor, temperature, and sensation
Assess limb for edema because massive
edema often accompanies replantation
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





Elevate the limb
Abstain from nicotine- and caffeine-containing
products for 7 to 10 days postoperatively
Enforce a strict ban on cigarette smoking
Room at 80° F to prevent compensatory
vasoconstriction of peripheral tissues
Loosen tight or restrictive gowns or pajamas
Administer ordered drugs; monitor effects
Discuss thoughts and feelings about the
replantation, disfigurement, and loss of function
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
Strain
◦ Injuries to muscles or tendons that cause over
stretching

Sprain
◦ Injuries to ligaments-pain (torn ligaments)
◦ Emergency treatment
 Immobilize, elevate, cold
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



R—rest
I----ice
C---compression
E---elevation
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
Disclocation
◦ A severe injury of the ligamentous structures that
surround a joint
◦ Complete displacement or separation of the
articular surfaces of the joint
◦ Treatment
 ASAP (may lead to avascular necrosis
 Closed reduction
 immobilization
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
Subluxation
◦ Partial or incomplete displacement of joint surface
◦ s/s similar to dislocation; less severe
◦ Treatment
 Same as for dislocation
 Less time to heal
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




CBC
UA
CMP
EKG
Chest x-ray
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
Should always be individualized to client
Osteoarthritis
◦ Low calorie diet
◦ No use of glucosamine or chondroitan if allergic to
shellfish

RA
◦ Easily fatigued
◦ Omega-3 fatty acids
◦ Corticosteroids: requires low salt diet
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Gout
◦ No ETOH
◦ Limit purine (sardines, herring, mussels very high)
◦ Moderate : chicken, salmon, crab, veal, mutton,
bacon, pork, beef and ham
◦ Mild: milk, cheese, ice cream, chocolate
◦ Limit oxalate: spinach, rhubarb, asparagus,
cabbage, tomatoes, beets, nuts, celery, instant
coffee, tea
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
Fractures
◦
◦
◦
◦
Need protein intake of 1 g/kg of body wt
Vitamins: esp B&C, calcium
Fluid intake: 2000-3000 ml/day
High fiber
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