Skeleton Classification of Bones

8/14/2019 Skeleton Classification of Bones

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Review of Anatomy and

Physiology Skeleton

Classification of bones Compact (dense)

Cancellous (spongy) Bone marrow

Axial section

Appendicular section

Joint articulations Muscles


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Diagnostic Tests andAssessments

Radiologic tests Are diagnostic studies performed using x-

rays, with or without injection of contrastmedia, to detect musculoskeletal problemsand monitor effectiveness of treatment

X-ray (radiograph): most common and

widely used radiologic test for assessmentof musculoskeletal problems andeffectiveness of treatment


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Diagnostic Tests and

Assessments EMG (electromyogram or myogram):

records and evaluates the electricalactivity of muscles during contraction

Detects abnormal electrical activity inmuscle

There are two different types of EMG:intramuscular (IM) EMG (more commonly

used) and surface EMG (SEMG)


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Assessments Long, small-gauge needles are inserted through

the skin into muscle

Needles detect electrical activity of the muscle

and transmit information into electromyogrammachine; electrical activity is displayed visuallyon an oscilloscope or heard audibly through anaudiotransmitter (microphone)

(SEMG): electrodes are placed above muscle to

detect electrical activity


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Assessments Arthroscopy: a surgical procedure used

to examine the internal structure of a jointusing an arthroscope il-sized device with

optical fibers and lenses), which is insertedinto very small skin incisions; device isconnected to a video camera to allow forvisualization of the interior of the joint


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Assessments Procedure may be used for diagnosis or

treatment of musculoskeletal disorders suchas osteoarthritis, rheumatoid arthritis,

infectious types of arthritis, and internal jointinjuries like meniscus tears, ligament strainsor tears and cartilage deterioration

Arthroscopic surgery can be done during

procedure to repair joint tissues;arthroscopic surgery creates less tissuetrauma, less pain, and allows for a rapidrecovery


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Assessments Client education: postprocedure Encourage client to take analgesics for comfort

and limit activity as directed

Instruct client to observe site for hematoma orbleeding

Teach client how to perform neurovascularassessment (temperature, color, capillary refill,movement, and sensation) on affectedextremity

Teach client about signs and symptoms ofinfection to report; elevated temperature,warmth at injection site, purulent discharge,

and redness


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Assessments Arthrogram: contrast media or air

is injected into the joint cavity toallow for visualization of jointstructures; client moves jointthrough a series of movements whilea series of x-rays are taken; assess

for allergy to contrast media


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Assessments

Client education preprocedure: if injectedcontrast dye is used, inform client that once thedye is injected there may be a feeling of warmth,nausea, headache, salty taste in the mouth,itching, hives, and rash throughout the body(symptoms are usually temporary and will betreated if necessary

Client education postprocedure

Inform client that temporary discoloration of theskin and urine is normal after injection of dye

Teach client to perform neurovascular assessmenton affected extremity


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Assessments CT scan (computerized axial

tomography): combines x-rays withcomputer technology to produce ahighly detailed, cross-sectionalimage of internal organs andstructures of the body; also known as

CAT scan


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Assessments Body is visualized from skin to central part

of the body being examined; recordedimage is called a tomogram

Client education If ingested contrast dye is used, instruct client

to increase fluid intake to assist in eliminationof dye

Monitor for evacuation of contrast media and

possible constipation Initial stools may be white in color, which is

normal until all contrast media is evacuated


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Assessments MRI (magnetic resonance imaging):

radiologic technique (without radiation)that uses magnetism, radio waves, and a

computer to produce cross-sectionalimages of the body structures

Machine is extremely noisy and may cause orexacerbate a claustrophobic sensation


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Assessments Client education Explain procedure to the client; a mild sedative may

be given preprocedure to help decrease any anxietyassociated with a claustrophobic feeling

Instruct client to notify healthcare providers of anymetallic body parts such as implants, pacemakers,artificial joints, metallic bone plates, prostheticdevices, surgical clips, bullet fragments, metallicclips, or other al objects within the body that can

distort the MRI image or affect the magnetic field


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Assessments

Bone scan: technique used to create images ofbones on a computer screen or on a film using asmall amount of radioactive material that travelsthrough the bloodstream Radioactive material is especially absorbed in

abnormal areas of a bone; degree of dye absorption isrelated to the amount of blood flow to the bone

A camera scans the entire body and a recording ismade on a special film

Increased dye absorption is seen with osteomyelitis,

osteoporosis, fractures, Pagets disease and cancer ofthe bone


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AssessmentsArthrocentesis (joint aspiration)

and analysis: fluid is removed fromjoint to reduce swelling and pain

and/or obtain fluid for examinationusing a sterile needle and syringe Post-procedure complications are

uncommon but may include localizedbruising, minor bleeding into the jointcavity, and loss of pigment at injectionsite (septic arthritis is a rare butserious complication)


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Assessments Client education

If cortisone medication was injected into the joint,teach client to monitor for inflammation of the

injected area, atrophy or loss of pigment at theinjection site, and increased blood glucose

Instruct client to follow post-procedure activityrestrictions as directed by healthcare provider

Instruct client to monitor for post-procedurecomplications and check dressing for excessivebleeding


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Laboratory Studies

Antinuclear antibodies (ANA): sensitivescreening blood test used to detectautoimmune disease

ANAs destroy the nucleus (innermost core of thecell that contains the DNA) of the cells

Test not definitive but suggests presence ofauto-antibodies (antibodies directed against thebodys own tissue)

Present in clients with a number of autoimmunediseases such as rheumatoid arthritis, systemiclupus erythematosus, scleroderma, and others


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Laboratory Studies

Calcium (Ca++): one of the most abundantelectrolytes in the body that causesneuromuscular irritability and contractions; adultnormal reference value is 9 to 11 mg/dL Stored in bone and gives bone stability

Blood specimen is obtained to monitor calcium level Normal ranges vary slightly among healthcare

institutions Decreased calcium levels may be found in

osteomalacia, inadequate dietary intake of calcium,renal disease, and hypoparathroidism

Increased calcium levels may be seen in boneneoplasm, multiple fractures, immobilization, renalcalculi, and hyperparathyroidism


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Laboratory Studies

Phosphorus (2.5 to 4.5 mg/dL is normalreference range): blood sample is obtained tomonitor level and compare phosphorus level withother electrolytes in the body (such as calcium) A high percentage of total phosphorus in the body is

combined with calcium in teeth and bones Decreased levels can be seen with hypercalcemia,

starvation, malabsorption syndrome, osteomalacia, andvitamin D deficiency

Increased levels can be seen with healing fractures,metastatic bone tumors, and hypocalcemia


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Laboratory Studies

Rheumatoid factor (RF) (Normal-negative or


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Laboratory Studies

Erythrocytes sedimentation rate(ESR); normal is


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Laboratory Studies Uric acid(Normal male 4.5 to 6.5 mg/dL,

female 2.5 to 5.5 mg/dL): test generally used tomonitor serum uric acid levels during thetreatment of gout and may be used to diagnoseother health problems

Uric acid is the end product of purine metabolism;the kidneys normally excrete excess uric acid

Hyperuricemia (elevated urine or serum uric acidlevels) occurs because of poor renal function,excessive purine metabolism, and/or excessive

dietary intake of purine foods Elevated uric acid level is seen in gout


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Common Nursing

Techniques andProcedures


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Common Nursing Techniques

and Procedures Instructing the client on the use of

crutches

Crutch gaits: safe method of walkingusing crutches, alternating bodyweight on one or both legs and thecrutches;


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Instruction for the Client on

the Use of Crutches Four-Point Gait

Slow gait

Require good coordination Weight bearing is on both legs

Move each foot and crutch forward

separately (right crutch, left foot;left crutch, right foot)


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Instruction for the Client onthe Use of Crutches

Two-point gait

Faster than four-point gait

Requires more balance

There is partial weight-bearing on eachfoot

Arm movement simulate arm movementwhen walking

Move left crutch and right foot forwardtogether; move right crutch and left footforward together


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the Use of Crutches Three-point gait

Fast gait

Two crutches and unaffected legbear weight alternately

Weaker leg and both crutchesmove together followed bystronger leg


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the Use of Crutches Swing-to gait

Fast gait

Used by clients with paralysis oflegs and hips

Prolonged use may lead to atrophyand unused muscles

Advance crutches forward together,lift body using arms, then swing tomeet crutches


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Common Nursing Techniquesand Procedures

Traction: direct pulling forceapplied to a fractured extremity

that results in realignment of bone Reduces fracture, lessens muscle

spasms, relieves pain, correctsdeformities, promotes rest, and

allows for exercise


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Skin and skeletal traction are mostcommonly used; manual traction is onlyused briefly under physician direction

Skin traction (using tape, boots, splints) Assists in reduction of a fracture (does notprimarily achieve reduction) and helpsdecrease muscle spasms

Generally used for short-term treatment (48 to72 hours) and is applied directly to the skin

Weights range from 5 to 10 pounds


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Balanced suspension (traction that is ahanging support to immobilized body partin a desired position)

Used with skeletal traction to improvemobility while maintaining alignment offracture

Body part is suspended using splints, ropes,

and weights

Client able to perform activities such astoileting and personal hygiene; bed linen canbe changed without disturbing tractionalignment


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Countertraction: pulling forceexerted in the opposite direction toprevent the client from sliding to theend of the bed; examples ofcountertraction include the clientsweight, elevating the foot of the bed

(Trendelenburg), and elevating thehead of the bed with cervicaltraction


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Nursing Care for the Client in

Traction

Ensure that all ropes, weights, and pulleys arehanging freely, not shredded or torn, in astraight line

Bed linen should be kept off traction ropes

Teach client that weights should not be lifted forany reason (lifting weights alters the line of pulland could potentially interfere with bone healing)

Ensure that the ordered amount of weight ismaintained at all times


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Traction Teach client how to perform skin

assessment to monitor and prevent skinbreakdown on bony prominence and

pressure areas Ensure that body is always kept in proper

alignment to prevent complications such asexternal rotation of the joint, increase pain,

and poor healing of the fracture Teach client how to monitor for infection at

pin sites


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Traction

Inform client to avoid massaging calves orreddened areas to prevent clotdislodgement caused by venous stasis

Encourage client to increase fluid intake

(2,500 mL per day unless contraindicated)and roughage in diet to preventconstipation, UTI, and renal calculi

Teach client how to perform deep-breathing

and coughing exercises to preventrespiratory complication


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Traction Encourage client to use the overhead trapeze

(and unaffected leg if possible) to reposition forcomfort, shift weight to prevent skin breakdown,perform exercises, and assist with personal care,toileting and bed linen changes

Encourage client to adhere to exercise regimento maintain muscle tone, endurance, andprevent bone demineralization


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Traction Provide diversional activities and

encourage social interaction withfamily and friends to preventpotential isolation


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Cast care: a cast is applied forimmobilization to ensure stability ofa fracture


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Nursing Care of the Client in

a Cast

Instruct the client to avoid covering a new castwith blanket or plastic for extended periods

Turn client from side to side (using palms notfingertips) every 2 hrs to facilitate to drying forthe first 24 to 72 hrs

Instruct client to apply ice for the first 24 hrsover fracture side to control edema, ensuringthat ice is securely contained so cast does notbecome wet


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Nursing Care of the Client in

a Cast Instruct the client to elevate the extremity above

the level of the heart to promote venous return forthe first 24 hrs after application

Instruct client to perform active ROM to jointsabove and below immobilized extremity

Teach client about signs and symptoms to reportto healthcare provider: increasing pain inimmobilized extremity, excessive swelling anddiscoloration of exposed limb, burning or tinglingunder cast, sores, or foul odor under cast


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Splinting and immobilization: likecasts, splints are used to immobilizea fractured extremity to ensure

stability after closed reduction andexternal fixation; teach client how toperform neurovascular assessment

(color, temperature, capillary refill,and pulses)


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Nursing Management of ClientUndergoing Musculoskeletal Surgery

Laminectomy: surgical incision of the lamina doneprimarily to relieve symptoms related to herniatedintervertebral disc

Assess effectiveness of pain management

Perform neurological and neurovascular assessment;monitor bowel and bladder function

Assess client for complaints of severe headache orleakage of cerebrospinal fluid (CSF), nausea, abdominaldiscomfort, incontinence, amount and character ofdrainage on dressing


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Use the logroll technique (turning a client as aunit) to turn and reposition client; maintainproper alignment of the spine at all times

Inform client that bed rest may be maintained

for the first 24 to 48 hours after procedure;pillows may be used for comfort under thethighs in the supine position and between thelegs in the side-lying position

Assist client to rise as a unit when getting

out of bed (especially for the first time) Instruct client that paresthesias (numbness

and tingling of extremities) may not berelieved immediately after procedure


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Internal fixation: fracture immobilizationwith a metal device (made of screws, pins,and/or plates) that is surgically inserted torealign and maintain a fracture

Inform client that x-rays will be taken atregular intervals to ensure proper alignmentof the fixation device

Instruct client about signs and symptoms toreport related to infection; elevated

temperature, localized pain and warmth,tenderness, chills, malaise, and changes inneurovascular status of affected extremity


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Joint replacement, total hip replacement(THR) THR is frequently performed for client with

conditions such as rheumatoid arthritis,malignant bone tumors, arthriris associatedwith Pagets disease, juvenile rheumatoidarthritis, and hip fracture

Advantages of THR: substantial relief of pain,improved function and quality of life

Teach client about plan for effective painmanagement and side effects/adverse effectsof pain medications


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Teach client about dislocation precautions Avoid extremes of internal rotation, adduction,

and 90-degree flexion of affected hip for at least4 to 6 weeks after procedure

Prevent adduction: use an abduction pillow, avoidcrossing the legs, avoid twisting to reach forobjects behind, and avoid driving a car and takingtub baths for at least 4 to 6 weeks

Modify equipment to avoid 90-degree hip flexion(raised toilet seats, platform under chair, use ofreaches, long-handled shoe horns, and sockpullers)


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Teach client about signs and symptoms to reportto healthcare provider Infection-redness, swelling, abnormal drainage, foul

odor, and elevated temperature

Deep vein thrombosis (pain, sudden swelling in

affected extremity, enlargement of superficial veins,skin discoloration, and localized warmth)

Inform client that physical therapy exercises will beginon the first postoperative day to restore and maintainrange of motion, muscle strength, and mobility, and toprevent complications such as DVT


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Instruct client that homecaremanagement program will include: Ongoing nursing assessment of pain

management

Periodic dressing changes and monitoring forinfection Monitoring and adjustment of coagulation

status weekly if taking warfarin (Coumadin)and less often if taking enoxaparin (Lovenox), alow-molecular-weight heparin

An exercise program assisted by a physicaltherapist to assess and restore musclestrength and range of motion


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Instruct client to inform all healthcareproviders (dentists, etc.) of history of joint

replacement surgery so that prophylacticantibiotics can be prescribed as necessary

Inform client that periodic x-rays will berequired as follow-up throughout lifetime


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Amputation Provide client teaching about

effective pain managementtechniques; signs and symptoms toreport: redness, elevatedtemperature, and/or unusual, foul

smelling drainage; abrasions; and anyother signs of skin breakdown


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Teach client how to care for residual limb:wash daily using warm water andbacteriostatic soap, rinse and gently pat

dry thoroughly, expose to air for at least20 minutes after washing; avoid use oflotions, alcohol, powder, or oils unlessprescribed by healthcare provider; change

limb sock daily, wash sock using mild soapand dry flat and discard sock that is inpoor condition


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Instruct client to perform upper extremity activerange of motion (AROM) exercise daily

Instruct client to lay prone for 30 minutes 3 to 4times/day (if client is able and if part of standard ofcare) and avoid elevat6ing or sitting with residuallimb on pillows to prevent flexion contractures

Tell client that pain mat persist in the amputatedextremity and that this is normal and real; thediscomfort will be treated with analgesics or otherinterventions


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Disorders of theMusculoskeletal System


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Osteoporosis (porous

bone) Osteoporosis (porous bone)Disease characterized by low bone

mass and structural deterioration of

bone tissue, causing the bone(especially weight-bearing bonessuch as the hip, spine, and wrist) tobecome fragile and more susceptibleto fractures

Affects both women and men;however, women are at greater risk


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bone) Etiology and pathophysiologyAs people age, bone resorption happens

faster than bone formation, which causes the

bone to lose Ca++ and bone density; sincemost of the bodys calcium is stored in bonesand teeth, this rapid bone resorption leads toporous bone or osteoporosis

When serum Ca++ decreases, the bodytakes stored Ca++ from bone


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bone) AssessmentRisk factors include female gender,

increasing age; thin, small body frame

Caucasian or Asian-American ethnicity;family history; inadequate dietary intake ofcalcium; sedentary lifestyle; smoking;excessive alcohol intake; steroidmedications; postmenopausal state; chronic

liver disease; anorexia; and malabsorption


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bone) Females are at higher risk for osteoporosis than men Women have smaller body frames, which contribute to

less bone density

Bone resorption begins at an earlier age in women and

is accelerated in menopause

Breast-feeding and pregnancy deplete skeletal reservesunless calcium intake is increased to match demands

Since currently women often live longer than men,longevity increases the likelihood of osteoporosis


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bone)

Planning and implementation Provide client teaching about prevention:

take adequate amounts of Ca++ throughoutlifetime to decrease the incidence ofosteoporosis;

proper nutrition for adequate calcium intake;

weight-bearing exercises to force Ca++ backinto the bone;

safety measures to prevent falls that can resultin fractures;

bone mineral density (BMD) tests to measurebone mass in clients at risk for developingosteoporosis


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bone)Provide clients with informationabout recommended daily dietaryintake of calcium: Ca++ 1,000

mg/day for premenopausal andpostmenopausal women takingestrogen replacement therapy(ERT), and 1,500 mg/day forpostmenopausal women who arenot taking ERT


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bone)Provide information about foods high in Ca++ and the importance of calcium intake withvitamin D: dark, green leafy vegetables (suchas broccoli, bok choy,collard greens,spinach), sardines, salmon with the bone,dairy products (such as milk, cottage cheese,cheese, yogurt, and ice cream); Ca++supplements can also be used to supplement

dietary intake


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bone) Medication therapy Estrogen replacement therapy (ERT) is generally

used for prevention of osteoporosis after menopause Usually given in the form of a pill or skin patchDecreases bone demineralization and symptoms

of menopause

Can increase risk for endometrial cancer(progesterone may be given with estrogen, calledhormone replacement therapy or HRT, to decrease

risk)Client is at risk for developing deep vein

thrombosis (DVT)


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bone)Alendronate (Fosamax): prevents boneresorption; used to treat both men andwomen with glucocorticoid-induced

osteoporosisReloxifene (Evista): used for prevention

and treatment of osteoporosis; selectivereceptor modulator (SERM) thatprevents bone loss; side effects are rarebut may include hot flashes or DVT


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bone) Risedronate sodium (Actonel): biphosphonate, used forprevention and treatment of osteoporosis inpostmenopausal women and for prevention and treatmentof glucocorticoid-induced osteoporosis in both men and

women Slows and stops bone loss, increases mineral densityand reduces the risk of fractures

Instruct client to take drug with a glass of water at least30 minutes before the first food or beverage of the day

and avoid eating for at least 30 minutes after taking themedication


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bone) Client educationReinforce the importance of weight-

bearing exercises (jogging, walking,

hiking, stair climbing, tennis, dancing,and weight training

Encourage client to stop smoking

Encourage client to avoid excessiveintake of alcohol


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bone)


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Osteomyelitis

Osteomyelitis

Acute or chronic infection of the

bone usually caused by thestaphylococcus aureus organism


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Osteomyelitis

Etiology and pathophysiology

Infection can occur from direct orindirect invasion of infectious

organisms

Direct invasion generally occurs frominvasive procedures such as surgery

(joint prosthesis, arthroplasty) andinjuries such as fractures


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Osteomyelitis

Infection can also be caused by indirectinvasion (also referred to ashematogenous dissemination), where the

infection of the bone tissue or joint iscaused by spread of the infectiousorganism, through the bloodstream from apreexisting infectious focus; course and

virulence of infection is influenced byblood circulation to the affected bone


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Osteomyelitis

Long bones are common sites of infection inchildren, and spine, hip, and foot are commonsites of infection in adults

At-risk populations include children, elderly, andindividuals with weakened immune systems

Osteomyelitis warrants aggressive immediatetreatment with antibiotics or surgery (wounddebridement) if infection of bone is extensive


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Osteomyelitis

li i


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Osteomyelitis

AssessmentObserve for symptoms of local and/or systemic

infection: elevated temperature, chills,restlessness, severe bone pain unrelieved by

analgesics or rest and aggravated bymovement, swelling, redness, and warmth atthe infection site

Wound culture, bone scan, CT scan, and MRIprovide information for diagnosis andassessment of the extent of infection

O li i


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Osteomyelitis

Planning and implementation Explain all therapies and interventions to client

and family to decrease anxiety and enhancecooperation with plan of care

Use a rating scale to assess pain and evaluateeffectiveness of pain management measures

Provide ongoing education and emotionalsupport since the seriousness of the infectious

process duration and uncertainty surroundingtime for recuperation, potential complications,and associated risk can be a very fearfulexperience for client and family

O li i


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Osteomyelitis

Teach client about risk factors forosteomyelitis, which include previous jointreplacement surgery and implants

Use sterile technique for all dressingchanges and manipulation of affected limb;handle extremity very gently

Avoid activities that increase circulation toaffected area or cause edema, pain, and

pathologic fractures, such as exercise,application of heat, or keeping extremity independent position

O t liti


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Osteomyelitis

Immobilize affected extremity as prescribed byphysician and keep body in proper alignment

Monitor temperature at least every 2 hours

Provide cool environment, light clothing, antipyretic

medication, antibiotics, and other therapies asprescribed and/or appropriate to keep temperaturewithin the clients baseline

Keep client well hydrated to prevent dehydrationfrom insensible water loss

O t liti


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Osteomyelitis

If long-term management is required,provide client with instructions aboutwound care using sterile technique,

medication regimen (includinginstruction on venous access devices ifneeded), antibiotic administration,proper diet, rest, followup visits, and

laboratory tests

O t liti


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Osteomyelitis

Provide information about adverse effectsof antibiotic therapy such as ototoxicityand nephrotoxicity (aminoglycosides) and

hepatotoxicity cephalosporins) Instruct and assist client with interventions

to prevent complications associated withimmobility (turn and reposition every two

hours, coughing and deep breathingexercises, etc.)

O t liti


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Osteomyelitis

Medication therapy

Indicated with or without surgicalintervention

Generally includes antibiotics andanalgesics

Reinforce information about adverse

effects of antibiotic therapy asoutlined in previous section

O t liti


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Osteomyelitis Client education

Teach client about the importance of takingantibiotic medications as prescribed (for thefull duration) and to report adverse effectsof the medication to prescriber

Review medication regimen and have clientverbalize an understanding of teaching

Reinforce the importance of rest and proper

diet to facilitate healing, and preventconstipation and dehydration

Reinforce the importance of limbimmobilization during treatment

O t liti


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Osteomyelitis

M l d t h (MD)


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Muscular dystrophy (MD)


Group of genetic childhood disorderscharacterized by progressive muscleweakness, muscle wasting ofsymmetrical groups of muscles, andincreasing disability and deformity

Types of muscular dystrophy includeduchenne, myotonic, Beckers,facioscapulohumeral, and limb girdle

Most common form is Duchenne

muscular dystrophy

M l d t h (MD)


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Inherited sex-linked group of disorders

Significant risk factor is family history

Each type differs in regard to musclegroups affected, age at onset, rate ofprogression, and pattern of inheritance

Each type of MD affects specific musclegroups

M sc lar d stroph (MD)


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AssessmentMuscle biopsy is the primary test to confirm

diagnosis (test show degeneration of musclefibers)

EMG is also used as a diagnostic test thatidentifies origin of muscle weakness(destruction of muscle or nerve damage)

Progressive muscle weakness, hypotonia (lossof muscle mass), and delayed development of

motor skills such as walking may be observedand reported by parent or caregiver



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Planning and implementation

Provide support and assist family withdecision-making process surrounding

Development of a homecare plan to supportas much independence as possibleModifications in home environment to

support the clients maximal functional

abilityEncourage family to actively involve client in

care



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Family members may experience a myriad ofemotions including fear, guilt, anger and blame;support family to enhance coping with clientsprogressively worsening disease; refer to local

support groups including the MuscularDystrophy Association of America

Assist client and family to cope with theprogressive, incapacitating, and fatal nature of

the disease



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Muscular dystrophy (MD)Encourage family to interact with the familybased on developmental and not chronologicalage

Teach family strategies to prevent skinbreakdown (frequent skin care and linen

changes if incontinent, turn and reposition atleast 2 hours, use of protective barrierointments, and adequate fluid intake)

Perform passive range of motion exercises tomaintain function in unaffected extremities

and prevent/delay contractures in affectedextremities



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Medication therapy

There is no effectivepharmacological or other treatment

Corticosteroids are often used toincrease muscle strength



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Client education

Provide information about healthcareteam members and roles, including

those involved in homecare programfor client

Instruct family to offer client soft foods

and to cut into small pieces to preventaspiration and choking


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Pagets disease (osteitis


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Paget s disease (osteitisdeformans)

Pagets disease (osteitis deformans)

Description

Chronic skeletal bone disease with insidious

onsetDiagnosed around the fourth decade of life

Results in enlarged, deformed bones butdoes not affect normal bones

Generally affects skull, long bones, spine,and ribs



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Cause of disease unknown; however,viral infection has been hypothesized

as a probable etiologyHereditary factor: may be seen in

more than one family member

Early diagnosis and treatment isimportant to prevent diseaseprogression and deformity



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Excessive bone resorption followed bybone formation leads to weakenedbone, bone pain, arthritis, deformity,

and potential pathologic fracturesNormal bone marrow is replaced by

vascular, fibrous, connective tissue thatleads to formation of larger,

disorganized, and weaker bone tissue


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Symptoms include bone pain (most commoncomplaint) and other symptoms depending onwhich bones are affected with the disease

for example, if the skull is affected, headacheand hearing loss may be reported as well as

increasing head size

Hip pain may be present if the pelvis or femuris involved

Bowing of the lower extremities producing a

waddling gait and curvature of the spine may beseen in advanced stages of the disease



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Prognosis is good especially if treatmentis started before major deformity occurs

Provide analgesics and muscle relaxantsfor comfort

Administer medications as directed tocontrol progression of disease (seemedication section)



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Encourage client to take medication as directed byhealthcare provider since deformity and loss of bonestrength will continue without prescribed medications

If skull is affected, assists with diet modification,dentures, and eating utensils since teeth may

become weak from the diseaseHearing aid may be recommended if hearing lossresults from the disease

Refer client and family to support group



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Medication therapyThe goal of treatment is to control progression

of the disease

The following medications are approved by the

Federal Drug Administration (FDA):biophosphonates, etidronate disodium(Didronel), pamidronate disodium (Aredia),alandronate sodium (Fosamax), tiludronatedisodium (Skelid), residronate sodium

(Actonel), and calcitonin (Miacalcin)


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Paget s disease (osteitisdeformans) Encourage client to participate in an exercise

program to maintain skeletal muscle health, idealbody weight, and joint mobility

Instruct client to sleep on a firm mattress if backdiscomfort is present; if back brace is needed,instruct client on the prevention of skin breakdown

under brace (undershirt) and safety measures (nodriving with brace)

Encourage client to modify environment at home toprevent falls that may lead to subsequent fractures

Encourage client to participate in community supportgroup



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Musculoskeletal trauma


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FracturesDescription A fracture is a break in the continuity of the

bone

Fractures may be classified as:Closed (simple fracture): the bone breaksbut the skin remains intact

Open (compound fracture): broken endsof the bone penetrate the skin



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Fractures may also be classified as: Avulsion: a fracture resulting fromthe tearing of the supporting tendonsand ligaments

Comminuted: the broken bonefragments into more then two pieces

Compressed: the bone is crushed

Impacted: ends of the broken aredriven into each other



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Depressed such as in skull fracture,where the bone structure is broken andpressed inward

Spiral: the break spreads in a spiral

fashion along the bone shaft; is usuallycaused by sports injuries

Greenstick: an incomplete break in thebone where one side splinters leavingthe other side bent or intact; morecommon in children



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Fractures occur in all age group,although the elderly are more proneto fractures resulting from falls

When a bone breaks, the healing

process occurs in three phasesA fracture initiates an inflammatoryresponse (inflammatory phase)

Calcium eventually is deposited in the

area osteoblasts promote new boneformation (resparative phase)

Eventually the ends of the fracturereunite (remodeling phase)


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Crepitus may also be present in palpation;

crepitation is a popping or grating soundcreated by the movement of broken bonefragments

Muscle spasms may be noted near the

fractured boneEcchymosis or a bluish discoloration of the

area caused by blood extravasation intothe surrounding subcutaneous tissues

Pain that may be intense and possiblyshock if blood loss is severe


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Elevate the fractured extremity to reduceswelling and pain

Apply ice to the affected extremity

Assist in fracture reduction

Closed: involves external manipulation torealign the bones

Open: involves a surgical procedure torealign the bones

Maintain traction as prescribed; see sectionon nursing care of the client in traction



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uscu os e e a au a Monitor for complications compartment syndrome:impairment of circulation within inelastic fasciacaused by external pressure (> 30 mmHg) thatresults in tissue death and nerve injury;

external pressure can be created by casts,splints, or dressings;

manifestations include unrelieved pain,extremity, tingling, or diminished sensation(paresthesia), loss of sensation, pallor, coolness ofthe extremity, and weakness; bivalving may benecessary if the cast is too tight



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Infection: wound drainage, fever, painand odor

Fat embolism: chest pain, dyspnea,

tachycardia, decreased O2 saturation,apprehension, changes in l;evel ofconciousness, petechiae on upper trunkand axilla

Deep vein thrombosis: calf pain andtenderness, swelling or edema



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Medication therapy: includes analgesics and

antibioticsClient education

teach the client to exercise the extremities notimmobilized to prevent muscle atrophy

teach client regarding cast care, splint, and/ortraction (see previous discussions)

teach the client about neurovascular assessmentsthat need to be done

teach client regarding pin care procedure andmethods of preventing wound infection

Hip fracture


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Hip fracture

Description: the hip can be fractured atdifferent sites, namely, the head, neck,

and trochanteric areas;Pathophysiology: incidence of hip

fracture increases with age; 90 percentof hip fractures are caused by falls



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Assessment a hip fracture is a medical emergencyhip fractures are generally sustained from

falls; monitor level of consciousness and

assess for other injuriesperform neurovascular assessment on

affected extremity

extremity of affected hip will be shorter than

unaffected extremityfractured hip will generally externally rotate

Musculoskeletal traumal i d i l i


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Prepare client for surgical intervention (verifyallergies, informed consent, etc.)

Instruct client that an abductor pillow or splintmay be necessary to prevent disarticulation ofthe femur

Inform client that sandbags may be usedalong the external border of the affected limbto prevent external rotation

Inform client that pain medication will beavailable for comfort postoperatively(generally patient controlled analgesia [PCA] isused)


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Teach client about the pain rating scale to beused postoperatively and encourage client toreport any discomfort

Teach client deep-breathing and coughingexercises preoperatively

Use aseptic technique for dressing changes andwound drainage

Provide information on therapies and equipmentto expect postoperatively (indwelling urinaycatheter, PCA, IV therapy, possible traction, etc.)

Monitor preoperative use of skin traction toimmobilize the limb until surgery is ordered



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Client education

Reinforce deep-breathing and coughingexercises postoperatively

Preoperatively teach client about

postoperative precautions to prevent hipdislocation (no hip flexion greater than 90degrees, internal rotation of affected hip, oradduction of affected hip); these include such

activities as avoiding low chairs, using raisedtoilet seat, no excessive bending

Reinforce teaching about postoperativecourse

Sprains and strains


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Sprains and strainsDescription

A sprain is a stretch and/or tear ofa ligamentA strain is a twist, pull, and/ortear that may involve bothmuscles and tendons


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Medication therapy: analgesicsmuscle relaxants, and anti-inflammatory agents as necessary

Client education: reinforceinformation covered above inplanning and implementation section

Gout


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Gout


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Primary form of disease is hereditary;secondary form is acquired

Laboratory findings show elevated

serum uric acid (hyperuricemia)Characterize by recurring attacks of

acute joint inflammation

Gout


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Etiology and Pathophysiology

Inherited abnormality in the bodys abilityto process uric acid

Hyperuricemia is caused by increasedpurine synthesis and/or decreased renalexcretion of uric acid

Elevated serum uric acid level can also be

caused by prolonged fasting andexcessive alcohol intake

Gout


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AssessmentRisk factors:

Obesity, excessive weight gain,

excessive alcohol intake, impaired renalfunction, hypertension,

chemotheraphy for leukemia andcertain lymphomas, certain thiazide

diuretics, aspirin, and tuberculosismedications


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Gout


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Gout Planning and implementation


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Prevent any bed linen from touching affected

extremity because of extreme tenderness (bedcradle and/or footboard can be used)

Instruct client to adhere to activity restriction suchas bed rest and immobilization of affected extremity

during periods of exacerbationMonitor uric acid levels to prevent exacerbation and

evaluate effectiveness of treatment

Instruct client about precipitating factors for the

diseaseEncourage diet low in purines

Gout


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Medication theraphy:

anti-inflammatory agents, (such ascolchicines, NSAIDs or

corticosteroids),

antihyperuricemic (such as allop-urinol [Zyloprim]) and uricosurics

(such as prebenecid [Probalan])


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Degenerative Joint Disease(DJD) O h i i (OA)


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(DJD) or Osteoarthritis (OA)

Osteoarthritis (OA)


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Slowly progressive disorder of articulatingjoints especially weight-bearing joints

Commonly affects hand and weight-bearingjoints (knees, hips, feet, and back)

Breakdown of articular cartilage occurs

Injury is usually limited to joint andsurrounding tissue

Disease ranges from very mild to very severe

Osteoarthritis (OA)


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Osteoarthritis (OA)


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Cartilage degeneration causes bones to rubagainst each other, causing pain and decreasingfunction of the joint

Risk factors

Age (most significant): primarily affectsmiddle-age to older adults

Obesity (generally causes arthritis of theknees)

Repetitive joint injuries caused by sports,accidents, or work-related injuries

Osteoarthritis (OA)


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Genetics (especially seen with OA ofthe hands): client may be born withdefective cartilage or slight defect in

the way the joint fits together, and asthe client ages, the joint cartilagecontinues to progressively, degenerateand enzymes (hyaluronidase) are

released, which cause furtherbreakdown

Osteoarthritis (OA)


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Assessment

Disease is diagnosed with physical examand a history of symptoms

X-ray confirms the diseaseJoint pain is present with movement and

weight-bearing and is relieved by rest

There is limited range of motion with

progressive loss of function

Osteoarthritis (OA)


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There is joint stiffness after rest

Crepitation (grating sensation caused by roughjoint surfaces rubbing together) occurs

Heberdens nodes (raised bony growths over the

distal interphalangeal joints) are presentBouchards nodes (raised bony growths over the

proximal interphalangeal joint of the hand) arenoted

Osteoarthritis (OA)


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Osteoarthritis (OA)


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Instruct client to apply heat/cold therapyto affected joint temporary pain relief

Assist client in planning scheduled restperiods to relieve stress on joints

Assist client with activities of daily living(ADL) as needed

Provide information aboutcomplementary therapies such as visualimagery and relaxation techniques forpain control

Osteoarthritis (OA)


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Medication therapy

Acetaminophen is generally used to controlmild pain without inflammation

Therapy also includes anti-inflammatoryagents such as NSAIDs and corticosteroids

If NSAIDs are ineffective in controllinginflammation and pain, glucocorticosteroidsmay be injected directly into the joint

Osteoarthritis (OA)


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Client education

Teach client about the nature of and treatment of disease

Teach client principles of good body mechanics

Instruct client about the correct use of assistive devicesand encourage use as needed

Assist client in planning daily activities and tasks thatallow for schedule rest periods

Teach client to avoid activities that put excessive stresson joints and caused pain


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Low Back Pain


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Low Back PainP i b lt f t t d t


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Pain may be a result of acute or repeated stress on

the lower back over a period of yearsPain occurs because of degeneration and/or acute

injury to the tissue of the lower back

Caused by sprain or strain of ligaments andmuscles

Pain may be felt at the site of the injury or referred

Overall health of muscles of the lower backdetermines the degree of risk for injury as well asthe speed of recovery


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Low Back Pain


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Assessment

Risk factors include but are not limitedto: degenerative disc disease, poormuscle tone of the lower back,

sedentary lifestyle, obesity, poor bodymechanics, smoking, and stress

Client will report pain caused by a shiftof one vertebra on another or pinching

and irritation of the nerve rootMuscle spasms are a common symptom


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Low Back Pain


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Planning and implementationThe goal of treatment is to improve

symptoms and slow progression of

the degenerative process Include client and family in plan of

care

Provide emotional support

Low Back Pain


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Medication therapyMedication therapy includes but is not

limited to analgesics, NSAIDs, and

muscle relaxantsEpidural corticosteroid injections may

be used if conservative treatment isineffective

Low Back PainClient education


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Client education

Teach client about expected therapeuticeffects, side/adverse effects, andcontraindications with medication use

Teach client about the pain rating scale

Teach client the importance of adhering toactivity restrictions such as bed rest asindicated

Teach client the importance of adhering to

gradual to activity restrictions such asadherence with exercise plan

Low Back Pain


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Teach client the importance ofmaintaining ideal body weight

Inform client that physical therapy will

be part of the rehabilitation process toassist in maintaining muscle strengthand flexibility as well as improvingmuscle tone

Teach client the use of heat/cold forcomfort

Low Back Pain

Teach client about the importance of adhering to the principles of


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p g p pbody mechanics to avoid excessive strain on the lower back

Encourage client to sleep on a firm mattress

Have client demonstrate correct sleeping position using the principlesof body mechanics (side lying or supine with knees and hips flexed)

Encourage client to avoid or stop smoking

Teach client about use of prescribed brace or corset (if needed) to

prevent flexion and extension motions of lower back

Low Back Pain


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Skeleton Classification of Bones

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