Care of the Patient with a Musculoskeletal · PDF fileCare of the Patient with a...
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Chapter 44Chapter 44
Care of the Patient with a
Musculoskeletal Disorder
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
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Overview of Anatomy and
Physiology
Overview of Anatomy and
Physiology
• Functions of the skeletal system
� Support
� Protection
� Movement
� Mineral storage
Slide 2Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Mineral storage
� Hemopoiesis
• Structure of bones
� Four classifications based on form and shape
• Long, short, flat, and irregular
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Figure 44-2Figure 44-2
Slide 3Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Skeleton, anterior view.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Figure 44-3Figure 44-3
Slide 4Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Skeleton, posterior view.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Overview of Anatomy and
Physiology
Overview of Anatomy and
Physiology
• Articulations (joints)
� Allow movement
� Three types according to degree of movement
• Synarthrosis—no movement
• Amphiarthrosis—slight movement
• Diarthrosis—free movement
Slide 5Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Diarthrosis—free movement
• Divisions of the skeleton
� Axial skeleton
� Appendicular skeleton
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Figure 44-1Figure 44-1
Slide 6Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Structure of a freely movable (diarthrotic) joint.
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
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Overview of Anatomy and
Physiology
Overview of Anatomy and
Physiology
• Functions of the muscular system
� Motion
� Maintenance of posture
� Production of heat
• Skeletal muscle structure
Slide 7Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Skeletal muscle structure
� Epimysium
� Perimysium
� Endomysium
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Figure 44-5Figure 44-5
Slide 8Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Anterior view of the body.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Figure 44-6Figure 44-6
Slide 9Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Posterior view of the body.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Overview of Anatomy and
Physiology
Overview of Anatomy and
Physiology
• Nerve and blood supply� Blood vessels provide a constant supply of oxygen and nutrition, and nerve cells/fibers supply a constant source of information
• Muscle contraction� Muscle stimulus—when a muscle cell is adequately stimulated, it will contract
Slide 10Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
stimulated, it will contract
� Muscle tone—skeletal muscles are in a constant state of readiness for action
� Types of body movements—flexion, extension, abduction, adduction, rotation, supination, pronation, dorsiflexion, and plantar flexion
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Laboratory and Diagnostic
Examinations
Laboratory and Diagnostic
Examinations
• Radiographic studies
� Myelogram
� Nuclear scanning
� Magnetic resonance imaging (MRI)
� Computed axial tomography (CT or CAT scan)
� Bone scan
Slide 11Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Bone scan
• Endoscopic examination
� Arthroscopy
� Endoscopic spinal microsurgery
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Laboratory and Diagnostic
Examinations
Laboratory and Diagnostic
Examinations
• Aspiration
� Synovial fluid aspiration
• Electrographic procedure
� Electromyogram (EMG)
• Laboratory tests
Slide 12Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Laboratory tests
� Calcium
� Erythrocyte sedimentation rate (ESR)
� Lupus erythematosus (LE) preparation
� Rheumatoid factor (RF)
� Uric acid (blood)
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Rheumatoid arthritis
� Etiology/pathophysiology
• Most serious form of arthritis
• Chronic, systemic disease
• Most common in women of childbearing age
• Autoimmune disorder, but may also be genetic
Slide 13Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Autoimmune disorder, but may also be genetic
• May affect lungs, heart, blood vessels, muscles, eyes,
and skin
• Chronic inflammation of the synovial membrane of the
diarthrodial joints (movable)
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• Rheumatoid arthritis (continued)
� Clinical manifestations/assessment
• Characterized by periods of remission and exacerbation
• Malaise
• Muscle weakness
• Loss of appetite
Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
Slide 14Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Loss of appetite
• Generalized aching
• Edema and tenderness of joints
• Limited range of motion (morning stiffness)
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Figure 44-7Figure 44-7
Slide 15Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Rheumatoid arthritis of hands.
(From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.)
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Rheumatoid arthritis (continued)
� Diagnostic tests
• Radiography studies show loss of articular cartilage and
change in bone structure
• Laboratory tests
Slide 16Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Erythrocyte sedimentation rate (ESR)
� Rheumatoid factor (RF)
� Latex agglutination test
� Synovial fluid aspiration
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Rheumatoid arthritis (continued)
� Medical management/nursing interventions
• Pharmacological management
� Salicylates, NSAIDs, COX-2 inhibitors, anti-inflammatory
agents, disease-modifying antirheumatoid drugs
• Rest: 8 to 10 hours of sleep a night
Slide 17Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Rest: 8 to 10 hours of sleep a night
• Exercise: Range of motion two to three times per day
• Heat: Hot packs, heat lamp, and/or hot paraffin
• Rehabilitation
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Ankylosing spondylitis
� Etiology/pathophysiology
• Chronic, progressive disorder of the sacroiliac and hip
joints, the synovial joints of the spine, and the adjacent
soft tissues
• Most common in young men
Slide 18Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Most common in young men
• Strong hereditary tendency
� Clinical manifestations/assessment
• Pain and stiffness in back; decreased ROM
• Elevated temperature; tachycardia; hyperpnea
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Ankylosing spondylitis (continued)
� Diagnostic tests
• Hemoglobin, hematocrit, ESR, alkaline phosphatase
• Radiographic
� Medical management/nursing interventions
Slide 19Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Pharmacological management
� Analgesics, NSAIDs
• Exercise program: swimming and walking
• Surgery: replace fused joints
• Maintain spine alignment
• Turn, position, and breathing exercises every 2 hours
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Osteoarthritis (degenerative joint disease)
� Etiology/pathophysiology
• Nonsystemic, noninflammatory disorder that
progressively causes bones and joints to degenerate
• Primary
Cause is unknown
Slide 20Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Cause is unknown
• Secondary
� Caused by trauma, infections, previous fractures,
rheumatoid arthritis, stress on weight-bearing joints
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Figure 44-9Figure 44-9
Slide 21Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Heberden’s nodes.
(From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.)
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Osteoarthritis (degenerative joint disease)
(continued)
� Clinical manifestations/assessment
• Joint edema, tenderness, instability, and deformity
• Heberden’s nodes
Slide 22Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Bouchard’s nodes
� Diagnostic tests
• Radiographic studies
• Arthroscopy
• Synovial fluid examination
• Bone scans
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Osteoarthritis (degenerative joint disease) (continued)
� Medical management/nursing interventions
• Pharmacological management
� Salicylates, NSAIDs, corticosteroids, glucosamine
supplements
Slide 23Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
supplements
• Exercise balanced with rest
• Heat applications
• Gait enhancers (canes, walkers, etc.)
• Surgery
� Osteotomy
� Joint replacement
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Gout (gouty arthritis)
� Etiology/pathophysiology
• Metabolic disease resulting from an accumulation of
uric acid in the blood
• Caused by an ineffective metabolism of purines
• Primary: hereditary factors
Slide 24Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Primary: hereditary factors
• Secondary: use of certain drugs, complication of other
diseases, or idiopathic
• Affects men more frequently than women
• Does not occur before puberty in males or before
menopause in females
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Gout (gouty arthritis) (continued)
� Clinical manifestations/assessment
• Excruciating pain
• Edema
• Inflammation (most common in the great toe)
Slide 25Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Tophi
� Diagnostic tests
• Serum and uric acid level, CBC, ESR
• Radiography studies
• Synovial fluid aspiration
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Inflammatory Disorders of the
Musculoskeletal System
Inflammatory Disorders of the
Musculoskeletal System
• Gout (gouty arthritis) (continued)
� Medical management/nursing interventions
• Pharmacological management
� Colchicine, phenylbutazone (Butazolidin), indomethacin
(Indocin), corticosteroids, allopurinol (Zyloprim),
sulfinpyrazone (Anturane)
Slide 26Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
sulfinpyrazone (Anturane)
• Encourage fluid intake
• Monitor intake and output
• Bed rest and joint immobilization
• Dietary restrictions
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Other Disorders of the
Musculoskeletal System
Other Disorders of the
Musculoskeletal System
• Osteoporosis
� Etiology/pathophysiology
• Reduction of bone mass
• Most common in women ages 55 to 65
• Contributing factors: immobilization; steroids; high
intake of caffeine; diet low in calcium, high in protein;
Slide 27Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
intake of caffeine; diet low in calcium, high in protein;
smoking; sedentary lifestyle
� Clinical manifestations/assessment
• Backache
• Porous and brittle bones
• Dowager’s hump
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Other Disorders of the
Musculoskeletal System
Other Disorders of the
Musculoskeletal System
• Osteoporosis (continued)
� Diagnostic tests
• CBC, serum calcium, phosphorus, alkaline
phosphatase, blood urea nitrogen, creatinine level,
urinalysis, liver and thyroid function tests
• Radiography studies
Slide 28Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Radiography studies
� Medical management/nursing interventions
• Pharmacological management
� Calcium supplements, vitamin D
� Estrogen, alendronate (Fosamax)
• Weight-bearing exercises
• Dietary recommendations
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Other Disorders of the
Musculoskeletal System
Other Disorders of the
Musculoskeletal System
• Osteomyelitis
� Etiology/pathophysiology
• Local or generalized infection of the bone and bone
marrow
• Staphylococci are the most common cause
• Introduced through trauma (injury or surgery) or via the
Slide 29Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Introduced through trauma (injury or surgery) or via the
bloodstream from another site in the body to the bone
• Bacteria invade the bone and degeneration of bone
occurs
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Other Disorders of the
Musculoskeletal System
Other Disorders of the
Musculoskeletal System
• Osteomyelitis (continued)
� Clinical manifestations/assessment
• Persistent, severe, and increasing bone pain
• Wound draining purulent fluid
• Signs and symptoms of infection: temperature,
tachycardia, and tachypnea
Slide 30Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
tachycardia, and tachypnea
• Edema of affected area
� Diagnostic tests
• Radiography studies; bone scan
• CBC; ESR; cultures of blood and drainage
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Other Disorders of the
Musculoskeletal System
Other Disorders of the
Musculoskeletal System
• Osteomyelitis (continued)
� Medical management/nursing interventions
• Pharmacological management
� Antibiotic therapy
• Surgery: removal of necrotic bone
Slide 31Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Absolute rest of affected extremity
• Wound care
� Irrigate with hydrogen peroxide or antibiotic solution;
cover with sterile dressing
• Drainage and secretion precautions
• Dietary recommendations: high in calories, protein, and
vitamins
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Other Disorders of the
Musculoskeletal System
Other Disorders of the
Musculoskeletal System
• Fibromyalgia syndrome (FMS)
� Etiology/pathophysiology
• Musculoskeletal chronic pain syndrome
• Unknown etiology
� Clinical manifestations/assessment
Slide 32Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Generalized aching
• Irritable bowel syndrome
• Tension headache
• Paresthesia of upper extremities
• Sensation of edematous hands
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Other Disorders of the
Musculoskeletal System
Other Disorders of the
Musculoskeletal System
• Fibromyalgia syndrome (FMS) (continued)
� Diagnostic tests
• No specific laboratory or radiographic tests diagnose
FMS
� Medical management/nursing interventions
• Pharmacological management
Slide 33Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Pharmacological management
� Tricyclic antidepressants
• Patient education and reassurance
• Exercise
• Relaxation techniques
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Surgical Interventions for Total
Knee or Total Hip Replacement
Surgical Interventions for Total
Knee or Total Hip Replacement
• Knee arthroplasty (total knee replacement)
� Replacement of the knee joint
� Restore motion of the joint, relieve pain, or correct
deformity
• Hip arthroplasty (total hip replacement)
Slide 34Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Hip arthroplasty (total hip replacement)
� Replacement of the hip joint
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Figure 44-11Figure 44-11
Slide 35Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
A, Tibial and femoral components of total knee prosthesis. B, Total knee
prosthesis in place.
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.)
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Figure 44-14Figure 44-14
Slide 36Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Hip arthroplasty (total hip replacement).
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Surgical Interventions for Total
Knee or Total Hip Replacement
Surgical Interventions for Total
Knee or Total Hip Replacement
• Arthroplasty
� Nursing interventions
• Intake and output
� Drainage from operative drains
� Oral and intravenous intake
Urinary output
Slide 37Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Urinary output
• Promote respiratory function
� Give oxygen 2 to 3 L/min
� Incentive spirometer; cough and deep-breathe
• Bed rest for 24 to 48 hours
• Change dressing as ordered
• Diet as ordered
• Neurovascular checks and vital signs every 4 hours
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Surgical Interventions for Total
Knee or Total Hip Replacement
Surgical Interventions for Total
Knee or Total Hip Replacement
• Arthroplasty (continued)
� Nursing interventions (continued)
• Physical therapy will initiate ambulation and prescribe
routine
• Antiembolisim stockings
• Avoid dislocation of prosthesis
Slide 38Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Avoid dislocation of prosthesis
� Avoid adduction and hyperflexion of hip
� Use toilet riser to prevent hyperflexion of hip
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FracturesFractures
• Fracture of the hip
� Etiology/pathophysiology
• Most common type of fracture
• Women at higher risk due to osteoporosis
• Types: intracapsular and extracapsular
Slide 39Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Clinical manifestations/assessment
• Severe pain at site
• Inability to move the leg voluntarily
• Shortening or external rotation of the leg
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Figure 44-16Figure 44-16
Slide 40Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Fractures of the hip.
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis:
Mosby.
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FracturesFractures
• Fracture of the hip (continued)
� Diagnostic tests
• Radiographic examination
• Hemoglobin
� Medical management/nursing interventions
Slide 41Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Buck’s or Russell’s traction until surgery
• Surgical repair
� Internal fixation
� Neufeld nail and screws, Kuntscher nail
� Prosthetic implants
o Austin Moore prosthesis, bipolar hip replacement
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FracturesFractures
• Fracture of the hip (continued)
� Medical management/nursing interventions
(continued)
• Postoperative interventions
� Wound and drain assessment
� Vital signs
Slide 42Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Vital signs
� Incentive spirometer and turning every 2 hours
� Antiembolic stockings; anticoagulation therapy
� Maintain leg abduction
� Limit weight-bearing on affected side
� Chairs and commode seats should be raised to prevent
flexion of hip beyond 60 degrees
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FracturesFractures
• Fracture of the hip (continued)
� Medical management/nursing interventions
(continued)
• Patient teaching for open reduction internal fixation
(ORIF)
� Assess ability to understand
Slide 43Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Assess ability to understand
� Assist to dangle at bedside
� No weight on operative side
� Turn every 2 hours, maintain abduction
� Physical therapy will instruct as to ambulation and
weight-bearing
� As patient progresses, encourage continuing ambulation
only with assistance
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FracturesFractures
• Fracture of the hip (continued)
� Medical management/nursing interventions
(continued)
• Patient teaching for hip prosthetic implant
� Avoid hip flexion beyond 60 degrees for approximately
10 days; beyond 90 degrees for 2 to 3 months
Slide 44Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
10 days; beyond 90 degrees for 2 to 3 months
� Avoid adduction of the affected leg beyond midline for
2 to 3 months (maintain abduction)
� Maintain partial weight-bearing for approximately 2 to
3 months
� Avoid positioning on the operative side
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FracturesFractures
• Other fractures
� Etiology/pathophysiology
• A traumatic injury to a bone in which the continuity of
the tissue of the bone is broken
• Pathological or spontaneous fractures
• Types of fractures: open, closed, greenstick, complete,
Slide 45Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Types of fractures: open, closed, greenstick, complete,
comminuted, impacted, transverse, oblique, spiral,
Colle’s, and Pott’s
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FracturesFractures
• Other fractures (continued)
� Clinical manifestations/assessment
• Pain
• Loss of normal function
• Obvious deformity
• Change in the curvature or length of bone
Slide 46Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Change in the curvature or length of bone
• Crepitus (grating sound with movement)
• Soft tissue edema
• Warmth over injured area
• Ecchymosis of skin surrounding injured area
• Loss of sensation distal to injury
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FracturesFractures
• Other fractures (continued)� Diagnostic tests
• Radiographic examination
� Medical management/nursing interventions
• Splinting to prevent edema
• Body alignment
Slide 47Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Body alignment
• Elevation of body part
• Application of cold packs, first 24 hours
• Administration of analgesics
• Assess for change in color, sensation, or temperature
• Observe for signs of shock
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FracturesFractures
• Other fractures (continued)� Medical management/nursing interventions
(continued)
• Closed (simple)
� Closed reduction; immobilization; traction
� Open reduction with internal fixation device
Slide 48Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Open reduction with internal fixation device
• Open (compound)
� Surgical debridement and culture of wound
� Administration of tetanus toxoid
� Observation for signs of infection
� Closure of wound
� Reduction and immobilization of fracture
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FracturesFractures
• Fracture of the vertebrae
� Etiology/pathophysiology
• Diving accidents
• Blows to the head or body
• Osteoporosis
• Metastatic cancer
Slide 49Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Metastatic cancer
• Motorcycle and car accidents
• Displaced fracture may place pressure on or sever the
spinal cord nerves
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FracturesFractures
• Fracture of the vertebrae (continued)
� Clinical manifestations/assessment
• Pain at site of injury
• Partial or complete loss of mobility or sensation
• Evidence of fracture/fracture dislocation on x-ray
Medical management/nursing interventions
Slide 50Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Medical management/nursing interventions
• Stable injuries
� Pain medication, muscle relaxants
� Back support, brace, or cast
• Unstable fractures
� Traction, open reduction
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FracturesFractures
• Fracture of the pelvis
� Etiology/pathophysiology
• Falls, automobile accidents, crushing accidents
� Clinical manifestations/assessment
• Unable to bear weight without discomfort
• Pelvic tenderness and edema
Slide 51Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Pelvic tenderness and edema
• Signs of shock
� Medical management/nursing interventions
• Bed rest—More severe fractures may require surgery
and/or spica or body cast
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Complications of FracturesComplications of Fractures
• Compartment syndrome
� Cause
• Progressive development of arterial vessel compression
and reduced blood supply to an extremity
� Clinical manifestations/assessment
Slide 52Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Sharp pain with movement, numbness or tingling in the
affected extremity, cool and pale or cyanotic, slow
capillary refill
� Medical management/nursing interventions
• Fasciotomy (incision into the fascia)
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Figure 44-26Figure 44-26
Slide 53Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Compartment syndrome.
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
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Complications of FracturesComplications of Fractures
• Shock
� Cause
• Blood loss, pain, fear
� Clinical manifestations/assessment
• Altered level of consciousness, restlessness
Slide 54Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Hypotension, tachycardia, and tachypnea
• Pale, cool, moist skin
� Medical management/nursing interventions
• Restore blood volume; shock trousers
• Oxygen
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Complications of FracturesComplications of Fractures
• Fat embolism
� Cause
• Embolization of fat tissue with platelets
� Clinical manifestations/assessment
• Irritability, restlessness,disorientation, stupor, coma,
chest pain, and dyspnea
Slide 55Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
chest pain, and dyspnea
� Medical management/nursing interventions
• IV fluids
• Steroids, digoxin
• Oxygen
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Complications of FracturesComplications of Fractures
• Gas gangrene
� Cause
• Infection of skeletal muscle by Clostridium
� Clinical manifestations/assessment
• Pain at site of injury
Slide 56Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Signs of infection; gas bubbles under the skin
• Necrotic skin at site; foul odor from wound
� Medical management/nursing interventions
• Excision of gangrenous tissue
• Antibiotics; strict aseptic technique
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Complications of FracturesComplications of Fractures
• Thromboembolus
� Cause
• Blood vessel is occluded by an embolus
� Clinical manifestations/assessment
• Area tingles and is cold, numb, and cyanotic
Slide 57Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Pulmonary embolus causes a sharp thoracic pain
� Medical management/nursing interventions
• Anticoagulants
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Complications of FracturesComplications of Fractures
• Delayed fracture healing
� Healing is delayed but will eventually occur
• Nonunion
� The ends of the fracture fail to stabilize and heal after
6 to 9 months
Slide 58Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
6 to 9 months
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Skeletal Fixation DevicesSkeletal Fixation Devices
• External fixation devices
� Skeletal pin external fixation
• Immobilizes fractures by the use of pins inserted
through the bone and attached to a rigid external metal
frame
• Casts/cast brace
Slide 59Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Casts/cast brace
� Made of layers of plaster of Paris, fiberglass, or plastic
roller bandages
� Stockinette applied, then a sheet of wadding, and
casting material
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Nonsurgical Interventions for
Musculoskeletal Disorders
Nonsurgical Interventions for
Musculoskeletal Disorders
• Traction
� The process of putting an extremity, bone, or group of
muscles under tension by means of weights and
pulleys to:
• Align and stabilize a fracture site
• Relieve pressure on nerves
Slide 60Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Relieve pressure on nerves
• Maintain correct positioning
• Prevent deformities
• Relieve muscle spasms
� Skeletal or skin
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Traumatic InjuriesTraumatic Injuries
• Contusion: A blow or blunt force that causes local
bleeding under the skin
• Sprains: Wrenching or hyperextension of a joint
• Whiplash: Injury at cervical spine caused by
hyperextension
Slide 61Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
hyperextension
• Strains: Microscopic muscle tears as a result of
overstretching muscles and tendons
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Traumatic InjuriesTraumatic Injuries
• Contusions, sprains, whiplash, strains
� Medical management/nursing interventions
• Elevate injured area
• Cold compresses for 15 to 20 minutes intermittently for
12 to 36 hours
• Warm compresses for 15 to 30 minutes four times a
Slide 62Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Warm compresses for 15 to 30 minutes four times a
day after 24 hours
• Compressive dressings and/or splint
• Surgery
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Traumatic InjuriesTraumatic Injuries
• Dislocations
� Etiology/pathophysiology
• Temporary displacement of bones from their normal
position
� Clinical manifestations/assessment
• Erythema; discoloration
Slide 63Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Erythema; discoloration
• Edema
• Pain
• Limitation of movement
• Deformity or shortening of the extremity
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Traumatic InjuriesTraumatic Injuries
• Dislocations (continued)
� Medical management/nursing interventions
• Closed reduction
• Open reduction
• Cold compresses first 24 hours and warm compresses
after 24 hours
Slide 64Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
after 24 hours
• Elevate injured extremity
• Elastic bandage
• Immobilize
• Analgesics
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Traumatic InjuriesTraumatic Injuries
• Carpal tunnel syndrome
� Etiology/pathophysiology
• Compression of the median nerve between the carpal
ligament and other structures
• Predisposing factors
Obese, middle-aged women
Slide 65Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Obese, middle-aged women
� Employment in occupations involving repetitious motions
of the fingers and hands
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Figure 44-38Figure 44-38
Slide 66Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
A, Wrist structures involved in carpal tunnel syndrome. B,
Decompression of median nerve.
(From Thompson, J.M., et al. [2002]. Mosby’s clinical nursing. [5th ed.]. St. Louis: Mosby.)
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Traumatic InjuriesTraumatic Injuries
• Carpal tunnel syndrome (continued)
� Clinical manifestations/assessment
• Paresthesia
• Hypoesthesia
• Burning pain or tingling in the hands
Slide 67Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Inability to grasp or hold small objects
• Edema of the hand, wrist, or fingers
• Muscle atrophy
• Depressed appearance at the base of the thumb on the
palmar side
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Traumatic InjuriesTraumatic Injuries
• Carpal tunnel syndrome (continued)
� Diagnostic tests
• Physical exam—Tinel’s sign
• Electromyogram
• MRI
Slide 68Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Medical management/nursing interventions
• Immobilizer
• Elevate extremity
• ROM exercises
• Hydrocortisone injections
• Surgery
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Traumatic InjuriesTraumatic Injuries
• Herniation of intervertebral disk
� Etiology/pathophysiology
• Rupture of the fibrocartilage surrounding an
intervertebral disk, releasing the nucleus pulposus that
cushions the vertebrae above and below
• Lumbar and cervical herniations are most common
Slide 69Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Lumbar and cervical herniations are most common
• May occur from lifting, twisting, trauma, or degenerative
changes
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Figure 44-39Figure 44-39
Slide 70Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Sagittal section of vertebrae showing both normal and herniated
disks.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Traumatic InjuriesTraumatic Injuries
• Herniation of intervertebral disk (continued)
� Clinical manifestations/assessment
• Lumbar
� Low back pain that radiates over the buttock and
numbness and tingling in affected leg
• Cervical
Slide 71Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Cervical
� Neck pain, headache, and neck rigidity
� Diagnostic tests
• CAT scan, myelography, and electromyelography
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Traumatic InjuriesTraumatic Injuries
• Herniation of intervertebral disk (continued)
� Medical management/nursing interventions
• Pharmacological management
� Analgesics
� Muscle relaxants
• Bed rest
Slide 72Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Bed rest
• Physical therapy
• Traction
• Surgery
� Laminectomy, spinal fusion, diskectomy,
chemonucleolysis
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TumorsTumors
• Tumors of the bone
� Etiology/pathophysiology
• May be primary or secondary
• Benign or malignant
• Osteogenic sarcoma
Slide 73Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Osteochondroma
� Clinical manifestations/assessment
• Spontaneous fractures
• Anemia
• Pain especially with weight-bearing
• Edema and discoloration of skin at site
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TumorsTumors
• Tumors of the bone (continued)
� Diagnostic tests
• Radiography studies
• Bone scan; bone biopsy
• CBC; platelet count; serum protein levels
Slide 74Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Serum alkaline phosphatase level
� Medical management/nursing interventions
• Surgery
• Chemotherapy and radiation
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AmputationAmputation
• Amputation of a portion of or an entire extremity
� Malignant tumors, injuries, impaired circulation,
congenital deformities, infections
• Postoperative nursing interventions
� Raise foot of bed to elevate extremity
Slide 75Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Encourage movement
� Place in prone position at least two times a day
� Teach strengthening exercises
� Elastic wraps to shape residual extremity
� Assess for respiratory complications
� Phantom-limb pain is normal
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Figure 44-40Figure 44-40
Slide 76Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Correct method of bandaging amputation stump.
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
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Nursing ProcessNursing Process
• Assessment
� Scoliosis
• Lateral curvature of the spine
� Kyphosis
• A rounding of the thoracic spine
Slide 77Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
• Hump-backed appearance
� Lordosis
• An increase in the curve at the lumbar region
� Blanching test
• Capillary nail refill
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Nursing ProcessNursing Process
• Nursing diagnoses
� Mobility, impaired physical
� Mobility, impaired bed
� Coping, ineffective
� Anxiety
Slide 78Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
� Anxiety
� Pain
� Knowledge, deficient