Jaw disorder

7/26/2019 Jaw disorder

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Pagets Disease (Osteitis Deformans) Excess of bone destruction & unorganized

bone formation and repair. The 2ndmost

common bone disorder in the .!.

The etio"og# is un$no%n

sua""# affects the axia" s$e"eton 'ertebrae

and s$u"" a"though the pe"'is tibia femur are

the other common sites of disease.

ost persons are as#mptomatic & diagnosis is

incidenta".


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Pagets Disease (Osteitis Deformans)

ascu"arit# is increased in affected portions of thes$e"eton. *esions ma# occur in one or more bonesdoes not spread from bone to bone.

Deformities & bon# en"argement often occur.

+o%ing of the "imbs & spina" cur'ature in persons%ith ad'anced disease.

+one pain, is the most common s#mptom. -s isusua""# %orse %ith ambu"ation or acti'it# but ma#

a"so occur at rest. -n'o"'ed bones ma# fee" spong#& %arm because of increased 'ascu"arit#.

!$u"" pain is usua""# accompanied %ith headache%armth tenderness & en"argement of the head.


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Pagets Disease (Osteitis Deformans

Patho"ogic fractures, because of the increased'ascu"arit# of the in'o"'ed bone,b"eeding is a

potentia" danger.

"$a"ine phosphatase "e'e"s, mar$ed"# e"e'atedas the resu"t of osteob"ast acti'it#.

!erum ca"cium are norma" except %ith

genera"ized disease or immobi"ization. /out and h#perurecemia ma# de'e"op as a

resu"t of increased bone acti'it# %hich causes an

increase in nuc"eic acid catabo"ism.


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Pagets Disease (Osteitis Deformans

0adiograph re'ea"s radio"ucent areas in the bone

t#pica" of increased bone resorption. Deformities &

fractures ma# a"so be present.

/oa"s of the treatment, to re"ie'e pain & pre'ent

fracture & deformities. Pharmaco"ogic agents are used to suppress osteoc"astic

acti'it#. +isphosphonates & ca"citonin are effecti'e

agents to decrease bone pain & bone %armth & a"so

re"ie'e neura" decompression 1oint pain & "#tic "esions.

se of ana"gesics & !-Ds. ssisti'e de'ices

inc"uding cane %a"$er.


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Pagets Disease (Osteitis Deformans Deformities ma# be corrected b# surgica" inter'ention

(osteotom#). O0-3 ma# be necessar# for fractures. The patient ma# benefit from a PT referra". *oca"

app"ication of ice or heat ma# he"p a""e'iate pain.

regu"ar exercise shou"d be maintained4 %a"$ing isbest. 'oid extended periods of immobi"it# to a'oid

h#perca"cemia.

nutritiona""# ade5uate diet is recommended.

ssistance in "earning to use canes or other ambu"ator#aids.

The rthritis 3oundation & Paget 3oundation are

usefu" resources for patients & their fami"ies.


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Osteomyelitis -nfection of the bone most often of the cortex

or medu""ar# portion. -s is common"# caused

b# bacteria fungi parasites & 'iruses.

6"assified b# mode of entr#, 6ontiguous or

exogenousis caused b# a pathogen from

outside the bod# or the b# the spread of

infection from ad1acent soft tissues. The

organism is !taph aureus. Examp"e, pathogensfrom open fracture. The onset is insidious7

initia""# ce""u"ites progressing ti under"#ing

bone.


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Osteomyelitis 8ematogenous, caused b# b"oodbornepathogens originating from infectious sites%ithin the bod#.Ex7 sinus ear denta"respirator# & / infections. The infection

spreads from the bone to the soft tissues & cane'entua""# brea$ through the s$in becoming adraining fistu"a. gain !taph aureus is themost common causati'e organism.

cute Osteom#e"itis "eft untreated orunreso"'ed after 9: da#s is considered chronic.ecrotic bone is the distinguishing feature ofchronic osteom#e"itis.


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Osteomyelitis

The pathoph#sio"og# is simi"ar to that infectious

processes in an# other bod# tissue.

+one inf"ammation is mar$ed b# edema

increased 'ascu"arit# & "eu$oc#te acti'it#.

The patient report fe'er ma"aise anorexia &

headache. The affected bod# ma# be

er#thematous tender & edematous. There ma#

be fistu"a draining puru"ent materia".

+"ood test, increase ;+6s E!0 & 6,protein

"e'e"s.


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Osteomyelitis

Treatment is difficu"t & cost"#. The goa" are comp"ete

remo'a" of dead bone & affected soft tissue contro" of

infection & e"imination of dead space (after remo'a" of

necrotic bone).

The nursing management,use of aseptic techni5ueduring dressing changes. Obser'ed for !

infection & administered antibiotic on time.

0O exercises are encouraged to pre'ent contractures

& f"exion deformities & participation in D* to the

fu""est extent is encouraged.


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Tumor of the MSS !! constitute => of a"" ma"ignant tumors.

a"ignant tends to cause more bone

destruction in'asion of the surrounding

tissues & metastasis.

+enign tumors, tend to be "ess destructi'e to

norma" bone.

The cause of bone tumors is un$no%n. The tumor is defined as a ne% gro%th or

h#perp"asia of ce""s. This gro%th is in

response to inf"ammation or trauma.


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Tumor of the MSS Osteosarcoma, ma"ignant tumor originating

from osteob"ast (bone,forming ce""s). Occurs t%ice asfre5uent"# in ma"es as in fema"es.

sua""# "ocated at the end of the "ong bones(metaph#sis). ost fre5uent"# seen at the dista" end

of the femur or the proxima" end of the tibia. *ungs a common site of metastasis.

Pain and s%e""ing at the site & "imitation ofmo'ement.

+one biops# is used to confirm the diagnosis.

?,ra# fi"ms 6T scans 0- & bone scans sho%tumor "ocation & size.

8istorica""# the treatment of choice is amputation.


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Tumor of the MSS Ewings sarcoma, ma"ignant tumor of thebone originating from m#e"ob"asts %ith ear"#metastases to "ung "#mph nodes & other bones.

sua""# "ocated on the shaft of the "ong bones.

3emur tibia & humerus are common sites.

Poor prognosis. 6ommon in person@ A: #ears o"d.

ffect ma"es more than fema"es.

Pain increased %ith %eight bearing. a# comp"ain

of %eight "oss ma"aise or anorexia. 6auses patho"ogic fractures.

Treatment7 Pa""iati'e radiation chemotherap#.


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Tumor of the MSS Chondrosarcoma, sua""# affects personsB:,C: #ears o"d. ccounts for 2:> of a"" bonetumors

ffect ma"es than fema"es.

!"o% gro%ing insidious onset. ost common inhumerus femur pe"'is.

*oca"ized pain s%e""ing. a# ha'e pa"pab"e

mass. !e'ere persistent pain. a# infi"trate1oint space & soft tissue & metastasize to the"ungs.

Treatment7 !urgica" incision amputation.


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Tumor of the MSS Fibrosarcoma, sua""# affects persons =:,

B: #ears o"d. ffects fema"es than ma"es.

Occurs in bon# fibrous tissue of femur & tibia.

ccounts for A> of primar# ma"ignant bone

tumors.

a# resu"t from radiation therap# pagets

disease or chronic osteom#e"itis.

ight pain s%e""ing possib"e pa"pab"e mass.

a# cause patho"ogic fractures.

a# metastasize to the "ungs.


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Fractures brea$ in the continuit# of bone caused b# trauma

t%isting or as a resu"t of bone deca"cification. 0esu"ts%hen the bone is unab"e to absorb the stress. 0esu"tof an accident or in1ur# stress fracture occur as aresu"t of norma" acti'it# or after minima" in1ur#.

Causes of Fracture7 3atigue, musc"es are "esssupporti'e to bone therefore cant absorb the forcebeing exerted. +one neop"asms, ce""u"arpro"iferations of ma"ignant ce""s rep"ace norma"

tissue causing %ea$ened bone. etabo"ic disorders,poor minera" absorption & hormona" changesdecreases bone ca"cification %hich resu"ts in a%ea$ened bone. +edrestor disuse, atropic musc"es

& osteoporosis causes decreased stress resistance.


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Fractures (types) /reenstic$, crac$4 bending of a bone %ith incomp"ete

fracture. On"# affects one side of the periosteum.6ommon in s$u"" fractures or in #oung chi"dren %hen

bones are p"iab"e.

6omminuted7+one comp"ete"# bro$en in a trans'erse

spira" or ob"i5ue direction ( indicates the direction of

the fracture in re"ation to the "ong axis of the fracture

bone). +one bro$en into se'era" fragments.

Open or compound7 +one is exposed to the air throughbrea$ in the s$in. 6an be associated %ith soft tissue

in1ur#. -nfection is common comp"ication due to

exposure to bacteria" in'asion.


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Fractures (types) 6"osed or simp"e7 !$in remains intact. 6hances are

great"# decreased for infection. 6ompression7 3re5uent"# seen %ith 'ertebra"

fractures. +one has been compressed b# other bones.

6omp"ete7 +one is bro$en %ith disruption of both

sides of the periosteum. -mpacted7 one part of fractured bone is dri'en into

another.

Depressed7 sua""# seen in s$u"" or facia" fractures.+one or fragments of bone are dri'en in%ard.

Patho"ogica"7 brea$ caused b# disease process.

-ntracapsu"ar7+one bro$en inside the 1oint.

Extracapsu"ar7 3racture outside the 1oint.


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Fractures (stages of bone healing) Occurs o'er se'era" %ee$s

e% bone tissue occurs in region of brea$

0epair is initiated b# migration of b"ood 'esse"sand connecti'e tissue from periosteum in brea$

area. Dense fibrous tissue fi""s from periosteum in

brea$ area. Osteob"ast near the bro$en area.

6hondrob"ast further a%a# from bro$en area. 6e""s deposit carti"age bet%een bro$en surfaces

6arti"age is s"o%"# rep"aced b# minera"ized bonetissue %hich comp"etes repair.


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Fractures (signs & symptoms)

Pain or tenderness o'er in'o"'ed area. *oss of function of the extremit#

6repitation7 sound of grating bone fragments

Ecch#mosis or er#thema Edema

usc"e spasm

Deformit#7 O'erriding4 ngu"ation, "imb is in

unnatura" position.


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Fractures (Emergency care) -mmobi"ize affected extremit# to pre'ent further

damage to soft tissue or ner'e. -f compound fracture is e'ident dont attempt to reduce

it. pp"# sp"int. 6o'er open %ound %ith steri"e dressing.

se sp"int7 Externa" support is app"ied around a

fracture area to immobi"ize the bro$en ends. ateria"used7 %ood p"astic (air sp"ints) magazines.

3unction of the sp"inting7 Pre'ent additiona" traumareduce pain decrease musc"e spasm "imit mo'ementpre'ent comp"ications such as fat embo"i if "ong bonefracture.

Pro'ide specific care for fracture treatment7 tractioncast. !urgica" inter'ention.


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Traction 3orce app"ied in t%o directions to reduce and< or

immobi"ize a fracture to pro'ide proper bonea"ignment and regain norma" "ength or toreduce musc"e spasm.

Closed reduction7 anua" manipu"ation.sua""# done under anesthesia to reduce pain &re"ax musc"es thereb# pre'enting comp"ications.6ast is usua""# app"ied fo""o%ing c"osed

reduction. Open reduction7 !urgica" inter'ention.

sua""# treated %ith interna" fixation de'ices

(scre%s p"ates %ires). 6ast app"ication.


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Traction Skeletal Traction7 echanica" app"ied to bone

using pins (!teinmann) %ires (irscher) or tongs(6rutchfie"d). ost often used in fractures of femurtibia humerus.

Skin traction7 app"ied b# use of e"astic bandages

mo"es$in strips or adhesi'e. sed most often ina"ignment or "engthening (for congenita" hipdisp"acement) or to re"ie'e musc"e spasms in preop hipc"ients. ost common t#pes are7 0usse"" +uc$s

6er'ica"(used for %hip"ashes & cer'ica" spasm) ,pu"" isexerted on one p"ane & used for temporar#immobi"ization4 Pe"'ic traction(used for "o% bac$pain).


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Traction(Principles) The "ine of pu"" must be maintained. 6enter the

patient in the bed & p"ace in good a"ignment.

The pu"" of traction must be continuous.

0emo'e or add %eights on"# %ith D order.

The ropes & %eights must be free of friction.

+e certain the %eights hangs free at a"" times &

that the ropes are o'er the center of the pu""e#.

There must be sufficient countertraction

maintained at a"" times. eep the patient from

s"iding to the foot of the bed.


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Cast Care fter app"ication of cast a""o% 2A to A hours for dr#ing. 3or

s#nthetic cast a""o% =: minutes

6ast %i"" change from du"" to shin# substance %hen dr#. Dont hand"e cast during d#ing process because indentation

from fingermar$s can cause s$in brea$do%n under cast.

eep extremit# e"e'ated to pre'ent edema.

Pro'ide for smooth edges surrounding cast. !mooth edgespre'ent crumb"ing and brea$ing do%n of edges. !toc$inet canbe pu""ed o'er edge & fastened do%n %ith adhesi'e tape tooutside of cast.

Obser'e casted extremit# for signs of circu"ator# impairment.6ast ma# ha'e to be cut if edematous condition continues.

"%a#s obser'e for sign & s#mptoms of comp"ications7 pains%e""ing disco"aration ting"ing or numbness diminished or

absent pu"se para"#sis coo" to touch.


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Cast Care -f there is an open draining area on the affected

extremit# a %indo% (cut out portion of cast) can beuti"ized for obser'ation and


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Cast (complications) 0espirator# comp"ications7 ha'e c"ient cough & D+ 5

2 hours. Turn 5 2 hours if not contraindicated. Thrombus & embo"ic formation. pp"# !6D. !tart

anticoagu"ation therap# if needed. Obser'e for !

pu"monar# and


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Cast (complication) Pre'ent constipation7 Encourage f"uids

Pro'ide high,fiber diet. dminister "axati'eor enema as ordered.

Pro'ide ps#cho"ogica" support7 ""o% to

'enti"ate fee"ings of dependence. Encourageindependence %hen possib"e. Encourage

'isitors for short time periods. Pro'ide

di'ersionar# acti'ities.


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Fractures (Complications) 6ompartment !#ndrome7 n increase in the pressure

%ithin the a fascia" musc"e compartment Tissue damage can occur %ithin =: minutes &

e"e'ated pressure for more than A hours can resu"t inirre'ersib"e damage & "imb "oss.

!igns & s#mptoms7 F Ps. Pain,se'ere unre"entingunre"ie'ed b# ana"gesia & increased b# e"e'ation ofthe extremit#. Pa""or, coo"ness s"o% capi""ar# refi"".Pu"se"essness,diminished or absent pu"ses. -ncreasepressure and paresthesia & para"#sis.

/oa"s of treatment7 decreasing tissue pressurerestoring b"ood f"o% & preser'ing function of the"imb.

Diagnosis7 -ntracompartment pressure @ =: mm hg.


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Fractures (Complications)

Treatment7 3asciotom#,open the affected

compartment, decrease the pressure & restore normalperfusion. The wound is covered with wet saline

dressing.

Fat embolism syndrome (FES)fat globules &tissue thromboplastin are released from the bone marrow.

The fat molecules enter the venous circulation, travel to

the lungs & embolize the small capillaries & arterioles.

S/S: hypoxemia, tachypnea, fever, chest pain alteredmental status.The presence of unexplained fever,

accompanied by a change in mental status & petechiae,

shld. lert the caregiver to the possibility of !"S. The

#$ shld. %e notified immediately.


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Fractures (Complications) -nfection7 "eading cause of de"a#ed union &

nonunion occurs primari"# in open orcompound fractures. The most s#mptoms

occur %ithin A %ee$s of the in1ur#.

!


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!"P fractures 8igh incidence in e"der"# group,most common cause

of traumatic death after age CB. 3ractures caused b# britt"e bones (osteoporosis) C

fre5uent fa""s in the e"der"#.

E"der"# %ith hip fractures fre5uent"# ha'e associated

medica" conditions (6D rena" disorders).

ssessment7 Intracapsular,bone bro$en inside the1oint,treated b# interna" fixation,rep"acement of

femora" head %ith ustin oore prosthesis. P"aced in s$in traction first for immobi"ization &

re"ief of musc"e spasm.


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!"P fractures Etracapsular7 trochanteric fracture outside the

1oint. 6an be treated b# ba"anced suspension traction. 3u""

%eight,bearing usua""# in F to %ee$s %hen hea"ingta$es p"ace.

!urger#7 usua""# interna" fixation %ith %ire.

Intertrochanteric fracture7 extends frommedia" region of the 1unction of the nec$ & "essertrochanter to%ard the summit of the greatertrochanter. Treated initia""# %ith ba"anced suspensiontraction. -nterna" fixation used %ith nai"p"ate scre%s& %ire. ot a""o%ed to f"ex hip to the side on the sideof the bed or in a "o% chair. ;hen hip is f"exed

disp"acement can occur.

l hi l


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Total hip replacement 0ep"acement of both the acetabu"um & the head of

the femur %ith meta" or p"astic imp"ants. sed in degenerati'e diseases or %hen fracture of the

head of femur has occurred %ith nonunion.

To pre'ent f"exion $eep operati'e "eg in abduction b#use of pi""o% or abductor sp"ints.

eep hemo'ac in p"ace unti" drainage has subsided

(2A to GF hours).

Pre'ent edema7 read1ust !6D at "east e'er# A to

hours.

Pre'ent infections, monitor proph#"actic antibiotic.

f


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!"P fractures

6ontinuous passi'e motion (6P) first da#

postop %ith increasing degree of f"exion to G:degrees.

mbu"ate c"ient carefu""# at bedside,first orsecond da#. Dont a""o% to bear %eight onaffected hip. p %ith %a"$er 2ndpost.op da#.

Pre'ent thrombus formation from 'enousstasis,promote "eg exercises,f"exing feet &an$"es.

!tart ph#sica" therap# asap. -nstruct not to use "o% chairs or sit on edge of

bed. se commode extenders high stoo"s no

bending o'er acti'ities.

!"P f t


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!"P fractures

Obser'e for neuro'ascu"ar prob"ems in

affected "eg7 6o"or and temperature edema in"eg pain on passi'e f"exion of foot numbness,

abi"it# to mo'e "eg peda" pu"ses & capi""ar#

refi"".

T t l ! " l t


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Total !nee "eplacement -mp"antation of a meta""ic upper portion that

substitutes for the femora" cond#"es & a highpo"#mer p"astic "o%er portion that substitutes

for the tibia" 1oint surfaces.

6ontinuous passi'e motion(6P) ma# beordered postop.,moderate f"exion & extension,

increase circu"ation & mo'ement.

Perform 5uad,setting & straight,"eg raisingexercises e'er# hour.

Perform 0O.

Do not dang"e to pre'ent disc"ocation.

Total !nee


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Total !nee"eplacement 8emo'ac is inserted to drain excessi'e

b"ood and drainage. aintain accurate

-


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#mputations The surgica" remo'a" of a "imb a part of a

"imb or a portion of a bone e"se%here than at

the 1oint site.

0emo'a" of a bone at the 1oint site is termed

disarticu"ation.

ore than 99:::: are performed each #ear in

the .!. & G9> of them are "o%er extremit#

amputations. Occurs in patients %ith diabetes 9B times more

fre5uent"# than in other patients %ith chronic

arteria" occ"usi'e disease.


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#mputations (types) +e"o% the nee (+)

bo'e the $nee ()

mputations of the foot and an$"es (s#mes)

mputation of the foot metatarsus and tarsus(he#s or "isfrancs)

8ip disarticu"ation,remo'a" of the "imb from

the hip 1oint. 8emicorporectom#, remo'a" of ha"f of the

bod# from the pe"'is and "umbar areas.

#mputations (#ssessment)


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#mputations (#ssessment)

E'a"uate dressing for signs of infection or

hemorrhage. Obser'e for signs of a de'e"oping necrosis or

neuroma in incision.

E'a"uate for phantom "imb pain. Obser'e for signs of contractures.

Pro'ide preop. nursing care management.

8a'e c"ient practice "ifting buttoc$s off bed%hi"e in sitting position. Pro'ide 0O tounaffected "eg. -nform about phantom "imbsensation, pain & fee"ing that amputated "eg

sti"" there4 caused b# ner'es in the stump.

# t ti


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#mputations Pro'ide post. Op. care. Obser'e stump dressing for

signs of hemorrhage & infection. Obser'e for s#mptoms of a de'e"oping necrosis or

neuroma in area of incision.

Pro'ide stump care7 re%rap ace bandage = to A times

dai"#. ;ash stump %ith mi"d soap & %ater. -f s$in is

dr# app"# "ano"in or 'ase"ine to stump.

Teaching re"ated stump care. +,dont hang stump

o'er edge of bed. Dont sit for a "ong periods of time. bo'e the $nee,pre'ent externa" or interna" rotation

of "imb. P"ace ro""ed to%e" a"ong outside of thigh to

pre'ent rotation.

#mputations


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#mputations Position in prone position to stretch f"exor musc"e & to pre'ent

f"exion contractures of hip. Done usua""# after first 2A to A

hours postop. P"ace pi""o% under abdomen C stump. eep "egsc"ose together to pre'ent abduction.

Teach crutch,%a"$ing and %hee"chair transfer.

Prepare stump for prosthesis. !tump must be conditioned for

proper fit. !hrin$ing & shaping stump to conica" form b#app"#ing bandages or an e"astic stump shrin$er. cast readiesstump for the prosthesis.

Pro'ide care for temporar# prosthesis %hich app"ied unti"stump has shrun$ to permanent state.

0ecognize & respond to c"ients ps#cho"ogica" reactions toamputation. 3ee"ings of "oss grie'ing "oss of independence"o%ered se"f,image depression.

6ontinue discussing phantom "imb pain %ith c"ient.

Jaw disorder

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