exam 3 Flashcards
Two Types of Bone Tissue
cancellous
corticol
Cancellous:
spongey bone found on interior of the bone. Lattice like pattern
Cortical:
outer shell of bone
Four Categories of Bones
long
short
flat
irregular
long bones
like the femur
short bones
like the metacarpals
flat bones
like the skapula or sternum
irregular bones
like the vertibrae
three bone cell types
osteoclasts
osteoblasts
osteocytes
osteoblasts
secretes matrix of bone formation
osteoclasts
break down bone
osteocytes
maintain function of the bone. a bone cell, formed when an osteoblast becomes embedded in the matrix it has secreted.
Bone Maintenance
process of remodeling and resorption (osteoclasts)
Remodeling
maintains bone structure: continuous process
Resorption
removes bone tissue
Hormones involved in bone system
calcitrol parathormone/calcitonin growth hormone thyroid hormone and cortisol estrogen
calcitrol
active form on vitamin D. Functions to increase amount of calcium to the blood from the GI tract. Facilitates bone mineralization.
parathormone/calcitonin
regulators of calcium homeostasis. Promotes movement of calcium from the bone. When there are low levels of Ca in the blood, there is an increased level of parathormone. Calcitonin increases deposit of calcium in the bone
Growth hormone
direct and indirect effects on skeletal growth and remodeling. Stimulates skeletal growth, especially in children.
Thyroid hormone and cortisol
Increases bone mass and mineralization
estrogen
stimulates osteoblasts and inhibits osteoclasts
six phases of bone healing page 1079 in book
- hematoma formation/inflammation
- fibrocartilage formation
- cartilage calcification
- cartilage removal
- bone formation
- remodeling
Three kinds of joints
synathrosis (immovable)-skull
amphiarthrosis (limited motion)-vertabrae
diarthrosis (freely movable)-hip/elbow
tendons
attach muscle to bone
ligaments
attach bone to bone
Types of musculoskeletal pain
Bone pain: boring pain Muscular pain: cramping Fracture pain: intense and sharp Sprain or strain: hurts with moving Radiating: hard to identify where it's coming from
Altered sensation
Parasthesia: pins and needles/numbness
Past, Family, and Social History
Past History: Broken bones Hx of musculoskeletal disease Family History: Limitations Musculoskeletal diseases Social History: Activity level of patient Exercises (frequently exercising, or new regimen) High-risk activities or sports
Physical Assessment Components
Posture
Gait: have them walk ahead of you and note changes
Bone integrity: xrays and alignment/symmatry
Joint function: passive and active range of motion
Muscle strength and size: assess bilaterally
Skin: look for breakdown, edema, turgor
Neurovascular status
Posture assessment
normal curvature is convex in thoracic and concave in other parts
kyphosis:
Hunchback
Scoliosis
crooked spine
lordosis
exaggerated curvature of the lumbar spine
Neurovascular status
capillary refill-less than 3 seconds
sensation-paresthesia, numbness, burning
ROM (passive and active)
symptoms of decreased neurovascular status
decreased ROM numbness cold extremity Compartment syndrome: swelling severe pain esp with passive movement
imaging options
xray
compound tomography
magnetic resonance imaging
arthography
xray
val for people with possible fracture. Shows texture and erosion. Widening or narrowing of bone. Any irregularities. Downside, multiples might be needed to assess the structure you’re looking at. Serial xrays to find degenerative diseases or healing of bone.
Compound Tomography
CT. Shows detail of specific plane of soft tissues. Can ID location and extent of fracture that’s difficult to evaluate
Magnetic resonance imaging:
MRI-magnetic field help us see abnormalities like tumors or tissues in bones. Soft tissues and bone
checklist to determine if there’s a metal implant.
Ink from tattoos might have an effect on MRI.
Arthrography:
in combo with CT or MRI. Finds acute or chronic tears and joints. Inject a contrast into the joint they want to look at, then perform range of motion. When there is a tear in the joint, contrast leaks out of the joint capsule. Metformin/kidney functions in high risk patients.
Bone Densitometry
xrays or ultrasound to find osteoporosis
Bone scan
detects metastasis or primary bone tumors (not common) Most often there is a malignancy elsewhere that metastasizes in the bone.
Isotope injected, scanned, and lights up where the tumors might be.
arthroscopy
Allows you to visualize joints.
arthroscope goes into the joint to find tears of tendons or ligaments
arthrocintesis
joint aspiration-removing fluid from a joint. Most likely has a joint effusion due to infection.
electromyography
EMG: gives us information on muscles and nerves. Assesses muscle weakness.
Can be painful
biopsy
determines structure and composition of marrow, bone, and muscle to diagnose specific diseases.
Blood tests related to musculature
CBC: Hgb level: especially in fracture cases WBC count: Coagulation studies: Serum calcium levels- Serum phosphorus levels- Vitamin D levels: Serum enzyme Serum myoglobin, Calcium in the urine:
CBC
common blood study (complete blood count): fractures cause a lot of blood loss
WBC
infection (osteomylitis or infection after surgery)
Coagulation studies
to be certain bleeding time (stop warfarin, aspirin, lovanox a week before surgery)
Serum calcium levels
inversely related to phosphorus
Serum phosphorus levels
dx parathyroid function. Acid phosphatase in paget’s disease or metastatic cancer.
Vitamin D levels
Assesses bone metabolism
Serum enzyme
levels of creatin kinase elevate with injury
Serum myoglobin
especially with severe muscle trauma
Calcium in the urine
bone destruction (breakdown of bone)
Aging on the Musculoskeletal System :
all affect ability to do ADLs. 40-1 on 1082
Effects on bone due to aging
- Gradual progressive loss of bone mass: reduced height, posture height, loss of flexibility, back pain, inflesion of hips and knees, decreased ROM.
- Bones fragile and prone to fracture: assess their activity levels. Light weight bearing and stretching to increase bone mass. fall prevention: hip and wrist
Effects on muscle due to aging
Diminish in size: atrophy. Decreased collagen
Loss of strength and flexibility: tendons become less elastic. Diminished agility. Decreased response time and loss of balance.
Effects on joints due to aging
Progressive cartilage deterioration: increased pain.
Stiffness, reduced flexibility and pain in joints.
Effects on ligaments due to aging
Lax ligaments
Weakness
Common reason for PCP visit
Caused by many musculoskeletal problems
Acute lumbosacral strain Unstable lumbosacral ligaments & weak muscles OA of the spine Spinal stenosis Intervertebral disk problems (herniated disk/bulging disk) Unequal leg length Osteoporosis Metastasis Obesity
Diagnostic Procedures for lower back pain
X-ray of spine
Bone scan & blood studies for presence of infection or biomarkers
CT, MRI, EMG
Pain associated to lower back pain
Radiating down the leg (radiculopathy)
Sciatica: low back down thigh then down below the knee. There is usually an impingement on the nerve.
Muscle spasm
Nursing Diagnosis related to lower back pain
Acute Pain
Activity Intolerance
Risk of falls
Ineffective coping
Outcomes related to nursing plans for lower back pain
Management of causes Body mechanics pain management: tens unit, massage, acupuncture, heat or ice, rest, inversion tables. Increased activity Decrease pain
Intervention plans around lower back pain
Weight loss: walking 30 minutes 3-4 times a week
Physical therapy: teaches the patient strengthening exersizes
Pain control (pharmacological and non-pharmacological)
Teach them how to properly get out of bed. (log roll then have them sit up with arms. Takes practice.)
After surgery, no twisting or 90 degree bending. Walking is best. might get a back brace.
Upper Extremity Problems
Bursitis and Tendinitis Carpal Tunnel Syndrome Impingement Syndrome Ganglion Dupuytren’s Disease
Bursa
little sack in the joint that is filled with fluid
Tendonitis
inflammation of the tendon
Treatments for burstitis and tendonitits
Rest
Ice and heat
NSAID’s: (nursing considerations GI bleeds and kidneys)
Arthroscopy if pain & weakness continue: synovectomy to remove the inflamed portion of the joint. Surgery doesn’t help.
Impingement Syndrome
Caused by overuse of shoulder. Untreated can cause a rotator cuff tear.
s/s of impingement syndrome
Pain
Shoulder tenderness
Limited movement and spasm
Atrophy
treatment of impingement syndrome
Rest NSAIDs Joint injections of corticosteroid Physical therapy Arthroscopic debridement to get impingement out of the joint.
Carpal Tunnel Syndrome
Neuropathy of median nerve in the wrist. Compressed by band that wraps around the nerve. Commonly caused by repetitive wrist movements.
Tinel’s sign:
purcuss on inner aspect of the wrist. Numbness/tingling=positive sign.
s/s of carpal tunnel syndrome
Pain
Numbness & paresthesias
Weakness along median nerve (thumb, index and middle fingers)
Treatment/Management of carpal tunnel syndrome
Wrist splints useful in preventing hyperextension. Decrease of repetitive motions. Yoga, acupuncture, OT NSAIDs and cortisone injections Surgery traditional open nerve release endoscopic nerve release Conservative first
Ganglion cyst
Collection of gelatinous material near tendon sheaths and joints.
May be asymptomatic
Occurring between the 2nd and 3rd decade of life
Treatment of ganglion
Aspiration Corticosteroid injection Surgical excision compression dressing immobilization splint
Dupuytren’s Disease
Slow, progressive contracture of palmar fascia.
Flexion of fourth and fifth fingers and sometimes the middle finger.
Treatment of dupuytren’s disease
Finger stretching to prevent contracture
Palmar and digital fasciotomies
dupuytren’s disease is caused by:
Autosomal recessive trait
Most frequently in men older than 50
Drug therapy for epilepsy, diabetes
Alcoholism
Common Foot Problems
Plantar Fasciitis
Bunion
diseases related to common foot problems
Diabetes
Peripheral vascular disease
Plantar Fasciitis
Inflammation of foot supporting fascia
Acute onset of heel pain r/t plantar fasciitis
First steps in the morning
Anterior medial aspect of heel
management of plantar fasciitis
Stretching exercises should help the pain. Long stretch of the calf muscle.
Supportive shoes and cushioning
Orthotic devices: spend the money on good shoes.
NSAIDs
Hallux Valgus (Bunion)
Great toe deviates laterally
risk factors for hallux valgus
Heredity
Ill-fitting shoes
Aging
Osteoarthritis
Treatment for hallux valgus
Depends on pt. age, severity of deformity, and severity of symptoms. If its not complicated, you can just get shoes… corticosteroid therapy, surgery.
Complications: limited ROM after surgery. Lots of pain post-op=pain medications initially. Elevate foot to level of the heart.
Toe flexion and extension after surgery.
Get proper shoes
Education for disease related foot problems
Peripheral neuropathy with decreased sensation Skin ulcers Education: don't clip your own nails assess feet every day
Nursing Interventions: Upper & Lower Extremity Conditions
Promote tissue perfusion relieve pain increase activity Prevent infection Promote home and community based care
Promoting tissue perfusion in the patient with upper/lower extremity conditions
Neurovascular assessment: circulation, sensation, movement every 1-2 hours post operatively.
Temperature, color, capillary refill, peripheral pulses
Pain management options
Pharmacologic (analgesics) vs nonpharmacologic methods (ice, tens unit, elevation, drinking uncontrollably)
Activity assistance in the patient with upper/lower extremity conditions
Assist with ADL’s following surgery and have them gradually increase activities on their own
What is the weight bearing status of the limb? Non weight bearing=no pressure at all. Time will vary and might change after the healing continues
Preventing infection in the patient with upper or lower extremity conditions
Dressing care, education on symptoms of infection s/s: warm/red/tender increased pain fever/chills
Osteoporosis Characteristics
Reduction of bone density and change in bone structure
- Bones become progressively porous, brittle, and fragile
- Fracture easily under stresses that would not break normal bone
- Fractures are often first manifestation of osteoporosis: hip and compression fractures in the spine. Wrists too.
Patho of osteoperosis
Increased bone breakdown
Decreased bone formation leads to porous, brittle bones that lead to fractures.
Reduced total bone mass
Manifestations of osteoperosis
- Kyphosis: result of the compression of vertebrae. -Abdominals begin to stick out and lead to pulmonary issues- fatigue r/t compression of the lungs if hunched over.
- Loss of height
- DEXA scan: used to diagnose osteoporosis. 2.5 SDs or more from the normal range is a diagnosis of osteoporosis. Measures the bone density that’s been lost.
Risk factors for osteoperosis
Genetics
Age: post menopause. Decreased calcitonin in men and women. Hormone replacement therapy is no longer first line defense
Nutrition: vitamin D and calcium. Inadequate calorie intake.
Physical Exercise: sedentary lifestyle with no weight bearing exercises. Bones need the stress of being active for remodeling.
Lifestyle Choices: caffeine and alcohol. Smoking. Lack of sunlight. all these reduce osteogenesis
Medications: corticosteroids can reduce bone mass. Anti seizure medication can inhibit calcium.
Comorbidity: anorexia, renal failure, parathyroid or thyroid issues.
Pharmacological therapy for osteoperosis
- Bisphosphates
- Calcitonin
Education r/t bisphosphates for osteoperosis
reduce spine and hip fractures by inhibiting osteoclast activity. Adequate vit D and calcium is needed for these medications to work. (fosomax with vit D or actinel with calcium) Could have GI adverse effects (nausea, flatulence/diarrhea, ulcer formation) take in the morning with an empty stomach with a full glass of water and then sit upright for 30-60 minutes after taking.
Education r/t calcitonin for osteoperosis
inhibits osteoclasts to reduce bone loss. increased activity of osteoblasts. Regulate calcium and increase absorption in the bone. Nasal spray (might cause nasal irritation or flushing of the face) or sub-q or IM injection. Can cause GI problems or urinary frequency.
Preventing injury for patients with osteoperosis
Regular weight bearing exercises-strengthen muscles and improves balance which decreases falls.
20-30 minutes of aerobic exercise like walking 3-4 days a week.
Fracture management for patients with osteoperosis
Conservative treatment or surgery Hip fractures: hip pinning. Compression fractures of the vertebrae: conservative treatment bone cement Fall prevention
Patient education r/t nutrition for osteperosis patients
- Calcium
- Vitamin D
From the book:
Three glasses of skim or whole vitamin D milk/calcium enriched orange juice/cheese and other dairy/steamed broccoli/canned salmon with the bones
1300 mg daily thru adolescence then 1000 mg a day in adulthood
Paget’s Disease
Pathophysiology
Proliferation of osteoclasts-primary=bone resorption.
localized, rapid bone turnover
Compensatory increase of osteoblasts
Blasts are more increased to compensate for the osteoclast overactivity
Results in disorganized bone
Manifestations of paget’s disease
Most patients never experience symptoms but have skeletal deformity
Skeletal deformity involves skull and long bones
Pain, tenderness, and warmth over bones
pain relief for paget’s disease
NSAIDs -monitor for GI adverse effects and kidney functions
Gait problems monitored with orthopedic devices and supportive devices
Education for those with paget’s disease
Adequate calcium and vitamin D
Maintain healthy weight to limit pressure on the bones
Pharmacologic therapy for Paget’s disease
Calcitonin
bisphosphates
cytotoxic antibiotics antineoplastic medications. Plicamyacin
Cytotoxic antibiotics for paget’s disease
can be used to help control paget’s. Reserved for people who are severely affected: thickened skulls causing nerual problems.
antineoplastic medications: Plicamyacin
bisphosphates
produce rapid reduction of bone turn over. Educate about GI side effects.
calcitonin
slows down the breakdown of bone. Gets everything at a more normal rate of adsorption and build up. decreases number of osteoclasts. Effect may not be evident until 3-6 months.
Osteomyelitis:
infection in the bone. Hard to treat because bone is not very vascular
Three ways bone can become infected
- Extension of soft tissue infection (infected pressure or vascular ulcer, incisional infection).
- Direct bone contamination from bone surgery, open fracture, or traumatic injury (gunshot wound): always considered contaminated. Risk is huge. Usually within 30 days after surgery.
- Hematogenous (bloodborne) spread form other sites of infection (infected tonsils, boils, infected teeth, upper respiratory infection)
Patients at risk for osteomyelitis
elderly
immunocompromised
corticosteroid therapy
disease or conditions that affect wound healing
Manifestations and Assessment of bloodborn osteomyelitis
Sudden onset
Clinical & lab manifestations resembling sepsis
high fever
rapid pulse
area of bone becomes tender and very painful with movement
Manifestations and assessment of acute osteomyelitis
Soft tissue swelling on x-ray
within 12 weeks: calcification
Leukocytosis and elevated ESR
Pain, but not as severe as blood borne.
Manifestations and assessment of chronic osteomyelitis
Large irregular cavities on bone from prolonged infection. Abscesses in the area as well.
Anemia associated with chronic infection
Development of abscess
Assessment of patient with osteomyelitis
Acute onset of s/s of localized pain, erythema, fever or recurrent drainage of an infected sinus tract with associated pain, edema, and low-grade fever
Physical exam: inflamed, edematous, warm, tender area with potential purulent drainage and elevated temperature
Diagnosis of patient with osteomyelitis
Acute pain Impaired physical mobility Risk for extension of infection Deficient knowledge Risk for falls Ineffective coping as a result of amputation
Planning for the patient with osteomyelitis
Pain relief,
improved physical mobility as soon as possible
control & eradication of infection
knowledge of treatment regimen
Long term antibiotics:
superinfections: c diff, yeast infections
Interventions for patients with osteomyelitis
Relieving pain -immobilize affected extremity -elevate to reduce the swelling -pain meds Improving physical mobility -there might be mobility restrictions (usually non weight bearing in the affected limb) -Use limbs that can be used. Controlling the infectious process -Treat with broad spectrum antibiotics have good coverage across wide variety of infections -Culture the infection to get a more specific antibiotic -Teach about superinfections Teaching patients self-care -Education about infusions -Monitor for healing -no increased pain -persistent fever -decreased pain and drainage, increased ROM are signs of healing.
Evaluation of patients with osteomyelitis
Experiences pain relief
- Reports decreased pain
- No tenderness at site & no discomfort with movement
Increases physical mobility
-Participates in ADL’s as much as possible
Shows absence of infection**most important.
- Takes antibiotics as prescribed
- Normal temperature
- Negative wound cultures
Adheres to therapeutic plan
- Takes medications as prescribed
- Wound care
- No recurrence of symptoms
Medical management of bone tumors
Primary bone tumor: goal is to destroy or remove the tumor in some way. Usually in benign bone tumors, you would just monitor them. Most common in teens.
Secondary bone tumor: patient has cancer that started some other place, so goal is palliative.
Nursing management for a patient with bone tumors
Patient education
- explain what the goals of treatment are
- explain any diagnostic tests that the patient will have.
Relieving pain
- bone tumors are very painful.
- analgesics/nonpharm treatment
Prevent pathologic fracture
-teach about fall prevention
Promote coping skills & self-care
- helps the patient and their family
- we want them to do as much as they can
Managing complications
Levels of amputation
Below-knee amputation (BKA)
Above-knee amputation (AKA)
Complications from amputations
- hemorrhage
- skin breakdown
- phantom limb pain
- contracture
phantom limb pain
some patients have no difficulty with this, but other patients have a hard time with it. Might feel like numbness, tingling, cramping
- medications might be used to help manage the pain
- acupuncture
- Do not “elevate” the amputated extremity (don’t elevate the nub)
contracture due to amputation
nurse should educate them to not sit for prolonged periods of time
after first 24 hours, reposition to laying prone
Management /interventions for new amputees
Promoting rehabilitation: the way they move is forever changed, get PT involved early, get prosthetics involved early. It might take time to find a prosthetic they like. Encourage them to do as many of their ADLs that they can do. Get family involved in encouraging them to move as much as possible.
Minimizing altered sensory perceptions
Helping achieve physical mobility
Total Hip Replacement
Surgical replacement of the hip joint with artificial prosthesis
Indications for total hip replacement
Indicated for OA, acetabular dysplasia, RA, AVN, traumatic injury (fracture)
Post-op hip precautions
elective will be weight bearing as tolerated.
Don’t bend past 90 degrees: raise toilet seat, pillows in chairs
No crossing legs when sitting
no internal rotating
Post-op knee replacements
Surgical replacement of the knee joint with artificial prosthesis
Indicated for pt. with severe pain and functional disabilities such as arthritis
Preop assessment for total joint replacements
respiratory, renal, history of DVT or increase risks: pts with varicose veins, neurovascular status
Pre-op interventions for total joint replacements
Cleanse skin before surgery to prevent infection
IV antibiotic right before surgery. At least two more doses post operatively.
Educate about mobility: educate them many times esp. before surgery before sedation or anesthesia
Positioning for total joint replacements
hip replacements: no bending past 90 degrees, don’t internally rotate, don’t cross midline
Knee replacement: no pillows under the knee.
Continuous passive motion device: some patients will have these while in bed. It extends and bends the knee for them while they are laying down.
Preventing infections in total joint replacements
Pre-op assessment for infections
Pre-op skin prep
Prophylactic antibiotics: once before and at least twice after
Intraoperative management for total joint replacements
Blood loss management
- Reinfusion devices
- Monitor EBL closely: estimated blood loss
Adherence to sterile procedures
-Prevent infection
Culture of joint during surgery
-May be helpful in identifying subsequent infections
Postoperative management for total joint replacements: repositioning
no pillows under knee if total knee replacement. If they want it elevated, slant the bed up. Teach about flexion and extension exercises. Teach about transferring
Postoperative management for total joint replacements: promoting ambulation
Get out of bed as soon as possible. Even just stand the day of surgery to know what it feels like to walk or stand with their new knee.
Postoperative management for total joint replacements: monitoring for complications/preventing DVT
DVT is a big complication (SED, Ted hose, foot flexion and extension) monitor drainage from surgical site, pressure ulcer precautions (especially on their heels), a vascular necrosis, heterotrophic _________
Postoperative management for total joint replacements: Monitoring Wound Drainage
we expect 200-500 mls of blood drainage in the first 24 hours. By 48 hours, that number significantly decreases. 50 Mls every 8 hours or less. More than that and you should tell the physician.
Postoperative management for total joint replacements: preventing infection
dressing changes, signs and symptoms of an infection. Home health may include physical therapy with a nurse who can change a dressing. The ones with total hip surgery are the ones who really need the extra help with dressing changes. Post op infection can occur 4-24 months after surgery.
Patients with a cast: quad setting exercises
position patient supine with leg extended. Instruct patient to push knee back onto the mattress by contracting the anterior thigh muscles. Encourage pt to hold the position for 5-10 seconds then relax. Repeat 10x
Patients with a cast: gluteal setting exercises
Position the patient supine with legs extended, if possible. Instruct the patient to contract the muscles of the buttocks. Encourage the patient to hold the contraction for 5-10 seconds then let them relax. Repeat 10x
Monitoring & Managing Potential Complications in patients with casts
- Compartment syndrome
- Pressure ulcers: pain and tightness in the affected area. Warmth over the area. Drainage might occur.
treatment: cut a window from the cast to release pressure - Disuse syndrome: when muscles are left inactive for a long period of time. Strengthening exercises of flexion and resistance
Patient teaching about casts from book
Cast care:
- move about as normal
- Use a sling if it’s on an upper extremity
- Perform Rx exercises regularly
- Don’t attempt to scratch the skin under the cast
- cushion he rough edges of the cast with tape
- Keep the cast dry, but don’t cover it with plastic or rubber because it causes condensation
- report persistant pain, swellng that doesn’t respond to elevation, changes in sensation, decreased ability to move exposed fingers or toes, changes in cap refill, skin color, and temperature.
- note odors around the cast, stained areas, warm spots, and pressure areas
- don’t try to fix a broken cast yourself
Cast materials
Fiberglass: lighter weight and water resistant
Plaster: can’t get this wet
Heterotropic Ossification
Abnormal formation of bone in response to trauma
Will resolve over time, but it might have to be excised
Management:
- Early mobilization
- NSAIDs
Internal Fixation Devices
Pain and decreased function indicate problem
Problems include mechanical failure, material failure (device ends up getting recalled then needs to be replaced), corrosion, allergic response to the metal of the implant
External Fixation Devices : considerations
Infection
- purulent drainage
- redness and warmth
- increased pain
Pin care
-to prevent infection. There will be physicians orders on it
Avascular Necrosis (AVN)
Occurs when bone loses blood supply
Common in femoral neck fractures and dislocation
Bone may collapse or reabsorb
Management:
Attempts to revitalize bone with bone grafts
Prosthetic replacement
Arthrodesis (joint fusion)
Disseminated Intravascular Coagulation (DIC)
Systemic disorder resulting in widespread hemorrhage
Manifestations:
- Unexpected bleeding after surgery particularly bleeding from mucus membranes, IV sites, GI tract
- Bleeding from mucous membranes, venipuncture sites and GI and urinary tracts
Management of DIC
Treatment discussed in Chapter 20
Watch for early signs of bleeding
Notify provider immediately
Venous Thromboembolism risk factors
Include Deep Vein Thrombosis and Pulmonary embolism
Risk factors
Bedrest/immobilization
Fractures of lower extremities or pelvis
Manifestations of thromboembolism
Vary with size and location of emboli
Most frequent are: sudden shortness of breath, restlessness, increased Respirations, tachycardia, chest pain, low grade fever in PE
Swelling, warmth, and pain in the affected extremity in a DVT
Management of thromboembolism
Preventions:
-foot flexion and extension
-Lovenox (don’t massage after administration, change sites, watch for signs of bleeding) or warfarin
compression devices (Ted hose, SEDs)
-Encourage them to get out of bed as much as possible and as soon as possible
-Incentive spirometer (10 times every hour)
Educate about not ambulating
Delayed union
Prolonged healing of fracture
usually in patients who smoke, have diabetes, or take long term corticosteroids
Malunion
Flawed allignment/union of fractured bone
Pt might have persistent pain at the fracture site with decreased ROM
Nonunion
Failure of fractured bone to unite in normal alignment
Nurse and physician can recognize discomfort/pain might be pointing to this or malunion (pain would be relieved with something, otherwise its compartment syndrome)
Treatment for nonunion
internal fixations with plates and pins and screws
bone grafts
electrical bone stimulation to help stimulate the bone to grow
Go back to being immobilized and non weight bearing to facilitate bone healing
Management of delayed union, malunion, or nonunion
- Avoid things that delay healing like NSAIDS, smoking, corticosteroids
- Assess risk factors for delayed healing
- Internal fixation, bone grafting, electrical bone stimulation, immobilization, non-weight bearing exericses
Management/prevention of fat embolism syndrome
- The sooner we recognize it, the better
- Immobilization
- early surgical fixation with minimal manipulation
- Adequate support during turning/positioning
- Maintenance of fluid and electrolyte balance
- *****Prompt respiratory support *priority measure. In acute respiratory distress, you administer O2 then call physician. Continuously monitor O2 saturation.
- Oxygen therapy, mechanical ventilation,
- IV corticosteroids for inflammation, vasopressor medications IV for prevention and treatment of shock and hypotension
- Fluid replacement therapy
Manifestations of a fat embolism
Change in behavior (disoriented and restless), disorientation, respiratory compromise are presenting features (tachypnia, hypoxia)
Hypoxia, axillary, subconjunctival or anterior chest wall petechiae, tachypnea, tachycardia and fever (> 39.5)
FIRST would be change of behavior and change in respiraty status
Fat embolism syndrome
Often in pts with pelvic, long bone, or particularly traumatic fractures
Fat globules released when bone fractures and act like a clot
Occlude small blood vessels
Rapid onset
24-72 hrs. after injury
Risk factors for fat embolism
Trauma, fracture of long bones or pelvic bones
Multiple fractures
Crush injuries
Young adults 20-30 years & elderly over 65 (usually result of a hip fracture)
Complications of Fractures
- Fat embolism syndrome
- Delayed union, malunion, & nonunion
- Venous thromboemboli
- Disseminated intravascular coagulation (DIC)
- Avascular necrosis (AVN)
- Reaction to devices
- Heterotropic ossification
Nursing Management of the Patient with a Fracture: varies with type of fracture
varies with type of fracture
presence of infection
Relieving pain from a fracture
- analgesics-opioids
- Cold or ice packs to the site
- sometimes muscle relaxants
- If pain doesn’t get better with meds=compartment syndrome
Improving mobility after fracture
might take several months to regain function and mobiliity
That limb may atrophy
Do full range of motion exercises to regain function. We want to facilitate them to do as much as they can while maintaining non weight bearing orders.
Focus on early mobility to ward off DVT
flexion and extension exercises every hour. Compression machines are ok, but they still need to do flexion and extension
Evaluating neurovascular status after a fracture
assess every hour for 8-12 hours or 24 hours if there’s a great need.. Assess every 4 hours after that.
Maintaining and Restoring Function after fracture
exercises with PT or rehab. Most are strengthening exercises. Transferring exercises (bed to chair) especially if they have orders for no weight bearing Don't rush into weight bearing. Follow physicians orders re weight bearing status.
Open fractures considerations
Open fractures have a very high risk of osteomyelitis. Prompt cleaning and infection prevention. Usually done in OR under anesthesia.
Fixation with internal (screws and rods inside) or external fixation devices (screws and rods on the outside. Pin care is the care for where the screws go into the skin.) All open fractures are considered contaminated.
Treatment of contamination for open fractures
broad spectrum, systemic antibiotic started within 3 hours of injury
if infection starts, culture it and adjust antibiotics appropriately
Goals in managing a patient with open fractures
prevent infection
- follow strict orders for dressing changes using sterile techniques (aseptic later down the road)
- If the wound has to remain open, you’ll have a wound care consult for a wound vac. Once risk is gone, close the wound
educate the family on what to watch for
- purulent drainage
- redness and increased temp
- report any of these signs to the physician immediately
Wound debridement
Remove foreign bodies, debris, & bacteria
Infection prevention in open fractures
Sterile dressing changes Antibiotics Wound debridement Monitor temperature Report s/s of infection promptly
Closed reduction
Closed reduction: mostly done without anesthesia
Accomplished through manipulation & manual traction
Cast or splint applied
Anesthesia with percutaneous pinning
Might be done without surgery
Retraction: skeletal (pins go into the bone) or skin (weights placed on a boot to realign hip fractures)
After closed reduction, you get an immobilizing device
Lots of xrays used. Series of xrays to make sure reduction was successful
Open reduction
ORIF (open reduction internal fixation) surgical procedure to surgically allign the fracture fragments using plates and rods to help maintain alignment of the bone. Depends on the severity of the fracture to determine how much hardware is used.
Surgical intervention to align bone fragments
Placement of internal fixation devices (pins, wires, screws,
plates, nails, or rods)
Educate that these hardware are not designed to carry full body weight.
Bone graft: from patient or cadaver
Done when there’s an open fracture (when the bone comes through the skin)
Neurovascular Status
5 P’s
Warning signs that something is wrong with perfusion
pain
poikilothermia- cold limb
pallor-paleness
parethesia- numbness to burning/pain/itching/tingling
pulselessness or weak pulse with delayed cap refill
If they have all 5 Ps, it might be too late to save that limb
Blood Loss r/t fractures
Large amount of blood may be lost d/t trauma to the surrounding tissue. There are arteries around bones.
Femur fracture 1000-1500 mls-risk of hypovolemic shock
Hypovolemic Shock manifestations
Thirst, anxiety & restlessness, elevated HR, weak pulse, decreased BP (Box 42-2) decreased LOC, anxiety and restlessness, decreased urine output (regular is 30 mls)
Nursing considerations for shock:
slow the blood loss if you can
monitor closely
get to help as soon as possible
Clinical manifestations of fractures
- pain
- loss of function
- shortening and deformity
- crepitus: Grating sensation on palpation
- swelling
- discoloration: ecchymosis
pain r/t fractures
Immediate, continuous, increasing severity the longer they go without immobilization and treatment
initial 20 minutes after the fracture, there might be no pain.
spasms usually accompany a fracture
Might have crepitus, swelling, discoloration around the site
shortening and deformity in the affected bone (internal rotation in a hip)
sometimes the deformity is visible, sometimes only palpable
Contusions
Soft tissue injury caused by blunt force-falling, kicking, hitting something
Hematoma
Strain
“pulled muscle”
Injury to muscle/tendon unit
Caused by repetitive movements, stress, new exercise regiment
Sprain
Injury to ligaments and supporting muscle fibers
Ligaments connect muscle to bone
Dislocation
Articular surfaces no longer in alignment
Avascular necrosis
Nursing Interventions for musculoskeletal trauma
resting and elevating the extremity, ice, compression, assess neurovascular function
immobilization after musculoskeletal trauma
Until definite diagnosis is determined
Rediction of dislocation=putting the thing back in place. Pt will receive some pain medication and muscle relaxants
respiratory status
fall risk
About a week after reduction: ROM exercises will begin with a PT, adhering to exercises
RICE for musculoskeletal trauma
Rest
Ice
Compression
Elevation
Chronic illness
medical illnesses or health problems with associated symptoms or disabilities that require long-term management (3 months or longer). Disease with a nonreversible pathology. Could be a gradual onset, or acute. Pts are individual and progress goes at their own rate. Unlikelihood of cure and require long term surveillance, maintenance, and might lead to disability.
Prevalence & Causes of Chronic Illnesses
Lifestyle factors:
Obesity
Chronic stress & sedentary lifestyle
Smoking, excessive drinking, & poor nutrition
Longer lifespan
Causes for increased chronic illness:
people are living longer
Better advances in technology, nutrition, pharmacology, safer working conditions, and greater access to healthcare
Improved screening and diagnostic procedures
start treatment earlier, so disease progresses slower
Characteristics of Chronic Illnesses in the acute setting
chances are you won’t be addressing the chronic illness directly. This means it must be integrated into the care of the acute disease process.
Characteristics of chronic illness
Chronic illnesses impact the social and psychological aspects of life in the patient and family. Altars body image and self esteem.
Phases of Chronic illness
- Acute
- Stable
- Unstable
- Remission
- Exacerbation
Pts can travel through these phases in any order. See table in book that includes nursing implications for each phase.
Comorbidities
Potential for development of other chronic disease
Diabetes leads to neurovascular changes or kidney disease
Trajectory Model of Chronic Illness
Pretragectory Trajectory onset Stable Unstable Acute Crisis Comeback Downward Dying
Pre-trajectory phase of chronic illness
Lifestyle risk factors habits that place the person at risk for a chronic disease (genetic predisposition, cardiac disease risk factors)
Trajectory onset of chronic illness
appearance of manifestations. Onset of disease. Time of diagnostic work up.
stable phase of chronic illness
When the illness course and symptoms are under control. Everyday life activities can be completed in light of the illness. Family and caregiver are “humming along smoothly”
Unstable phase of chronic illness
development of complication or exacerbation of symptoms
Acute phase of chronic illness
severe presentation of symptoms. May enter hospitalization, may be put on bedrest, disruption of daily life
Crisis phase of chronic illness
critical or life threatening situation that requires emergency intervention
Comeback of chronic illness
gradual return to the way of life prior to complication, may have new things to adapt to after last complication
Downward phase of chronic illness
rapid or gradual decline of a condition.Physical decline with disability results in worsening of management of everyday life.
Dying phase of chronic illness
X P
Chronic Illness & Nursing Practice
Direct Care
Physical, clinic, hospital
Patient’s home
Depends on status of illness. Could be home care, wound care, education
Chronic Illness & Nursing Practice
Supportive Care
Monitoring & education
Counseling,
advocacy for the patient and the family, especially for primary care giver
make sure their needs are met
referring to case management, support groups
Referral or case management
Ongoing monitoring/counseling about stages
Chronic Illness & Nursing Practice
Holistic Care
Mind, body and soul
Make sure you aren’t treating them as just the illness they came it with. Make sure you are caring for their entire beings.
Chronic illness and nursing practice
Acceptance
Accept negative personal choices (i.e. smoking, drinking, poor diet, no exercise)
non judgemental communication
be accepting of how they choose to deal with their diagnosis
Communication toward patients with chronic illness
Inform the patient and family in layman’s terms with supportive team: case workers, chaplains, etc. Goal is to let them know there is support around them.
Best time to talk- let the family guide this. Sometimes it’s not the best time for you.
Presence- active listening. You may be super busy, but it is important to slow down and let them talk to you.
Safe setting with no inturruptions
Allow pt. and family to set agenda-allow them to determine the duration, ask questions, and where the conversation leads.
Hospice Care
Patient’s illness is deemed life-limiting
PCP states that death is expected in 6 months:
—usually a requirement for insurance
A service that is team centered:
-Focus on dying person’s needs (i.e. physical, psychological, social, spiritual) Preparation.
Keep them as pain and symptom free as possible
With insurance, there are specific regulations that are required in order to approve hospice care.
Usually done in the home, but sometimes it doesn’t work out.
Medicare vs Medicaid hospice:
physician determination that death is within 6 months
diagnosis of terminal illness
Palliative Care
- Provide relief from pain & other symptoms
- Can be applicable early in an illness
- Does not need physician’s word saying they will die within 6 months
- Affirms life and regards dying as a natural process
- Neither hastens nor postpones death of patient
- Sometimes is done a little late because of projection of feelings onto a situation
- be the patient’s advocate to get them a palliative care counsel
- Rely heavily on advance directives and offer supportive care.
- Integrates psychological & spiritual aspects of care
- Provides support for patient & family
- Team approach to address needs
- Influences QOL & may positively influence illness trajectory
- Applicable early in course of illness, in conjunction with other therapies
People with terminal illnesses need these three things
know what’s happening to them and be able to talk about the reality of it with someone who will listen
allowed to experience the pain of feeling bad
be able to participate in the plans for how they will spend their final days
Predeath period
Primary responsibility of the nurse is to establish a relationship with the dying person
gain trust
help them come up with a plan to meet their goals
Death event
Anticipate problems such as distressing symptoms
Be present when patient dies if possible. Can be hard if the person wants to be alone when they pass.
Bereavement
Time after death
Help family to relive the death event
Support family
Methods of Stating End-of-Life Preferences
- advance directives
- Durable power of attorney
- living will
advance directives
Written documents, individual of sound mind
Document preferences regarding EOL care to be followed when individual cannot communicate their wishes
Always get a copy and document it
make sure everyone knows about it (physicians, etc)
Advocate for this
living will
Individual documents treatment preferences
Provides instructions for care when individual cannot communicate wishes
Durable power of attorney
Legal document
Signer appoints another to make medical decisions on his/her behalf
Nursing Tasks at End-of-Life
Pain & symptom management
Communicate effectively with dying patients and their families
Educate patients and families about EOL decision making: we can usually prevent a situation of fighting from happening, but education will hopefully diminish the risk of there being conflict. Assess the feelings of the family members so you can address things directly.
Help other professional caregivers develop plan of care that coheres with the wishes of patients and families
Provide care to patients who are close to death
Are present at the time of death
After death, attend to families’ loss, grief, and bereavement
Achieve quality of life care at the end of life by providing culturally sensitive care during entire hospice-care experience
Loss, Grief, & Bereavement
Loss: losing a loved one
Grief: personal feelings that accompany an anticipated or actual loss
Stage of grief (Kubler-Ross)
Mourning: individual, family, group & cultural expressions of grief and associated behaviors
Bereavement: period of time in which mourning takes place
Professional caregivers are not immune to grief!
Stages of Grief
Denial Sadness Anger Bargaining Fear Acceptance
Type of sinoarthosis joint
skull
Type of amphiarthosis joint
vertabral joints
Types of diarthosis joints
Ball and socket (hip and shoulder) Hinge (elbow and knee) Saddle (thumb) Pivot (radius and ulna) Gliding (wrist)
