Orthopedic Nursing

ORTHOPEDIC NURSING

04/08/23 RON R.N.,M.D. 1

Review of Anatomy and Physiology• The musculo-skeletal system consists of

the muscles, tendons, bones and cartilage together with the joints

• The primary function of which is to produce skeletal movements

04/08/23 RON R.N.,M.D. 2

Muscles

Three types of muscles exist in the body• 1. Skeletal Muscles

• Voluntary and striated• 2. Cardiac muscles

• Involuntary and striated• 3. Smooth/Visceral muscles

• Involuntary and NON-striated

04/08/23 RON R.N.,M.D. 3

TENDONS

• Bands of fibrous connective tissue that tie bones to muscles

04/08/23 RON R.N.,M.D. 4

LIGAMENTS

• Strong, dense and flexible bands of fibrous tissue connecting bones to another bone

04/08/23 RON R.N.,M.D. 5

BONES

• Variously classified according to shape, location and size

• Functions

1. Locomotion

2. Protection

3. Support and lever

4. Blood production

5. Mineral deposition

04/08/23 RON R.N.,M.D. 6

JOINTS

• The part of the Skeleton where two or more bones are connected

04/08/23 RON R.N.,M.D. 7

CARTILAGES

• A dense connective tissue that consists of fibers embedded in a strong gel-like substance

04/08/23 RON R.N.,M.D. 8

BURSAE

• Sac containing fluid that are located around the joints to prevent friction

04/08/23 RON R.N.,M.D. 9

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM

• The nurse usually evaluates this small part of the over-all assessment and concentrates on the patient’s posture, body symmetry, gait and muscle and joint function

04/08/23 RON R.N.,M.D. 10

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM• 1. HISTORY• 2. Physical Examination

• Perform a head to toe assessment• Nurses need to inspect and palpate • The special procedure is the

assessment of joint and muscle movement

• Usually, a tape measure and a protractor are the only instruments

04/08/23 RON R.N.,M.D. 11

ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM• Gait• Posture• Muscular palpation• Joint palpation• Range of motion• Muscle strength

04/08/23 RON R.N.,M.D. 12

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES• 1. BONE MARROW ASPIRATION

• Usually involves aspiration of the marrow to diagnose diseases like leukemia, aplastic anemia

• Usual site is the sternum and iliac crest

• Pre-test: Consent• Intratest: Needle puncture may be

painful• Post-test: maintain pressure

dressing and watch out for bleeding04/08/23 RON R.N.,M.D. 13

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM

LABORATORY PROCEDURES• 2. Arthroscopy

• A direct visualization of the joint cavity• Pre-test: consent, explanation of procedure,

NPO• Intra-test: Sedative, Anesthesia, incision will

be made• Post-test: maintain dressing, ambulation as

soon as awake, mild soreness of joint for 2 days, joint rest for a few days, ice application to relieve discomfort

04/08/23 RON R.N.,M.D. 14

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES3. BONE SCAN• Imaging study with the use of a contrast

radioactive material• Pre-test: Painless procedure, IV

radioisotope is used, no special preparation, pregnancy is contraindicated

• Intra-test: IV injection, Waiting period of 2 hours before X-ray, Fluids allowed, Supine position for scanning

• Post-test: Increase fluid intake to flush out radioactive material

04/08/23 RON R.N.,M.D. 15

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES

4. DXA- Dual-energy XRAY absorptiometry

• Assesses bone density to diagnose osteoporosis

• Uses LOW dose radiation to measure bone density

• Painless procedure, non-invasive, no special preparation

• Advise to remove jewelry

04/08/23 RON R.N.,M.D. 16

04/08/23 RON R.N.,M.D. 17

Common musculoskeletal problems

The Nursing Management

04/08/23 RON R.N.,M.D. 18

Nursing Management of common musculo-skeletal problems

PAIN• These can be related to joint

inflammation, traction, surgical intervention

• 1. Assess patient’s perception of pain

• 2. Instruct patient alternative pain management like meditation, heat and cold application, TENS and guided imagery

04/08/23 RON R.N.,M.D. 19

Nursing Management

PAIN• 3. Administer analgesics as prescribed

• Usually NSAIDS• Meperidine can be given for severe

pain• 4. Assess the effectiveness of pain

measures

04/08/23 RON R.N.,M.D. 20

Nursing Management

IMPAIRED PHYSICAL MOBILITY• 1. Instruct patient to perform range of

motion exercises, either passive or active

• 2. Provide support in ambulation with assistive devices

• 3. Turn and change position every 2 hours

• 4. Encourage mobility for a short period and provide positive reinforcements for small accomplishments

04/08/23 RON R.N.,M.D. 21

Nursing Management

SELF-CARE DEFICITS• 1. Assess functional levels of the patient• 2. Provide support for feeding problems

• Place patient in Fowler’s position• Provide assistive device and supervise mealtime• Offer finger foods that can be handled by patient• Keep suction equipment ready

04/08/23 RON R.N.,M.D. 22

Nursing Management

SELF-CARE DEFICITS• 3. Assist patient with difficulty bathing and

hygiene• Assist with bath only when patient has

difficulty• Provide ample time for patient to finish

activity

04/08/23 RON R.N.,M.D. 23

Musculoskeletal Modalities

• Traction

• Cast

04/08/23 RON R.N.,M.D. 24

Nursing Management

Traction• A method of fracture immobilization by

applying equipments to align bone fragments

• Used for immobilization, bone alignment and relief of muscle spasm

04/08/23 RON R.N.,M.D. 25

Traction

• Skin traction- Buck, Bryant

• Skeletal traction

04/08/23 RON R.N.,M.D. 26

Traction

• Balanced Suspension traction

• Running/Straight traction

04/08/23 RON R.N.,M.D. 27

Traction

• Pulling force exerted on bones to reduce or immobilize fractures, reduce muscle spasm, correct or prevent deformities

04/08/23 RON R.N.,M.D. 28

Traction

• TO decrease muscle spasms• TO reduce, align and immobilize

fractures• To correct deformities

04/08/23 RON R.N.,M.D. 29

04/08/23 RON R.N.,M.D. 30

04/08/23 RON R.N.,M.D. 31

Nursing Management

Traction: General principles• 1. ALWAYS ensure that the

weights hang freely and do not touch the floor

• 2. NEVER remove the weights• 3. Maintain proper body alignment• 4. Ensure that the pulleys and ropes

are properly functioning and fastened by tying square knot

04/08/23 RON R.N.,M.D. 32

Nursing Management

Traction: General principles• 5. Observe and prevent foot drop

• Provide foot plate• 6. Observe for DVT, skin irritation and

breakdown• 7. Provide pin care for clients in skeletal

traction- use of hydrogen peroxide

04/08/23 RON R.N.,M.D. 33

Nursing Management

Traction: General principles

8. Promote skin integrity• Use special mattress if possible• Provide frequent skin care• Assess pin entrance and cleanse the pin with

hydrogen peroxide solution• Turn and reposition within the limits of traction• Use the trapeze

04/08/23 RON R.N.,M.D. 34

Nursing Management

CAST• Immobilizing tool made of plaster of Paris

or fiberglass• Provides immobilization of the fracture

04/08/23 RON R.N.,M.D. 35

Nursing Management

CAST: types

1. Long arm

2. Short arm

3. Short leg

4. Long leg

5. Spica

6. Body cast

04/08/23 RON R.N.,M.D. 36

Casting Materials

• Plaster of Paris• Drying takes 1-3 days• If dry, it is SHINY, WHITE, hard and

resistant• Fiberglass

• Lightweight and dries in 20-30 minutes• Water resistant

04/08/23 RON R.N.,M.D. 37

Cast application

1. TO immobilize a body part in a specific position2. TO exert uniform compression to the tissue3. TO provide early mobilization of UNAFFECTED

body part4. TO correct deformities5. TO stabilize and support unstable joints

04/08/23 RON R.N.,M.D. 38

Nursing Management

CAST: General Nursing Care• 1. Allow the cast to air dry (usually 24-72 hours)• 2. Handle a wet cast with the PALMS not the

fingertips

04/08/23 RON R.N.,M.D. 39

Nursing Management

CAST: General Nursing Care• 3. Keep the casted extremity ELEVATED using a

pillow• 4. Turn the extremity for equal drying. DO NOT

USE DRYER for plaster cast• Encourage mobility and range of motion

exercises

04/08/23 RON R.N.,M.D. 40

Nursing Management

CAST: General Nursing Care

• 5. Petal the edges of the cast to prevent crumbling of the edges

• 6. Examine the skin for pressure areas and Regularly check the pulses and skin

04/08/23 RON R.N.,M.D. 41

Nursing Management

CAST: General Nursing Care

• 7. Instruct the patient not to place sticks or small objects inside the cast

• 8. Monitor for the following: pain, swelling, discoloration, coolness, tingling or lack of sensation and diminished pulses04/08/23 RON R.N.,M.D. 42

Nursing Management

CAST: General Nursing Care• Hot spots occurring along the cast

may indicate infection under the cast

04/08/23 RON R.N.,M.D. 43

Common Musculoskeletal conditions

Nursing management

04/08/23 RON R.N.,M.D. 44

METABOLIC BONE DISORDERSOsteoporosis• A disease of the bone characterized by a

decrease in the bone mass and density with a change in bone structure

04/08/23 RON R.N.,M.D. 45

METABOLIC BONE DISORDERSOsteoporosis: Pathophysiology• Normal homeostatic bone turnover is

altered rate of bone RESORPTION is greater than bone FORMATION reduction in total bone mass reduction in bone mineral density prone to FRACTURE

04/08/23 RON R.N.,M.D. 46

METABOLIC BONE DISORDERS

Osteoporosis: TYPES• 1. Primary Osteoporosis- advanced age, post-

menopausal• 2. Secondary osteoporosis- Steroid overuse, Renal

failure

04/08/23 RON R.N.,M.D. 47

METABOLIC BONE DISORDERS

RISK factors for the development of Osteoporosis

• 1. Sedentary lifestyle• 2. Age• 3. Diet- caffeine, alcohol, low Ca and

Vit D• 4. Post-menopausal• 5. Genetics- caucasian and asian• 6. Immobility

04/08/23 RON R.N.,M.D. 48

METABOLIC DISORDER

ASSESSMENT FINDINGS• 1. Low stature• 2. Fracture

• Femur• 3. Bone pain

04/08/23 RON R.N.,M.D. 49

METABOLIC DISORDER

LABORATORY FINDINGS• 1. DEXA-scan

• Provides information about bone mineral density

• T-score is at least 2.5 SD below the young adult mean value

• 2. X-ray studies

04/08/23 RON R.N.,M.D. 50

METABOLIC DISORDER

Medical management of Osteoporosis• 1. Diet therapy with calcium and

Vitamin D • 2. Hormone replacement therapy• 3. Biphosphonates- Alendronate,

risedronate produce increased bone mass by inhibiting the OSTEOCLAST

• 4. Moderate weight bearing exercises• 5. Management of fractures

04/08/23 RON R.N.,M.D. 51

METABOLIC DISORDER

Osteoporosis Nursing Interventions1. Promote understanding of

osteoporosis and the treatment regimen

• Provide adequate dietary supplement of calcium and vitamin D

• Instruct to employ a regular program of moderate exercises and physical activity

• Manage the constipating side-effect of calcium supplements

04/08/23 RON R.N.,M.D. 52

METABOLIC DISORDER

Osteoporosis Nursing Interventions• Take calcium supplements with meals• Take alendronate with an EMPTY stomach

with water• Instruct on intake of Hormonal

replacement

04/08/23 RON R.N.,M.D. 53

METABOLIC DISORDER

Osteoporosis Nursing Interventions

2. Relieve the pain• Instruct the patient to rest on a firm

mattress• Suggest that knee flexion will cause

relaxation of back muscles• Heat application may provide comfort• Encourage good posture and body

mechanics• Instruct to avoid twisting and heavy lifting04/08/23 RON R.N.,M.D. 54

METABOLIC DISORDER

Osteoporosis Nursing Interventions• 3. Improve bowel elimination• Constipation is a problem of calcium

supplements and immobility• Advise intake of HIGH fiber diet and

increased fluids

04/08/23 RON R.N.,M.D. 55

METABOLIC DISORDER

Osteoporosis Nursing Interventions• 4. Prevent injury• Instruct to use isometric exercise to

strengthen the trunk muscles• AVOID sudden jarring, bending and

strenuous lifting• Provide a safe environment

04/08/23 RON R.N.,M.D. 56

Juvenile rheumatoid Arthritis

• Definition:• AUTO-IMMUNE inflammatory joint

disorder of UNKNOWN cause• SYSTEMIC chronic disorder of

connective tissue

• Diagnosed BEFORE age 16 years old

04/08/23 RON R.N.,M.D. 57


• PATHOPHYSIOLOGY : unknown

• Affected by stress, climate and genetics

• Common in girls 2-5 and 9-12 y.o.

04/08/23 RON R.N.,M.D. 58


Systemic JRA Pauci-articular Polyarticular

FEVER MILD joint pain and swelling

Morning joint stiffness and fever

Salmon-pink rash

IRIDOCYCLITIS Weight Bearing joints

Five or more joints

Less than 4 joints

Five or more joints

Anorexia, anemia, fatigue

Very Good prognosis

Poor prognosis

04/08/23 RON R.N.,M.D. 59

JRA

• Symptoms may decrease as child enters adulthood

• With periods of remissions and exacerbations

04/08/23 RON R.N.,M.D. 60

JRA

Medical Management

1. ASPIRIN and NSAIDs- mainstay treatment

2. Slow-acting anti-rheumatic drugs

3. Corticosteroids

04/08/23 RON R.N.,M.D. 61

JRA

Nursing Management

1. Encourage normal performance of daily activities

2. Assist child in ROM exercises

3. Administer medications

4. Encourage social and emotional development

04/08/23 RON R.N.,M.D. 62

JRA

Nursing Management

During acute attack:• SPLINT the joints• NEUTRAL positioning• Warm or cold packs

04/08/23 RON R.N.,M.D. 63

DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS• The most common form of degenerative

joint disorder

04/08/23 RON R.N.,M.D. 64

DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS• Chronic, NON-systemic disorder of joints

04/08/23 RON R.N.,M.D. 65

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS: Pathophysiology• Injury, genetic, Previous joint damage, Obesity,

Advanced age Stimulate the chondrocytes to release chemicals chemicals will cause cartilage degeneration, reactive inflammation of the synovial lining and bone stiffening

04/08/23 RON R.N.,M.D. 66

DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Risk factors• 1. Increased age• 2. Obesity• 3. Repetitive use of joints with previous

joint damage• 4. Anatomical deformity• 5. genetic susceptibility

04/08/23 RON R.N.,M.D. 67


OSTEOARTHRITIS: Assessment findings• 1. Joint pain• 2. Joint stiffness• 3. Functional joint impairment limitation• The joint involvement is ASYMMETRICAL• This is not systemic, there is no FEVER, no

severe swelling• Atrophy of unused muscles• Usual joint are the WEIGHT bearing joints

04/08/23 RON R.N.,M.D. 68

DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Assessment findings

1. Joint pain• Caused by

• Inflamed cartilage and synovium• Stretching of the joint capsule• Irritation of nerve endings

04/08/23 RON R.N.,M.D. 69


OSTEOARTHRITIS: Assessment findings2. Stiffness commonly occurs in the morning after commonly occurs in the morning after

awakeningawakening Lasts only for less than 30 minutes DECREASES with movement, but worsens after

increased weight bearing activitry Crepitation may be elicited

04/08/23 RON R.N.,M.D. 70

DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Diagnostic findings1. X-ray• Narrowing of joint space• Loss of cartilage• Osteophytes2. Blood tests will show no evidenceno evidence of

systemic inflammation and are not useful

04/08/23 RON R.N.,M.D. 71


OSTEOARTHRITIS: Medical management• 1. Weight reduction• 2. Use of splinting devices to support joints• 3. Occupational and physical therapy• 4. Pharmacologic management

• Use of PARACETAMOL, NSAIDS• Use of Glucosamine and chondroitin• Topical analgesics• Intra-articular steroids to decrease inflam

04/08/23 RON R.N.,M.D. 72


OSTEOARTHRITIS: Nursing Interventions1. Provide relief of PAIN

• Administer prescribed analgesics• Application of heat modalities. ICE PACKS may

be used in the early acute stage!!!• Plan daily activities when pain is less severe• Pain meds before exercising

04/08/23 RON R.N.,M.D. 73

DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Nursing Interventions

2. Advise patient to reduce weight• Aerobic exercise• Walking

3. Administer prescribed medications• NSAIDS

04/08/23 RON R.N.,M.D. 74

DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS: Nursing Interventions

4. Position the client to prevent flexion deformity • Use of foot board, splints, wedges and

pillows

04/08/23 RON R.N.,M.D. 75

Rheumatoid arthritis

• A type of chronic systemic inflammatory arthritis and connective tissue disorder affecting more women (ages 35-45) than men

04/08/23 RON R.N.,M.D. 76


FACTORS:

Genetic

Auto-immune connective tissue disorders

Fatigue, emotional stress, cold, infection

04/08/23 RON R.N.,M.D. 77


Pathophysiology• Immune reaction in the synovium attracts

neutrophils releases enzymes breakdown of collagen irritates the synovial liningcausing synovial inflammation edema and pannus formation and joint erosions and swelling

04/08/23 RON R.N.,M.D. 78


ASSESSMENT FINDINGS

• 1. PAIN

• 2. Joint swelling and stiffness-SYMMETRICAL, Bilateral

• 3. Warmth, erythema and lack of function

• 4. Fever, weight loss, anemia, fatigue

• 5. Palpation of join reveals spongy tissue

• 6. Hesitancy in joint movement04/08/23 RON R.N.,M.D. 79


ASSESSMENT FINDINGS• Joint involvement is SYMMETRICAL and

BILATERAL• Characteristically beginning in the hands, wrist and

feet• Joint STIFFNESS occurs early morning, lasts MORE

than 30 minutes, not relieved by movement, diminishes as the day progresses

04/08/23 RON R.N.,M.D. 80


ASSESSMENT FINDINGS• Joints are swollen and warm• Painful when moved• Deformities are common in the hands and feet

causing misalignment • Rheumatoid nodules may be found in the

subcutaneous tissues

04/08/23 RON R.N.,M.D. 81


Diagnostic test• 1. X-ray

• Shows bony erosion• 2. Blood studies reveal (+) rheumatoid factor,

elevated ESR and CRP and ANTI-nuclear antibody• 3. Arthrocentesis shows synovial fluid that is cloudy,

milky or dark yellow containing numerous WBC and inflammatory proteins

04/08/23 RON R.N.,M.D. 82


MEDICAL MANAGEMENT• 1. Therapeutic dose of NSAIDS and Aspirin to

reduce inflammation• 2. Chemotherapy with methotrexate, antimalarials,

gold therapy and steroid• 3. For advanced cases- arthroplasty, synovectomy• 4. Nutritional therapy

04/08/23 RON R.N.,M.D. 83


MEDICAL MANAGEMENT

GOLD THERAPY:• IM or Oral preparation• Takes several months (3-6) before effects can be

seen• Can damage the kidney and causes bone marrow

depression• May NOT work for all individuals

04/08/23 RON R.N.,M.D. 84


Nursing MANAGEMENT

1. Relieve pain and discomfort• USE splints to immobilize the affected

extremity during acute stage of the disease and inflammation to REDUCE DEFORMITY

• Administer prescribed medications• Suggest application of COLD packs during

the acute phase of pain, then HEAT application as the inflammation subsides

04/08/23 RON R.N.,M.D. 85


Nursing MANAGEMENT2. Decrease patient fatigue• Schedule activity when

pain is less severe• Provide adequate periods

of rests3. Promote restorative sleep

04/08/23 RON R.N.,M.D. 86


Nursing Management4. Increase patient mobility• Advise proper posture and

body mechanics• Support joint in functional

position• Advise ACTIVE ROME• Avoid direct pressure over the

joint 04/08/23 RON R.N.,M.D. 87


Nursing Management5. Provide Diet therapy• Patients experience anorexia,

nausea and weight loss• Regular diet with caloric

restrictions because steroids may increase appetite

• Supplements of vitamins, iron and PROTEIN

04/08/23 RON R.N.,M.D. 88


6. Increase Mobility and prevent deformity:

• Lie FLAT on a firm mattress• Lie PRONE several times to

prevent HIP FLEXION contracture• Use one pillow under the head

because of risk of dorsal kyphosis• NO Pillow under the joints because

this promotes flexion contractures

04/08/23 RON R.N.,M.D. 89


• Capsaicin• Unknown mechanism, probably

Inhibits substance “P”• Reduces pain• Applied over the affected area• Do NOT bandage the area• Side effect: burning sensation• Wash hands after application

04/08/23 RON R.N.,M.D. 90

Hot versus Cold

HOT Cold

Use to RELIEVE joint stiffness, pain and muscle spasm

Use to control inflammation and pain

After acute attack ACUTE ATTACK

04/08/23 RON R.N.,M.D. 91

OA versus RA

RA OA

Onset is early Onset is late

Chronic systemic disease

Degenerative disease

Involves the synovium Involves the cartilages

Involved joints are symmetrical- fingers, cervical spine

Involved joints are unilateral- weight bearing knee, hips spine

Malaise, fever, anemia No other S/SX systemic04/08/23 RON R.N.,M.D. 92

OA versus RA

RA OA

Joint tenderness, swelling, warmth and redness

Subcutaneous nodules

Stiffness that dimishes

Crepitus, stiffness in the morning decreases after activity

Rest the joint, cold and heat modalities, ASA, NSAIDS, DMARDS

Rest the joints, Avoid overactivity, Weight reduction, cold and warm modalities, ASA

04/08/23 RON R.N.,M.D. 93

Gouty arthritis

• A systemic disease caused by deposition of uric acid crystals in the joint and body tissues

• CAUSES:• 1. Primary gout- disorder of Purine metabolism• 2. Secondary gout- excessive uric acid in the

blood like leukemia

04/08/23 RON R.N.,M.D. 94

04/08/23 RON R.N.,M.D. 95

04/08/23 RON R.N.,M.D. 96

Gouty arthritis

• ASSESSMENT FINDINGS• 1. Severe pain in the involved joints, initially the big

toe• 2. Swelling and inflammation of the joint• 3. TOPHI- yellowish-whitish, irregular deposits in

the skin that break open and reveal a gritty appearance

• 4. PODAGRA-big toe

04/08/23 RON R.N.,M.D. 97

Gouty arthritis

ASSESSMENT FINDINGS• 5. Fever, malaise• 6. Body weakness and headache• 7. Renal stones

04/08/23 RON R.N.,M.D. 98

Gouty arthritis

DIAGNOSTIC TEST• Elevated levels of uric acid in the blood• Uric acid stones in the kidney• (+) urate crystals in the synovial fluid

04/08/23 RON R.N.,M.D. 99

Gouty arthritis

• Medical management• 1. Allupurinol- take it WITH FOOD

• Rash signifies allergic reaction

• 2. Colchicine• For acute attack

• 3. Probenecid• For uric acid excretion

in the kidney

04/08/23 RON R.N.,M.D. 100

Gouty arthritis

Nursing Intervention

1. Provide a diet with LOW purine• Avoid Organ meats, aged and processed foods• STRICT dietary restriction is NOT necessary

2. Encourage an increased fluid intake (2-3L/day) to prevent stone formation

3. Instruct the patient to avoid alcohol

4. Provide alkaline ash diet to increase urinary pH

5. Provide bed rest during early attack of gout04/08/23 RON R.N.,M.D. 101

Gouty arthritis

Nursing Intervention

6. Position the affected extremity in mild flexion

7. Administer anti-gout medication and analgesics

04/08/23 RON R.N.,M.D. 102

Fracture

• A break in the continuity of the bone and is defined according to its type and extent

04/08/23 RON R.N.,M.D. 103

Fracture

• Severe mechanical Stress to bone bone fracture

• Direct Blows• Crushing forces• Sudden twisting motion• Extreme muscle contraction

04/08/23 RON R.N.,M.D. 104

Fracture

TYPES OF FRACTURE• 1. Complete fracture

• Involves a break across the entire cross-section

• 2. Incomplete fracture• The break occurs through only a part of

the cross-section

04/08/23 RON R.N.,M.D. 105

04/08/23 RON R.N.,M.D. 106

Fracture

TYPES OF FRACTURE• 1. Closed fracture

• The fracture that does not cause a break in the skin

• 2. Open fracture• The fracture that involves a break in the

skin

04/08/23 RON R.N.,M.D. 107

04/08/23 RON R.N.,M.D. 108

Fracture

TYPES OF FRACTURE• 1. Comminuted fracture

• A fracture that involves production of several bone fragments

• 2. Simple fracture• A fracture that involves break of bone

into two parts or one

04/08/23 RON R.N.,M.D. 109

Fracture

ASSESSMENT FINDINGS• 1. Pain or tenderness over the

involved area• 2. Loss of function• 3. Deformity• 4. Shortening• 5. Crepitus• 6. Swelling and discoloration

04/08/23 RON R.N.,M.D. 110

Fracture

ASSESSMENT FINDINGS

1. Pain• Continuous and increases in severity • Muscles spasm accompanies the fracture

is a reaction of the body to immobilize the fractured bone

04/08/23 RON R.N.,M.D. 111

Fracture

ASSESSMENT FINDINGS

2. Loss of function• Abnormal movement and pain can result

to this manifestation

04/08/23 RON R.N.,M.D. 112

Fracture

ASSESSMENT FINDINGS

3. Deformity• Displacement, angulations or rotation of

the fragments Causes deformity

04/08/23 RON R.N.,M.D. 113

Fracture

ASSESSMENT FINDINGS

4. Crepitus• A grating sensation produced when the

bone fragments rub each other

04/08/23 RON R.N.,M.D. 114

Fracture

• DIAGNOSTIC TEST• X-ray

04/08/23 RON R.N.,M.D. 115

Fracture

EMERGENCY MANAGEMENT OF FRACTURE• 1. Immobilize any suspected fracture• 2. Support the extremity above and below

when moving the affected part from a vehicle • 3. Suggested temporary splints- hard board,

stick, rolled sheets• 4. Apply sling if forearm fracture is suspected

or the suspected fractured arm maybe bandaged to the chest

04/08/23 RON R.N.,M.D. 116

Fracture

EMERGENCY MANAGEMENT OF FRACTURE

• 5. Open fracture is managed by covering a clean/sterile gauze to prevent contamination

• 6. DO NOT attempt to reduce the facture

04/08/23 RON R.N.,M.D. 117

Fracture

MEDICAL MANAGEMENT • 1. Reduction of fracture either open or

closed, Immobilization and Restoration of function

• 2. Antibiotics, Muscle relaxants such as METHOCARBAMOL and Pain medications

04/08/23 RON R.N.,M.D. 118

Fracture

General Nursing MANAGEMENT

For CLOSED FRACTURE• 1. Assist in reduction and immobilization• 2. Administer pain medication and muscle

relaxants• 3. teach patient to care for the cast• 4. Teach patient about potential complication

of fracture and to report infection, poor alignment and continuous pain

04/08/23 RON R.N.,M.D. 119

FractureGeneral Nursing MANAGEMENT For OPEN FRACTURE• 1. Prevent wound and bone infection• Administer prescribed antibiotics• Administer tetanus prophylaxis• Assist in serial wound debridement• 2. Elevate the extremity to prevent edema formation• 3. Administer care of traction and cast

04/08/23 RON R.N.,M.D. 120

Fracture• FRACTURE COMPLICATIONS• Early• 1. Shock• 2. Fat embolism• 3. Compartment syndrome• 4. Infection • 5. DVT

04/08/23 RON R.N.,M.D. 121

Fracture• FRACTURE COMPLICATIONS• Late• 1. Delayed union• 2. Avascular necrosis• 3. Delayed reaction to fixation devices• 4. Complex regional syndrome

04/08/23 RON R.N.,M.D. 122

Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Occurs usually in fractures of the long bones• Fat globules may move into the blood stream because

the marrow pressure is greater than capillary pressure• Fat globules occlude the small blood vessels of the

lungs, brain kidneys and other organs

04/08/23 RON R.N.,M.D. 123

Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Onset is rapid, within 24-72 hours• ASSESSMENT FINDINGS• 1. Sudden dyspnea and respiratory distress• 2. tachycardia• 3. Chest pain• 4. Crackles, wheezes and cough• 5. Petechial rashes over the chest, axilla and hard palate

04/08/23 RON R.N.,M.D. 124

Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Nursing Management• 1. Support the respiratory function• Respiratory failure is the most common cause of

death• Administer O2 in high concentration• Prepare for possible intubation and ventilator support

04/08/23 RON R.N.,M.D. 125

Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Nursing Management• 2. Administer drugs• Corticosteroids• Dopamine• Morphine

04/08/23 RON R.N.,M.D. 126

Fracture• FRACTURE COMPLICATIONS: Fat Embolism• Nursing Management• 3. Institute preventive measures• Immediate immobilization of fracture• Minimal fracture manipulation• Adequate support for fractured bone during

turning and positioning• Maintain adequate hydration and electrolyte

balance

04/08/23 RON R.N.,M.D. 127

Fracture• Early complication: Compartment syndrome• A complication that develops when tissue perfusion in

the muscles is less than required for tissue viability

04/08/23 RON R.N.,M.D. 128

Fracture

04/08/23 RON R.N.,M.D. 129

Fracture

• Early complication: Compartment syndrome• ASSESSMENT FINDINGS1. Pain- Deep, throbbing and UNRELIEVED pain by opiods• Pain is due to reduction in the size of the muscle

compartment by tight cast• Pain is due to increased mass in the compartment by edema,

swelling or hemorrhage

04/08/23 RON R.N.,M.D. 130

Fracture

• Early complication: Compartment syndrome• ASSESSMENT FINDINGS• 2. Paresthesia- burning or tingling sensation• 3. Numbness • 4. Motor weakness• 5. Pulselessness, impaired capillary refill time and

cyanotic skin

04/08/23 RON R.N.,M.D. 131

Fracture

• Early complication: Compartment syndrome• Medical and Nursing management• 1. Assess frequently the neurovascular status of the

casted extremity• 2. Elevate the extremity above the level of the

heart• 3. Assist in cast removal and FASCIOTOMY

04/08/23 RON R.N.,M.D. 132

Strains

• Excessive stretching of a muscle or tendon

• Nursing management• 1. Immobilize affected part• 2. Apply cold packs initially, then heat

packs• 3. Limit joint activity• 4. Administer NSAIDs and muscle

relaxants04/08/23 RON R.N.,M.D. 133

Sprains

• Excessive stretching of the LIGAMENTS• Nursing management• 1. Immobilize extremity and advise rest• 2. Apply cold packs initially then heat packs• 3. Compression bandage may be applied to

relieve edema• 4. Assist in cast application• 5. Administer NSAIDS

04/08/23 RON R.N.,M.D. 134

Herniated disk

• Occurs when all or part of the nucleus pulposus forces through the weakened or torn outer ring (annulus pulposus

04/08/23 RON R.N.,M.D. 135

Herniated disk

• Impingement on the spinal nerves will result to BACK PAIN

04/08/23 RON R.N.,M.D. 136

Herniated disk

• Causes

1. Trauma

2. Strain

3. Joint degeneration

04/08/23 RON R.N.,M.D. 137

Herniated disk

ASSESSMENT findings

1. Severe lower BACK PAIN that may radiate to the buttocks or legs and feet

2. Motor and sensory loss in the area supplied by the compressed nerves

04/08/23 RON R.N.,M.D. 138

Herniated disk

DIAGNOSIS of Herniated disk

1. Straight leg raising test• (+) leg pain

2. LeSegue’s test• 90 degrees knee and thigh (-) DTR

3. XR

4. CT

5. MRI

04/08/23 RON R.N.,M.D. 139

Herniated disk

Nursing Implementation

1. Provide complete BED rest for several days

2. Advise heat application over the area to lessen pain and muscle spasm

04/08/23 RON R.N.,M.D. 140

Herniated disk


3. Provide exercise on bed

4. Assist in pelvic traction application

5. Provide the drugs as ordered

Aspirin

Diazepam

Muscle relaxant

04/08/23 RON R.N.,M.D. 141

Herniated disk


6. Provide care for laminectomy

04/08/23 RON R.N.,M.D. 142

Laminectomy

• Removal of the spinal lamina to stabilize the vertebral joint and

Removal of the protruding disk

• Usually accompanied by insertion of metal plates

04/08/23 RON R.N.,M.D. 143

Laminectomy

• Pre-operatively• Routine pre-operative care• Remind the patient that he should lie

non his BACK after the operation• Monitor for worsening of symptoms• Use anti-embolic stocking• Encourage ROME• Coordinate with the PT

04/08/23 RON R.N.,M.D. 144

Laminectomy

• Pre-operatively• Fluids to prevent renal stones• Incentive spirometry• Maintain on BED rest

04/08/23 RON R.N.,M.D. 145

Laminectomy

• POST-operatively• Maintain BED rest• VERY IMPORTANT : LOG ROLLING TECHNIQUE

to turn• Never lie on PRONE• HEMOVAC drainage system= check tubing for

kinks, record amount, report colorless moisture in dressing

• Provide straight BACKED chair for LIMITED sitting ONLY

04/08/23 RON R.N.,M.D. 146

Laminectomy

• HOME CARE• AVOID sitting for a prolonged period of time• AVOID twisting, bending at the waist• Sleep on BACK• Proper weight to PREVENT lordosis

04/08/23 RON R.N.,M.D. 147

Amputation

Nursing InterventionsPost-operative care: after amputation• Elevate stump for the FIRST 24

HOURS to minimize edema and promote venous return

• Place patient on PRONE position after 24 hours

04/08/23 RON R.N.,M.D. 148

Amputation

Nursing Interventions

Post-operative care: after amputation

• Assess skin for bleeding and hematoma

• Wrap the extremity with elastic bandage

04/08/23 RON R.N.,M.D. 149

04/08/23 RON R.N.,M.D. 150

Orthopedic Nursing

Documents

Transcript of Orthopedic Nursing