Download 10.Ortho2

Nursing care of the Client
with Musculoskeletal
Stressors #2
Zelne Zamora, DNP, RN
NRSG 308
Important Facts
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Age 65> = 90% of hip fx hosp.
Females 2-3 times more likely
Whites , Asians have higher incidence
> 320,000 Americans hospitalized yearly
More than 1.5 million osteoporotic
fractures yearly
Hip Fractures in the Elderly
Risk Factors
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Age related BMD loss
Chronic diseases
Gender/Heredity
Malabsorption
Risk Factors
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Deficient nutrition
Tobacco and alcohol use
Medications
Environmental hazards
Hormone imbalances
Public Enemy #1
OSTEOPOROSIS
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Reduction of bone density
Change in bone structure
Increase susceptibility to fracture
Rate of bone resorption greater than bone formation
OSTEOPOROSIS
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Loss of bone mass universal phenomenon
associated with aging
Calcitonin decreased
Estrogen decreased
PTH increased
OSTEOPOROSIS
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Primary
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Occurs in women after menopause (usually 45-55
years of age)
May occur in men later in life
Failure to develop peak bone mass earlier in life
due to lifestyle
Secondary
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Result of medications, conditions, or diseases that
affect bone metabolism
Osteoporosis
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Genetics
Gender
Age
Nutrition
Physical exercise
Lifestyle choices
Medications
Co-morbidity
Osteoporsis – s/s
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Suboptimal nutrition of in
children can contribute to
disease
Bones become
progressively brittle and
fragile
Calcium Supplement Debate
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Children need RDA in the diet
(recommended daily allowance)
12-15 y.o. modest benefit to
spine
30-42 y.o. benefit with exercise
only
After menopause (45-55 y.o.)
beneficial
Osteoporsis – s/s
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Compression fractures
common - pathological
More common in women
than men
More common in
Caucasians and Asians
Osteoporosis
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Postmenopausal women
Less tall – compression of
spine  curvature of
spine, drooped posture
Weak abdominal muscles
– protruding abdomen
Compression of lungs from
posture – resp
insufficiency
The Available Evidence For
Increasing Peak Bone Mass:
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RDA of CA+ and Vitamin D
Exercise like an athlete
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45 min at 80-90% maxHR 3 X wk
Calorie intake adjusted to
maintain energy balance
Bone Mineral Density Testing
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Measures strength of bones
Density of minerals, i.e.,
calcium
Osteopenia – natural
thinning of bones
DEXA scan – way to
measure BMD
Bone Mineral Density
Normal
2.5-1 below the young adult reference
range (2.5 to -1)
Osteopenia
-1 to -2.5
Osteoporosis
-2.5 or less
Severe
Osteoporosis
-2.5 or less and presence of at least
one bone fracture
Drugs Used for Osteoporosis
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Estrogen Replacement Therapy
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Selective Estrogen Receptor
Modulator
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Premarin
Raloxifene (Evista)
Calcitonin (Micalcin, Calcimar)
Forteo (PTH)
Biphosphonates
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Fosamax, Boniva,
Zometa, Actonel
Compression Fracture
Hip Fracture Locations
Signs and Symptoms
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Pain hip/groin
Inability to put weight on
injured leg
Stiffness, bruising and
swelling
Shorter leg one side
Leg turns inward or
outward
Screening and Diagnosis
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X-Rays
Palpation
Range of Motion
Dexa Scan
Hip fracture classifications
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Displaced
Impacted
Comminuted
Displaced
Impacted
Comminuted
Metal Screws
Avascular Necrosis
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Death of tissue due to
insufficient blood supply
Broken bone interrupts
blood supply
Bone may collapse or
reabsorb
Avascular Necrosis
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Contributing factors
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Fractures
Dislocations
Slow intervention
Prolonged
corticosteroid therapy
Treatment
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Traction may be ordered
initially
Metal screws
Prosthetic Replacement
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Hemiarthroplasty
Total hip arthroplasty
(THA)
Hip Replacement
Hip Replacement
Total Hip Replacement
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Replacement of the upper femur and the
socket in the pelvic bone with a prosthesis
Hip Replacement
Total Hip Replacement
Hemiarthroplasty
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The replacement of one of the articular
surfaces
Indications for THA
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Femoral neck fractures
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osteoporosis
Osteoarthritis
Rheumatoid arthritis
Failure of previous
prosthesis
Avascular Necrosis
Abductor pillow
Activities to Avoid
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Avoid extremes of internal and external rotation,
adduction, and 90 degree flexion of affected hip for
4-6 weeks post-op
Use abduction pillow
Avoid crossing the legs
Use raised toilet seats
Platform under chair
Avoid twisting and reaching down, tying shoes, (use
long- handled shoe horns and sock pullers)
Prevention Strategies: Post-op
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Anti-embolism stockings – i.e., SCDs, TEDs
Pneumatic compression devices
Anti-coagulant therapy (LMWH or Coumadin)
Fluid intake
Prevention Strategies: Post-op
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Pressure ulcers
Neuro-vascular - the 6 P’s
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Pain
Paresthesias
Pressure
Paralysis
Poikilothermia
Pallor/Pulselessness
Immobility
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A telectasis
W asting of Bones
F unctional loss of
muscle
U rinary Stasis
L ast, but not least,
constipation
Postop complications
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DVT/ Fat Embolism/ PE
Infection
Pain
Postop complications
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Urinary Retention
Hip Dislocation
Neuro-cognitive
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Delirium
Depression
Prevention of Hip Fractures
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Calcium & Vit.D
Weight bearing
No smoking/alcohol
Treat osteoporosis
HRT
Home Safety
Sensible shoes
Eye exams
Medication safety
Total Knee Replacement
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Damaged bone and cartilage from your
thighbone, shinbone and kneecap
Replaced with an artificial joint (prosthesis)
made of metal alloys, high-grade plastics and
polymers
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http://www.edheads.org/activities/knee/
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Total Knee Replacement
Continuous Passive Motion Machine
Continuous Passive Motion Machine
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Increases circulation and flexion to knee
Usually patient is placed in CPM
immediately after surgery
Initially 0-40 degrees flexion to a goal of 090 degrees
Increase 10 degrees every shift as patient
tolerates
Nursing Interventions
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Assess bleeding to
dressing
Reduce swelling
CSM checks
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Peroneal nerve palsy
Monitor drain output
Know weight bearing
status
Complications
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DVT
Peroneal nerve palsy
Infection
Limited range of
motion
Discharge Planning
Musculoskeletal Complications
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Osteomyelitis
Delayed Union
Non Union
Malunion
Osteomyelitis
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Infection of the bone
Can occur
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Through soft tissue
infection
Direct bone
contamination
Through bloodborne
spread from other sites
of infections
Osteomyelitis
Pathophysiology
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70-80% of infection caused by
Staphylococcus Areus
Abscess formation occurs in the bone
Scar tissue develops
Low blood supply
Leads to chronic osteomyelitis
Signs and Symptoms
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Swelling
Tenderness
Warmth
Constant pulsating
pain
May see drainage
May see fever
Treatment
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Remove drains ASAP
Aseptic wound care
Antibiotics
Immobilization
Hydration
High protein diet
Pain control
Delayed Complications
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Delayed Union
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Nonunion
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Healing of the bone does
not occur at normal rate
Failure of the ends of the
fractured bone to unite
Malunion
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Failure of ends of fractured
bone to unite in in normal
alignment
Treatment
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Internal fixation
Bone grafts
Bone healing
stimulator
Immobilization
Non-weight bearing
Educate on s/s of
infection
Cumulative Trauma Disorders
(CTD’s)
CTD’s: Work-Related
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Caused by repeated
movements
Can cause significant
disability
Are costly to society
Carpal Tunnel Syndrome
Treatment CTS
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Splinting
Diuretics
Vit B6
Treatment CTS
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Massage
Ergonomic
improvements
Surgical
decompression
Low Back Pain
80% of Cases are Idiopathic
Low Back Pain Prevention
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Reject sedentary lifestyle
Build flexibility & strong abdominal muscles
Use good body mechanics
Proper positions
Low Back Pain Prevention
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Ergonomics
Stop smoking
Maintain ideal weight
Regular exercise
Herniated Lumbar Disc
Herniated disk
Laminotomy
Laminectomy
Diskectomy
Fusion
Nursing Management
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Pain control
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PCA
Respiratory care
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Incentive
spirometer
Cough and DB
Nursing Management
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Proper positioning/ logrolling
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Neurovacsular checks (CMS)
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Turn q2
Look at activity orders
Report deficit
Monitor bladder and bowel function
Nursing Management
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Mobility promotion
Education
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No bending/twisting
Fall prevention
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Use assistive devices as
needed
Assess home situation
QUESTIONS