Transcript West Coast University

Musculoskeletal System Disorder
-Degenerative Joint Disease
-Hip Fracture
-Joint Replacement (Hips and Knees)
-Osteoporosis
-Contractures
-Mobility Issues and Aids
-Cast Care
-Splints, slings, crutches, and braces
Degenerative Joint Disease
Osteoarthritis (OA)
 Is the most common joint disorder.
 Progressive deterioration of the articular
cartilage.
 It is non-inflammatory (unless localized)
 Non systemic disease.
 No longer a wear and tear disease associated with
aging.
 It involves process where new tissue is produced as a
result of cartilage destruction within the joint.
Osteoarthritis (OA)
 The destruction overweighs the production.
 There is formation of bone spur (osteophytes) after the
cartilage and bone beneath the cartilage erode.
 The changes within the joint lead to pain, immobility,
muscle spasms, and potential inflammation.
Risk Factors:
1. Age
4. Possible genetic link
2. Decrease muscle strength 5. Difficult to
3. Obesity
distinguish early in
disease process
from Rheumatoid
Arthritis (RA)
Symptoms
 Deep aching joint pain that gets worse after exercise or putting
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weight on it, and is relieved by rest or inactivity.
Pain that is worse when you start activities after a period of no
activity.
Pain with joint palpation or ROM
Observe for muscle atrophy, loss of function, limp when walking.
Over time, pain is present even when you are at rest
Grating of the joint with motion (crepitus) in one or more
affected joints.
Increase in pain during humid or moist weather
Joint swelling
Limited movement
Muscle weakness around arthritic joints
Heberden’s nodes (enlarged at the distal interphalaageal joints.
Bouchard’s nodes (proximal interphalangeal joints) may occur
bilaterally.
Rheumatoid Arthritis
 Synovial membrane inflammation resulting in cartilage
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destruction and bone erosion.
Inflammatory
Note for swelling, redness, warmth, pain at rest, after
immobility (morning stiffness).
Involves all joints.
Usually may occur to client who are underweight.
Swan neck and Boutonniere deformities of hands.
Systematic involvement- lung, hearth, skin, extra-articular.
Symmetrical.
DX Test – X-rays, positive rheumatoid factor.
Rheumatoid Arthritis
 Is an autoimmune disease that causes chronic
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inflammation of the joints.
Can cause inflammation of the tissue around the joints, as
well as in other organs in the body.
Autoimmune diseases are illnesses that occur when the
body's tissues are mistakenly attacked by their own
immune system.
Because it can affect multiple other organs, it is referred to
as a systemic illness and is sometimes called rheumatoid
disease.
Is a chronic illness, clients may experience long periods
without symptoms.
Typically a progressive illness that has the potential to
cause joint destruction and functional disability.
Characterized by exacerbation and remission.
Rheumatoid Arthritis
 The cause is unknown.
 Infectious agents such as viruses, bacteria, and fungi
have long been suspected, none has been proven as
the cause.
 It is believed that the tendency to develop rheumatoid
arthritis may be genetically inherited.
 It is also suspected that certain infections or factors in
the environment might trigger the activation of the
immune system in susceptible individuals.
Rheumatoid Arthritis Complications
 Inflammation of the glands of the eyes and mouth can cause
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dryness - Sjogren's syndrome.
Pleuritis - causes chest pain with deep breathing, shortness of
breath, or coughing.
Lung tissue can become inflamed, scarred, and with nodules of
inflammation.
Pericarditis, can cause a chest pain that typically changes in
intensity when lying down or leaning forward.
The rheumatoid disease can reduce the number of red blood
cells (anemia) and white blood cells.
Decreased white cells can be associated with an enlarged spleen
(Felty's syndrome) and can increase the risk of infections.
Firm lumps under the skin (rheumatoid nodules) can occur
around the elbows and fingers where there is frequent
pressure.
Nerves can become pinched in the wrists to cause carpal tunnel .
Osteoarthritis
Tests & diagnosis
 A physical exam can show:
 Joint movement may cause a cracking (grating) sound
 Joint swelling (bones around the joints may feel larger than
normal)
 Limited range of motion
 Tenderness when the joint is pressed
 Normal movement is often painful
 No blood tests are helpful in diagnosing osteoarthritis.
 An x-ray of affected joints will show a loss of the joint
space. In advanced cases, there will be a wearing down of
the ends of the bone and bone spurs.
Nurse to assess or monitor
 Pain level 0 – 10, location, characteristics, quality, and
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severity.
Degree of functional limitation.
Levels of pain and pain after activity.
Range of motion.
Proper functional/joint alignment.
Home barriers.
Activity to perform activities of daily living (ADLs).
Treatment
 The goals of treatment are to:
- Increase the strength of the joints
- Maintain or improve joint movement
- Reduce the disabling effects of the disease
- Relieve pain
Diagnostic Procedures and Nsg Interventions
 Erythrocyte Sedimentation Rate (ESR) and high sensitivity
C-reactive protein. Result may be slightly elevated secondary to
synovitis.
 Radiographs – can determine structural damage within the
joint.
 Computed Tomography (CT) – imaging scan to determine
vertebral involvement.
Rheumatoid Arthritis
1. Abnormal antibodies can be found in the blood of people with
rheumatoid arthritis. An antibody called "rheumatoid factor“.
2. "antinuclear antibody" (ANA) is also frequently found in
people with rheumatoid arthritis.
3. ESR
MEDICATIONS
 Acetaminophen (Tylenol) first, because it has fewer
side effects than other drugs.
 Non-steroidal anti-inflammatory drugs (NSAIDs).
These drugs help relieve pain and swelling. Types of
NSAIDs include Aspirin, Ibuprofen, and Naproxen.
 Long-term use of NSAIDs can cause stomach
problems, such as ulcers and bleeding.
 Corticosteroids injected right into the joint can also be
used to reduce swelling and pain. However, relief only
lasts for a short time.
MEDICATIONS
 Capsaicin (Zostrix) skin cream may help relieve pain.
Client may feel a warm, stinging sensation when first
apply the cream. This sensation goes away after a few
days of use. Pain relief usually begins within 1 - 2
weeks.
 Glucosamine and chondroitin sulfate. There is some
evidence that these supplements can help control
pain, although they do not seem to grow new cartilage.
Some doctors recommend a trial period of 3 months to
see whether glucosamine and chondroitin work.
Medications
 NSAIDS Ex.
 Toradol (ketorolac tromethamine) is a prescription medication
for short-term relief of moderate to severe pain. "Short-term" is
defined as no longer than five days for adults. Children should
not receive more than one dose of Toradol.
 The medication is most often used to treat pain following a
procedure, but may also be used for such things as pain caused
by kidney stones, back pain, or cancer pain.
 Belongs to a class of drugs called nonsteroidal anti-inflammatory
drugs.
Toradol
 Toradol side effects include:
Headache, Abdominal pain (or stomach pain) ,
Nausea,
Heartburn or indigestion, Diarrhea, Dizziness,
Drowsiness,
Swelling.
 Other side effects with Toradol occurring in more than
1 percent of people include but are not limited to:
High blood pressure (hypertension), Itching,
Unexplained rash, Gas , Constipation , Vomiting,
Sweating Pain at the injection site if injection.
Toradol – Serious Side Effects
 Allergic reactions
 Stomach or intestinal problems, including bleeding,
ulcers (known as a perforation).
 Liver damage, which can cause nausea, fatigue,
yellowing of the skin or whites of the eyes, and
excessive tiredness.
 Kidney problems, including kidney failure
 Fluid retention or unexplained weight gain
Nursing Interventions
1. Conservative Therapy:
 Balance rest with activity.
 Use bracing or splints.
 Apply therapies (heat or cold)
 Analgesic therapy – Acetaminophen, NSAIDS, Topical
salicylates, Glucosamine rebuild cartilage.
 Intra-articular injections of glucocorticoids (treat
localized inflammation).
2. Joint Replacement Surgery – to relieve the pain and
improve mobility and quality of life.
Osteotomy is done to remove damaged cartilage and
correct the deformity.
Nursing Interventions
 Instruct the client on the use of analgesics and NSAIDS
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prior to activity and around the clock as needed.
Balance rest with activity.
Instruct the client on proper body mechanics.
Encourage use of thermal applications. Heat to alleviate
pain; ice for acute inflammation.
Encourage use of complementary and alternative
therapies. E.g. acupuncture, tai chi, magnets, and
music therapy.
Encourage use of splinting. For protection.
Encourage use of assistive device to promote
independence. E.g. elevated toilet seat, shower bench,
long handled reacher.
Encourage use of a daily schedule of activities.
Encourage a well balanced diet and ideal body weight.
Prevention
OSTEOARTHRITIS
 Weight loss can reduce the risk of knee osteoarthritis
in overweight client.
Complications
 Adverse reactions to drugs used for treatment
 Decreased ability to perform everyday activities, such
as personal hygiene, household chores, or cooking.
 Decreased ability to walk.
 Surgical complications.
Fracture
 Fracture is a break or disruption in the continuity of a
bone.
TYPES
 Closed or simple – does not break through the skin.
 Open or compound – disrupt the skin integrity.
Concern - risk for infection
Grade 1 – minimal skin damage
Grade 11 – damage includes skin and muscle
contusions.
Grade 111 – damage to skin, muscles, nerves, and
blood vessels.
TYPES of FRACTURES cont.
 Complete fracture – goes through entire bone.
 Incomplete fracture – goes through part of the bone.
OTHER COMMON TYPES OF FRACTURES
 Displace – bone fragments are not in alignment.
 Non-displace – Bone fragments remains in alignment.
 Comminuted – Bone is fragmented.
 Oblique – Fracture occurs at oblique angle.
 Spiral – Fx occurs from twisting motion (physical abuse
type)
 Impacted – Fracture bone is wedge inside opposite
fractured fragment.
 Greenstick – Fracture in only one cortex of the bone.
 Pathological – Fracture resulting from a tumor or lesion
that has weakened the bone.
 Segmented – Fracture resulting in two or more bone pieces.
Risk Factors for Fractures
 Osteoporosis
 Falls
 Motor Vehicle crashes
 Substance Abuse
 Diseases ( Bone Cancer, Paget’s Disease)
Paget's disease of the bone. It is a chronic disorder
that typically results in enlarged and deformed bones.
 Contact sports and hazardous recreational activities
(football, skiing).
 Physical Abuse
Diagnostic Procedures
 X-Ray
 Computed Tomography (CT)imaging scan
 Magnetic Resonance
Nursing Assessments
 Signs and symptoms of fracture;
1. Pain, Swelling and Tenderness
2. Deformity, loss of functional ability. May observe
internal rotation of extremity, shortened extremity,
visible bone with open fracture.
3. Discoloration, bleeding at the site through an open
wound.
4. Crepitus: crackling sound between two broken
bones. Created by the rubbing of bone fragments.
5. Muscle spasms: due to pulling forces of the bone
when not aligned.
6. Edema: Swelling from trauma.
7. Ecchymosis: Bleeding into underlying soft tissues from
trauma.
Nursing Interventions
 Assess/monitor
- Hx of trauma, metabolic bone disorders, chronic
conditions (use of steroid therapy).
- Neurovascular assessment: (Priority)
Pain- Early sign, increasing pain not relieved with
elevation or pain medication.
Paresthesia – Early sign, teach client to report any
numbness or tingling, pins and needle.
Pallor – Late, assess cap refill, check for increased
cap. Refill time > 3 sec. , blue fingers or toes.
Polar – Late, cool/cold fingers or toes.
Paralysis – Late, assess mobility, moves fingers or toes, check
for inability to move fingers or toes.
Pulses – Late, weak palpable pulses, unable to palpate pulses,
pulses detected only with Doppler.
Diagnostic Procedure of Hip Fracture
 A hip fracture is a fracture in the proximal end of the
femur (the long bone running through the thigh), near the
hip joint.
 X-rays of the affected hip usually make the diagnosis
obvious; AP and lateral views should be obtained.
 In situations where a hip fracture is suspected but is not
obvious on x-ray, a CT scan with 3D reconstruction may be
helpful. MRI has gained importance in the diagnosis of
occult fractures of the femoral neck. Within 24 hours
changes can be seen on MRI.
 As the client most often require an operation (surgery), full
pre-operative general investigation is required. This would
normally include blood tests, ECG and chest x-ray.
X-Ray of Hip Fracture
Hip Fx treated screws
Types of Hip Fractures and Treatment
 Femoral neck - Femoral neck fractures involve the
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narrow neck between the round head of the femur and
the shaft. This fracture often disrupts the blood supply
to the head of the femur.
Treatment for this type of fracture by replacing the
fractured bone with a prosthesis arthroplasty.
Alternative treatment is to reduce the fracture
(manipulate the fragments back into a good position)
and fix them in place with three metal screws.
ORIF – Open Reduction Internal Fixation
A serious but common complication of a fractured
femoral neck is avascular necrosis.
NANDA NURSING Diagnosis
 Risk for peripheral neurovascular dysfunction.
 Acute pain
 Risk for infection
 Impaired physical mobility
Nursing Interventions for Fracture
 Preoperative Nursing Care
A. First address life-threatening complications of
injury.
- Maintain ABC’s , monitor V/S, Monitor Neuro
status, digital pressure to proximal artery nearest
the fx., position in supine position, keep client
warm.
B. Risk for impaired skin integrity.
- Monitor pressure points
- Perform ROM to unaffected joints to prevent
contracture (fx to hip requires ROM to ankles and
toes).
Nursing Interventions for Fracture
 C. Risk for hypovolemic shock- assess fx, assess
abdomen, bladder for bleeding.
- Monitor V/S, monitor I and O, Promote hydration
(IV therapy), Keep client in supine position.
D. Stabilization of injured area (Cast, splints and
traction).
E. Risk for peripheral vascular dysfunction.
- Perform neurovascular assessments ( Assess the 5
P’s).
F. Risk for compartment syndrome.
Compartment syndrome is the compression of nerves and
blood vessels within an enclosed space. This leads to
muscle and nerve damage and problems with blood flow.
Compartment Syndrome
 Hallmark symptom of compartment syndrome is
 Severe pain that does not go away when you take
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pain medicine or raise the affected area.
Symptoms may include: Decreased sensation ,
Paleness of skin, Weakness.
A physical exam will reveal:
Severe pain when moving the affected area (for
example, a person with compartment syndrome in the
foot or lower leg will experience severe pain when
moving the toes up and down)
Tensely swollen and shiny skin
Pain when the compartment is squeezed
Confirming the diagnosis involves directly measuring
the pressure in the compartment.
Compartment Syndrome Management
 Perform neurovascular assessment.
 Assess pain or massive stretch.
 Do not elevate extremity further to avoid further ischemia.
 Looses bandage or immobilizer/bivalve cast
G. Pain – Assess on scale 0f 0-10
- Provide analgesics and assess relief
- Position for comfort.
H. Open fractures or fracture blister.
- Monitor V/S
- Monitor lab. Values: WBC, ESR,
- Provide aseptic wound care.
Nursing Interventions for Fracture
 Post- Operative Nursing Care
A. Risk for peripheral vascular compromise.
- Perform neurovascular assessment.
B. Acute Pain - Assess pain on scale of 1-10. Provide
analgesics/antispasmodic and assess relief.
- Position for comfort.
C. Risk for infection – Assess s/s of infection:Monitor V/S (temp).
- Monitor lab. Values – WBC, ESR
- Provide surgical aseptic wound care.
D. Impaired physical mobility – consult PT/OT for ambulation and
ADLs.
- Monitor orthostatic BP when getting out of bed for the first
time.
- Turn and position q 2 Hours.
- Instruct to get out of bed from unaffected side.
- Position for comfort.
Nursing Interventions for Fracture
Post – Op Nursing Management
E. Imbalance Nutrition – Encourage increased calorie
intake.
- Ensure use of Calcium supplements.
- Encourage small, frequent meals with snack.
- Monitor for Constipation.
Hip Fracture Post-Op Activity
 It is important to start some activities immediately to
offset the effects of the anesthetic, help the healing,
and keep blood clots from forming in the leg veins.
 The MD, PT and OT can provide specific instructions
on wound care, pain control, diet, and exercise.
 They should also indicate how much weight you can
put on your affected leg.
 Pain management is important in early recovery.
Initially, client may get pain medication through an IV
(intravenous) using a PCA machine.
Hip Fracture Post-Op Activity
 It is easier to prevent pain than to control it and client
do not have to worry about becoming addicted to the
medication; after a day or two, injections or pills will
replace the IV tube.
 Besides the pain medication, client will also need
antibiotics and blood-thinners to help prevent blood
clots from forming in the veins of your thigh and calf.
 Client may lose appetite and feel nauseous or
constipated for a couple of days. These are ordinary
reactions.
Hip Fracture Post-Op Activity
 Client may have a urinary catheter inserted during surgery
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and be given stool softeners or laxatives to ease the
constipation caused by the pain medication after surgery.
Client will be taught to do breathing exercises to keep
chest and lungs clear.
A physical therapist will visit client, usually on the day after
your surgery, and teach client how to use your new joint.
It is important that client get up and about as soon as
possible after hip replacement surgery.
Even in bed, client can pedal his/her feet and pump ankles
regularly to keep blood flowing in your legs.
Client may have to wear elastic stockings and/or a
pneumatic sleeve to help keep blood flowing freely.
Pedaling may done via CPM machine.
Hip Surgery – Home Activity that are safe.
 Do not have to reach up or bend down.
 Rearrange furniture so can get about on a walker or
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crutches.
May want to change rooms (make the living room the
bedroom, for example) to stay off the stairs.
Get a good chair—one that is firm and has a higher-thanaverage seat.
Remove any throw rugs or area rugs that could cause you
to slip.
Securely fasten electrical cords around the perimeter of the
room.
Install a shower chair, grab bar, and raised toilet in the
bathroom.
Use assistive devices such as a long-handled shoehorn, a
long-handled sponge, and a grabbing tool or reacher to
avoid bending too far over.
Activities Post Hip Replacement
 Dos and Don't: These precautions will help to prevent the
new joint from dislocating and to ensure proper healing. Here
are some of the most common precautions:
The Don'ts
 Don't cross your legs at the knees for at least 8 weeks.
 Don't bring your knee up higher than your hip.
 Don't lean forward while sitting or as you sit down.
 Don't try to pick up something on the floor while you are
sitting.
 Don't turn your feet excessively inward or outward when you
bend down.
 Don't reach down to pull up blankets when lying in bed.
 Don't bend at the waist beyond 90°.
 Don't stand pigeon-toed.
 Don't kneel on the knee on the unoperated leg (the good side).
 Don't use pain as a guide for what you may or may not do.
Activities Post Hip Replacement
The Dos
 Do keep the leg facing forward.
 Do keep the affected leg in front as you sit or stand.
 Do use a high kitchen or barstool in the kitchen.
 Do kneel on the knee on the operated leg (the bad side).
 Do use ice to reduce pain and swelling, but remember that
ice will diminish sensation. Don't apply ice directly to the
skin; use an ice pack or wrap it in a damp towel.
 Do apply heat before exercising to assist with range of
motion. Use a heating pad or hot, damp towel for 15 to 20
minutes.
 Do cut back on your exercises if your muscles begin to
ache, but don't stop doing them!
Fracture Complications and Nursing Implications
 Compartment Syndrome – pressure in one or more
muscle compartments of the extremity compromises
circulation resulting in an ischemia-edema cycle.
- capillaries dilates to attempt to pull O2 into the
tissues.
- Increase capillary permeability from the release of
histamine leads to edema from plasma proteins
leaking into interstitial space.
- increased edema causes pressure to the nerve
endings resulting to pain.
- Blood flow is reduced and ischemia persist.
Compartment Syndrome
Causes – External Sources
 Tight cast
 Constrictive bulky dressing
Causes – Internal Source
 Accumulation of blood or fluid within muscle compartment.
S/S – increased pain unrelieved with elevation, paresthesia and
pallor.
- If untreated, tissue necrosis can result. Neuromuscular
damage occurs within 4-6 hours.
Normal compartment pressure is 0-8 mmHg. Pressure
greater than 8 requires FASCIOTOMY.
Prevention:
 Cutting the cast on one side (univalve) or both sides (bivalve).
 Loosening constrictive dressing or cutting the bandage or tape.
Surgical Treatment - Fasciotomy
 A surgical incision is made through the subcutaneous
tissue and fascia of the affected compartment to relieve the
pressure and restore circulation.
 Post fasciotomy – open wounds require sterile packings
and dressing until secondary closure occurs. Skin graft
maybe necessary.
COMPLICATIONS OF COMPARTMENT SYNDROME
 Infection from tissue necrosis
 Persistent motor weakness or contracture from injured
nerves
 Myoglobinuric renal failure from muscle tissue breakdown
(rhabdomyolysis). Myoglobin can occlude distal
tubules of kidneys resulting in acute renal failure.
Fracture Complications and Nursing Implications
 SHOCK – can occur as bone trauma may lead to
hemorrhage. Treatment: same as shock prevention
and treatment.
 FAT EMBOLISM – can occur usually within 48 hour
following long bone fracture. Fat globules from the
bone marrow are released into the vasculature and
travel to the small blood vessels including those in the
LUNGS resulting in acute respiratory insufficiency.
 Careful differentiation between fat embolism and
pulmonary embolism is very important.
Clinical Manifestation of Fat Embolism
 Earliest Sign – Altered Mental Status due to low O2
level.
 Respiratory distress
 Tachycardia
 Tachypnea
 Fever
 Cutaneous petechia – flat red marks that occur on
the neck, chest, upper arm, and abdomen.
Treatment:
 Adequate splinting following fracture, bedrest
andhydration to avoid hypovolemic shock, analgesia,
oxygenation, and blood transfucion.
Fracture Complications and Nursing Implications
 DEEP VEIN THROMBOSIS – is the most common
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complication following trauma, surgery, or disability
related to immobility. Early mobilization is the prevention.
OSTEOMYELITIS – inflammation within the bone
secondary to penetration of organism (trauma/surgery)
S/S – bone pain that is worse with movement.
initially, erythema, edema, and fever may occur.
Diagnostic procedure – BONE BIOPSY, Cultures
performed to possible aerobic and anaerobic organisms.
Treatment : LONG COURSE (e.g. 3 months) of IV and oral
antibiotic therapy.
Surgical Debridement may also be indicated
Unsuccessful treatment can result in amputation.
Osteomyelitis
Fracture Complications and Nursing Implications
 AVASCULAR NECROSIS – results from the
circulatory compromise that occurs after a fracture.
Blood flow is disrupted to the fracture site and the
resulting ischemia leads to tissue necrosis.
 FAILURE OF FRACTURE TO HEAL
- Delayed union: fracture that has not healed within 6
months of injury.
- Non union: Fracture that never heals (electrical bone
stimulation and bone grafting can be used to treat
nonunion.
- Malunion: Fracture heals incorrectly.
Needs of the Older Adult related to Fractures
 Bone healing is affected by age.
 Pause menopausal women who lose estrogen are
unable to form strong new bone.
 Chronic conditions such as PVD (ARTERIAL
INSUFFICIENCY) or poor nutrition affects the client’s
ability to fom a new bone. Adequate amounts of
calcium phosphorous , protein and Vit. D are essential
in the production of new bone.
 Surgical of hip fractures is becoming the most
common surgical procedure for client’s over the age of
85.
Joint Replacement
 Surgical Procedure in which a mechanical device, designed
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to act as a joint, is used to replace a diseased joint.
Most commonly replaced joints:
- Hip
- Knee
- Shoulder
- Finger
Prosthesis maybe ingrown or cemented.
Accurate fitting is essential
Client must have a healthy bone stock for adequate healing.
Infection is concern postoperatively.
Joint Replacement
 Nursing Assessment:
A. Joint Pathology (causes)
- Arthritis
- Fracture
B. Pain not relive by medication
C. Poor ROM in the affected joint.
NANDA NURSIN DIAGNOSIS (Analysis)
 Risk for infection r/t
 Pain r/t
 Chronic pain r/t
 Risk for injury to affected limb r/t
Joint Replacement Nursing Plans and Interventions
 Provide post-operative care for wound and joint.
- Assess for bleeding and drainage.
Ortho wounds have tendency to ooze more than other
wounds. Suction drainage device usually accompanies the client to
the post op floor. Check drainage often.
- Assess suture line for erythema and edema.
- Assess suction drainage apparatus for proper functioning.
- Assess for signs of infection. (A big problem after joint
replacement).
 Monitor functioning of extremity .
- Check circulation, sensation, and movement of extrtemity distal to
replacement.
- Provide proper alignment of affected extremity.
- Provide abductor appliance or continuous passive motion device if
indicated.
Joint Replacement Nursing Plans and Interventions
 Monitor I and O every shift including suction drainage.
Fx of bone predispose client to anemia, especially if long bones are involve.
Check hematocrit every 3-4 days to monitor erythropoiesis.
 Encourage client to have a fluid intake 3 L per day.
 Encourage client to perform self-care activities at maximal
level.
- Get client out of bed ASAP.
- Keep client out of bed as much as possible.
- Keep abductor pillow in place while client is in bed (hip
replacement)
- Use elevated toilet seats and chairs with high seats for
those who had hip replacement or knee replacement.
- Do not flex hip more than 90 degrees (hip replacement).
 Provide discharge planning that includes rehabilitation on
an outpatient basis as prescribed.
Cast, Splint and Immobilizers
 Immobilization secures the injured extremity in order to –
prevent further injury
- Promotes healing/circulation
- Reduce pain
- Correct a deformity
 Cast, Splints, External Fixation and Immobilizers
 Use to secure the position of the body parts being treated.
 Hold the bone in alignment while allowing enough movement
for other parts of the body to carry out activities of daily living.
Cast- is a solid mold that is used to immobilized a fracture can be
made of plaster of Paris, fiberglass, thermoplastic resins,
thermolabile plastic and polyester-cotton knit impregnated with
polyurethane.
Cast
 Plaster of Paris – anhydrous calcium sulfate embedded in
gauze. Least expensive type of cast used.
 Dries after about 24 to 72 hours depending on the size and
location.
 Can withstand weight-bearing and other stresses as long as
dry and strong.
 Petaling – short pieces of tape placed over the edges of the
cast to prevent skin irritation by rough edges and to protect
the cast from moisture and soiling.
Cast
 Cast fiberglass - is a synthetic material used for
cast that is lighter and has shorter drying time
than plaster of Paris.
 Drying time 10 -15 minutes, and can stand weightbearing 30 minutes after application.
 Cast split down the front to allow the casting
material and padding to spread.
 Bivalved cast is cut down both sides so that the
front portion can be removed while the back
portion maintain immobilization.
 Windowed cast – opening is cut into the cast to
allow inspection of the body area or to relieve
pressure. Cut out window need to be saved.
4 main groups of cast
 Upper extremity cast – use for breaks in the
shoulder, arm, wrist and hand.
- Wearing an arm cast should keep the arm elevated
above the heart when lying in bed to prevent swelling.
- Arm is kept in a sling for support when the patient is
up.
 Lower extremity cast- used for breaks in the upper
and lower leg, ankle and foot.
- A leg cast is used to allow mobility and maybe used
with crutches.
- Affected leg should be elevated on several pillows
during the first few days after the break to prevent
swelling.
 Cast brace – supports the affected part while allowing
the knee to bend . Applying a cast above and below the
knee and connecting them with hinge.
4 main groups of cast
 Body or spica cast
- Used when a fracture is located somewhere in the
trunk of the body.
- The body cast encircles the trunk , whereas a spica
cast encase the trunk plus one or two extremities.
 Body or spica cast severely limit mobility and may
cause complications related to lack of movement
such as skin breakdown, respiratory problem,
constipation, and joint contractures.
Cast Syndrome
 It is cause by compression of a portion of the
duodenum between the superior mesenteric artery
and the aorta and vertebral column.
 Sign and symptoms:
- nausea
- abdominal distention
Cast Care
 Cast is removed only on physician’s order.
 Cast cutter – use to cut the plaster
 Skin under the cast will be noted tender and dry and
may have crust of dry skin. (Normal)
 Gently wash the area and explain that the skin will
regain its normal appearance after few days.
 Muscle atrophy may be apparent. Assure the patient
that muscle mass will be restored with use of limb.
Patient Teaching – Cast Care
 Keep plaster cast dry: follow physician’s instructions
regarding wetting synthetic cast.
 Do not remove any padding.
 Do not insert any foreign object inside the
cast.
 Do not bear weight on a new plaster cast for 48 hours
( synthetic , less than an hour.)
 Do not cover the cast with plastic for prolonged periods.
 Do report swelling, discoloration of toes or fingers, pain
during motion, and burning or tingling under the cast to
health care provider.
 Elevate the cast above the level of the heart during the first
24 – 48 hours after application to prevent swelling.
Splint
 A splint is a medical device for the immobilization of
limbs or of the spine.
 Splints are removable and allow for monitoring of skin
swelling or integrity.
 Splints can be used to support fractures/injured areas
or used for post paralysis injuries to avoid joint
contractures.
Splints
Splints
Splint and Immobilizers
Client instruction regarding Cast or Splint.
 Client can't move your fingers or toes.
 Client have severe pain or increased pain that you
think is from swelling, and your cast or splint feels too
tight.
 Client hand or foot feels numb or tingles.
 Client have a lot of swelling below your cast or splint.
 The skin under client cast or splint is burning or
stinging.
Traction
 Exerts a pulling force on a fracture extremity to provide
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alignment of the broken bone fragments.
It is also use to correct deformity, decrease muscle
spasm, promote rest, and maintain the position of the
diseased or injured part.
Correct or prevent further deformities.
Applied directly to skin ( skin traction)
Attached directly to the bone ( skeletal traction) by
means of metal pin or wire.
Skin Traction
Types of Traction
 Manual
 Skin Traction Used intermittently.
 Weight is no more than 5 to 10 lbs to prevent
injury to the skin.
 Buck’s traction – used for hip and knee
contractures, muscles spasms, and alignment of
hip fractures.
Skin Traction – Buck’s Traction
Traction
Skeletal Traction – Used continuously.
 Provides a strong, steady, continuous pull and can
be used for prolonged periods of time.
 e.g. Gardner-Wells, Crutchfield, and Vinke tongs
and a halo vest, in which pins are inserted into the
skull on either side. Heavier weights can be used
with skeletal traction , usually from 15 – 30 lbs.
Cruthcfield traction and a halo vest are used for
reduction and immobilization of fractures of the
cervical or high thoracic vertebrae.
Halo Traction
 Screws are placed through ther bone and are attached
to rods that secure to a non-movable vest worn by the
client.
 Wrench is use to release the rods from the vest and
taped to the front of the vest.
 Client is moved as a unit without pressure applied to
the rods attached to the vest and halo ring. This is
done to avoid loosening of the pins.
Traction Guidelines
 Maintain body alignment and realign if the client
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seems uncomfortable or reports pain.
Avoid lifting or removing weights.
Assure the weights hang freely.
If weights are accidentally displaced, replace the
weight. Report to care provider if problem is not
corrected.
Assure that the pulley ropes are free of knots.
Notify MD if client experienced severe pain from
muscle spasm unrelieved by medication and or
repositioning.
Routinely monitor skin integrity and document .
Osteoporosis
 Osteoporosis is a disease of bones that leads to an
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increased risk of fracture.
Metabolic disease in which bone is demineralized =
decreased bone density and subsequent fractures.
The cause is unknown.
Most common in women after menopause ( higher
risk).
May also develop in men and
May occur in anyone in the presence of particular
hormonal disorders and other chronic diseases or as a
result of medications, specifically glucocorticoids.
Risk
 Post menopausal, thin Caucasian women are at
highest risk for development of Osteoporosis.
 Encourage exercise.
 Diet high in Calcium, and supplemental calcium.
 Tums are excellent source of calcium, but also high in
Sodium.
NANDA NURSING DIAGNOSIS:
 Risk for injury
 Impaired physical mobility
 Deficient knowledge
Osteoporosis
 The main cause of fracture in the elderly, especially in
women, is osteoporosis. The main fractures sites seem
to be hip, vertebral bodies, and Colles fracture of the
forearm.
Osteoporosis
Osteoporosis – Nursing Assessment
 Classic Dowager’s hump, or Kyphosis of the Dorsal
spine.
 Back pain, often radiating around the trunk.
 Pathologic Fx, often occur in the distal end of the
radius and upper third of the femur.
 May also result to compression fracture of the
spine: It is important to assess ability to void and
defecate.
Nursing Plan and Interventions
A.
B.
C.
D.
E.
F.
G.
H.
I.
Create a hazard free environment.
Keep bed in low position.
Encourage client to wear shoe or slippers when out of bed.
Encourage environmental safety.
Provide assistance with ambulation
Teach regular exercise program. ROM, ambulation several times a day.
Provide diet that is high in protein, calcium, and Vit. D. Discourage use of
alhocol and caffeine.
Encourage preventive measures for females.
1. HRT for pause menopausal women but also can increase risk of breast
cancer, CVD, and stroke. If taken, the benefit should outweigh the risk.
2. High Calcium and Vit. D intake beginning in early adulthood.
3. Calcium supplementation after menopausal (Fosamax)
4. Weight –bearing exercises
Bone density study as a baseline after menopause, with frequency as
recommended by healthcare provider.
Post Lecture Exercise:
The nurse will provide priority nursing intervention to which
client?
a. Client who has been prescribed hormone
replacement therapy and complaining of
shortness of breath after exercise.
b. Client with cast on left lower extremity
complaining of pain unrelieved by analgesic
taken.
c. Client who has a cast on his left upper
extremity verbalizing itchiness.
d. Client who is post left hip replacement sitting
and has a temperature of 102 degrees Fahrenheit.
The nurse is initiating a nursing care plan for a client with
osteoporosis. Which intervention should the nurse
delegate to the UAP?
a. Identify the factors that increase risk for falls.
b. Monitor gait, balance and fatigue level with
ambulation.
c. Collaborate with physical therapy to provide client
with walker.
d. Assist the client with ambulation to bathroom and in
halls.
The nurse is teaching a client newly diagnosed with
osteoporosis about strategies to prevent falls. Which
statement by the nurse is correct ?
 Keep your throw rugs only on the living room.
 It is not necessary to exercise that often.
 Expect a few bumps and bruises when you go home.
 You should wear a hip protector when ambulating.
The UAP is ambulating the client down the hallway
with a walker. Which action by the UAP warrants
intervention by the nurse?
a. The UAP has the client to move the uninvolved side first.
b. The UAP ensured the client is wearing rubber soled shoes.
c. The UAP has the client to move the walker forward 6 to 8
inches
d. The UAP has the client’s elbows bent slightly.
Think about incorrect procedure.
The nurse is caring for a client diagnosed with
osteomyelitis. Which V/S result requires intervention
immediately?
a. Temperature of 99.9 degree F.
b. Blood pressure 136/80
c. Hear rate 96/minute
d. Respiratory rate 24/minute
During discharge preparations, a client with osteoporosis
makes all these statements. Which statement indicates
to the nurse that the patient needs additional teaching ?
a. “ I take my Ibuprofen every morning as soon as I get
up.”
b. “ My daughter removed all the throw rugs in my
home.”
c. “My husband helps me every afternoon with range of
motion exercises.”
d. “ I rest in my recliner chair every day for at least an
hour.”
The client suffered a fracture femur. Which of the
following would the nurse tell the UAP to report
immediately?
a. The client’s complains of pain.
b. The client appears confused.
c. The client’s blood pressure is 136/88.
d. The client voided using the bedpan.
The client with long leg cast complain a cold right foot,
absent pedal pulse, and is unable to move the right
foot. Which intervention should the nurse implement
first?
a. Document the findings in the chart.
b. Notify the health care provider.
c. Assess the posterior tibial pulse.
d. Elevate the right leg on two pillows.
If pt. is in distress will you assess? Is the client in
distress? Therefore, will you assess or provide
intervention? If intervention what will you do first?
The nurse is reviewing the client’s laboratory
data. Which data warrants immediate notification
the client’s health care provider?
a. The client with muscle cramping who has a potassium
level of 3.2 mEq/L.
b. The client with a compound fracture who has a WBC
of 9,000 cell per cubic centimeter.
c. The client diagnosed asthma whose aminophylline
level of 20 mcg/ml.
d. The client with fluid deficit who has a serum sodium
level of 144 mEq/L.
Which one is considered normal /abnormal findings?
The client who is diagnosed with osteoarthritis of the
right hip is prescribed with NSAIDs. Which priority
intervention should the nurse discuss in the
medication teaching?
a. Instruct the client to use a soft bristle tooth brush.
b. Take the medication when the pain level is at a “5”.
c. May take it with empty stomach for efficacy.
d. Tell the client to take the medication with food.
What would you instruct the client to prevent possible
complication to GI when taking NSAIDS? Think about
safety first.
The nurse is assessing the newly placed cast on the
client. The nurse noticed swelling and unable to insert
two fingers in the distal portion of the client’s below the
knee cast. Which intervention should the nurse
implement first?
a. Elevate the client’s leg on pillows.
b. Notify the client’s health care provider.
c. Document the findings in the chart.
d. Prepare to bifurcate (split)the cast.
What would you do initially to reduce edema?
The nurse is assigned to a client who is immobile due to
application of skeletal traction. Which intervention should the
nurse implement for the client who is immobile to help prevent
contractures?
a. Position the client to fowler’s position.
b. Perform ROM exercises every 4 hours.
b. Reposition client side to back to side every 2 hours.
d. Place the client in the prone position every 4 hours.
The nurse is teaching the client how to ambulate using a crutch.
Which statement by the client best described understanding
walking with a 3-point gait?
a. “ I will move both crutches and involved leg together,
then uninvolved leg is advance forward after.”
b. “ I will move the right crutch, then the left foot, then
the left crutch, then the right foot.”
c. “ I will move both crutches forward together; weight is
shifted onto hands for support and both legs are then
swing forward to meet the crutches.”
d. “ I will move both crutches are forward together, then
weight is shifted onto the hands for support and both
legs are swing forward beyond the point of crutch
placement.”
The nurse assign the UAP to ambulate the client. The client is
wearing a closed toed shoes in the hallway using a gait belt. Which
action should the nurse implement?
a. Tell the UAP to provide client with walker for more safety.
b. Validate the UAP’s action of using a gait belt makes
ambulation safe for the client.
c. Report the unsafe behavior of the UAP to the supervisor.
d. Request the UAP go to the nurse’s station and finish
ambulating the client.
 Which statement denotes the UAP observed safety action
for the client?
The client is diagnosed with rheumatoid arthritis tells
the clinic nurse that even when medication is taken that
the pain persist. Which statement by the nurse
considered the best?
a. “The pain is expected and there is nothing we can do.”
b. “Applying warm compresses to your joints may help
decrease the pain.”
c. “There are some experimental drugs you may want to
try.”
d. “I will refer you to a physical therapist to help with the
pain.”
The nurse is caring for a client who is one day
postoperative total right knee replacement. Which
intervention should the nurse implement?
a. Keep the right leg in a continuous passive motion
machine (CPM).
b. Assess the client’s right hip surgical dressing every
shift.
c. Check the client’s neurological status every two hours.
d. Ensure the client has the abductor pillow in place and
secure.