Background of Anatomy and Physiology

1
Background of Anatomy and Physiology

• Human skeleton made up of 206 bones
• 1. Axial skeleton includes
• a. Bones of skull
• b. Ribs and sternum
• c. Vertebral column
• 2. Appendicular skeleton includes
• a. Bones of limbs
• b. Shoulder girdles
• c. Pelvic girdle

2
Classification of bones by shape
3
Functions of bones

• 1. Form structure and provide support for soft
  tissues
• 2. Protect vital organs from injury
• 3. Serve to move body parts by providing points
  of attachment for muscles
• 4. Store minerals
• 5. Serve as site for hematopoiesis
• Bone cells include
• 1. Osteoblasts cells that form bone
• 2. Osteocytes cells that maintain bone matrix
• 3. Osteoclasts cells that resorb bone

4
Clients with Musculoskeletal Disorders

• Background
• 1. Normal bone remodeling process involves
  sequence of bone reabsorption and formation
• 2. Adults replace about 25 of trabecular bone
  (the porous type of bone found in the spine and
  all articulating joints) every 4 months through
  reabsorption of old bone by osteoclasts and
  formation of new bone by osteoblasts

5
Client with osteoporosis

• Definition
• a. Disorder characterized by loss of bone mass,
  increased bone fragility, increased risk for
  fractures
• b. Imbalance of processes that influence bone
  growth and maintenance associated with aging,
  but may result from endocrine disorder or
  malignancy
• c. Significant health threat for Americans
  estimated 28 million persons more common in
  aging women half of women over 50 experience
  osteoporosis-related fracture in lifetime (hip,
  wrist, vertebrae)

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Client with osteoporosis

• Risk Factors
• a. Risk of developing osteoporosis depends on
  amount of bone mass achieved between ages 25 35
• b. Unmodifiable risk factors
• 1. Aging decrease in osteoblastic and
  osteoclastic activity related to decreasing
  levels of hormones (estrogen in females
  testosterone in males)
• 2. Gender women have 10 15 less peak bone
  mass than men bone loss begins earlier (30s)
  and proceeds more rapidly (before menopause)
• 3. European Americans and Asians have less bone
  density than African Americans
• 4. Endocrine disorders affecting metabolism
  hyperthyroidism, hyperparathyroidism, Cushings
  syndrome, diabetes mellitus

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Client with osteoporosis

• Modifiable risk factors
• 1. Calcium deficiency insufficient calcium in
  diet results in body removing calcium from bones
  diets high in protein lead to acidosis, and high
  in diet soda are high in phosphate
• 2. Menopause, decreasing estrogen levels
  estrogen replacement therapy can reverse bone
  changes but may increase risk for other diseases
• 3. Cigarette smoking decreased blood supply to
  bones
• 4. Excessive alcohol intake toxic effect on
  osteoblastic activity high alcohol intake
  frequently associated with nutritional
  deficiencies
• 5. Sedentary life style weight-bearing exercise
  such as walking positively influences bone
  metabolism
• 6. Use of specific medications
  aluminum-containing antacids, corticosteroids,
  anticonvulsants, prolonged heparin therapy,
  antiretroviral

8
A normal spine at 40 years, and the osteoporotic
changes at ages 60 and 70 years
9
Client with osteoporosis

• Pathophysiology
• a. Diameter of bone increases, thinning outer
  supportive cortex
• b. Trabeculae (spongy tissue) lost and outer
  cortex thins
• c. Minimal stress leads to fracture
• 4. Manifestations (silent disease bone loss
  occurs without symptoms)
• a. Loss of height
• b. Progressive curvature of spine (dorsal
  kyphosis, cervical lordosis, accounting for
  dowagers hump)
• c. Low back pain
• d. Fractures of forearm, spine or hip

10
Client with osteoporosis

• Complications
• a. Fractures (gt 1.5 million fractures yearly),
  many spontaneous or resulting from everyday
  activities
• b. Persistent pain and associated posture changes
  restrict client activities and ability to perform
  ADL
• 6. Collaborative Care
• a. Stopping or slowing osteoporosis
• b. Alleviating symptoms
• c. Preventing complications

11
Client with osteoporosis

• Diagnostic Tests
• a. Xrays picture of skeletal structures but
  osteoporotic changes not seen untilgt 30 of bone
  mass lost
• b. Quantitative computed tomography (QCT) of
  spine measures trabecular bone within vertebral
  bodies
• c. Dual-energy Xray absorptiometry (DEXA)
  measures bone density in lumbar spine or hip
  highly accurate
• d. Alkaline phosphatase (AST) elevated post
  fracture
• e. Serum bone Gla-protein (osteocalcin) marker of
  osteoclastic activity and is indicator of rate of
  bone turnover used to evaluate effects of
  treatment

12
Client with osteoporosis

• Medications
• a. Estrogen replacement therapy reduces bone
  loss, increases bone density in spine and hip,
  reducing risk of fractures in postmenopausal
  women.
• 1. Recommended for women who have undergone
  surgical menopause before age 50
• 2. Associated risk for estrogen therapy alone is
  increased risk of endometrial cancer
• 3. Hormone replacement therapy (estrogen and
  progestin) associated with increased risk for
  cardiovascular disease and breast cancer
• b. Raloxifene (Evista) selective estrogen
  receptor modulator (SERM) that prevents bone loss
  by mimicking estrogen effects on bone density
  side effects are hot flashes contraindicated for
  women with history of blood clots
• c. Biphosphonates potent inhibitors of bone
  resorption used to prevent and treat osteoporosis
• 1.Alendronate (Fosamax)
• 2.Risedronate (Actonel)
• 3.Etidronate (Didronel)
• d. Calcitonin (Miacalcin) hormone increases bone
  formation and decreases bone resorption
  available as nasal spray or parenteral
• e. Sodium fluoride stimulates osteoblast
  activity, decreases risk of spinal fractures but
  associated with increased risk of other fractures
  including hip

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Client with osteoporosis

• Nursing Care
• a. Emphasis is prevention and education of
  clients under age of 35
• b. Prevention of complications in those with
  osteoporosis
• Health Promotion
• a. Calcium intake
• 1. Maintain daily intake of calcium at
  recommended levels, in divided doses
• a. Age 19 50 1000mg
• b. Age 51-64 1200 mg
• c. Age 65 and gt 1500 mg)
• 2. Optimal intake before age 30 35 increases
  peak bone mass
• 3. Foods high in calcium include milk, milk
  products, salmon, sardines, clams, oysters, dark
  green leafy vegetables
• 4. Supplementationcalcium carbonate (Tums)
  calcium combined with Vitamin D for older adults

14
Client with osteoporosis

• Exercise
• 1. Physical activity that is weight-bearing
• 2. Walking 20 minutes, 4 or gt times per week
• Health-related behaviors
• 1. Include not smoking
• 2. Avoid excessive alcohol
• 3. Limit caffeine to 2 3 cups of coffee daily
• 4. Limit diet soda

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Client with osteoporosis

• Nursing Diagnoses
• a. Health Seeking Behaviors
• b. Risk for Injury
• c. Imbalanced Nutrition Less than body
  requirements
• d. Acute Pain
• Home Care Focus is on education including safety
  and fall prevention inside and outside the home

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Client with Pagets Disease (osteitis deformans)

• Description
• a. Progressive skeletal disorder with excessive
  metabolic bone activity leading to affected bones
  becoming larger and softer
• b. Affects femur, pelvis, vertebrae, sacrum,
  sternum, skull
• c. Relatively rare
• d. Occurs more often in whites
• e. Slightly more common in males
• f. Familial tendency

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Client with Pagets Disease (osteitis deformans)

• Pathophysiology
• a. Bones are initially soft and bowing occurs
  then become hard and brittle leading to fractures
  
• b. Slow progression with 2-stage process
• 1. Excessive osteoclastic bone resorption
• 2. Excessive osteoblasticbone formation

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Client with Pagets Disease (osteitis deformans)

• Manifestations
• a. Most are asymptomatic
• b. Localized pain of long bones, spine, pelvis,
  cranium pain is mild to moderate deep ache which
  is aggravated by pressure and weight-bearing
  noticed at night and when resting
• c. Flushing and warmth over areas of bone
  involvement

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Client with Pagets Disease (osteitis deformans)

• Complications
• a. Degenerative osteoarthritis
• b. Pathological fractures
• c. Nerve palsy syndromes from involvement of
  upper extremities
• d. Compression of spinal cord causing tetraplegia
• e. Mental deterioration from skull involvement
  and brain compression

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Client with Pagets Disease (osteitis deformans)

• Collaborative Care
• a. Pain relief
• b. Suppression of bone cell activity
• c. Complication prevention
• Diagnostic Test
• a. Xray (often incidental) slow localized areas
  of demineralization in early phase later
  enlargement of bones with tiny cracks in long
  bones or bowing in weight-bearing bones
• b. Bone scan active Pagets disease

21
Client with Pagets Disease (osteitis deformans)

• c. CT scans and MRI show degenerative problems,
  spinal stenosis, nerve root impingement
• d. Serum alkaline phosphatase steady rise as
  disease progresses
• e. Urinary collagen pyridinoline testing
  indicator of rate of bone resorption

22
Client with Pagets Disease (osteitis deformans)

• Medications
• a. Mild symptoms relieved by aspirin or NSAIDs
• b. Bone resorption retarded by
• 1. Biphosphonates calcium supplements are
  prescribed in addition
• a. Alendronate (Fosamax)
• b. Pamidronate (Aredia)
• c. Tiludronate (Skelid)
• 2. Calcitonic works as analgesic for bone pain
• a. Salmon calcitonin (Calcimar)
• b. Human calcitonin (Cibacalcin)

23
Client with Pagets Disease (osteitis deformans)

• Surgery
• a. Total hip or knee replacement is usually
  required when client with Pagets disease
  develops degenerative arthritis of hip or knee
• b. May require surgery for spinal stenosis, nerve
  root compression
• Nursing Diagnoses
• a. Chronic Pain
• 1. May involve wearing a back brace for relief of
  back pain
• 2. Heat therapy and massage
• b. Impaired Physical Mobility
• Home Care manifestations often relieved by
  treatment

24
Client with osteomalacia (adult rickets)

• Metabolic bone disorder characterized by
  inadequate or delayed mineralization of bone
  matrix leading to marked deformities of weight
  bearing bone and pathologic fractures
• Pathophysiology
• a. Primary causes are vitamin D deficiency and
  hypophosphatemia
• 1. Vitamin D deficiency
• a. Present in
• 1. Older adults
• 2. Very-low-birth weight infants
• 3. Strict vegetarians
• b. Caused by
• 1. Diet low in vitamin D
• 2. Impaired intestinal absorption of fats
• 3. Inadequate sun exposure
• 4. Some types of renal failure
• 2. Hypophosphatemia most commonly caused by
  alcohol abuse

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Process of vitamin D metabolism in the body
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Client with osteomalacia (adult rickets)

• Other causes
• 1. Insufficient calcium absorption in intestines,
  due to lack of calcium or resistance to action of
  Vitamin D
• 2. Increase loss of phosphorus through urine
• Manifestations
• a. Bone pain and tenderness
• b. Common fractures are distal radius and
  proximal femur
• Collaborative Care requires differential
  diagnosis from osteoporosis

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Client with osteomalacia (adult rickets)

• Diagnostic Tests
• a. Xray demonstrates generalized bone
  demineralization
• b. Serum calcium levels are normal or low
• c. Serum parathyroid hormone is frequently
  elevated as compensatory response
• d. Alkaline phosphatase level usually elevated

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Client with osteomalacia (adult rickets)

• Medications
• a. Treatment of underlying condition
• b. Vitamin D therapy with calcium and phosphate
  supplements
• c. Radiologic evidence of healing apparent within
  weeks of therapy

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Client with osteomalacia (adult rickets)

• Nursing Care
• a. Assessment of dietary intake of Vitamin D,
  calcium, phosphorus, exposure to ultraviolet
  light
• b. Management of client responses to bone pain
  and tenderness, fractures, muscle weakness
• c. Vitamin D sources include dairy products
  fortified with Vitamin D and cod liver oil
• d. If client takes supplements, must be aware of
  potential for toxicity with fat soluble vitamins
• e. Fall prevention

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Client with osteomyelitis

• 1. Infection of the bone, may occur as acute,
  subacute, or chronic
• 2. Consequence of bacteremia, invasion from
  contiguous focus of infection, skin breakdown
  more prevalent in adults over age of 50
• 3. Pathophysiology
• a. Usually bacterial in nature most commonly
  Staphylococcus aureus
• b. Sources of infection
• 1. Direct contamination of bone from open wounds
  (trauma)
• 2. Complication of surgery
• 3. Extension of chronic ulcers including venous,
  arterial, diabetic
• c. Infection develops in bone, which may
  interfere with vascular supply to bone, and
  necrosis occurs difficult for antibiotics to
  reach the bacteria within the bone

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Osteomyellitis

• Osteomyellitis

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Client with osteomyelitis

• Collaborative Care
• a. Pain relief
• b. Infection elimination or prevention
• c. Early diagnosis to prevent bone necrosis by
  early antibiotic therapy
• d. Often requires bone debridement and long
  course of antibiotics

33
Client with osteomyelitis

• Diagnostic Tests
• a. MRI and CT scans show abscesses and soft
  tissue changes
• b. Radionucleotides bone scans determine whether
  infectious or inflammatory changes in bone
• c. CBC and ESR WBC and ESR are elevated
• d. Blood and tissue cultures identify infectious
  organism and determine appropriate antibiotic
  therapy

34
Client with osteomyelitis

• Medications
• a. Antibiotics mandatory to prevent acute case
  from becoming chronic osteomyelitis
• b. Initially treated as staph infection until
  results of culture are obtained
• c. Definitive antibiotics prescribed according to
  culture results
• d. Continued at least 4 6 weeks with
  intravenous or oral antibiotics

35
Client with osteomyelitis

• Surgery
• a. Needle aspiration or percutaneous needle
  biopsy performed to obtain specimen specimen may
  also be obtained during debridement procedure
• b. Surgical debridement is primary treatment for
  chronic cases wound is opened, irrigated
  drainage tubes may be inserted for irrigation,
  suction, and antibiotic instillation

36
Client with osteomyelitis

• Nursing Care
• a. Persons with chronic osteomyelitis face
  frequent and lengthy treatments
• b. Client needs to be aware of manifestations of
  recurrent infection (inflammation in area,
  temperature elevation)
• c. Prognosis is uncertain and client must be
  maintained under care to prevent amputation or
  functional deficits

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Client with osteomyelitis

• Nursing Diagnoses
• a. Risk for Infection
• b. Hyperthermia interventions include
  maintenance of adequate fluid intake
• c. Acute Pain splinting or use of immobilizer
  may limit swelling and improve pain
• d. Anxiety
• Home Care
• a. Often vital part of treatment of osteomyelitis
• b. Referral to home care agency for support with
  wound treatment, antibiotic administration,
  obtaining supplies, nutritional teaching

38
Neoplastic Disorders Bone Tumors

• Description
• 1. Tumors may be malignant or benign
• a. Benign tumors grow slowly and do not invade
  surrounding tissues
• b. Malignant tumors grow rapidly and metastasize
• 2. Tumors can be primary (rare) or metastatic
  lesions originating from primary tumors of
  prostate, breast, kidney, thyroid, lung

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Neoplastic Disorders Bone Tumors

• Pathophysiology
• 1. Cause unknown, but connection exists between
  bone activity and development of primary bone
  tumors
• 2. Primary tumors cause osteolysis, bone
  breakdown, which weakens bone and leads to bone
  fractures
• 3. Malignant bone tumors invade and destroy
  adjacent bone tissue

40
Neoplastic Disorders Bone Tumors

• Manifestations often history of fall or blow to
  extremity brings mass to attention
• 1. Pain
• 2. Mass
• 3. Impaired function

41
Neoplastic Disorders Bone Tumors

• Diagnostic Tests
• 1. Xray shows location of tumors and extent of
  bone involvement
• a. Benign tumors show sharp margins separating
  from normal bones
• b. Metastatic bone destruction characteristic
  moth-eaten pattern
• 2. CT scan evaluation of extent of tumor
  invasion into bone, soft tissues, neurovascular
  structures
• 3. MRI determine extent of tumor invasion,
  response of bone tumors to radiation and
  chemotherapy, recurrent disease
• 4. Needle biopsy to determine exact type of bone
  tumor
• 5. Serum alkaline phosphatase elevated with
  malignant bone tumors
• 6. RBC count elevation
• 7. Serum calcium elevated with massive bone
  destruction

42
Neoplastic Disorders Bone Tumors

• Treatments
• 1. Chemotherapy
• a. Used to shrink tumor before surgery
• b. Control reoccurrence
• c. Treat metastasis
• 2. Radiation
• a. Often combined with chemotherapy
• b. Used for pain control with metastatic
  carcinomas
• c. Eliminate tumor remains after surgery
• 3. Surgery
• a. Eliminate primary bone tumors to eliminate
  tumors completely may involve excise tumor or
  amputate affected limb
• b. With some surgeries, cadaver allografts or
  metal prostheses used to replace missing bone to
  avoid amputation

43
Neoplastic Disorders Bone Tumors

• Nursing Diagnoses
• 1. Risk for Injury (pathologic fractures)
• 2. Acute and Chronic Pain
• 3. Impaired Physical Mobility
• 4. Decisional Conflict assist client in gaining
  information for informed decisions regarding
  treatment options
• Home Care
• 1. Client education regarding treatment plan,
  wound care, activity and weight bearing
  restrictions
• 2. Support with referral to prosthetic specialist
  or hospice as case indicates

44
Client with a Fracture

• Fracture any break in continuity of bone
• 1. Occurs when bone is subjected to more kinetic
  energy than the bone can absorb
• 2. Mechanisms producing fracture
• a. Direct energy applied at or near site of
  fracture
• b. Indirect transmitted from point of impact to
  site where bone is weaker

45
Client with a Fracture

• Classifications of fractures
• a. Simple (closed) skin intact over fracture or
  compound (open) where skin is interrupted over
  injury and there is increased risk for infection
• b. Fracture line may be
• 1. Oblique at 45o angle to bone
• 2. Spiral curves around the bone
• 3. Avulsed occurs when fracture pulls bone and
  other tissues away from point of attachment
• 4. Comminuted bone breaks in many small pieces
• 5. Compressed bone is crushed
• 6. Impacted broken bone ends are forced into
  each other
• 7. Depressed broken bone is forced inward

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Common types of fractures
47
Open fracture
48
Closed fracture
49
Client with a Fracture

• c. Complete fracture involves entire width of
  bone incomplete fracture does not involve the
  entire width of bone
• d. Stable (nondisplaced) fracture is fracture in
  which bones maintain their anatomic alignment
  unstable (displaced) fracture fracture in which
  bones move out of correct anatomic alignment
• e. Description according to point of reference
  i.e. midshaft, intrarticular

50
Client with a Fracture

• Manifestations
• a. May be accompanied by soft tissue injuries
  involving muscles, arteries, veins, nerves, skin
• b. May be alteration in circulation, sensation,
  swelling, pain
• c. May be obvious deformity or fracture
• d. May have felt the breakage of bone during the
  injury event

51
Client with a Fracture

• Fracture healing
• a. Phases include
• 1. Inflammatory phase
• a. Bleeding and inflammation develop at site of
  fracture
• b. Hematoma forms around the bone surface
• c. Necrosis of osteocytes leads to vasodilation
  and edema
• d. Collagen forms and allows calcium to be
  deposited
• 2. Reparative phase
• a. Callus begins to form
• b. Osteoblasts promote formation of new bone
• c. Osteoclasts destroy dead bone and assist in
  synthesis of new bone

52
Client with a Fracture

• Remodeling phase
• a. Excess callus is removed
• b. New bone is laid down along the fracture line
• c. Eventually fracture site is calcified and bone
  is reunited
• b. Healing of fracture influenced by
• 1. Age and physical condition of client
• 2. Type of fracture
• c. Time
• 1. Uncomplicated fracture of arm or foot heals in
  6 8 weeks
• 2. Fractured hip heals in 12 16 weeks

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The stages of bone healing
54
Client with a Fracture

• Emergency care involves
• a. Immobilization of fracture
• 1. Immobilize above and below the deformity
• 2. Splint to maintain normal anatomical alignment
  and prevent further dislocation or damage
• 3. Use air splint or splint to body
• b. Maintenance of tissue perfusion
• 1. Control obvious bleeding with pressure
  dressing
• 2. Assessment of pulses, movement, sensation any
  alteration requires prompt medical evaluation
• c. Prevention of infection Cover open wounds
  with sterile dressing

55
Client with a Fracture

• Diagnostic Tests
• a. History of incident and initial assessment
• b. Xray of bones involved in fracture
• c. Additional tests as indicated CBC, blood
  chemistries, coagulation studies to assess for
  blood loss, renal function, muscle breakdown,
  excessive bleeding or clotting
• 8. Medications
• a. Pain relief according to degree of injury and
  clients assessment of pain (may require
  narcotics)
• b. NSAIDs for anti-inflammatory affect as well as
  analgesia
• c. Medications to guard against ulcers
• d. Stool softeners to prevent constipation
• e. Antibiotics especially with open fractures
• f. Anticoagulants, if client considered at risk
  for deep vein thrombosis

56
Client with a Fracture

• Treatments
• a. Surgery
• 1. Indications
• a. Requires direct visualization and repair
• b. Fracture associated with long-term
  complications
• c. Severely comminuted fracture, which threatens
  vascular supply

57
Client with a Fracture

• Types
• a. External fixation external fixator (frame
  connected to pins inserted into long axis of
  bone) maintains immobilization of fracture but
  increases independence of client
• b. Internal fixation surgical procedure open
  reduction internal fixation (ORIF) involves
  reducing fracture and applying hardware (pins,
  nails, screws, or plates) to hold bones in place

58
External fixation of a fracture
59
Internal fixation hardware
60
Internal fixation hardware
61
Client with a Fracture

• Traction application of straightening or pulling
  force to maintain or return fractured bones in
  normal alignment prevent muscle spasms
• 1. Weights are used to maintain necessary force
• 2. Types of traction
• a. Manual by hand
• b. Straight pulling force in straight line
  Bucks traction straight skin traction often
  used with fractured hip
• c. Balanced suspension involves more than one
  force of pull
• d. Skeletal application of pulling force through
  placement of pins into the bone allows use of
  more weight to maintain alignment increased risk
  of infection

62
Client with a Fracture

• Casting rigid device applied to immobilize
  bones and promote healing
• 1. Extends above and below the fractured bone
  which must be relatively stable
• 2. Types include
• a. Plaster 48 hours needed to dry
• b. Fiberglass dries within one hour
• d. Electrical bone stimulation application of
  electrical current at the fracture site used to
  treat fractures that are not healing properly
• 1.Increases migration of osteoblasts and
  osteoclasts to fracture site
• 2.May be accomplished invasively or noninvasively
• 3.Contraindicated in presence of infection

63
Client with a Fracture

• Complications
• a. Compartment syndrome excess pressure in
  limited space, constricting structures within and
  reducing circulation to muscles and nerves
  normal pressure is 10 20 mm Hg
• 1. Results from hemorrhage and edema following a
  fracture or crush injury or external compression
  of limb, if cast is too tight
• 2. May result in cyclic ischemia and edema
  increasing risk for loss of limb or sepsis
• 3. Usually develops within first 48 hours of
  injury
• 4. Manifestations include progressive pain often
  distal to injury not responsive to analgesia,
  decreased sensation, loss of movement pulses may
  remain normal

64
Client with a Fracture

• Fat Embolism Syndrome (FES)
• 1. Fat globules lodge in pulmonary vascular bed
  or peripheral circulation occurs with long bone
  fracture, pressure within bone marrow rises,
  exceeds capillary pressure and fat globules leave
  bone marrow and enter circulation
• 2. Manifestations characterized by neurologic
  dysfunction, pulmonary insufficiency, petechial
  rash on chest, axilla, and upper arms within few
  hours or week after injury
• 3. May result in pulmonary edema, atelectasis,
  ARDS
• 4. Prevention early stabilization of long-bone
  fractures

65
Client with a Fracture

• Deep vein thrombosis (DVT) blood clot forms in
  lining of large vein can lead to pulmonary
  embolism
• 1. Prevention early immobilization of fracture
  and early ambulation
• 2. Prophylactic anticoagulation, antiembolism
  stocking and compression boots
• 3. Prompt diagnosis of DVT and adequate treatment
• Infection any complication decreasing blood
  supply increases risk may result from
  contamination at time of injury or during surgery
• 1. Organisms include Pseudomonas, Staphylococcus
  or Clostridium
• 2. May lead to osteomyelitis, infection within
  the bone

66
Client with a Fracture

• Delayed union prolonged healing of bones beyond
  usual time period
• 1. Risk Factors include
• a. Poor nutrition
• b. Inadequate immobilization
• c. Prolonged reduction time
• d. Infection, necrosis, age
• e. Immunosuppression
• f. Severe bone trauma
• 2. Detected by serial xrays (xray findings lag 1
  2 weeks behind the healing process)

67
Client with a Fracture

• Nonunion
• 1. Persistent pain and movement at fracture site
• 2. Treatments
• a. Surgery internal fixation, bone grafting
• b. Debridement if infection present
• c. Electrical stimulation
• Reflex Sympathetic Dystrophy
• 1. Poorly understood post-traumatic condition
• 2. Manifestations of persistent pain,
  hyperesthesias, swelling, changes in skin color,
  texture, temperature, and decreased motion
• 3. Treatment includes sympathetic nerve block

68
Client with a Fracture

• Nursing Care involved with fractures includes
  management of
• 1. Pain
• 2. Impaired physical mobility
• 3. Impaired tissue perfusion
• 4. Neurovascular compromise
• 5. Assessment of clients response to trauma
• Health Promotion
• 1. Emphasis is trauma prevention
• 2. Maintain good bone health including
  weight-bearing exercise, avoiding obesity,
  adequate calcium intake

69
Client with a Fracture

• Nursing Diagnoses
• 1. Acute Pain
• 2. Risk for Peripheral Neurovascular Dysfunction
• 3. Risk for Infection
• 4. Impaired Physical Mobility
• 5. Risk for Disturbed Sensory Perception Tactile
• Home Care Client and family teaching focuses on
  individualized needs
• 1. Cast care
• 2. Following physicians directions regarding
  weight bearing
• 3. Home physical therapy referral
• 4. Obtaining needed equipment

70
Client with an Amputation

• Partial or total removal of body part resulting
  from traumatic event or chronic condition
• B. Causes of amputation
• 1. PVD is major cause
• 2. Trauma is major cause of upper extremity
  amputation
• 3. Other traumatic events resulting in amputation
  include frostbite, burns, electrocution
• C. Underlying cause of amputation is interruption
  in blood flow either acute or chronic

71
Client with an Amputation

• Levels of amputation
• 1. Determined by local (ischemia and gangrene)
  and system factors (cardiovascular status, renal
  function, severity of diabetes mellitus)
• 2. Goals
• a. Alleviate symptoms
• b. Maintain health tissue
• c. Increase functional outcome joints are
  preserved whenever possible to allow for greater
  function
• Types of amputation
• 1. Open (guillotine) performed when infection is
  present and remains open to drain
• 2. Closed (flap) wound is closed with flap of
  skin sutured in place over stump

72
Common sites of amputation
73
Client with an Amputation

• Amputation site healing
• 1. Immediate post-operative assess circulation
  to stump
• 2. Rigid or compression dressing is applied to
  prevent infection and minimize edema
• 3. Stump is wrapped in Ace bandage to allow a
  conical shape to form and prevent edema applied
  from distal to the proximal extremity

74
Client with an Amputation

• Complications
• 1. Infection
• a. Local
• 1. Drainage or odor
• 2. Redness
• 3. Positive wound culture
• 4. Increased discomfort at suture line
• b. System
• 1. Fever, chills
• 2. Increased heart rate or decreased blood
  pressure
• 3. Positive wound or blood cultures

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Client with an Amputation

• Delayed healing
• a. Slower rate of healing than normal
• b. Factors include
• 1. Poor or inadequate nutrition
• 2. Poor blood flow, possibly related to smoking
• 3. Decreased cardiac output limits circulation
• Chronic stump pain
• a. Results from neuroma formation causing severe
  burning pain
• b. Treatments include
• 1. Medications
• 2. Nerve blocks
• 3. Transcutaneous electrical nerve stimulation
  (TENS)
• 4. Surgical stump reconstruction

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Client with an Amputation

• Phantom limb pain/ phantom limb sensation
• a. Majority of amputees have sensations such as
  tingling, numbness, cramping or itching in the
  phantom foot or hand, often self-limited
• b. Phantom limb pain is pain often difficult to
  treat may be referred to pain clinic for
  comprehensive pain management

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Client with an Amputation

• Contracture
• a. Abnormal flexion and fixation of joint caused
  by muscle atrophy and shortening
• b. Common complication associated with above the
  knee amputation
• c. Interventions include
• 1. Lying prone for periods throughout day
• 2. Active and passive range of motion
• 3. Avoid prolonged sitting

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Client with an Amputation

• Prosthesis
• a. Type depends on level of amputation, clients
  occupation and life style
• b. Client with lower extremity amputation often
  fitted with early walking aids pneumatic device
  that fits over stump and allows early ambulation,
  decreased postoperative swelling

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Client with an Amputation

• Nursing Diagnoses
• a. Acute Pain
• b. Risk for Infection
• c. Impaired Skin Integrity
• d. Risk for Dysfunctional Grieving
• e. Disturbed Body Image
• f. Impaired Physical Mobility
• Home Care Education and information for client
  and family regarding stump care, prosthesis
  fitting and care, assistive devices, exercises,
  rehabilitation, safety issues

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Stump dressing