1. Description: Bone union or healing is the process that occurs after the integrity of a bone is interrupted.

2. Stages

[image]

1. Description: Arthrocentesis is used to diagnose joint inflammation and infection.

a. Arthrocentesis involves aspirating synovial fluid, blood, or pus via a needle inserted into a joint cavity.

b. Medication, such as corticosteroids, may be instilled into the joint if necessary to alleviate inflammation.

2. Interventions

a. Obtain informed consent.

b. Apply an elastic compression bandage postprocedure as prescribed.

c. Use ice to decrease pain and swelling.

d. Pain may worsen after aspirating fluid from the joint; analgesics may be prescribed.

e. Pain can continue up to 2 days after administration of corticosteroids into a joint.

f. Instruct the client to rest the joint for 8 to 24 hours postprocedure.

g. Instruct the client to notify the health care provider (HCP) if a fever or swelling of the joint occurs.

1. Description: Arthrography is used in unexplained joint pain or inflammation to diagnose trauma to the joint capsule or ligaments.

a. Arthrography is a radiographic examination of the soft tissues of the joint structures.

b. A local anesthetic is used for the procedure.

c. A contrast medium or air is injected into the joint cavity, and the joint is moved through range of motion as a series of x-rays are taken.

2. Interventions

a. Instruct the client to fast from food and fluids for 8 hours before the procedure as prescribed.

b. Assess the client for allergies to iodine or shellfish before the procedure.

c. Obtain informed consent.

d. Inform the client of the need to remain as still as possible, except when asked to reposition.

e. Minimize the use of the joint for 12 hours after the procedure.

f. Instruct the client that the joint may be edematous and tender for 1 to 2 days after the procedure and may be treated with ice packs and analgesics as prescribed.

g. Instruct the client that if edema and tenderness last longer than 2 days, the HCP should be notified.

h. If knee arthrography was performed, an elastic compression wrap over the knee may be prescribed for 3 to 4 days and ice applied to decrease pain and swelling.

i. If air has been used for injection, crepitus may be felt in the joint for up to 2 days.

1. Description: Arthroscopy is used to diagnose and treat acute and chronic disorders of the joint.

a. Arthroscopy provides an endoscopic examination of various joints.

b. Articular cartilage abnormalities can be assessed, loose bodies removed, and the cartilage trimmed.

c. A biopsy may be performed during the procedure.

2. Interventions

a. Instruct the client to fast for 8 to 12 hours before the procedure.

b. Obtain informed consent.

c. Administer pain medication as prescribed postprocedure.

d. Assess the neurovascular status of the affected extremity.

e. An elastic compression bandage should be worn postprocedure for 2 to 4 days as prescribed.

f. Instruct the client that walking without weight bearing usually is permitted after sensation returns but to limit activity for 1 to 4 days as prescribed following the procedure.

g. Instruct the client to elevate the extremity as often as possible for 2 days following the procedure and to place ice on the site to minimize swelling.

h. Reinforce instructions regarding the use of crutches, which may be used for 5 to 7 days postprocedure for walking.

i. Advise the client to notify the HCP if fever or increased knee pain occurs or if edema continues for more than 3 days postprocedure.

1. Dual-energy x-ray absorptiometry

a. Dual-energy x-ray absorptiometry measures the bone mass of the spine, wrist and hip bones, and total body.

b. Radiation exposure is minimal.

c. Dual-energy x-ray absorptiometry is used to diagnose metabolic bone disease and to monitor changes in bone density with treatment.

d. Inform the client that the procedure is painless.

e. All metallic objects are removed before the test.

2. Quantitative ultrasound

a. Quantitative ultrasound evaluates strength, density, and elasticity of various bones, using ultrasound rather than radiation.

b. Inform the client that the procedure is painless.

1. Description: A bone scan is used to identify, evaluate, and stage bone cancer before and after treatment; it is also used to detect fractures.

a. Radioisotope is injected intravenously and will collect in areas that indicate abnormal bone metabolism and some fractures, if they exist.

b. The isotope is excreted in the urine and feces within 48 hours and is not harmful to others.

2. Interventions

a. Food and fluids may be withheld, before the procedure.

b. Obtain informed consent.

c. Remove all jewelry and metal objects.

d. Following the injection of the radioisotope, the client must drink 32 oz of water (if not contraindicated) to promote renal filtering of the excess isotope.

e. From 1 to 3 hours after the injection, have the client void to clear excess isotope from the bladder before the scanning procedure is completed.

f. Inform the client of the need to lie supine during the procedure and that the procedure is not painful.

g. Monitor the injection site for redness and swelling.

h. Encourage oral fluid intake following the procedure.

No special precautions are required after a bone scan because a minimal amount of radioactivity exists in the radioisotope used for the procedure.

1. Description: Biopsy may be done during surgery or through aspiration or punch or needle biopsy.

2. Interventions

a. Obtain informed consent.

b. Monitor for bleeding, swelling, hematoma, or severe pain.

c. Elevate the site for 24 hours following the procedure to reduce edema.

d. Apply ice packs as prescribed following the procedure to prevent the development of a hematoma and decrease site discomfort.

e. Monitor for signs of infection following the procedure.

f. Inform the client that mild to moderate discomfort is normal following the procedure.

1. Description: EMG is used to evaluate muscle weakness.

a. Electromyography measures electrical potential associated with skeletal muscle contractions.

b. Needles are inserted into the muscle, and recordings of muscular electrical activity are traced on recording paper through an oscilloscope.

2. Interventions

a. Obtain informed consent.

b. Instruct the client that the needle insertion is uncomfortable.

c. Instruct the client not to take any stimulants or sedatives for 24 hours before the procedure.

d. Inform the client that slight bruising may occur at the needle insertion sites.

e. Mild analgesics can be used for the pain.

1. Strains are an excessive stretching of a muscle or tendon.

2. Management involves cold and heat applications, exercise with activity limitations, antiinflammatory medications, and muscle relaxants.

3. Surgical repair may be required for a severe strain (ruptured muscle or tendon).

1. Sprains are an excessive stretching of a ligament, usually caused by a twisting motion, such as in a fall or stepping onto an uneven surface.

2. Sprains are characterized by pain and swelling.

3. Management involves rest, ice, a compression bandage, and elevation (RICE) to reduce swelling, as well as joint support. RICE is considered a first-aid treatment, rather than a cure for soft tissue injuries.

4. Casting may be required for moderate sprains to allow the tear to heal.

5. Surgery may be necessary for severe ligament damage.

1. The musculotendinous or rotator cuff of the shoulder can sustain a tear, usually as a result of trauma.

2. Injury is characterized by shoulder pain and the inability to maintain abduction of the arm at the shoulder (drop arm test).

3. Management involves nonsteroidal antiinflammatory drugs (NSAIDs), physical therapy, sling support, and ice-heat applications.

4. Surgery may be required if medical management is unsuccessful or a complete tear is present.

Closed or Simple: Skin over the fractured area remains intact.

Comminuted: The bone is splintered or crushed, creating numerous fragments.

Complete: The bone is separated completely by a break into two parts.

Compression: A fractured bone is compressed by other bone.

Depressed: Bone fragments are driven inward.

Greenstick: One side of the bone is broken and the other is bent; these fractures occur most commonly in children.

Impacted: A part of the fractured bone is driven into another bone.

Incomplete: Fracture line does not extend through the full transverse width of the bone.

Oblique: The fracture line runs at an angle across the  axisof the bone.

Open or Compound: The bone is exposed to air through a break in the skin, and soft tissue injury and infection are common.

Pathological: The fracture results from weakening of the bone structure by pathological processes such as neoplasia; also called spontaneous fracture.

Spiral: The break partially encircles bone.

Transverse: The bone is fractured straight across.

A. Description: A fracture is a break in the continuity of the bone caused by trauma, twisting as a result of muscle spasm or indirect loss of leverage, or bone decalcification and disease that result in osteopenia.

C. Assessment of a fracture of an extremity

1. Pain or tenderness over the involved area

2. Decrease or loss of muscular strength or function

3. Obvious deformity of affected area

4. Crepitation, erythema, edema, or bruising

5. Muscle spasm and neurovascular impairment

D. Initial care of a fracture of an extremity

1. Immobilize affected extremity with cast or splint.

2. Assess neurovascular status of the extremity.

3. Interventions for a fracture: Reduction, fixation, traction, cast

If a compound (open) fracture exists, splint the extremity and cover the wound with a sterile dressing.

E. Reduction restores the bone to proper alignment.

1. Closed reduction is a nonsurgical intervention performed by manual manipulation.

a. Closed reduction may be performed under local or general anesthesia.

b. A cast may be applied following reduction.

2. Open reduction involves a surgical intervention; the fracture may be treated with internal fixation devices.

1. Internal fixation follows an open reduction

[image]

a. Internal fixation involves the application of screws, plates, pins, or intramedullary rods to hold the fragments in alignment.

b. Internal fixation may involve the removal of damaged bone and replacement with a prosthesis.

c. Internal fixation provides immediate bone stabilization.

2. External fixation is the use of an external frame to stabilize a fracture by attaching skeletal pins through bone fragments to a rigid external support

[image]

a. External fixation provides more freedom of movement than with traction.

b. Monitor pin stability and provide pin care to decrease infection risks.

c. Risk of infection exists with both fixation methods.

d. External fixation is commonly used when massive tissue trauma is present.

[image]

A, Buck’s traction. B, Russell’s traction. C, Head halter traction. D, Pelvic traction. E, Balanced suspension traction.

1. Description

a. Traction is the exertion of a pulling force applied in two directions to reduce and immobilize a fracture.

b. Traction provides proper bone alignment and reduces muscle spasms.

2. Interventions

a. Maintain proper body alignment.

b. Ensure that the weights hang freely and do not touch the floor.

c. Do not remove or lift the weights without an HCP’s prescription.

d. Ensure that pulleys are not obstructed and that ropes in the pulleys move freely.

e. Place knots in the ropes to prevent slipping.

f. Check the ropes for fraying.

1. Description

a. Traction is applied mechanically to the bone with pins, wires, or tongs.

b. Typical weight for skeletal traction is 25 to 40 lb.

2. Interventions

a. Monitor color, motion, and sensation of the affected extremity.

b. Monitor the insertion sites for redness, swelling, drainage, or increased pain.

c. Provide insertion site care as prescribed. 

Skin traction

1. Description: Skin traction is applied by using elastic bandages or adhesive, foam boot, or sling.

2. Cervical skin traction relieves muscle spasms and compression in the upper extremities and neck.

a. Cervical skin traction uses a head halter and chin pad to attach the traction.

b. Use powder to protect the ears from friction rub.

c. Position the client with the head of the bed elevated 30 to 40 degrees, and attach the weights to a pulley system over the head of the bed.

3. Buck’s (extension) skin traction is used to alleviate muscle spasms and immobilize a lower limb by maintaining a straight pull on the limb with the use of weights.

a. A boot appliance is applied to attach to the traction.

b. The weights are attached to a pulley; allow the weights to hang freely over the edge of bed.

c. Not more than 8 to 10 lb of weight should be applied as prescribed.

d. Elevate the foot of the bed to provide the traction.

4. Russell’s skin (sling) traction. See Fig. 68-4 and Chapter 46 regarding this type of traction.

5. Pelvic skin traction is used to relieve low back, hip, or leg pain or to reduce muscle spasm.

a. Apply the traction belt snugly over the pelvis and iliac crest and attach to the weights.

b. Use measures as prescribed to prevent the client from slipping down in bed.

1. Description

a. Balanced suspension traction is used with skin or skeletal traction.

b. Used to approximate fractures of the femur, tibia, or fibula

c. Balanced suspension traction is produced by a counterforce other than the client.

2. Interventions

a. Position the client in a low Fowler’s position on either the side or the back.

b. Maintain a 20-degree angle from the thigh to the bed.

c. Protect the skin from breakdown.

d. Provide pin care if pins are used with the skeletal traction.

e. Clean the pin sites with sterile normal saline and hydrogen peroxide or povidone-iodine (Betadine) as prescribed or per agency policy.

1. Description: Plaster, fiberglass, or air casts are used to immobilize bones and joints into

correct alignment after a fracture or injury.

2. Interventions

a. Keep the cast and extremity elevated.

b. Allow a wet plaster cast 24 to 72 hours to dry (synthetic casts dry in 20 minutes).

c. Handle a wet plaster cast with the palms of the hands until dry.

d. Turn the extremity every 1 to 2 hours, unless contraindicated, to allow air circulation and promote drying of the cast.

e. A hair dryer can be used on a cool setting to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin).

f. Prepare for bivalving or cutting the cast if circulatory impairment occurs.

g. Petal the cast or apply moleskin to the edges to protect the client’s skin; maintain smooth edges around the cast to prevent crumbling of the cast material.

h. Monitor for signs of infection such as increased temperature, hot spots on the cast, foul odor, or changes in pain.

i. If an open draining area exists on the affected extremity, the HCP will make a cutout portion of the cast known as a window.

j. Instruct the client not to stick objects inside the cast.

k. Teach the client to keep the cast clean and dry.

l. Instruct the client in isometric exercises to prevent muscle atrophy.

Monitor a casted extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. Notify the HCP immediately if circulatory compromise occurs.

1. Notify the health care provider (HCP).

2. Administer oxygen.

3. Administer intravenous fluids.

4. Monitor vital signs and respiratory status.

5. Prepare for intubation and mechanical ventilation if necessary.

6. Document the event, actions taken, and the client’s response.

A fat embolism originates in the bone marrow and occurs after a fracture when a fat globule is released into the bloodstream. Fat embolism can occur within the first 48 to 72 hours following the injury and clients with long bone fractures are at the greatest risk for the development of a fat embolism. Findings are similar to those noted with pulmonary embolism and include restlessness, hypoxemia, mental status changes, dyspnea, tachypnea, tachycardia, and hypotension. In addition, a petechial rash may present over the upper chest and neck. The HCP is notified immediately while

initiating emergency care. The client is maintained on bed rest and is repositioned only as necessary and gently. Oxygen is administered and intravenous hydration is administered to prevent hypovolemic shock. Vital signs and respiratory status are monitored closely and the client is prepared for intubation and mechanical ventilation if necessary. Corticosteroids may also be prescribed for the client. The nurse then documents the event, actions taken, and the client’s response.

1. Description

a. Tough fascia surrounds muscle groups, forming compartments from which arteries, veins, and nerves enter and exit at opposite ends.

b. Compartment syndrome occurs when pressure increases within one or more compartments, leading to decreased blood flow, tissue ischemia, and neurovascular impairment.

c. Within 4 to 6 hours after the onset of compartment syndrome, neurovascular damage is irreversible if not treated.

2. Assessment

a. Unrelieved or increased pain in the limb

b. Tissue that is distal to the involved area becomes pale, dusky, or edematous.

c. Pain with passive movement

d. Loss of sensation (paresthesia)

e. Pulselessness (a late sign)

3. Interventions

a. Notify the HCP immediately and prepare to assist HCP.

b. If severe, assist the HCP with fasciotomy to relieve pressure and restore tissue perfusion.

c. Loosen tight dressings or bivalve restrictive cast as prescribed.

1. Description: Infection and osteomyelitis (inflammatory response in bone tissue) can be caused by the introduction of organisms into bones leading to localized bone infection.

2. Assessment

a. Tachycardia and fever (usually above 101° F).

b. Erythema and pain in the area surrounding the infection

c. Leukocytosis and elevated erythrocyte sedimentation rate (ESR)

3. Interventions

a. Notify the HCP.

b. Prepare to initiate aggressive, long-term intravenous antibiotic therapy.

c. Administer hyperbaric oxygen therapy to promote healing.

d. Surgery is performed for resistant osteomyelitis with sequestrectomy and/or bone grafts.

1. Description: Avascular necrosis occurs when a fracture interrupts the blood supply to a section of bone, leading to bone death.

2. Assessment

a. Pain

b. Decreased sensation

3. Interventions

a. Notify the HCP if pain or numbness occurs.

b. Prepare the client for removal of necrotic tissue because it serves as a focus for infection.

1. Description: Pulmonary embolism is caused by the movement of foreign particles (blood clot, fat, or air) into the pulmonary circulation.

2. Assessment

a. Restlessness and apprehension

b. Sudden onset of dyspnea and chest pain

c. Cough, hemoptysis, hypoxemia, or crackles

3. Interventions

a. Notify the HCP immediately if signs of emboli are present.

b. Administer oxygen and other prescriptions; intravenous (IV) anticoagulant therapy may be prescribed.

A. Description

1. An accurate measurement of the client for crutches is important because an incorrect measurement could damage the brachial plexus.

2. The distance between the axillae and the arm pieces on the crutches should be two to three fingerwidths in the axilla space.

3. The elbows should be slightly flexed, 20 to 30 degrees, when the client is walking.

4. When ambulating with the client, stand on the affected side.

5. Instruct the client never to rest the axillae on the axillary bars.

6. Instruct the client to look up and outward when ambulating and to place the crutches 6 to 10 inches diagonally in front of the foot.

7. Instruct the client to stop ambulation if numbness or tingling in the hands or arms occurs.

B. Crutch gaits

[image]

C. Assisting the client with crutches to sit and stand

1. Place the unaffected leg against the front of the chair.

2. Move the crutches to the affected side, and grasp the arm of the chair with the hand on the unaffected side.

3. Flex the knee of the unaffected leg to lower self into the chair while placing the affected leg straight out in front.

4. Reverse the steps to move from a sitting to standing position.

D. Going up and down stairs

1. Up the stairs

a. The client moves the unaffected leg up first.

b. The client moves the affected leg and the crutches up.

2. Down the stairs

a. The client moves the crutches and the affected leg down.

b. The client moves the unaffected leg down.

A. Description: Canes and walkers are made of a lightweight material with a rubber tip at the bottom.

B. Interventions

1. Stand at the affected side of the client when ambulating; use of a gait or transfer belt may be necessary.

2. The handle should be at the level of the client’s greater trochanter.

3. The client’s elbow should be flexed at a 15- to 30-degree angle.

4. Instruct the client to hold the cane 4 to 6 inches to the side of the foot.

5. Instruct the client to hold the cane in the hand on the unaffected side so that the cane and weaker leg can work together with each step.

6. Instruct the client to move the cane at the same time as the affected leg.

7. Instruct the client to inspect the rubber tips regularly for worn places.

C. Hemicanes or quadripod canes

1. Hemicanes or quadripod canes are used for clients who have the use of only one upper extremity.

2. Hemicanes provide more security than a quadripod cane; however, both types provide more security than a single-tipped cane.

3. Position the cane at the client’s unaffected side, with the straight, nonangled side adjacent to the body.

4. Position the cane 6 inches from the unaffected client’s side, with the hand grip level with the greater trochanter.

D. Walker

1. Stand adjacent to the client on the affected side.

2. Instruct the client to put all four points of the walker flat on the floor before putting weight on the hand pieces.

3. Instruct the client to move the walker forward, followed by the affected or weaker foot and then the unaffected foot.

Safety is the priority concern when the client uses an assistive device such as a cane, walker, or crutches. Be sure that the client demonstrates correct use of the device.

A. Types

1. Intracapsular (femoral head is broken within the joint capsule)

a. Femoral head and neck receive decreased blood supply and heal slowly.

b. Skin traction is applied preoperatively to reduce the fracture and decrease muscle spasms.

c. Treatment includes a total hip replacement or open reduction internal fixation (ORIF) with femoral head replacement.

d. To prevent hip displacement postoperatively, avoid extreme hip flexion, and check the surgeon’s prescriptions regarding positioning.

2. Extracapsular (fracture is outside the joint capsule)

a. Fracture can occur at the greater trochanter or can be an intertrochanteric fracture.

b. Preoperative treatment includes balanced suspension or skin traction to relieve muscle spasms and reduce pain.

c. Surgical treatment includes open reduction internal fixation with nail plate, screws, pins, or wires.

B. Postoperative interventions

1. Monitor for signs of delirium and institute safety measures.

2. Maintain leg and hip in proper alignment and prevent internal or external rotation; avoid extreme hip flexion.

3. Follow the HCP’s prescriptions regarding turning and repositioning; usually, turning to the unaffected side is allowed.

4. Elevate the head of the bed 30 to 45 degrees for meals only.

5. Assist the client to ambulate as prescribed by the HCP.

6. Avoid weight bearing on the affected leg as prescribed; instruct the client in the use of a walker to avoid weight bearing.

7. Weight bearing is often restricted after an ORIF and may not be restricted after total hip arthroplasty (THA); always refer to the HCP’s prescriptions.

8. Keep the operative leg extended, supported, and elevated (preventing hip flexion) when getting the client out of bed.

9. Avoid hip flexion greater than 90 degrees and avoid low chairs when out of bed.

10. Monitor for wound infection or hemorrhage.

11. Neurovascular assessment of affected extremity: Check color, pulses, capillary refill, movement, and sensation.

12. Maintain the compression of the Hemovac or Jackson-Pratt drain to facilitate wound drainage.

13. Monitor and record drainage amount, which decreases consistently about 80 mL every 8 hours until 48 hours postoperatively.

14. Carry out postoperative blood salvage to collect, filter, and reinfuse salvaged blood into the client.

15. Use antiembolism stockings or sequential compression stockings as prescribed; encourage the client to flex and extend the feet to reduce the risk of deep vein thrombosis (DVT).

16. Instruct the client to avoid crossing the legs and activities that require bending over.

17. Physical therapy will be instituted postoperatively with progressive ambulation as prescribed by the HCP.

A. Description: Total knee replacement is the implantation of a device to substitute for the femoral condyles and tibial joint surfaces.

B. Postoperative interventions

1. Monitor surgical incision for drainage and infection.

2. Begin continuous passive motion 24 to 48 hours postoperatively as prescribed to exercise the knee and provide moderate flexion and extension.

3. Administer analgesics before continuous passive motion to decrease pain.

4. Prepare the client for out-of-bed activities as prescribed; have the client avoid leg dangling.

5. Avoid weight bearing and instruct the client in the use of the prescribed assistive device, such as a walker.

6. Postoperative blood salvage may be prescribed to collect, filter, and reinfuse salvaged blood into client.

A. Dislocation: Injury of the ligaments surrounding a joint, which leads to displacement or separating of the articular surfaces of the joint

B. Subluxation: Incomplete displacement of joint surfaces when forces disrupt the soft tissue that surrounds the joints

C. Assessment

1. Asymmetry of the contour of affected body parts

2. Pain, tenderness, dysfunction, and swelling

3. Complications include neurovascular compromise, avascular necrosis, and open joint injuries.

4. X-rays are taken to determine joint shifting.

D. Interventions

1. Focus of treatment includes pain relief, joint support, and joint protection.

2. Immediate treatment is done to reduce the dislocation and realign the dislocated joint.

3. Open or closed reduction is done with a postprocedural joint immobilization.

4. Intravenous conscious sedation, local, or general anesthesia is used during joint manipulation.

5. Initial activity restriction is followed by gentle range-of-motion activities and a gradual return of activities to normal levels while supporting the affected joint.

6. A weakened joint is prone to recurrent dislocation and may require extended activity restriction.

B. Cervical disk herniation occurs at the C5 to C6 and C6 to C7 interspaces.

1. Cervical disk herniation causes pain radiation to shoulders, arms, hands, scapulae, and pectoral muscles.

2. Motor and sensory deficits can include paresthesia, numbness, and weakness of the upper extremities.

3. Interventions

a. Conservative management is used unless the client develops signs of neurological deterioration.

b. Bed rest is prescribed to decrease pressure, inflammation, and pain.

c. Immobilize the cervical area with cervical collar or brace.

d. Apply heat to reduce muscle spasms and apply ice to reduce inflammation and swelling.

e. Maintain head and spine alignment.

f. Instruct the client in the use of analgesics, sedatives, antiinflammatory agents, and corticosteroids as prescribed.

g. Prepare the client for a corticosteroid injection into the epidural space if prescribed.

h. Assist and instruct the client in the use of a cervical collar or cervical traction as prescribed.

4. Cervical collar is used for cervical disk herniation.

a. A cervical collar limits neck movement and holds the head in a neutral or slightly flexed position.

b. The cervical collar may be worn intermittently or 24 hours daily.

c. Inspect the skin under the collar for irritation.

d. When prescribed and after pain decreases, exercises are done to strengthen the muscles.

5. Client education related to cervical disk conditions

a. Avoid flexing, extending, and rotating neck.

b. Avoid the prone position and maintain neck, spine, and hips in a neutral position while sleeping.

c. Minimize long periods of sitting.

d. Instruct the client regarding medications such as analgesics, sedatives, antiinflammatory agents, and corticosteroids.

C. Lumbar disk herniation most often occurs at the L4 to L5 or L5 to S1 interspace.

1. Herniation produces muscle weakness, sensory deficits, and diminished tendon reflexes.

2. The client experiences pain and muscle spasms in the lower back, with radiation of the pain into one hip and down the leg (sciatica).

3. Pain is relieved by bed rest and aggravated by movement, lifting, straining, and coughing.

4. Interventions

a. Conservative management is indicated unless neurological deterioration or bowel and bladder dysfunction occurs.

b. Apply heat to decrease muscle spasms and apply ice to decrease inflammation and swelling.

c. Instruct the client to sleep on the side, with the knees and hips flexed, and place a pillow between the legs.

d. Apply pelvic traction as prescribed to relieve muscle spasms and decrease pain.

e. Begin progressive ambulation as inflammation, edema, and pain subside.

5. Client education related to lumbar disk conditions

a. Instruct the client in the use of prescribed medications such as analgesics, muscle relaxants, antiinflammatory agents, or corticosteroids.

b. Instruct the client about application techniques for corsets or braces to maintain immobilization and proper spine alignment.

c. Instruct the client in correct posture while sitting, standing, walking, and working.

d. Instruct the client in the correct technique to use when lifting objects such as bending the

knees, maintaining a straight back, and avoiding lifting objects above the elbow level.

e. Instruct in a weight control program as prescribed.

f. Instruct the client in an exercise program to strengthen back and abdominal muscles as prescribed.

D. Disk surgery is used when spinal cord compression is suspected or client’s symptoms do not respond to conservative treatment

Diskectomy: Removal of herniated disk tissue and related matter

Diskectomy with Fusion: Fusion of vertebrae with bone graft

Laminectomy: Excision of part of the vertebrae (lamina) to remove the disk

Laminotomy: Division of the lamina of a vertebra

1. Preoperative interventions

a. Routine preoperative instructions are provided.

b. Instruct the client about logrolling and range-of-motion exercises.

2. Postoperative interventions: Cervical disk

a. Monitor for respiratory difficulty from inflammation or hematoma.

b. Encourage coughing, deep breathing, and early ambulation as prescribed.

c. Monitor for hoarseness and inability to cough effectively because this may indicate laryngeal nerve damage.

d. Use throat sprays or lozenges for sore throat, avoiding anesthetic lozenges that may numb the throat and increase choking risks.

e. Monitor the surgical wound for infection, swelling, redness, drainage, or pain.

f. Provide a soft diet if the client complains of dysphagia.

g. Monitor for sudden return of radicular pain, which may indicate cervical spine instability.

3. Postoperative interventions: Lumbar disk

a. Monitor for wound drainage and bleeding.

b. Monitor lower extremities for sensation, movement, color, temperature, and paresthesia.

c. Monitor for urinary retention, paralytic ileus, and constipation, which can result from decreased movement, opioid administration, or spinal cord compression.

d. Prevent constipation by encouraging a high-fiber diet, increased fluid intake, and stool softeners as prescribed.

e. Administer opioids and sedatives as prescribed to relieve pain and anxiety.

f. Assist and instruct the client to use a prescribed back brace or corset with cotton underwear to prevent skin irritation.

4. Postoperative lumbar disk positioning

a. In the immediate postoperative period, the client may be expected to lie supine or have other activity restrictions, depending on the specific surgical intervention.

b. Instruct the client to avoid spinal flexion or twisting and that the spine should be kept aligned.

c. Instruct the client to minimize sitting, which may place a strain on the surgical site.

d. When the client is lying supine, place a pillow under the neck and slightly flex the knees.

e. Avoid extreme hip flexion when lying on the side.

Following disk surgery, instruct the client in correct logrolling techniques for turning and repositioning and for getting out of bed.

A. Description

1. Amputation is the surgical removal of a limb or part of the limb.

2. Complications include hemorrhage, infection, phantom limb pain, neuroma, flexion contractures

B. Postoperative interventions

1. Monitor for signs of complications.

2. Mark bleeding and drainage on the dressing if it occurs.

3. Evaluate for phantom limb sensation and pain; explain sensation and pain to the client, and medicate the client as prescribed.

4. To prevent hip flexion contractures, do not elevate the residual limb on a pillow.

5. First 24 hours: Elevate the foot of the bed to reduce edema; then keep the bed flat to prevent hip flexion contractures, if prescribed by the HCP.

6. After 24 to 48 hours postoperatively, position the client prone to stretch the muscles and prevent hip flexion contractures, if prescribed.

7. Maintain surgical application of dressing, elastic compression wrap, or elastic stump (residual limb) shrinker as prescribed to reduce swelling, minimize pain, and mold the residual limb in preparation for prosthesis

[image]

8. As prescribed, wash the residual limb with mild soap and water and dry completely.

9. Massage the skin toward the suture line if prescribed, to mobilize scar and prevent its adherence to underlying bone.

10. Prepare for the prosthesis and instruct the client in progressive resistive techniques by gently pushing the residual limb against pillows and progressing to firmer surfaces.

11. Encourage verbalization regarding loss of the body part, and assist the client to identify coping mechanisms to deal with the loss.

C. Interventions for below-knee amputation

1. Prevent edema.

2. Do not allow the residual limb to hang over the edge of the bed.

3. Discourage long periods of sitting to lessen complications of knee flexion.

D. Interventions for above-knee amputation

1. Prevent internal or external rotation of the limb.

2. Place a sandbag, rolled towel, or trochanter roll along the outside of the thigh to prevent external rotation.

E. Rehabilitation

1. Instruct the client in the use of a mobility aid such as crutches or a walker.

2. Prepare the residual limb for a prosthesis.

3. Prepare the client for fitting of the residual limb for a prosthesis.

4. Instruct the client in exercises to maintain range of motion and upper body strengthening.

5. Provide psychosocial support to the client.

F. Traumatic amputation: Emergency care

1. Obtain emergency medical assistance (call 911)

2. Stay with the victim, check the amputation site, apply direct pressure with gauze or cloth (do not remove applied pressure dressing to prevent dislodging of a formed clot).

3. Elevate the extremity above heart level.

4. If finger(s) were amputated, place in a watertight sealed plastic bag and place the bag in ice water (not directly on ice) and transport to the emergency department with the victim.

A. Description

1. Rheumatoid arthritis is a chronic systemic inflammatory disease (immune complex disorder); the cause may be related to a combination of environmental and genetic factors.

2. Rheumatoid arthritis leads to destruction of connective tissue and synovial membrane within the joints.

3. Rheumatoid arthritis weakens the joint, leading to dislocation and permanent deformity of the joint.

4. Pannus forms at the junction of synovial tissue and articular cartilage and projects into the joint cavity, causing necrosis.

5. Exacerbations of disease manifestations occur during periods of physical or emotional stress and fatigue.

6. Vasculitis can impede blood flow, leading to organ or organ system malfunction and failure caused by tissue ischemia.

B. Assessment

1. Inflammation, tenderness, and stiffness of the joints

2. Moderate to severe pain, with morning stiffness lasting longer than 30 minutes

3. Joint deformities, muscle atrophy, and decreased range of motion in affected joints

4. Spongy, soft feeling in the joints

5. Low-grade temperature, fatigue, and weakness

6. Anorexia, weight loss, and anemia

7. Elevated ESR and positive rheumatoid factor

8. Radiographic study showing joint deterioration

9. Synovial tissue biopsy reveals inflammation

C. Rheumatoid factor

1. Blood test used to assist in diagnosing rheumatoid arthritis

2. Values

a. Nonreactive: 0 to 39 international units (IU)/mL

b. Weakly reactive: 40 to 79 IU/mL

c. Reactive: Higher than 80 IU/mL

D. Medications: Combination of pharmacological therapies includes nonsteroidal antiinflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and glucocorticoids

E. Physical mobility

1. Preserve joint function.

2. Provide range-of-motion exercises to maintain joint motion and muscle strengthening.

3. Balance rest and activity.

4. Splints may be used during acute inflammation to prevent deformity.

5. Prevent flexion contractures.

6. Apply heat or cold therapy as prescribed to joints.

7. Apply paraffin baths and massage as prescribed.

8. Encourage consistency with exercise program.

9. Use joint-protecting devices.

10. Avoid weight bearing on inflamed joints.

F. Self-care

1. Assess the need for assistive devices such as raised toilet seats, self-rising chairs, wheelchairs, and scooters to facilitate mobility.

2. Work with an occupational therapist or health care provider to obtain assistive or adaptive devices.

3. Instruct the client in alternative strategies for providing activities of daily living.

G. Fatigue

1. Identify factors that may contribute to fatigue.

2. Monitor for signs of anemia and administer iron, folic acid, and vitamins as prescribed.

3. Monitor for medication-related blood loss by testing the stool for occult blood.

4. Instruct the client in measures to conserve energy, such as pacing activities and obtaining assistance when possible.

H. Disturbed body image

1. Assess the client’s reaction to the body change.

2. Encourage the client to verbalize feelings.

3. Assist the client with self-care activities and grooming.

4. Encourage the client to wear street clothes.

I. Surgical interventions

1. Synovectomy: Surgical removal of the synovia to help maintain joint function

2. Arthrodesis: Bony fusion of a joint to regain some mobility

3. Joint replacement (arthroplasty): Surgical replacement of diseased joints with artificial joints; performed to restore motion to a joint and function to the muscles, ligaments, and other soft tissue structures that control a joint

Assist the client to identify and correct safety hazards in the home.

Instruct the client in the correct use of assistive or adaptive devices.

Instruct the client in energy conservation measures.

Review the prescribed exercise program.

Instruct the client to sit in a chair with a high straight back.

Instruct the client to use only a small pillow when lying down.

Instruct the client in measures to protect the joints.

Instruct the client regarding the prescribed medications.

Stress the importance of follow-up visits with the health care provider. 

A. Description

1. Osteoarthritis is marked by progressive deterioration of the articular cartilage.

2. Osteoarthritis causes bone buildup and the loss of articular cartilage in peripheral and axial joints.

3. Osteoarthritis affects the weight-bearing joints and joints that receive the greatest stress, such as the hips, knees, lower vertebral column, and hands.

4. The cause of primary osteoarthritis is not known. Risk factors include trauma, aging, obesity, genetic changes, and smoking.

B. Assessment

1. Client experiences joint pain that diminishes after rest and intensifies after activity, noted early in the disease process.

2. As the disease progresses, pain occurs with slight motion or even at rest.

3. Symptoms are aggravated by temperature change and climate humidity.

4. Presence of Heberden’s nodes or Bouchard’s nodes (hands)

5. Joint swelling (may be minimal), crepitus, and limited range of motion

6. Difficulty getting up after prolonged sitting

7. Skeletal muscle disuse atrophy

8. Inability to perform activities of daily living

9. Compression of the spine as manifested by radiating pain, stiffness, and muscle spasms in one or both extremities

C. Pain

1. Administer medications as prescribed such as acetaminophen (Tylenol) or topical applications; if acetaminophen or topical agents do not relieve pain, then NSAIDs may be prescribed.

Muscle relaxants may also be prescribed for muscle spasms, especially those occurring in the back.

2. Prepare the client for corticosteroid injections into joints as prescribed.

3. Position joints in function position and avoid flexion of knees and hips.

4. Immobilize the affected joint with a splint or brace until inflammation subsides.

5. Avoid large pillows under the head or knees.

6. Provide a bed or foot cradle to keep linen off of feet and legs until inflammation subsides.

7. Instruct the client in the importance of moist heat, hot packs or compresses, and paraffin dips as prescribed.

8. Apply cold applications as prescribed when the joint is acutely inflamed.

9. Encourage adequate rest.

D. Nutrition

1. Encourage a well-balanced diet.

2. Maintain weight within normal range to decrease stress on the joints.

E. Physical mobility

1. Instruct the client to balance activity with rest and to participate in an exercise program that limits stressing affected joints.

2. Instruct the client that exercises should be active rather than passive and to stop exercise if pain occurs.

3. Instruct the client to limit exercise when joint inflammation is severe.

F. Surgical management

1. Osteotomy: The bone is resected to correct joint deformity, promote realignment, and reduce joint stress.

2. Total joint replacement or arthroplasty

a. Total joint replacement is performed when all measures of pain relief have failed.

b. Hips and knees are replaced most commonly.

c. Total joint replacement is contraindicated in the presence of infection, advanced osteoporosis, or severe joint inflammation.

A. Description

1. Osteoporosis is a metabolic disease characterized by bone demineralization, with loss of calcium and phosphorus salts leading to fragile bones and the subsequent risk for fractures.

2. Bone resorption accelerates as bone formation slows.

3. Osteoporosis occurs most commonly in the wrist, hip, and vertebral column.

4. Osteoporosis can occur postmenopausally or as a result of a metabolic disorder or calcium deficiency.

5. Client may be asymptomatic until the bones become fragile and a minor injury or movement causes a fracture.

6. Primary osteoporosis

a. Most often occurs in postmenopausal women; occurs in men with low testosterone levels

b. Risk factors include decreased calcium intake, deficient estrogen, and sedentary lifestyle.

7. Secondary osteoporosis

a. Causes include prolonged therapy with corticosteroids, thyroid-reducing medications, aluminum-containing antacids, or anticonvulsants.

b. Associated with immobility, alcoholism, malnutrition, or malabsorption

8. Risk factors

■ Cigarette smoking

■ Early menopause

■ Excessive use of alcohol

■ Family history

■ Female gender

■ Increasing age

■ Insufficient intake of calcium

■ Sedentary lifestyle

■ Thin, small frame

■ White (European descent) or Asian race

B. Assessment

1. Possibly asymptomatic

2. Back pain occurs after lifting, bending, or stooping.

3. Back pain that increases with palpation

4. Pelvic or hip pain, especially with weight bearing

5. Problems with balance

6. Decline in height from vertebral compression

7. Kyphosis of the dorsal spine, also known as “dowager’s hump”

8. Degeneration of lower thorax and lumbar vertebrae on radiographic studies

The client with osteoporosis is at risk for pathological fractures.

C. Interventions

1. Assess risk for and prevent injury in client’s personal environment.

a. Assist client to identify and correct hazards in his or her environment.

b. Position household items and furniture to ensure an unobstructed walkway.

c. Use side rails to prevent falls.

d. Instruct in use of assistive devices such as a cane or walker.

e. Encourage the use of a firm mattress.

2. Provide personal care to client to reduce injuries.

a. Move the client gently when turning and repositioning.

b. Assist with ambulation if client is unsteady.

c. Provide gentle range-of-motion exercises.

d. Apply a back brace as prescribed during an acute phase to immobilize the spine and provide spinal column support.

3. Provide client instructions to promote optimal level of health and function.

a. Instruct the client in the use of good body mechanics.

b. Instruct the client in exercises to strengthen abdominal and back muscles to improve posture and provide support for the spine.

c. Instruct the client to avoid activities that can cause vertebral compression.

d. Instruct the client to eat a diet high in protein, calcium, vitamins C and D, and iron.

e. Instruct the client to avoid alcohol and coffee.

f. Instruct the client to maintain an adequate fluid intake to prevent renal calculi.

4. Administer medications as prescribed to promote bone strength and decrease pain.

A. Description

1. Gout is a systemic disease in which urate crystals deposit in joints and other body tissues.

2. Gout results from abnormal amounts of uric acid in the body.

3. Primary gout results from a disorder of purine metabolism.

4. Secondary gout involves excessive uric acid in the blood caused by another disease.

B. Phases

1. Asymptomatic: Client has no symptoms but serum uric acid level is elevated.

2. Acute: Client has excruciating pain and inflammation of one or more small joints, especially the great toe.

3. Intermittent: Client has intermittent periods without symptoms between acute attacks.

4. Chronic: Results from repeated episodes of acute gout

a. Chronic gout results in deposits of urate crystals under the skin.

b. Chronic gout results in deposits of urate crystals within major organs, such as the kidneys, leading to organ dysfunction.

C. Assessment

1. Swelling and inflammation of the joints, leading to excruciating pain

2. Tophi: Hard, irregularly shaped nodules in the skin containing chalky deposits of sodium urate

3. Low-grade fever, malaise, and headache

4. Pruritus from urate crystals in the skin

5. Presence of renal stones from elevated uric acid levels

D. Interventions

1. Provide a low-purine diet as prescribed, avoiding foods such as organ meats, wines, and aged cheese.

2. Encourage a high fluid intake of 2000 mL/day to prevent stone formation.

3. Encourage weight reduction diet if required.

4. Instruct the client to avoid alcohol and starvation diets because they may precipitate a gout attack.

5. Increase urinary pH (above 6) by eating alkaline ash foods (see Chapter 62).

6. Provide bed rest during acute attacks, with the affected extremity elevated.

7. Monitor joint range-of-motion ability and appearance of joints.

8. Position the joint in mild flexion during acute attack.

9. Protect the affected joint from excessive movement or direct contact with sheets or blankets.

10. Provide heat or cold for local treatments to affected joint as prescribed.

11. Administer medications such as analgesic, antiinflammatory, and uricosuric agents as prescribed.