RESOURCE UNIT Nursing Care Management 104

ORTHOPEDIC NURSING I. OVERVIEW

. MUSCU!OS"E!ET ! S#STEM
The musculoskeletal system is collectively the largest organ system in the body. Bony structures and connective tissues account for approximately 25% of the body weight and the muscles account for approximately 50% of the total body weight. The health and function of the musculoskeletal system are interdependent with the rest of the body system !melt"er and Bare# $%%2&. I. $%nes 'arieb# 2002& There are 20( bones in the human body. Bones are constructed of cancellous trabecullar or spongy& or cortical compact& bone tissue. )ompact bone is dense and looks smooth and homogenous. !pongy bone is composed of small needlelike pieces of bone and lots of open spaces. *+,*-!.!/ Bones are considered to be the framework of the body# however# besides contributing to the si"e and form of the body# bones are responsible for some bodily functions. $. !upport to surrounding tissues and serves as framework of the bone. 2. *rotects the vital organs and other soft tissues. 0. Blood cell formation or hematopoiesis occurs within the marrow cavities of certain bones. 1. Body movement by providing leverage and attachment of muscles. 5. !torage area for minerals# salts like calcium and phosphorous. T2- '345 6474!4-5! The skeleton is subdivided into two 2& ma8or divisions9 those that comprises the longitudinal axis of the body are referred to as axial bones and those that comprises the limbs and girdles are called the appendicular bones. $. 3xial bones : Body;s upright structure9 the bones that forms the longitudinal axis of the body9 <0 bones ..g. skull# vertebrae# ribs 2. 3ppendicular bones : refers to the body;s appendages9 $2( bones. ..g. limbs and girdle bones T=*.! -> B-5.! Bones come in many si"es and shapes. The uni?ue shape of each bone fulfills a particular need. $. @ong bones : bones in which the length exceeds the breadth and thickness9 shaped like rods# or shafts with rounded ends. e.g. humerus# radiusAulna# femur. tibiaAfibula. PARTS OF LONG BONES 1. DIAPHYSIS (SHAFT)- BONES LENGTH, COMPOSED OF COMPACT BONE 2. PERIOSTEUM- FIBROUS CONNECTIVE MEMBRANE THAT COVERS AND PROTECTS THE DIAPHYSIS 3. EPIPHYSEAL LINE- A THIN LINE THAT SPAN THE EPIPHYSIS, THE REMNANT OF THE EPIPHYSIAL PLATE THAT CLOSES WHEN THE GROWING BONE HAS REACHED ITS FULL LENGTH 2. !hort bones : bones that are generally cubed shaped and contain mostly e.g. metatarsal# metacarpals spongy bones

0. >lat bones : thin flattened and usually curved. 4mportant site for hematopoiesis and fre?uently provide vital organ protection. They are made of cancellous bone layered between compact bones. e.g. skull bones# ribs# sternum 1. 4rregular bones A bones that do not fit in any of the above classification but have uni?ue shapes in relation to their function. e.g. vertebrae# hipbone. B-5. ).@@! Bones in order to continue its normal functioning must be maintained to its optimum health or condition. !everal bone cells are involve to keep to its maximum functioning. $. -steoblast : involved in bone formation by secreting bone matrix. 'atrix is a framework in which inorganic mineral salts are deposited. 2. -steocytes : mature bone cells involved in the bone maintenance functions and are located in the osteons bone matrix unit&. 0. -steoclasts : multinuclear cells involved in bone destruction# resorption and remodeling. BONE MARROW - A VASCULAR TISSUE LOCATED IN THE MEDULLARY (SHAFT) CAVITY OF LONG BONES AND FLAT BONES. . YELLOW MARROW- A STORAGE AREA FOR ADIPOSE TISSUE !. RED MARROW- PRODUCED RED AND WHITE BLOOD CELLS LOCATED IN STERNUM, ILIUM, VERTEBRA AND RIBS II. &%ints !melt"er B Bare $%%2& 3n articulation or 8oint is a point of contact between bones# between cartilages and bones or between teeth and bones. The scientific study of 8oints is termed arthrology. )@3!!4>4)3T4-5 -> C-45T! !melt"er B Bare $%%2& The 8unction where bones of the body are 8oined together to allow a variety of movement is called 8oints or articulation. 5o matter is the amount of possible# the point of contact between two or more bones is termed as 8oint )lassification of 8oints is based on the amount of movement it can accomplish. $. !=53,TD,-!.! : immovable 8oints. !uture : unites the bones in the skull. Eomphosis : a coneA shaped peg fits into a socket. e.g. articulation of the teeth with the socket of the alveolar process of the maxilla and mandible. !ynchondrosis : a cartilaginous 8oint in which the connecting material is a hyaline cartilage. e.g. epiphyseal plate 2. 3'*D43,TD,-!.! : slightly movable 8oints. !yndesmosis : a fibrous 8oint in which there is considerably more fibrous connective tissue than there is in the suture. The fibrous connective tissue forms an interosseous membrane or ligament that permits some degree of flexibility and movement. e.g. distal articulation between the tibia and fibula. !ymphysis : the connecting material is broad# flat discs or fibro cartilage. e.g intervertebral disc between the bodies of the vertebrae. 0. 6=!3,TD,-!.! : freely movable 8oints. Ball and !ocket 8oints or !pheroid : a ballAlike surface fits into a cuplike depression. Best exemplified by the shoulder and hip 8oint. *ermits full freedom of movement. Triaxial flexionA extension9 abductionAadduction9 rotation& Dinge 8oint or Einglymus : convex surface fits into a concave surface. *ermits bending in one direction only and best exemplified By the elbows and knees. 'onoaxial flexionAextension& !addle 8oints or !ellaris A articular surface of one bone is saddleAshaped# and the articular surface of the other bone is shape like the legs of a rider sitting in a saddle. 3llows movement in two planes at right angles to each other. The 8oint at the base of the thumb is a saddle 8oint. Biaxial flexionAextension# abductionAadduction.

*ivot 8oint or Trochoid : rounded or pointed surface fits into a ring. >ormed partly by bone and partly by ligament. )haracteri"ed by the articulation between the radius and ulna and between the atlas and axis. 'onoaxial rotation& Eliding 8oints or 3rthrodial : articulating surface are usually flat. 3llows for limited movement in all directions and are located at the intercarpal and intertarsal 8oints. )ondyloid or ellipsoidal 8oint : oval shaped condyle fits into an elliptical cavity. Coint between the radius and carpals best exemplified this 8oint. Biaxial flexionAextension# abductionA adduction&

'-7.'.5T! -> TD. !=5-743@ C-45T! Tortora# $%%(& 3. 35E+@3, : there is a decrease or increase at the angle between bones. $. >lexion : there is a decrease in the angle between the surfaces of the articulating bones. 2. .xtension : increase in the angle between the articulating bones. 0. Dyperextension : continuation of extension beyond anatomical position. 1. 3bduction : movement of bone away from the midline. 5. 3dduction : movement of a bone towards the midline. (. )ircumduction : a combination of flexionAextension and abduction in succession# in which the distal end of a part of the body moves in a circle B. E@4645E A the surface of one bone moves back and forth and from side to side over another surface. 6uring the movement there is no angular or rotary motion. ). ,-T3T4-5 A movement of bone around its longitudinal axis# maybe medial towards the midline& or lateral away from the midline&. 6. !*.)43@ : occur at specific 8oints $. 4nversion : movement of the soles inward so that they face each other. 2. .version : movement of the soles outward so that they face away from each other. 0. 6orsiflexion : bending the foot in the direction of the dorsum upper surface&. 1. *lantar flexion : bending the foot in the direction of the plantar surface. 5. *rotraction : movement of the mandible or shoulder girdle forward on a plane parallel to the ground. (. ,etraction : movement of the mandible or shoulder girdle backward on a plane parallel to the ground. F. !upination : movement of the forearm in which the palm is turned anteriorly or superiorly. <. *ronation : movement of the forearm in which the palm is turned posteriorly or inferiorly. %. .levation : movement of the body part upward. $0. 6epression : movement of the body part downward. III. Muscles (Tortora, 1996) Because flexing muscles look like mice scurrying beneath the skin# some scientists long ago dubbed them "#$%&'$ from the @atin word "#$ meaning &())&' "*#$' 'areib# 2002&. >+5)T4-5! 'uscles accomplishes some vital functions in the body. $. *rovide shape to the body. 2. *rotect the vital organs 0. 'aintain posture 1.)ause movement of body parts by contraction. '+!)@. 3)T4-5! The primary and only movement accomplish by muscles is contraction. Through the coordination of muscle groups# the body is able to perform a wide variety of movement !mellt"er and Bare# $%%2.& $. *rime mover : muscle that causes a particular motion. 2. !ynergists : muscles assisting the prime movers. 0. 3ntagonists : muscle causing the movement opposite to that of the prime mover. T=*.! -> '+!)@. )-5T,3)T4-5! The contraction of muscle fiber can result to either isotonic or isometric contraction of of the muscle.

$. 4sometric contraction : the length of the muscles remains constant but the force generated by the muscles is increased. ..g. pushing against immovable wall. 2. 4sotonic contraction : characteri"ed by shortening of the muscle with no increased in tension within the muscle. T=*.! -> '+!)@.! There are three 0& types of muscle tissues but differ in their cell structure# body location and how they are stimulated to contract. $. )ardiac muscleA involuntary muscle9 found only in the heart. 2. !mooth muscle : involuntary muscle9 found in the walls of hallow structure. e.g. intestines 0. !keletal muscle : voluntary muscle9 striated muscles )D3,3)T.,4!T4)! -> !G.@.T3@ '+!)@.! !keletal muscles are instrumental for the movement of the various parts of the body and it possesses characteristics uni?ue from the two other muscles. $. 3ttached to the skeleton at the point of origin and to the bones at the point of insertion. 2. Dave properties of contraction and extension# as well as elasticity to permit isotonic shortening and thickening of the muscle& and isometric increased muscle tension& movement. 0. )ontraction is innervated by nerve stimulation SKELETAL MUSCLE FUNCTION . FACILITATE OF VOLUNTARY BODY MOVEMENT BY CONTRACTION !. MAINTAINS BODY POSTURE %. PRODUCE BODY HEAT IV. Carti'age 3 dense connective tissue that consists of fibers embedded in a strong# gel like substance. )artilage is avascular and lacks innervation. -IS A NON-VASCULAR, SUPPORTING CONNECTIVE TISSUE COMPOSED OF VARIOUS CELLS AND FIBERS T=*.! >ibrous )artilage : forms the symphysis pubis and intervertebral discs. A 2D4T.# T-+ED# >4,-+! T4!!+. >-+56 45 TD. G5.. Dyaline )artilage : covers the articular bone where one or more bones meet at a 8oint&9 connects the ribs to the sternum9 and appears in the trachea# bronchi and the nasal septum. - PEALY, BLUE CARTILAGE THAT COVERS ATRICULAR BONE SURFACES .lastic )artilage : located in the auditory canal and the intervertebral discs9 it also cushions and absorbs shock# preventing direct transmission to the bone. - YELLOW CARTILAGE- ELASTIC, FIBROUS CARTILAGE FOUND IN THE LARYN+ AND E+TERNAL EAR V. Ten(%ns an( !igaments a. Ten(%ns Bands of fibrous connective tissue that attached muscle to the periosteum fibrous membrane covering the bone&. .nables the bone to move when muscle contracts. ). !igaments 6ense strong# flexible bands of fibrous connective tissue that attached one bone to another. )onnect 8oint ends articular ends& of the bones9 these bones can either limit or facilitate movement and provide structural stability. VI. $ursa @ocated at friction points and around 8oints# between tendons# ligaments and bones.

!mall synovial fluid sacs that act as cushions# decreasing stress on ad8acent structures. ..g. shoulders subacromial bursae9 knees prepatellar bursa

$. NURSING PROCESS
3 thorough and comprehensive nursing assessment is vital in the making of ?uality nursing care to the clientele. 4t is the fundamental basis of identifying nursing problem and interventions thus9 it must be done with complete care. 4t is also imperative to consider the individuality and uni?ueness of each patient. !teps of the nursing process are universal but its application should be individuali"ed. I. * SSESSMENT The nursing assessment of the patient with musculoskeletal dysfunction includes an evaluation of the effect of the problem on the client;s performance of normal functions. The nurse is concerned with assisting persons with musculoskeletal problem $0 maintain general health# 2& fulfill activities of daily living# and 0& manage treatment modalities.

3. 5ursing Distory
$.& B4-E,3*D4)3@ 63T3 356 6.'-E,3*D4) 63T3 H personal information enables individuali"ed care planning H age and sex : suggest possible cause of musculoskeletal problem H age : <5 % of people older than F0 yrs old have arthritis osteosarcoma : rare after age 10. H sex : osteporosis : post menopausal women )arpal tunnel syndrome : often in women 2.& )+,,.5T D.3@TD a.& )hief )omplaint : reasons for seeking health care. : common symptoms pain# tenderness# muscle tightness or weakness# 8oint stiffness# cramps# muscle# spasms# swelling# redness# deformity# reduce movement or 8oint ,-'# sensory changes and abnormal sensation. : 3ssess for onset# duration# location# precipitating and predisposing factor. : 3ssess for +ar(ina' signs %, a'tere( mus+u'%s-e'eta' ,un+ti%n / pain# limitations of movement# edema# altered sensation# contour deformity# asymmetry# contusions. b.& 5eurovascular assessment $.& *345 : signals beginning of muscle ischemia. A assess on scale of 0A$0. A pharmacologicI nonA pharmacologic approach A institute appropriate safety measures. A evaluate the effectiveness of medication 2.& *+@!. : *ulselessness indicates decrease of arterial blood flow. A assess various location A !trength 0 : no pulse9 1. / weak pulse9 0. A normal9 1. A strong9 4. / bounding& 0.& *3@@-, : indicates disruption of arterial blood flow. A check capillary refill. 1.& *3,.!TD.!43 : nerve function maybe disrupted by compression. A numbness# tingling# feels pinching or touching of the affected extremity. 5.& *3,3@=!4! : increasing edema causes nerve compression. A determine if the client could move or lift the affected extremity. A can push affected extremity against pressure. (.& *-@3, : or coldness A indicates disrupted arterial blood flow. A extremity feels cool or has bluish color. A complains of cold extremity.

2.& *3!T D.3@TD D4!T-,= H *revious trauma# accidents surgery involving bones or 8oints H previous accidents# resulting to fracture may predispose to degenerative changes. a.& )hildhood and 4nfectious disease H TB# poliomyelitis# inflammatory or degenerative arthritis# rickets b.& 'a8or illness and hospitali"ations $.& ask for past and present minor and ma8or in8uries# including/ a. circumstances of in8ury b. diagnosis of in8ury c. treatment received d. duration of treatment e. current problems resulting from the in8ury 2.& 'usculoskeletal in8ury : fractures# sprains# strains# dislocation 0.& ,esidual impairment from in8ury : use of assistive device c.& 'edications $.& *rescribe meds 2.& -T) 0.& Derbal a. ,easons b. 6ose and fre?uency c. duration d. observed side effects J corticosteroids : can cause necrosis of the femur head# septic arthritis and muscle weakness. J anticongalants : may produce hemarthrosis blood in the 8oints.& J anticonvulsants : may cause osteomalacia J phenothia"ines : produce gait disturbance J potassium : depleting diuretics : may cause cramps and muscle weakness. J 3mphetamines and caffeine : generali"ed weakness in muscle activity J D,T Dormonal ,eplacement Therapy& : modify the effects of osteoporosis in post menopausal women 0.& >3'4@= D4!T-,= A hereditary disease or diseases with familial disposition such as arthritis# osteoporosis and gout. 1.& *!=)D-!-)43@ -ccupation : lifting or strenuous activity9 prolonged sitting. 36@ : limitations in activities of daily living. .xercise : recreational activity and exercise pattern. 5utrition A -besity : may cause low back pain due to stresses on weightAbearing 8oints A 6ecrease 4ntake of )alcium : may cause deminerali"ation of the bone and fracture. A 3de?uate intake of protein# 7itamin 3 and 6 and )alcium is important. 5.& *D=!4)3@ .K3'453T4-5 3. 4nspection Body alignment and posture )ontour# alignment length and symmetry ,ange of motion# crepitus# clicks and smoothness Coint alignment# si"e# shape# stability# tenderness# heat and swelling Eait# coordination rhythm# stride and balance

 'uscle discrepancies# hypertrophy# atrophy# spasms B. *alpation 'uscle mass# shape si"e# contour# symmetry and firmness 'uscle strength# resistance and contractility !+BC.)T47. 63T3 3!!.!!'.5T o *atient;s report of presence of pain# tenderness. Tightness and abnormal sensations. o 'ust be assessed and documented 1. Pain : common to patient with diseases and traumatic conditions of the muscles# bones and 8oints. !harp pain may result from bone infection with muscle spasm or pressure on a sensory nerve. 'ost musculoskeletal pain are relieved by rest. *ain that increases with activity may indicate 8oint sprain or muscle strain# whereas steadily increasing pain suggests to a progression of an infectious process osteomyelitis&# a malignant tumor# or vascular complications. *ain is variable and its assessment and nursing management should beindividuali"ed. *ain and discomfort are important to the patient and must be manage successfully. 5ot only is pain exhausting but if prolonged it can force the patient to become increasingly preoccupied and dependent. L Bone *ain : dull deep ache that is boring in nature. L 'uscular *ain : sore and aching and is fre?uently referred to as Mmuscle crampsN. L >racture pain : sharp piercing pain and is relieved by immobili"ation. 0. 'tere( Sensati%ns !ensory disturbances are fre?uently associated with musculoskeletal problems. The patient may described the presence of paresthesia burning or tingling sensation& and numbness. These sensations maybe due to a pressure on nerves or circulatory impairment. !oft tissue swelling or direct trauma to these structures can impaire their function. $. NURSING DI GNOSES 2OR C!IENTS WITH MUSCU!OS"E!ET ! DISORDERS !tein and Cacobson#$%%2&. 4dentification of nursing diagnoses for patient with musculoskeletal problems should be based on the actual and behavioral manifestation of the patient. The nurse must be vigilant and religious in the assessment of hisIher patient because nursing diagnoses changes as the patient;s respons1e to the treatment changes. The following are nursing diagnoses applicable to the patients with musculoskletal disorders# however# individuality of the patient must be considered in the identifying specific diagnosis for each patient. 3nxiety related to changes in body integrity. Gnowledge deficit related to therapeutic regimen *ain related to musculoskeletal disorder. 3ltered peripheral tissue perfusion related to physiologic responses to in8ury# swelling or increased pressure within a close space. 4mpaired physical mobility related to musculoskeletal impairment. !elf care deficit *otential for 4n8ury *otential for infection -ther diagnoses $. Body image disturbance 2. *otential for 6isuse syndrome

C. P! NNING ND IMP!EMENT TION GO !S3 The goals of nursing management on patients with musculoskeletal disorder are geared towards/ $. ,eduction of anxiety 2. +nderstanding of therapeutic regimen 0. ,elief of pain. 1. 'aintenance of ade?uate tissue perfusion 5. 4mproved physical mobility (. *revention of infection and in8ury F. achievement of maximum level of health care D. NURSING INTERVENTIONS 1. Re(u+e an4iet5 3ssist patient in coping with problems associated with musculoskeletal dysfunction and associated therapies. 0. Patient E(u+ati%n an( ,ami'5 tea+6ing 4ncreasing patient understanding foster active participation from the patient in the development and implementation of therapeutic regimen. 4nclude explicit instructions that the patient understand indicating activities that may or may not be performed. .ducate patient about untoward signs and symptoms to be reported to the physician. 4mportance of followAup visit. 1. Re'ie, %, Pain +se of narcotic and other pain relievers. ,elieving pressures over bony prominences to eradicate pain and prevent further tissue damage. ,elaxation techni?ues 4ntermittent application of ice pack at the site of in8ury for 20A00 minutes. .levate the in8ured area to prevent swelling. 4. Im7aire( tissue 7er,usi%n )heck capillary refill or blanch test !igns of diminished tissue perfusion L !kin cool to touch L !kin appears dusky# pale or blue 8. Im7r%9e( m%)i'it5 Dealth maintenance +ltimate restoration of function 4sometric exercise of immobili"ed extremities help to maintain muscle strength. 4nvolvement in 36@ : provides sense of independence and accomplishments. .xercise of nonAimmobili"ed muscles and 8oints L Delps maintain strength and function L 'inimi"es cardiovascular deterioration L *revents disuse osteoporosis. :. Pre9ent in,e+ti%n ;. Pr%te+t 7atient ,r%m in<ur5 =. Pr%m%te se', +are a+ti9ities> +'ient 7arti+i7ati%n E. E9a'uati%n 1. E46i)it minima' an4iet5 3ppears relax and confident in abilities. +ses effective coping strategies *articipates in care

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0. Re'ates 7'an ,%r +%ntinue( 6ea't6 management 6escribes planned treatment regimen !tates sign and symptoms to be reported to the physician 'akes appointment for followAup care 1. +6ie9es 7ain re'ie, an( i(enti,5 a77r%7riate +%m,%rt measures )ontrols discomfort with occasional oral medications 'oves with minimal discomfort +ses positioning to increase comfort. 4. Maintain a(e?uate tissue 7er,usi%n an( sens%r5 ,un+ti%n )ontrols swelling 6emonstrate motor function 6emonstrate normal capillary refill ,eports normal sensations 8. Dem%nstrate im7r%9e( 765si+a' m%)i'it5 an( a)i'it5 t% use assisti9e (e9i+e 7r%7er'5. Transfers self independently or with minimal assistance *articipates in activities of daily living +ses mobility aids safely. :. N% signs %r s5m7t%ms %, s5stemi+ '%+a' in,e+ti%n. ;. Resumes n%rma' a+ti9it5 6emonstrate proper performance of rehabilitative exercises and safety precautions. 'aintains independence in self care. *articipates in self care activities and 36@

C. ! $OR TOR# ND DI GNOSTIC TESTS

!melt"er and Bare# $%%2& 6iagnostic and laboratory studies are essential to aid the physician confirm the diagnosis of the patient. >urther more# these examinations will help identify proper medical and nursing interventions and management appropriate to the need of the patient. *reparation of the patient for laboratory and diagnostic tests is the responsibility of the nurse. *reparation for these studies includes assessment of the patient for indicators pregnancy# claustrophobia. 'etal implants# ability to tolerate re?uired positioning due to old age# disability# deformity& that may affect patient undergoing the study. The nurse communicate to physician and the appropriate department concerning identified problems related to completion of the prescribed diagnostic test !mellt"er and Bare# $%%2&. . !a)%rat%r5 stu(ies )B) : provide information concerning the hemoglobin level fre?uently lower after bleeding associated with trauma& and 2B) indicates possibilities of developing infection&. A35.'43!# D.'-,,D3E.# 45>.)T4-5!# 5.-*@3!T4) )-564T4-5!# !@.# 3@@.,E4.!# !T,.!! )oagulation !tudies : performed to determine bleeding tendencies. .!, : elevated in !@. and arthritis. +ric acid : detects abnormally high levels of uric acid in the blood Eout& 5ormal value/ 'ale : 0.5 :F.5 mgIdl >emale : 2.< : (.< mgIdl ,heumatoid >actor : detects antibodies indicating possible rheumatoid arthritis# lupus or scleroderma. Blood level of greater than $/<0 titer is indicative of rheumatoid arthritis. - MEASURES THE PRESENCE OF A MACROGLOBULIN TYPE OF ANTIBODY FOUND IN RHEUMATOID ARTHITIS AND OTHER CONNECTIVE TISSUE DISEASES. 3ntinuclear 3ntibodiesA assesses tissue antigen antibodies. 5ormal finding is negative. 3 positive result is indicative of rheumatoid arthritis.

AL,ALINE PHOSPHATASE STUDIES -IDENTIFY INCREASE IN OSTEOBLASTIC ACTIVITY AND INFLAMMATORY CONDITIONS CREATININE PHOSPHO,INASE -ELEVATION MAY IDENTIFY S,ELETAL MUSCLE NECROSIS, ATROPHY OR TRAUMA LACTATE DEHYDROGENASE -ELEVATION INDICATES S,ELETAL MUSCLE DAMAGE SERUM CALCIUM STUDIES -IDENTIFIES BONE LOSS DENSITY C-REACTIVE PROTEIN TEST- SEVERITY AND COURSE OF INFLAMMATOTY PROCESS SUCH AS A BACTERIAL INFECTION OR RHEUMATIC DISEASE

$. Diagn%sti+ Stu(ies 1. @/R # OR ROENTGENOGR PH# A an electromagnetic radiation of extremely short wavelengths which pass through matter to varying degrees depending on its density. A !T,+)T+,.# 45T.E,4T=# T.KT+,. -, 6.5!4T= *,-B@.'# 64!.3!. *,-E,.!!4-5 356 4.>>4)3)= *+,*-!./ 6one primarily to detect bone fracture. 5+,!45E 3)T4-5/ 3ssesses the patient;s level of exposure to radiation. 0. $ONE SC N/ the examination of the bone using ultrasonography# computeri"ed tomography# ',4 or scintigraphy. - DETECTS S,ELETAL TRAUMA AND DISEASE *+,*-!./ 6etects bone tumors# metastatic growths# bone in8ury or degenerative bone disease# osteomyelitis. *,-).6+,./ 3n 47 in8ection or oral dose of radioisotope is given and after interval time for a substance to be absorbed by the bone# the area is scanned by a scintillation camera. 5+,!45E 3)T4-5/ $. .xplain the purpose and procedure. 2. )heck for allergies and pregnancy. 0. 4nstruct patient to lie still during the procedure. 1. 4nstruct the patient to void immediately before the procedure. 5. 3ll metals should be removed from the area to be scanned. (. Tell the client that the isotopes are eliminated from the body in (A21 hours. 1. RTHROSCOP# A inspection of 8oint cavity with an arthroscope enabling performance of percutaneous surgery such as meniscectomy and biopsy to be performed. *+,*-!./ 4nspect the interior aspect of the 8oint# usually a knee# to diagnose problems of the patella# meniscus and synovium. 3lso used to evaluate the progress of arthritis or effectiveness of treatment. *,-).6+,./ 3fter in8ection of local anesthesia# an incision is made# and the arthroscope is introduced into the interior of the 8oint9 instrument for tissue biopsy or surgical procedures maybe passed through the arthroscope. 5+,!45E 3)T4-5!/ $. .xplain the purpose and procedure. 2. 3dminister sedative prior to the procedure as ordered. 0. 3pply pressure dressing for 21 hours. 1. 3pply ice packs immediately post procedure period. 5. 3ssess for swelling# circulation# and sensation periodically to detect complications. (. 4nstruct patient to limit activities for several days.

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4. RTHROCENTESIS / aspiration of synovial fluid# blood or pus through a puncture needle. *+,*-!./ *erformed to extract synovial fluid for analysis and reduce swelling. *,-).6+,./ 3 needle is inserted into the 8oint space and synovial 8oint is aspirated. 5+,!45E 3)T4-5!/ $. .xplain the purpose and procedure. 2. 4f large amount of fluid is aspirated# immobili"e the 8oint by an elastic bandage. 0. 3pply ice packs to relieve pain and reduce swelling. 1. 4f corticosteroid is in8ected into the 8oint# administer analgesic as ordered. 8. M#E!OGR PH# / a speciali"ed method of KAray examination to demonstrate the spinal canal that involves the in8ection of a radiopa?uecontrast medium into the subarachnoid space.

IN-ECTION OF CONTRAST AGENT INTO SUBARACHNOID SPACE OF THE SPINE TO DETECT HERNIATION, TUMOR, AND CONGENITAL OR DEGENERATIVE CONDITION OF THE SPINAL CANAL *+,*-!./ 6one to determine disc herniation# spinal stenosis narrowing of the spinal canal& or the site of the tumor. *,-).6+,. @umbar puncture is done to withdraw a small amount of )!># which is replaced with a radiopa?ue dye. 5+,!45E )3,./ $. .xplain procedure and purpose. 2. !ecure consent. 0. )heck for iodine allergy. 1. Geep on 5*- after li?uid breakfast. 5. 4f waterAbased dye amipa?ue& is used# place the patient on sei"ure precaution. .levate the head of the bed to prevent upward dispersion of the dye# which causes meningeal irritations. (. 4f oilAbased dye pantopa?ue& is used# position patient flat on bed :. E!ECTROM#OGR PH# BEMG* A a continuous recording of the electrical activity of a muscle by means of electrodes inserted into the muscle fibers. The tracing is displayed on a oscilloscope. AMEASURES MUSCLE ELECTRICAL IMPULSES FOR DIAGNOSIS OF MUSCLE OR NERVE DISEASE *+,*-!./ 'easures and records activity of contracting muscle in response to electrical stimulation. *,-).6+,./ 5eedles electrodes are inserted in affected muscles and as muscle are stimulated# the electrical impulses generated by the muscle contains are amplified and displayed on an oscilloscope9 tracing are made on graph paper. 5+,!45E 3)T4-5/ $. .xplain procedure and purpose. 2. !ecure consent. 0.3void stimulants and sedatives before the procedure. 1..xplaine that there will be slight discomfort when the electrodes are inserted. 5.4nstruct the patient that he will be asked to relax and contract the muscles. ;. $IOPS# A the removal of a small piece of living tissue from an organ or part of the body for microscopic study. - STUDIES BONE, SYNOVIUM, OR MUSCLE TISSUE *+,*-!./ Bone biopsy done to detect tumor cells. 'uscle biopsy done to obtain tissue for cellular analysis.

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*,-).6+,./ +nder local anesthesia# a piece of bone or muscle is excised and sent for pathologic analysis. 5+,!45E 3)T4-5/ $. .xplain procedure and purpose. 2.Eive medication as ordered to relieve discomfort after the procedure. 0. 3pply ice packs to decreased swelling. 1.-bserve for bleeding. 5. *erform circulation and sensation check distal to the area biopsied Ot6er (iagn%sti+ stu(ies $.)-'*+T.6 T-'-E,3*DD= )T& !)35 : useful in orthopedic diagnosis by revealing tumors of the soft tissues or in8uries to the ligaments or tendons. 4t is helpful in identifying the location and extent of areas difficult to define. -SHOW SOFT TISSUE, BONE, AND SPINAL CORD IN 3-DIMENTIONAL, CROSS-SECTIONAL IMAGES 2. '3E5.T4) ,.!-535). 4'3E45E ',4& : a nonAinvasive# special imaging techni?ue that uses magnetic fields# radio waves and computers to demonstrate abnormalities e.g. tumors or narrowing of tissue pathways through bones& bone of soft tissue such as muscle# tendon and cartilage. -. ALLOWS STUDY OF SOFT TISSUE IN MULTIPLE PLANES OF THE BODY 5+,!45E 3@.,T/ )ontraindicated to pregnant woman# claustrophobic# patterns with unstable vital sign# patients with metal implants. 0.35E4-E,3*D= -, 3,T.,4-E,3*D= 3ngiography is the study of the vascular structures. 3rteriography is the study of the arterial system. 3 radiopa?ue contrast medium into the selected artery and serial films are taken of the supplied arterial system. The procedure is useful for determining the amount of an extremity to be computed. 1.64E4T3@ !+BT,3)T4-5 35E4-E,3*D= 6!3& : uses computer technology to demonstrate the arterial system from a venous catheter access. 7enogram is a study of a venous system fre?uently used to detect venousAthrombosis. 5.64!)-E,3*D= : study of the intervertebral discs in which a contrast medium is in8ected into the disc and its distribution is noted. (.3,TD,-E,3*D= : in8ection of a radiopa?ue substance or air into the 8oint cavity in order to outline softAtissue structures and the contour of the 8oint. The 8oint is put on its range of motion while a series of radiograph is taken. 3rthrography is useful in identifying acute or chronic tears of the 8oint capsule or supporting ligaments of the knee# shoulders# ankle# hip or wrist. 4f a tear is present# the contrast medium will reach out of the 8oint and will be evident on the radiograph. -IN-ECTION OF RADIOPA.UEOR AIR INTO THE -OINT CAVITY TO IDENTIFY ACUTE OR CHRONIC TEARS OF -OINT CAPSULE OR SUPPORTING LIGAMENTS FOR THE ,NEE, SHOULDER, AN,LE, HIP OR WRIST. 5+,!45E 3)T4-5/ $.4mmobili"e the 8oints for $2 to 21 hours. 2.)ompression elastic bandage is applied for 2 to 5 days or as prescribed. 0.*rovide comfort measure as prescribed. F.TD.,'-E,3*D= : measures the degree of heat radiating from the skin surface. 4nflammatory conditions such as arthritis and infections# as well as neoplasm are detected. <.!45E@. 356 6+3@ *D-T-5 3B!-,*T4-'.T,= : nonAinvasive tests to determine bone mineral content at the wrist or vertebral. -steoporosis may be monitored with this type of densitometry. C. ORTHOPEDIC SURGERY - ORTHOPEDIC SURGERY REFERS TO VARIOUS SURGICAL PROCEDURES INVOLVING THE S,ELETAL SYSTEM AND ITS -OINTS, MUSCLES, AND ASSOCIATED STRUCTURES.

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OPEN REDUCTION- INVOLVES REDUCTION AND ALIGHNEMENT OF FRACTURE THRU SURGICAL OPENING. INTERNAL FIXATION- INVOLVES STABILI/ATION OF REDUCED FRACTURE WITH SCREWS,PLATES, NAILS OR PINS. BONE GRAFT- INVOLVES PLACEMENT OF BONE TISSUE FOR HEALING, STABILI/ATION, OR REPLACEMENT. ARTHROPLASTY- INVOLVES -OINT REPAIR THROUGH SMALL ARTHROSCOPE TO AVOID INCISION JOINT REPLACEMENT- INVOLVES THE EPLACEMENT OF -OINT SURFACE WITH METAL OR PLASTIC MATERIALS0 TOTAL HIP REPLACEMENT INVOLVES REPLACEMENT OF THE BALL AND SOC,ET OF A SEVERELY DAMAGED HIP -OINT0 TOTAL ,NEE REPLACEMENT 1 REPLACEMENT OF TIBIA, FEMORAL AND PATELLAR -OINT SURFACES TENDO TRANSFER- INVOLVES MOVEMENT OF A TENDON INSERTION TO IMPROVE FUNCTION TENOTOMY- INVOLVES CUTTING TENDON FASCIOTOMY- INVOLVES REMOVAL OF MUSCLE FASCIA, RELIEVING CONSTRICTION OSTEOTOMY- INVOLVES ALIGNMENT OF BONE BY REMOVAL OF WEDGE FRACTURES

II. P! NNING ND IMP!EMENT TION

. HE !TH PROMOTION 1. E@ERCISE A aims to achieve the maximum body function for each particular individual. Is%metri+ E4er+ise A these are exercises wherein the client exerts force without changing the length of the muscles. 4t helps in maintaining muscle tone. E4am7'e. $. G'utea' mus+'e setting A done by contracting and relaxing the buttocks. 2. Cua(ri+e7s setting A performed by pressing the popliteal space against the mattress. Is%t%ni+ E4er+ise A the muscle contracts9 it is used to promote muscle strength. E4am7'e : lifting. 0. PROPER $OD# MECH NICS A the safe use of muscles of the body to accomplish mechanical tasks. $. Bend knees to lift ob8ects from the floor 2. +se wide base of support by placing the feet $2A$< inches apart when moving ob8ects. 0. *ulling is easier than pushing. 1. 2ork is best accomplished at the center of gravity. 5. 2orking at the waist level is most efficient. 1. DIET : 3 balance diet is important in maintaining bones or muscles for optimum activity and must contain ade?uate sources of phosphorus# calcium and 7it 6 for bone growth and prevention of osteoporosis. Ca'+ium A for bone and teeth formation# blood clotting muscle activity and nerve function. ,egular 4ntake : %00mgs *hosphorous : for bone and teeth formation# important in energy transfer# component of nucleic acid. ,egular 4ntake : %00mgs 7itamin 6 : *romotes )alcium and phosphorous absorption9 >or bone and teeth formation. ,egular 4ntake : (.5 mcg 1. ,4!G '353E.'.5T $. 4nformation in the use of seat belts# helmets# and other safety devices and the avoidance of driving if drinking alcoholic beverages.

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2. 0.

,ugs must be secure. !tairways lit and clear of debris +se of body mechanics to protect risk of in8ury.

$. HE !TH M INTEN NCE ND RESTOR TION

1. C STS 4. 6efinition )3!T : form of support obtained as a gypsum rendered anhydrous by calcinations# which when mixed with water# swells# sets and forms rapidly a hard cement. *-) 'anual& 44. *urposes +ntalan# 2005& $. >or immobili"ation 2. To prevent and correct deformity 0. >or support 1. >or elevation 5. To obtain a mold of the limb to serve as a model for making an artificial limb. 444. )asting materials *-) 'anual& $. !tockinet A comes in contact with the patient;s skin. 2. 2adding !heet 0. Eau"e bandage 1. *laster of *aris : traditional cast a. takes 21 : F2 hours to dry b. precautions must be taken until cast is dry to prevent dents which may cause pressure areas. c. !igns of a dry cast : shiny white# hard# resistant. d. 'ust be kept dry since water can ruin a plaster cast. 5. !ynthetic castA e.g. fiber glass a. strong# light weight# sets in about 20 minutes. b. can be dried using cast dryer or hair blow dryer on cool setting9 some synthetic cast needs special lamp to harden. c. water resistant9 however# if cast becomes wet# must be dried thoroughly to prevent skin problems under the cast. 47. )ast 6rying : *laster )ast *-) 'anual& $. +se palms of hands# not fingertips to support cast when moving or lifting clients. 2. Turn patient every two 2& hours to reduce pressure and promote drying. 0. 6o not cover the cast until it is dry may use fan&. 1. 6o not use heat lamp or hair dryer on plaster cast. 7. )ast Techni?ue $. 2indowing : putting a hole on the cast on the site of an open wound of a casted extremity for the purpose of visuali"ation# inspection# dressing as well as the application of medication. 2. Bivalving : cutting the cast into halves from the upper portion to Othe bottom for the purpose of relieving possible tightness# for xAray and inspection of the casted extremity. 0. ,einforcing : application of plaster of *aris for the purpose of regaining strength in of wetting the cast which resulted to the instability of the cast. 74. Types of )asts B+)5 'anual& 3. T,+5G )3!T! $. )ollar )ast : affection of the cervical spine. 2. Body )ast A affection of the lower lumbar spine 0. ,i""er;s Cacket : for scoliosis M!N type or for thoracoAlumbar spine affection. 1. 'inerva )ast : for scoliosis# upper dorsal and cervical spine affection. 5. !houlder !pica : affections of the shoulder 8oints and shaft of the humerus. B. )3!T! -> TD. +**., .KT,.'4T4.! B+)5 'anual&

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$. @3)) : @ong 3rm )ircular )ast A affections of radius and ulna. 2. !3)) : !hort 3rm )ircular )ast A affection of the wrist 8oints# metacarpals and phalanges. 0. 'unster or >uenster cast : affections of radiusA ulna with good callus formation. 1. Danging cast : affection of the shaft of the humerus 5. 3irplane cast : for the affection of the neck of the humerus and shoulder 8oint (. >unctional cast : for the affection of the 'I0rd of the humerus with good callus formation. ).& )3!T -> TD. @-2., .KT,.'4T4.! B+)5 'anual& $. @@)) : @ong @eg )ircular )ast A for the affection of the tibia and fibula 2. !@)) : !hort @eg )ircular )ast A for the affection of the ankle 8oints# metatarsals and phalanges of the feet. *TB )ast : *atella Tendon Bearing )ast A for the affection of the tibia fibula with good callus formation. 0. PuadrilateralI4schial 2eight Bearing )ast : fracture of femur with callus formation 1. Dip !pica )ast : affection of the hip and femur a. !ingle Dip !pica : one hip @ or ,& and one $& femur. b. $ Q Dip !pica : Both hips @ and ,& and one $& femur. c. 6ouble Dip !pica A Both hips @ and ,& and two 2& femurs. 2. *antalon )ast : for pelvic fractureIinstability as in malgaine fracture. 0. )ast Brace A for the affection of upper portion of the tibiaAfibula andIor lower portion of the femur with good callus formation. 1. 2alking cast : for the affection of the ankles and toes with good callus formation. 5. 6elvit )ast : for tibiaAfibula affection with good callus formation to allow dorsiflexion and planter flexion of the toes. (. Basket )ast : for affection of the knee with massive in8ury that needs fre?uent dressing. F. )ylinder )ast : for the affection of the knee. <. >rog )ast A congenital hip dislocation. )D6& %. 4nternal Board ,otator : for patient who had undergone *artial ,eplacement Dip *rosthesis *,D*& or Total Dip *rosthesis to prevent internal or external rotations of the legs. 2. 'O!DS 3.& 6efinition '-@6! : use for splinting the affected parts of the body wherein there in an open wound# inflammation# abrasion# swelling or infection. *-) 'anual& A being applied posteriorly. B.& Types of molds *-) 'anual& $. !3*' : !hort 3rm *osterior 'old A for affection of wrist and fingers with infection and inflammation. 2. @3*' : @ong 3rm *osterior 'old A for affection of radiusAulna with open wound# swelling 0. !ugar Tong : for compound fracture of the humerus with open wound# inflammation and infection. 1. @@*' : @ong @eg *osterior 'old A for the affection of tibiaAfibula with infection and inflammation. 5. !@*' : !hort @eg *osterior 'old A for affection of ankle and toes with infection and open wound. (. )ylinder mold : for the affection of kneeIpatella with swelling and infection. F. 5ight splint : for post polio with residual paralysis. M N GEMENT O2 P TIENT WITH C ST ND MO!DS *-) 'anual& 3. 3!!.!!'.5T

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$. *erform neuromuscular checks to area distal to cast. a. ,eport absent diminished pulse# cyanosis or blanching# coldness# lack sensation# inability to move fingers or toes# excessive swelling. b. ,eports complaint of burning# tingling or numbness. 2. 5ote any odor from the cast that may indicate infection. 0. 5ote any bleeding on cast in a surgical client. 1. )heck for Mhot spotsN that may indicate inflammation under the cast. B. E.5.,3@ )3,. $.4nstruct client to wiggle toes or fingers to improve circulation. 2. .levate affected extremity above heart level to reduce swelling. 0.3pply ice bags to each side of the cast if ordered Cast Care 3ssess for/ $. )irculatory stasis : by making that there is ade?uate circulation to points distal to the cast. The fingers or toes pressed to see if they blanch followed by capillary filling. 6igits with ade?uate circulation are warm and have healthy color. 4t should not be so tight that the nurse cannot insert one or 2 fingers between the body and the chest. 2. *ressure on nerves : by asking the client to wiggle his digits# separate them and flex them in a dorsal plantar direction. 3ny numbness or tingling is indicative of abnormal pressure on the nerves. 0. .dema : this can be prevented by elevating the foot of the bed. !lings may also be used to maintain the involved part in elevation. !welling that cannot be relieved by poisoning should be reported to the physician. 4f the limb is casted# it may be necessary to bivalve the cast : cut it from top to bottom and separate the plaster to increase the width of the cast to relieve pressure. 2hen swelling has subsided# the window is reinserted and secured. 1. Bleeding : check vital signs. 3rea should be circled to detect further bleeding. ,estlessness may be a sign of an impending shock. 5. *ain : *ain medications *,5. *osition to relieve any discomfort. +nusual pain could be attributed to a tight cast should be reported to the physician. (. 4nfection : evidenced by odors and elevated temperature. The cast should be maintained clean and dry. )ast may be wiped with a damp cloth and powdered cleanser. The use of water and sponging should be avoided so that the plaster is not softened# when the cast dried# shellac maybe applied to keep it protected and clean. J 5o protective covering should be put on until the cast is dried# to avoid mildew. J The skin under the cast often becomes dry itches. 2hen the nurse bathes a client# it is important to wash under the cast to massage the skin with rubbing alcohol# because F0% isopropyl rubbing alcohol& strengthens the skin and prevent skin breakdown. !ome physicians may insert a strip of gau"e under the cast. The gau"e scratchier maybe used to gently massage the skin. 3 vacuum or 3septo syringe may be used to blow air through the cast to provide relief from itching. ).& -B!.,73T4-5 $. !igns of impaired circulation on toes and fingers a. color : cyanosis b. temperature : coldness of the skin c. movement : loss of function d. sensation : numbness e. pulsation : pulseless in extremity f. severe pain g. marked swelling 2. 5erve damage due to pressure in the nerve as it passes over a bony prominences. a. pain increasing# persistent and locali"ed b. anesthesia A numbness c. feeling of deep pressure

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d. paresthesia e. motor weakness or paralysis 0. 4nfection# tissue necrosis due to skin breakdow 1. *ressure on axilla# elbow# wrist and metacarpal# iliac crest# trochanter# groin# knee# ankle and metatarsals 6. )3!T )-'*@4)3T4-5! J 5eurovascular )ompromise : characteri"ed by changes in neurovascular status. $. C%m7artment s5n(r%me : a condition of marked increase in venous pressure 5ormal value : $5A25 mmDg& brought about because of constriction of edematous tissue within the muscle compartment. J S(23$ 34 S5"6)*"$/ edema# increase pain or passive movement. J )onstriction is caused by unyielding facial coverings over muscles. 2ith trauma# bleeding and inflammatory changes in8ured tissue# venous pressure rises as venous return is compromised by the traumas and decrease actual inflow toward ischemia. @onger than (R ischemia lead toward permanent tissue damage. J 4ntervention to lessen venous pressure $. elevation : $ to 2 pillows 2. cutting the cast 0. surgical fascietomy : which permits the edematous muscles to expand J .levation of in8ured limb to heart level increase 7, usually& through gravity because loss venous interstitial pressure need the MpushN of elevation to flow faster toward the heart. 2. Cast s5n(r%me : a series of events caused by loss of blood flow through the superior mesenteric artery# resulting in severe small intestinal ileus at times# small bowel ischemia obstruction. J This results from excessive bending or kinking of the artery because of the patients position in the body or hips spica cast# although it can also occur in persons in other type of cast. J 6ecreased blood supplies leads to stasis# increased intestinal putrefaction and ileus. 4leus alone can also be caused by the excessive air swallowing aerophagic& in an anxious or nervous patient. 4n this second situation# the patient need not be in a body or spica cast. J !Is/ $. feeling of being blocked 2. fullness in the stomach 0. as if the cast is too tight that they cannot take a deep breath 1. nausea 5. if the syndrome cautioner# vomiting# vital signs become elevated dysphea. J ,x/ bivalving the cast. 5ext 47;s# sedative# surgical resection of the ischemic bowel. . 6. )@4.5T T.3)D45E! 356 64!)D3,E. *@35545E $. 4sometric exercises when cleared with physician 2. ,einforcement of instruction given on crutch walking. 0. 6o not wet cast9 wrap cast in plastic bag when bathing or take a sponge bath. 1. 4f a cast had already dried and hardened does become wet# may use blow dryer on low setting over wet spots9 if large area of plaster cast becomes wet# call the physician. 5. 6o not scratch or insert foreign bodies under cast9 may direct cool air from blow dryer under cast for itching. (. ,ecogni"ed and report signs and impaired circulation or infection. F. )ast cleaning a.& )lean surface of plaster cast with a slightly damp clothes9 mild soap may be used for synthetic case. b.& To brighten cast a plaster cast# apply white shoe polish sparingly.

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Cast Rem%9a' J The cast is removed when healing has occurred. 3n electric cast saw is used to remove a cast. This saw vibrates against the plaster to separate it# but will not vibrate when in contact with the skin. J The skin beneath the cast is fre?uently dry with flakes of dead skin when the cast is removed9 wash the area with mild soap# taking care not to irritate the tender skin. !everal washing is more effective than one vigorous bath. @anolin can be used top soften the skin. J 'uscle may be weak without the support from the cast# and initially the client may have aches and pains. !ome physicians may bivalve the cast several days before cast removal so that the client can begin active and passive ,-'. There may be some swelling as circulation is reestablished9 elastic bandages may use to minimi"e swelling. .P+4*'.5T >-, )3!T ,.'-73@ *-)& )ast !preader : widen the cast Trimming knife : smoothen the edge of the cast !tryker cast cutter : used to bivalve the cast manually )ast !cissor : used to cut the wadding sheet and stockinette during cast removal..lectric )ast cutter : used in windowing and bivalving of cast but is electrically operated. 1. TR CTION 4. 6efinition T,3)T4-5A the act of pulling and drawing which is associated with counter 'anual& A the patient;s body weight serves as the counter traction. *-) 'anual& 44. 4ndicationsIpurposes $. 2. 0. 1. 5. (. +ntalan# 2005& >or immobili"ation. To prevent and correct deformity. >or support To reduce muscle pain and spasm. To reduce fracture. To maintain good alignment. traction. *-)

444. Basic concepts on traction. 3dopted from Eapu"# 2001& T A Trape"e bar overhead is used to raise and lower the upper body. , A ,e?uires free hanging weights 3 A 3nalgesics is given to relieve pain. ) A )heck the patient;s circulation. T A Temperature monitoring 4 A 4nfection prevention. - A -utput and intake monitoring. 5 A 5utritionIappropriate diet. ! A !kin must be checked fre?uently. 47. )lassification of Traction +ntalan# 2005& $. 'anual Traction : )7 %)(*3 66&('4 )* )8' !*45 !5 )8' 8 34$ *9 )8' *6'7 )*7. A )'"6*7 75 "' $#7' $*"')("'$ '"6&*5'4 (3 %'7:(% & $6(3' (3;#75 *7 4#7(32 % $) 66&(% )(*3. 2. !keletal Traction : )7 %)(*3 66&('4 )* )8' !*3'$ <()8 )8' #$' *9 6(3$, <(7'$ 34 )*32$. a. %0A%0 degrees : for supracondylar fracture and fracture of the shaft of the femur

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b. -verhead traction : for supracondylar fracture of the humerus. c. DaloApelvic traction : for scoliosis. The patient is allowed to ambulate. d. DaloA femoral traction :for scoli osis. e. )rutchfield tong traction : for cervical spine affection. f. 7inke skull caliper traction : for cervical spine affection for patients with bigger body built. g. Balance !keletal Traction : femoral affection 6.74).!/ *-) 'anual& 3. *ins and 2ires : indicated for the affection of long bones. A pins are heavier than wires. e.g. ,adiusAulna9 tibiaAfibula9 humerus9 femur B. Tongs : indicated for the upper dorsal# cervical spine. $. )rutchfield Tong : inserted at the parietal region outer table of the skull. 2. 7inke !kull )aliper : inserted at the temporal region outer table of the skull. 1. !kin traction : the application of a pulling force to the skin from where it is transmitted to the muscles and then to the bones T=*.! $. 3dhesive type : traction applied to the skin with the use of elastic bandage# adhesive tape and spreader. a. 6unlop traction : supracondylar fracture of the humerus b. Buck;s extension traction : affections of hip and femur. c. Bryant traction : affection of hip and femur among children below six (& years old. d. Sero degree traction : Aaffection of neck and head of the humerus. 2. 5onAadhesive type : traction applied to the body with the use of canvas# laces# buckles and leather. a. Dead halter traction : affection of the cervical spine b. Dammock suspension traction : affection of the pelvis. c. *elvic girdle traction : affections of the lumbar spine such as in D5*# low back pain. d. )otrel traction : combination of head halter and pelvic girdle strap. 4ndicated for scoliosis 4. Un+'assi,ie( t57e %, tra+ti%n a.

Boot cast traction : for flexion contracture of hip and knee.

SUMM R# O2 TR CTIONS )@3!!4>4)3T4-5 $. %0A%0 6.E,.!! 2. -verhead traction 0. DaloApelvic traction 1. DaloA femoral 5. B!T (. 6unlop traction F. Sero 6egree <. Buck;s extension %. Bryant traction !keletal !keletal !keletal !keletal !keletal skin:adhesive skinAadhesive skinAadhesive skinAadhesive skinAnonAadhesive skinAnonAadhesive skinAnonAadhesive skinAnonAadhesive unclassified 4564)3T4-5 A fracture of supracondylar and shaft of the femur A supracondylarfracture of the humerus A scoliosis A scoliosis A affection of the femur A supracondylar fracture of the humerus. A affection of neck and head of the humerus. A affections of hip and femur. A affection of hip B femur of children below ( years old. A cervical spine affection A affection of the lumbar spine A scoliosis A affection of the pelvis A flexion contracture of hip and knee.

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$0. Dead halter $$.*elvic girdle $2.)otrel traction $0. Dammock !uspension $1. Boot )ast 7. *rinciples of traction *-) 'anual& $. *atient should be in dorsal recumbent position. 2. @ine of pull should be in line with the deformity. 0. Traction should be continuous. 1. 3void friction. 5. *rovide counter traction. 74. -bservations to be made in *atients with traction *-) 'anual& $. The patient should be free from/ a. impaired circulation of the extremities b. respiratory distress c. deformity like footdrop# contacture of 8oints. d. !igns of infection. e. !kin complications 2. Bone alignment and position of extremity in which the purpose of traction is being accomplished. 0. *atients comfort. Traction should never be a source of undue discomfort. 1. *rovisions of exercise. 5. *rovisions of supportive therapy. (. )heck nutritional status of the patient. F. .very complaint of the patient should be investigated. <. )heck the traction set up for the following/ a. check the apparatus if it is accomplishing its purpose of traction and the e?uipment are safe as possible. b. !ash cord and pulleys should not be obstructed. c. .xamine knots# clamps and weights to be certain they are tightened. d. 6o not bump the bed and traction causing the weights to swing. e. 3lways check the traction apparatus after a patient has moved to make certain that patient is correctly well positioned. 744. 3pplication of Balance !keletal Traction. ,evision of the leaflet distributed by the *-)& 1. Veri,5 (%+t%rDs %r(er. Dis+uss t6e im7%rtan+e %, (%+t%rDs %r(er. ,ationale/ . T* =3*< )8' 99'%)'4 '>)7'"()5. !. T* =3*< )8' )56' *9 )7 %)(*3. %. T* =3*< )8' <'(28) *9 )8' 6 )('3) 9*7 67*6'7 % &%#& )(*3 *9 )8' )7 %)(*3 34 $#$6'3$(*3 <'(28). 0. In,%rm t6e 7atient a)%ut t6e nee( an( 7ur7%se %, t6e 7r%+e(ure. ,ationale/ 3lley anxiety and cooperation *urposes of Traction . F*7 (""*!(&(? )(*3. !. T* 67':'3) 34 %*77'%) 4'9*7"()5. %. F*7 $#66*7). foster

20

4. '. 9.

T* 7'4#%' "#$%&' 6 (3 34 $6 $". T* 7'4#%' 97 %)#7'. T* " (3) (3 2**4 &(23"'3)

3. ssem)'e t6e e?ui7ment nee(e(. 3. *3,T! -> TD. -,TD-*.64) B.6 $. Bed with fracture board 2. >irm mattress 0. Bed elevator or shock block 1. Balkan frame .@ :'7)(% & ! 7$ !.2 8*7(?*3) & ! 7$ %.1 %#7:' ! 7 4.2 %7*$$ ! 7$ '.1 4( 2*3 & ! 7 9. 3 6#&&'5$ 2. %& "6$ )* 8*&4 ! 7$ )*2')8'7 8 .*:'7 8' 4 )7 6'?' B. .P+4*'.5T >-, B!T $.Thomas splint 2. *earson;s attachment 0. ,est splint 1. >oot rest or foot board 5. 5 clips or safety pins (. )ord sashes . L*32- )8(28 7*6' !. L*32'7- )7 %)(*3 7*6' %. L*32'$) 1 $#$6'3$(*3 7*6' F. 2eight bags . T7 %)(*3 <'(28) 1 1AB *9 )8' )*) & !*45 <'(28) !. S#$6'3$(*3 <). 1 CAB *9 )8' )7 %)(*3 <'(28). <. 5 slings of different si"es . 2 &*32'7 34 <(4'7 $&(32$- )8(28 6*7)(*30 A)) %8 )* )8' T8*" $ $6&(3) !. 3 $8*7)'7 34 $" &&'7 $&(32$- &'2 6*7)(*30 A3%8*7 )* )8' P' 7$*3$ )) %8"'3)

2$

3dopted from B+)5 -rthopedic 'anual& 4. tta+6e( t6e T6%mas s7'int an( Pears%nDs atta+6ment t% t6e rest s7'int 8. 77'5 s'ings %n t6e T6%mas s7'int an( Pears%nDs atta+6ment. *,45)4*@.!/ $. 5ot to tight and not too loose 2. -ne inch distance between each slings. Tto promote aeration or ventilation. 0. *opliteal and heel portion should be free from any slings. 1. !mooth and right side should come in contact with the patient;s skin. 5. Two longer and wider slings should be in the thigh portion and the three shorter and smaller slings should be in the leg portion.

D-2 T- 3**@= TD. !@45E!. $. !tart from the medial to the lateral side. 2. !ecure both ends together. 0. >an fold nicely on the lateral side. 1. !ecure with clip or pin. :. tta+6 t6ig6 r%7e at t6e me(ia' u7rig6t %, t6e T6%mas s7'int Eit6 a s'i7 -n%t an( tem7%rari'5 an+6%r at t6e s+reE %, t6e Pears%nDs atta+6ment. )-5!46.,3T4-5!/ $.anchor rope at the leather portion to avoid slippage. 2..Gnot should be away from the patient;s skin. ;.Trans,er a,,e+te( e4tremit5 t% t6e assem)'e( T6%mas s7'int an( Pears%nDs atta+6ment. 45!T,+)T4-5 T- TD. *3T4.5T $. Dold on to the trape"e 2. >lex the unaffected extremity 0. 3t the count of three# to lift the buttocks and the affected extremity. )-5!46.,3T4-5!I3)T4-5! $.Three 0& manpower is needed . F(7$) )* (3$'7) )8' 66 7 )#$. !. S'%*34 )* 66&5 )8' " 3# & )7 %)(*3. c. T8(74 )* $$($) )8' 99'%)'4 '>)7'"()5. 2.The whole apparatus should be inserted under the affected extremity. 0. 'anual traction should only be released upon the completion of traction weight on the third pulley. 1. 3t the count of three# simultaneously the three 0& man power should do their 8ob =. C6e+- t6e a'ignment %, Pears%nDs s+reE Eit6 t6e -nee <%int. F. 77'5 tra+ti%n Eeig6t. )-5!46.,3T4-5!I3)T4-5!

22

$. ,ope should be attached to the !teinman;s pin holder to run along the third pulley. +se a slipknot. 2. 3ttached the prescribed weight. 0. )heck the principles of sling applications and make the necessary ad8ustments. 1. )heck the alignment. 5.Traction weight should be at bed level 10. 77'5 sus7ensi%n Eeig6t. )-5!46.,3T4-5!I3)T4-5! $. -ne end of the thigh rope should be attached to the lateral aspect of the ischial ring of the Thomas splint with a slipknot. 2. 3ttached suspension rope on the mid part of the thigh rope# run along the first pulley# insert suspension weight# hang it on the first pulley# run the suspension rope to the second pulley# then under the rest splint# anchor the rope to the Thomas splint with a clove hitch knot and another clove hitch knot to the *earson;s attachment. )onsume the remaining knot9 close it with a knot to secure it. 0. Dang the suspension weight on the rope between the first and the second pulley. 1. Be sure to maintain the traction rope inside and the suspension rope outside . 11. Rem%9e t6e rest s7'int 10. 77'5 ,%%t 7e(a'. CONSIDER TIONSG CTIONS $ .+se ribbon knot in tying. 2.The two 2& shorter cord in the Thomas splint and the two 2& longer cord should be anchored in the *earson;s attachment. 0. )ord should not come in contact with the patient;s skin. 1. The longer cords should be anchored between the first and the second slings passing under the first sling. $0. )heck the principles of traction. *,45)4*@.! -> T,3)T4-5 $. *atient should be in dorsal recumbent position 2. @ine of pull should be in line with the deformity. T$st pulley should be in line with the thigh. T2nd pulley should be in line with the knee or *earson;s screw. T0rd pulley should be in line with the $st and the 2nd pulley. 0. There should always be a continuous traction. .mphasi"ed the importance of manual traction. 1. *rovide counter traction. The patient;s body weight serves as the counter traction.
5. 3void friction.

'.TD-6! T- 37-46 >,4)T4-5 a. ,ope should be running along the groove of the pulley. b. Gnots should be away from the pulley. c. 2eights should be hanging freely. d. -bserve for the wear and tear on the ropes and bags.

20

$1. )heck the efficiency of traction

)-5!46.,3T4-5!I3)T4-5! $. 3sk the patient to hold on to the trape"e. 2. >lex the unaffected extremity. 0. !wing the patient to and fro and side to side. 18. Dis+uss nursing +are in 7atients Eit6 $ST. 3. 3ssessment : assess level of understanding and consciousness. B. *rovisions of general comfort. $. !kin care : head to toe. >ocus on the sponging of the affected extremity. D-2 T- !*-5E.U !tart at the anterior portion of the thigh. ,emove sling one at a time then sponge# soap# rinse# dry and replace the sling. ,emove the next sling. ,emove foot board# sponge and replace. 2. )hanging of linens. 0. *rovide bedpan as needed. !erve bedpan at the unaffected side# provide pillow to support the back of the patient and provide privacy. 1. 6o perineal care. ). *revent potential complications. $. +,T4 : prevent possibilities of hypostatic pneumonia. A bronchial tapping#deep breathing and coughing exercises. 2. Bedsores : good perineal care# proper skin care# turning patients every 2 hours# lift the buttocks once in a while. 0. +rinary and Gidney problems : good perineal care# increase fluid intake. 1. Bowel complications : related to fear of the apparatus# lack of privacy# inade?uate fluid intake# ineffective perineal care. 5. *in site infection : observe for signs and symptoms of infection. @oosening pin tract# pus draining# foul smelling discharges# fever. -bserve proper aseptic techni?ue and proper referral. (. 6eformity : contracted knee# atrophy of muscles# foot drop# 8oint contractures. 6. *rovisions of exercises $. ,-' with the use of the trape"e. 2. 6eep breathing exercises. 0. !tatic ?uadriceps exercises. 4nstruct the patient to alternately relax and contract the ?uadriceps muscles. 3lways start with the unaffected extremity . 1. Toe pedal exercises. .. 5utritional status : appropriate for the patient. Digh fiber : prevent constipation. 4ncrease fluid intake 7it ) : boast the resistance of the patient. 4ncrease )alcium : for bone healing. 7it 6 : promote absorption of )alcium. Digh protein : for repair of tissues. >. *sychological supportA related to fear of the unknown# fear of death# fear of the apparatus# fear of losing 8ob# financial related fear. E. *rovision of !upportive and 6iversional therapy : offer book to read# something to listen to such as radio# provide tv# discover interest. D. !piritual aspect : know the religion# encourage relatives to give spiritual communion# chaplain visit. $. 2. 0. 1. 5. (.

21

Rem%9a' %, $ST. *-) 'anual& $.3pply the rest splint. 2. Dang securely suspension weight on the first pulley. 0. ,emove the knot on the *earson;s attachment and Thomas splint. )ompletely remove the suspension weight. 1 'anual traction on the !teinman;s pin holder. 5. ,emove the traction weight from the 0rd pulley. (. !ecure the traction rope on the rest splint# then clove hitch knot on the Thomas splint and *earson;s attachment. )onsume remaining rope.

Summar5 %, t6e Ste7s in t6e 77'i+ati%n %, $a'an+e S-e'eta' Tra+ti%n

$. )heckIsee doctor;s order. 2. 4nform the patient about the procedure and purpose of traction. 0. 3ssemble the needed e?uipment. 1. 3ttach rest splint on Thomas splint and *earson;s attachment. 5.3pply slings on the Thomas splint and *earsons attachment (. 3ttached thigh rope at the medial upright. F. Transfer extremity to the assembled Thomas splint and *earson;s attachment. <. )heck alignment of the *earson;s screw with knee 8oint. %. 3pply traction weight. $0. 3pply suspension weight. $$. ,emove rest splint $2. 3pply foot pedal $0. 4dentify principles of traction.

25

$1. )heck the efficiency of traction. $5. 6iscuss nursing care of patient with traction. 1. $R CES 3. 6.>454T4-5 B,3). : 'echanical support for weakened muscles# 8oints and bones in rehabilitation as supporting body weight9 control involuntary movements# to prevent and correct deformities *-) 'anual& B. *+,*-!.! *-) 'anual& $. immobili"ation 2.control involuntary movement 0. support 1. permits patient to walk without fatigue 5. prevent and correct deformities (. maintain body alignment ).T=*.! $. !hant" collar brace : for cervical spinal affection 2. *hiladelphia collar brace : for cervical spinal affection. 0. 'ilwaukee Brace : for scoliosis 1. =amamoto Brace : for scoliosis 5. Cewett Brace : affection of the lower thoracic spine or *ott;s disease in dorsoAlumbar spine affection. (. Taylor brace : affection of the upper thoracic spine or *ott;s disease in thoracic spine affection. F. >orrester Brace : affection of the cervicoAthoracoAlumbarAspine. <. !-'4 :!ternoA-ccipitoA'andibular 4mmobili"er %. )hair back Brace : indicated for lumboAsacral affection $0. >our 1& poster Brace : affection of the cervical spine. $$. Ban8o splint : indicated for the affection of radiusAulna with peripheral nerve in8ury. $2. )ock up splint : support of the wrist to prevent wrist drop deformity $0. 6ennis Brown !hoe : for congenital talipes e?uino varus )T.7& or clubfoot $1. +nilateral long leg Brace : indicated for post polio with residua $5. Bilateral long leg brace : indicated for post polio both feet& with residua $(. !hort leg brace Icorrective shoe : for clubfoot -TD., B,3).! $. Dead halter strap : for cervical spine affection 2. *elvic girdle strap : for D*5 0. 3nklet strap : affection of hip and femur 1. Dammock suspension : affection of the pelvis 8. H RDW RES Dardware are generally implants used to manage and correct fractures. They are classified as internal and external implants . RODS OR N I!S ,od or nails are used to stabili"e diaphysis fractures of the middle thirds of long bones. The location of the in8ury determines the type of rod selected. 3 rod or nail maybe inserted using the closed or open method. 3s with other systems# instrumentation is specific for the type of rod or nail being inserted. $. SCREWS !crews are used either to fasten plates or similar devices onto bones9 to hold fragments of bones together9 or tissues to tissues# such as ligaments and tendons to bones. !crews have different ?ualities that must be recogni"ed in preparing instrumentation. The screw points are selfAtapping# nonAself tapping# trocar point#

2(

standard point or pilot point. The holding power of the screw in bones is most dependent on the density and ?uality of the bone. Bone is either cortical or cancellous and screws have been developed for each structural need C. P! TES *lates are devices# which are fastened to the bone for the purpose of providing fixation. They are protection or neutrali"ation Vplates# buttress plates# compression plates and tendon tension band plates. The shape of the plate is an adaptation of the plate to the local anatomy and does not denote any function. Thus# straight and angled blade plates can function as protection plate# tension band plates or buttress plates. D. C%mm%n Har(Eares an( In(i+ati%ns $. 4li"arov .xternal >ixatorA indicated for malAunion or nonAunion of long bones and for bone lengthening. 2. ,oger 3nderson .xternal >ixator ,3.>& : for comminuted fracture of the long bone. 0.Dybrid .xternal >ixator : )ombination of 4li"arov and ,3.> external fixators with delta frame. 4ndicated for unstable# comminuted fracture and periarticular fracture of the knee 8oint and ankle 8oint. 1. 4' 5ail :indicated for the fracture of the 'I0rd of the femur# tibia or fibula. 5. 4' 5ail .xtractor : ,emoval of 4' nails. (. >emoral and Tibial component : >or Total Gnee ,eplacement 3rthroplasty. F. 3ntibiotic Beads : indicated for bone infection# e.g. -steomyelitis <. Dip *rosthesis femoral component& : *artial ,eplacement hip *rosthesis9 indicated for fracture of the neck or head of the femur. %. Dip *rosthesis femoral with acetabular component& : Total Dip ,eplacement *rosthesis9 indicated for fracture of the head or neck of the femur including the acetabulum. $0. @u?ue ,od : indicated for scoliosis9 spinal cord in8ury. $$. )ompression plate : !ubtrochanteric or intertrochanteric affection. $2. Buttress *late : >racture of the distal tibia. $0. Bone *late : affection of radius and ulna. $1. Doffman >ixator : 4ndicated for pelvic fracture. $5. Dip !pacer : ,eplacement for hip prosthesis once infection set in9 resembles a hip prosthesis but contains antibiotic. $(.)irclage 2iring : indicated for fracture of the patella. $F. Eigli !aw : for amputation. $<. Darrington ,od : indicated to correct scoliosis9 placed along the spine. $%. -ssicilation !aw : use to cut the femoral neck. 20. Tower;s .xternal >ixator : indicated for the fracture of the mandible. 2$. 4nterdental wiring : >racture of the mandible. :. SSISTED !OCOMOTION A 'aybe needed for clients with difficulty maintaining balance. Before beginning assisted locomotion# patient should do exercises that strengthen weightAbearing muscles of the uninvolved limbs. 3ctive and passive ,-' can be done initially to maintain muscle strength. @ater# exercises to develop muscles that will be used for ambulation are performed. *ush up and pull ups using the over head trape"e help develop the biceps and triceps. Puadriceps can the strengthened with straight leg raises and ?uadriceps setting exercises.. These exercises should be done for 5 minutes every hour. Before walking with assistance# the client should dangle his legs and then stand at the bedside in supportive shoes to achieve sense of balance. ssisti9e De9i+es ,%r Wa'-ing *otter B *erry $%%0& 'usculoskeletal anomalies may temporarily or permanently cause impairment in the locomotion of the patients. 3ssistive devices are introduce to patients to assist them in moving. Dowever# proper choice of the device must be given consideration to fit the need of the patient. . C NE : used to provide wide base of support and balance. 2hen one cane is used for balance it should be held in the hand opposite the involved leg. )ane should be measured from the floor to the waist of the client and tip should be covered with a rubber cup to prevent slipping on the floor.

2F

*urposes/ a. To assist the client walk with greater balance and support with less fatigue. b. To relieve pressures on weight bearing 8oints c. To provide forces to push and pull the forward or to restrain the forward motion of the patient while walking. Techni?ues for walking with canes a. Dold the cane on the hand opposite the affected extremity good side&. b. 3dvanced the cane at the same time the affected limb is moved forward. c. Geep the cane fairly close to the body to prevent leaning. d. 4f the client is unable to hold the cane on the opposite hand# the cane may be carried on the same side and advanced it when the affected leg is advanced. e. To go up and down the stairs/ !et up on the unaffected extremity Then place the cane and the affected extremity on the step. ,everse this procedure for descending steps. The strong legs goes up first and comes down last. Eood leg up9 bad leg down& Types/ !ingle# tripod cane# ?uadripod cane

$. W !"ER A used primarily to provide balance for clients who can bear weights although they may be used when only partial or limited weight bearing is permitted with the involved leg $. 3 mechanical device with four legs for support. 2. 5ursing )are/ Teach the client to hold upper bars of walker at each side# then to move walker forward and step into it. C. CRUTCHES Teaching the client the proper use of crutches is an important nursing responsibility. $. 3ssure *roper length a. 2hen client assumes erect position# the top crutch is 2 inches below the axilla# and the tip of each crutch is ( inches in front and to the side of the feet. 2 inches towards the front and 1 inches to the sides& b. )lients elbow should be slightly flexed when hand is on the hand grip 00 degrees&. c. 2eight should not be borne by the axilla# but on the palms of the hands to prevent crutch palsy ),+T)D *3@!= : paralysis of the extensor muscle of the hand and arm due to pressure against the axillary region pressing the radial nerve&. 2. )rutch Eaits a. >our point Eait : used when weight bearing is allowed on both extremities. $. 3dvance right crutch 2. !tep forward with left foot 0. 3dvance left crutch 1. !tep forward with right foot b. Three point Eait : used when weight bearing is allowed on one extremity only. $. 3dvance two 2& crutches and affected extremity several inches maintaining good balance. 2. 3dvance the unaffected leg to the level of the crutches9 support the weight of the body on the hands. c. Two point Eait : typical walking pattern9 an acceleration of four 1& point gait. $. 3dvanced right crutch and left leg together. 2. !tep forward moving left crutch and right leg together. d. !wing to Eait : used for clients with paralysis of both lower extremities who are unable to lift feet from the floor. $. Both crutches are advanced forward. 2. )lient swings forward so that the feet will be at the level of the crutch. e. !wing through Eait : same indications as of swing to gait.

2<

$. Both crutches are placed forward. 2.)lient swings body pass through the level of the crutches

III. COMMON HE !TH PRO$!EMS . NEON TE ND IN2 NT 1. C'u),%%t )lubfoot is a congenital deformity of the foot usually with ankle involvement characteri"ed by a twisting out of a normal position that is unable to be manipulated into a different position. The deformity is typed and named according to the position of the foot . Talipes varus : foot inversion Talipes valgus : foot eversion Talipes e?uinus :plantar flexion Talipes calcaneus A dorsiflexion 'ost cases of talipes are combination of these with the most common deformity known as Talipes e?uinovarus inversion and plantar flexion of the foot&. *athophysiology/ Eenetic >actor 3rrested development of .mbryo in early stages .nvironmental factor 3bnormal position in the utero ,estricted movement in the utero

+nilateral or Bilateral 6eformity of foot and ankle

2%

Talipes .?uinovarus most common& >oot pointed downward and inward plantar flexion and inversion&

Talipes calcaneovalgus >oot pointed upward and outward dorsiflexion and eversion&

'anipulation and taping or !uccessive casting to accommodate growth or !urgical correction 5ursing diagnoses/ $. 4mpaired physical mobility related to musculoskeletal impairment talipes deformity& 2. ,isk for impaired skin integrity related to physical immobili"ation by cast s&# internal factors of altered circulation# sensation by cast pressure. 0. 6elayed growth and development related to effects of physical disability immobili"ation& 1. Gnowledge deficit related to lack of information about condition.

T !IPES ECUINOV RUS The heel cord 3chilles; tendon& is tight# causing the heel to be drawn up toward the leg. This position is referred to as Me?uinesN and it is impossible to place the foot flat on the ground. !ince the condition starts in the first trimester of pregnancy# the deformity is often ?uite rigid at birth. .T4-@-E=/ The cause is unknown. >or idiopathic clubfoot# a heredity factor can be found approximately 20% of the cases. D=*-TD.!.! '-!T 246.@= 3)).*T.6 $. 3rrested or anomalous development of this particular part of the embryo in first trimester of pregnancy. 2. 3t about 0rd month of intrauterine life# foot occupies normally an e?uinovarus position. 0. 3bnormality of the relative maturity and length of the muscles as well as variation in their tendon insertions. )@454)3@ '354>.!T3T4-5/ $. The heel is drawn up# the entire foot below the talus is inverted and the anterior half is adducted. 2. The medial border of the foot if concave# the later border is convex and there is a transverse case across the level to bear weight normally. 0. 'uscles of the leg ?uickly before fatigued and soon show marked atrophy. 1. *ain is experienced by patients where arthritis changes developed. 5. There is some degree of stiffness. '.64)3@ '353E.'.5T $. .xercise

00

2. 0. 1.

)asting cast is changed periodically to change angle of foot&. 6ennis Brown !plint bar shoes& : metal bar with shoes attached to the bar at specific angle. !urgery and casting for several months.

5+,!45E 45T.,7.5T4-5! $. *erform exercise as ordered 2. *rovide cast care or care for child in a brace. 0. )hild who is learning to walk must be prevented from trying to stand9 apply restraint if necessary. 1. *rovide diversional activities. 5. 3dapt care routines as needed for cast and brace. (. 3ssess toes to be sure cast is not too tight. F. *rovide skin care. <. *rovide client teaching and discharge planning concerning/ 3pplication or care of immobili"ation device *reparation for surgery if indicated. 5eed to monitor special shoes for continued fit throughout the treatment.

0. T%rti+%'is %r Wr5 ne+/ a congenital anomaly when the sternocleidomastoid muscle is in8ured and bleeds during birth. / derived from tortus twisted& and colum neck&. / this tends to occur in newborns with wide shoulders when pressure is exerted on the head to deliver the shoulder.

Pat6%765si%'%g5 4n8ury pressure on the msternocleidomastoid muscle& Bleeding and hematoma formation >ormation of mass in the lower half of the affected !ternocleidomastoid $0A$1 days after birth& Tightening or shortening of the particular muscle T%rti+%''is ssessment3 Dead is tilted at the affected side >ace is rotated to the opposite side 3symmetry of the face Management3 !tretching exercise A Tilting the head away from the affected side so that the ear can be brought into contact with the opposite shoulder. A ,otating the chin toward the tight sternocleidomastoid muscle.

0$

2hen the heads is in stretched position# it should be held there for $0 seconds. !hould be done1A( times per day with 20 repetitions of each exercise each time. !upport the head with sandbag in the corrected position when lying. 4f correction is not instituted early surgery is done after $< months of age. Traction or bracing after surgery 3ctive and passive exercise after surgery.

$. CHI!D 1. !egg/ Ca'9e Pert6es Disease B-stoechondritis deformans& A a disease of the femoral head occurring in children between 0A$2 years old. A cause is unknown but it is characteri"ed by necrosis of the femoral head which results from an impaired circulation of the femoral epiphysis extending to the acetabulum. !T3E.!/ !tage $. 373!)+@3, : necrosis and degeneration of the femoral head !pontaneous interruption of the blood supply to the upper femoral epiphysis Bone forming cells in the epiphysis die and bone ceases to grow. !light widening of the 8oint space occurs. !welling of the soft tissues around the hips occur. !tage 2. ,.73!)+@3,4S3T4-5 : bone absorption and vasculari"ation Erowth of new vessels supplies the area of necrosis# both bone resorption and deposition occurs The new bone is not strong and pathologic fractures may occur. 3bnormal forces on the weakened epiphysis may produce progressive deformity !tage 0. ,.*3,3T47. : new bone formation with ossification The head of the femur gradually reforms 5ucleus of the epiphysis breaks up into a number of fragments with cyst like fragments between them 5ew bone starts to develop at the medial and lateral edges of the epiphysis which becomes widen 6ead bone is removed and is replaced with new bone which gradually spreads to heal the lesions. !tage 1. ,.E.5.,3T47. : reformation of the femoral head to a sphere 2ithout treatment head of the femur flattens and becomes mushroom shaped# incongruity between the head of the femur and acetabulum persists )omplete recovery# head of the femur becomes spherical# acetabulum becomes normal '354>.!T3T4-5! Coint dysfunction with 8oint pain or ache @imp that is continuous or intermittent 6ecreased ,-' *ainful gait 3trophy of thigh muscle 'uscle spasm T,.3T'.5T Eoal/

02

$. to reduce hip irritability 2. achieve and maintain ,-' 0. prevent the ball from extruding or collapsing !urgical Treatment $. Tenotomy : surgery to release an atrophied muscle that has shortened to limping 2. -steotomy : cutting the bone to repositioning A surgical realignment of the femur so that the head of the femur is securely contained the acetabulum. A re?uires (A< weeks of a hip spica cast after surgery and may be preceded by traction. '.64)3@ )3,. @/R # A reveals changes in the femoral head and hip from a flattened appearance !tage $& and to a mottled appearance progressing to increased bone density and normali"ation of the rounded appearance of the femoral head. MRI : useful early in the disease to detect changes. A later in the disease# ',4s are useful in assessing containment of the femoral head in the acetabulum. )(u+ti%n Tra+ti%n A used to increase the ,-' in a child who has developed limitedhip motion from pain and spasm. Seria' Casting A casting of the hip in an abducted position with weekly cast changes using a progressively longer bar until the full rang of abduction is achieve. )asting may also contains the femoral head in the acetabulum. '.64)3T4-5!/ NS ID A given to relieve mild to moderately severe pain. 5+,!45E 643E5-!.! 4mpaired physical mobility related to musculoskeletal impairment femoral head& ,isk for impaired skin integrity related to physical immobili"ation# pressure or appliance and altered circulation# sensation.& 6elayed growth and development related to effects of immobili"ation. 6eficient knowledge related to lack of information about the disease. 5+,!45E 45T.,7.5T4-5!/ )aring for the child re?uiring traction or a spica cast. .valuating the home and providing guidance to the family regarding the child;s home care. .nabling the child to participate in as many activities of life as possible. *roviding emotional support to the child and his family because of the long term nature of the illness. 0. &u9eni'e R6eumat%i( rt6ritis /a chronic inflammatory disease that involves the synovium of the 8oints resulting in effusion and eventual erosion and destruction of the 8oint cartilage. / it is classifierd into different types and characteri"ed by remission and exacerbations# with the onset most common between 2A5 and %A$2 years of age. T57es3 $. *auciarticular 3rthritis : involves only few 8oints# usually less than five. 2. *olyarticular 3rthitis : involves many 8oints# usually more than four

00

0.

!ystemic 3rthritis : involves the presence of arthritis and associated with high temperature# rash and effects on other organs such as heart# lungs# eyes and those located in the abdominal cavity. 3utoimmunologic response )hronic inflammation of synovial membrane

*athophysiology

7asodilation 4ncreased blood flow 4ncreased capillary permeability 2armth ,edness *ain 4ridocyclitis ,ash or mucocutA aneous lesions *ericarditis 7asculitis >ever 'alaise

Coint .ffusion Thickened# hyperemic cellular membrane pannus& .rosion# destruction# fibrosi of articular cartilage

,educed 8oint motion 3dhesions between 8oint surfaces 3nkylosis of 8oint

!tructural changes Coint instability 'uscle atrophy !tretched ligaments

>ibrous tissue irreversible destructive changes

'edical 'anagement/ 3ntiAinflammatories 5!346& A for analgesia# antipyretic action as well as antiA inflammatory and antirheumatic effects. 3ctions thought to be the inhibition of prostaglandin synthesis. 'ay be used in combination with steroids and gold salts. 3ntiAinflammatories !teroids& : prednisone 6eltasone& given *- to suppress inflammatory responses and reactions# also reduces antibody titers and inhibits phagocytosis and release of allergic substances. 3ntirheumatics : to inhibit collagen formation to alter immune response and inhibit prostaglandin synthesis in the treatment of rheumatic diseases. )ytotoxics : to treat rheumatoid arthritis when response to other antiAinflammatory drugs are not effective if the disease is severe and debilitating. Coint KAray : reveals widened 8oint spaces with nlater 8oint destruction and effusion# evidence of osteoporosis and inflammation at the affected 8oint sites. .!, : reveals increases in systemic type but may be decreased or increased depending on the degree of inflammation. 3ntinuclear antibodies : reveals presence in F5% of rheumatoid factor with a positive result in 25%9 positive or negative result depending on the type of arthritis. ,heumatoid >actor : reveals presence in those with later onset type with positive results in pauciarticular type. )B) : reveals increase 2B) in the earlier stages. !ynovial >luid )ulture A reveals absence of infectious process and confirms absence of other conditions by 8oint aspiration of fluid for examination.

01

)ommon 5ursing 6iagnoses $. 4mpaired physical mobility related to musculoskeletal impairment# pain and discomfort. 2. ,isk for impaired skin integrity related to external factor or physical immobili"ation. 0. 6elayed growth and development related to effects of physical disability. 1. Dyperthermia related to illness of inflammation 5. 4mbalance nutrition less than body re?uirements related to inability to ingest food. C. DO!ESCENT 1. S+%'i%sis !coliosis is a lateral curvature of the spine. 4t can be classified as either functional or structured. !coliosis is common among girl adolescents. T=*.!/ IDIOP THIC SCO!IOSIS/ +5G5-25 A45>35T4@./ 0A09 C+7.54@./ 0A$09 36-@.!).5T/ $0A+*9 D4ED 45)46.5). T- >.'3@. F/$ CONGENIT !/ +5G5-259 T=*. 4A >34@+,. -> 7.,T.B,3@ B-6= >-,'3T4-59 T=*. 44A>34@+,. -> !.E'.5T3T4-5 NEURO/MUSCU! R SCO!IOSIS/ 6+. T- 5.+,-'+!)+@3, )-564T4-5#A ).,.B,3@ *3@!=I 5-5A3'B+@3T-,=I 6=!T,-*D= )3+!.!/ )ause is unknown )ondition affecting the neuromuscular system 3bnormal development of the bone in the spine

*artial unilateral failure of formation wedge vertebrae&

)omplete unilateral failure of formation Demivertebra&

+nilateral failure of segmentation congenital bar&

Bilateral failure of segmentation block vertebrae&

$. >unctional or *ostural : a.k.a. M)N curve 5o fixed deformity of the spinal column 6ue to posture9 can be corrected voluntarily and disappears when child lies down 5ot progressive 2. !tructural and progressive : a.k.a. M!N curve 4diopathic !tructural change of the spine does not disappear with position change 'ore aggressive intervention are needed !4E5! 356 !='*T-'! $. *hysical characteristic *oor posture

05

 4ncrease or decrease thoracic kyposis or lumbar lardosis @eg length discrepancy +neven shoulder : right side is higher than the left !capular prominence Truncal imbalance @ump on the back +neven breast si"e 2. 7isuali"ation of deformity 0. Back pain ,4!G >3)T-,!/ 3ge >amily members who had scoliosis 6elayed puberty and menarche in girls

*3TD-*D=!4-@-E= *,.64!*-!45E >3)T-,! 3ge !ex Eenetic *,.)4*4T3T45E >3)T-,! *resence of other diseases 5ature of living

>ailure of vertebral body

>ailure of segmentation -steopathic conditions such as fracture# bone disease# arthritis and infection spinal irradiation and nerve root irritation vertebral column develops curvature changes in the thoracic case# ribs and sternum lead to rib hump !)-@4-!4!

0(

)@3!!4>4)3T4-5 -> )+,73T+,. $. '4@6 A20R A W10R X examined every 0 months9 exercise program may strengthen torso muscle heel lift may also help. 2. '-6.,3T. : 10R A W(0R X!pinal exercises9 braces 0. !.7.,. A X(0R Xlateral curvature progresses Xspinal fusion 643E5-!T4) *,-).6+,. $. 3dams forward bending test 2. KAray of the spine in an upright position : show characteristic curvature. 0. ',4# 'yelograms# Tomogram# )T scan : indicated for children with severe curvature who have known or suspected spinal column anomaly before management is made. 1. *ulmonary function test : for compromised respiratory status. 5. !coliometry : measurement of the curvature of the spine )obb;s method& !)-@4-'.T., : device use in scoliometry (. 3rthrography : identify acute or chrnic tears of 8oint capsules or supporting ligaments. '.64)3@ '353E.'.5T $. -bservation : periodic physical and radiographic examination to detect curve progression. 2. Bracing : to prevent progression of curve with the use of 'ilwaukee or yamamoto brace. BRACE MANAGEMENT- PREVENT CURVE PROGRESSION0 FAITHFUL COMPLIANCE0 23 HOURSDDAY0 BRACING FOR S,ELETAL IMMATURE CHILDREN WITH CURVES 2C-@A DEGREES 0. Traction : DaloApelvic9 haloAfemoral# cotrel 1. )ast : 'inerva9 ,i"""er;s 8acket 5. !urgery : spinal fusion9 D,49 stryker frame (. .xercise therapy has been promoted to help maintain flexibility in the spine and prevent muscle atrophy during prolonged bracing. 5+,!45E 643E5-!.! 4mpaired physical mobility related to musculoskeletal impairment )urvature of the spine&. ,isk for impaired skin integrity related to physical immobili"ation# traction or brace and altered sensation and circulation# surface electrical stimulation. 6elayed growth and development related to effects of immobili"ation and restricted movement from spinal curvature.. Gnowledge deficit related to lack of information about correction of functional or structural scoliosis. 6isturbed body image related to biophysical and psychosocial factors of spinal deformity. 5+,!45E 45T.,7.5T4-5/ $. TeachIencourage client to exercise as ordered. 2. *rovide cast or traction care. 0. 3ssist with modifying clothing for immobili"ation devices 1. *rovide care for the client with D,4. 5. 3d8ust diet for decreased activity T57es %, )ra+es3 $%st%n %rt6%sis/ for low thoracic and thoracolumbar curves Mi'Eau-ee/ thoracic or double ma8or curves. !tandard brace has neck ring wI chin rests C6ar'est%n $en(ing )ra+e/ night time usage Surgi+a' C%rre+ti%ns/

0F

!pinal fusion Darrington rod instrumentation and posterior spinal fusion 'ultiple @evelA!egmental >usion !ystem such as/ Texas !cottish ,ite Dospital T!,D& system or )-T,.TA6+B-+!!.T !=!T.'9 @+P+. T.)D54P+.A 24TD 6+3@ ,-6! 24TD !+B@3'453@ 24,. !.E'.5T3@ >4K3T4-59 62=., -, 35T.,4-, T!,DA 45)+,. !T3*@. 356 )3B@. -, ,-6 !=!T.'!

Nursing inter9enti%ns3 .xpress feelings 6iscuss options for brace wearing 6iscuss scoliosis with peers# treatment and disease process *rovide peer support *roper fitting of the braceIcast 3ssess skin integrity 2ear cotton clothes

D. #OUNG DU!T 1. Oste%geni+ Sar+%ma -steosarcoma is a kind of bone cancer. 4t cae from the words MosteoN which means bone and MsarcomaN meaning cancer. 4t most often starts in a leg bone either the femur or the tibia& in the area of the knee or in the upper arm bone the humerus& near the shoulder. -steosarcoma can spread metastasi"e& to other parts of the body# most often to the lungs or other bones. ,4!G >3)T-,!/ Teenage growth spruts Tall for the specific age *revious treatment with the radiation for other cancer *resence of bone benign diseases !4E5! 356 !='*T-'!/ *ain intermittent at first# later severe and constant& !welling# fre?uently reported @imited 8oint movement .ventually fever and general debilitatiuons Digh fre?uency of pathological fractures 'etastasis seeding of the malignancy in other parts of the body& : occurs early and death usually results from the spread of the disease to the lungs. !yndromes of )ancer $. weight loss 2. muscular weakness 0. anorexia 1. severe depression 5. toxemia (. acidosis -ther 5ame/ -steogenic !arcoma *3TD-*D=!4-@-E=

0<

*,.64!*-!45E >3)T-,! >amilial tendencies in8ury and infection

*,.)4*4T3T45E >3)T-,! exposure to sunlight and ultra violet rays metabolic and hormonal disturbances irradiation and assimilation of irritant substances smoking# oil# tar& -ther organic cause

new growth in the tumor in the bones

bones

Bone destruction 2eakness of the bone remodeling

ad8acent normal bones respond by altering its normal pattern of

bone fracture malignant bone tumor osteosarcoma invade and destroy ad8acent bone tissue metastasis death 643E5-!T4) *,-).6+,.!/ $. 2. 0. 1. 5. KA,3= : will show tumor location and si"e ',4 and )T scan : determine how much bone tumor has destroyed and the tumor has metastasi"ed outside the bone into the nearby muscles. B-5. !)35 : to determine if cancer has spread to other bones. B4-*!= : confirm that the tumor is osteosarcoma B@--6 T.!T : reveal an elevated serum alkaline

'.64)3@ '353E.'.5T

0%

The treatment depends on the si"e# location of the tumor# presence of metastasis# patient; age# general health# life style and preferences. *hysical therapy : to improve muscle tone and range of motion Dormonal and chemotherapy Xsteroid compound X,adioactive isotopes X3lkanating agents 3ntibiotics 7itamins preparation !urgery Xexcision Xamputation X@imb !alvage *rocedure @!!& ,esection of metastasis *rosthesis ,esection of the knee 8oint 5+,!45E '353E.'.5T 6iscussion of diagnosis# prognosis and treatment options. .xploration of the patients understanding of the risk benefits and expected outcomes treatment available *reoperative preparation regarding preoperative experience including allograph# hardware and possible need of transfusion .xplanation of potential complications .xplanation of the patients expected functional activities 4nstruction and supervision of correct use of supportive devices !upport of decisionAmaking abilities of the patient and family ,eferral to support groups on community services *romotion of independence within capabilities .ncouragement of effective coping strategies *romotion of mobility *romotion of acceptance of body image *revention of complications 'onitor patients response to pain control measures ,ecogni"e signs of toxicity from chemotherapy ,ecogni"e signs of toxicity and radiotherapy

E. ADULT 1. Ar !r" "# (G$% & R!'%() $"*& O# '$)r !r" "#) A. RHEUMATOID A.(ARTHRITIS DEFORMANS) -CHRONIC SYSTEMIC DISEASE CHARACTERI/ED BY INFLAMMATORY CHANGES IN -OINTS RELATED STRUCTURES, RESULTING IN CRIPPLING DEFORMITIES - AUTOIMMUNED GENETICSD METABOLIC FACTORS - MORE COMMON IN WOMEN (3E1) - 2A-@A YEARS OLD

10

- USUALLY AFFECTING PRO+IMAL -OINTS AND SYNOVIAL MEMBRAINE BEFORE INVOLVING LARGER WT-BEARING -OINTS 1 '>. HANDS, WRIST, ELBOW, SHOULDER, ,NESS, HIPS, AN,LE AND -AW

PATHOE SYNOVITIS PANNUS FORMATION BONY AN,YLOSIS (F7*?'3 -*(3))

FIBROUS AN,YLOSIS

F6 33#$ 9*7" )(*3- 3 (39& "" )*75 '>#4 )' *:'7&5(32 )8' $53*:( & %'&&$ *3 )8' $(4' *9 )8' ;*(3) F 3=5&*$($- (""*!(&()5 34 %*3$*&(4 )(*3 *9 ;*(3)0 (9(!7*#$ .) 4'%7' $'4 ;*(3) "*!(&()5 4#' )* 67*&(9'7 )(*3 *9 9(!7*#$ )($$#'$0 (!*35 .) #3(*3 *9 )8' !*3'$ *9 ;*(3) !5 67*&(9'7 )(*3 *9 !*3' %'&&$ o O$)'*6*7*$($ ($ %*""*3

ASSESSMENT 9 )(2#', 3*7'>( , <) &*$$, $&(28) '&': )(*3 *9 )'"6., 6 (39#&, < 7", $<*&&'3 ;*(3)$(8 34$ 34 9'')) <D &("()'4 "*)(*3, $)(993'$$ (3 "*73(32 34 9)'7 6'7(*4$ *9 (3 %)(:()50 S-OGRENS SYNDROME- '>%'$$(:' 4753'$$ *9 "*#)8, '5'$ 34 : 2(3 0 FELTYS SYNDROME- &'#=*6'3( , $6&'3*"'2 &50 $':'7' 3'"( 34 (3%7' $'4 ESR MANAGEMENTE BED REST, PASSIVE ROM0 HEAT AND COLD APPLICATION0 WARM BATH IN THE MORNING TO RELIEVE MORNING STIFFNESS SURGERYE OSTEOTOMY- 7'"*: & *9 <'42' 97*" ;*(3)0 SYNOVECTOMY- 7'"*: & *9 $53*:( 0 ARTHROPLASTY- 7'6& %'"'3) *9 ;*(3)$ <D 67*$)8'$'$ DRUGSE ASPIRIN, NSAIDS- (34*%(3, (!#67*9'3, 9'3*67*9'3, 3 67*>'30 CORTICOSTEROIDS0 GOLD COMPOUNDS- N )8(*" & )', #7 3*9(3, 2*&4 $ &)$ B. OSTEOARTHRITIS (DEGENERATI+E ).)-A DEGENETATIVE -OINT DISEASE0 CHRONIC DISEASE INVOLVING THE WEIGHT BEARING -OINTS, NON-SYSTEMATIC DEGENERATION OF ARTICULAR CARTILAGE ( $6(3', =3''$, 8(6$ 34 '34$ *9 9(32'7$) Pr'*"#,$#"-. F)/ $r#0 2(32 )7 #" '>%'$$(:' #$' *9 ;*(3), *!'$()5 EG# & (3%(4'3%' 9*7 " &' 34 9'" &' PATHOPHYSIOLOGYE DEGENERATION OR ARTICULAR CARTILAGE RESULTING TO NEW BONE FORMATIONE HEBERDEN1S NODES (BONY NODULES OR SPURS ON THE DORSOLATERAL ASPECTS OF DISTAL -OINTS OF FINGERS) ASSESSMENTE STIFFNESS IN THE MORNING0 PAIN AGGRAVATED BY TEMP, WT BEARING RELIEVED BY RSY0 HEBERDENS NODES0 DECREASED ROM0 CREPITATION MANAGEMENTE RELIEF OF -OINT PAIN AND ROM0

1$

CANE WAL,ER0 POSTURE AND BODY MECHANICS0 AVOID E+CESSIVE WT. BEARING AND CONTINUOUS STANDING PHYSICAL THERAPY0 -OINT REPLACEMENT AS NEEDED C. GOUTY ARTHRITIS -INFLAMMATION OF A -OINT CAUSED BY GOUT(URIC ACID CRYSTALS DEPOSITED IN -OINT) HTOPHII- RESULTING TO PAIN AND INFLAMMATION - FRE.UENT TO MEN0 FAMILIAL0 2A-@A YEARS OLD0 AFFECTING TERMINAL -OINTGREAT TOES AND AN,LES ASSESSMENTE -OINT PAIN, REDNESS, HEAT, SWELLING OF GREAT TOES AND AN,LES, HEADACHE, MALAISE, FEVER, TOPHI IN OUTER EAR, HANDS AND FEET0 INCREASED IN URIC ACID MANAGEMENTE COLCHICINE (ANTIGOUT)2 SE. DIARRHEAD NJVD ABD. PAIND ANEMIA0 NSAID$0 ALLOPURINOL (3YLOPRIM)- INHIBITS URIC ACID FORMATION WITH MEALS, SE. GI DISTRESS, DROWSINESS, ANEMIA, S,IN RASH0 ENCOURAGE FLUIDS 4-3L5DAY WHEN GIVING ANTI-GOUT DRUGS TO PREVENT ,IDNEY STONES0 LOW PURINE DIET0 AVOID ORGAN MEATS, SHELFISH, LEGUMES, SARDINES, SALTED ANCHIOVES, MUSHROOMS, BEER AND WINE

COMP R TIVE T $!E O2 RTHRITIS *rocess ,heumatoid 3rthritis )hronic inflammation of synovial membrane leading to erosion of cartilage# bone# ligaments and tendons Dands usually proximal and smaller 8oints&# feet# wrist# knees# elbow and ankles -steoarthritis 6egeneration and progressive softening and loss of cartilage leading to formation of new bone at cartilage lining Dand usually distalA Deberden 8oints&# cervical and lumbar spine# previous Eouty 3rthritis 4nflammatory reactions to urate crystals Big toe

)ommon locations

12

*attern -nset

!ymmetrical# bilateral# Eenerali"ed symptoms

in8ured 8oints and weightA bearing 3ssymetrical 4nsidious

,edness 2armth Tenderness !tiffness *redisposition !ignificant @aboratory

!eldom red -ften warm Tender @asting an hour or more after prolonged inactivity or in the mornings 0 x more common in women# age 00A55 years old Y& )Areactive# Y& 3ntinuclear 3ntibody 353& Test# elevated .rythrocyte !edimentation ,ate .!,&

,arely red !eldom warm *ossible tender Brief inactivity or in mornings 5ot sex specific# 15 years or older

+sually single point involvement !udden# at night after in8ury# excessive eating or alcohol intake ,ed Dot .x?uisitely tender 6evelops as symptoms become chronic

.levated !erum +ric 3cid

0. Oste%ma'a+ia

A softening of the bone tissue and is characteri"ed by inade?uate minerali"ation of the

osteoid. A 7itamin 6 deficiency is the most important factor in the development of osteomalacia. .tiologic >actor/ 7it 6 6eficiency : related to lack of exposure to sunlight or dietary intake. 'alabsorption of 7it 6 from the small bowel : in cases of partial or total gastrectomy and bypass resection surgery of the small intestines )rhon;s 6isease : decrease 7it 6 absorption. @iver and pancreatic disorder : interrupts 7it 6 metabolism. )hronic ,enal 4nsufficiency : interferes with the synthesis of calciferol the most active vitamin metabolite.& 'alignant bone tumors 6rug 4nduced : 4ntake of anticonvulsants# barbiturates and fluoride. )linical and *hysical manifesatation/ 'uscle weakness and 8oint pain 2addling or unsteady gait : contribute to falls and fracture Dypophostanemia : leads to inade?uate production of muscle cell 3T* thus resulting in a decrees muscle cell energy. Dypocalcemia : results to muscle cramping. 6iagnostic 3ssessment/ K : ray : bone tissue reveal a decrease in the trebeculae of the cancellous bones and lack of osteoid sharpness. A presence of radiolucent bands @ooser;s lines or "ones : pseudofractures that represents stress fractures that have not minerali"ed&. Bone Biopsy : increase amount of opteoids. 6.K3 scan A a method of measuring bone density based on the proportion of a beam of photons that passes through the bones.

10

)alcium level A low or normal *hosphate level : low or normal *arathyroid hormone : high or normal 3lkaline *hosphatase : high

Dealth *romotion and 4llness prevention 4ncrease 7it 6 through dietary intake# sun exposure or drug supplementation A >oods rich in 7it 6 : soy and rice milk9 tofu and other soy products. A foods which are 7it 6 fortified A eggs# sword fish# chicken liver# cereals and bread products enriched with 7it 6. 4ntervention/ 7it 6 supplementation : ma8or treatment ,63Z 100 4+& 4n older adults : (00A<00 4+ because adults are prone to develop bone deminerali"ationdue to aging and osteomalacia. 5ursing 4ntervention/ 3dvise client to get sun exposure at least 5 minutes weekly. ,ecommend to the client to eat food high in calcium to promote 7it 6 absorption and utili"ation in the small intestine. !uggest that clients eat natural or fortified food containing 7it 6# including meat and dairy products such as ice cream or ice milk&# yogurt and cheese. ,ecommend that clients; exercise on a regular basis at least 0K a week for 20A00 minutes& to prevent bone loss. 1. Car7a' Tunne' S5n(r%me. A occurs when the median nerve becomes compressed as a result of inflammation and swelling of the synovial lining of tendon sheaths surrounding the nerve. !igns and symptoms $. !ub8ective A *ain that increases after any body movement that stretches the nerve involve. A 6iminished sensation9 paresthesia A 6ifficulty grasping or holding small or heavy ob8ect. 2. -b8ective A Tinel;s !ign : direct tapping of the median nerve at the wriest that elicit a distal tingling sensation. A Thenal .minence : atrophy of the padded area below the thumb. 4nterventions $. ,esting and splinting the wrist. 2. !teroids in8ection into the area. 0. !urgery to release the transverse carpal ligaments to reduce compression of the median nerve.

5ursing )are 3. 3!!.!!'.5T a. Distory of prolonged flexion of the wrist# repetitive tasks using the hand and wrist and arthritis. b. 3ssess status of the extremititesincluding color# peripheral pulses# motor strength# sensation# pain and atrophy. B. 5+,!45E 643E5-!.! a. ,isk for disuse syndrome b. ,isk for 4n8ury

11

c. *ain d. 4mpaired physical mobility ). *@35545E 356 4'*@.'.5T3T4-5 a. 3dminister pain reliever as ordered. b. Teach patient alternative method of pain control including distraction# relaxation techni?ues and imagery. c. *rovide emotional support for the client during the course of hospitali"ation d. 4nstruct client regarding resting and splinting the wrist. e. Teach importance of avoiding in8uries to extremities because of altered sensations. 6. .73@+3T-5I-+T)-'.! a. ,eport decrease severity of pain. b. 3voids exposing extremities with diminish sensation to heat of other environmental ha"ards. c. 6emonstrate correct use of splints.

4. Oste%7%r%sis
- IS A DISORDER OF BONE METABOLISM 0 REDUCTION OF TOTAL BONE MASS, BONES PRONE TO FRACTURE0 AFFECTING K OF OLDER ADULTS0 HIGH INCIDENCE WITH WHITE FEMALES BET. AGES OF CA TO LA YEARS. ETIOLOGY MAY BE IATROGENIC OR SECONDARY TO OTHER DISORDERS. PREDISPOSING FACTORSE POSTMENOPAUSAL STATUS LONG-TERM CORTICOSTEROID USE PROLONGED IMMOBILI/ATION NUTRITIONAL DEFICIENCY

PATHOPHYSIOLOGY THE RATE OF BONE LOSS(RESORPTION) E+CEEDS BONE FORMATION, RESULTING TO DECREASE IN TOTAL BONE MASS0 BONES LOSS CALCIUM AND PHOSPHATE SALTS, RESULTING TO POROUS, BRITTLE BONES LEADING TO FRACTURE CLINICAL MANIFESTATIONS

FRACTURES, VERTEBRAL COMPRESSION, HIP FRACTURES AND LONG BONE FRACTURES PAIN VISIBLE ,YPHOSIS LOSS OF HEIGHT CONSTIPATION

LABORATORY AND DIAGNOSTIC STUDY FINDINGS RADIOGARPHIC AND BONE DENSITY STUDIES REVEAL LOSS OF BONE DENSITY IN CLIENTS WITH 2CB TO @AB BONE DEMINERALI/ATION SERUM CALCIUM, PHOSPHORUS AND AL,ALINE PHOSPHATASE LEVELS ARE WITH IN NORMAL RANGES

15

NURSING MANAGEMENT

ADM MEDS- ANTI RESORPTIVE THERAPY, NONNARCOTIC ANALGESICS, AND CALCIUM SUPPLEMENTS PREVENT FRACTURE- CAUTION WHEN TURNING, LIFTING, TRANSFERING CLIENT PROMOTE SPINAL STABILITY APPLY A LUMBOSACRAL CORSET PROVIDE CLIENT TEACHING 1. 2. 3. @. C. M. ENCOURAGE INCREASED INTA,EE MIL,, CHEESE, SALMON, SPINACH, BROCCOLI, VIT. D, FIBER AND PROTEIN TEACH ,NEE FLE+ION AND MUSCLE-RELA+ING E+ERCISES MOVE THE TRUN, AS A UNIT0 MAINTAIN GOOD POSTURE AND BODY MECHANICS PERFORM ROM TWICE DAILY .SLEEP ON A FIRM. NONSAGGING MATTRESS ENCOURAGE A REGULAR, MODERATE E+ERCISE REGIMEN, WAL,ING, SWIMMING, LOW IMPACT AEROBICS

2. CROSS THE !I2E SP N 1. 2ra+ture >racture is a break in the continuity of the bone. 3 fracture occurs when the stress placed on the bone is greater than the bone can absorb. 'uscles# blood vessels# nerve# tendons# 8oints and other organs may also be in8ured when fracture occurs. 45)46.5). $. )ommon to male $5A20 years old : very active 2. elderly A degenerative 0. high vices9 occupation )3+!.! $. !tress >racture a. 6irect : direct blow to the bone b. 4ndirect : too much contraction of the muscle. 2. *athologic >racture : bones are weakened due to disease or tumor )@3!!4>4)3T4-5 -> >,3)T+,. . Genera' C'assi,i+ati%n BT%rt%na> 1FF:* $. !imple or )losed >racture : bone fragments does not penetrate the skin. 2. )ompound or -pen >racture : bone fragments penetrate the skin. a. Erade 4 : minimal soft tissue in8ury with a clean wound less than $ cm long. b. Erade 44 : @aceration greater than $$ cm without extensive tissue damage. c. Erade 444 : with extensive tissue in8ury. 0. 4ncomplete >racture : involves a portion of the cross section of the bone or may be longitudinal. )ontinuity of the bone is not completely interrupted. 1. )omplete >racture : involves the entire cross section of the bone and is fre?uently displaced. The continuity of the bone is completely interrupted. $. C'assi,i+ati%n %, 2ragment 7%siti%n $. )omminuted : Bone is splintered in to fragments. 2. 4mpacted or Telescoped : >ragments of bones wedge into other bone fragments.

1(

0. 5onAdisplaced : two segments of the bone maintain essentially normal alignment. 1. 6isplaced : bone fragments are separated at the fracture line and are deformed. 5. -verriding : fragments overlap# shortening the total bone length. (. 3vulsed : fragments are pulled from normal position by muscle contractions or ligament resistance. F. 6epressed : bone fragments are driven inward. <. )ompressed : bone collapse on itself. %. Ereenstick : an incomplete break in the long bone in which one side of the bone is broken and the other side is bent. C. C'assi,i+ati%n %, ,ra+ture 'ine $. @inear : the fracture line runs parallel to the bone;s axis. 2. -bli?ue : the fracture line crosses the bone at roughly 15 degree angle to the bone;s axis. 0. !piral : the fracture liner crosses the shaft of the bone at an obli?ue angle creating a spiral pattern. 1. Transverse : fracture line forms a right angle with the bone;s axis. *3TD-*D=!4-@-E= . *redisposing factors 3ge !ex Deredity Eenes Broken bone Dematoma form in the medullary canal *eriosteum bone tissue ad8acent to the fracture dies 5ecrotic tissue !timulation intense inflammatory response *recipitating factors !moking 6rinking alcohol @ifestyle 6iet

7asodilatations .dema *ain @oss of normal function .xudation of plasma and leukocytes 4nfiltration of other 2B) SIGNS AND SYMPTOMS *ain .cchymosis 'uscle spasm shortening loss of normal function tenderness abnormal mobility impaired sensationInumbness

1F

COMPLICATION OF FRACTURE (Smeltzer & Bare) $. N%n/ uni%n A refers to a failure of the bone to grow and glass the gap between the broken ends. 4n this condition# the gap fills with dense fibrous and cartilaginous tissue rather than new bones. 2. 2at Em)%'ism : refers to a condition in which fat globules originating in the bone marrow at the in8ury site are thought to enter the circulation9 this condition is potentially fatal# particularly when it occurs in the long bones. 'a8or symptoms of fat embolism are respiratory insufficiency# cerebral involvement# and petecchial rash. 0. C%m7artment S5n(r%me : an abnormal increase in pressure within a confined anatomic space resulting in impaired circulation# nerve in8ury# and loss of muscle function. T,.3T'.5T 356 '353E.'.5T *rinciples of >racture Treatment B(e Witt> 1FF0* $. R'*%/ "$- $r r')6".-('- $7 8$-' 7r).('- # a. )losed manipulation : use of casts and slings. b. 4nternal >ixation : a surgical intervention open reduction& in which various types of holding devices are used. c. .xternal >ixation : pins are inserted into the bone above and below the fracture and held in place by a clamping device. 0. M)"- '-)-/' $7 r')6".-('- 89 "(($8"6":) "$a. )losed reduction : this is accomplished by application of external devices. !plints .xternal fixators Braces Traction )asts Bandage *ins in plasters b. -pen ,eduction A immobili"ation is done by internal devices. 5ails screws *lates wires rods 0. R'!)8"6" ) "$- $r r'# $r) "$- $7 7%-/ "$-#. 'aintain reduction and immobili"ation. .levate to minimi"e swelling. 'onitor neurovascular status. )ontrol anxiety and pain. 4sometric and muscle setting exercises. *articipation in activities of daily living. Eradual resumption of activity. 643E5-!T4) .73@+3T4-5 *-) 'anual& $. KAray and other imaging studies : to determine the integrity of the bone. 2. Blood studies : )B)# electrolytes& with blood loss and extensive muscle# damage : may reveal decreased hemoglobin and hematocrit. 0. 3rthroscopy : to detect 8oint involvement. 1. 3ngiography : if fracture is associated with blood vessel in8ury. 5. 5erve conduction and electromyogram.. 5+,!45E '353E.'.5T *-) 'anual& $. *rovide emergency care of fracture. a. -bserve for signs of fracture/ pain# swelling# tenderness# ecchymosis# crepitations# loss of function# exposed bone fragment. b. )over open fracture with sterile dressing to prevent infection.

1<

c. 4mmobili"e any suspected fracture by splinting the 8oint below and above the in8ury. d. *erform neurovascular check of the area distal to the fracture9 assess for color# temperature# capillary refill# sensation# movement# pulse. 2. -bserve for signs of fat embolism in multiple long bone fracture&. a. respiratory distress. b. mental disturbances c. fever d. petechiae 0. .ncourage diet high in protein and vitamins to promote healing. 1. .ncourage increase fluid intake to prevent constipation# renal calculi and +T4. 5. *rovide care in client with traction# cast or with open reduction. (. *rovide client teaching and discharge planning concerning/ a. )ast care b. crutch walking c. signs of complications and the need to report them. Imme(iate A shock9 fat embolism9 in8ury to skin# muscle# blood vessels# nerves A 8oint stiffness9 infection gangrene# tetanus# osteomyelitis Ear'5 A nonAunion9 delayed union9 malunion !ate F. +se a splint to immobili"e the fracture and prevent further in8ury. <. 3ssist the physician with closed reduction if necessary9 afterward# immobili"ed the affected body part using a splint# cast or traction. %. *repare the patient for surgery if closed reduction is impossible. $0. 'onitor the patient for complications related to the fracture as well as for problems associated with periods of immobility. $$. 'edicate the patient appropriately# as fractures are very painful. !T3E.! -> B-5. D.3@45E Tortora# $%%(& $. D.'3T-'3 !T3E. : when bone is fractured# blood extravagates into the area between and around the fragments and the bone marrow. 2. ).@@+@3, *,-@4>.,3T4-5 : takes place at the fracture site after several days. The combination of periostial elevation and the granulation tissue containing blood vessels# fibroblasts and osteoblasts produce a substance called osteoids forming a bridge across the fracture site. 0. )3@@+! >-,'3T4-5 : after the following weeks minerals are deposited in the osteoid forming a large mass of differentiated tissue bridging the fracture called callus. 1. -!!4>4)3T4-5 : final laying down of bone# is the stage in which the fracture ends knit together. 5. )-5!-@463T45E 356 ,.'-6.@@45E : when consolidation is completed# the excess cells are absorbed. The primary cancellous bone is remodeled# compact bone being formed according to stress patterns. ,emodeling continues as bone is formed in relation to its function. 0. Ot6er In<uries a. Dis'%+ati%nGSu)'u4ati%n Dis'%+ati%n is the displacement of a bone from its correct articulating position within a 8oint. Su)'u4ati%n is a partial dislocation in which the ends of the bone are in partial contact within the 8oint. 6islocation and subluxation both occurs at the 8oints of the shoulders# elbows# wrist# digits# hips# knees# ankles and feet and it commonly causes extreme pain. 3 displaced bone may damage surrounding muscles# ligaments# nerves and blood vessels# esp. if reduction is delayed.

)3+!.! dislocation and subluxation may be caused by a congenital problem congenital dislocation of the hip&

1%

follow trauma rotation in8uries&# disease of surrounding 8oint tissues *aget;s disease of the bone&# arthritis# rheumatoid arthritis# osteoarthritis9 neuromuscular diseaseI use of neuromuscular drugs.

*3TD-*D=!4-@-E4) *,-).!!.! 356 '354>.!T3T4-5 3 sensation of MpoppingN or Mgiving outN at the effected site typically occurs after dislocation )ommon manifestations include pain in the affected area# limited 8oint movement# and observable in8ury 3n outwardly rotated leg is a common sign of hip dislocation -7.,74.2 -> 5+,!45E 45T.,7.5T4-5! $.3ssess all infants for congenital hip displacement 2.3ssist the physician in reducing the dislocation# as necessary 0.4mmobili"e the 8oint# as ordered# to promote healing 1.>or a patient with knee dislocation/ a.teach the patient app. exercises for strengthening the ?uadriceps to prevent recurrences. b.instruct the patient on using a knee brace for activity 5.*rovide patient teaching covering/ a. causes of the dislocation and the potential for recurrences b. need for follow up care c. importance of exercises d application of brace if needed (.*repare the patient for surgery if necessary ). S7rain an( Strain S7rain is a complete or incomplete tear in the supporting ligaments surrounding a 8oint9 a sprained ankle and knee are common 8oint in8uries. Strain is an in8ury to muscle or tendinous attachment9 can be acute or chronic. Both in8uries usually heal without repair. )3+!.! !prain/ follows a sharp twisting motion of the affected 8oint !train acute& usually results from vigorous muscle overuse# overstress# or overstretching of a single muscle or muscle group cervical spine# lower back# feet& *3TD-*D=!4-@-E4) *,-).!!.! 356 '354>.!T3T4-5 Tendons and ligaments are com0osed of dense connective tissue with a limited blood supply. This tissue is primarily made up of intercellular bundles of collagen fibers aligned for directional pull. 3 pull or twist in the opposite direction results in trauma to the soft tissue9 this cause inflammation# pain and possibly loss of mobility which may occur hours after the in8ury. .cchymosis may be present as a small blood vessels rupture. 3fter then in8ury# capillaries permeate the in8ured area# supplying the fibroblasts with the substances needed to produce great amounts of collagen. Eradual healing of the long collagen bundles restores strength9 healing occurs over weeks# varying with the degree of in8ury. -7.,74.2 -> 5+,!45E 45T.,7.5T4-5!/ $..levate the affected area to reduce edema 2.3pply ice at the time of in8ury to limit inflammation and tissue destruction. To decrease pain# and to reduce muscle spasm 0.+se compression wraps to limit edema and reduce pain from movement# making sure the wrap is not so tight as to impair blood flow

50

1.Dave the patient rest the in8ured tissue to minimi"e hemorrhaging within the 8oint or muscle and to reduce swelling 5.'anage pain an important part of treatment& (.'aintain ade?uate nutrition and fluid intake 1. Ot6er C%n(iti%ns a. P%ttDs Disease *ott;s disease is a presentation of extrapulmonary tuberculosis that affects the spine. The lower thoracic and upper lumbars vertebral are the areas of the spine most affected. 4t is caused by mycobacterium tuberculosis tubercule bacilli& *3TD-E5-'-54) !4E5! Eibbus formation Gyphosis -TD., 53'.! TB of spine TB spondylitis *ott;s curvature !piral spondylitis 6avid;s disease ,4!G >3)T-,! *resence of pulmonary TB Deredity : family history of TB .conomic status Trauma and resistance -vercrowding dwelling *oor hygiene 4nfection 'alnutrition Eait disturbances *aralysis *alpable mass

)-''-5 !4E5! 356 !='*T-'! Back pain !tiffness >ever 'uscle spasm 5ight sweats 'alaise >atigue @oss of appetite 3norexia @eg weakness 2eight loss +rinary distention 643E5-!4! 4! B3!.6 -5 Blood testAelevated .!, !kin tests ,adiographs of the spine Bone scan )T of the spine Bone biopsy @3T. )-'*@4)3T4-5 !evere kyphosis !inus formation *araplegia pott;s paraplegia&

5$

*3TD-*D=!4-@-E= M9/$8)/ 'r"%( %8'r/%6$#"# causative agent& .nters respiratory tract 6rug resistant strains AAAA spread of TB bacilli in the thoracic cavity

!tepping out of TB bacilli 4n the cavity

*rolonged loss of appetite

6estruction of spine and vertebral disk spongy appearance&

@ow to moderate fever AAAA4nfection in the afternoon

@oss of weight .mancipation

caseous necrosis compression in the spine AAAA pain in the spine forming hunchback deformity leading to gibbus formation immobility weak ness paresis& of the lower extremities Xbone pragments encroaching the cord Xparavertebral abcess Xgranulomatous tissue formed around the cord complication if prolonged may lead to paraplegia

!+,E4)3@ T,.3T'.5T ,e?uired if there is a spinal deformity or neurological signs and symptoms of spinal cord compression 3nterior decompression spinal fusion : done through thoracotomy incision under general anesthesia. @aminectomyA surgical cutting into the backbone to obtain access to the spinal cord. 6one to remove tumors# to treat in8uries of the spine or to relieve pressure on the spinal cord or roots.

3rthrodesis : the fusion of the bones across a 8oint space by surgical means which eliminate movement. *erformed when a 8oint is very painful# highly unstable# grossly deformed or chronically infected.

'.64)3@ '353E.'5.T 4mmobili"ation : cast or brace taylor;s brace& for (A$< months )hemotherapy : ethambutol# isonia"id# rifampicin *roper positioning : prone or lateral .nsure spinal alignment L log rolling techni?ue L turn patient as a unit L support the cervical and the lumbar portion when turning the patient 5+,!45E '353E.'.5T *osition patient comfortably. *rone or side lying are more appropriate. *romote and emphasi"e the need for good rest habit. 3dvise patient to do ,-' every morning to avoid bedsores. *roper diet/ high protein# high caloric# vitamin ) and high fiber diet. The nurse should emphasi"e the need for compliance to medication even after surgery or any orthoprognosis. 3mbulatory support such as cast# braces should be used by patients and the nurse should give procedure in using them. ). Oste%m5e'itis -steomyelitis is infection in the bones# which could either be acute or chronic onset. -ften# the original site of infection is elsewhere in the body# and spreads to the bone by the blood. 3ffected bone may have been predisposed to infection because of recent trauma. Bacteria or fungus may sometimes be responsible for osteomyelitis. - A SEVERE PYOGENIC BONE INFECTION )3+!3T47. 3E.5T/ !taphylococcus 3ureus : most common !taphylococcus pyogenes# streptococcus# pneumococccus# salmonella and .. )oli ,-+T.! -> 45>.)T4-5/ $. Dematogenous : blood stream 2. .xogenous source : direct introduction of microorganism into the bone 0. .ndogenous source : ad8acent soft tissue infection !='*T-'! *ain in the bone @ocal swelling# redness and warmth >ever 5ausea 'alaise 6rainage of pus through the skin -TD., !='*T-'! 3!!-)43T.6 24TD TD. 64!.3!. .xcessive sweating )hills @ow back pain !welling of the ankles# feet and legs

*3TD-*D=!4-@-E= *,.64!*-!45E >3)T-, Trauma# boils 6ecrease body resistance 6evelopment of cellulites *oorly nourished# obesity )hronic illness 6'# *heumatoid 3rthritis *,.)4*4T3T45E >3)T-,! J!taphylococcus 3ureus J*roteus species J.. )oli

!kin tension inflammation& 4nfecting bacteria will be spread By the blood stream 4ncreased vascularity .dema Thrombosis of the blood vessel occurs in the area 4schemia with bone necrosis 4nfection extends into the medullary cavity and under the pereosteum !pread into the ad8acent soft tissue and 8oints

Treatment does and ,ecovery 'edication !urgical interventions

$%ne a)s+ess 3bscess cavity dead bone tissue which not easily li?uefy drain The cavity could not collapse and heal easily

5ew bone growth forms and surrounds the se?uestrum )hronically infected se?uestrum remains and producing recurrent abscess throughout the patients; life ASSESSMENT FINDING

CLINICAL MANIFESTATIONS LOCALI/ED BONE PAIN TENDERNESS, HEAT, AND EDEMA GUARDING RESCTRICTED MOVEMENT HIGH FEVER0 CHILLS- ACUTE LOW-GRADE FEVER AND GENERALI/ED WEA,NESS- CHRONIC PURULENT DRAINAGE FROM THE S,IN ABSCESS

! $OR TOR# STUDIES Bone scan : indicates infected bone )B) : shows elevated white blood cells leucocytosis& .,! : elevated Blood culture : help identify causative organisms 3n ',4 and needle aspiration : 6one around infected bone for culture Bone lesion biopsy and culture may be positive for the organism 3 skin lesion with sinus tract the lesion MtunnelsN under the tissues& may yield drainage of pus for culture RADIOGRAPH AND BONE SCAN DEMONSTRATE BONE INVOLVEMENT T,.3T'.5T Dospitali"ation and intravenous antibiotics *ain killing medication @ife style changes# such as ?uitting cigarettes to improve blood circulation Treatment for underlying cause# such as 6iabetes ,eplacement of infected prosthetic part# if needed. Xuse of hip spacer and antibiotic beads. !urgery to clean and fluck out the infected bone debridement& !kin graft is necessary X3utograph X3llograph XKenograph 3mputation in severe cases X3mputation X6isarticulation

5+,!45E 45T.,7.5T4-5/ $. ,elieve pain 3dminister opoids for acute pain9 nonAnarcotic for chronic pain. 3dminister medication round the clock rather than *,5 to maintain blood level. 4ncrease in pain must be reported. 4t indicates worsening of infection. 2. 4ncrease patient;s knowledge 6escribe the infectious process and rationale for prolonged treatment with osteomyelitis. .xplain strict adherence to infection control practices sterile techni?ue# handwashing# selection of roommate& to prevent spread of infection in some cases. 0. *romoting rest without complications !upport the affected extremity splint or traction& to minimi"e pain. 4f the patient is on bed rest# prevent ha"ards of immobility passive ,-'# position changes# cough and deep breathing exercises&. *rovide diversional activities. 1. *,-T.)T >+,TD., 45C+,4.! 5. *,-'-T. D.3@45E 356 T4!!+. E,-2TD 23,' !3@45. !-3G!&9 *,-746. 64.T D4ED 45 *,-T.45# 74T. ) 356 6 (. *,.*3,. >-, !+E4)3@ T,.3T'.5TA 6.B,46.'.5T# B-5. E,3>T45E# 3'*+T3T4-5 (. Herniate( Nu+'eus Pu'7%sus Derniated nucleus pulposus or slipped disk is a condition in which part or all the soft# gelatinous central portion of an intervertebral disk the nucleus pulposus& is forced through the weakened part of the disk. This results in back and leg pain lumbar herniation& or neck pain or arm pain cervical herniation& due to nerve root irritation. The part of the nucleus pulposus that seeps through the ligament into the spinal canal is called slipped disk# ruptured disk or herniated disk. -TD., 53'.!/ ,uptured disk# prolapsed intervertebral disk lumbar radiculopathy# cervical radiculopathy# herniated intervertebral disk. ,4!G >3)T-,!/ $.6egeneration aging&# trauma and congenital predisposition 2.!edentary occupation 0.-besity )3+!.! -> D.,543T4-5 -> 5+)@.+! *+@*-!+! Twisting of the back in a sudden motion @ifting an ob8ect in a stooped position 6irect in8ury to the back !='*T-'! BHERNI TED !UM$ R DIS"* !evere low back pain aggravated by snee"ing# coughing and 'uscle spasm bending *ain radiating to the buttocks# legs and feet Tingling or numbness in legs or feet 'uscle weakness or atrophy on later legs *ain mad worse with coughing# straining or laughing !='*T-'! BHERNI TED CERVIC ! DIS"& 5eck pain esp. on the nape and sides

6eep pain deep or over the shoulder blades of the affected side *ain radiating to the shoulder# upper arm# forearm and rarely the hand# fingers or chest 4ncreased pain when bending the neck or turning head to the side !pasm of the neck muscle 3rm muscle weakness *ain made worse with coughing# straining or laughing.

*3TD-*D=!4-@-E= M"-$r5();$r r)%()

4ncreased pressure 6isk protrudeIherniated *ain

5th cervical root stiffness of neck shoulder pain

Fth vertebral root paresthesia sensory loss in the index finger

0rd lumbar root arterior thigh pain 1th lumbar root lower thigh and medial upper tibia

$st sacral root

back of calf and lateral knee

weakness of triceps '&

increased or loss of triceps reflex

2nd lumbar root lateral calf and toe

(th vertebral root weakness of biceps decreased biceps reflex

<th vertebral root forearm pain

643E5-!T4) T.!T $. !*45. KA,3= : to role out other causes of back or neck pain. Dowever# it is not possible to diagnose herniated disk by spinal xAray alone. 2. !*45. ',T 356I-, !*45. )T : will show spinal canal compression by the herniated disk. 0. '=.@-E,3' A To define the si"e and location of disk herniation. 1. .'E : to determine the exact nerve root s& that is are& involved 5. 5erve )onduction 7elocity '.TD-6! -> T,.3T45E D.,543T.6 64!) $.)-5!.,73T47. T,.3T'.5T b. Bed rest c. Traction @umbosacral disk : pelvic girdle traction )ervical disk : cervical traction d. 6rug therapy 5!346 'uscle relaxant 3nalgesic 2.@3'45.)T-'= : removal of parts of one or more vertebral laminal along with the protruding disk. 0.)D.'-5+)@.-@=!4! : in8ection of chemopapain# an en"yme from papaya to dissolve disk. *reAop care of the client with chemonucleolysis 3dminister cimitidine tagamet& and diphenhydramine D)@ benadryl& as ordered to reduce possibility of allergic reaction. *ossibly administer corticosteroids before the procedure. *ostAop care of client with chemonucleolysis -bserve for anaphylaxis -bserve for signs of less serious allergic reactions rash# itching# rhinitis# difficulty in breathing& 'onitor for neurologic deficits numbness or tingling in the extremities or inability to void& 5+,!45E 45T.,7.5T4-5/ $..nsure bed rest on a firm mattress with bed board. 2.3ssist client in applying pelvic or cervical tractions as ordered. 0.'aintain proper body alignment. Turn patient properly. b. turn patient as a unit c. use long rolling techni?ue d. support the cervical and lumbar area 1. 3dminister medication as ordered 5.*rovide additional comfort measure to relieve pain (. *revent complications of immobility F. *ost laminectomy instruct patient to avoid stretching bowing out& of the lower back in any motion or activity <.*rovide client teaching and discharge planning Back stretching exercises as prescribe 'aintenance of good posture +se of proper body mechanics# how to lift heavy ob8ects correctly a. maintain straight spine b. flex legs and hips while stooping

c. keep load close to body prescribe medications and side effects proper application of corset or cervical collar weight reduction if needed

e. Hi7 ,ra+ture A B,-G.5 D4*! 45)@+6. >,3)T+,. 2I 45 TD. D.36 -> TD. >.'+,# 3!!-. 24TD -!T.-*-,-!4! 356 '45-, T,3+'39 .KT,3)3*!+@3, >,3)T+,. TD3T -))+, B.@-2 TD. )3*!+@. 3,. )3+!.6 B= !.7.,. T,3+'3 -> >3@@ A 45),.3!. 45 45)46.5). 3>T., 3E. (0 A '-,. )-''-5 45 2-'.5 TD35 '.5 45T.,7.5T4-5 'edical / )@-!. ,.6+)T4-5 24TD T,3)T4-5 !urgical / -*.5 ,.6+)T4-5 356 45T.,53@ >4K3T4-5 3!!.!!'.5T/

@.E !D-,T.5.6# .KT.,53@@= ,-T3T.6 3B6+)T.6# !.7.,. *345 T.56.,5.!!

5+,!45E '353E.'.5T $. 353@E.!4)! 2. $u+-Ds TR CTION/ ,.@.47.! '+!)@. !*3!'I .6.'3 0. *,.7.5T .KT.,53@ ,-T3T4-5 -> 3>>.)T.6 @.E 1. >4,' '3TT,.!!# B.6 B-3,6# -7.,D.36 T,3*.S.# >--T B-3,6# B.6 ,34@!A ,3*46 D4* *345 '3= 4564)3T. 64!@-)3T4-5 5. >.'-,3@ D.36 *,-!TD.!4!A *,.7.5T 45T.,53@ ,-T3T4-5 356 '345T345 3B6+)T4-5A*4@@-2 B.T2..5 @.E! (. T+,5 P2D F. *,.7.5T 3)+T. >@.K4-5 -> D4*9 G..* D.36 -> B.6 @-2 <. *T. 45 45T.,53@ >4K3T4-5 2I 534@! -, *45!A SIT PT. UP IN CH IR/1/0 D #S POST OPH P RTI ! WT $E RING/ 1 MONS.H 2U!! WT $E RING/ : MONTHS POST OP ,. Hi7 Dis'%+ati%n A D.36 -> TD. >.'+, 64!*@3).6 >,-' TD. .).T3B+@+' T=*.!/ DEVE!OPMENT ! DIS!OC TION O2 HIP BDDH*/ 45>35)=I >.'3@.!I45),.3!.6 45)46.5T 45 B,..)D 6.@47.,4.! NEURO!OGIC DIS!OC TION O2 THE HIP/ !*453 B4>4639 ).,.B,3@ *3@!= T,.3T'.5T/ !*4)3 )3!T45E -*.5 ,.6+)T4-5 3!!.!!'.5T/

$. 45>35TA @4'4T.6 3B6+)T4-5 -> D4*# 246. *.,45.+'# !D-,T.545E -> @.E -5 3>>.)T.6 !46.9 3!=''.T,= -> TD4ED 356 E@+T.3@ >-@6! E3@.3SS4;! !4E5I 3@@4! !4E5&9 )@4)G45E 2D.5 @.E 3B6+)T.6 9@.!! TD35 1 2..G! -> 3E. -,T-@354;! !4E5& 9 D356 *@3). -7., G5..!# 366+)T TD. @.E *3!T '46@45.9 3B5-,'3@ '-7.'.5T 4! *-!4T47. 45 B3,@-2;! !4E5 2. -@6., )D4@6A 2D.5 )D4@6 !T356! -5 3>>.)T.6 @.E# *.@74! T4@T! 6-2523,6 -5 +53>>.)T.6 !46. 45!T.36 -> +*23,6# @4'* -5 3>>.)T.6 !46. 356 >@3TT.545E -> B+TT-)G;! -5 3>>.)T.6 !46. T,.56.@.5B+,E !4E5& '.6 '353E.'.5T/ TOT ! HIP REP! CEMENTA ,.*@3).'.5T -> B-TD 3).T3B+@+' 356 D.36 -> >.'+, 24TD *,-!TD.!4!9 *,.7.5T D4* >@.K4-59 37-46 366+)T4-5 356 D4* >@.K4-59 6-5;T +!. @-2 )D34,96- 5-T ),-!! @.E!96- 5-T B.56 6-259 +!. 0A*-45T ),+T)D 23@G45E E34T 3!!.!! >-, 2-+56 45>.)T4-5 g. PagetDs Disease/ B -steitis deformans& A a disorder of locali"ed rapid bone turnover# most commonly affecting the skull# femur# pelvic bones and the vertebrae. A an idiopathic disorder characteri"ed by abnormal and accelerated bone resorption and formation in one or more bone. A the normal bone is replaced by abnormal structurally weaker bone that is prone to fracture. A produces painful deformities of the femur# tibia# lower spine pelvis and the cranium. A occurs in about 2A0% of the population older than 50 years 9ol. A highly greater incidence in males. A family history has been noted but the exact cause is unknown. *3TD-*D=!4-@-E= *rimary proliferation of the osteoclasts produces bone resorption& )ompensatory increase in the osteoblastic activity That replace the bone 3s bone turnover continues# a classic mosaic disorgani"ed& pattern of bone develops 6ue to the vasculari"ed and structurally 2eak bones in *aget;s disease *athologic factor structural bowing of the legs 'al alignment of the hip# knee

ankle and 8oints 3rthritis# back and 8oint pain '354>.!T3T4-5! '+!)+@-!G.@.T3@ Bone and 8oint pain maybe a single bone& that is aching# poorly described and is aggravated by walking. @ow back and sciatic nerve pain Bowing of the long bones femur and tibia& @oss of normal spinal curvature .nlarge thick skull *athologic fracture -steogenic sarcoma ,heumatoid arthritis# ankylosing spondylitis !keletal deformity barrelAshaped chest# kyphosis& 5erve compression vertigo# hearing loss with tinnitus and blindness& !G45 >lushed# warm skin

-TD., '354>.!T3T4-5! 3pathy# lethargy# fatigue Dyperparathyroidism Eout +rinary and renal stones Deart failure from fluid overload 3!!.!!'.5T 356 643E5-!T4) >45645E! .levated serum phosphatase concentration +rinary hydroxyproline excretion K :ray : increased bone expansion and density +ric acid : elevated because nucleic acid from overactive bone metabolism increases Bone scan : most reliable '.64)3@ '353E.'.5T Eait problems : walking aids# shoe lifts and physical therapy. 2eight reduction : to reduce stress on the weakened bone and malaligned 8oints >ractures : healing occurs with fracture reduction# immobili"ation and stability !evere degenerative arthritis : total 8oint replacement @oss of hearing : hearing aids 7itamin 6 and )alcium : elevated )alcium in immobile patients due to bone resorption 5!346 : pain management 4buprofen& )alcitonin : retards bone resorption by decreasing the number and availabity of osteoclasts A facilitates remodeling of abnormal bone into normal lamellar bone# relieves bone pain# helps alleviate neurologic and biochemical signs and symptoms.

Biphosphonates : etidronate disodium 6idronel& and alendronate sodium >osamax& A produce rapid reduction of bone turnover and relief of pain. A reduce serum alkaline phosphatase and urinary hydroxyproline level *licamycin : 'ithracin& used to control *aget;s disease. A reserve for severely affected patients with neurologic compromise and for those whose disease is resistant to pother therapy. A pain reduction and on serum )alcium# alkaline phosphatase and urinary hydroxyproline levels.