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Below the knee amputation

Nursing Intervention
• Preoperative
• Offer support/encouragement
• Discuss:
• Rehabilitation program & use of prosthesis
• Upper extremity exercise such as push ups in bed
• Crutch walking
• Amputation dressing/cast
• Phantom limb sensation as a normal occurrence
• Observe stump dressing for signs of hemorrhage
and mark outside of dressing so rate of bleeding
can be assessed (tourniquet at bedside)
Post-operative Care

• Prevent edema
• Raise extremity with pillow support for first 24 h
• Prevent hip/knee contractures
• Avoid letting patient sit in chair with hips flexed for long
periods of time
• Have patient assume prone position several times a day and
position hip on extension
• Avoid elevation of stump after 24 hrs
• For BKA: hip & knee exercises
• For AKA: hip exercises
• Pain medication as ordered (phantom limb pain)
• Ensure that stump bandages fit tightly and are applied
properly to enhance prosthesis fitting
Inflammatory Disorders of the
Musculoskeletal System
Rheumatoid arthritis
• chronic systemic
inflammatory disease
• destruction of connective
tissue and synovial
membrane within the joints
• weakens and leads to
dislocation of the joint and
permanent deformity
Risk Factors
• exposure to infectious agents
• fatigue
• stress
Rheumatoid Arthritis
Signs and Symptoms
• Morning stiffness
• Fatigue
• Weight loss
• Joints are warm,
tender, and swollen
• Swan neck deformity-
Diagnostic Studies
Swan neck deformity
• X-ray
• Elevated WBC,
platelet count, ESR*,
and positive RF
No cure for RA
Rheumatoid Arthritis
• Aspirin- mainstay of treatment, has both analgesic and
anti-inflammatory effects
• Nonsteroidal anti-inflammatory drugs (NSAIDs):
• Indomethacin (Indocin)
• Phenylbutazone (Butazoldin)
• Ibuprofen (Motrin)
• Fenoprofen (Nalfon)
• Naproxen (Naprosyn)
• Sulindac (Clinoril)
• Immunosuppressives: Methotrexate
• Gold Standard for RA treatment
• Teratogenic
• Gold compounds
• Injectable form: sodium thiomalate,
aurothioglucose; given IM once a week; takes 3-6
months to become effective
• Oral form: auranofin- smaller doses are effective;
diarrhea is a common side effect

• Corticosteroids
• Intra-articular injections
Rheumatoid Arthritis
• Surgical Procedures: synovectomy, arthrotomy,
arthrodesis, arthroplasty

Nursing Management
• Advised bed rest during acute pain
• Passive ROM exercise of joints
• Splint painful joints
• Heat & Cold application
• Advised warm bath in the morning
• Protect from infection
• Advised well-balanced diet

Osteoarthritis (Degenerative Joint Disease)
• Progressive
degeneration of the
joints as a result of wear
and tear

• affects weight-bearing
joints and joints that
receive the greatest
stress, such as the knees,
toes, and lower spine.
Risk Factors
• aging (>50 yr)
• rheumatoid arthritis
• arteriosclerosis
• obesity
• trauma
• family history

Signs and Symptoms

• Dull, aching pain,* tender joints
• fatigability, malaise
• crepitus
• cold intolerance*
• joint enlargement
• presence of Heberden’s nodes or
Bouchard’s nodes
• weight loss
• inhibits cyclooxygenase enzyme, diminishes the formation of prostaglandins
• anti-inflammatory, analgesic, antipyretic action
• inhibit platelet aggregation in cardiac disorders
Adverse effects
• Epigastric distress, nausea, and vomiting
• In toxic doses, can cause respiratory depression
• Hypersensitivity
• Reye’s syndrome

• use for chronic treatment of rheumatoid and osteoarthritis
• less GI effects than aspirin
Adverse effects
• dyspepsia to bleeding
• headache, tinnitus and dizziness
• inhibits cyclooxygenase enzyme
• more potent than aspirin as an anti-inflammatory
Adverse effects:
• nausea, vomiting, anorexia, diarrhea
• headache, dizziness, vertigo, light-headedness,
and mental confusion
• Hypersensitivity reaction
Nursing Intervention
• Promote comfort: reduce pain, spasms, inflammation, swelling
• Heat to reduce muscle spasm
• Cold to reduce swelling and pain
• Prevent contractures: exercise, bed rest on firm mattress, splints to maintain
proper alignment
• Weight reduction
• Isometric and postural exercises
Nursing Diagnosis
• Pain related to friction of bones in joints
• Risk for injury related to fatigue
• Impaired physical mobility related to stiff, limited movement
Gouty Arthritis
• Metabolic disorder that develops as
a result of prolonged hyperuricemia
• Caused by problems in synthesizing
purines or by poor renal excretion of
uric acid.
• Acute onset, typically nocturnal and
usually monarticular, often
involving the first
metatarsophalangeal joint

Risk Factors
• Men
• Age (>50 years)
• Genetic/familial tendency
Gouty Arthritis
Signs and Symptoms
• extreme pain
• swelling
• erythema of the involved
• fever
• Tophi
Laboratory Findings
• elevated serum uric acid
(>7.0 mg/dl)*
• urinary uric acid
• elevated ESR and WBC
• crystals of sodium urate
aspirated from a tophus
confirms the diagnosis*
- a purine analog
- reduces the production of uric acid by competitively inhibiting uric acid
biosynthesis which are catalyzed by xanthine oxidase.
Effective in the treatment of primary hyperuricemia of gout and hyperuricemia
secondary to other conditions (malignancies).
• Adverse effects: hypersensitivity reactions, nausea and diarrhea

• Effective for acute attacks
• Anti-inflammatory activity alleviating pain within 12 hours
• Adverse effects: nausea, vomiting, abdominal pain, diarrhea, agranulocytosis,
aplastic anemia, alopecia

• uricosuric agents
• increases the renal excretion of uric acid
• Sulfinpyrazone used as a preventive agent.
• Adverse effects: nausea, rash & constipation
Nursing Implementation
• Maintain a fluid intake of at least 2000 to 3000 ml a day to avoid kidney stone.

• Avoid foods high in purine such as wine, alcohol, organ meats, sardines,
salmon, anchovies, shellfish and gravy.

• Take medication with food.

• Have a yearly eye examination because visual changes can occur from
prolonged use of allopurinol

• Caution client not to take aspirin with these medication because it may trigger
a gout attack and may cause an elevated uric acid levels.

• Encourage rest and immobilize the inflamed joints during acute attacks

• Avoid excessive alcohol intake

• Notify physician if rash, sore throat, fever or bleeding develops.

• Infection of the bone

• Staphylococcus
aureus is the most
common pathogen.

• Other organisms
include Proteus,
Pseudomonas and E.
Risk Factors
• poorly nourished, elderly or obese
• impaired immune systems
• chronic illnesses
• long term corticosteroid therapy

Clinical Manifestation
• area appears warm, swollen and extremely
• systemic manifestations (fever, chills,

Diagnostic Studies
• X-ray
• Bone Scan
• Blood and wound culture
Nursing Management
Promote comfort
• Immobilized affected bone by maintaining splinting.
• Elevate affected leg
• Administer analgesics as needed.
Control infectious process
• Apply warm, wet soaks 20 min. several times a day.
• Administer antibiotics as prescribed.
• Use aseptic technique when dressing the wound.
Encourage participation in ADL within the physical
limitations of the patient.
• reduction of total bone

• change in bone
structure, which
increases susceptibility
to fracture

• bone becomes porous,

brittle, and fragile
Risk Factors
• Menopause
• aging
• long term corticosteroid
• high caffeine intake
• smoking
• high alcohol intake
• sedentary lifestyle or
• insufficient calcium intake or
• hereditary predisposition
• coexisting medical conditions
Clinical Findings
• loss of height
• fractures of the wrist, vertebral column and hip
• lower back pain
• kyphosis
• Respiratory impairment

Diagnostic Findings
• X-rays
• Dual-energy x-ray absorptiometry (DEXA)
• Serum calcium
• Serum phosphatase
• Urine calcium excretion
Medical Management
Pharmacologic Therapy

• Hormone replacement

• Alendronate (Fosamax)

• Calcitonin- ↓ plasma levels

of Ca, ↑ deposition of Ca in
the bone
Nursing Management
• Adequate dietary or supplemental calcium
• Regular weight bearing exercise
• Modification of lifestyle
• Calcium with vitamin D supplements
• Administer HRT, as prescribed
• Relieving pain
• Improving bowel elimination
• Preventing injury

Nursing Activities
• Encourage use of assistive devices when gait is unstable
• Protect from injury (side rails, walker)
• Encourage active/passive ROM
• Promote pain relief
• Encourage good posture and body mechanics
Bone Tumors

• Most common primary bone
• Occurs between 10-25 years of
age, with Paget's disease and
exposure to radiation
• Exhibits a moth-eaten pattern
of bone destruction.
• Most common sites:
metaphysis of long bones
especially the distal femur,
proximal tibia and proximal
Clinical Manifestation
• local signs – pain ( dull, aching and
intermittent in nature), swelling,
limitation of motion
• palpable mass near the end of a long
• systemic symptoms: malaise,
anorexia, and weight loss

Diagnostic Findings
• Biopsy- confirms the diagnosis
• X-ray
• Bone Scan
• Increase alkaline phosphatase
Medical Management
• Radiation
• Chemotherapy
• Surgical management
• amputation
• limb salvage procedures

• Prognosis: poor prognosis (rapid growth rate)

Nursing Management
• Promote understanding of the disease process
and treatment regimen
• Promote pain relief
• Prevent pathologic fracture
• Assess for potential complications (infection,
complications of immobility).
• Encourage exercise as soon as possible (1st or
2nd post-op day)
Total Hip Replacement
• a plastic surgery that
involves removal of the
head of the femur
followed by placement
of a prosthetic implant
Nursing Management
• Teach client how to use crutches

• Teach client mechanics of transferring.

• Discuss importance of turning and positioning post-op.

• Place affected leg in an abducted position and straight

alignment following surgery

• Prevent hip flexion of more than 90 degrees.

• Apply support stockings

• Advise client to avoid external/internal rotation of

affected extremity for 6 months to 1 year after surgery

• Instruct client to avoid excessive bending, heavy lifting,

jogging, jumping
Metallic implant
• Encourage intake of foods rich in Vitamin C, protein,
and iron.

• Administer prescribed medications.

• Infection

• Hemorrhage

• Thrombophlebitis

• Pulmonary embolism

• Prosthesis dislocation

• Prosthesis loosening
Dysplasia of the Hip

• condition in which the

head of the femur is
improperly seated in
the acetabulum, or hip
socket, of the pelvis.

• Congenital or develop
after birth
Neonates: laxity of the
ligaments around the hip,
allowing the femoral head to
be displaced from the
acetabulum upon

• Splinting of the hips with
Pavlik harness to maintain
flexion and abduction and
external rotation (neonatal
Pavlik harness
• Asymmetry of the gluteal and thigh
skin folds when the child is placed
prone and the legs are extended
against the examining table.

• Limited range of motion in the

affected hip.

• Asymmetric abduction of the

affected hip when the child is
placed supine with the knees and
hips flexed.

• apparent short femur on the

affected side
Congenital Hip Dysplasia
• Traction and/or surgery
to release muscles and

• Following surgery,
positioning and
immobilization in a
spica cast until healing
is achieved.
The walking child
• minimal to pronounced
variation in gait with
lurching toward the
affected side; positive
Trendelenburg sign

• Positive Barlow or
Ortolani’s maneuver Ortolani’s Barlow
maneuver maneuver
• Lateral curvature of
the spine
• Most common
during the growth
spurt, early
adolescent stage
• F>M
• visible curve fails to
straighten when the child
bends forward and hangs
arms down toward feet
(Adam’s position)
• Asymmetrical shoulder
height, scapula and flank
• rib prominence and rib
• Screening begins at 8 yrs
• Milwaukee Brace- worn between
16-23 hrs/day
• Not curative, but preventive:
Slows/Halts progression of the
curvature when child reaches
skeletal maturity
• Inspect the skin for signs of redness
or breakdown
• Keep the skin clean and dry, avoid
lotions and powders
• Advise the child to wear soft,
nonirritating clothing under the

• Supplemental exercises: to prevent

atrophy of spinal and abdominal
• Support in coping: Adolescents may
modify lifestyle, may feel stigmatized
from peers by being “different”
• Surgery: Internal Fixation and Instrumentation
combined with Spinal arthrodesis (fusion)
• Logroll when turning, to maintain alignment
• Assess extremities for neurovascular status
• Promote coughing & DBE, incentive spirometry
• Give pain meds as ordered
• WOF vomiting, abdominal distention: Superior
Mesenteric Artery syndrome r/t mechanical
changes in position of abdominal contents
during surgery
• Prepare child in using molded plastic jacket
during activity
• Surgical incision of part of posterior arch of
vertebrae and removal of protruded disc
• Nursing Intervention
• Teach patient log rolling and use of bedpan
• Position as ordered
• Lower spinal surgery- flat
• Cervical spine surgery: slight elevation of head of
• Proper body alignment- cervical spinal surgery:
avoid flexion of neck and apply cervical collar
Laminectomy: Postoperative Care
• Avoid:
• Acute hip flexion (bending, stooping, crossing the
• Prolonged sitting/standing
• Running, jogging, horseback riding
• Lie in side- lying with hip flexion
• Back- strengthening exercises
• Prone position
• Walk in seawater
Laminectomy: Postoperative Care
• Patient teaching and Discharge Planning
• Wound care
• Good posture and proper body mechanics
• Activity level as ordered
• Recognition and reporting of complications such
as wound infection, sensory or motor deficits
• A bone mineral analysis reveals that a pt. who
is post menopausal has severe osteoporosis.
Which of the following instructions should the
RN give to the pt’s family to ensure a safe
environment for the pt?
A. disinfect the bathroom weekly
B. carpet floor surfaces
C. install handrails on stairway
D. keep the light dim
• Which of the following guidelines should a
RN include in the teaching plan for a pt with
A. achieve IBW (ideal body weight)
B. increase daily calcium to 1,500 mg
C. maintain high fiber diet
D. sleep at least 10 hrs/day
• Which of the following measures would a
nurse encourage to a pt with acute stages of
gout attack to minimize complications?
A. drinking a minimum of 3L of fluid/day
B. eating a minimum of 2,500 cal/day
C. walking at least 3 miles/day
D. resting at least 3 hrs/day
• A pt with a leg length discrepancy is being
discharged with an Ilizarov External Fixator
(IEF). Which should be included in the
discharge teaching?
A. Methods to manage bed rest at home until IEF
is removed
B. Daily observations of the color and movement
of LE
C. Importance of not touching the pins and
keeping pins free from any moisture
D. Importance of returning to the MD for all
distractions to be done
• While a pt is in pelvic traction for low
back pain, which of the following
assessments should be included in the
pt’s plan of care?
A. Checking for skin excoriation over the hips due to
irritation by traction belt
B. Checking for inequality of femoral pulses due to
pressure of the traction on common iliac artery
C. Checking for swelling in the feet and ankles
associated with immobility
D. Checking for foot drop resulting from pressure on
peroneal nerve
• A pt who has fractured hip is placed on
Buck’s traction. A RN would explain to the pt
that its purpose is to?
A. prevent contractures
B. promote circulation
C. conserve body energy
D. maintain body alignment
• A pt who has a R hip replacement should be
instructed to carry out which of the following
techniques when turning in bed?
A. bring both knees to the chest before
B. keep an abductor pillow between legs
C. maintain flexion of affected hip
D. move affected leg with unaffected foot
• Which of the following statements if made by
a pt who had total hip replacement would
indicate to a RN that the discharge teaching
has been effective?
A. “I will need to buy an exercise bike.”
B. “I can bend to tie my shoelaces.”
C. “I can sit with my legs crossed at the
D. “I will need to make my toilet seat higher.”
• Following a hip replacement, a pt should have the
affected hip placed in which of the following
A. extended with a wedge between legs
B. flexed with the knee supported on sandbags
C. elevated with pillows under the leg from knee to
D. rotated externally with trochanter roll in place
• In the immediate post-op period following a
hip replacement, the pt should be assisted to
perform which of the following exercises on
the affected extremity?
A. leg raising
B. dorsiflexion and extension of feet
C. flexion and extension of knee
D. quadriceps setting
• Prior to surgery for correction of congenital
hip dysplasia in a 4-month old infant, which of
the following home instructions should be
included in the child’s plan of care?
A. apply double diapers
B. perform passive ROM exercises on LE
C. support legs in adducted position with
pillows during sleep
D. avoid placing the infant in upright position
• A pt with long leg cast on her L leg is instructed in
crutch walking without weight bearing on her L leg.
Which of the following observation indicates further
A. She is using 3-point gait
B. Her elbows are slightly flexed
C. Places the crutches approx. 6-8 in (15-20 cm) in
front of her with each step
D. She is supporting her weight on the axillary bars
and hand pieces of the crutch
• A 6 y/o child who sustained a fracture has a
long leg cast on L leg. Which of the following
statements is made by the parent, would
indicate need for further teaching?
A. “I will call the clinic if my child complains
of sudden pain on his foot.”
B. “I will check the skin temperature of my
child’s toes at least once each day.”
C. “I should not expect my child to have
sensation in the toes while the cast is on.”
D. “I should not let my child put anything
inside the cast to relieve itching.”
• Which of the following nursing measures is
appropriate when caring for a pt who has
undergone R AKA?
A. ambulating the pt in the hallway
B. placing the pt in chair during waking hours
C. keeping the pt’s stump elevated on pillow
D. encouraging the pt to lie prone in bed
• A pt is to begin taking Fosamax. Which of the
following statements should be included in
the pt’s teaching plan?
A. Crush the meds and mix with food
B. Take the meds with swallow of water
C. Dissolve meds under the tongue
D. Remain upright for 30 minutes after
swallowing the meds
• Which of the following manifestations should
indicate to a RN that a pt receiving Ibuprofen
(Motrin) requires follow up before another
dose is given?
A. Loss of hair
B. Sensitivity to light
C. Ringing in the ears
D. Swelling of gums
• A 12 year-old child diagnosed with scoliosis
is to be treated with a Milwaukee brace.
Which of the following nursing diagnosis
would a RN give priority?
A. Skin integrity
B. Self care deficit
C. Impaired gas exchange
D. Sleep pattern disturbance
• A 15 year-old boy has undergone spinal
instrumentation at T4-T5 level for scoliosis.
Because there is an order to maintain strict
bed rest, a RN should use which of the
following techniques when repositioning the
A. Assist pt in pulling himself up with the
overbed trapeze bar
B. Turn the pt’s head to one side and then
have him reach for the rail to turn
C. Place the bed in Trendelenburg position
then have the boy roll to one side
D. Use an assistant and logroll the pt to
desired side
• A RN would assess the pt who has undergone
lumbar laminectomy for which of the
following after surgery complication?
A. Deep vein thrombosis
B. Urinary frequency
C. Intermittent claudication
D. Flank pain