Transcript Understanding Medical Surgical Nursing, 4th Edition

Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Chapter 46
Nursing Care of Patients with
Musculoskeletal and
Connective Tissue
Disorders
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Bone and Soft Tissue
Disorders
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Strain
Sprain
Dislocation
Bursitis
Rotator Cuff Injury
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Carpal Tunnel Syndrome
 Median Nerve Compression in Wrist’s
Carpal Tunnel
 Occurs with Swelling in Tunnel
 Finger, Hand, Arm Pain/Numbness
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Carpal Tunnel Syndrome (cont’d)
 Relieve Inflammation and Rest Wrist
 Splint
 Anti-inflammatory
 Surgery
 Teach Prevention
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Fractures
 Break in a Bone
 Cause
 Trauma
 Pathological (From Disease )
 Open – Breaks Skin
 Closed – Does Not Break Skin
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Types of Fractures
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Signs and Symptoms
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Pain
Decreased ROM
Limb Rotation
Deformity, Shortening of Limb
Swelling
Bruising
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Diagnostic Tests
 X-Ray
 CT scan
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Emergency Treatment
 Splint It As It Lies!
 Seek Medical Treatment
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Fracture Management
 Goals
 Realignment of Bone Ends
 Immobilization
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Fracture Healing Phases
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Closed Reduction
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Manual Realignment
Bandages/Splints
Casts
Traction
 Skin
 Skeletal
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Types of Skin Traction
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Balanced Suspension and
Skeletal Traction
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Fracture Management (cont’d)
 Open Reduction with Internal Fixation
 External Fixation
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External Fixation
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Complications of Fractures
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Nonunion
Neurovascular compromise
Hemorrhage
Infection
Thromboembolitic Complications
Acute Compartment Syndrome
Fat Embolism Syndrome
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Compartment Syndrome
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Bivalving Cast
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Nursing Diagnoses
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Acute Pain
Impaired Physical Mobility
Impaired Walking
Ineffective Health Maintenance
Risk for Peripheral Neurovascular
Dysfunction
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Nursing Diagnoses (cont’d)
 Risk for Ineffective Tissue Perfusion
 Risk for Ineffective Skin Integrity
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Palming the Cast
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Nursing Care
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Cast Care
Traction Care
Pain Control
Neurovascular Checks
Skin Care
Nutrition
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Nursing Care (cont’d)
 Self Care Deficits
 Psychosocial
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Patient Education
 Cast Care
 Pin Care
 Nutrition
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Osteomyelitis
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Infection of Bone
Prevention is Key!
Fever, Redness, Heat, Pain, Swelling, Pain
Long-term Antibiotic Therapy
Incision and Drainage
Amputation
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Osteomyelitis (cont’d)
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Osteomyelitis (cont’d)
 Nursing Care
 Medication Teaching
 Hand Hygiene
 Sterile Dressing Changes
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Osteoporosis
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Low Bone Mass as Bone Loses Density
Prone to Fractures Occur
Spine, Wrist, Hip Most Common
All Bones Affected
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Osteoporosis Prevalence
 10 Million People
 8 Million Females
 2 Million Males
 Over Age 50 Fractures
 1 in 2 Women
 1 in 4 Men
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Osteoporosis Fracture Effects
 Hip/Vertebral Fractures
 Reduced Quality of Life
 Increased Disability
 Risk of Death (During Year After Fracture)
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Osteoporosis Prevention
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Build Bone Through Age 30
Obtain Adequate Calcium and Vitamin D
Exercise (Especially Childhood )
Avoid Alcohol and Smoking
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Osteoporosis (cont’d)
 Imbalanced Remodeling Process
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Osteoporosis Risk Factors
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Aging
Female
Caucasian/Asian
Fracture History
Family History
Petite Body Build
Postmenopausal Women
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Osteoporosis Risk Factors (cont’d)
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Low Testosterone and Estrogen
Low Calcium Intake
Low Vitamin D
Excessive Caffeine, Protein, Sodium
Sedentary Lifestyle
Excessive Alcohol Use
Cigarette Smoking
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Osteoporosis (cont’d)
 Signs and Symptoms
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Dowager’s Hump
Kyphosis
Height Decreases
Back Pain
Fracture
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Osteoporosis (cont’d)
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Body System Effects
Functional Effects
Emotional effects
Socialization
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Osteoporosis Diagnostic
Tests
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Dual-energy X-Ray Absorptiometry
Serum Calcium, Vitamin D Decreased
Serum Phosphorus Increased
Serum Alkaline Phosphatase Increased
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Osteoporosis Therapeutic
Interventions
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Reduce Risk Factors
Calcium Supplements
Vitamin D Supplements
Medications
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Antiresorptive Medications
 Bisphosphonates
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Alendronate (Fosamax)
Ibandronate (Boniva)
Risedronate (Actonel)
Zoledronic acid (Reclast)
 Calcitonin (Fortical, Miacalcin)
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Antiresorptive Medications
(cont’d)
 Selective Estrogen Receptor Modulator
 Raloxifene (Evista)
 Estrogen Therapy
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Anabolic (Bone Forming)
 Teriparatide (Forteo)
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Osteoporosis Nursing Care
 Pain Relief
 Symptom Management
 Education
 Diet: Increase Calcium, Vitamin D
 Exercise
 Medication
 Fall Prevention
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Paget's Disease
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Increased Bone Loss
Disorganized Bone Deposits
No Obvious Symptoms Usually
X-Ray, Bone Scan
Calcitonin (Calcimar)
Relieve Pain, Teach, Promote Life Quality
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Bone Cancer
 Primary Malignant Tumors
 Osteosarcoma
 Most Common
 50% Occur in Distal Femur in Young Men
 Metastasizes to Lung Within 2 Years
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Bone Cancer (cont’d)
 Primary Malignant Tumors
 Ewing’s Sarcoma
 Most Malignant
 Chrondrosarcoma
 Cancer of Cartilaginous Cells
 Better Prognosis
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Primary Bone Cancer
 Therapeutic Interventions
 Surgery, Chemotherapy, Radiation
 Nursing Care
 Postoperative Care
 Supportive
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Metastatic Bone Disease
 Bone-seeking Cancers
 Prostate, Breast, Lung, Thyroid
 Pathological Fractures
 Severe Pain
 Therapeutic Interventions
 Radiation
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Metastatic Bone Disease (cont’d)
 Nursing Care
 Supportive Care as with Other Cancers
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Gout
 Pathophysiology
 Systemic Connective Tissue Disorder
 Uric Acid Build Up
 Urate Crystals Deposited in Joints/Connective
Tissues
 Severe Inflammation
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Causes and Types
 Primary – Inherited Problem with Purine
Metabolism
 Secondary – Another Health Problem
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Signs and Symptoms
 Acute
 Swollen, Red, Hot, Painful Inflamed Joints
 Great Toe
 Chronic Gout
 Urate Deposits Under Skin
 Renal Stones
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Diagnostic Tests
 Serum Uric Acid
 Joint Fluid – Uric Acid Crystals
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Therapeutic Interventions
 Medication
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Colchicine
NSAIDs
Allopurinol (Zyloprim)
Probenecid (Benemid)
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Nursing Care
 Teaching
 Diet: Avoid Foods High in Purines
 Avoid Aspirin, Diuretics, Alcohol
 Increase Fluids
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Systemic Lupus
Erythematosus
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Autoimmune Disease
Genetic Link
Remissions and Exacerbations
Systemic Type
Skin Type – Discoid Lupus Erythematosus
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Pathophysiology
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Abnormal Antibodies
Immune Complex Formation
Complement System Activation
Affects Connective Tissue
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Signs and Symptoms
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Butterfly Rash
Photosensitive
Fever
Fatigue, Malaise
Arthralgia, Myalgia
Weight Loss
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Signs and Symptoms (cont’d)
 Mucosal Ulcers
 Alopecia
 Skin Lesions
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Diagnostic Tests
 Biopsy
 Erythrocyte Sedimentation Rate
 Immunological Tests
 Antinuclear Antibody Titers
 Antibodies Against SR Proteins
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Therapeutic Interventions
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NSAIDs
Corticosteroids
Antimalarials
Immunomodulating Drugs
Topical Cortisone
Chloroquine (Aralen)
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Nursing Diagnoses
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Acute Pain
Chronic Sorrow
Fatigue
Disturbed Body Image
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Nursing Diagnoses (cont’d)
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Ineffective Coping
Ineffective Health Maintenance
Powerlessness
Risk for Impaired Skin Integrity
Self-care Deficit
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Patient Education
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Skin Care
Avoid Prolonged Exposure to Sunlight
Exercise
Immunization
Stress Reduction
Community Support Groups
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Scleroderma
 Inflammation Develops into Fibrosis and
Sclerosis of Tissues
 Autoimmune Response
 Progress Very Rapidly
 Remissions and Exacerbations
 Poor Prognosis
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Signs and Symptoms
 Arthritis, Fatigue
 Scleroderma
 Pitting Edema, Tightening, Hardening,
Thickening of Skin Tissue
 Loss of ROM
 Contractures
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Diagnosis
 History
 Physical
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Therapeutic Interventions
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Steroids
Immunosuppressant
Antacids, Histamine Blockers
Rehabilitative Therapy
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Nursing Care
 Pain Control
 Bed Cradle
 Sock/Gloves
 Skin Protective
 Mild Soaps and Lotions
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Nursing Care (cont’d)
 Small, Frequent, Bland Meals
 Cut Food into Small Pieces
 Thicker Liquids
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Osteogenesis Imperfecta
 Congenital Abnormality Characterized by
Skeletal Bone Fragility
 Brittle Bones Disease
 Pathological Fractures
 Collagen Synthesized Abnormally
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Osteogenesis Imperfecta (cont’d)
 Signs and Symptoms
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Fragile Bones
Triangular Shaped Face
Potential Hearing Loss
Scoliosis
Loose Joints
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Osteogenesis Imperfecta (cont’d)
 Signs and Symptoms (cont’d)
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Alterations in Muscle Tone or Development
Blue, Purple, Grey Tint to Sclera
Brittle or Discolored Teeth
Smooth, Thin Skin
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Osteogenesis Imperfecta (cont’d)
 Diagnosis
 History of Fractures
 Physical
 Skin Biopsy
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Osteogenesis Imperfecta (cont’d)
 Therapeutic Interventions
 No Treatment
 Fracture Care
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Osteogenesis Imperfecta (cont’d)
 Nursing Care
 Careful Handling
 Teaching
 Support Groups
 Osteogensis Imperfecta Foundation
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Polymyositis
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Diffuse Inflammation of Skeletal Muscle
Dermatomyositis – with Rash
Progressive
Remissions and Exacerbations
Women Greater Than Men
Treatment: Prednisone
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Polymyositis (cont’d)
 Nursing Care
 Supportive Care
 Education
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Muscular Dystrophy
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Group of Nine Disorders
Loss of Muscle Tissue
Progressive Muscle Weakness
Genetic
Skeletal Muscle Fibers Degenerate,
Atrophy
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Therapeutic Interventions
 Supportive Care
 Prevention of Complications
 Gene Therapy Research
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Nursing Diagnoses
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Impaired Physical Mobility
Ineffective Breathing Pattern
Self-care Deficits
Deficient Knowledge
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Osteoarthritis
 Degenerative Joint Disease (DJD)
 Common
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Pathophysiology
 Articular Cartilage/Joints Bone Ends
Deteriorate
 Joint Space Narrows, Bone Spurs Develop,
Joint Inflamed
 Joint Deformities, Pain, Immobility
 Weight-bearing Joints
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Joints Affected by Osteoarthritis
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Causes
 Unknown
 Risk Factors
 Aging
 Obesity
 Excessive “Wear and Tear” on Synovial Joints
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Signs and Symptoms
 Joint Pain
 Intensifies After Physical Activity
 Stiffness
 Heberden’s and Bouchard’s Nodes
 Bony Nodes on Joints of Fingers
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Diagnostic Tests
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X-Rays
CT scan
MRI
Synovial Fluid Analysis
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Therapeutic Interventions
 No Cure
 Medication
 NSAIDs
 Rest and Exercise
 Heat or Cold
 Weight Control
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Therapeutic Interventions (cont’d)
 Complementary Therapies
 Imagery, Music Therapy, Acupressure,
Acupuncture
 Surgery
 Total Joint Replacement
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Nursing Diagnoses
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Chronic Pain
Activity Intolerance
Chronic Sorrow
Disturbed Body Image
Impaired Physical Mobility
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Nursing Diagnoses (cont’d)
 Self-care Deficit
 Ineffective Health Maintenance
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Patient Education
 Protect Joints
 Conserve Energy
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Rheumatoid Arthritis
 Chronic, Progressive, Systemic
Inflammatory Disease
 Destroys Synovial Joints and Other
Connective Tissues
 Includes Major Organs
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Rheumatoid Arthritis (cont’d)
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Pathophysiology
 Synovitis
 Synovium Thickens, Fluid Accumulates
 Destructive Pannus Erodes Joint Cartilage,
Destroys Joint Bone
 Pannus Converted to Bony Tissue
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Pathophysiology (cont’d)
 Joint Deformity
 Other Connective Tissue Affected
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Etiology
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Unknown
Genetic Predisposition
Environmental
Autoimmune Response – Antibodies
(Rheumatoid Factor)
 Local and Systemic Inflammation
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
 Remissions and Exacerbations
 Varies by Individual
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms (cont’d)
 Early Symptoms
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Bilateral, Symmetrical Joint Inflammation
Reddened, Warm, Swollen, Stiff, Painful
Stiffness After Resting
Activity Decreases Pain and Stiffness
Low Grade Fever, Weakness, Fatigue,
Anorexia
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms (cont’d)
 Late Symptoms
 Joint Deformity
 Secondary Osteoporosis
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Joint Abnormalities in
Rheumatoid Arthritis
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
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
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Rheumatoid Factor (RF)
Red Blood Cell (RBC)
C4 Complement Decreased
Erythrocyte Sedimentation Rate (ESR)
Antinuclear Antibody (ANA)
C-reactive Protein (CRP)
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions
 Medication
 Disease-modifying Antirheumatic Drugs
 Leflunomide (Arava)
 Etanercept (Enbrel)
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions (cont’d)
 Medication (cont’d)




Methotrexate
Gold
Prednisone
NSAIDs
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions (cont’d)
 Heat/Cold
 Balanced Rest and Activity
 Surgery – Total Joint Replacement
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Nursing Diagnoses
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
Acute Pain
Disturbed Body Image
Fatigue
Self-care Deficit
Impaired Physical Mobility
Deficient Knowledge
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Patient Education





Disease Process
Medication Management
Rest and Exercise
Vocational Counselor
Community Resources
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Hip Replacement
 Acetabular Cup Inserted Into Pelvic
Acetabulum
 Femoral Component Inserted Into Femur
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Hip Replacement (cont’d)
 Preoperative Care
 Total Joint Education Programs
 Autologous Blood Donation
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Hip Replacement (cont’d)
 Postoperative Care to Prevent
Complications
 Hip Dislocation
 Prevent Adduction or Hyperflexion
 Skin Breakdown
 Prevent Pressure Ulcers
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Abductor Pillow
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Hip Flexion After Total Hip
Replacement
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Hip Replacement (cont’d)
 Pain
 Provide Pain Relief
 Infection
 Prophylactic Antibiotics
 Coughing and Deep Breathing
 Incisional Care
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Hip Replacement (cont’d)
 Bleeding
 Monitor Incision/Drainage from Drain
 Neurovascular Compromise
 Neurovascular Checks
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Hip Replacement (cont’d)
 Ambulation
 Physical Therapy
 Use Walker/Crutches
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Hip Replacement (cont’d)
 Thromboembolitic Complications
 Compression Devices
 Leg Exercises
 Enoxaparin (Lovenox)
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Hip Replacement (cont’d)
 Self-care
 Assistive Dressing Devices
 Raised Toilet Seat
 Rehabilitation
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Total Knee Replacement
 Femoral Component, Tibial Component,
Patellar Button
 Dislocation Not a Concern
 Care like Total Hip Replacement
 Continuous Passive Motion Machine (CPM)
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Continuous Passive Motion
Machine
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Amputation
Removal of a body part
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Amputation (cont’d)
 Surgical Amputations
 Ischemia from Peripheral Vascular Disease
 Bone Tumor, Frostbite, Congenital Problems,
Infections
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Amputation (cont’d)
 Traumatic Amputations
 Accidents
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Amputation (cont’d)
 Replantation
 Wrap Severed Body Part in Cool, Slightly Moist
Cloth
 Place in Sealed Plastic Bag Submerged in
Cold Water
 Transported to Hospital
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Amputation (cont’d)
 Levels of Amputation




Below-the-knee (BKA)
Above-the-knee (AKA)
Below-the-elbow (BEA)
Above-the-elbow (AEA)
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Amputation Nursing Care
 Preoperative Nursing Diagnoses
 Deficient Knowledge
 Teach Preoperative Procedures
 Disturbed Body Image
 Begin Support Services
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Amputation Nursing Care
(cont’d)
 Postoperative
 Hemorrhage Prevention
 Infection
 Pain Control
 Phantom Pain
 Mobility and Ambulation
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Bandaging for Above-theKnee Amputation
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Amputation Nursing Care
(cont’d)
 Postoperative Nursing Diagnoses
 Prosthesis
 Lifestyle Adaptation
Copyright © 2011. F.A. Davis Company