fracture and casts updated 2011
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Fractures
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What is a fracture?
A fracture is a break in the continuity of a
bone.
Other structures may be involved.
There might be soft tissue edema,
hemorrhage into muscles and joints, joint
dislocations, ruptured tendons , severed
nerves, damaged blood vessels and injury
to body organs.
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Classifications of Fractures
Complete - fracture involving the entire
cross section of the bone; usually
displaced.
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Incompletefracture involving only a
portion of the cross section of bone;
usually undisplaced.
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Open break in the skin and underlying
soft tissue leading directly into fracture or
its hematoma.
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Closed Fracture does not
communicated with outside area.
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Specific Types of Fractures
Greenstick one side of a bone is
broken, and the other side is bent.
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Transverse fracture straight across the
bone.
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Oblique fracture occurring at an angle
across the bone.
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Comminuted bone has splintered into
several fragments.
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Clinical Manifestations Pain
Loss of function; inability to use the part
Localized swelling and discoloration of the
skin
Deformity (visible or palplable)
False motion; abdominal mobility atfracture site
Crepitation (grating sensation)
Bone might be visible through skin
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Fracture
TYPES OF FRACTURE
1. Complete fracture
Involves a break across the entire
cross-section 2. Incomplete fracture
The break occurs through only a part of
the cross-section
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Fracture
TYPES OF FRACTURE
1. Closed fracture
The fracture that does not cause a
break in the skin 2. Open fracture
The fracture that involves a break in the
skin
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Fracture
TYPES OF FRACTURE
1. Comminuted fracture
A fracture that involves production of
several bone fragments 2. Simple fracture
A fracture that involves break of bone
into two parts or one
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Fracture
ASSESSMENT FINDINGS
1. Pain or tenderness over the
involved area
2. Loss of function
3. Deformity
4. Shortening
5. Crepitus
6. Swelling and discoloration
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Fracture
ASSESSMENT FINDINGS
1. Pain
Continuous and increases in severity
Muscles spasm accompanies the fractureis a reaction of the body to immobilize the
fractured bone
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Fracture
ASSESSMENT FINDINGS
2. Loss of function
Abnormal movement and pain can result
to this manifestation
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Fracture
ASSESSMENT FINDINGS
3. Deformity
Displacement, angulations or rotation of
the fragments Causes deformity
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Fracture
ASSESSMENT FINDINGS
4. Crepitus
A grating sensation produced when the
bone fragments rub each other
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Fracture
DIAGNOSTIC TEST
X-ray
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Fracture
EMERGENCY MANAGEMENT OF FRACTURE
1. Immobilize any suspected fracture
2.S
upport the extremity above and belowwhen moving the affected part from a vehicle
3. Suggested temporary splints- hard board,
stick, rolled sheets
4. Apply sling if forearm fracture is suspectedor the suspected fractured arm maybe
bandaged to the chest
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Fracture
EMERGENCY MANAGEMENT OF
FRACTURE
5. Open fracture is managed by covering a
clean/sterile gauze to preventcontamination
6. DO NOT attempt to reduce the facture
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Fracture
MEDICAL MANAGEMENT
1. Reduction of fracture either open or
closed, Immobilization and Restoration of
function 2. Antibiotics, Muscle relaxants such as
METHOCARBAMOL and Pain
medications
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Fracture
General Nursing MANAGEMENT
ForCLOSED FRACTURE
1. Assist in reduction and immobilization 2. Administer pain medication and muscle
relaxants
3. teach patient to care for the cast
4. Teach patient about potential complicationof fracture and to report infection, poor
alignment and continuous pain
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Fracture
General Nursing MANAGEMENTFor OPEN FRACTURE
1. Prevent wound and bone infection
Administer prescribed antibiotics
Administer tetanus prophylaxis Assist in serial wound debridement
2. Elevate the extremity to prevent edema formation
3. Administer care of traction and cast
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Fracture FRACTURE COMPLICATIONS Early
1. Shock
2. Fat embolism
3. Compartment syndrome
4. Infection
5. DVT
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Fracture FRACTURE COMPLICATIONS Late
1. Delayed union
2. Avascular necrosis
3. Delayed reaction to fixation devices
4. Complex regional syndrome
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Fracture FRACTURE COMPLICATIONS:FatEmbolism Occurs usually in fractures of the long bones
Fat globules may move into the blood stream becausethe marrow pressure is greater than capillary pressure
Fat globules occlude the small blood vessels of thelungs, brain kidneys and other organs
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Fracture FRACTURE COMPLICATIONS: Fat Embolism
Onset is rapid, within 24-72 hours
ASSESSMENT FINDINGS
1. Sudden dyspnea and respiratory distress
2. tachycardia
3. Chest pain 4. Crackles, wheezes and cough
5. Petechial rashes over the chest, axilla and hard palate
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Fracture FRACTURE COMPLICATIONS: Fat Embolism Nursing Management
1. Support the respiratory function
Respiratory failure is the most common cause ofdeath
Administer O2 in high concentration
Prepare for possible intubation and ventilator support
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Fracture FRACTURE COMPLICATIONS: Fat Embolism Nursing Management
2. Administer drugs
Corticosteroids
Dopamine
Morphine
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Fracture FRACTURE COMPLICATIONS: Fat Embolism NursingManagement
3. Institute preventive measures
Immediate immob
ilizationoffracture Minimalfracture manipulation
Adequate support forfractured bone during
turning and positioning
Maintain adequate hydration and electrolyte
balance
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Fracture Early complication:Compartment syndrome
This results from fractures of arms or legs whereclosed compartment are present.
Compartment contains blood vessels, nerves,
muscles which are enclosed by fascia.
A complication that develops when tissue perfusion inthe muscles is less than required for tissue viability
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Fracture
Tight dressing
Tight cast
Edema of contents of the compartment
Increase pressure within closed compartment
5 Ps
Pain
Pallor
Pulselessness
Paresthesia
paralysis
Contractures
e.g. Volkmanns contractures
(Irreversible wrist drop)
Function disability
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Fracture
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Fracture
Early complication:Compartment syndrome
ASSESSMENT FINDINGS
1. Pain- Deep, throbbing and UNRELIEVED pain by opiods
Pain is due to reduction in the size of the musclecompartment by tight cast
Pain is due to increased mass in the compartment by edema,swelling or hemorrhage
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Fracture
Early complication:Compartment syndrome
ASSESSMENT FINDINGS
2. Paresthesia- burning or tingling sensation
3. Numbness 4. Motor weakness
5. Pulselessness, impaired capillary refill time and
cyanotic skin
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Fracture
Early complication:Compartment syndrome
Medical and Nursing management
1. Assess frequently the neurovascular status of the
casted extremity 2. Elevate the extremity above the level of theheart
3. Assist in cast removal and FASCIOTOMY
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Open Reduction Internal Fixation
(ORIF)
- Surgical insertion of internal fixation devices like metal pins, wires or
screws to keep bone fragment in position.
PRE-OPERATIVE CARE:
1. Immobilize the affected bone
2. Handle the affected bone gently
3. Cover open fractures with sterile gauze.
POST-OPERATIVE CARE
1. Monitor neuromascular status
2. Monitor for signs of nerve damage 5Ps
3. Monitor for complications: DVT (Homans sign), thromboplebitis,
infection
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CARPAL TUNNEL SYNDROME:
Compressionofthe mediannerve ofthe wrist.
Most common in women 30-50 years ofage.
Usually associated with job-related tasks (typists,computeroperators, assembly line workers,
truck drivers, carpenters)
Initialmanifestations:paresthesia, clumsinesswhwn using the hands
Othermanifestations;
NumbnessPain
Paresthesia
Pain radiating toforearm, shoulder and chest
Loss offine motormovement ofthe hand.
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LABORATORY DATA:
(+) Tinels Sign tapping the mediannerve at the wristproduces the symptoms
(+) Phalens test holding the wrist in acute flexionfor
60 s produces the symptoms
Splint the wrist
Administered steroid as ordered
Prepare the client for surgical intervention:
(decompressionofthe mediannerve)
Prepare the client foroccupation and jo
bcounselling
Post-operatively, elevate the hand and arm 24h
Encourage the client to handle normal activities ofdaily
living, 2-3 days following surgery
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Strains
Excessive stretchingofa muscle or
tendon
Nursingmanagement
1. Immobilize affected part
2. Apply cold packs initially, then heat
packs 3. Limit joint activity
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Sprains
Excessive stretching of the LIGAMENTS
Nursing management
1. Immobilize extremity and advise rest 2. Apply cold packs initially then heat packs
3. Compression bandage may be applied to
relieve edema
4. Assist in cast application
5. Administer NSAIDS
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Herniated disk
Occurs when allorpart ofthe nucleus
pulposus forces through the weakened
or tornouter ring (annulus pulposus
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Herniated disk
Impingement on the spinalnerves will
result to BACKPAIN
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Treatment
Reduction setting the bone; restoration
of fracture fragments into anatomical
position and alignment.
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Methods
Closed reduction
Traction
Open reduction
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Open Reduction
Operative intervention to achieve fracture
reduction
Bone fragments are repositioned under
direct visualization
Internal fixation devices(metallic pins,
wires, screws, plates, nails, rods) may be
used to hold bone fragments in position
After closure of wound, cast may be
applied
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Musculoskeletal Modalities
Traction
Cast
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Nursing Management
Traction
A method of fracture immobilization by
applying equipments to align bone
fragments Used for immobilization, bone alignment
and relief of muscle spasm
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Traction
Skin traction- Buck, Bryant
Skeletal traction
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Traction
Pullingforce exerted onbones to
reduce or immobilize fractures, reduce
muscle spasm, correct orprevent
deformities
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Balance suspension traction (skeletal)
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Bucks traction (Skin)
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Nursing Management
Traction:General principles
1. ALWAYS ensure that the
weights hang freely and do not
touch the floor 2. NEVERremove the weights
3. Maintain proper body alignment
4. Ensure that the pulleys and ropesare properly functioning and
fastened by tying square knot
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Nursing Management
Traction:General principles
5. Observe and prevent foot drop
Provide foot plate
6. Observe for DVT, skin irritation andbreakdown
7. Provide pin care for clients in skeletal
traction- use of hydrogen peroxide
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Nursing Management
Traction:General principles
8. Promote skin integrity
Use special mattress if possible
Provide frequent skin care Assess pin entrance and cleanse the pin
with hydrogen peroxide solution
Turn and reposition within the limits of
traction Use the trapeze
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Nursing Management
CAST
Immobilizing tool made of plaster of Paris
or fiberglass
Provides immobilization of the fracture
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Casting Materials
Plaster of Paris
Drying takes 1-3 days
If dry, it is SHINY, WHITE, hard and
resistant Fiberglass
Lightweight and dries in 20-30 minutes
Water resistant
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Cast application
1. TO immobilize a body part in a specificposition
2. TO exert uniform compression to thetissue
3. TOprovide early mobilizationofUNAFFECTED body part
4. TO correct deformities
5. TO stabilize and support unstable
joints
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Nursing Management
CAST:GeneralNursingCare
3. Keep the casted extremity
ELEVATED using a pillow
4. Turn the extremity for equal drying.DONOTUSEDRYER forplaster cast
Encourage mobility and range of
motion exercises
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Nursing Management
CAST:GeneralNursingCare
5. Petal the edges ofthe cast to
prevent crumblingofthe edges
6. Examine the skinforpressureareas and Regularly check the
pulses and skin
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Nursing Management
CAST:GeneralNursingCare
7. Instruct the patient not to
place sticks or smallobjects
inside the cast
8. Monitorfor the following:
pain, swelling, discoloration,
coolness, tingling or lack ofsensation and diminished
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Nursing Management
CAST:GeneralNursingCare
Hot spots occurring along the cast
may indicate in
fecti
on under the cast
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Common
Musculoskeletal
conditions
Nursing management
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What is a cast?
A cast holds a broken bone in place as it
heals. Casts also help to prevent or decrease
muscle contractions, and are effective at
providing immobilization, especially after
surgery.
Casts immobilize the joint above and the joint
below the area that is to be kept straight and
without motion. For example, a child with a
forearm fracture will have a long arm cast to
immobilize the wrist and elbow joints.
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What are casts made of?
The outside, or hard part of the cast, is made from two
different kinds of casting materials.
plaster- white in color.
fiberglass - comes in a variety of colors, patterns, and
designs.
Cotton and other synthetic materials are used to line the
inside of the cast to make it soft and to provide padding
around bony areas, such as the wrist or elbow.
Special waterproof cast liners may be used under a
fiberglass cast, allowing the child to get the cast wet.
Consult your child's physician for special cast care
instructions for this type of cast.
Wh t th diff t t f
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What are the different types of
casts?
Short arm cast: Applied below the elbow to
the hand.
Use: Forearm or wrist fractures. Also
used to hold the forearm or wrist muscles
and tendons in place after surgery.
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Long arm cast: Applied from the upper arm to
the hand.
Use: Upper arm, elbow, or forearm
fractures. Also used to hold the arm or
elbow muscles and tendons in place after
surgery.
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Shoulder spica cast: Applied around the
trunk of the body to the shoulder, arm, and
hand.
Use:Shoulder dislocations or after
surgery on the shoulder area
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Minerva cast: Applied around the neck and
trunk of the body.
Use: After surgery on the neck or upper
back area.
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Short leg cast: Applied to the area below the
knee to the foot.
Use: Lower leg fractures, severe ankle
sprains/strains, or fractures. Also used to
hold the leg or foot muscles and tendons
in place after surgery to allow healing.
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Leg cylinder cast: Applied from the upper
thigh to the ankle.
Use: Knee, or lower leg fractures, knee
dislocations, or after surgery on the leg or
knee area.
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One and one-halfhip spica cast: Applied
from the chest to the foot on one leg to the
knee of the other leg. A bar is placed between
both legs to keep the hips and legs
immobilized.
Use: Thigh fracture. Also used to hold the
hip or thigh muscles and tendons in place
after surgery to allow healing.
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Bilaterallongleg hip spica cast: Applied
from the chest to the feet. A bar is placed
between both legs to keep the hips and legs
immobilized.
Use: Pelvis, hip, or thigh fractures. Also
used to hold the hip or thigh muscles and
tendons in place after surgery to allow
healing.
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Abductionboot cast: Applied from the upper
thighs to the feet. A bar is placed between
both legs to keep the hips and legs
immobilized.
Use: To hold the hip muscles and tendons
in place after surgery to allow healing.
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How canmy child move around
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y
while in a cast?
Assistive devices for children with casts
include:
crutches
walkers
wagons
wheelchairs
reclining wheelchairs
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Older children with body casts may need to use a
bedpan or urinal in order to go to the bathroom.
Tips to keep body casts clean and dry and prevent
skin irritation around the genital area include the
following:
Use a diaper or sanitary napkin around the
genital area to prevent leakage or splashing of
urine.
Place toilet paper inside the bedpan to prevent
urine from splashing onto the cast or bed.
Keep the genital area as clean and dry as
possible to prevent skin irritation.
When to call your child's
physician:
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physician:
Contact your child's physician or healthcareprovider if your child develops one or more of
the following symptoms:
fever greater than 101 F
increased pain
increased swelling above or below the cast
complaints of numbness or tingling
drainage or foul odor from the cast
cool or cold fingers or toes
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METABOLIC BONE
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DISORDERS
Osteoporosis: Pathophysiology
Normal homeostatic bone turnover is
altered rate of bone RESORPTION is
greater than bone FORMATION
reduction in total bone mass reduction inbone mineral density prone to
FRACTURE
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METABOLIC BONE
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DISORDERS
Osteoporosis: TYPES
1. Primary Osteoporosis- advanced age,
post-menopausal
2.S
econdary osteoporosis-S
teroidoveruse, Renal failure
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METABOLIC BONE
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DISORDERS
RISK factors for the development of
Osteoporosis
1. Sedentary lifestyle
2. Age 3. Diet- caffeine, alcohol, low Ca
and Vit D
4. Post-menopausal
5. Genetics- caucasian and asian
6. Immobility
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METABOLIC DISORDER
ASSESSMENT FINDINGS
1. Low stature
2. Fracture
F
emur 3. Bone pain
4/28/2011 RON R.N.,M.D. 111
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T-score and World Health Organization
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T-score and World Health Organization
Diagnosis of Bone Density:
T-score Diagnosis
0 to -0.99 SD Norma BMD
-1.0 to -2.49 SD Low Bone density
(osteopenia)
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METABOLIC DISORDER
Medical management of Osteoporosis
1. Diet therapy with calcium and
Vitamin D
2. Hormone replacement therapy 3. Biphosphonates- Alendronate,
risedronate produce increased bone
mass by inhibiting the
OSTEOCLAST
4. Moderate weight bearing
exercises
5. Management of fractures
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METABOLIC DISORDER
Osteoporosis Nursing Interventions
1. Promote understanding ofosteoporosis and the treatmentregimen
Provide adequate dietarysupplement of calcium and vitaminD
Instruct to employ a regular programof moderate exercises and physicalactivity
Manage the constipating side-effectof calcium supplements4/28/2011 RON R.N.,M.D. 115
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METABOLIC DISORDER
Osteoporosis Nursing Interventions
Take calcium supplements with meals
Take alendronate with an EMPTY stomach
with water
Instruct on intake of Hormonal
replacement
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METABOLIC DISORDER
Osteoporosis Nursing Interventions
2. Relieve the pain
Instruct the patient to rest on a firm
mattress
Suggest that knee flexion will cause
relaxation of back muscles
Heat application may provide comfort
Encourage good posture and body
mechanics
Instruct to avoid twisting and heavy lifting
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METABOLIC DISORDER
Osteoporosis Nursing Interventions
3. Improve bowel elimination
Constipation is a problem of calcium
supplements and immobility
Advise intake of HIGH fiber diet and
increased fluids
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METABOLIC DISORDER
Osteoporosis Nursing Interventions
4. Prevent injury
Instruct to use isometric exercise to
strengthen the trunk muscles
AVOID sudden jarring, bending and
strenuous lifting
Provide a safe environment
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Juvenile rheumatoid Arthritis
Definition:
AUTO-IMMUNE inflammatory joint
disorder of UNKNOWN cause
SYSTEMIC chronic disorder of
connective tissue
Diagnosed BEFORE age 16 years old
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Juvenile rheumatoid Arthritis
PATHOPHYSIOLOGY : unknown
Affected by stress, climate and genetics
Common in girls 2-5 and 9-12 y.o.
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Systemic JRA Pauci-articular Polyarticular
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FEVER MILD joint pain
and swelling
Morning joint
stiffness andfever
Salmon-pink
rash
IRIDOCYCLITIS Weight
Bearing joints
Five or more
joints
Less than 4
joints
Five or more
joints
Anorexia,
anemia, fatigue
Very Good
prognosisPoor prognosis
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JRA
Symptoms may decrease as child enters
adulthood
With periods of remissions and
exacerbations
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JRA
Nursing Management
1. Encourage normal performance of daily
activities
2. Assist child in ROM exercises
3. Administer medications
4. Encourage social and emotional
development
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JRA
NursingManagement
During acute attack:
SPLINT the joints
NEUTRAL positioning
Warm or cold packs
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DEGENERATIVE JOINT DISEASES
Types of Arthritis
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Rheumatoid Arthritis Gouty Arthritis Osteoarthritis
Main Problem Recurrentinflammation of the
synovial lining of the
joints, usually the
upper extremities. It
is more common in
women
Metabolic disorderof uric acid
formation and
excretion. It is
more common in
men
Degeneration ofthe articular
cartilage in the
joints. It affects
both men and
women ( more
common inmen)
Initial
manifestation
Morning stiffness
relieved by warm
bath or soaks
Initially
asymptomatic. A
common sign is
dusky red hotswollen joints,
usually of the
great big toe
Pain and swelling
in a weight-
bearing joint,
usuallyaggravated by
activity
Types of ArthritisRheumatoid arthritis Gouty Arthritis Osteoarthritis
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y
Other
manifestations
-joint instability
-ulnar deviation offingers (ulnar drift)
-swan-neck deformity
of the hands
-ankylosis
* Boutonnieredeformity
-joint pain
-redness andswelling in joints
-tophi
accumulation of
urate crystals
-Malaise-fever
-joint stiffness
-crepitus-Heberdens
(DIP)nodes-distal
joints of the
fingers
-Bouchardsnodes-(PIP)
proximal joints of
the fingers
-Increased pain in
cold weather
-Decreased range
of motion
Laboratory data Elevated ESR Elevated urate
crystals synovial
fluids
X-ray
Rheumatoid Arhritis Gouty Arthritis Osteoarthritis
Priorit Pain related to Joint Pain related to Joint Pain related to
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Priorit
y
Nursi
ng
Diagn
osis
Pain related to Joint
Inflammation
Pain related to Joint
Inflammation
Pain related to
bone
degenerations in
the joints
Interv
entio
ns
Teach the patient to take
aspirin regularly as ordered
even in the absence ofsymptoms.
-Instruct the client that
tinnitus is a side effect of
aspirin
-Apply moist heat for 15-30min to reduce muscle
spasm
-Use ice packs during
acute phase to decrease
the pain
Teach the client to
maintain purine-
restricted diet (avoidorgan meats,alcohol,
beans, sardines)
-inc. oral fluid intake
-Avoid aspirin and
diuretics as theseinterfere with uric acid
secretion
-complication
kidney stone
Priority: minimize
discomfort
Implement WHAT:
W weight control
H hot compress
or icepacks
A aspirin use
T trunk assistive
devices (canes)
DEGENERATIVE JOINT
DISEASE
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DISEASE
OSTEOARTHRITIS The most common form of degenerative
joint disorder
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DEGENERATIVE JOINT
DISEASE
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DISEASE
OSTEOARTHRITIS:Pathophysiology Injury, genetic, Previous joint damage,
Obesity, Advanced age
Stimulate the chondrocytes to releasechemicals
chemicals will cause cartilage
degeneration, reactive inflammation of
the synovial lining and bone stiffening
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This process may affect any joint in the
body, though the knees and hands are
most commonly affected, followed by thespine, hips, ankles and shoulders. Elbows
and wrists aren't usually affected. Usually
between one and four separate joints are
involved
DEGENERATIVE JOINT
DISEASE
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DISEASE
OSTEOARTHRITIS: Risk factors
1. Increased age
2. Obesity
3. Repetitive use of joints with previous
joint damage
4. Anatomical deformity
5. genetic susceptibility
4/28/2011 RON R.N.,M.D. 136
OSTEOARTHRITIS: Assessment findings
1 Joint pain
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1. Joint pain
2. Joint stiffness 3. Functional joint impairment
limitation
The joint involvement is
ASYMMETRICAL This is not systemic, there is no FEVER,
no severe swelling
Atrophy of unused muscles
Usual joint are the WEIGHTbearing
joints
4/28/2011 RON R.N.,M.D. 137
DEGENERATIVE JOINT
DISEASE
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DISEASE
OSTEOARTHRITIS: Assessment findings
1. Joint pain
Caused by
Inflamed cartilage and synovium
Stretching of the joint capsule
Irritation of nerve endings
4/28/2011 RON R.N.,M.D. 138
DEGENERATIVE JOINT
DISEASE
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DISEASE
OSTEOARTHRITIS: Assessment findings
2. Stiffness
commonly occurs in the morning aftercommonly occurs in the morning afterawakeningawakening
Lasts only forless than 30 minutes DECREASES with movement, but worsens
after increased weight bearing activitry
Crepitation may be elicited
4/28/2011 RON R.N.,M.D. 139
DEGENERATIVE JOINT
DISEASE
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DISEASE
OSTEOARTHRITIS: Diagnostic findings
1. X-ray
Narrowing of joint space
Loss of cartilage
Osteophytes2. Blood tests will show no evidenceno evidence of
systemic inflammation and are not useful
4/28/2011 RON R.N.,M.D. 140
DEGENERATIVE JOINT DISEASE
OSTEOARTHRITIS: Medical
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OSTEOARTHRITIS:Medical
management
1. Weight reduction
2. Use of splinting devices to support
joints
3. Occupational and physical therapy 4. Pharmacologic management
Use of PARACETAMOL, NSAIDS
Use of Glucosamine and chondroitin
Topical analgesics
Intra-articular steroids to decrease inflam
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DEGENERATIVE JOINT
DISEASE
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DISEASE
OSTEOARTHRITIS: Nursing Interventions
2. Advise patient to reduce weight
Aerobic exercise
Walking
3. Administer prescribed medications
NSAIDS
4/28/2011 RON R.N.,M.D. 143
DEGENERATIVE JOINT
DISEASE
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DISEASE
OSTEOARTHRITIS: Nursing Interventions
4. Position the client to prevent flexion
deformity
Use of foot board, splints, wedges and
pillows
4/28/2011 RON R.N.,M.D. 144
Rh t id th iti
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Rheumatoid arthritis
A type of chronic systemic inflammatory
arthritis and connective tissue disorder
affecting more women (ages 35-45) than
men
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Rhe matoid arthritis
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Rheumatoid arthritis
FACTORS:
Genetic
Auto-immune connective tissue disorders
Fatigue, emotional stress, cold, infection
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Rheumatoid arthritis
ASSESSMENT FINDINGS
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ASSESSMENT FINDINGS
1. PAIN 2. Joint swelling and stiffness-
SYMMETRICAL, Bilateral
3.W
armth, erythema and lack offunction
4. Fever, weight loss, anemia,
fatigue
5. Palpation of join reveals spongy
tissue
6. Hesitancy in joint movement4/28/2011 RON R.N.,M.D. 148
Rheumatoid arthritis
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Rheumatoid arthritis
ASSESSMENT FINDINGS
Joint involvement is SYMMETRICAL andBILATERAL
Characteristically beginning in the hands, wrist
and feet Joint STIFFNESS occurs early morning, lasts
MORE than 30 minutes, not relieved bymovement, diminishes as the day progresses
4/28/2011 RON R.N.,M.D. 149
Rheumatoid arthritis
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Rheumatoid arthritis
ASSESSMENT FINDINGS
Joints are swollen and warm
Painful when moved
Deformities are common in the hands and
feet causing misalignment
Rheumatoid nodules may be found in
the subcutaneous tissues
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Rheumatoid arthritis
Nursing MANAGEMENT
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Nursing MANAGEMENT
1. Relieve pain and discomfort USEsplints to immobilize the affected
extremity during acute stage of the
disease and inflammation to REDUCE
DEFORMITY Administer prescribed medications
Suggest application ofCOLD packs
during the acute phase of pain, then
HEATapplication as the inflammation
subsides
4/28/2011 RON R.N.,M.D. 154
Rheumatoid arthritis
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Rheumatoid arthritis
Nursing MANAGEMENT
2. Decrease patient fatigue
S
chedule activity whenpain is less severe
Provide adequate periods
of rests3. Promote restorative sleep
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Rheumatoid arthritis
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Nursing Management4. Increase patient mobility
Advise proper posture and
body mechanics Support joint in functionalposition
Advise AC
TIVE ROME Avoid direct pressure over
the joint4/28/2011 RON R.N.,M.D. 156
Rheumatoid arthritis
N i M t
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Nursing Management
5. Provide Diet therapy
Patients experience anorexia,nausea and weight loss
Regular diet with caloricrestrictions becausesteroids may increase
appetite Supplements of vitamins,
iron andPROTEIN4/28/2011 RON R.N.,M.D. 157
Rheumatoid arthritis
6 Increase Mobility and prevent
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6. Increase Mobility and prevent
deformity:
Lie FLATon a firm mattress
Lie PRONEseveral times topreventHIPFLEXION contracture
Use one pillow under the headbecause of risk of dorsalkyphosis
NOPillow under the jointsbecause this promotes flexioncontractures
4/28/2011 RON R.N.,M.D. 158
Rheumatoid arthritis
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Rheumatoid arthritis
Capsaicin Unknown mechanism, probably
Inhibits substance P
Reduces pain Applied over the affected area
Do NOTbandage the area
Side effect: burning sensation
Wash hands after application
4/28/2011 RON R.N.,M.D. 159
Hot versus Cold
HOT Cold
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HOT Cold
Use to RELIEVE
joint stiffness, pain
and muscle spasm
Use to control
inflammation and
pain
After acute attack ACUTE ATTACK
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OA versus RA
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OA versus RA
RA OA
Joint tenderness,
swelling, warmth and
redness
Subcutaneous nodules
Stiffness that
diminishes
Crepitus, stiffness in
the morning decreases
after activity
Rest the joint, cold andheat modalities, ASA,
NSAIDS, DMARDS
Rest the joints, Avoidoveractivity, Weight
reduction, cold and
warmmodalities, ASA4/28/2011 RON R.N.,M.D. 162
Gouty arthritis
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Gouty arthritis
A systemic disease caused by depositionof
uric acid crystals in the joint and body
tissues
CAUSES:
1. Primary gout- disorder ofPurinemetabolism
2. Secondary gout- excessive uric acid in
the blood like leukemia
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Gouty arthritis
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Gouty arthritis
ASSESSMENT FINDINGS
1. Severe pain in the involved joints, initiallythe big toe
2. Swelling and inflammation of the joint
3. TOPHI- yellowish-whitish, irregulardeposits in the skin that break open andreveal a gritty appearance
4. PODAGRA-big toe
4/28/2011 RON R.N.,M.D. 166
Gouty arthritis
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Gouty arthritis
ASSESSMENT FINDINGS
5. Fever, malaise
6. Body weakness and headache
7. Renal stones
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Gouty arthritis
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Gou y a s
Medical management
1. Allupurinol- take it WITH FOOD
Rash signifies allergic
reaction
2. Colchicine
For acute attack
3. Probenecid
For uric acid excretion
in the kidney
4/28/2011 RON R.N.,M.D. 169
Gouty arthritis
Nursing Intervention
1 Provide a diet with LOW purine
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1. Provide a diet with LOWpurine
Avoid Organ meats, aged and processedfoods
STRICTdietary restriction is NOT
necessary
2. Encourage an increased fluid intake (2-
3L/day) to prevent stone formation
3. Instruct the patient to avoid alcohol
4. Provide alkaline ash diet to increaseurinary pH
5. Provide bed rest during early attack of gout4/28/2011 RON R.N.,M.D. 170
Gouty arthritis
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y
Nursing Intervention
6. Position the affected extremity in mild
flexion
7. Administer anti-gout medication and
analgesics
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