2/16/2009 Hip Fracture Musculoskeletal System • Fracture of the head, neck, or trochanteric area of the femur Bones, Joints, Muscles, Cartilage, • Great incidence elderly female Tendons, and Ligaments • Predisposing factors: osteoporosis • Traction (Buck’s/Russell) as a temporary measure to maintain alignment and reduce pain of muscle spasm • Surgery – ORIF with pins, nails, and/or plates – Hemiarthroplasty: insert a prosthetic femur head Hip Fracture Hip Fracture Assessment Interventions • Pain in affected limb • Traction care • Affected limb is shortened and • Elderly - Reorient frequently and safety externalexternally rrotatedotated • Neurovascular ccheckshecks • X ray shows fracture • Prevent complications of immobility • Trapeze to facilitate movement • Analgesics for pain Hip Fracture Interventions Hip replacement • Post op ORIF • Replacement of acetabulum and head – Check dressings for bleeding , drainage, infection of femur with prosthetic – Empty hemovac, record output, keep compressed to facilitate drainage • Indications – Turn q 2 – RA, osteoarthritis causing severe disability – Place 2 pillow between legs while turning and and intolerable pain when lying on side – Prevent thrombus - elastic stockings, – Fractured hip with nonunion plantar/dorsiflexion, anticoagulants – Bowel/bladder - fluids, fiber – OOB per MD order 1st/2nd post op day – No weight bearing affected side - pivot 1 2/16/2009 Hip replacement Hip replacement Interventions Interventions • Post op • Discharge teaching – Maintain abduction of limb with abductor splint or – Prevent adduction of affected limb & hip flexion two pillow between legs • Do not cross legs – Prevent external rotation with trochanter roll along • Use raised ttoiletoilet seat leg • Do not bend down to put on shoes/socks – Prevent hip flexion; HOB flat, raise 45 degrees for • Do not sit in low chairs meals – s/s infection – Turn only to unoperative side; use pillows between – Exercise program legs when turning & while on side – Partial weight bearing until MD Orders full weight – 2nd post op day OOB, no weight bearing, avoid bear adduction and hip flexion; do not use a low chair Herniated Disc Herniated Disc • Protrusion of the central part of the • Medical Mgmt intervertebral disc into spinal canal – Conservative causing compression of spinal nerve • BR roots • Traction; lumbar-pelvic tx • NSAIDs, muscle relaxants, analgesics • Men > women • Heat application • Common site: 4th & 5th intervertebral • Lumbosacral corset space lumbar • Steroid injections - epidural – Surgery • Causes: heavy lifting or pulling forces • Discectomy/laminectomy with or without spinal fusion Herniated Disc Herniated Disc Assessment Intervention • BR on firm mattress • Back pain radiate across buttock and down • Apply traction leg (along sciatic nerve) • Maintain body alignment • Weakness of leg & foot on affected side • Prevent complications ofof immobility • N/T in toes and foot • Comfort measures for pain • Positive straight-leg test; pain on raising leg • Client teaching • Muscle spasm in lumbar region – Back strengthening exercises • Diagnositic – Good posture – Proper body mechanics – Myelogram localizes site of herniation – Flex knees and hips, don’t bend from waist – Keep load close to body 2 2/16/2009 Discectomy/Laminectomy Discectomy/Laminectomy • Discectomy - Excision of herniated fragments Postop of intervertebral disc – Lumbar - keep bed flat, turn q 2-4 hrs - log roll, pillow • Laminectomy - excision of lamina to reduce between legs pressure onon the pinalinal cord, nerves, or ttoo – Cervical - slight elevate of HOB to prevent airway provide access for removing the disc edema – Monitor CSM • Indication – Check dressing for hemorrhage, infection – herniated discus that does not respond to conservative therapy or decreased sensory/motor – Comfort – SCI to remove bone fragments – Bladder/bowel function – Remove spinal neoplasms or abscess – OOB day after surgery – If allowed to sit, use straight back chair, feet flat on floor Spinal Fusion Spinal fusion • Fusion of spinous processes with bone • Post op – Keep bed flat for first 12 hours then elevate HOB graft from iliac crest to provide 30 degrees stabilization of spine – Apply brace before getting pt OOB • In conjuction with – Assist with ambulation laminectomy/discectomy – Pain control • Teaching – Brace for 4 months – It takes 1 year until graft becomes stable – Walking good exercise - do not walk to fatigue – Wt control Rheumatoid Arthritis (RA) Rheumatoid Arthritis (RA) • Medical Mgmt • Chronis systemic disease with – Analgesic and anti inflammatory inflammatory changes in joints • ASA, NSAIDS - relieve pain and inflammation by inhibiting • Women > Men; age 35-45 the synthesis of prostaglandins – Gold compounds • Cause unknown, may be autoimmune; • Injectable; IM 1x/wk; takes 3-6 months for effect; side effects include proteinuria, mouth ulcers, skin rash. aplastic genetics may play a role anemia. Monitor blood and urine • Affects bilateral joints - symmetric – Steroids – Hands, wrists, elbows, shoulders, knees, • Injection into joint temporarily suppress inflammation • Systemic used only when pt. does not respond to NSAIDs hips, ankles, jaw – Methotrexate, Cytoxan • Suppress immune response; side effect-bone marrow suppression 3 2/16/2009 Rheumatoid Arthritis (RA) Rheumatoid Arthritis (RA) • Assessment • Diagnostics – Fatigue, anorexia, malaise, wt loss, slight – X rays - stages of joint disease temperature – CBC - anemia common – Joints - pain, warm, swelling, limited ROM, – ESR - elevated stiff in AM that increases with inactivity. – RA positive Long standing disease - crippling deformity – ANA - may be positive – Muscle weakness r/t inactivity – C reactive protein elevated – Remissions & exacerbations Rheumatoid Arthritis (RA) Rheumatoid Arthritis (RA) • Interventions • During acute exacerbations – Assess joints-pain, swelling, ROM – Maintain body alignment if on BR – Promote joint mobility and muscle strength – Avoid pillow under knees – Keep joints mainly in extension • ROM several times/day – MD may order cold treatments • Heat before exercise may decrease pain • Use isometric to strengthen muscle • For chronic pain control, heat treatments reduce stiffness, pain, & muscle spasm – Frequent position change - sit, stand, lie – Warm bath, shower or whirlpool – Comfort: balance activity and rest; rest & • Psychological support support inflamed joints • Set realistic goals - focus on strengths Rheumatoid Arthritis (RA) Osteoarthritis • Discharge Teaching • Chronic, non systemic joint disorder – Use of medications – Degeneration of articular cartilage – Self help devices to increase independence – Balance activity & rest – Women & men both aaffectedffected – Energy conservation – Increases with age – ROM & isometric – Cause unknown; factors include wear & – Well-balanced diet tear on joints (aging); obesity, joint trauma – Control stress – f/u care – Joints affected: spine, knees, hips and terminal interphalangeal 4 2/16/2009 Osteoarthritis Osteoarthritis Assessment Interventions • Assess ROM and pain • Pain - aggravated by use, relieved by rest • Relieve strain & prevent trauma to joints • Heberden’s nodes - bony overgrowths ant – Balance activity and rest; Avoid continuous standing terminal interphalangeal joints – Use cane or walker • Decreased ROM, may have crepitus with joint – Promote ideal wt movement • Maintain joint mobility & muscle strength – ROM, proper body alignment • X rays show deformity • Comfort • Sed Rate elevated when disease is – ASA, NSAIDS inflammatory – Heat or ice – Intra articular steroid inject to relieve pain and improve mobility Gout Gout • Disorder of purine metabolism; causes • Acute attack - colchicine IV or po- probably reduces urate crystals and inflammation by high levels of uric acid in blood and the decreasing WBC motility, phagocytosis and precipitation of urate crystals in joints lactic acid production • Joints inflamated r/t urate crystals • Prevent attacks – Probenecid, anturanel - increases renal excretion • Men > women of uric acid • Familial tendency – Allopurinol - inhibits uric acid formation – Joint rest & protection – Heat or cold therapy Gout Gout Assessment Interventions • Joint pain, redness, heat swelling; great • Assess joints for pain, appearance toe joint most commonly affected • Analgesics and antigout meds • headache, malaise, anorexia • Increase fluid intake to 2-3L/dy to prevent formation of renal calculi • Tachycardia, fever • Heat or cold • Uric acid elevated • Bed cradle to keep pressure of sheets off joint 5 2/16/2009 Systemic Lupus Erythematosus (SLE) SLE • Chronic connective tissue disease involving • Management multiple organ systems – ASA & NSAIDs to relieve mild s/s (fever • Women>men arthritis) • Cause may be immune, genettiic, and/or viral – Steroids to suppress the inflammatory • A defect in immune mechanism produces response (exacerbation) antibodies in the serum, attacking own cell nuclei. Cells are affected throughout the body – Plasma exchange to temporarily reduce resulting in disease in joints, skin, kidney, the amount of circulating antibodies CNS, & cardiopulmonary system – Support organ systems SLE SLE Assessment Assessment • Fatigue, fever, anorexia, wt loss, malaise, • Diagnostics remissions & exacerbations – ESR elevated • Joint pain, morning stiffness – CBC: anemia; WWBCBC & pplateletslatelets decreased • Skin: red rash on face, neck, or extremeties, butterfly rash-bridge of nose & cheeks – ANA positive • Alopecia – Anti-DNA positive • Renal: proeteinuria, hematuria, renal failure – Chronic false-positive for syphilis • CNS: periph neuritis, seizure, OBS, psychosis • Cardiopulmonary: pericarditis, pleurisy SLE Intervention • Assess to determine systems involved • VS, I&O, daily wt • Seizure precautions and safety with CNS • Psychological support client/family • Teach – Disease process, medication regimen, needs rest, daily heat & exercise for arthritis, avoid physical/emotional stress, balanced diet, avoid exposure to infection, f/u care 6.