Types of Bones

1
Types of Bones

•    Long bones femur
• Short bones somewhat cubed- shaped
  as in the phalanges
•    Flat bones broad surface for muscular
  attachment or protection of organs (skull, ribs,
  shoulder blades, sternum.
•    Irregular bones wrist, vertebrae

2
Functions of Bones

• Support protect body tissues and organs
• Provides the skeletal framework of the body
• Provides movement through the attachment of
  muscles
• Storehouse for minerals CA 99 makeup
  of bones PO4 90 Po4
• Production of blood cells) which takes place in
  the bone marrow

3
Diarthrodial/Synovial Joints

• -  Ball socket i.e. shoulder hip which
  permits movement in any direction
• - Hinge i.e. elbow movement along one plane
  allows flexion extension
• -  Condylar functions like a hinge joint but
  can
• rotate slightly
•  

4
Synovial Joint Capsule

• Fibrous connective tissue covers the ends of
  bone.  Ligaments and tendons reinforce the joint
  capsule
• Bundles of rich, white fibrous tissue are
  supplied with nerves. Nerves are sensitive to
  rate and direction of motion, compression,
  tension, vibration and pain
• Blood vessels, and lymphatic vessels.
•  

5
Skeletal Muscles

• Primary Function
• Provides voluntary movement
• Maintains posture
• Body Movement contraction relaxation

6
Skeletal Muscles

• Points of Attachment
• Point of Origin attachment of muscle to a more
  stationary bone
• Point of insertions attachment to a more
  movable bone

7
Head to Toe Assessment

• Health History
• Musculoskeletal disorders
• Nutritional status
• Pain History
• ADLs, endurance, assistive devices
• Medications prescription and OTC

8
Assessment Skills

• Inspection symmetry, body alignment, function,
  skin changes, swelling, deformity, contractures,
  gait, non-verbal indication of pain
• Palpation Skin temperature, swelling, nodules,
  masses, Crepitus
• Joint Structure ROM
• Muscle mass strength (atrophy, flaccidly,
  spasticity, paralysis)

9
Connective Tissue Disorders

• Rheumatoid Arthritis
• Osteoarthritis
• Lupus Erythematous
• Gout

10
Rheumatoid Arthritis

• Autoimmune connective tissue disorder
  characterized by inflammatory destructive changes
  in the joints
• Systemic disease Inflammatory changes can
  affect skin, heart, lungs, eyes, blood vessels
  nerves

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Etiology of Rheumatoid Arthritis

• Autoimmune theory Normal antibodies become
  autoantibodies (RH Factors) and attack the
  tissue.
• Genetic Factor 2-3 times with family Hx
• Virus Epstein-Barr
• Stressful events

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Stages of Joint Deterioration

• Stage 1 Initiation - Some changes in the
  synovial lining no loss of functional capacity
• Stage 2 Immune Response Joint swells
  thickens. Functional capacity impaired
• Stage 3 Inflammatory Progressive involvement of
  blood vessels. Limited ADL
• Stage 4 Destructive Granulation tissue hardens
  (Pannus). Leads to ankylosis. Confined to bed or
  wheel chair

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Assessment Data

• Subjective
• - Stiffness especially in a.m. or after
• inactivity
• - Proximal joint pain in the fingers
• - Fatigue, weakness, 2-3 weight loss, low
  grade fever

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Assessment Data

• Objective Manifestations
• - Swollen, reddened, warm joints
• - Weak hand grasp
• - Deformities (late stages)
• Swan Neck
• Ulnar Drift
• Boutonnière (buttonhole)
• Rheumatoid Nodules
• Vasculitis, Sjogrens Syndrome

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Diagnostic Tests

• Blood Tests
• - Rheumatoid Factor
• - Antinuclear Antibody Titer
• - Erythrocyte Sedimentation Rate
• - CBC WBC

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Diagnostic Tests

• Radiographic determines cartilage erosion, joint
  space narrowing, bone cysts
• - Arthrography- x-ray with contrast medium
• - Arthroscopy endoscopic exam of joint
• - Arthrocentesis needle aspiration of
• synovial fluid

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Nursing CareArthroscopy Post-procedure

• Assess Neurovascular status (Sx. of
  thrombophlebitis)
• Monitor for bleeding or leakage at site
• Assess for pain, edema, redness
• Ice for swelling, mild analgesic pain

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Pain Management

• Prescribed Drug Therapy on timely basis
• Rest periods
• Warm shower, hot packs
• Avoid sudden, jarring of joint
• Warn clients about quacks (miracle cures)

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Impaired Physical Mobility

• Exercise joint, but not beyond pain
• Positioning body alignment
• Support joints for optimal function
• Assistive Devices proper fit instruction

20
Self-care Deficit

• Routine that includes pacing activities
• Encourage sleep routine
• PT for conditioning
• Occupational Therapy Assistive devices

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Drug Therapy

• Salicylates (ASA)
• NSAIDs (Advil, Indocin, Toradol, naprosyn)
• Side effects/Precautions
• Tinnitus, GI distress, prolonged bleeding. Give
  with food, milk. Avoid anti-coagulants

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Drug Therapy

• Side effects/Precautions
• GI (do not crush enteric coated) give after
  meals or with food
• Dizziness, Diarrhea, headache, rash

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Drug Therapy

• Glucocorticoids (dexamethasone, hydrocortisone,
  prednisone.)
• Side Effects/Precautions
• Depression, euphoria, anorexia, nausea,
• weight gain, bruising. Taper dosage when
  discontinuing.

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Drug Therapy

• Slow-acting Antirmalirial drugs (plaquenil)
• Side Effects/Precautions
• Retinal edema, GI disturbance
• Toxic Gold Salts (solganol, myochrysine)
• Side Effects/Precautions
• Dizziness, flushing, metallic taste, skin rash
  assess CBC UA prior to administration

25
Drug Therapy

• Cytoxic Drugs (Methotrexate, Imuran, Cytoxan)
• Side Effects/Precautions
• Pneumocystis Carni pneumonia, mouth sores, bone
  marrow suppression, hepatotoxicity

26
Degenerative Joint Disease(Osteoarthritis)

• Non-inflammatory disease of the weight bearing
  joints (hips, knees, spine, hands)
• Incidence in post-menopausal women
• Risk Factors age, obesity, overuse of joints,
  trauma (fractures, sports injuries)

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Osteoarthritis

• Pathophysiology Articular cartilage becomes
  yellow opaque, joint space narrows, bone spurs
  (osteophyte), cysts
• Symptoms Joint pain / diminishes on rest
  crepitus (grating sensation) Joint enlargement,
  Herberdens nodes, Bouchards nodules, decrease
  ROM, joint effusion

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Osteoarthritis

• Diagnostic Tests X-rays of joints indicates
  narrowing of joint spaces CT Scan MRI of
  spine Bone Scan
• Differential features of RA DJD
• OVERHEAD Table 24-1

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Osteoarthritis

• Medical Management
• Drug therapy for pain (NSAIDs), muscle
  relaxants(Flexeril), injection of cortisone
• Rest immobilization with splint, brace, sleep
  (8 hours/night)
• Position of joints to maintain alignment avoid
  contractures
• Heat hot packs, PT diathermy
• Exercise walking, water aerobics

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Osteoarthritis

• Surgical Management
• Hemiarthroplasty one part of a joint is
  replaced, i.e. head of femur
• Total Hip replacement Head of femur the
  acetabulum replaced
• Total Knee replacement both articular surfaces
  of the knee replaced
• Interphalangeal joint replacement

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Total Hip Replacement

• Preoperative Care Skin preparation, IV
  antibiotics, education re nature of prosthesis,
  mobility restrictions, exercises
• Types of Prosthesis
• - Cemented 10 year life
• - Uncemented bone growth occurs into the
  metallic surfaces within 6-12 weeks

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THR - Postoperative

• Pain control
• Wound drain assessment
• Neurovascular Assessment
• Activity bed rest with abduction splint or
  pillow, OOB with PT (NO hip flexion 90) weight
  bearing dependent on type of prosthesis
• Use of walker crutches - cane

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THR - Potential Complication

• Thromboembolism
• Subluxation - Hip Dislocation
• Neurovascular Compromise
• Hemorrhage

34
THR Hip Precautions

• Avoid hip flexion 90
• Avoid low, soft chairs
• Avoid excessive trunk flexion in reaching
• Maintain hip adduction
• No leg crossing at knee
• Use raised toilet seat

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Total Knee Replacement

• Preoperative Care similar to THR
• Postoperative Care
• - Pain control
• - Wound drain assessment
• - Neurovascular Assessment
• - Elevate leg on Pillow for comfort
• - Head of bed elevated for comfort
• - Continuous Passive Motion Machine

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TKR - Potential Complications

• DVT pulmonary emboli
• Prosthetic Dislocation
• Infection

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Lupus Erythematous

• Definition Autoimmune disease involving diffuse
  inflammatory changes in vascular connective
  tissue
• Pathophysiology Antigen-antibody interactions
  results in deposits of immune complexes in
  tissues cells that damage the organs and or
  blood vessels

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Discoid Lupus

• Cutaneous manifestations butterfly
• rash on face
• Risk Factors Sun exposure intensifies
• Treatment Cortisone creams, sun screens 30
  SPF, avoid sun at peak hours

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Systemic Lupus

• Organs affected Heart, lungs, kidney, Brain,
  blood vessels, joints
• Systemic symptoms Fatigue, myalgia, joint pain,
  low grade fever, anorexia
• System specific symptoms Tachycardia, chest
  pain, poteinuria, hip knee necrosis, psychosis,
  seizures

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Laboratory Tests of SLE

• Skin biopsy scrapings of skin cells
• Immune tests RF, ANA, Sed Rate
• CBC (pancytopenia), Sed Rate, Cardiac Liver
  Enzymes

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Pharmacological Management Lupus

• NSAIDS
• Cortico-steroids
• Immunosuppresive Agents

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Nursing Care - Lupus

• Pain Management
• Encourage rest periods
• Decrease protein in diet (kidney involvement) and
  sodium restriction (fluid retention)
• Referral Local National Lupus Foundation

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Potential Complications Lupus Erythematous

• Vasculitis
• Cardiopulmonary pericarditis, pleural effusion
• CNS psychosis, seizures, peripheral
  neuropathies
• Avascular Necrosis

44
Gout

• Definition Systemic disease involving pain
  inflammation of joints due to urate crystal
  deposits
• Pathophysiology Inbalance of purine metabolism
  kidney function
• Incidence Middle aged men

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Types of Gout

• Primary Inherited defect in purine metabolism
• Secondary Disease i.e renal, diuretic therapy
  chemotherapeutic agents

46
Clinical Manifestations of Gout

• Asymptomatic phase Elevated Uric Acid
• Acute Phase Sustained elevated Uric Acid
  causing extremely painful, swollen, and reddened
  joint
• Chronic Phase Urate crystal deposits appear in
  cartilage, synovial membranes, tendons, soft
  tissues

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Drug Therapy - Gout

• Acute Phase Colchicine, NSAIDS
• Chronic Phase Allopurinol (Benemid)
• Colbenemid
• Avoid aspirin diuretics

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Diet Therapy - Gout

• Low purine (avoid organ meats, shellfish, oily
  fish with bones
• Avoid Alcohol
• Increase fluid intake to 3,000 cc/day
• High alkaline ash foods citrus fruits and
  juices, certain dairy products

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Other Connective Tissue Disorders

• Polymyalgia Rheumatica
• Anklosing Spongylitis (Marie-Strümpell Disease)
• Sjögrens syndrome
• Lymes Disease
• Fibromyalgia

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Osteoporosis

• Types
• Primary - Bone loss related to loss of estrogen
  in menopausal women and low testosterone levels
  in men
• Secondary Bone loss related to disease process
  (hyperthyroidism, renal failure, GI malabsorption
  problems

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Pathophysiology Bone Remodeling

• Resorption Worn out bone cells are removed by
  bone-resorbing cells called osteoclasts
• Formation New bone is laid down by bone-forming
  cells called osteoclasts

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Incidence/Risk FactorsOsteoporosis

• Age
• Race
• Gender
• Life Style
• Diet
• Heredity

53
Prevention of Osteoporosis

• Exercise weight bearing types
• Diet modifications
• Calcium intake OTC i.e. Tums, Oscal, Calcium
  carbonate, Dietary supplement

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Clinical ManifestationsOsteoporosis

• Height loss
• Vertebral deformities
• Restricted movement
• Back pain
• Fractures

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Diagnostic TestsOsteoporosis

• Laboratory serum calcium, Vitamin D,
  phosphorus, alkaline phosphatase
• Radiological X-ray, CT Scan, MRI
• - Dual energy x-ray absorptiometry

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Medical ManagementOsteoporosis

• Drug Therapy
• Estrogen replacement Premarin
• Calcium supplements
• Bone resorption inhibitor Fosamax
• Vitamin D

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Nursing ManagementOsteoporosis

• High Risk for Injury Prevention of falls and
  fractures
• - safe environment
• (non-skid slippers, shoes, clean spills, avoid
  scatter rugs, lighting, access to items for ADL,
  hand rails, Avoiding lifting heavy objects, use
  of walker, cane.)

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Nursing ManagementOsteoporosis

• Impaired Physical Mobility
• Increase mobility to level of independence in
  ADL
• Interventions
• - Physical therapy program (strengthening
  weight bearing exercises)
• - Occupational Therapy (Adaptive Devices)

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Nursing ManagementOsteoporosis

• Pain Management - Reduce alleviate pain
• Interventions
• - Drug Therapy - opiod, non-opiod Analgesics,
  muscle relaxants, Anti-inflammatory agents
• Use of heat
• Orthotic devices braces, splints

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Other Metabolic Degenerative Bone Disorders

• Osteomalcia
• Pagets Disease
• Herniated Nucleus Pulposus
• - Laminectomy
• - Spinal Fusions

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Fractures

• Definition Interruption in normal bone
  continuity, which is accompanied by soft tissue
  injury
• Classification
• - Simple or closed
• - Open or compound

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Fracture Patterns

• Oblique Line of Fx. Angled
• Transverse Across the bone
• Longitudinal Length of bone
• Spiral Twisting or rotation of bone
• Comminuted broken in 2 places
• Impacted Fragments driven into each other
• Displaced or Avulsed torn away by a ligament or
  tendon

63
Classification by Anatomical Location

• Humerus
• Tibia, Fibula
• Pelvis
• Hip
• Skull
• Mandible
• Ribs
• Vertebrae

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Stages of Bone Healing

• Hematoma
• Granulation
• Callus Formation
• Osteoblastic Proliferation
• Bone Remodeling
• Complete Healing

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Bone Healing Problems

• Delayed Union - 6 months to a year
• Nonunion -
• Malunion Bone healed in state of deformity

66
Assessment of Fractures

• Subjective Data History, complaints of pain,
  loss of sensation, movement
• Objective Data Warmth, edema, ecchymosis,
  neurovascular impairment, splinting, anxiety, fear

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Emergency Care

• Inspect area
• Control bleeding
• Immobilize/splint
• Prevent shock
• Transport safely to ER

68
Nursing Diagnoses

• Acute Pain
• Risk for Neurovascular Dysfunction
• Risk for Infection
• Altered Mobility
• Activity Intolerance

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Complications of Fractures

• Shock
• Neurovascular Compromise
• DVT Pulmonary Emboli
• Aseptic Necrosis
• Acute Compartment Syndrome
• Fat Embolism Syndrome
• Osteomyelitis

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Shock

• Etiology Hemorrhage into damaged tissues,
  especially thorax, pelvis, extremities
• Treatment Control bleeding and restore blood
  volume

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Neurovascular Compromise

• Etiology Damage to nerves from fragments of
  bone, pressure from casts, splints, traction
• Treatment 6 Ps Pain, Pulslessness,
  Paresthesia, Pallor, Paralysis, Poikothermia

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Fat Embolism Syndrome

• Etiology Release of particles of fat into the
  blood stream from the yellow marrow at site of
  injury
• Risk Factors Fx. of long bones, multiple fx.,
  high serum glucose or cholesterol level

73
DVT Pulmonary Emboli

• Etiology Immobility, trauma, surgery
• Risk Factors Incidence in fractures of the lower
  extremities Smoking, obesity, Heart Disease
• Treatment Anticoagulants

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Avascular Necrosis

• Etiology Loss of blood supply to bone
• Risk Factors Hip fractures or any fracture where
  this bone displacement
• Treatment Surgical joint replacement

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Compartment Syndrome

• Etiology Massive compromise in circulation from
  external (Tight, bulky dressings, casts)
  internal (blood fluid)
• Treatment Immediately loosen any tight
  dressings MD can bivalve cast
• Surgery Decompression fasciotomy for edema and
  bleeding

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Osteomyelitis

• Acute infection in another part of the body
  invades bone tissue or occurs from penetrating
  trauma
• Chronic Infection persists especially in a
  patient with compromised circulation

77
Medical Management of Fractures

• Closed Reduction immobilization Manual
  traction to align the bone
• External Fixation Percutaneous placement of
  pins implanted into bone
• - Kronner 4-Barr Compression Frame
• - Hex-Fix External device for tibial fractures
• - Halo Traction Cervical spinal fractures

78
Nursing Care External Fixation

• Teach patient patient to grasp frame when moving,
  rather than limb
• Frequent observation neurovascular assessments
• Pin Care Note symptoms of infection
• Assess for loosening or shifting of devices

79
Casts

• Purpose Immobilze, correct deformity, allow
  early mobility, provide support protection
• Types Plaster of Paris Fiberglass

80
Plaster Cast Care

• Instruct that cast will feel warm
• Handle cast with palms of hands
• Turn client q 1-2 hours for drying
• Elevate on pillow î than heart
• Pedal rough edges with moleskin
• Inspect q 4-8 hours drainage, cracking, odor,
  alignment fit

81
Cast Complications

• Circulatory impairment
• Peripheral nerve damage
• Impaired skin integrity
• Pneumonia, DVT, Constipation
• Compartment Syndrome
• Cast Syndrome Body cast
• Fracture blisters

82
Traction

• Definition Pulling force that is applied to part
  of an extremity while a counter traction pulls in
  the opposite direction
• Purpose Reduce Fracture, immobilize, decrease
  pain muscle spasm, correct deformities, stretch
  tight muscles

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Types of Traction

• Continuous or Running Bucks, Russell
• Circumferential Pelvic
• Cervical
• Suspension or Balanced Thomas Ring
• Skeletal Steinmann pins, Kirschner wires,
  Crutchfield tongs

84
Nursing Assessment

• Equipment weights, pulleys, ropes, Balkan
  frame
• Mobility
• Skin integrity
• Neurovascular
• Gastrointestinal
• Urinary

85
Fractured Hip

• Incidence Prevalent women 65 200,000
  annually by age 80 1 in 5
• Risk Factors Falls, osteoporosis, age related
  changes in balance

86
Anatomy of Hip

• Head of femur
• Acetabulum
• Femoral neck
• Greater trochanter
• Lesser or sub-trochanter

87
Types of Hip Fractures

• Femoral Neck displaced, impacted, comminuted
• Intertrochanteric (Intracapsular, Extracapsular)
• Subtrochanteric

88
Signs Symptoms of Hip Fractures

• Pain hip or thigh
• Adduction, external rotation
• Shortening of leg
• Inability to move or bear weight

89
Surgical Intervention

• Total Hip Arthroplasty
• - Cemented allows full weight bearing
• - Uncemented Full weight bearing not
  permitted for 6-8 weeks
• ORIF Intramedullay rods, plates, compression
  screws allows early ambulation

90
Post-operative Care - ORIF

• Bedrest 1st day OOB with walker
• HOB î 35 - 40
• Avoid hip flexion 90
• Trochanter roll for hip alignment
• Pillow splint when turning (per MD)
• Isometric exercises
• Pain control narcotic analgesics

91
Complications ORIF

• DVT, PE
• Hemorrhage
• Infection
• Subluxation or dislocation

92
Carpal Tunnel Syndrome

• Definition compression of the medial nerve in
  the wrist
• Etiology Repetitive motions, wear tear,
  Fracture of wrist
• Symptoms Pain, paresthesia, difficulty in
  grasping

93
Diagnostic Tests CTS

• Phalens wrist flexed back to back results in
  paresthesia 60 seconds
• Tinels Tapping over the median nerve pain,
  tingling, numbness or inflating a BP cuff will
  result in same SX.
• X-ray
• EMG

94
Interventions CTS

• Non-invasive wrist support, immobilization with
  splint, frequent breaks, cushion grippers on
  pencils pens, Rest, Ice, Heat,
  Anti-inflammatory agents
• Invasive Cortisone Injections, Surgery