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yanira
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chapter 64
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  1. Osteomyelitis
    is a severe infection of the bone, bone marrow, and surrounding soft tissue
  2. What the common microorganism that causes osteomylelitis
    • Staphylococcus aureus is the main cause for this infection
    • Aerobic gram negative bacteria alone or mixed with gram positive organism are often found
  3. The area of devitalized bone eventually seperates from the surrounding living bone, roming sequestra, the part of the periosteum that continues to have a blood supply forms new bone called involucrum
  4. How can sequestra be removed
    • The sequestrum can move out of the bone and into the soft tissues and may be revascularize and then undergo removal by normal immune response process
    • Or it can be surgically removed through debridement of necrotic bone
  5. Acute osteomyelitis...how long does it occur for and what are the symptoms
    • It can last for 1month or less
    • Systemic includes fever, night sweats, chills, restlessness, nausea, and malaise
    • Local includes cnstant bone pain that is not relieve by rest and worsen by activity, swelling, tenderness, and warmth
  6. rHow can Osteomyelitis be tested/diagnose
    • Bone or soft tissue biopsy
    • Blood ir wound culture
    • Elevated WBC and ESR
    • Radiologic signs after 10days-1 week
    • Radionuclitide bone scans (gallium and indium) are helpful
    • MRI and CT scan are helpul to see the extent of damge
  7. Collaboratiave care for Osteomyelitis
    • IV antibiotic are usually give, it can take up to 4-6wks-36monhs
    • For chronic infection antibiotics may be given orally for 6-8 weeks or after IV is comleted (Cipro)
    • -protection of the limb or surgical site wit a casts or brace
    • -negative pressure Wound VAC to drawn wound together
    • -Hyperbaric O2 therapy with 100% O2
    • -Amputation
    • -Bone graft
  8. The patient wth osteomyelitis should avoid exercise and heat applications becuase they can increase swelling and circulation and serve as stimuli to the spread of infection
  9. Signs of toxicity after prolonged intake of antibiotics?
    • hearing deficit
    • fluid retention
    • neurotoxicity (with aminoglycosides....tobramycin, neomycin
    • jaundice
    • colitis
    • photosensitivity rom cephalosporins (cefazolin)
  10. Lengthy use of antibiotics can result in the overgrowth of ___________?
    Candida albicans
  11. Bone cancer....sarcomas
  12. Osteochondroma-characteritics and diagnoses
    • its a benign bome tumor that is characterized by an overgrowth of cartilage and bone near the end of the bone at the growth plate...usually found in the long bones of the legs, pelvis, and scapula
    • hereditary with multiple tumors forming beore age 10yrs....up 10-25
    • -Diagose with x-day,ct scan and MRI
    • usually the person does not feel pain uneless if the tumor is touching muscle,one limb longer than the other
  13. Osteogenic sarcoma
    • its a primary bone tumor that is extremly aggresive amd rapidly metastasizes to distant sites (usually lungs), usually occurs in the metaphyseal region
    • affects young childrem amd adults and older adults age 60 associated with pagets disease
    • Diagnose with biopsied, x ray, PET
    • increase levels of alkaline phosphate and calcium are found
    • Treatment
    • surgery
    • chemo
    • amputation
  14. Warning signs of bone cancer
    • swelling
    • bone pain of unexplained origin
    • limitation of joint function
    • changes in skin temp
  15. Muscle dystrophy
    • its the wasing of muscle and inherited
    • genitic mutation of dystrophin gene
    • Diagnostic test inclide serum enzymes such as creatine kinase
    • electromyogram
    • muscle myopathy
    • genic pedrigree
    • biopsy
    • Treatment
    • no treatment to stop it completely but u can delay it by
    • corticosteroids therapy halts disease up tp 3yrs
    • preserving mobility and exercise
    • nutrition
  16. Low back pain
    its reasons for causing pain
    • -second most complian of besides headaches
    • -lumbar regionbears most of the weight
    • -is the most flexible region f the spinal column
    • contains nerveroots
    • has an inherently poor biochemical structure
    • -risk are smoking, muscle tone and posture, seating a lot, excess body weight, repetitive lifting
    • diagnoses
    • straight leg test
    • mri AND cT SCANS
  17. Whats the Charite disk for
    its used in patients wit disk damage associated with DDD. This artiical is ade up of high density core snadwiched between two cobalt chromium endplates
  18. Nursing management after spinal surgery
    • Proper alignment of the spine at all times until healing has
    • Logrolling patient-pillows can be used under the thighs of each leg when supine and between legs in between the legs when in side laying
    • Opioids medication administration such as morphine through IV oral medication such as acetaminophen
    • Look out for CSF
    • Assess the clients pheripheral neurologic every 2-4hrs...
    • assess extremities ...color, temp, capillary refill, pulse, parathesias-this may not be relieve right after surgery
    • Paralytic ileus
    • monitor I&Ocheck if there is incontinence or retention it can indicate a problem
  19. After surgery the client is given IV and oral medications name 1 IV and 5 oral med
    • Morphine is an IV medication
    • If fluids are being taken the client client can switch to oral medications such as
    • acetaminophen with codeine
    • hydrocodone (Vicodin)
    • oxycodone ( Percocet)
    • diazepam (Valium) for muscle relaxant
  20. Because there is a potential CSF leakage what should you monitor and report
    • Severe headache
    • Leakage of CSF is slightly clear or yellow and it should not appear in dressing, if u want to make a dipstick test, positive glucose appears
  21. Bone graft
    Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly.
  22. Neck pain
    there is benign neck pain caused by poor posture, every day activities, prolonged sitting, positioning....or serious from trauma

    It can be treated with surgery but if done in cervical spine the nurse must be aware of signs of resp distress and worsening of neurologic status of the upper extremities
  23. Foot disorders
    • Foot disorder can be caused by
    • Congenital conditions
    • structural weakness
    • traumatic injuries
    • systemic conditions such as diabetes and RA
    • improper shoes
    • Hallox valgus (bunion)
  24. Interventions with foot problems
    • teach the client the important of wearing proper shoes...heel must not be greater than 1 in
    • NSAIDs , shoke wave therapy, icing, physical therapy, alterationsin foot wear, stretching, warm soaks, orthotics, ultrasound, and corticosteroid injections
  25. Whats the proper terminology for bunion
    Hallux Valgus
  26. What are the 3 metbolic bone disease
    • Osteomalacia
    • Osteoporosis
    • Pagets disease
  27. What is osteomealacia
    • its the softening of the bones do to deficiency of vitamin D resulting in decalcification and softening of the bones
    • -signs are low back pain and bone pain
    • muscular weakness especially in the pelvic girdle
    • weight loss
    • deformity of back ex.kyphosis
    • delayed healing up to 2-3 months insetead of 6-10days of minralization
    • LAB
    • decreased serum calcium and phosphorus levels
    • increased serum alkaline phosphate
  28. Treatment of osteomalacia
    signs and symptoms
    labs
    diet
    • Correcting Vitamin D...patient is given Vitamin D3 (cholecalciferol) D4 (ergocalciferol)
    • calcium salts and phosphorus
    • dietary ingestion such as
    • eggs, low fat milk, fish, veges
    • exposure to sunlight
  29. Reason why can someone develop osteomalacia
    • lack of exposure to ultraviolet rays
    • GI malabsorption
    • extensive burning
    • chronic diarrhea
    • pregnancy
    • kidney disease
    • Dilatin drugs (antiseizure)
  30. Osteoporosis
    • more common in woman 8 X higher
    • - is a chronic progressive metabolic bone disease characterized by low bone mass and structural deteroration of bone tissue, leading to increased bone fragility
    • called the silent thief because it slowl steals skeletol resources throguh out the yrs
  31. When should screening for osteoporosis begin
    should begin at age 60 and 65 and older should routinely check
  32. Reason why osteoporosis is higher among woman
    • woman tend to intake calcium less than men
    • bone mass frame is smaller than males
    • bone resorption begins in earlier age and accelerated in menapause
    • pregnancy and breastfeeding unless taking calcium supplements
  33. Risk for developing osteoporosis
    • advanced age
    • asian or caucasian
    • female
    • diet wth los calcium intake
    • excessive use of alcohol
    • smoking
    • inactive life style
    • long term used of corticosteroids, thyroid replacement, heparin, long acting sedatives antiseizures drugs
    • anorexia,bulimia
    • malabsorption
    • chronic liver
    • excessive caffeine
    • low testosterone
  34. -the problem with osteoporosis is when bone resorption exceeds bone deposition
  35. Medications that interfere with bone metabolism are
    • Valproate (Depakote
    • Phenytoin (Dilatin)
    • Aluminium containing antaacids
    • Heparin
    • Certain cancer treatment
    • Excissive thyroid hormones
    • Cortecosteroids
  36. Signs and Diagnostic test for osteoporosis
    • symptoms back pain, loss of height, spinal deformities such as kyphosis
    • Diagnose
    • X-ray but till 25-40% is lost
    • QUS quantitive ultrasound measure bone density
    • ....ultrasound in heel, kneecap, or shin
    • DEXA Dual energy xray...measures bone density in spine, hips, forearm, used to see effectiveness of treatment
    • T scores of 2.5 or less not good 1.0-2.5 osteopenia
  37. How much calcium should a woman be taken
    • Premenapausal and postmenapausal taking estrogen should take 1000mg/day and postmenapausal nottaking estrogen should take 1500mg/day
    • -this help inhib bone loss but it does not produce new bone
  38. How much vitamin D
    • Being in the sun 20min/day is good
    • 400/800 IU for older adults
  39. What exercises would u reccomend a person to build up bone
    • exercise increases bone mass and build up muscle for strenght
    • walking, hiking , weight training, stair climbing, tennis, dancing...anything that does not put to much stress to bones such as high impact aerobic...running
    • walking 30min 3X a week is good
  40. Estrogen is believed to prevent osteoporosis by inhibiting osteoclast acitivity
  41. Medication for osteoporosis
    -what are the side affects of this medications
    -instructions to tell client
    • Bisphosphonates
    • aledronate (Fosamax)
    • -available once a week
    • raloxifene (Evista)
    • Estrogen therapy
    • Salmon calcitonin (calcimar)
    • ibandronate (Boniva)
    • tiludronate (Skelid)
    • pamidronate (Aredia)
    • Teriparatide (Forteo)
    • raloxifine (Evista)
    • -this medications inhibit osteoclast mediated bone resorption increasing BMD by 5%
    • side effects- anorexia, weight loss, and gastritis
    • Instruct the client to take medication with a full glass of water and take it 30min before food and other medication
    • remain upright or at least 30min after taking
  42. What is Salmon calcitonin (Calcimar)
    • calcitonin is secreted by the thyroid gland and inhibits osteoclastic bone resorption
    • Salmon calcitonin (Calcimar) is available in IM, SQ, and Intranasal
    • -it has been shown that administration of this drug reduce side affects of nausea and facial flushing.....intranasal does not produce nausea
  43. What does raloxifene (Evista)do and or what disease
    • Its a selective estrogen receptor modulators ...it mimics the effect of estrogen on bone by reducing bone resorption without stimulating the tissue of the brest amd uterus
    • side affects are leg cramps and hot flashes
  44. -Soy milk is better and more used instead of estrogen therapy for osteoporosis
  45. Teriparatide (Forteo)
    • treatment of osteoporosis in men and woman who are at high risk for having a fracture
    • - this medications worlks like the parathyroid hormone PTH by increasing osteoblast action
    • -side effect cramps and dizziness
    • -given once daily by SQ
    • - if used for more than 2yrs it can cause osteosarcoma
  46. make sure an arthroscopy is not performed while the client as an infection
  47. Bone scans-explain
    • radionuclide is used sych as gallium or thallium
    • its injected 4-6hrs before scanning
    • takes 30-60min so instruct client to stay still
    • -osteomyelitis, osteoporosis, bone cancer
    • -encourage the client to intake lots fluid to flush out
  48. DEXA Dual energy xray absorptiometry
    • meause bone mass in the wrist hip and spine, femur
    • used to diagnose osteropororis or postmenapausal state or monitor changes with treatment
  49. EMG Electromyogram
    thin needes are placed in the muscke understudy and attached to an electrode

    • Potential diagnoses
    • Lower neuron disease such as amyotropic latera sclerosis, myasthenia gravis, carpal tunnel, guillian barre

    • make sure the client does notconsume any caffeine and no sedatives administration for 24hrs before procedure
    • -if the client is taking any anticougulant or muscle relaxants then its contraindicated
    • sign consent form
  50. Arthroplasty surgery
    • its usuall performed to client to eliminate pain, restore joint motion, imrove the client quality life and uctional status
    • Labs should be monitor before procedure such as CBC, urinalysis, BUN, Creatine,
    • Chest x ray to rule out pulmonary surgical contraindication infection tumor
    • ECG- dysrhythmias are contraindicated
  51. At what levels are blood transfussion used
    • if levels are less than 9g/dl
    • -after surgery Hcg and Hct continues to drop for 24-48hrs
  52. -artificial joint last up 10-20yrs
  53. Drugs that are usually given for surgery on anthroplasty
    • Anagelsics- opiods, epidural, PCA, IV, oral
    • Antibiotics-prophylaxis and postoperatively
    • Anticougants- aspirin, low molecular heparin such as enopraxin (lovenox); warfarin (coumadin)
  54. What postition should the client be at for hip replacement
    • after surgery the client should be in supine position and pillows are to be between legs abduccting legs and while turning
    • seat, toilets should be elevated
    • externally rotate toes not internally
  55. DVT signs
    • pain in calf
    • swelling
    • redness
  56. signs of pumonary embolism
    • shorteness of breath, chest pain, and bleeding if the client is taking anticougulants
    • in other word dyspnea, tachycardia, and pleuritic chest pain
  57. Warfarin Coumadin
    Warfarin (also known under the brand names Coumadin, Jantoven, Marevan, Lawarin, Waran, and Warfant) is an anticoagulant. It is most likely to be the drug popularly referred to as a "blood thinner," yet this is a misnomer, since it does not affect the thickness or viscosity of blood. Instead, it acts on the liver to decrease the quantity of a few key proteins in blood that allow blood to clot
  58. Thus, common clinical indications for warfarin use are atrial fibrillation, the presence of artificial heart valves, deep venous thrombosis, and pulmonary embolism (where the embolized clots first form in veins).
  59. Normal Platelet count
  60. Levels of PT thrombin tme and INR
  61. Coumadin can reduce bone density
  62. Contraindication for anticougulants
    • liver and renal failure
    • hemophillia
    • thrombocytopenia
    • a dificiency of protein C
    • taking omega 3 oilin which it decreases clotting as well
    • NSAIDs
    • GI bleeding
  63. NSAIDs mechanism and aspirin
    • NSAIDs work on a chemical level. They block the effects of special enzymes -- specifically Cox-1 and Cox-2 enzymes. These enzymes play a key role in making prostaglandins. By blocking the Cox enzymes, NSAIDs stop your body from making as many prostaglandins. This means less swelling and less pain.
    • -aspirin is a type of NSAIDs but it has an advantage that it can work as a blood cloth inhibitor as well

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