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What is bone resorption?
It is the breakdown of bones by osteoclasts
What happens to inactive bones?
osteoclasts breakdown the bone causing bone resorption
internal visualization of joints
What are indications a person needs arthoscopy of a joint?
- Pt. has:
- joint swelling
- joint instability
Pre-procedure nursing actions for a person having arthroscopic surgery.
- teach post procedure exercises or
- refer to PT
- ensure pt. has signed consent
- reinforce explanation of the procedure
Post-Procedure nursing actions for a person having arthroscopic surgery.
- It's done on outpatient basis
- Assess neuro status
- Assess dressing of limb-CSM
- Teach pt to ice and elevate the extremity
- Teach pt. to take PRN analgesics
When should a person who had arthroscopic surgery be taught to call their Dr.?
- excessive swelling
- increased joint pain
Complications of orthoscopic surgery
Infection...notify Dr. immediately of swelling, redness or fever
What does Radionucleotide bone scan dx?
How's it done?
Mainly hairline bone fx but also....
2-3 hrs before scan radioactive materials injected in to pt.
What are Gallium and Thallium scans used to detect?
How does it work?
dx diseases of brain, liver, bone cancer and breast cancer, arthritis, fractures
Radionucleotides are injected in to the patient 4-6 hrs before scanning. The radioisotope migrates toward the above mentioned tissues
What would a person complain of to warrant a Gallium or Thallium scan?
Pre-procedure of a Gallium or Thallium Scan
- Assess for allergy to radioisotope
- **Kidney Disease
How long does a Gallium and Thallium scan take? What are some issues?
- 30-60 minutes and they must hold still....so may be sedated.
- Empty your bladder!!!
What's important post procedure for a Gallium and Thallium scan?
Drink lots of fluids to excrete radioisotope in urine and feces
What does Dual X ray Absorptiometry and Nerve Conduction study dx?
Clients are give a score that relates their amount of bone density to that of other people in their age group and gender
Why would a person get a Dual X Ray Absorptiometry?
- Baseline postmenopausal (40 yo)
- Loss of height?
- Bone pain?
What does an Electromyography (EMG) test dx?
- Myasthenia Gravis
- Guillian Barre
- Carpel Tunnel
- Neuromuscular Disorders
thin needles are placed in the muscle and attached to electrodes. Electrical activity is recorded during a muscle contraction.
What is contraindicated for a patient receiving an EMG?
anticoagulants and muscle relaxers
How does a nerve study work?
tape flat electrodes to the skin and shoot a low electrical current through them and the muscle will respond
EMG and Nerve conduction studies are done together....which one goes first?
Nerve conduction study
Complications of osteoperosis
- Persistent pain
- Posture changes that restrict client activities and ability to perform ADL's
What's compartment syndrome?
when pressure within one or more of the muscle compartments of an extremity compromises circulation, resulting in ischemia-edema cycle
What happens with a person who has compartment syndrome?
edema will occur that will reduce blood flow to the area and cause ischemia and compromising neurovascular status.....NECROSIS
How does a person logistically get compartment syndrome?
- tight cast
- constrictive, bulky dressing
- internal source-accumulation of blood or fluid within the muscle compartment
Clinical manifestations of compartment syndrome
- 5 P's....
How fast can neuromuscular damage occur?
How do you treat compartment syndrome?
- Fasciotomy to relieve pressure
- Loosen dressings
- Teach pt to report tingly, numbness
Who's at the greatest risk for a fat embolism?
Adults 70-80 y/o
Person with hip or pelvis fx
When do fat embolisms usually occur? Where?
usually within 48 hrs following long bone fx or with total joint arthroplasty.
How do fat embolisms occur?
fat globules from the bone marrow are released into the vasculature and travel to the sm. blood vessels (lung) resulting in acute respiratory insufficiency and organ perfusion
Clinical manifestations of Fat Embolism
- Chest pain
- Decreased O2 sat
- Decreased mental status
- Resp. Distress
Early sign of a fat embolism?
Late sign of a fat embolism?
Early-decreased mental acquity (low ABG)
Late-cutaneous petachie on neck, chest, upper arms and abdomen
Nursing actions for a person with a fat embolism
- Stay in bed
- Admin. corticosteroids for edema and vasopressors
- Fluid replacement
- Pain management
Nursing actions to prevent a DVT
- admin anticoagulants
- encourage fluids
- perform ROM
an infection of the bone that begins as an inflammation within the bone secondary to penetration by infectious organism following trauma or surgery
What's avascular necrosis?
when after a fx a person has circulatory compromise which results in ischemia and leads to tissue/bone necrosis
Who's at risk for having an Avascular Necrosis problem?
person on long term corticosteroids
How do you treat Avascular Necrosis?
replace the damaged bone with a bone graft or prosthesis
What's "Delayed Union"?
when a fracture hasn't healed after 6 months of the injury....seen mostly in older adults
Malunion...fx heals incorrectly
Nonunion...fx that never heals
- Blood loss requiring transfusion
- Cardiac complications
- Systemic complications-pneumonia, renal failure, stroke and sepsis
Describe a local infection after amputation
- Positive wound culture
- Increased discomfort at suture line
Describe a systemic infection after amputation
- FEVER, CHILLS
- INCREASED HR
- DECREASED BP
- Delayed wound healing
What causes delayed wound healing?
- Poor or inadequate nutrition
- Poor blood flow....related to smoking?
- Decreased cardiac output limiting circulation
How is phantom limb pain treated?
send to a pain clinic for pain management
What a contracture and what are my interventions?
abnormal flexion and fixation of a joint caused by muscle atrophy and shortening
Active and Passive ROM exercises and teach pt to avoid long periods of sitting
Who commonly gets contractures?
Above the knee amputee
Describe collaborative management for osteomalacia
- Correct V. D deficiency by.....
- sunlight exposure
- wt bearing exercise
Examples of foods to eat to increase V. D.
- oily fish
- breakfast cereal Fortified with calcium and V. D
- loss of bone mass
- increased bone fragility
- increased risk for fx
It is an imbalance of processes that influence bone growth and maintenance associated with aging
What disorders can also cause osteoporosis?
endocrine and malignancies
Most common sites for osteoperosis
Patho of osteoperosis
- the diameter of bone increases....
- thinning supportive cortex....
- causing loss of trabeculae and thinning of outer cortex.....
Result-minimal stress leads to fx
Manifestations of osteoporosis..."the silent disease"
- loss of height
- progressive curvature of the spine
- low back pain
- fx of forearm, spine or hip
Examples of spine curvatures....names
- dorasal kyphosis
- cervical lordosis
- dowager's hump
Risk factors for osteoperosis
- Small framed women
- Pregnancy and breast feeding
Risk of developing osteoporosis depends on the amount of bone mass achieved btwn ages
Endocrine disorders that cause osteoporosis
- Cushings Syndrome
Name modifiable risk factors for osteoporosis that we can manipulate
- Calcium supplements
- Estrogen replacement
- Stop smoking cigarettes
- Stop drinking alcohol excessively
What are specific meds that cause osteoporosis
- prolonged heparin therapy
seen in older persons and women past menopause in which bone loss is accelerated over that predicted for their age and sex
results from a variety of identifiable conditions...drugs, hormones
Collaborative care for a patient with Osteoporosis
- Stop or slow down osteoporosis
- Alleviate symptoms
- Prevent complications
Estrogen therapy for osteoporosis....how does it work?
Recommended for who?
reduces bone loss, increases bone density in spine and hip, reducing risk of fractures in postmenopausal women
Recommended for women who have undergone surgical menopause before age 50
Hormone replacement therapy consists of estrogen and progestin and is associated with increased risk for CV disease and BREAST and UTERINE CANCER
Name the estrogen replacement therapy drug.
- hot flashes
- leg cramps
- blood clots
What's the name of the IV infusion that can prevent osteoporosis for 2 years after a single infusion?
- Flu symptoms for the first few days following admin.
- Precaution with taking biphosphonates
What are you precautions when taking a Biphosphonate?
- Take with a full class of water
- Take 30 minutes before food or other meds
- MUST remain upright for at least 30 min after taking!!!!
How do you give Miacalcin for Osteoporosis?
IM, Subq or intranasal
Intranasal....alternate nostrils and watch for dryness
IM and Subq....give at night to decrease side effect of nausea and facial flushing
Who gets Forteo for Osteoporosis?
Men and women at risk for fx
- Subq injection 1/day
- Side effects-leg cramps and dizziness
- If you use for more than 2 years you will have an increase for osteosarcoma
What's nursing care for osteoporosis?
Prevent and educate those under age 35
Prevent complications in those with disease
Amt. of calcium supplements for each age....
- 19-50 y/o- 1000mg
- 51-65 y/o-1200mg
- 65+ y/o-1500 mg
Two drinks that cause osteoporosis
- caffeine....limit coffee to 2-3 cups /day
- Diet soda
infection of the bone or bone marrow...acute or chronic
How do you get osteomyelitis?
Infection from the blood, local infection like cellulitus or trauma including joint replacement or internal fixation of a fx
- leukocytes engulf the organism and they release enzymes that lyse the bone....
- pus spreads to bones blood vessels impairing blood flow....
- absess is formed....
- body tries to create new bone around area of necrosis....
Constant bone pain, warmth and swelling
Local-pain that is unrelieved by rest and worsens with activity....signs of drainage from the signs tract to the skin and fracture site.
Dx for Osteomyelitis
- X ray
- Bone Scan
- Biopsy of soft tissue or bone
Management for chronic osteomyelitis
- Prolonged antibiotic therapy for 6-8 weeks
- (fluoroquinolones) in a PICC line
- Wound vac
- Pain Management
- HBO Therapy
- Sterile dressing change
Management for acute osteomyelitis
- Prolonged antibiotic treatment for 4-6 weeks in a PICC line
- Immobilize joint, body part
- Prevent/Correct further deformities
What's the purpose of traction?
- Prevent or reduce muscle spasms
- Immobilization of a joint/body part
- Reduce fracture or dislocation
- Realignment of bone fragments
- Prevent or correct further deformities
How is traction set up?
- Alignment at the DISTAL fragment to the PROXIMAL fragment
- Remains constant
- Allows for adequate exercise, movement and diversion
Important details to monitor when you have a patient in traction
- Monitor skin integrity and pin sites for infection...including under bandaids
- Monitor neurovascular....CSM
- Keep in mind hazards of immobility
How often do you reposition a person in traction?
When do you notify the provider if you have a client in traction?
when the patient experiences severe pain from muscle spasms and its unrelieved with meds and/or repositioning.
Keep in mind when an older person has a cast that....
they have an increased risk for impaired skin integrity due to the loss of elasticity of the skin and decreased sensation.
Especially lower extremities
How can a person with a cast relieve the itching?
by blowing cool air from a hair dryer under the cast
2 causes of amputation
- Trauma is a major cause of upper extremity amputation
amputation performed through a joint
What's a syme amputation?
the removal of a foot with the ankle saved
this is done when an active infection is present. The wound remains open to drain and the skin flap is closed at a later date
Closed Flap amputation
When the wound is closed with the flap of skin sutured in place over the stump to create a weight bearing residual limp or stump
Why are older adults poor candidates for prosthetic training?
Cuz it requires a lot of energy to use for ambulation
Goal of amputation surgery:
- Preserve length and function of extremity
- Remove all infection, pathologic or ischemic tissue
- Improve possibility of good prosthetic, cosmetic and function satisfaction
What determines where the amputation is done?
Name diagnostic procedures....
it is determined by level at which there is adequate blood flow for healing.
- Dopler laser
- Transcutanous oxygen pressure (TcPO2)
- Ankle Brachial Index
Pre Op care for an amputee.
- Mostly done for those that have time...
- Strengthen upper body
- Improve Nutritional status
- Stabilize chronic medical conditions
- Mt. with Prosthetic Specialist
Care for a person with a residual limb leg amputation
- Watch for irritation/infections
- D/c use of prosthesis if stumps irritated
- Wash residual limb each night with warm water and bacteriostatic soap. Rinse thoroughly and dry gently.
- Expose stump to air for 20 min.
- No LOTIONS, ALCOHOL, POWDERS
- Wear only residual limb sock and change daily
- Pain Management
- ROM exercises
What don't you do with a residual limb?
Elevate on a pillow....lay prone with hip in extension for 30 minutes 3-4 xs daily
Osteomalacia vs. Osteoporosis
osteomalacia is a defect in bone building and osteoporosis is a weakness of existing bones
osteomalacia in kids is called....
Side effects of just estrogen replacement
Side effects of estrogen and progestin replacement
estrogen and progestin-cv disease, breast and uterine cancer
Why would a person receive estrogen and progestin
because they haven't had their uterus removed
Main side effect of Biphosphonates
Who receives Prolia?
postmenopausal women with osteoporosis at high risk for fractures
subcutaneous injection every 6 months
How do you know it is chronic osteomyelitis?
they have had an infection in the bone for more than 1 month and it hasn't responded to antibiotic therapy
How do you know it is acute osteomyelitis?
because they will have pain in the bone that is unrelieved by rest and worsens with activity