Download - 1 Orthopedic System Alteration in Mobility Integumentary System Med/Surg I, Module 4 Part 1 of 4
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Orthopedic SystemAlteration in MobilityIntegumentary System
Med/Surg I, Module 4Part 1 of 4
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Chronic Musculoskeletal Conditions
Curvature of the Spine Osteoporosis Osteomyelitis Osteoarthritis
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Curvature of the SpineKyphosis (left) and Lordosis (right)
KyphosisSource: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center.http://medicine.ucsd.edu/clinicalimg/thorax-kyphosis.html
LordosisSource: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center.http://medicine.ucsd.edu/clinicalimg/thorax-kyphosis.html
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Scoliosis
Source: Wikimedia Commons, Public Domainhttp://commons.wikimedia.org/wiki/Category:Orthosis
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Osteoporosis
Increased Risk Family history Female Menopause-related low
estrogen females, low testosterone males
Medications Lifestyle
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Osteoporosis
Prevention Diet Calcium supplements Stop smoking Alcohol and caffeine intake weight-bearing exercise Sunlight
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Osteoporosis
Diagnosis Dual-energy x-ray
absorptiometry (DEXA) scan Qualitative ultrasound (QUS)
of heel or calcaneus
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OsteoporosisCollaborative Management Replace estrogen or testosterone Raloxifene (Evista) Biphosphonates: Alendronate
(Fosamax) and risedronate (Actonel) Teriparatide (Forteo) Ibandronate sodium (Boniva) Calcitonin (Miacalcin) Sodium fluoride
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Osteoporosis
Nursing Care Prevent falls Treat pain Orthotic devices Refer to physical therapy Range of motion exercises
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Osteomyelitis
Local swelling Redness Tenderness Pain Fever Bone pain Source: UCSD Catalog of Clinical Images, Photographs by Charlie
Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California, 92093-0611http://medicine.ucsd.edu/clinicalimg/extremities-Toe-Osteo.htmlhttp://medicine.ucsd.edu/clinicalimg/extremities-osteomyelitis.html
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Diagnosis
Bone scan Biopsy MRI, CT or ultrasound: fluid
collection, abscess, periosteal thickening
Elevated WBC, positive blood cultures
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Collaborative Care Surgical debridement is the primary treatment Postoperative care: wound irrigation with
strict sterile technique; monitor site for signs of infection, monitor temperature and WBC
Most cases caused by Staphylococcus aureus: Parenteral antibiotics based on wound, blood
cultures for 4-6 weeks or Oral twice-daily ciprofloxacin if chronic Hyperbaric oxygen therapy to promote healing
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Osteoarthritis
Reprinted with permission: Charles J. Eaton, M.D. of The Hand Centerhttp://www.eatonhand.com/
Reprinted with permission: DePuy Orthopaedics, Inc.http://www.depuyorthopaedics.com/
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Clinical Manifestations Crepitus Joint stiffness Pain with movement Heberden’s nodes (distal joints) and
Bouchard’s nodes (proximal joints) Knees: Joint effusions Muscle atrophy Spine: radiating pain, stiffness,
muscle spasms in extremities Hips: pain referred to inguinal area,
buttock, thigh or knee; loss of internal rotation
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Collaborative Care
Analgesics Rest Heat Weight control TENS
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Total Joint Arthroplasty
Source: Hughston Foundationhttp://www.hughston.com/hha/a.11.2.1.htm
Source: Hughston Foundationhttp://www.hughston.com/hha/a.11.2.1.htm
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Postoperative Care
Abduction pillow, neutral position
Prevent embolus Prevent infection Assess for bleeding Neurovascular compromise Manage pain Promote activity
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Total Knee Arthroplasty Continuous passive motion (CPM)
device Ice or hot/ice machine Keep knee in neutral, no rotation
inward or outward Monitor: thromboembolism,
infection, bleeding, CSM Teach: no hyperflexion or
kneeling for 6 weeks
Acute Musculoskeletal
conditions: FRACTURES
Source: Wikimedia Commons/Creative Commons LicencePhote courtesy of “Mexican 2000”/Flickrhttp://commons.wikimedia.org/wiki/Image:Clavicle_fracture.jpg
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Open or Closed?
Photo source: American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=A00139
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Compound Fractures Grade I
o Small wound
Grade IIo ~1 cm to 10 cmo skin & muscle contusions
Grade IIIo Largeo Damaged skin, muscle, nerves,
vessels
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Assessment
Can he move it? Does it hurt? Is it deformed?
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Key Treatments
Closed reduction Immobilization
o Splinto Cast
Open reduction
Open reduction; External FixationNational Institutes of Health Osteoporosisand Related Bone Diseases National ResourceCenter http://jama.ama-assn.org/cgi/reprint/291/17/2160.pdf
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Cast Care
Prevent indentations when wet
Elevate uniformly Air dry CSM – What am I looking
for? No scratching implements!
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Skin Traction To decrease muscle spasm Weight 5-7 pounds attached
w/ adhesive tape Used before surgical repair Check sling, tape for
placement Keep pulley, weights in place
Photo Source: www.HealCentral.org, Royal College of Surgeons of Ireland (RCSI), Creative Commons
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Buck’s Traction
Hip fracture assessment What to do immediately? Buck’s traction assessments What should be done later? What teaching is needed?
Buck’s TractionSource: DeRoyal Patient Care http://www.deroyal.com/PDFCatalogs/orthopedicCatalog.aspx
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Other Skin Traction
Russell’s Cervical Thomas splint Bryant’s Cervical Pelvic
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Skeletal Traction
Weight 25-40 pounds Are the ropes on the pulleys? Are the weights hanging free? Where are the knots? Monitor CSM Pin care? Skin care
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Balanced Suspension
Counter-traction by weights Check ropes, knots, weights Are traction bars tightened? Is patient in alignment? How do pin sites look? When can I remove weights?
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Spinal Traction
Where are the knots? Are the weights hanging free? What do the pin sites look
like? How do I turn the patient? How can I make the patient
comfortable?
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Complications
Compartment syndrome Fat embolism DVT Osteomyelitis Aseptic necrosis
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Compartment Syndrome
Preventiono Check CSMo Ice, elevateo Loosen dressing, open cast
Emergency careo Fasciotomy:
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Fat Embolism
Long bones, multiple fractures Elderly: hip fractures Altered mental status Respiratory distress Petechiae on trunk Prevention: early
immobilization of fracture
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Deep Venous Thrombosis Most common
complication Predisposing factors Common sites: leg,
pelvic fx Pulmonary embolus
preventionDeep Vein ThrombosisSource: National Heart & Blood Institute http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt/DVT_WhatIs.html
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Osteomyelitis
Sources: open wounds, implanted hardware
Staphylococcus aureus usually
Rx: IV antibiotics
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Aseptic Necrosis
Death of bone tissue Hip fractures or bone
displacement Hardware interferes with
circulation
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Amputation
Diabetic, smoker, infected foot ulcer
Trauma Grieving loss Altered self concept Coping Family response
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Surgical WoundsWeb Resource
http://alfa.saddleback.edu Click tab titled, “Med-
Surg 1” Drop down menu choose
“Wound Care”
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Wound AssessmentMeasure the wound in centimetersAssess phase of wound healing
• Reaction • Regeneration • Remodeling
Wound location, color of wound bed, condition of wound margins, integrity of surrounding skin
Signs and symptoms of infection Drainage: amount, color, consistency, odor
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Wound Care Dressing
The ideal dressingo Keeps wound moisto Prevents macerationo Protects from contaminationo Contains wound fluido Protects granulation tissue
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Traditional dry dressings
o Wounds exposed to air are more inflamed, painful, itchy and have thicker crusts than moist wounds
o Epithelium migrates into wound bed: if must burrow between any eschar (crust or Wet to dry dressing significantly increase healing time
o Nonocclusive: increased risk of contamination and infection
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Moist Wound Healing
•No eschar develops (crust, scab) •Enhances autolytic debridement: promotes role of macrophages and leukocytes
•Bacterial barriers: prevent wound contamination
•Wound fluids kept at site: contain growth factors and enzymes that promote autolysis and healing
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Potential for Infection
Signs of infection–I-induration –F-fever –E-erythema –E-edema
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Absorptive powders and pastes
Used in heavily draining wounds: absorb up to 100x weight in fluid: may increase wound pH above physiological levels May require wrapping in gauze before inserting into wound bed Pastes easier to remove from wound
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Wound Healing
Normal healing (3R's)oReaction: inflammatory
process (72 hours) oRegeneration: proliferation (up
to three weeks) oRemodeling: (three weeks to
two years)
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Black Wound = EscharCellular debris will escape wound edges as
necrotic tissue begins to separate from granulation tissue
If eschar becomes contaminated:• becomes excellent medium for infection • wound remains in reaction or
inflammatory stage • systemic signs of infection
Eschar delays regeneration phase by interfering with cell migration and wound closure
Risk of wound infection increases as the amount of necrotic tissue increases
Needs debridement
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Yellow Wound
Tissue not damaged enough to form an eschar so wound covered with thick yellow fibrous debris or viscous exudateo High risk of infection due to
excellent medium for bacterial growth
o Needs continuing debridement Photo courtesy of Saddleback College, California, http://www.saddleback.edu/alfa/N170/woundclassification.aspx
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Red Wound
Red indicates presence of granulation tissue.o Color of granulation tissue affected
by nutritional status and blood supply• full thickness ulcer: crater with pale pink
to beefy red granulation tissue • crater slowly fills with granulation tissue
from bottom upward
o Wound contraction and epithelialization continues. Epithelialization occurs from wound edges inward.
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Wound Drainage Devices
Decrease pressure in the wound by removing excess exudate thereby promoting healing from the inside (secondary healing).
Examples: Penrose drain, Jackson-Pratt & Hemovac suction devices
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Dehiscence/Evisceration
Partial or complete separation of the outer wound layers. If the internal organs below the wound protrude out of it, the wound has eviscerated. Highest risk is in obese patients, diabetics or those receiving steroids.
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Bacterial skin infections Folliculitis, furuncles, cellulitis:
these infections are usually caused by Staphylococcus aureus. Folliculitis involves the hair follicle. Furuncles (boils) are deeper.
Cellulitis is a general infection and involves deeper connective tissue.
Topical antibiotics: Neomycin sulfate (Neosporin)
Teach: wash area daily with antibacterial soap, allow skin to dry, prevent cross contamination
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Herpes Simplex Virus
Type 1 causes common cold sore, type 2 causes genital herpes. After first infection, recurrence is triggered by stress. Spreads by direct contact. Patient is contagious for the first 3-5 days.
Topical acyclovir (Zovirax) shortens the period of infection
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Herpes Zoster (Shingles)
Caused by reactivation of varicella (chickenpox). Occurs in the dermatome corresponding to the infected nerve. Eruptions follow several days after pain in the area, last several weeks.
Acyclovir (Zovirax), given topically and/or orally controls the severity of the lesions and decreases pain.
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Acute Burns
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Superficial Sunburn
oEpidermis pink to redoMild edemaoPainfuloHealing time: 3-5 daysoNo skin graft
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Partial Thickness Burn
Brief contact: scald, flames, grease, chemicals
Epidermis and dermis damaged Blisters if mild burn, pale,
mottled, waxy white with deeper Painful Healing time: 2-6 weeks No grafting unless healing
prolonged
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Full Thickness Burn
Prolonged contact: scald, flame, tar, grease, chemical, electricity
Epidermis, dermis & underlying tissues damaged
Waxy white, dry, leathery, charredNo painHealing: Weeks to monthsSkin grafts required
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Percentage of Burn Injury
Source: Burn diagrams courtesy of BioTel Emergency Medical Service (EMS), Texas Department of Health, http://www.biotel.ws/protocolsHTML/Protocols2004/BurnDiagramBurnFormula.asp
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Emergency Management
Excessive leakage of plasma, especially in the first eight hours post-burn, causes hypovolemia, hypoproteinemia, hemoconcentration, electrolyte imbalances and acid base disturbances.
In the absence of prompt fluid replacement, burn shock is imminent.
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Fluid ResuscitationInitial 24 hours:
Lactated ringer's 2-4 ml/kg/%burn/24 hours - given in the first 8 hours post-injury.
Additional fluid required for inhalation injury.
Maintain urine output of 30 ml/hr.5% albumin – keep albumin >2.5
gm/dl
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Monitoring Fluid shift lasts 24 to 72 hours. Hematocrit, electrolytes,
osmolality, calcium, glucose, albumin
Urine output >30 ml/hr Myoglobinuria and hemoglobinuria Pulse rate and pulse pressure Normal sensorium and adequate
peripheral capillary refill
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Type Cause Priority
Thermal Flame, steam, liquids
Smother flames; Remove smoldering clothing & metal objects
Chemical Acids, strong alkalis, organic compounds
Brush off dry chemicals Remove clothing; ascertain type of chemical
Electrical Direct or alternating currentLightning
Separate patient from electrical currentSmother any flamesStart CPR; Obtain EKG
Radiation Solar, X-raysRadioactive agents
Remove from radiation sourceRemove clothing if contaminated using tongs or lead glovesSend to radiation decontamination center
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Skin Care
Hydrotherapy daily to debride eschar and cleanse wounds
Topical enzyme such as collagenase (Santyl) or Accuzyme will debride more rapidly
Silver coated anti-microbial dressing (Acticoat)
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Grafting: Allograft (skin from a
cadaver) Synthetic such as
Biobrane Bioengineered skin
substitute (Transcyte)
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Prevention of Pressure Ulcers
Patients at risk Inspect skin frequently Move at least every 2 hours Use life sheet or slide board Pad bony prominences Remove excess moisture Adequate nutrution Use protective barriers
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Braden Scale 1 2 3
4Sensory Completely
limitedVery limited
Slightly limited
No impairment
Moisture Constantly moist
Very moist Occasionally moist
Rarely moist
Activity Bedfast Chairfast Walks occasionally
Walks frequently
Mobility Completely immobile
Very limited
Slightly limited
No limitations
Nutrition
Very poor Probably inadequate
Adequate Excellent
Friction/Shear
Problem Potential problem
No apparent problem
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Pressure UlcersStage I: Redness only
Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures http://www.saddleback.edu/alfa/
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Stage 2 Pressure UlcerLoss of epidermis and partial
loss of dermis not extending into subcutaneous tissue
Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures http://www.saddleback.edu/alfa/
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Stage 3 Pressure UlcerFull thickness wound. Includes loss of epidermis and dermis.
Extends into subcutaneous tissue.
Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures http://www.saddleback.edu/alfa/
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Stage 4 Pressure UlcerDeep penetrating wound. Includes
loss of epidermis, dermis and subcutaneous tissue. Extends into
muscle and/or bone.
Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures http://www.saddleback.edu/alfa/
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Basal Cell Carcinoma
Malignancy of the basal cell layer of the epidermis.
Genetic predisposition, chronic irritation, and ultra-violet exposure are risk factors.
Photo Source: Wikimedia Commonshttp://commons.wikimedia.org/wiki/Image:Basaliom2.jpg
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Squamous Cell Carcinoma
Cancers of the epidermis Chronic irritation, skin
damage risk factors
Photo Source: Wikimedia Commonshttp://commons.wikimedia.org/wiki/Image:Squamous_Cell_Carcinoma.jpg
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Malignant Melanoma
Pigmented cancers in the melanin-producing epidermal cells.
Risk factors: predisposition, excess ultra-violet exposure.
Photo Source: Wikimedia Commonshttp://en.wikipedia.org/wiki/Image:Malignant_melanoma.jpg
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Preventing Skin Cancer
Avoid sun between 11:00 am and 3:00 pm
Use sunscreen Wear a hat, opaque clothing,
sunglasses in the sun Examine body monthly for
lesions
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Seek Medical Attention Changes color, especially darkening or
spreading Changes in size Change in shape – sharp border becomes
irregular or flat becomes raised Surrounding redness or edema Change in sensation, especially itching
or tenderness Change in character: oozing, crusting,
bleeding, scaling
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Photo Acknowledgement:All unmarked photos and clip
art contained in this module were obtained from the
2003 Microsoft Office Clip Art Gallery.