Muscular-Skeletal Lecture 3. Amputation Pg 1080 Amputation “removal of a body part, often an extremity”

Muscular-Skeletal

Lecture 3

Amputation

• Pg 1080

Amputation

• “removal of a body part, often an extremity”

Amputation

• Common Causes– Peripheral Vascular

Disease (PVD)– Trauma– Osteomyelitis– Tumor

• osteosarcoma

Which of the following type of amputation is the most common?

A. Upper extremityB. Lower extremity

Amputation

• Reason–Relieve symptoms–h function–h quality of life

• Which of the following is the preferred type of amputation

A. AKAB. BKA

Amputation

• Most distal point

AmputationNursing Assessment

• Pre-op– Neurovascular status• CMS• Doppler • Ultrasound

AmputationNursing Assessment

• Pre-op– Function– S&S of infection• C&S• Lymph nodes

– Psych. status

Amputation

• Complications– Hemorrhage– Hematoma– Infection– Skin breakdown– Edema– Phantom limb pain– Contracture

Table Question

• What would you identify as the priority nursing diagnosis for a client who is post-op BKA?

Nrs Dx: for Amputation

• Acute pain• Disturbed sensory perception• Impaired skin integrity• Grieving • Self-care deficit• Impaired physical mobility

Acute Pain

Nrs Dx: Acute Pain

• Opioid • Evacuation • Δ position• Sandbag • Distraction

Nrs Dx: Altered Sensory Perception

• h activity• Rehab• Distraction• Rx– Analgesics– Tricyclic antidepressants– Anticonvulsants

Nrs Dx: Impaired skin integrity

• Gentle• Aseptic tech.• Diet– h protein– vitamins

• Residual limb shaping– Elastic dressing– Cast

Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site?

A. Thoroughly irrigate the wound before collecting the specimen.

B. Use a sterile swab and wipe the crusty area around the outside of the wound.

C. Gently roll a sterile swab from the center of the wound outward to collect drainage.

D. Use a sterile swab to collect drainage from the dressing.

NURSING ALERT• If the cast or elastic dressing comes off, the

residual limb must be immediately wrap with an elastic compression bandage. If not, excessive edema will develop leading to a delay in rehabilitation.

• Notify the surgeon so that another cast can be applied promptly

Nrs Dx: Impaired body imageNrs Dx: Grieving

• Relationship of trust• Pt. care for limb• Independence• Realistic goals• Support systems• Referrals

Nrs Dx: Self Care Deficit

• Practice• Nursing impact

Nrs Dx: Impaired physical mobility

• Prevent contractures• Avoid– Abduction– External rotation– Flexion

• Prone*• ROM• Upper body exercises

Nursing Alert• The residual limb should not be

placed on a pillow because a flexion contracture of the hip may result.

A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? A. The client should be placed in a room with

negative pressure. B. Infection requires close contact; therefore, the

door may remain open. C. Transmission is highly likely, so the client should

wear a mask at all times. D. Infection requires skin-to-skin contact and is

prevented by hand washing, gloves, and a gown.

A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?A. "The pain will go away in a few days.“B. "The pain is due to peripheral nervous system

interruptions. I will get you some pain medication."

C. "The pain is psychological because your foot is no longer there."

D. “The pain and itching are due to the infection you had before the surgery."

The primary reason for rapid continuous rewarming of the area affected by frostbite is to:A. Lessen the amount of cellular

damage B. Prevent the formation of blisters C. Promote movement D. Prevent pain and discomfort

You are assigned to care for a patient with a Below the Knee Amputation (BKA). Among the patient’s orders is one which states that the patient should be placed in the prone position twice daily. The nurse knows that the reason for this is:A. Changing the patient’s position will help to

prevent skin breakdownB. To observe the stump for signs of infectionC. To assist the patient in doing ROM (Range of

Motion) exercisesD. To stretch the flexor muscles and prevent

flexion contractures

Small Group Questions

1. Look at the list of complications associated with an amputation. Identify ways to assess for each complication and treatment.

2. Describe the assessment of a patient going into surgery for a non-traumatic BKA.

What is the number one reason people go to their doctor?

A. Respiratory infectionB. Back painC. Ear infectionD. Head achesE. Complaint of symptoms assoc. with heart

attacks

What is the number TWO reason people go to their doctor?

A. Complaints of arthritis in the handsB. Back painC. Ear infectionD. Head achesE. Complaint of symptoms assoc. with heart

attacks

Low Back Pain

• Pg 1117

Low Back Pain

• Multiple causes

Spinal Column

• Vertebrae• Intervertebral disk

Intervertebral disks

• Youth– Cartilage – nucleus pulposus

• Age– Cartilage

• Dense• △ Shape

Term # vertebrae Body area Abrv.Cervical 7 Neck C1 – C7 Thoracic 12 Chest T1 – T12Lumbar 5 Low back L1 – L5Sacrum 5 (fused) Pelvis S1 – S5 Coccyx 3 Tailbone

Spinal Column

• Facet joints• Ligaments• Muscles

Spinal Curves

• Shock Absorbers

http://www.spineuniverse.com/anatomy/cervical-spine-anatomy-animation

Disk degeneration

• Most common areas– L4 – L5– L5 – S1

Disk protrusion

• AKA– Herniated nucleus

pulposus– “Slipped disk”

• pressure on the nerve

• “Radiating” pain• “Sciatica”

Low Back PainS&S

• Acute – < 3 months

• Chronic – > 3 months

Low Back PainS&S

• Muscle spasm• i Lumbar curve

If a paravertebral muscle is in spasm, how would you describe the muscle

tone?

A. AtonicB. FlaccidC. Increased muscle toneD. Decreased muscle tone

Low Back PainAssessment

• Hx & PE• Reflexes• CSM• Pain.

Low Back PainMedical Management

• If no serious problem • No additional testing• for 4 weeks.

Low Back PainMedical Management

• Self-limiting– 4 wks

• With– Rx– Rest– Relaxation

Medical Management: Rx

• Analgesics– Acetaminophen– NSAIDs

• Muscle Relaxants– Cyclobenzaprine

(Flexeril) – S/E• Drowsiness

Medical Management: Rx

• Tri-cyclic Antidepressants– Amitriptyline (Elavil)

Low Back PainMedical Management

• Rest • No– Twisting–Bending – Lifting–Reaching

Low Back PainMedical Management

• Bed rest – 1-2 days

• Δ position frequently

• No sitting > 50 min. • Gradual

Nonpharmacologic Interventions

• Relaxation– Heat– Spinal manipulation

Low Back PainNursing interventions

• Assess pain – i analgesics

• Mattress– Firm– No sag

• Lumbar flexion

Low Back PainNursing interventions

• h activities gradually• Low stress exercise• 2 wks abd. & trunk

exercises• Improve posture

Good body mechanics: Standing

• Short duration• 1 foot on a stool • ⌀ high hills• ⌀ flexion• Shift wt • Stand on cushion • ⌀ Lock knees

Good body mechanics: Sitting

• Short duration• Chair– Straight back – Arm rests

• Knees h than hips• Back support• i extension • Alt. sitting / walking

Good body mechanics: Lifting

• NEVER BEND AT THE WAIST!

• Bend knees• Squat• Hold item close Lift

with your legs

No-No’s!• Bending at the waist• lifting without bending

knees• twisting and lifting• Slouching• Holding breath when

lifting

Carpal Tunnel Syndrome

• Pg 1078

Carpal Tunnel Syndrome

• “Entrapment neuropathy”

• http://video.about.com/ergonomics/Carpal-Tunnel-Syndrome.htm

Carpal Tunnel SyndromePathophysiology

• Median nerve • Compressed

Carpal Tunnel SyndromeEtiology

• Men vs Women?– Women

• Age?– 30-60

• Risk Factor– Repetitive

movements

Carpal Tunnel Syndrome:S&S

• Pain– Night

• Paresthesia• ? weakness

Carpal Tunnel SyndromeAssessment & Dx

• Tinel’s sign– Percussing over the

median nerve • Tingling• Numbness• Pain

– Test = +

Carpal Tunnel SyndromeTx

• Corticosteroids• Wrist splint

Carpal Tunnel SyndromeSurgery

• Open nerve release • Endoscopic laser• Local anesthetic• Cut carpal ligament

Small Group Questions

1. What medications are frequently prescribed to a clinic with acute low back pain? What are their actions

2. What are the 3-R’s of Low Back pain treatment?3. Mr. Jones is suffering from acute back pain, what

would you advice him to do? (What would your teaching plan include)?

4. Describe the pathophysiology of carpal tunnel syndrome.

5. Demonstrate how to perform the Tinel sign.

Osteoporosis:

• Pg. 1089

Osteoporosis:Pathophysiology

Bone resorption Bone formationosteoclasts osteoblasts

Osteoporosis:Pathophysiology

Bone Resorption > Bone formation = i bone mass

Osteoporosis:Pathophysiology / Hormones

• Age related changes• i Calcitonin– Resorption• i

– Formation• h

Osteoporosis:Pathophysiology / Hormones

• Age related changes• i Estrogen– Resorption• Inhibits

Osteoporosis:Pathophysiology / Hormones

• Age related changes• h PTH– Resorption• h

– Formation• i

Osteoporosis:Pathophysiology

• Porous• Brittle• Fragile • Fx easily

• http://www.youtube.com/watch?v=rHyeZhcoZcQ

Osteoporosis

• > 10 million Am. Have osteoporosis

• 33.6 million have osteopenia

• Men vs Women– Men < Women

OsteoporosisS&S

Fractures may be the first clinical manifestation of

osteoporosis

OsteoporosisMost Common Fx

• Compression– Thoracic spine– Lumbar spine

• Hip • Colles– wrist

OsteoporosisS&S

• Collapsed vertebra • Asymptomatic • Kyphosis • i height

• protruding abdomen• Pulm. insufficiency

OsteoporosisRisk Factors

• Age• Men vs Women– WOMEN

• Small framed vs. large framed– Small framed

• Caucasian vs. Asian– Asian

OsteoporosisRisk Factors

• Nutritional factors–Adequate Cal.–Calcium–Vit. D

OsteoporosisRisk Factors

Physical Activity stimulates bone formation & remodeling

OsteoporosisRisk Factors

• Immobility

OsteoporosisAssessment

• X-ray – Lumbar• Biconcave

– Thoracic• Wedge shaped

OsteoporosisAssessment

• Bone densitometry – Detect bone mineral

density (BMD)

• http://www.youtube.com/watch?v=heTObdmOU8o

OsteoporosisMedical management

• PREVENTION!!!!!!• Diet– Calcium

• h

– Vitamin• D

• Exercise– Weight bearing

OsteoporosisPrevention

• Lifestyle–Alcohol– Smoking–Carbonated

drinks?–Caffeine

OsteoporosisMedical Management

• Rx– Calcium

• 1,000 mg/day

OsteoporosisMedical Management

• Rx– Calcium

• 1,000 mg/day

– Vit. D• 600 IU/day

– Vit. C• 2,000 mg/day

OsteoporosisMedical Management: Rx

• Calcium Supplement• Caltrate / Citracal• Split dose• S/E– Abd. distention– Constipation

OsteoporosisMedical Management: Rx

• Bisphosphonates• Action– i bone resorption– h bone density

• Nrs implications– AM– Water – NPO (ā & ṗ)– Hold Ca+ – ⌀ lye down

OsteoporosisMedical Management: Rx

• Estrogen replacement

OsteoporosisMedical Management: FX

• Colles Fx• Distal Radius• D/T– Fall on open hand

• Reduced• Active ROM

OsteoporosisMedical Management: FX

• Hip• ORIF

OsteoporosisMedical Management: FX

• Compression Fx of vertebrae

• Conservative*• If acute pain – Vertebroplasty

OsteoporosisNrs Process

• Acute Pain– D/T compression fx

• Rest– Supine– Side-lying– △ position frequently– Flex knees– No twisting

• h activity as pain i

OsteoporosisNrs Process

• Risk for constipation• D/T– Immobility– Meds

• Assess– Intake– BS– BM

OsteoporosisNrs Process

• Risk for constipation• Fiber– h

• Fluids– h

• Rx– Stool softeners

Paget’s Disease

• Page 1093

Paget’s diseasePathophysiology

• Rapid Bone Turnover• h # of osteoclasts • h bone resorption• F/B• h osteoblast activity • Bone replacement

Paget’s diseasePathophysiology

• Disorganized bone replacement

• Vascular • Weak • Pathologic fractures• bowed legs – Misalignment– Pain

Paget’s diseaseS&S

• Insidious• Deformity– Skull– Pelvis– Femur/tibia

• Pain• Warm • Fx

Paget’s DiseaseAssessment & Dx

• Serum Ca+–Normal

• X-ray• Bone scan• Bone biopsy

Paget’s DiseaseMedical Management

• Pain– Rx• NSAIDs

• Gait– Assistive devices– Shoe lifts– PT

• Wt. control

Paget’s DiseaseMedical Management: Rx

• Calcitonin• Action– i bone resorption– i osteoclasts

• Route– Sub q– Nasal

Paget’s DiseaseMedical Management: Rx

• Bisphosphonates• Action– i bone turnover

Paget’s Disease:Nrs Management

• Teaching

Osteomalacia

• Page 1093

Osteomalacia

• AKA–Adult Rickets

• Deficit or impaired absorption of–Ca+–Vit. D

OsteomalaciaS&S

• Pain• Difficulty △

positions*• Weak*• Waddle*• Kyphosis• Pathologic fx

OsteomalaciaMedical Management

• Rx–Calcium–Vit. D–Bisphosphonate–Calcitonin

Small Group Questions

1. What is the pathophysiology of Osteoporosis?2. What effect do the hormones calcitonin, estrogen and

PTH have on bone remodeling?3. What are Bisphosphonates? What advice would you give

to a client with these?4. What is a Colles’ fracture? What is a compression fx (of

the vertebrae)5. What is the pathophysiology of Paget’s Disease and

Osteomalacia?6. How are Paget’s Disease and Osteomalacia similar and

how are they different?

During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?

A. Administer an antibiotic B. Contact the physician for an order for

immune globulin C. Administer an antiviral D. Tell the client that he should remain in

isolation for 2 weeks

A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to: A. Have a Protime done monthly B. Eat more fruits and vegetables C. Drink more liquids D. Avoid crowds

Following an amputation, the advantage to the client for an immediate prosthesis fitting is:A. Ability to ambulate soonerB. Less chance of phantom limb

sensationC. Dressing changes are not necessaryD. Less edema