Herniated intervertebral disk (most commonly affecting L4-L5 or L5-S1 interspaces) 2. Fracture of the spine 3. Spine dislocation 4.

Osteoarthritis 5. Scoliosis 6. Tension 7. Poor posture and body mechanics 8. Lack of muscle tone 9. Degenerative disk disease 10. Obesity
1.

1. Myelography 2.MRI, Ct scan 3. Electromyogram (EMG) 4.Diskogram

1. Depressed or absent Achilles

tendon reflex; positive straight-leg raise test 2. Guarded movement 3. Decreased ROM of spine 4. Diagnostic studies

To relieve pain and muscular spasm Administer appropriate medications (analgesics, NSAIDS, muscle relaxants, Flexeril) Apply moist heat Bedrest; patient in Fowlers position with moderate hip and knee reflexion Use firm mattress, bedboard, or floor for back support 2. To regain normal electricity of affected muscle Isometric exercises for abdominal muscles Daily exercise program
1.

3. To return joint to normal function

Assist with exercises for abdominal

4. Good body mechanics

Do not lean forward without bending

muscles ROM exercises

knees Exercise under direction of health care provider Do not stand in one position for prolonged time Sleep in side-lying position with knees and hips bent

1. 2. 3. 4.

5.
6. 7.

Exercise daily but avoid strenuous exercises Correct posture at all times Avoid prolonged sitting, standing, walking, and driving Rest at intervals Use hardboard for bed, or firm mattress Avoid prone position Avoid straining or lifting heavy objects

1. 2.

Conservative therapy Surgical therapy

a. Percutaneous laser diskectomy; herniated portion of disk is b. c. d. e.

lasered Diskectomy Laminectomy Laminectomy with fusion Postlaminectomy care

1) 2) 3) 4)

Maintain body alignment Leg-roll every 2 h Calf exercises Assess for sensations and circulatory status, especially of lower extremities 5) Monitor elimination 6) Assist with ambulation

1.

Contusions
a. Ecchymosis b. Hematoma

2.

Strains/sprains
a. Pain b. Swelling

3.

Joint dislocation
a. Pain b. Deformity

4. Fractures
Swelling Pallor, ecchymosis Loss of sensation to body parts Deformity Pain and/or acute tenderness Muscle spasm Loss of function Abnormal mobility Crepitus (grating sound on movement of ends of broken bone) j. Shortening of affected limb k. Decreased or absent pulses distal to injury l. Affected extremity colder than contralateral part
a. b. c. d. e. f. g. h. i.

Avulsion 2. Comminuted 3. Greenstick 4. Longitudinal 5. Oblique 6. Impacted 7. Interarticular 8. Pathological 9. Spiral 10. Stress 11. Displaced
1.

1.

Types

a. Fat emboli b. Hemorrhage

c. Delayed union/nonunion
d. Sepsis

e. Compartment syndrome
f. Peripheral nerve damage

1. 2. 3. 4.

Contusions Strains/sprains Dislocations Fractures

1) Immobilization before patient is moved by use of splints; immobilize joint below and above fracture 2) In an open fracture, cover the wound with sterile dressings or cleanest material available 3) Emergency room

a. Provide emergency care

b. Treatment
1) Splinting/immobilization of the affected part to prevent soft tissue from being damaged by bony fragments 2) Internal fixation 3) Open reduction/surgical dissection and exposure of the fracture for reduction and alignment

a. Purposes
1) 2) 3) 4) Immobilize fracture Alleviate pain and muscle spasm Prevent or correct deformities Promote healing

b. Types of traction 1) Skin (Bucks extension, Russells, pelvic or cervical traction) 2) Skeletal (halo, Crutchfeild tongs)

c. Nursing management
1) Maintain straight alignment of ropes and pulleys 2) Assure that the weights hang free 3) Frequently inspect skin for breakdown 4) Maintain position for countertraction 5) Encourage movement of unaffected areas 6) Investigate every compliant immediately and thoroughly 7) Maintain continuous pull 8) Clean pints with half-strength peroxide and sterile swabs 1-2times/d

a.

Immediate care 1) Avoid covering cast until dry (48 h or longer), handle with palms, not fingertips 2) Avoid resting cast on hard surfaces or sharp edges 3) Keep affected limb elevated above heart on soft surface until dry; no heat lamp 4) Watch for danger signs, e.g., blueness or paleness, pain, numbness or tingling sensations on affected area; if present, elevate casted area; if it persists, contact physician

b. Immediate care 1) When cast is dry, patient should be mobilized 2) Encourage prescribed exercises (Isometrics) 3) Report to physician any break in cast or foul odor from cast 4) Tell patient not to scratch skin underneath cast; skin may break and infection can set in 5) If fiberglass cast gets wet, dry with hair dryer on cool setting

c. After-cast care
1) Wash skin gently
2) Apply baby powder, cornstarch, or baby oil 3) Have patient gradually adjust to

movement without support cast 4) Inform patient that swelling is common after cast is removed; elevate limb and apply elastic bandage

1. Leg shortened, abducted,

externally rotated 2. Pain 3. Hematoma, ecchymosis 4. Confirmed by x-rays

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Total hip replacement Abduction of affected extremity Turn patient as ordered Ice to operative site Overbed trapeze to lift self onto fracture bedpan Initial ambulation with walker Crutch walking Chair with arms, wheelchair, semireclining toilet seat Medications Dont sleep on operated side Dont flex hip more than 45-60 (dont elevate head of bed more than 45) Continuous passive motion device

13. Complications
a. b. c. d.
a. b. c. d. e. f. g. h.

Dislocation of prosthesis Excessive wound drainage Thrombeombolism Infection

Maintain abduction Avoid stooping Do not sleep on the operated side until directed to do so Flex hip only to circle Never cross legs Avoid position of flexion during sexual activity Walking is excellent exercise; avoid overexertion In 3 mo, will be able to resume ADLs, except strenuous sports

14. Postoperative discharge teaching

1. Trauma

2. Peripheral vascular disease

3. Osteogenic sarcoma

B. Types
1. Disarticulation 2. Above-the-knee amputation 3. Below-the-knee amputation 4. Guillotine or open surface 5. Closed or flap

C. Postoperative management
1. Delayed prosthesis fitting 2. Immediate prosthesis fitting

D. Nursing management
1. 2. 3. 4.

5.
6.

Prevent bleeding Promote circulation Prevent complications of immobility Provide comfort and relieve pain Provide psychological and emotional support Patient teaching, regarding stump care

A. Rheumatoid arthritis (RA)

1. Description 2. History a. Autoimmunity b. Environmental factors c. Viral or streptococcal infection d. Genetic

3. Assessment
a. b. c. d. e. Joint pain and swelling Limited joint movement Contractures; deformities Weakness, fatigue High fever and rheumatoid rash, particularly seen in juvenile RA (Stills disease) f. Nodules over bony prominences g. Ulnar drift

4. Diagnostic tests
a. Blood studies
1) 2) 3) 4) ASO titer (JRA) Later fixation C-reactive protein Sedimentation rate

b. Aspiration of synovial fluid

c. X-rays

5. Nursing management
a. Relieve pain and discomfort
1) Application of heat; e.g., warm tub baths, warm, moist compresses, paraffin dips 2) If inflammatory process is acute, application of cold packs or ice bag is sometimes effective 3) Support joints with splints; cervical collar in late stages 4) Administer analgesics

b. Promote rest and mobility

1) 2) 3) 4) Proper positioning Use firm mattress or bedboard ROM exercises as tolerated Encourage independence and acceptance of limitations

c. Reduce inflammation d. Provide adequate dietary intake; appropriate diet for obesity e. Provide operative care for patients undergoing musculoskeletal surgery, e.g., arthroplasty f. Preoperative teaching 1) Teach partial weight-bearing use of crutches, isometric exercises, and transfer techniques 2) Familiarize patient with overbed traction frame, trapeze, and abduction splint g. Preoperative teaching 1) Position patient flat in bed with affected extremity in abduction 2) Apply ice to operative area to reduce edema 3) Assess circulation of affected extremity 4) Administer medications to prevent postoperative complications a) Pulmonary embolism b) Infection

5) Encourage active foot and ankle motion the day following surgery to prevent circulatory stasis 6) Have patient do active knee and hip flexion with support to prepare for ambulation 7) Help patient ambulate gradually with walker, then crutches, using three-point gait

h. Postoperative discharge teaching

1) 2) 3) 4) 5) 6) 7) 8) Maintain abduction Avoid stooping Do not sleep on operated side until directed to do so Flex hip only to circle Never cross legs Avoid position of flexion during sexual activity Walking is excellent exercise; avoid overexertion In 3 mo, will be able to resume ADLs, except strenuous sports

1.

2.

Pathophysiology Characteristic clinical manifestations

a. Intermittent fever and chills b. Rheumatoid rash (salmon pink, macular rash on chest,

tights, and upper arms) c. Iridocyclitis (inflammation of the iris and ciliary body) d. Growth retardation
3.
4. 5.

Diagnosis Problems Treatment and nursing management

1. 2. 3.

Description Pathophysiology Clinical manifestations

a. Pain and stiffness b. Kyphosis

4. 5.

Diagnostic tests Problems

a. b. c. d.

Alteration in comfort (pain) Decreased mobility Potential for respiratory difficulty Potential for poor body image and low self-esteem

6. Treatment and nursing management

a. Analgesics; promote comfort
b. Anti-inflammatory drugs, salicylates

c. Physical therapy, heat application

d. Promote body alignment, especially of the spine 1) Postural exercises 2) Splinting, bracing e. Improve mobility 1) ROM exercises 2) Assist with ADLs f. Prevent respiratory complications

1. 2. 3.

Description Pathophysiology History

a. b. c. d.

4.

Assessment

Poor posture Trauma Stress on joints Obesity

a. Muscular spasm, pain, limitation of motion, stiffness;

impaired ADL performance b. Contractures, deformities c. Heberdens nodes on fingers d. Obesity/debilitation

5. Diagnostic test 6. Nursing management a. Reduce pain and discomfort 1) Balance rest with activity 2) Administer analgesics and anti-inflammatory drugs such as aspirin, Motrin, Clinoril, Indocin b. Heart application c. Maintain mobility 1) ROM 2) Encourage usual ADLs that involve using all joints d. Provide adequate nutrition; obese patients should

Description Pathophysiology 3. Predisposition

1. 2. a. Swollen, redden, painful joints b. Limitation of motion c. Deformity 4.

Diagnostic tests
a. X-rays
b. Blood tests c. Synovial aspiration

5. Nursing management
a. Relieve pain and discomfort 1) Rest affected joint 2)Administer analgesics b. Reduce urate level in the blood 1) Eliminate purine food from diet, e.g., liver, sardines 2)Administer medication (aspirin, Butazolidin, Indocin)

1. 2.

Description History
a. b. c.

3.

Assessment

Stress on joints Toxins Infections Pain Decreased mobility, especially on abduction Rest Immobilize affected joint by use of pillows, splints, slings Administer pain medication, muscle relaxants (Valium), steroids Apply heat/cold packs to decrease swelling Promote exercise (ROM) Assist in performance of ADLs by modifying activities relative to limitations Assist with cortisone injection, draining of bursae

a. b.

4.

Interventions

a. b. c. d. e. f. g.

1. 2. 3.

Description Pathophysiology Assessment

a. b. c. d. e. f.

4.

Nursing management

Pain and tenderness Enlarged skull Kyphosis Bowed legs Waddling gait Decrease in height

a. To relieve pain and discomfort b. Administer analgesics c. Encourage rest

1) Prevent pathological fractures by using safety precautions 2) Administer specific drugs to prevent bone destruction

1. 2. 3.

Description Pathophysiology History

a. b. c. d. e. f. g. h.

4.

Assessment

Decreased estrogen (menopause) Low calcium intake Vitamin D deficiency Malabsorptive disease of GI tract Immobility Hyperthyroidism Hyperparathyroidism Prolonged use of steroids

a. Lower back pain b. Kyphosis c. Decrease in height

5. Diagnostic tests 6. Nursing management

a. Provide optimal nutrition diet b. Assist in restoring hormonal balance, e.g., estrogen for

postmenopausal women (only after evaluation risk factors) c. Promote mobility and strength
1) Encourage weight-bearing on the long bones 2) ROM exercises 3) Physiotherapy

d. Prevent pathological fractures e. Promote and relieve pain

1) Bedrest 2) Use of back brace or splint for support 3) Use of bedboards or hard mattress

f. Prevent bone resorption

1. 2. 3.

Description Pathophysiology History

a. Chronic skin problems, i.e., decubitus ulcers, gangrene b. Compound fractures

4.

Assessment

a. Pain b. Swelling, redness, warmth on affected area c. Fever

5.

Diagnostic tests

a. b. c. d.

Leukocytosis Elevated sedimentation rate Culture and sensitivity X-ray of affected part

6. Nursing management
a. Promote comfort, relieve pain 1) Bedrest 2) Administer antibiotics 3) Support affected extremity with pillows, splints to maintain proper body alignment 4) Use room deodorant b. Reduce inflammatory process 1) Administer antibiotics 2) Apply heat to affected area 3) Encourage fluid intake 4) Monitor I and O c. Promote skin integrity 1) Asepsis 2) General skin care 3) Wound care

d. Provide emotional support

1)Allow for expression of fear and anxiety 2)Provide diversionary activities

e. Improve nutritional status

1)High-protein diet with sufficient carbohydrates, vitamins, and minerals 2)Small, frequent feedings

1. 2. 3.

Description Pathophysiology Assessment

a. b. c. d.

Bone pain and tenderness Muscle weakness Bowed legs Kyphosis

4. 5.

Diagnostic tests Nursing interventions

a. Relief of pain 1) Administration of analgesics 2) Bedrest 3) Maintain good body alignment

b. Promote mineralization of bone c. Promote safety

1)Assist with performance of ADLs to prevent pathological fractures 2)Regular medical follow-up