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Stressors
NUR240
JBorrero 10/08
Arthritis
Degenerative Joint Disease
Arthritis= joint inflammation.
Arthralgia= joint pain
Different types of arthritis:
Osteoarthritis
Rheumatoid arthritis
Gouty arthritis
Osteoarthritis
Rheumatoid arthritis
Trauma
Congenital deformity
Avascular necrosis
Total Hip Replacement
Indications for surgery:
Arthritis
Femoral neck fractures
Congenital hip disease
Failed prosthesis
Pre-op management
Assess medication history.
Assess Respiratory, neurovascular,
nutritional and integumentary status.
Presence of other diseases- COPD, CAD,
Hx. Of DVT or pulmonary embolism.
Discuss surgical procedure, informed
consent.
Prepare for autologous blood donation.
Pre-op teaching
Presence of drains and hemovac
postoperatively.
Pain management (epidural/PCA).
Coughing and deep breathing.
Use of incentive spirometer
ROM exercises to unaffected extremities.
Post-op restrictions:
Need to avoid bending beyond 90 degrees
Importance of leg abduction post-op.
Post-op Management of THR
Assess neurovascular status of involved
extremity.
Incision site, wound drains, hemovac.
Note excessive bleeding or drainage
Respiratory status- elderly population.
Position of affected joint and extremity
Mental alertness
Assess Hgb and Hct
Pain management
Total hip replacement-
Complications
Dislocation of hip prosthesis
Thromboembolism
Infection
Avascular necrosis
Loosening of the prosthesis
Dislocation of prosthesis
Increased pain, swelling
Acute groin pain
Shortening of the leg
Abnormal internal or external rotation
Restricted ability or inability to move leg
Reported popping sensation in hip.
Impaired physical mobility r/t joint
replacement and pain
Maintain bed rest with affected joint abducted
with wedge pillow.
Perform passive and teach active ROM to
unaffected joints, quad, isometric, gluteal
exercises.
Ambulate with assistance, WB restrictions
Turn pt. as ordered, monitor skin for
breakdown
Altered Tissue perfusion r/t
reduced flow and immobilization
Administer parenteral fluids with electrolytes
to increase tissue perfusion.
Monitor VS q4h and prn, I and O.
Assess NV status q1h for first 12 hrs., then
q4h. Color, temp., pulse, sensation.
Ambulation and exercises
Monitor CBC, electrolytes, PT/INR
Administer anticoagulants - phlebitis
Pain r/t surgical intervention and
impaired mobility
Assess location, intensity, quality pain.
Administer analgesics, sedatives, anti-
inflammatories, assess effectiveness,
Monitor PCA or continuous epidural
Change position frequently, back rubs.
Provide diversional activities- reduce
attention on pain.
Monitor - severe chest, affected joint pain.
Knowlwdge deficit R/T
Stress importance of rehab program and
exercises, no flexion greater than 90
degrees.
Discuss and demonstrate incision care
Medication teaching- especially
anticoagulants, instruct pt to be checked,
observe for bleeding, etc.
High protein, high fiber and increased fluid to
prevent constipation.
Pain Management
Discharge/home care
Safety: stairs with hand rails, no scatter rugs,
grab bars tub and toilet, good light.
Height of bed and chair for easy transfer.
Elevated toilet seat, fracture pan, urinal
Ability to care for wound, correct supplies and
hand washing technique.
Correct transfer techniques, ability to follow
rehab plan and exercises.
Arthroscopy
Pre-op: lab work- Hgb, Hct, Pt/PTT, urine,
PT,exercises
History of underlying problem, meds.
Post-op- N/V assessment, pulses distal to
Joint.
Teach: ROM to unaffected extremities,
limitations post-op, crutch walking prn, pain
management, reinforce explanation of
procedure.
Total Knee Replacement
Indications:Osteoarthritis, rheumatoid
arthritis, posttraumatic arthritis, bleeding into
joint.
Post-op compression bandage and ice.
Assess N/V status of leg, active flexion q1h.
While awake, CPM machine.
Wound suction drain
OOB within24 hrs., knee immobilizer and
elevated while sitting.
Care of the patient undergoing an
amputation
Pre-op monitor N/V status both extremities
Observe for ulceration, edema, necrosis.
Baseline VS and lab data, doppler studies,
angiography, ECG, chest x-ray.
Time for verbalization fears, anxieties.
Teach re; overhead trapeze, C and DB,
incentive spirometer.
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Post-op: amputation
Stump dressing, amt. and color of drainage,
hemovac drain.
Respiratory status and VS.
Presence of phantom limb pain.
Monitor for complications; infection, hemorrhage,
phantom pain, contractures, scar formation,
abduction deformity.
PT, diet, rest, activity, wound care
Pain management
Phantom limb pain
Immobility complications
Body image disturbance r/t loss
body part
Allow time for pt. to grieve, assess need for
counseling.
Encourage pt. to discuss and view stump
Assist in identifying positive coping strategies, praise
strengths observed.
Provide a supportive environment.
Demonstrate positive regard for pt. and acceptance
of personal appearance.
Assess religious beliefs re: care of amputated limb
Verbalize feelings re: change in role, job, family,
sexual perosn
Discharge/ Home care
planning
Environmental/safety status:
Hand rails- tub toilet, stairs, no scatter rugs.
Wide doorway to accommodate wheelchair,
walker, Ht. of bed, chair ok.
Ability to care for wound and has correct
supplies.
Ability and desire to follow prescribed rehab
plan and exercises.
Prosthesis fitting with orthotist
Osteoporosis
Primary or Secondary
Metabolic bone disorder- progressively porous,
brittle, fragile bones, low bone density, susceptible
to fractures
Occurs in postmenopausal women
Bone resorption (osteoclast) > bone formation
(osteoblast) activity
Dowagers hump progressive kyphosis gradual
collapse of vertebrae.
Post menopausal lose height, c/o fatigue.
Osteopenia, precursor to osteoporosis
Dx tests: Radiographs, Dexa scans
Osteoporosis- Risk Factors
Gerontologic- over 80 yrs. old, 84% have
osteoporosis.
Family hx, thin, lean body build
Postmenopausal estrogen deficiency
Hyperparathyroidism increases bone
resorption
Hx of low Ca intake and low levels of Vit D
Long tem corticosteroid use
Lack of physical activity/ prolonged immobility
Hx of smoking, high alcohol intake
Osteoporosis
Diagnosis:
Physical assessment:
Psychosocial assessment:
Pt. teaching- osteoporosis
Adequate dietary calcium- 1200mg/day with
fluids
Exercise, wt. bearing beneficial.
Walking outdoors- vitamin D absorption.
Good body mechanics
Safe home environment, fall prevention
Balanced diet- protein, Mg, Vit K & D, Ca
Modify lifestyle choices- smoking, alcohol and
caffeine intake and sedentary lifestyle.
Patient teaching- Meds
HRT-Raloxifene (Evista)
PTH- Forteo Subcut
Bisphosphonates- Fosamax,Boniva, Actonal
Reclast, Zometia
Calcitonin, Vit D
NSAIDs
Osteomyelitis
Infection of the bone
Endogenous:
Extension of soft tissue infection- infected pressure
ulcers or incision.
Blood borne (spread from other body sites)
At risk- poorly nourished, elderly, obese, impaired
immune systems, corticosteroid therapy, chronic
illnesses.
Prevention- proper tx. of infections, aseptic post op
wound care
Exogenous:
Organism enters from outside the body. Eg. Open fx
Osteomyelitis
Signs and symptoms-
High fever, chills, increased HR, general
malaise, swelling, tenderness, heat and
erythema, painful movement.
Draining ulcers, bone pain
Dx- increased WBCs, elevated ESR, positive
blood cultures, X-rays, bone scan, MRI.
Osteomyelitis Tx
Long term IV antibiotics
Hickman or other CVAD catheter
Strict sterile technique for tx
Hyperbaric oxygen tx
Surgery- bone exposed and necrotic tissue
removed, debridement, bone grafts,
amputation
Contusions, Strains, Sprains
Contusion-soft tissue injury, hematoma,
ecchymosis.
Strain- muscle pull over use over stretching.
Sprain an injury to ligaments surrounding
joint, caused by twisting.
Management- RICE = rest, ice, compression,
elevation.
Orthopedic Injuries
Joint dislocation- out of joint. If not treated
promptly, avascular necrosis can occur.
Reduced- put back in place = closed
reduction. Neurovascular status- check.
Rotator cuff injury/tear
Tennis elbow
Ligament injuries
Fractures (Fx)
Decreased sensation
Skin breakdown