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Orthopedic 3

Nursing interventions
Risk for peripheral neurovascular deficit
1. check neurovascular status often
2. elevate limb above level of heart (except with compartment syndrome)
3. apply cold to minimize edema
Pain
1. assess level of pain with a scale of one to ten
2. manage pain
  1. with drugs
  2. reposition client
  3. pad any bony prominences
3. teach relaxation techniques
Client teaching
1. how fractures heal
2. why the fracture is being immobilized
3. how to bear weight and how much (if permitted)
4. how bones heal
5. how to use assistive devices to walk
Risk for infection
1. related to
  1. open fractures
  2. surgical intervention
  3. superficial/deep wounds
2. monitor for findings of infection
3. provide proper wound care
4. administer antibiotic therapy as indicated
Risk for impaired skin integrity
1. causes
  1. open fractures
  2. soft tissue injuries
  3. pressure areas
2. additional factors
  1. age - elderly
  2. general condition of client
  3. preexisting skin conditions or diseases
3. interventions
  1. mobilize the client as soon as possible
  2. turn the client often at least every two hours
  3. position the client properly with alignment in mind
  4. use orthopedic devices to limit skin impairment
Impaired gas exchange
1. accompanies chest trauma
2. client risks fat embolism
3. client risks deep venous thrombosis
4. interventions
  1. mobilize as soon as possible
  2. frequent and effective pulmonary toileting
Fractures: factors that affect healin
Degenerative Disorders
Definition
1. Slowly progressive disorders of articular cartilage and subchondral bone
2. Do not affect the joints symmetrically (e.g., not necessarily both knees)
3. Worsen progressively
4. Eventually incapacitate, despite treatment
Osteoarthritis (OA)
1. Definition - degeneration of the articular cartilage and formation of new bone in the subchondral margins of the joint
2. Findings
  1. primarily involves weight-bearing joints
  2. non-inflammatory disorder
  3. localized: no systemic effects
  4. results in an abnormal distribution of stress on the joint
3. Incidence
  1. most common form of arthritis
  2. may begin as early as the 20s and peaks in the 60s
  3. by age 70, nearly 80% of afflicted people show findings
  4. over age 55, OA affects twice as many women as men
  5. two types: primary and secondary
1. Pathophysiology
  1. stage one: microfracture of the articular surface
    1. articular cartilage is worn away
    2. condyles of bones rub together: joint swells and is painful
    3. cartilage loses cushioning effect: joint friction develops
    4. prostaglandins may accelerate degenerative changes
  2. stage two: bone condensation
    1. erosion of cartilage
    2. cartilage may be digested by an enzyme in the synovial fluid
  3. stage three: bone remodeling
    1. matrix synthesis and cellular proliferation fail
    2. eventually the full thickness of articular cartilage is lost
    3. bone beneath cartilage hypertrophy and osteophytes form at joint margins
    4. result: joint degenerates
1. Findings
  1. joint stiffness after periods of rest
  2. pain in a movable joint, typically worse with action, relieved by rest
  3. paresthesia
  4. joint enlargement: bones grow abnormally; spurs form and synovitis sets in.
    1. Heberden's nodes
    2. Bouchard's nodes
  5. joint deformities
  6. tenderness on palpation
    1. may involve widely separated areas of the joint
    2. mild synovitis may be felt - positive bulge sign may be found
  7. pain on passive movement
  8. limitation in active range of motion because
    1. joint surfaces no longer fit
    2. muscles spasm and contract
    3. joints are blocked by osteophyte, loose bodies
    4. crepitation, crunching when joints are moved
    5. eventual ankylosis
  9. gait
    1. abnormal antalgic gait
    2. shortened stance
    3. widened base of support
    4. shortened step length

Diagnostics

to rule out autoimmune disorders
1. sedimentation rate
2. rheumatoid factor
3. c-reactive protein
CBC
1. analyze before NSAID therapy
2. within normal limits
kidney and liver
1. especially in older clients, analyze before starting NSAID therapy
2. repeat every six months
purified protein derivative (PPD)
1. analyze before starting steroids
2. clients testing positive for tuberculosis must receive INH at same time as steroid.
antinuclear antigen (ANA) titer
1. may be lower in the elderly
2. does not necessarily prove a connective-tissue disease
synovial fluid analysis distinguishes osteoarthritis from rheumatoid arthritis.
radiographs
1. taken in standing, weight-bearing condition
2. shows the prime sign of OA: joint space narrowing
3. x-ray does not necessarily reflect severity of disease
4. joint loses space asymmetrically because cartilage narrows from production of osteophytes or bone spurs
5. later stages may show bony ankylosis, spontaneous fusion
bone scans
1. radionuclide imaging
2. shows skeletal distribution of osteoarthritis
3. monitors complications of joint replacement surgery
MRI scans show the extent of joint destruction
computerized tomograms (CT) scans show cortical and cancellous bone density

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