1. Nursing intervention: teach prevention of ssteoporosis and its damage
   1. education
      1. increase awareness
      2. discourage risk-related behaviors
      3. reinforce positive behaviors and lifestyles
   2. reduce risk of falling
      1. teach proper lifting and movement techniques (illustration)
      2. encourage proper footwear
      3. install safety equipment in home
         
2. Paget's disease (osteitis deformans)
3. Definition: a slowly progressing resorption and irregular remodeling of bone.
4. Etiology
   1. bone resorbed; new bone poorly developed, weak, easily fractured
   2. mainly affects major bones: skull, femur, tibia, pelvis, and vertebrae 
   3. cause unknown
   4. possible viral implications
   5. family tendency - noted in siblings
5. Findings
   1. asymptomatic initially
   2. musculoskeletal
      1. deformity of long bones
      2. pain and point tenderness of affected limbs
         
6. Diagnostics
   1. radiographic findings
      1. bowing of long bones
      2. thickened areas of bone
      3. pathological fractures
      4. sclerotic changes
   2. laboratory analysis
      1. increased alkaline phosphatase means osteoblasts more active
      2. increased urinary hydroxyproline means osteoblasts more active
      3. serum calcium level will be normal
         
7. Management
   1. only treat if symptomatic
   2. conservative intervention
      1. medication
         • NSAIDs
         • calcitonin (osteocalcin) (illustration)
           • slows bone resorption
           • allows normal lamellarbone development
         • disodium etidronate (EHDP)
           • rapidly slows bone resorption
           • lowers levels of alkaline phosphataseand urinary hydroxyproline
           • may relieve pain
         • plicamycin (mithracin)
           • antibiotic
           • used only when Paget's disease bone is damaging nerves
   3. surgery
      1. reduce pathological fractures
      2. correct secondary deformity
      3. relieve neurologic impairment
      4. complications common
         • nonunion
         • malunion
           

8. Orthopedic Surgery

   1. Total hip replacement (illustration)
      1. Indications for surgery
         1. osteoarthritis
         2. rheumatoid arthritis
         3. femoral neck fractures
         4. avascular necrosis of femoral head caused by steroids
         5. failure of previous prosthesis
      2. Surgical modalities 

a.                  total hip replacement (hip arthroplasty) is the replacement of both articular surfaces of the hip joint, the acetabular socket and the femoral head and neck.

b.                  hemiarthroplasty of the hip is the replacement of one of the articular surfaces, usually the femoral head and neck.

3. Surgical and immediate postoperative care
   1. in first 24 hours, expect wound to drain blood and fluid up to 500ml.
   2. by 48 hours, wound drainage should be minimal
   3. clients may require transfusions (autologousis preferred) due to blood loss during surgery.
   4. best pain management is patient controlled analgesia (PCA) for the first 48 hours, advancing to non-narcotic oral analgesics by the fourth or fifth postoperative day.
   5. monitor for signs of deep venous thrombosis (DVT) and pulmonary embolism (PE) or fat embolism
   6. monitor neurovascular status of affected limb; color, temperature, presence of pulses.
4. Postoperative complications 
5. Nursing interventions
   1. an abduction deviceis used during the first postoperative week while the client is in bed or sitting in a chair
   2. to keep abduction device in place, turn client by logrolling
   3. to prevent flexion of the hip, use fracture bedpan
   4. client teaching
      1. use of assistive devices; crutches, walker, raised toilet seat
      2. methods to prevent dislocation
      3. can resume sexual activity when suture line heals. To avoid flexion of hip, client should be in dependent position for three to six months
         
1. Total knee replacement
   1. Indications for surgery
      1. osteoarthritis
      2. rheumatoid arthritis
      3. trauma
   2. Surgical modalities
      1. metal or acrylic prosthesis, hinged or semiconstrained
      2. choice of prosthesis depends on the strength of surrounding ligaments to provide joint stability
   3. Postoperative complications 
   4. Nursing interventions (knee replacement)
      1. for first 24 to 48 hrs, apply ice to the knee to minimize bleeding and edema
      2. in first eight hours, expect wound drainage up to 200 ml.
      3. by 48 hours, expect minimal wound drainage
      4. transfusions are rarely required
      5. within 24 hours, start aggressive physical therapy to promote knee flexion
      6. frequently health care provider prescribes a continuous passive motion machine (CPM)
      7. health care provider prescribes the amount of flexion and extension, measured in degrees, and increases that amount as client tolerates more
      8. when the CPM machine is not in use, a knee immobilizer is used
      9. keep leg elevated when the client is out of bed
      10. on first post-op day, client will begin to use crutches or walker
      11. best pain management is patient controlled analgesic (PCA) for the first 48 to 72 hours postoperatively. By fifth post-op day, nonnarcotic oral analgesia.
      12. monitor limb's neurovascular status, color, temperature, and pulses
      13. monitor for signs of DVT or PE
          
2. Amputation
   1. Purpose: relieve findings; improve function; save or improve quality of life
   2. Lower extremity indications
      1. progressive peripheral vascular disease (often secondary to diabetes mellitus)
      2. gangrene
      3. trauma such as crushing injuries, burns, or frostbite
      4. congenital deformities
      5. malignant tumor
   3. Upper extremity indications
      1. trauma
      2. malignant tumor
      3. infection
      4. congenital malformations
         
   4. Levels of amputation 
      1. amputate to most distal point that will heal successfully
      2. determined by circulation and functional status
   5. Potential postoperative complications
      1. hemorrhage
      2. infection
      3. skin breakdown
   6. Nursing interventions
      1. pain management - usually relieved with narcotic analgesics
      2. may require evacuation of accumulated fluid or hematoma
      3. muscle spasms may be relieved by heat or changing position
      4. phantom limb pain
         1. may occur any time up to three months post amputation
         2. most common with above-knee (AK) amputations
         3. relieved with
            • stump desensitization by kneading, or massage
            • transcutaneous electrical nerve stimulation (TENS)
            • distraction
            • beta-adrenergic blocking agents for burning, dull pain
            • anticonvulsants for sharp and cramping pain