CHAPTER 46 Bone and Soft Tissue Disorders PDF

LEARNING OUTCOMES Explain the pathophysiology, signs and symptoms, and complications of fractures. Plan nursing care for a patient in a splint, cast, traction, or external fixation. Describe the causes and prevention of osteomyelitis. Plan nursing care for osteomyelitis. Describe risk factors, pathophysiology, treatment, and nursing care for osteoporosis. Describe the pathophysiology, treatment, and nursing care for gout. Compare the care for osteoarthritis and rheumatoid arthritis. Plan nursing care for the patient with a fractured hip. Plan nursing care for a patient having a total joint replacement. Explain patient teaching for a patient with a lower extremity amputation and prosthesis. BONE AND SOFT TISSUE DISORDERS Strains A strain is a soft tissue injury that occurs when a muscle or tendon is excessively stretched. Causes of strains include falls, excessive exercise, and lifting heavy items. A mild strain causes minimal inflammation with swelling and tenderness. A moderate strain involves partial tearing of muscle or tendon fibers, causing pain and inability to move the affected body part. The most severe strain occurs when a muscle or tendon is ruptured, with separation of muscle from muscle, tendon from muscle, or tendon from bone. This can cause severe pain and disability. RICE is an acronym for Rest, Ice, Compression, and Elevation, which is the therapy for strain injuries. Immediately after a strain, the injured area should be Rested to protect it. Ice should be applied for 15 to 20 minutes, four times a day to decrease swelling and pain. Applying an elastic bandage for Compression and Elevating the affected area (if appropriate) supports the strained area and reduces swelling. After swelling stops, heat application (15 to 30 minutes four times a day) increases blood flow to the injured area for healing. Activity is limited until the soft tissue heals. NSAIDs and muscle relaxants may be prescribed. Severe strains may need surgical repair. Sprains A sprain is excessive stretching of ligaments from twisting movements during sports, exercise, or a fall. A mild sprain involves the tearing of a few ligament fibers, causing tenderness. RICE and NSAIDs are used for several days until swelling and pain diminish. In a moderate sprain, more fibers are torn but the joint remains stable. Moderate sprains may need immobilization with a brace or cast. A moderate sprain is uncomfortable, especially with activity. A severe sprain causes instability of the joint and usually requires surgical intervention for tissue repair or grafting. Pain and inflammation restrict mobility. Dislocations A dislocation is a common injury in which the ends of the bones (joints) are moved out of their normal position, usually caused by trauma or a disease such as rheumatoid arthritis. Severe pain, loss of range of motion of the joint, and joint deformity occur. Keep the joint immobile and apply ice. Immediate medical treatment is required to preserve function. Do not move the joint, as blood vessels, muscles, and nerves could be damaged. BE SAFE! BE VIGILANT! For patients with disease processes that could result in a dislocation or fracture, careful moving is essential. Use lifting devices such as draw sheets and mechanical devices when moving a patient rather than pulling on the patient’s extremities to avoid patient injury. Follow institutional policy for moving patients to avoid patient injury and liability for a patient’s injury. Bursitis Bursae (fluid-filled sacs) cushion tendons during movement to prevent friction between bone and tendon. Several joints have bursae (e.g., shoulder, elbow, hip, knee, ankle, heel). Inflammation of a bursa is called bursitis. It occurs from arthritis, gout, repetitive movement, infection, or sleeping on one’s side that compresses the shoulder bursa. Prevention is key because bursitis may become harder to cure over time. Educate patients to stretch and strengthen muscles, move frequently, avoid repetitive movements for long periods, use cushioned seats, and avoid leaning on the elbows. Symptoms of bursitis include achy pain, stiffness, swelling, redness, or burning pain over the joint area that worsens with activity. Usually, pain decreases in about a week. The condition can become chronic if it lasts more than 6 months. Treatment includes resting the joint and applying ice several times per day until joint warmth is gone, then switching to heat. Elevating the joint, ultrasound, massage, NSAIDs, antibiotics for infection, and physical therapy may also be used. Rotator Cuff Injury Short tendons that are connected to muscles around the shoulder form the rotator cuff. The cuff covers the top, front, and back of the shoulder. Muscle contraction causes these tendons to tighten and move or rotate the shoulder. Various cuff injuries can occur. With chronic impingement syndrome, the top tendon of the cuff (supraspinatus tendon) and bursae become impinged in the narrow space under the acromion bone. This causes inflammation when the arm is repeatedly moved forward, and pain results. Over time, the tendon can tear from the bone. Symptoms of rotator cuff injury include shoulder ache, increased pain with lifting arm, pain that worsens at night, weakness, and limited range of motion. Magnetic resonance imaging (MRI) diagnoses the injury. For minor injury, resting the shoulder, ice, NSAIDs, and physical therapy are recommended. For severe injury, arthroscopic surgery relieves impingement or repairs the tear. A sling or special brace is worn after surgery. Physical therapy is prescribed for rehabilitation. Carpal Tunnel Syndrome Carpal tunnel syndrome results in compression of the median nerve within the carpal tunnel caused by swelling, which can result from edema, trauma, rheumatoid arthritis, or repetitive hand movements (repetitive motion injury) used in some occupations such as typing. Preventive measures include alternating nonrepetitive tasks with repetitive movements and using ergonomically appropriate devices to minimize the pressure placed in the area of the wrist. Slow-onset finger, hand, and arm pain and numbness may occur. Painful tingling and paresthesia may also be present. Eventually, fine motor deficits and then muscle weakness may develop. Diagnosis is based on signs and symptoms, patient history, and a positive Phalen test (numbness with wrist flexion). Electromyography detects nerve abnormalities. Treatment initially aims to relieve the inflammation and rest the wrist using a splint. NSAIDs or cortisone injection into the tunnel reduce inflammation and pain. Endoscopic or open incision surgery may be needed to release the median nerve from compression. After surgery, elevate the patient’s hand. Explain the use of a splint as ordered. Teach the patient to restrict lifting for several weeks and report symptoms of neurovascular compromise such as numbness and tingling, coolness, lack of pulse, pale skin or nailbeds, or limited movement. Physical therapy helps recover extremity function. Fractures A fracture is a break in a bone that can be minor and treated on an ambulatory basis or complex and treated with surgical intervention and rehabilitation. WORD BUILDING arthritis: arthr(on)—joint + itis—inflammation Pathophysiology Bone is a dynamic, changing tissue. When it is broken, the body immediately begins to repair the injury (Fig. 46.1). For an adult, within 48 to 72 hours after the injury, a hematoma (blood clot) forms at the fracture site because bone has a rich blood supply. Various cells that begin the healing process are attracted to the damaged bone. In about a week, a nonbony union called a callus develops and is seen on x-ray examination. As healing continues, osteoclasts (bone-destroying cells) resorb necrotic bone, and osteoblasts (bone-building cells) make new bone as a replacement. This process is referred to as bone remodeling. Young, healthy adult bone completely heals in about 6 weeks; however, it can take up to a year before the whole process of remodeling is complete. An older person’s bones take longer to heal. Adequate nutrition that includes vitamins, minerals, and protein is essential to heal fractures (see Chapter 45). FIGURE 46.1 Fracture healing phases. Etiology and Types Fractures are caused by a fall, an accident, or a crushing injury. Bone disease, such as osteoporosis; metastatic bone cancer; malnutrition; and regular intake of carbonated beverages containing phosphoric acid (which may interfere with calcium absorption) can lead to fractures. Side effects from some medications can cause a decrease in bone density, resulting in fracture. When fractures result from disease, they are referred to as pathological fractures. There are many types of fractures (Table 46.1). Fractures can be described by the way the bone breaks (spiral or oblique; Fig. 46.2). In a complete fracture, the bone is broken into two pieces. Complete fractures have the potential to be life threatening, as sharp bone fragments can sever blood vessels and nerves. In an incomplete fracture, the bone does not divide in two. With a displaced fracture, bone sections are out of alignment. In a closed fracture, the bone does not disrupt the skin. In an open fracture, the bone breaks through the skin, creating infection risk. Signs and Symptoms This section focuses on fractures of upper and lower extremities. If the patient sustains a hairline (microscopic) fracture, signs and symptoms are not readily observable. The patient may report tenderness over the site of the injury or more severe pain when moving the affected part of the body. The patient with a hip fracture usually experiences pain either in the groin area (the hip is a deep joint) or at the back of the knee (referred pain). If the fracture is complete, the limb is often shortened because of contraction of the muscles pulling on the bone sections. In addition to pain, patients with complex fractures experience limb rotation or deformity and shortening of the limb (if a limb bone is broken). Range of motion is decreased. With movement, a continuous grating sound (crepitation) caused by bone fragments rubbing on each other may be heard. Do not move the extremity, as damage could occur to nerves and blood vessels. Inspect the skin for intactness. An open fracture creates a wound. A patient with a closed fracture may have ecchymosis (bruising) over the fractured bone from bleeding into the soft underlying tissue. Swelling may also be present and can impair blood flow, causing marked neurovascular compromise. CUE RECOGNITION 46.1 You are caring for a patient with an open fracture to the left foot that required surgery. What priority care do you provide to prevent a complication? Suggested answers are at the end of the chapter. Table 46.1 Types of Fractures Fracture Type Description Avulsion A piece of bone is torn away from the main bone while still attached to a ligament or tendon. Comminuted Bone is splintered or shattered into numerous fragments. Often occurs in crushing injuries. Impacted Bone is forcibly pushed together, resulting in bone being pushed into bone. Greenstick Bone is bent and fractures on the outer arc of the bend. Often seen in children. Interarticular Fracture involves bones within a joint. Displaced Bone pieces are out of normal alignment. One or more pieces may be out of alignment. Pathological (also called neoplastic) Caused when bone is weakened either by pressure from a tumor or an actual tumor within the bone. Spiral Fracture curves around the shaft of the bone. Longitudinal Fracture occurs along the length of the bone. Oblique Fracture occurs diagonally or at an oblique angle across the bone. Stress Results in the bone being fractured across one cortex. This is an incomplete fracture. Transverse Bone is fractured horizontally. Depressed Bone is pushed inward. Often seen with skull and facial fractures. Diagnostic Tests An x-ray can visualize bone fractures, malalignment, or disruption. A computed tomography (CT) scan detects fractures of complex areas such as the hip and pelvis. MRI shows the extent of associated soft tissue damage. Serum calcium level may be ordered to determine baseline values for bone repairs. With moderate to severe bleeding, hemoglobin and hematocrit levels are checked. Emergency Treatment Box 46.1 describes urgent care for the patient with an extremity fracture. A patient with a fracture often has other injuries. Observe the patient for respiratory distress, bleeding, and head or spine injury. Emergency care for these problems is provided prior to fracture care. LEARNING TIP For emergency care of a suspected fracture, do not try to reposition the limb. Remember: Splint it as it lies. Ensure that the limb is secured above and below the fracture to minimize movement. Fracture Management The goals of fracture management are reduction (alignment) of bone ends; immobilization of the fractured bone; preservation or restoration of surrounding soft tissue structures, such as vessels, tendons, ligaments, and muscles; prevention of deformity or further injury; preservation or restoration of function; promotion of early healing; and pain relief. CLOSED REDUCTION. Closed reduction is the most common treatment for simple fractures. Analgesia and/or procedural sedation is given before the procedure. While manually pulling on the bone (limb), the health-care provider (HCP) manipulates the bone ends into alignment. An x-ray confirms that the bone ends are aligned before the area is immobilized by a splint or cast. SPLINTS. An elastic wrap and splint may be used to immobilize the bone during the healing phase. Splints are used when there is a wound to care for or a need to allow for swelling. Perform neurovascular checks hourly to monitor adequate blood flow to the area until the concern for swelling is over (see Chapter 45). FIGURE 46.2 Types of fractures. CASTS. Casts provide stronger support than splints for fractured bones. Plaster or fiberglass casts are typically used. As casts dry, heat is produced. Plaster cast drying can take 24 to 72 hours. The plaster cast is dry when it is hard, firm, odorless, and shiny white. Synthetic material casts such as fiberglass harden quickly and dry in less than 2 hours. Box 46.2 and Figure 46.3 present care for a patient with a cast. A serious complication of a too-tight cast is compartment syndrome (discussed later). If the cast becomes too tight, it must be cut (bivalved) with a cast saw, per HCP orders, to relieve pressure and prevent necrosis of the underlying skin. If a wound is present or an odor is detected, a window opening into the cast is created to allow treatment of the skin. When wound care is not being provided, the cast window should always be taped in place to prevent the skin from “popping up” through the window and developing pressure points and ischemia. TRACTION. Traction is the application of a pulling force with prescribed weights to part of the body to position and hold bone fragments in correct alignment. Advances in orthopedic surgery have made traction primarily a temporary measure. Buck traction is skin traction, with 5- to 10-pound (2.2 to 4.5 kg) weights; it is used for patients with hip fractures to relieve muscle spasms and stabilize the fracture until surgery can be performed. Skeletal traction uses pins, wires, or tongs inserted into the bone for bone alignment as the fracture heals. Extremity skeletal traction is maintained with 20- to 40-pound (9 to 18 kg) weights that must hang freely at all times. Box 46.1 Urgent Management of Fractures Immediately immobilize the affected limb. If movement is required for splinting, support the limb above and below the fracture. Unless there is bleeding, apply splints and padding above and below the fracture site, directly over the clothing. For bleeding, the site may need to be seen before pressure can be applied to the origin of the bleeding. Keep the patient covered to preserve body heat. If the fracture is in the leg, the other leg can be used as a splint by bandaging both legs together if needed. An arm can be bandaged to the chest or put into a sling to minimize further tissue damage. Monitor color, warmth, circulation, and movement of the limb distal to the fracture. For an open fracture, cover protruding bone with a clean (sterile preferred) dressing. Do not attempt to straighten or realign a fractured extremity. Move the affected limb as little as necessary. If not in a hospital, transport for emergency medical care as soon as possible. Box 46.2 Nursing Interventions for a Patient With a Cast Monitor the following: Neurovascular checks 1 to 2 hours for 24 hours, then four times a day and as needed Cast for tightness (ask patient), and ask patient to move all digits distal to the cast Patient comments about the cast to take action to prevent complications Fiberglass casts dry within 15 to 30 minutes. Plaster casts may take 24 to 36 hours to dry. With newly applied casts, when drying: Do not grasp a wet cast to hold or move it. Use only the palms of the hands, as finger pressure on a wet cast can cause pressure points on the inside cast surface. Position cast on absorbent surface; do not place it on a surface that can cause an indentation. Placing on a pillow while drying traps heat and increases thermal injury risk. Inform the patient that the cast creates heat when drying. Thermal injuries can occur. Ensure a cast air dries (may require 24 to 72 hours for complete drying). Do not cover a cast, but keep it open to the air. Do not use drying aids such as hot blow dryers, which add more heat. If the patient is lying, assist the patient to turn every 1 to 2 hours to prevent flattening of a plaster cast surface during drying. Reduce swelling (essential for the first 48 hours): Elevate extremity above the patient’s heart level. Elevate casted arm while walking. Ice cast (first 48 hours). Can use ice packs, bags of frozen vegetables or leakproof plastic bags of ice wrapped with a towel. For casted arm, pump fingers 10 times per hour while awake. Maintain tissue integrity within the cast: Check visible skin for signs of impaired integrity. Ensure cast edges are smooth; cover with stockinet or gauze to prevent skin rubbing. Educate patient to keep cast dry; during bathing, cover with plastic and rubber band or tape ends. Monitor for signs of infection, such as foul odor, warmth, redness, and pain. Do not use skin products on affected limb. Monitor visible blood on the surface of the cast. Outline area with a pen to observe for increasing size. Shadowing of blood not quite reaching the surface of the cast is common but also should be circled and monitored. Never place an object inside the cast, and instruct patient not to do so. Explain the risk of tissue damage and infection. For itching, teach patient to try a blow dryer to blow cool air into the cast or tapping on the cast. Diphenhydramine may be helpful. OPEN REDUCTION WITH INTERNAL FIXATION. The fractured bone ends are reduced (aligned) by direct visualization through a surgical incision (open reduction). Bone ends are held in place by internal fixation devices such as metal plates and screws or by a prosthesis with a femoral component similar to that used for total joint replacement (Fig. 46.4). For hip surgery, the internal fixation device remains after the fracture heals. For ankle or long-bone surgery, hardware may need to be removed after healing due to loosening or pain. One of the most common indications for this surgical procedure is a fractured hip involving the proximal femur. Hip fractures affect older adults more than any other age group. Healthy People 2030 has an objective to reduce hip fractures among older adults (Office of Disease Prevention and Health Promotion, 2020). Open reduction with internal fixation of the hip allows early ambulation while the bone is healing. Monitor pain level and give analgesics for postoperative pain especially prior to activity such as physical therapy. Use a fracture bedpan as needed for ease and comfort. Apply thigh-high compression stockings or sequential compression device to unaffected limb as ordered. Remind the patient to practice leg exercises, and promote early ambulation as ordered. Administer anticoagulants as ordered to prevent blood clots. EXTERNAL FIXATION. External fixation is used when bone damage is severe, as in crushed or splintered fractures, or if the bone has numerous breaks. After the fracture is reduced, the surgeon inserts pins into the bone. The pins are held in place by an external metal frame to prevent bone movement (Fig. 46.5). External fixation allows visualization of soft tissue damage that also requires treatment. See “Nursing Care Plan for the Patient With External Fixation of the Lower Extremity.” FIGURE 46.3 A wet plaster cast is moved with the palms of the hand to prevent making indentations in the plaster that could become pressure points. FIGURE 46.4 Internal fixation. (A) Intertrochanteric fracture of the hip with fracture fixation via a side plate and screw combination device. (B) Side plate and screw fixation of radial fracture. FIGURE 46.5 External fixation for complex fractures and wound care. CLINICAL JUDGMENT Mrs. Martinez, a rehabilitation center resident, was found at 1900 lying on her left side, moaning and holding her left leg. She cried out with any movement and said she fell and her leg hurts. Vital signs are blood pressure 150/84 mm Hg, pulse 100 beats per minute, and respirations 20 breaths per minute. Her left leg is noticeably shorter than her right leg. The supervisor notified paramedics and the HCP. The licensed practical nurse (LPN) remained with Mrs. Martinez and instructed her not to move until help arrived. The LPN got blankets and a pillow for her head. At 1925, the paramedics took Mrs. Martinez to the hospital, where she was diagnosed as having an incomplete femoral neck (hip) fracture. Five pounds of Buck traction until surgery the next morning was applied. How does the LPN at the rehabilitation center document Mrs. Martinez’s fall? What data does the nurse at the hospital monitor for the Buck traction on Mrs. Martinez? Suggested answers are at the end of the chapter. CRITICAL THINKING Mr. Schnell, age 18, was in a motor vehicle accident that resulted in a fractured pelvis and an open right femoral fracture. Identify four priority nursing diagnoses related to Mr. Schnell’s care. What are nursing interventions and rationales for these diagnoses? Suggested answers are at the end of the chapter. NURSING CARE TIP When moving a limb that has an external fixation device, grasp the device and lift, raise, or move the limb as needed. Grasping the device reduces movement of the healing bone, lessening both trauma to the healing site and pain with movement. Care must be taken not to loosen any fasteners holding the pins in place. Nursing Care Plan for the Patient With External Fixation of the Lower Extremity Nursing Diagnosis: Risk for Infection related to open skin at pin site Expected Outcome: The patient does not develop an infection. Evaluation of Outcome: Does the patient remain free from infection? Intervention Rationale Evaluation Inspect pin sites and dressings for signs of infection (e.g., warmth, redness, heat, edema, drainage, pain). Early and frequent inspection allows for timely intervention to prevent infection. Are pin sites infected? Provide pin-site care per agency policy using strict aseptic technique. The pin is a pathway for microorganisms to directly enter bone tissue and cause osteomyelitis. Aseptic technique reduces risk of infection. Are pin sites clean with no crusting? Nursing Diagnosis: Impaired Physical Mobility related to the limb injury Expected Outcome: The patient will maintain desired level of mobility and activity. Evaluation of Outcome: Has the patient maintained desired level of mobility and activity? Intervention Rationale Evaluation Monitor the patient’s mobility with external fixation (EF) device in place. Data concerning the patient’s abilities allow intervention planning. Does the patient transfer and ambulate with or without assistance? Collaborate with other disciplines in educating patient on moving limb with EF device to ambulate and transfer safely. Physiotherapy can provide initial teaching or reinforce education needed to promote ambulation (e.g., with crutch walking). Has the patient used information learned from other disciplines to move the extremity with EF device? PRACTICE ANALYSIS TIP Linking NCLEX-PN® to Practice The LPN/LVN will use safe client handling techniques (e.g., body mechanics). NONUNION MODALITIES. Most bones heal properly with treatment. However, malunion (malalignment of healed bone) or nonunion (delayed or no healing) can occur. Bone healing is affected by age, nutritional status, and diseases that alter the healing process, such as diabetes mellitus. Identification of the reason for nonunion allows the appropriate treatment selection. Treatment methods for nonunion can include electrical bone stimulation, bone grafting, or external fixation. Complications of Fractures Monitor the patient for possible complications. Although rare, acute compartment syndrome or fat embolism syndrome (more common with fractures of long bones) can be life-threatening complications of fractures. NEUROVASCULAR STATUS. Neurovascular checks are done to detect abnormalities. Decreased or absent pulses, cool skin temperature, and dusky color indicate circulation problems. Numbness and tingling and decreased sensation and mobility indicate neurologic changes. These findings should be reported to the HCP right away. HEMORRHAGE. Bone is highly vascular. Damage to or surgery on bone (particularly the femur) can cause bleeding. Monitor for bleeding and monitor vital signs. INFECTION. Trauma can lead to infection, especially when the skin, the body’s first line of defense, is not intact. Wound infections, pin-site infections, drainage tube infections, and osteomyelitis (bone infection) can occur. THROMBOEMBOLIC COMPLICATIONS. Deep vein thrombosis (DVT) or pulmonary embolus (see Chapter 31) can develop in patients having orthopedic surgery. Leg exercises, early ambulation, and prophylactic anticoagulant therapy (such as with rivaroxaban [Xarelto], dalteparin [Fragmin], apixaban [Eliquis], or enoxaparin [Lovenox]) help to prevent them. ACUTE COMPARTMENT SYNDROME. Compartments are sheaths of fibrous tissue that support and partition nerves, muscles, and blood vessels, primarily in the extremities (Fig. 46.6). Each extremity has several compartments. Acute compartment syndrome is a limb- threatening condition in which pressure in limb compartments increases. This causes reduced circulation to the compartment’s muscles and nerves. Trauma, tight splints, casts, or dressings are common causes. WORD BUILDING osteomyelitis: osteo—bone + myel—bone marrow + itis—inflammation FIGURE 46.6 (A) Lower leg compartments. Each compartment contains muscles, an artery, a vein, and a nerve. (B) Compartment syndrome. Increased pressure in a compartment compresses structures within the compartment. The early symptom of acute compartment syndrome is the patient’s report of severe, increasing pain that is not relieved with opioids and occurs more in active movements than passive movements. Decreased sensation follows before ischemia becomes severe. To save the limb, report early symptoms immediately! In severe acute compartment syndrome, the patient may have the six Ps if treatment did not prevent late symptoms: Pain (severe, unrelenting, and increased with passive stretching) Paresthesia (painful tingling or burning) Pallor (but there may be warmth or redness over the area) Paralysis (late symptom) Pulselessness (late and ominous sign) Poikilothermia (temperature matches environment, i.e., the extremity is cool to touch). CUE RECOGNITION 46.2 You are caring for a patient with a femur fracture who reports pain that has increased to a 10/10 in the extremity. You note a decreased pulse in the patient’s lower extremity. What action do you take? Suggested answers are at the end of the chapter. Immediate pressure relief is the goal, achieved by removing the source of pressure. The HCP may bivalve the cast or perform a fasciotomy, which is an incision into the fascia enclosing the compartment. Fasciotomy allows compartment tissue the ability to expand, which relieves the pressure. These surgical incisions are left open until the pressure decreases, then are closed. If this condition continues without pressure relief, tissue necrosis, infection, Volkmann contracture (permanent flexion of hand at the wrist), rhabdomyolysis (muscle breakdown releases myoglobin, which is harmful to the kidneys), or acute kidney injury may result. CLINICAL JUDGMENT Mr. Kardos has a fracture of his right tibia, which required application of a cast 3 hours ago. His toes are edematous. He received 1 mg of hydromorphone (Dilaudid) intravenously for pain of 6. Now, 30 minutes later, he is reporting unrelieved pain of 8. What data do you collect now? What recommendation do you make during your ISBARR communication with the HCP? Suggested answers are at the end of the chapter. WORD BUILDING fasciotomy: fascia—fibrous tissue + otomy—opening into rhabdomyolysis: rhabdo—striped + myo—muscle + lysis—break down FAT EMBOLISM SYNDROME. Fat embolism syndrome is a serious complication of fractures. Small fat droplets are released from yellow bone marrow into the bloodstream (Table 46.2). These droplets travel to the lung fields, causing respiratory insufficiency that can lead to respiratory failure. This process occurs with long-bone fractures (especially the femoral shaft) and perhaps when the patient has multiple fractures. The older adult patient with a fractured hip is also at a high risk for fat embolism syndrome. This condition can occur up to 72 hours after the initial injury. Table 46.2 Fat Embolism Syndrome vs. Pulmonary Embolism Fat Embolism Syndrome Pulmonary Embolism Origin Multiple small fat droplets Large blood clot or fat globule Cause Long-bone fractures; surgical fracture repair; multiple fractures Hip fracture Complication of deep vein thrombosis Signs and Symptoms Gradual onset with tachypnea, dyspnea, and cyanosis Sudden onset, shortness of breath, and chest pain The three primary manifestations of fat embolism syndrome are respiratory failure, cerebral involvement, and skin petechiae. Pulmonary dysfunction is the earliest sign and includes tachypnea, dyspnea, and cyanosis. Cerebral changes are often seen and include confusion or drowsiness. A petechial (red, measles-like) rash may occur on the chest, neck, and axilla. Conjunctiva appears in some patients. Other signs include tachycardia, fever, and retinal changes. If a fat embolism is suspected, notify the HCP immediately. Treatment interventions may include the following: Promote oxygenation by administering oxygen at 2 L/min via nasal cannula and apply a pulse oximeter. Place the patient in high-Fowler position or raise the head of the bed as tolerated. Maintain bedrest and minimize movement of the extremity. Obtain arterial blood gas. Initiate venous access for medications. Administer corticosteroids. Prepare patient for a chest x-ray and an MRI of the brain. Provide emotional support and a calm environment. Nursing Process for the Patient With a Fracture Caring for the patient with a fracture requires collaborative care with other health-care team members. DATA COLLECTION. Frequent checking of neurovascular status (e.g., circulation, sensation, mobility) distal to a fracture is vital to detect problems (see Chapter 45). Pain is monitored using appropriate pain rating scales. NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION. Determination of the appropriate nursing diagnosis depends on the location and type of fracture. See the “Open Reduction With Internal Fixation” section for nursing interventions. Acute Pain related to bone fracture or movement Expected Outcome: The patient will report pain relief on a scale of 0 to 10 or be rated as pain-free using a nonverbal pain rating scale for those who cannot report pain. Identify pain level using appropriate pain rating scale to establish baseline for further interventions. (See “Nursing Care Tip.”) Provide regularly scheduled pain rating to determine need for analgesics for those who cannot report pain to ensure pain is being relieved. Administer analgesics and NSAIDs as ordered to relieve pain and swelling. Ensure proper positioning and alignment to promote pain relief and promote future functioning of body part. Explain use of appropriate complementary methods for pain relief, such as heat or cold therapy, guided imagery, distraction, massage therapy, to maximize relief of pain. Impaired Physical Mobility related to bone fracture or pain Expected Outcome: The patient will demonstrate increased mobility. Observe the patient’s mobility level to provide baseline data. Utilize other disciplines, such as occupational and physiotherapy, and equipment, such as crutches, as needed, to encourage and promote patient mobility. Provide pain management prior to mobility to improve ability to move. Encourage independence to prevent contributing to immobility. Encourage active range-of-motion exercises to prevent or minimize alteration in joint function while immobile. Provide chair seat 3 inches above height of knee and raised toilet seat or commode with arms to improve the ability of the older adult to stand up from seated position. Risk for Peripheral Neurovascular Dysfunction related to increased tissue volume or restrictive envelope Expected Outcome: The patient will maintain peripheral pulses, warm skin, sensation, and ability to move extremity. Monitor for swelling of affected extremity (especially if the patient has a cast, splint, or tight dressing) to detect complications. Monitor for compartment syndrome signs and symptoms (swelling, increasing pain even after analgesics) to allow prompt reporting of abnormalities to HCP. Report abnormalities immediately to allow prompt treatment and prevent complications. Administer anti-inflammatory as ordered to reduce pain and swelling. Apply cold therapy to fracture site as ordered to decrease swelling and pain. EVALUATION. The outcome is met if the patient reports or demonstrates that pain is within tolerable levels on a pain rating scale, peripheral pulses, warm skin, sensation, and the ability to move extremity are maintained, and the patient demonstrates increased physical mobility. PATIENT EDUCATION. For the patient with a cast, teach cast care (see Box 46.2), wound care if needed, and care of the extremity after cast removal (Box 46.3). Teach patient signs and symptoms of infection to report. Explain the importance of adequate intake of protein, calories, vitamins, and minerals in healing. PRACTICE ANALYSIS TIP Linking NCLEX-PN® to Practice The LPN/LVN will: Provide care to an immobilized client based on need. Reinforce education to client regarding care and condition. Box 46.3 Extremity Care After Cast Removal Cleanse skin by soaking rather than rubbing skin to remove dry scales. The extremity may be weak, with decreased range of motion. Move it gently and use analgesics as needed. Support extremity when resting with pillows until strength and range of motion return. Ensure active and passive range of motion are performed as recommended by physical therapist. Osteomyelitis Osteomyelitis is an infection of bone that can be either acute (lasts less than 4 weeks) or chronic (lasts more than 4 weeks). NURSING CARE TIP A patient who is confused or comatose may not be able to report pain. This can be problematic, as the most reliable indicator of pain is the patient’s report. Nonverbal indicators (e.g., grimacing, restlessness, elevated blood pressure, and heart rate) are not reliable for pain identification and should not be used to assume the absence of pain. Use pain assessment tools designed for those who are cognitively impaired to ensure their pain is adequately relieved. The Pain Assessment in Advanced Dementia (PAINAD) scale, for example, was developed for this purpose. Share pain research findings with institution administrators to establish policies that support proactive pain management for all patients. Prevent pain by anticipating it and treating it in advance. This can be done by recognizing causes of pain and understanding that the effects of mild but repetitive pain (as in turning several times a day) can adversely affect the patient (e.g., by leading to exhaustion). Causes of pain include conditions or diseases (such as fractures, trauma, or cancer), procedures (such as surgery, turning, or wound care), and biomedical devices (such as fixation devices, wound drains, urinary catheters, nasogastric tubes, and chest tubes). With few patients routinely being medicated before painful procedures (some of which, like turning, may be done several times a day), patients who are confused or comatose are at greater risk for lack of pain relief. To keep patients comfortable, administer analgesics as ordered before painful procedures and on a regular basis when pain is assumed to be present. For anticipated pain, use the acronym APP (assume pain present). Pathophysiology Bone infection results from invasion of bacteria into the bone and surrounding soft tissues. Inflammation occurs, followed by ischemia (decreased blood flow; Fig. 46.7). Bone tissue becomes necrotic (dies), which impairs healing and furthers infection, often as a bone abscess. Etiology Injury to the body, such as an open fracture, allows pathogens direct access to bone tissue. Infection in another part of the body can travel to a bone. For instance, a patient with a total hip replacement may acquire osteomyelitis from a urinary tract infection. The most common pathogen causing osteomyelitis is Staphylococcus aureus. Signs and Symptoms The patient with acute osteomyelitis has site pain, redness, warmth, and swelling as well as fever. Ulceration, drainage, and localized pain are signs and symptoms of chronic osteomyelitis. FIGURE 46.7 Sequence of osteomyelitis development. (A) Infection begins. (B) Blood flow is blocked in the area of infection. An abscess with pus forms. (C) Bone dies within the infection site, and pus formation continues. Diagnostic Tests The patient with osteomyelitis may have an elevated white blood cell count, an elevated erythrocyte sedimentation rate (ESR), positive bone biopsy for infection, and positive blood cultures. MRIs, x-rays, and CT scans show infected areas. Therapeutic Measures Infection in bone tissue is difficult to resolve. Treatment is individualized. Curative therapy can include surgical debridement, reconstruction, and antibiotics. Palliative therapy is provided with chronic suppressive antibiotic therapy. Amputation is used for patients who have severe infections that have not responded to one or more of the conventional treatments. Nursing Care Patients on long-term IV antibiotics can receive them at home. The home health nurse provides education on action, side effects, toxicity, interactions, and precautions for antibiotic therapy. If a soft tissue wound is present, sterile technique is used for dressing changes. The home health nurse educates the patient and family on how to perform dressing changes, the importance of hand hygiene before dressing changes, and how to avoid the spread of pathogens. Osteoporosis Osteoporosis (porous bone) is a metabolic disorder characterized by low bone mass and deterioration of bone structure, resulting in fragile bones that are prone to fracture. The spine, wrist, and hip are most commonly involved, although all bones can be affected. Prevalence More than 54 million Americans have osteoporosis or low bone density (National Osteoporosis Foundation, 2021). Women are at greatest risk because their bones are smaller than men’s bones. As the U.S. population ages, incidence and cost of osteoporosis will rise. Healthy People 2030 osteoporosis objectives strive to increase the proportion of older adults who get screened for osteoporosis, reduce the proportion of adults with osteoporosis, and increase the proportion of older adults who get treated for osteoporosis after a fracture (Office of Disease Prevention and Health Promotion, 2020). This is important because hip or vertebral fractures are associated with reduced quality of life, increased disability, and increased risk of death, especially within the year after a hip fracture. Pathophysiology Bone is living tissue that is constantly resorbing (breaking down) old bone tissue (osteoclast cells) and building new bone tissue (osteoblast cells). Normally, the bone remodeling process is balanced. In osteoporosis, there is an imbalance. Bone density (mass) peaks between ages 30 and 35. After these peak years, the rate of bone breakdown exceeds the rate of bone buildup. For postmenopausal women, decreased estrogen appears to slow the absorption of calcium, leading to increased bone loss. Types and Risk Factors Osteoporosis is categorized as either primary or secondary. Primary osteoporosis, the most common, is not associated with another disease. Some risk factors for primary osteoporosis cannot be modified, such as age, White or Asian ethnicity, family history of osteoporosis or fractures, female gender, history of fractures, low testosterone and estrogen in men, postmenopausal status, and small-boned, petite body build. Modifiable risk factors for osteoporosis can be reduced with lifestyle changes. These include anorexia nervosa, cigarette smoking, excessive alcohol use, nutrition (e.g., low calcium or vitamin D intake; excessive caffeine, protein, or sodium intake), and sedentary lifestyle. Secondary osteoporosis results from an associated medical condition or procedure, such as hyperparathyroidism; renal dialysis; medication therapy with steroids, certain antiseizure medications, sleeping medications, aluminum-containing antacids, hormones for endometriosis, or cancer medications; and prolonged immobility, such as from a spinal cord injury. Prevention To protect against osteoporosis, healthy lifestyle and nutritional habits that build bone are especially important through age 30, before bone mass begins to decrease. These habits include consuming recommended amounts of calcium (1,000 mg/day for ages 19 to 50 and 1,200 mg/day for ages 50 and over) and vitamin D (600 IU [15 mcg]/day for ages 1 to 70 and 800 IU [20 mcg] for ages 71 and over) (National Institutes of Health, 2021). Additional healthy habits include performing weight-bearing exercises, avoiding alcohol, and not smoking. Signs and Symptoms Most people do not realize they have osteoporosis until they fracture a bone, have vertebral compression fractures, lose height (up to 6 inches), or develop a forward curvature of the spine (kyphosis). Pain may not be present. The patient may be embarrassed by the change in body image and curtail social activities. Some patients cannot find clothes that fit comfortably. General effects of the disease go beyond the obvious bone deformities, often affecting quality of life and causing acute or chronic pain. Physiological effects can include decreased respiratory capacity due to spinal deformities. It can be difficult to expand the lungs because of curvature of the spine or painful vertebral fractures. This can increase fatigue and the risk of pneumonia. Osteoporosis can be associated with chronic obstructive pulmonary disease (COPD) because of limited activity related to dyspnea and corticosteroid therapy (which breaks down bone). Functional abilities (activities of daily living [ADLs] and instrumental ADLs [activities individuals do to function independently and care for self, e.g., finances, shopping, meals, housekeeping, laundry, transportation, telephone communication]) may be limited, increasing the patient’s dependence. Emotional effects relate to body image changes, depression, or fear of breaking a bone such as during intimacy. Socialization may be reduced because of activity limitations or fear of injury. Because these effects are interrelated, data should be collected on the whole person, not just the disease, for treatment that will improve quality of life. Diagnostic Tests Dual-energy x-ray absorptiometry (DEXA) is the standard screening tool to measure bone density (see “Gerontological Issues: Osteoporosis”). This noninvasive scan is a low-dose x- ray and takes about 5 minutes to perform while the patient lies on a table. The DEXA scan identifies low bone density at the hip and spine. It also can show response to treatment. Serum calcium and vitamin D values can decrease, and serum phosphorus may be increased. With severe bone loss, alkaline phosphatase levels may be elevated, confirming bone damage. Gerontological Issues Osteoporosis Bone mineral density testing can help determine the risk of fractures for residents in long- term care. Providing treatment for osteoporosis can reduce the risk of hip fractures. Therapeutic Measures There is no cure for osteoporosis, but it can be treated. The cornerstone of treatment for osteoporosis is medication and controlling risk factors to prevent bone loss. MEDICATION. Supplements and medication are used for prevention or treatment. These include calcium supplements, vitamin D, antiresorptive medications, and bone-forming medications. If serum calcium falls below normal levels, the parathyroid glands stimulate bone to release calcium into the bloodstream. The result is demineralized bone. Therefore, calcium supplements to maintain normal levels and prevent bone loss are important. The patient is taught to drink plenty of fluids to prevent calcium-based urinary stones. Vitamin D supplementation, to aid calcium absorption, also may be needed. This is especially important for patients who have reduced exposure to sunlight (e.g., residents of long-term care facilities or northern geographical areas) or who cannot metabolize vitamin D. Antiresorptive Medications. Bisphosphonates bind to bone and suppress osteoclast activity to prevent or reduce bone breakdown in osteoporosis. They include alendronate (Fosamax, Fosamax Plus D), ibandronate (Boniva), risedronate (Actonel, Actonel with calcium), and zoledronic acid (Reclast). Side effects of bisphosphonates include bone, muscle, or joint pain; gastrointestinal upset; gastric ulcers; and, rarely, osteonecrosis (bone death) of the jaw. Reinforce teaching on exactly how to take the medication to reduce side effects. The tablet or solution form is taken after arising in the morning on an empty stomach with 6 to 8 ounces of water only. The patient should wait 30 minutes before taking other medications. To prevent esophageal reactions, the patient should remain upright for at least 30 minutes after taking the medication. Older adults should be monitored for increased risk of gastrointestinal reactions. The synthetic thyroid hormone calcitonin (Fortical, Miacalcin) treats osteoporosis by decreasing bone loss. It is used for women who have been menopausal for 5 years. The monoclonal antibody denosumab (Prolia) inhibits the protein that signals bone removal. Raloxifene (Evista) is a selective estrogen receptor modulator (SERM) that increases bone mass by 2% to 3% each year. SERM medications are designed to mimic estrogen in some parts of the body while blocking its effects elsewhere. Estrogen therapy may be used to prevent the bone loss that occurs with menopause as estrogen levels fall. However, other treatments are usually considered first due to risk factors associated with estrogen therapy. Anabolic (Bone-Forming) Medications. Teriparatide (Forteo) is used for men and women who are at great risk for fracture. Teriparatide increases bone mass by increasing the action and number of osteoblasts that form bone. It should not be taken for more than 2 years. DIET. Increasing calcium and vitamin D intake are the main dietary considerations. Inform patients of foods that are high in calcium, such as dairy products, sardines, salmon, fortified breakfast cereals, and dark green, leafy vegetables. EXERCISE. Weight-bearing exercise, especially walking, stimulates bone building. The patient should wear well-supporting, nonskid shoes and avoid uneven surfaces that could cause falls. Exercise such as weight training is also beneficial (see “Gerontological Issues: Falls”). Gerontological Issues Falls Falls become more common as people age. Exercise that focuses on strength, balance, agility, and coordination is one way of reducing falls in older adults. Fall Prevention Osteoporotic bone may cause a pathological fracture, in which the hip breaks and causes a fall. On the other hand, a fall can cause a hip or other fracture. Therefore, fall prevention programs in health-care facilities are important. A walker or cane can provide support during ambulation. For the patient’s home, the patient and caregivers are taught to create a hazard-free environment, without slippery floors, rugs, clutter, and other obstacles. PRACTICE ANALYSIS TIP Linking NCLEX-PN® to Practice The LPN/LVN will: Provide for mobility needs (e.g., ambulation, range of motion, transfer, repositioning, use of adaptive equipment). Ensure availability and safe functioning of client care equipment. Nursing Care Nursing care for osteoporosis focuses on education for prevention, providing pain relief and support for symptoms, and medication teaching. For more information, visit the National Osteoporosis Foundation at www.nof.org. Paget Disease Paget disease is a rare metabolic bone disease. Increased breakdown and formation of bone results in weak, abnormal bones. This causes severe bone pain, deformities and fractures, and osteoarthritis. There is no cure for Paget disease. Older adults and men are mainly affected. X-rays show bones with punched-out areas. Increased serum alkaline phosphatase levels occur due to osteoblast activity. NSAIDs are given for pain control, and bisphosphonates reduce bone resorption. Calcitonin (Fortical, Miacalcin) decreases bone loss. Exercise helps maintain bone health and joint mobility. Nursing care promotes pain relief, teaching, and quality of life. Bone Cancer Bone tumors may be benign or malignant. Malignant tumors are primary (begin in the bone) or metastatic (migrate to bone from another site). Metastatic lesions often affect older adults. Osteosarcoma, or osteogenic sarcoma, is the most common malignant bone tumor. It occurs mainly in the ends of long bones, usually near the knees. It typically affects young people between ages 10 and 25 and males more than females. Swelling, bone pain, and/or pathological bone injury are common symptoms. It is treated with chemotherapy and radiation. Ewing sarcoma is a rare bone tumor or tumor of the soft tissue around bone. In addition to bone pain and swelling, low-grade fever, fatigue, and weight loss are common. The legs, pelvis, ribs, arms, and spine are affected, most often in those ages 10 to 20. Chemotherapy and radiation are used; then, if necessary, surgery is performed. Primary malignant tumors that occur in the prostate, breast, lung, and thyroid gland are called bone-seeking cancers because they migrate to bone more than any other primary cancers do. With metastasis, multiple sites in the bone are typically seen. Pathological fractures and severe pain are major concerns in managing metastatic disease (see Chapter 11). Signs and Symptoms Primary tumors cause pain and swelling at the site. A tender, palpable mass is often present. Metastatic disease is not as visible, but the patient reports diffuse severe pain, eventually leading to marked disability. Diagnostic Tests Diagnosis of bone cancer is made with x-ray, CT scan, bone scan, bone biopsy, positron emission tomography (PET) or PET-CT scan, or MRI (see Chapter 45). Patients with metastatic disease have elevated alkaline phosphatase levels and possibly an elevated ESR, indicating secondary tissue inflammation. WORD BUILDING osteosarcoma: osteo—bone + sarc—flesh + oma—tumor Therapeutic Measures Treatment of primary bone tumors is usually surgery with chemotherapy or radiation. Chemotherapy and surgical excision of the affected bone with bone grafting or amputation of the affected limb are common treatments for osteosarcoma. For patients with Ewing sarcoma or early osteosarcoma, external radiation may be the treatment of choice to reduce tumor size and pain. For metastatic bone disease, surgery is not appropriate. External radiation is given, primarily for palliation to shrink the tumor and reduce pain. Nursing Care Nursing care for the patient with bone cancer is similar to care for other types of cancer (see Chapter 11). Care of the postoperative patient is similar to that for any patient undergoing musculoskeletal surgery. Monitoring the neurovascular status of the operative limb is a vital nursing intervention (see Chapters 12 and 45). CONNECTIVE TISSUE DISORDERS Connective tissue disorders comprise more than 100 diseases in which the major signs and symptoms result from joint involvement. Some affect only one part of the body; others affect many body organs and systems. Gout, osteoarthritis, and rheumatoid arthritis are discussed. Gout Gout is an easily treated systemic connective tissue disorder occurring from the build-up of uric acid. Men, especially those middle aged and older, are most affected. Pathophysiology Uric acid is a waste product resulting from the breakdown of proteins (purines) in the body. Urate crystals are formed because of excessive uric acid build-up (hyperuricemia). They are deposited in joints and other connective tissues, causing severe inflammation (Fig. 46.8). The inflammation may resolve in several days, with or without treatment. Urate deposits (tophi) occasionally appear under the skin (outer ear, commonly) or in the kidneys or urinary system, causing stone (calculi) formation (see Chapter 37). FIGURE 46.8 Gout: subcutaneous nontender lesions near joints. Etiology and Types Primary gout, the most common type, is caused by an inherited problem with purine metabolism. Uric acid production is greater than the kidneys’ ability to excrete it. Therefore, the amount of uric acid in the blood increases. Acute attacks of gout may be triggered by stress, alcohol consumption, illness, trauma, dieting, or certain medications such as aspirin and diuretics. Uric acid is also increased in secondary gout. However, the increase is related to a health issue. Examples include renal insufficiency or medications, such as diuretic therapy and certain chemotherapeutic agents. Signs and Symptoms When an “attack” of acute gout occurs, the patient has severe pain and inflammation due to the uric acid crystals in one or more small joints, usually the great toe. The joint is swollen, red, hot, and usually too painful to be touched. Patients with chronic gout may not have obvious signs and symptoms. Renal stones can develop from elevated uric acid. Diagnostic Tests Diagnosis of gout is based on an elevated serum uric acid level. Joint fluid aspiration analysis can also identify uric acid crystals in the synovial fluid. Therapeutic Measures Medication therapy is the first-line treatment for primary gout. Treatment for secondary gout involves management of the underlying cause. For an acute gout episode, NSAIDs, colchicine (Colcrys), or steroids are prescribed until the joint inflammatory response subsides. Chronic gout patients for whom other medications are not effective may be helped by pegloticase (Krystexxa) by IV infusion every 2 weeks for about 6 months. Uricosuric medications are used to prevent increased serum uric acid levels. Febuxostat (Uloric) and allopurinol (Zyloprim) decrease uric acid production. Probenecid (Benemid) increases renal excretion of uric acid. Serum uric acid level is monitored during medication use. WORD BUILDING hyperuricemia: hyper—excessive + uric—uric acid + emia—in blood Prevention and Nursing Care Interventions for patient education to help prevent gout include the following: Drink plenty of fluids, especially water. Consider eating cherries or drinking cherry juice. Avoid high-purine (protein) foods, like organ meats, shellfish, and oily fish (e.g., sardines). Avoid alcohol. Avoid all forms of acetylsalicylic acid (aspirin) and medications containing it. Avoid diuretics. Avoid excessive physical or emotional stress. Osteoarthritis Osteoarthritis (OA) is the most common type of arthritis, affecting more than 32.5 million people in the United States (Centers for Disease Control and Prevention, 2020). It is more common with age and in women especially over age 50. OA is also known as degenerative joint disease. Pathophysiology OA is a disease of the joint that affects all the joint’s structures (Table 46.3). The cartilage and bone ends slowly break down. The joint space narrows, bone spurs develop, and the joint lining becomes inflamed. Ligaments and tendons may also be affected. The body’s repair process is not able to overcome this loss of cartilage and bone. Weight-bearing joints (e.g., hips and knees), hands, and the vertebral column are most often affected (Fig. 46.9). Table 46.3 Osteoarthritis and Rheumatoid Arthritis Summary Osteoarthritis Rheumatoid Arthritis Pathophysiology Articular cartilage and bone ends deteriorate. Joint is inflamed. Inflammatory cells cause synovitis. Synovium becomes thick and fluid accumulates, causing swelling and pain. Joint becomes deformed. Etiology Primary (idiopathic): Cause unknown. Risk factors include age, obesity, activities causing joint stress. Secondary: Causes include trauma, sepsis, congenital abnormalities, metabolic disorders, rheumatoid arthritis. Periodontal disease may be a cause. Is an autoimmune disease. Can occur at any age (including juvenile rheumatoid arthritis). Familial history possible. Signs and Symptoms Joint pain and stiffness occur. Pain increases with activity and decreases with rest. Nodes on joints of fingers appear (Heberden nodes, Bouchard nodes). Symptoms vary according to disease process. Early symptoms: Bilateral and symmetrical joint inflammation Redness, warmth, swelling, stiffness, pain Stiffness after resting (morning stiffness) Activity decreases pain and stiffness Low-grade fever, weakness, fatigue, anorexia (mild weight loss) Organ system involvement Late symptoms: Joint deformity Secondary osteoporosis Therapeutic Measures Medication NSAIDs Acetaminophen Muscle relaxants. Balanced rest and exercise Splinting of joint to promote rest Heat and cold Weight loss Complementary therapies Surgery for total joint replacement Medication Antibiotics NSAIDs Biological response modifier Prednisone Disease-modifying antirheumatic drug (DMARD) T-cell modulators Heat and cold Balanced rest and activity Surgery for total joint replacement Priority Nursing Diagnoses Acute Pain Impaired Physical Mobility Disturbed Body Image Acute Pain Self-Care Deficit(s) Fatigue FIGURE 46.9 Common joints affected by osteoarthritis and the changes that result in the joint. Etiology Risk factors for OA include heredity, obesity, and physical activities that create mechanical stress on synovial joints, such as long periods of standing or repetitive motions. OA may also develop because of trauma, sepsis, congenital anomalies, certain metabolic diseases, or rheumatoid arthritis. Signs and Symptoms Pain and stiffness, especially upon arising, commonly occur. Joint pain and swelling increase after activity. Stiffness is reduced with movement. The patient usually seeks medical attention when symptoms are severe or range of motion is limited while performing everyday activities. Painful bony nodes on the finger joint, called Heberden and Bouchard nodes, may occur. Women tend to have these more often than men. If the vertebral column is involved, the patient reports radiating pain and muscle spasms in the extremity innervated by the area affected. Diagnostic Tests X-ray examinations can outline the joint structure and detect bone changes. MRI is helpful in showing joint structure abnormalities. Analysis of synovial fluid aids in the diagnosis of OA. Evidence-Based Practice Clinical Question Can exercise effectively relieve chronic low back pain? Evidence In this systematic review, 89 studies were examined for the effectiveness of exercise for relieving nonspecific chronic low back pain (Owen et al, 2020). The results showed that resistance training and aerobic exercise training were most effective in relieving this type of pain. Implications for Nursing Practice Nurses can encourage patient participation in exercise programs to improve strength/resistance and coordination/stabilization. Reference: Owen, P. J., Miller, C. T., Verswijveren, S. J., Tagliaferri, S. D., Brisby, H., Bowe, S. J., & Belavy, D. L. (2020). Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. British Journal of Sports Medicine, 54(21), 1279–1287. CLINICAL JUDGMENT Mr. Finn, a 59-year-old hardware store manager, is 5′ 11″ and weighs 250 pounds. He visits his HCP because of knee pain. He has noticed that it is becoming increasingly difficult to bend to pick up heavy boxes, and reports knee stiffness, especially in the morning. The HCP suspects osteoarthritis. What data collection questions do you ask Mr. Finn? What risk factors do you identify that Mr. Finn has? What patient-centered care interventions do you provide for Mr. Finn? What health-care team members do you collaborate with? Suggested answers are at the end of the chapter. Therapeutic Measures There is no cure for OA. Symptom control is the focus of treatment. An interdisciplinary approach is needed to prevent decreased mobility and preserve joint function. EXERCISE. Joint pain from OA tends to decrease with rest, so pain is less severe in the morning. Activities should be scheduled at this time. A severely inflamed joint may be splinted by the occupational therapist or physical therapist to promote rest to a selected joint. However, rest must be balanced with exercise to prevent muscle atrophy from disuse. Exercise has been identified to maintain general health and weight, range of motion, and muscle strength, while decreasing anxiety and depression. To minimize muscle atrophy and to stabilize and protect arthritic joints, patients should be encouraged to perform exercises to strengthen their quadriceps if they have OA of the knee. Yoga and tai chi are helpful for gently stretching the joints to reduce stiffness. Joints should always be placed in their functional position—that is, a position that does not lead to contractures. For example, to prevent excessive neck flexion, only a small pillow should be placed under the head when sleeping. WEIGHT CONTROL. Obese or overweight patients benefit from losing weight to decrease stress on weight-bearing joints and thereby reduce pain. If the patient is on medications that can alter fluid volumes (corticosteroids), a low-sodium diet may be appropriate. MEDICATION. Medication therapy is commonly used to reduce pain in patients with OA. Often, it is combined with other pain-reducing therapies. The most common medications are NSAIDs (Table 46.4). NSAIDs have analgesic and anti-inflammatory effects. Common side effects include gastrointestinal distress and bleeding, which can be severe, and sodium and fluid retention. NSAIDs may increase the risk of cardiovascular events, such as myocardial infarction or stroke. Older patients taking NSAIDs routinely should be carefully monitored for heart failure and hypertension from fluid retention. Analgesics such as acetaminophen or corticosteroids may be used. Over-the-counter topical creams such as capsaicin (Arthricare) can be applied to the joints. Synvisc-One (one injection) or SYNVISC (three injections) is injected directly into osteoarthritic knees to replace the cushioning synovial fluid. Pain can be relieved and flexibility restored for up to 6 months. HEAT AND COLD. The patient with OA usually prefers heat therapy unless the joint is acutely inflamed. Hot packs, warm compresses, warm showers, moist heating pads, and paraffin dips provide sources of heat. Cold therapy may alter cutaneous pain receptors, thereby decreasing pain. Cold packs should be applied for no longer than 20 minutes at a time, as they narrow blood vessels. COMPLEMENTARY AND ALTERNATIVE THERAPIES. Complementary and alternative therapies can reduce pain. Acupressure, acupuncture, hydrotherapy, imagery, music therapy, massage, and other holistic modalities that foster the mind–body–spirit connection work well for many people. SURGERY. If the patient’s pain cannot be managed successfully, a total joint replacement may be indicated. Total joint replacement is the most common type of arthroplasty (see later section on musculoskeletal surgery). Table 46.4 Common Medications Used to Treat Connective Tissue Diseases: Osteoarthritis, Rheumatoid Arthritis, and Others Medication Class/Action Biological Response Modifiers Interleukin-1 inhibitors that reduce inflammation and cartilage degradation. Examples anakinra (Kineret) Nursing Implications Monitor neutrophils. Corticosteroids Reduce inflammation and swelling. Examples prednisone (Deltasone, Orasone) Nursing Implications Take daily weight. Monitor intake and output. Monitor for infection. Give with food/milk. Recommend patient obtain medic alert ID. Not used for osteoarthritis. Disease-Modifying Antirheumatic Drugs (DMARDs) For use in rheumatoid arthritis and ankylosing spondylitis; reduce symptoms, prevent joint damage, and preserve joint function by suppressing immune or inflammatory systems. Slow-acting and may take months for effect; other medications used to control symptoms until effective. Effect ends when medication stopped. Pyrimidine Synthesis Inhibitors Examples leflunomide (Arava) Nursing Implications Screen for tuberculosis before starting. Monitor blood pressure, complete blood count, liver function. Teach patient to report rash promptly. Gold Preparations Examples auranofin (Ridaura) aurothioglucose (Solganal) Nursing Implications Give test dose and monitor for allergic reaction for about 1 hour. Laboratory testing for gold toxicity recommended. Immunosuppressives Examples azathioprine (Imuran) cyclophosphamide (Cytoxan) cyclosporine (Sandimmune, Neoral) leflunomide (Arava; for rheumatoid arthritis only) methotrexate (Otrexyom, Rasuvo, Xatmep) d-penicillamine (Cuprimine, Depen) Nursing Implications Protect from infection. Monitor for infections. Tumor Necrosis Factor Inhibitors Examples adalimumab (Humira) adalimumab-adaz (Hyrimoz) adalimumab-adbm (Cyltezo) adalimumab-afzb (Abrilada) adalimumab-atto (Amjevita) adalimumab-bwwd (Hadlima) etanercept (Enbrel) etanercept-szzs (Erelzi) etanercept-ykro (Eticovo) golimumab (Simponi) inflizimab (Remicade) infliximab-dyyb (Inflectra) Nursing Implications Screen for tuberculosis. Antimalarials Examples chloroquine (Aralen) hydroxychloroquine (Plaquenil) Nursing Implications Report vision problems. Promote safety due to dizziness. NSAIDs Block activity of enzyme cyclooxygenase (COX-1, COX-2), which makes prostaglandins that produce inflammation, fever, and pain; support platelets; and protect stomach lining (COX- 1 only). Examples acetylsalicylic acid (aspirin) diclofenac sodium (Voltaren) etodolac (Lodine; for osteoarthritis only) ibuprofen (Motrin) indomethacin (Indocin) meloxicam (Mobic) naproxen (Aleve, Naprosyn) oxaprozin (Daypro) nabumetone (Relafen) sulindac (Clinoril) Nursing Implications Those with asthma at higher risk for allergic reaction. Explain risk of gastrointestinal bleeding. T-Cell Modulators Reduce activation of T cells in the inflammatory process. Examples abatacept (Orencia) Nursing Implications Screen for tuberculosis. Use silicone-free syringe only. Infuse over 30 minutes. Monitor for serious infections. Nursing Process for the Patient With Osteoarthritis DATA COLLECTION. The patient’s report of pain is documented. Affected joints are observed for signs of inflammation or deformity. Also examined are joint function, ADL performance, and mobility. NURSING DIAGNOSES, PLANNING, IMPLEMENTATION, AND EVALUATION. See the “Acute Pain” and “Impaired Physical Mobility” nursing diagnoses for Bone Fracture. Decreased Activity Intolerance related to pain Expected Outcome: The patient will participate in ADLs as tolerated. Provide pain relief measures before activity to enable an increase in activity level. Monitor pain during activity to provide baseline data to manage pain. Encourage independence but assist with ADLs as needed to prevent patient exhaustion. Collaborate with an interdisciplinary team, such as pain clinic members, an occupational therapist, and home health physiotherapist, to develop patient plan of care. Bathing, Dressing, Feeding, or Toileting Self-Care Deficit related to degenerative joint disease Expected Outcome: The patient will be able to provide own self-care. Observe the patient’s self-care abilities to gather baseline data for planning care. Encourage independence to decrease feelings of despair about being unable to care for self. Assist when necessary to minimize frustration when the patient cannot perform self- care. Reinforce teaching about assistive devices to help with ADL living to promote self-care. Collaborate with an interdisciplinary team, such as a home health nurse, occupational therapist, or physiotherapist, to acquire assistive devices and use alternate resources. Disturbed Body Image related to changes in joint function and structure Expected Outcome: The patient will demonstrate acceptance of changes in body image. Encourage the patient to discuss feelings and concerns to allow the nurse to understand what the patient is experiencing. Provide information and clarify misconceptions to ensure that the patient is aware of expected problems and concerns. Encourage socialization to improve patient’s perceptions of how they appear to others. Chronic Sorrow related to body image changes, altered role, pain, and ongoing losses Expected Outcome: The patient will verbalize improvement in feelings of sorrow. Observe patient’s affect and mood connected to pain and loss to provide baseline data. Allow time to discuss feelings and anticipate trigger events to ensure the patient is aware of what may increase feelings of sorrow. Encourage use of interdisciplinary team, such as a social worker, psychologist, clergy, or spiritual adviser, to provide alternative methods of dealing with sorrow. Encourage use of support groups to enable the patient to discuss concerns with others experiencing the same problems. EVALUATION. Outcomes are met if the patient rates pain at a tolerable level on an appropriate pain scale, demonstrates improved physical mobility, participates in ADLs, provides self-care, demonstrates acceptance of changes in body image, and verbalizes improvement in feelings of sorrow. PATIENT EDUCATION. A vital function of each member of the health-care team is health teaching. The patient with OA is seldom admitted to the hospital for treatment of OA unless surgery is scheduled. However, many patients with OA are admitted for other reasons. Their OA needs must also be considered in the plan of care. Most patients residing in long-term care facilities have OA, which can affect their participation in ADLs and recreational activities. Patients should be taught ways to protect their joints and conserve energy. For educational materials and self-help courses, visit the Arthritis Foundation at www.arthritis.org. Rheumatoid Arthritis Rheumatoid arthritis (RA) is a chronic, progressive, systemic inflammatory disease that destroys synovial joints and other connective tissues, including major organs. Pathophysiology Inflammatory cells and chemicals cause synovitis, an inflammation of the synovium (the lining of the joint capsule). As the inflammation progresses, the synovium becomes thick. Fluid accumulation causes joint swelling and pain. A destructive pannus (new synovial tissue growth infiltrated with inflammatory cells) erodes the joint cartilage and eventually destroys the bone within the joint (Fig. 46.10). Ultimately, the pannus is converted to bony tissue, resulting in loss of mobility. Joint deformity and bone loss are common in late RA (see Table 46.3). Any connective tissue may be affected in RA, including blood vessels, nerves, kidneys, pericardium, lungs, and subcutaneous tissue. Dysfunction or failure of the organ or system can occur. Death can result if the disease does not respond to treatment. Many patients experience spontaneous remissions and exacerbations (flare-ups) of RA. Symptoms may disappear without treatment for months or years. Then the disease flares up just as unpredictably, often due to physical or emotional stress. FIGURE 46.10 Rheumatoid arthritis. Etiology RA affects people with a family history of the disease two to three times more often than it affects others. Antibiotic prescriptions have been associated with a 60% increased risk of RA, although it is unknown if that effect results from the antibiotic itself or the infection being treated (Sultan et al, 2019). Oral pathogens may cause RA. Studies show that symptoms of RA improve with antibiotic treatment. In RA, an autoimmune response occurs that affects the synovial membrane of the joints. Antibodies (called rheumatoid factor; RF) are often found in patients with RA. It is suggested that these antibodies join with other antibodies and form antibody complexes. These complexes lodge in synovium and other connective tissues, causing local and systemic inflammation. They may be responsible for the destructive changes of RA in body tissues. Signs and Symptoms Signs and symptoms vary because the disease presents differently in each patient. In general, the signs and symptoms can be divided into early and late manifestations. The typical pattern of joint inflammation is bilateral and symmetrical. The disease usually begins in the upper extremities and progresses to other joints over many years (Fig. 46.11). Affected joints are slightly reddened, warm, swollen, stiff, and painful. The patient with RA often has morning stiffness lasting for up to an hour. Those with severe disease may report having stiffness all day. Generally, activity decreases pain and stiffness. Because of the systemic nature of RA, the patient may have a low-grade fever, malaise, depression, lymphadenopathy, weakness, fatigue, anorexia, and weight loss. As the disease worsens, major organs or body systems are affected. Joint deformities occur as a late symptom. Secondary osteoporosis (bone loss) can lead to fractures. FIGURE 46.11 Joint abnormalities in hands of patient with rheumatoid arthritis. Diagnostic Tests No specific diagnostic test confirms RA. An increase in white blood cells and platelets is typical. Immunological test findings for patients with RA usually include the following: Presence of RF in serum Decreased red blood cell count Decreased C4 complement Increased ESR Positive antinuclear antibody test Positive C-reactive protein test RF can indicate the aggressiveness of the disease. However, it is not specific to RA. The ESR test screens for inflammation. It measures the amount of time it takes for red blood cells to settle to the bottom of a test tube. In the presence of inflammation, red blood cells settle faster in the tube. Therefore, the ESR increases with the presence of inflammation. It also evaluates the effectiveness of treatment. If the disease responds to treatment, the ESR decreases. LEARNING TIP For those with rheumatoid arthritis, a verbal “Nice to meet you” greeting instead of a handshake avoids the pain caused by a handshake, even a weak one. X-ray examination and MRI detect joint damage and bone loss, especially in the vertebral column. A bone or joint scan assesses the extent of joint involvement throughout the body. With arthrocentesis, synovial fluid is cloudy, milky, or dark yellow with inflammatory cells present. Therapeutic Measures Antibiotics may improve the symptoms of RA. Chronic joint pain can interfere with mobility or the ability to perform ADLs. Medication therapy can relieve or reduce pain as well as slow the progression of the disease. Disease-modifying antirheumatic drugs (DMARDs) can prevent joint destruction, deformity, and disability with early single or combination medication use. NSAIDs and corticosteroids are also used (see Table 46.4). Many of these medications have potentially serious side effects, such as severe infection, and must be monitored carefully. Complementary therapies that may help decrease inflammation or pain include capsaicin cream, fish oil, and antioxidants such as vitamin C, vitamin E, and beta carotene (see Chapter 5). HEAT AND COLD. Heat applications or hot showers help decrease joint stiffness and make exercise easier for the patient. For acutely inflamed, or “hot,” joints, cold applications may be best. A program that balances rest and exercise is most beneficial for the patient. SURGERY. If nonsurgical approaches are not effective in relieving arthritic pain, the patient may have a total joint replacement (discussed later). Nursing Process for the Patient With Rheumatoid Arthritis DATA COLLECTION. A complete history and physical examination are needed for the patient with RA, as the disease can involve every system of the body. In addition to identifying physical signs and symptoms, explore the patient’s psychosocial, functional, and vocational needs. After having the disease for approximately 15 years, fewer than half of RA patients are totally independent in their ADLs. These limitations may place a burden on family members, who must be included in the care of the patient with RA. Many patients with the disease are young or middle-aged. RA can impair their ability to work, depending on the type of job they have. Occupational therapy assesses the patient’s work skills to determine the need for changes in the workplace or a need to train for a new type of work. NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION. See the “Acute Pain” and “Impaired Physical Mobility” nursing diagnoses for Bone Fracture and “Bathing, Dressing, Feeding, Toileting Self-Care Deficit” and “Disturbed Body Image” in the “Nursing Diagnoses, Planning, Implementation, and Evaluation” section under Osteoarthritis. Fatigue related to chronic pain and limited mobility Expected Outcome: The patient will have decreased episodes of fatigue. Monitor levels of fatigue through the day to determine patient’s reaction to various activities. Provide assistance as required to conserve the patient’s energy. Ensure regular rest periods throughout the day to avoid overexerting the patient. Reinforce teaching energy conservation techniques to reduce workload. Reinforce teaching the patient the need to delegate to avoid overexertion. EVALUATION. The outcomes are met if the patient has pain relief within acceptable levels on a pain rating scale, improved physical mobility, ability to provide self-care, acceptance of changes in body image, and decreased episodes of fatigue. PATIENT EDUCATION. The patient with RA needs extensive patient education regarding the disease process, medication management, and the comprehensive plan of care. In collaboration with health-care team members, help the patient plan a daily schedule that balances rest and exercise. A vocational counselor may be necessary for job training if the patient needs to pursue a different occupation. Patients who are unable to work may be able to qualify for disability benefits through the federal Social Security program. Inform the patient about community resources such as support groups (visit www.arthritis.org). CLINICAL JUDGMENT Mrs. Harris is a 48-year-old nurse who has had upper extremity joint pain and swelling for about 4 years. She was recently diagnosed with rheumatoid arthritis but has no systemic involvement. She has extreme fatigue at this time and is concerned that she will have to give up providing direct patient care on a busy medical unit in the local hospital. What questions do you ask Mrs. Harris about her illness? What do you discuss with Mrs. Harris about pain management? What complications do you look for in Mrs. Harris? Suggested answers are at the end of the chapter. MUSCULOSKELETAL SURGERY Some health problems cannot be managed conservatively and require surgery. The most common orthopedic surgeries are discussed here. Total Joint Replacement Total joint replacement (TJR) is most often performed for patients who have some type of connective tissue disease in which their joints become severely deteriorated. TJR may also be needed for cancer, trauma, or after long-term steroid therapy. Long-term use of steroids, trauma, and complications of joint replacement can cause avascular necrosis, a condition in which bone tissue dies (usually the femoral head) because of impaired blood supply. Advanced avascular necrosis is very painful and usually does not respond to conservative pain relief measures. The primary goal of TJR is to relieve severe chronic pain and improve ability to carry out ADLs when no other treatment is successful. Total hip replacement and total knee replacement are the most common replacement surgeries. Any synovial joint can be replaced. Another term used for joint replacement is arthroplasty. The prosthetic components are made of ceramic, polyethylene, or metal. Most implants are cementless and are secured by the patient’s bone as it grafts and connects to the porous prosthesis. Cemented prostheses are used when bone health is poor, such as in osteoporosis. The incision is closed with internal dissolvable sutures, skin glue, and skin sealer. Skin staples may be used. Total Hip Replacement Total hip replacement (THR) uses an acetabular cup inserted into the pelvic acetabulum and a femoral stem and head inserted into the femur to replace the femoral neck and head (Fig. 46.12). Various surgical approaches for THR can be done by surgeons, which then require differences in postoperative hip care and precautions. These approaches include posterior, anterior-lateral, and anterior. Tranexamic acid, an antifibrinolytic agent, may be given to reduce blood loss during surgery. A prophylactic antibiotic, usually given 1 hour prior to incision time, reduces the chance of an infection. The patient’s length of stay may be 1 to 3 days, although outpatient procedures are growing. In a study, THRs were found to last 25 years in 58% of patients (Evans et al, 2019). PREOPERATIVE CARE. THR is an elective procedure. It is scheduled to allow time for preoperative teaching and screening. A case manager (e.g., registered nurse or social worker) may assess the patient’s needs and support systems available postoperatively. The patient is taught about the procedure and what to expect postoperatively. Preoperative exercises to perform to help strengthen the operative leg may be explained by a physical therapist. A preoperative autologous (self) blood donation by a patient may be ordered in the event a postoperative blood transfusion is needed due to blood loss in surgery. This can reassure patients who are concerned about receiving donor blood. Preoperative preparation at home the night before surgery includes a shower and hair wash with no shaving of the skin to prevent microabrasions that could harbor bacteria. The patient is given prepackaged antibacterial skin cleansing cloths to use the night before and the day of surgery in the area illustrated on a diagram of the body. Preoperatively, the nurse obtains a patient history, including allergies and medications, and checks the neurovascular status of the operative extremity, level of pain, and mobility. WORD BUILDING arthroplasty: arthro—joint + plasty—creation of FIGURE 46.12 Total hip arthroplasty of arthritic right hip. POSTOPERATIVE. Care for the patient having a THR is interdisciplinary. Pain is managed with IV, IM, or oral analgesics, including paracetamol (Tylenol) and NSAIDs. Cold and heat therapy are used in 15- to 20-minute intervals. Within 2 hours after return to the patient’s hospital room, the physical therapist and occupational therapist will assist the patient with ambulation sessions that may include getting in and out of bed, standing, sitting, and walking every 2 hours and with managing assistive devices such as a walker, a cane, an elevated toilet seat, a long-handled shoehorn, and a sponge. In addition to providing general postoperative care that all patients undergoing general or epidural anesthesia require, plan and implement interventions to help prevent the common complications of THR (see Chapter 12). Hip Dislocation. The most common postoperative complication for the patient having a posterior or anterior-lateral THR is subluxation (partial dislocation) or total dislocation. Dislocation occurs when the femoral component becomes dislodged from the acetabular cup. Often, if a dislocation occurs, there is an audible “pop” followed by immediate pain in the affected hip. In addition to pain, the patient experiences shortening and possibly internal rotation of the surgical leg. If these signs and symptoms occur, notify the surgeon immediately and keep the patient in bed. Under anesthesia, the surgeon manually manipulates the hip back into alignment. Preventing dislocation is a major nursing responsibility. Correct positioning of the surgical leg is critical. The primary goals are to prevent hip adduction (across the body’s midline) and hyperflexion (bending forward more than 90 degrees). The patient is informed to use two regular pillows (one proximal and one distal) between the legs when sleeping and turn to the side of the body per HCP preference. When turning, it is important that the hip and legs turn together to minimize the chance of dislocation. Supporting the leg with a pillow during turning is required to decrease the chance of dislocation. Ensure that the patient does not adduct or hyperflex the surgical hip during transfer to a chair. To prevent hyperflexion, when sitting, ensure the patient is using a straight-back chair with arm rests and educate the patient to avoid chairs lower than knee height (Fig. 46.13). The toilet seat is also raised. Patients are instructed not to bend forward more than 90 degrees. Skin Breakdown. Because most patients having THR are older, skin breakdown prevention is a major part of postoperative care. Early ambulation is helpful. Protect the heels, elbows, and the sacrum, which can break down within 24 hours (see Chapter 54). Assisting the patient to use the toilet every 2 hours and using a protective barrier cream help prevent skin problems related to incontinence. Adequate diet and hydration are also important to prevent skin breakdown. Infection. Orthopedic surgery patients are at an increased risk for infection because of the nature of the surgery. Increased age also is a risk factor. When performing dressing changes, observe the incision for signs and symptoms of infection (e.g., redness, swelling, warmth, odor, pain, or yellow, green, or brown-tinged drainage). Monitor the patient’s temperature. An older patient with an infection might not experience a fever but may exhibit confusion due to the infection. CLINICAL JUDGMENT Mrs. Adam is 78 years old and had a left total hip replacement. When changing the surgical dressing, the home health nurse notices a purulent discharge. Cefaclor (Ceclor) 500 mg by mouth every 8 hours is ordered. Cefaclor is available as a 375 mg/5 mL suspension. How many milliliters should Mrs. Adam be given? Suggested answers are at the end of the chapter. FIGURE 46.13 Hip flexion after total hip replacement should be 90 degrees or less to prevent dislocation. Bleeding. The patient might need salvaged operative, autologous, or postoperative blood. By using orthopedic patient autotransfusion (such as OrthoPAT) during surgery, about 50% of lost blood can be recovered and saved for reinfusion into the same patient. Postoperatively, blood can be replaced by collecting shed blood via suction into a reservoir and then filtering and reinfusing it within 6 hours of collection. Surgical drains (e.g., Hemovac or Jackson-Pratt) are not recommended for routine use. Monitor for blood loss and signs of shock. Monitor dressings for drainage and report large or unexpected amounts. Neurovascular Compromise. For any musculoskeletal surgery or injury, frequent neurovascular checks for circulation (e.g., color, warmth, pulses), sensation, and movement are performed distal to the surgical procedure or injury (and compared with the unaffected side) when vital signs are checked. The procedure and significance of these checks are described in Chapter 45. Venous Thromboembolitic Complications. Patients having hip surgery are at greatest risk for DVT or pulmonary embolus. An anticoagulant medication is given to help prevent blood clot formation. In addition, thigh-high compression stockings and intermittent pneumatic compression devices may be used (see Chapter 12). BE SAFE! BE VIGILANT! When giving low molecular weight heparin medications such as enoxaparin (Lovenox) or dalteparin (Fragmin), to avoid possible tissue necrosis, medication should be administered in the abdomen subcutaneously. The air bubble should not be removed from the prefilled syringe before administration to ensure the entire dose is given. To minimize bruising, do not rub injection site after administration. Because DVT occurs mostly in the lower extremities, leg exercises taught preoperatively are started in the immediate postoperative period and continued until the patient is fully ambulatory. DISCHARGE. When the patient is medically stable, they are discharged home for about 2 weeks of in-home physical therapy and then receive outpatient physical therapy for 4 to 6 weeks for strengthening and fall prevention or else are discharged to a facility for short- term rehabilitation. Before hospital discharge, the interdisciplinary team provides patient education for home safety, including no use of throw rugs, no extension cords near walkways, safety measures to prevent falls in the shower, and any hip precautions that need to be used until the surgeon reevaluates the patient at the 6- to 8-week follow-up visit (Box 46.4). Posterior or anterior-lateral hip replacements require the use of safety precautions to prevent hip dislocation since muscles are cut that reduce hip stability. The surgeon may not specify any hip precautions for anterior hip replacements as there is little risk of hip dislocation since no muscles are cut during this surgical approach. Other surgeons may prescribe some hip precautions for this approach. The patient should follow their surgeons’ directions. Box 46.4 Patient Education After Posterior Total Hip Replacement Reinforce education for patients to prevent hip dislocation as specified by the HCP after a posterior or anterior-lateral THR: Keep legs abducted (away from center of body) with pillows. Sleep with pillows between legs to prevent abduction and on side specified by HCP. Do not bend at the waist (hip) more than 90 degrees per HCP’s instructions. Rise from a sitting position by pushing straight up off the chair or bed without leaning forward. Use a walker, if desired, to assist walking. Physiotherapy and occupational therapy can provide equipment that aids in putting on socks and shoes. Sexual activity can occur per HCP instructions when tolerated, provided hip safety measures are followed. Patient Perspective Bruce I found my total joint replacement (TJR) surgery for hip osteoarthritis at age 71 to be easy and uneventful. Two years earlier, I had a total shoulder replacement, which also went smoothly and immediately relieved my shoulder pain from the arthritis. The shoulder rehabilitation was a month longer and more intense than for the total hip replacement. I found the shoulder replacement initially limited the performance of my ADLs more than did the hip replacement. To prep for the hip surgery, I was instructed to shower the night before surgery and use antibacterial wipes over the surgical area and repeat the morning of surgery. My surgery took 2 hours, then I was back in my room and offered the option of being discharged that day (imagine that, the same day!) or the next day after 4 hours of “joint camp”—intense physical therapy (PT)/occupational therapy (OT) instruction and therapy. I went home after the joint camp and started 2 weeks of home PT (2 times a week) and 6 weeks of regular PT (3 times weekly). I had to be careful to prevent hip dislocation while doing my assigned exercises. I transferred from bed and ambulated into a chair with assistance about 4 hours after surgery. Later that night, I used a walker to ambulate up and down the hospital corridors. I used a cane for a month until I felt secure enough to walk without falling. The most important thing my nurses did for me was to pay attention to my pain level to make sure I could get up and walk to start the healing process. The nurses were also attentive to getting me up and moving, a vital process in healing, and in establishing a rapport with me. The nurses also took time to make sure I understood the discharge procedures and what I was and was not to do when arriving home. My pain level after surgery was 8 out of 10. I was prescribed acetaminophen/hydrocodone (Norco) for pain relief at home. I was able to walk, ride in the car, and climb stairs immediately with minimal pain, although I was told to limit the use of stairs. I had to have the transport person lift my leg into the car for my ride home from the hospital. Six months later, I am pain-free, and the numbness in my left quad is starting to resolve. The surgeon said it would take a year to fully heal. I did not start driving until about 4 weeks after surgery because it took time to rebuild the strength in my legs. My recovery has gone smoothly, but it will require perseverance and 6 more months of exercise for a full recovery. It likely helped that I am married to a former ortho nurse. Nurses rock! I am happy I had the surgeries done so I can live pain-free while I exercise and play golf. Total Knee Replacement The knee is the second-most commonly replaced joint. It requires three components for total replacement: a femoral component, a tibial component, and a patellar button (Fig. 46.14). For patients who do not yet need a total replacement, partial knee resurfacing is available. Nursing care for the patient with a total knee replacement (TKR) is similar to that required for a patient with a THR, except that dislocation and preventive positioning are not concerns. After surgery, a bulky dressing and possibly a surgical drain are in place. Again, it is important to monitor for bleeding along with usual postoperative interventions. Medical complications described for THR, such as DVT and infection, may occur with knee replacement. FIGURE 46.14 Total knee replacement. Amputation An amputation is the removal of a body part. It can be as limited as removing part of a finger or as devastating as removing nearly half the body. Amputations may be surgical as a result of disease or traumatic as a result of an accident. Surgical Amputation The main reason for surgical amputations is ischemia from peripheral vascular disease in the older adult. The rate of lower extremity amputation is much higher in diabetic than nondiabetic patients (see Chapter 40). Surgical amputations may also be done for bone tumors, thermal injuries (e.g., frostbite, electric shock), crushing injuries, congenital problems, or infections. Traumatic Amputation Traumatic amputations occur from accidents. Industrial machinery, motor vehicles, lawn mowers, chain saws, and snow blowers are common causes of accidental amputation. In these patients the amputated part is usually healthy, so attempts at replantation can occur. Fingers are the most common replantations. Pre-hospital care of the severed body part is discussed in Chapter 13. The surgical procedure is performed by specialists who operate using a microscope. Nerves, vessels, and muscle must be reattached. Levels of Amputation The most common surgical amputation site is the lower extremity. The more proximal the amputation, the more disability is present. Loss of the great toe affects balance and gait. If the lower leg is amputated, a below-the-knee amputation is preferred over an above-the- knee amputation to preserve joint function. The higher the level of amputation, the more energy required for ambulation. Hip disarticulation (removal through the hip joint) and hemipelvectomy (removal through part of the pelvis) are reserved for young patients with cancer or severe trauma. Upper extremity amputations are usually more significant than lower extremity amputations and more often result from trauma. The arms and hands are necessary for performing ADLs. Early replacement with a prosthesis is crucial to regain function in the patient with an upper extremity amputation. Preoperative Care Patients scheduled for elective amputations have the advantage of time for preoperative teaching, prosthesis fitting, grieving, and adjustment to the loss of part of their body. Preoperatively, the patient should be referred to a certified prosthetist-orthotist to begin plans for replacing the removed body part with a prosthesis. Preoperative teaching is started in the surgeon’s office. Postoperative and rehabilitative care is reviewed with the patient and family or significant other. WORD BUILDING replantation: re—again + plant—to plant + ation—process hemipelvectomy: hemi—half + pelv—pelvis + ectomy—removal of

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