NCMB 316 Medical Surgical Nursing 2 Finals Week 13-17 PDF

NCMB 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER FINALS 3RD YEAR NURSING WEEK 13 - Management of Patients with Neurologic particularly the white matter of the CNS myelin an...

NCMB 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER FINALS 3RD YEAR NURSING WEEK 13 - Management of Patients with Neurologic particularly the white matter of the CNS myelin and Dysfunction Oligodendrocytes cells. Degenerative Disorders − The white matter of the CNS is the one that insulates the axon and speed the conduction of impulses along Multiple Sclerosis (MS) the axon. − Oligodendrocytes cells are the one that produces − An autoimmune disorder myelin sheath in the CNS. − It is an immune-related, progressive, demyelinating − Demyelination happens and lead to interruption of flow disease of the CNS which results to the impaired transmission of nerve impulses. of nerve impulses that leads to plaques on − T cells is the one that promotes the infiltration of agents demyelinated axons which may further the interruption that can damage the immune system. of nerve impulses or permanent and irreversible − Onset: 20-50 years old (peak) but may occur at any damage. age 4 Clinical Forms of MS − Unknown cause; more common in cold climates − Environmental Risk Factors: 1. Remitting-Relapsing Multiple Sclerosis (RRMS) Obesity − It is characterized in each relapse recovery is usually Lack of Vit. D complete, however but if there is remission, residual High salt diet deficit may occur. − 4 clinical forms: − This residual deficit may accumulate over time which 1. Remitting-Relapsing MS can contribute to the decline of functions. 2. Secondary Progressive MS (SPMS) Relapsing (occurrence of symptoms) 3. Primary Progressive MS Remitting (period of recover) 4. Progressive-Relapsing MS − 85% of patients with multiple sclerosis have remitting- − Demyelination is the destruction of myelin sheets and relapsing multiple sclerosis. the myelin sheet is the destruction that conducts nerve − 50% of patients with RRMS can progress to SPMS impulses this is because the myelin sheet is a fatty within 10 years; 90% can progress to SPMS within 25 protein material that surrounds your nerve fibers in the years. brain and spinal cord. − In each relapse, the recovery is usually complete, but Pathophysiology if there is remission, residual deficits may occur over time which it can also contribute to decline of functions. NOTE: In normal circumstances, T-lymphocytes and B- 2. Secondary Progressive Multiple Sclerosis (SPMS) Lymphocytes enters the BBB to check for presence of antigens in the CNS then leave − Disease progression occurs, without relapses T-lymphocytes and B-lymphocytes enters the BBB to − Associated with worsening symptoms check for presence of antigens in the CNS then leave. 3. Primary-Progressive Multiple Sclerosis (PPMS) ↓ T-lymphocytes and B-lymphocytes remains in the CNS − Is characterized by disabling symptoms which increase ↓ with temporary minor improvement. Infiltration of agents / substances − There is a gradual deterioration of neurologic function ↓ without remission of signs and symptoms, and there is Damage of the immune system progressive disability and primary progressive is ↓ Damage to the White matter of the CNS myelin associated with quadriparesis. Oligodendroglia cells − Quadriparesis (muscle weakness in all limbs), ↓ cognitive function, visual loss. Demyelination − Onset: 40-60 years old ↓ Interruption of flow of nerve impulses 4. Progressive-Relapsing Multiple Sclerosis (PRMS) ↓ − Least common (5% of pt) Plaques on demyelinated axons ↓ − Is characterized by relapses or symptoms with Degeneration / permanent and irreversible damage continuous disabling progression between exacerbation or worsening. − T-lymphocytes and B-lymphocytes remains in the CNS − The client's condition does not return to baseline, there and promote the infiltration of agents and other agents is an absence of remission, and the deterioration occurs over several years. that damages the immune system. − Absence of remission − The damage immune system the own immune system that leads to the inflammation and destruction, 1 | JK MARIA  Clinical Manifestations Medical Management − The clinical manifestation depends on the site of No cure for Multiple Sclerosis. lesion or plaque and the primary symptoms include: Goals: Fatigue (most disabling) o Delay progression of disease Depression o Manage chronic symptoms Weakness o Treat acute exacerbations Numbness Pharmacologic Treatment: − If lesions occur in cerebellar and basal ganglia 1. Disease Modifying Agents - to reduce the manifestation would include: frequency of relapse, reduce duration of Ataxia, dysarthria, scanning of speech, relapse, and reduce the number of plaques. nystagmus, intention tremor (cerebellar o Interferon beta-1a & Interferon ganglia): beta-1b o Ataxia – difficulty in coordination ✓ Administered o Dysarthria – difficulty in speaking subcutaneously o Scanning of speech – type of ✓ Flulike symptoms ✓ Increased liver function dysarthria wherein the pt pauses in tests every syllable, or syllable are o Glatiramer Acetate pronounced very slowly. ✓ Administered o Nystagmus – involuntary rhythmic subcutaneously side-to-side, up-down, circular ✓ WOF injection site reaction motion of the eyes. ✓ Flushing (sudden redding o Intention tremor – involuntary of face due to increase rhythmic muscle contractions blood flow) − If lesions occur in sensory pathways manifestation o Teriflunomide, Fingolimod, may include: Dimethyl Fumarate Pain, paresthesia, dysesthesia, ✓ Administered orally proprioception loss (sensory pathways) ✓ For those with injection − If lesions occur in optic nerves, vision reactions disturbances: o IV Methylprednisolone Blurring of vision, diplopia (double vision), ✓ Key agent for relapse scotoma (patchy blindness), total blindness ✓ Has an anti-inflammatory where in affect the optic nerves. effect of T-cells and − If lesions occur at the pyramidal tract of CNS, cytokines Spasticity may occur: ✓ Administered for 3-5 days Characterized by muscle hypertonicity followed by an oral Increased resistance to stretch associated to prednisone weakness ✓ Side effects: mood swings, Increased DTR weight gain, electrolyte Diminished superficial reflexes imbalances Most often the spasticity occurs in the lower o Mitoxantrone extremities ✓ Administered thru IV for 3 − If lesions occurred in frontal or parietal lobe, months cognitive: ✓ Monitor for cardiac toxicity Psychosocial may occur 2. Symptoms Management Other complications: o Baclofen (GABA agonist) o Bladder, bowel, sexual dysfunctions ✓ Drug of choice for spasticity o UTI, constipation ✓ Administered orally or o Pedal edema Intrathecal (via spinal cord) for severe spasticity Diagnostic Findings ✓ Has a sedative effect NOTE: The important component of diagnosis is a o Benzodiazepines (Diazepam), presence of plaques, these are scar tissues brought by Tinazidine, Dantrolene demyelination, associated with atherosclerosis. ✓ Improve motor function Presence of plaques ✓ Treat spasticity o MRI - to determine multiple plaques that o Amantidine, Pemoline, represent in the CNS and show areas of Dalfampridine demyelination ✓ Fatigue o CSF electrophoresis - presence of o Beta-adrenergic blockers oligoclonal banding (Propranolol), Gabapentin − CT scan - to determine increase in density of white anticonvulsant), Benzodiazepine (Clonazepam) matter in relation of demyelination ✓ Ataxia 2 | JK MARIA |IR  Nursing Management − In normal circumstances, a chemical response promotes the release of Acetylcholine Goals: − The release of acetylcholine comes from the vesicles o Promote physical mobility of the nerve terminals of myoneural neural junction. o Avoidance of falls − Once release, this will attach to the receptor sites o Decreasing fatigue development of coping (found in the motor end plate) it will lead to stimulation strategies of muscle contraction. o Absence of complications. ✓ Walking - to improve gait and loss of position − Acetylcholine - chief neurotransmitter of sense. parasympathetic nervous system that contracts the o Assistive devices may be needed. smooth muscle, dilates blood vessels, increase body secretions and slows heart rate. o Instruct patient properly to ensure safe and correct use of assistive devices Pathophysiology ✓ Daily exercise - strengthen weak muscles; The antibodies target the acetylcholine receptor sites prevent contractures. ↓ o Contracture – permanent tightening of Damage to receptor sites, this may lead to fewer receptor sites that the muscles, tendons, skin, and nearby is available for muscle contraction ↓ tissues that causes the joints to shorten Impaired transmission of impulse across the myoneural junction or become very stiff ↓ ✓ Warm packs - To minimize spasticity 1 pack may Ocular ← Voluntary muscle Generalized be beneficial; avoid hot baths because of risk of muscle weakness → muscle weakness weakness ↓ burn injury secondary to sensory loss, and avoid ↓ NOTE: People with MG, they Weakness of facial extreme colds. Most have either thymic muscle and throat ✓ Stretch-hold-relax - This helps relax and treat common hyperplasia (enlargement of (bulbar symptoms) muscle spasticity. findings are thymus gland) or tumor in ↓ ✓ Stationary bicycling, swimming, progressive diplopia, thymus gland; thymus gland Bland facial due to produces mature immune expressions (facial bearing - reduce spasticity in legs double cells and believed to be the muscle weakness), ✓ Healthy eating, weight reduction, avoid vision site of antibody production dysphonia (throat alcohol, no smoking - to reduce weight and wherein, the that causes the autoimmune weakness), assist in mobility impairments patient is activity. dysphagia (throat o NOTE: many patients with MS are aware of two NOTE: Descending weakness) which images of Paralysis is due to increases risk of overweight due to corticosteroid the same myasthenia gravis, because aspiration medication and mobility impairments object that it represents a descending ↓ ✓ Coughing and deep breathing exercise - may occur in motor weakness from the Other findings: minimize complications of immobility their one or CNS to the muscles. weakness of all both eyes. limbs and ✓ Walking with feet apart - widens the base of ↓ weakness of support Other intercostal ✓ Watch feet while walking - to address loss of findings: are muscles which will proprioception sense ptosis or lead to decreased ✓ Wheelchair - If gait remains insufficient drooping of vital capacity that the upper will result to wheelchair may be necessary. eyelid. respiratory failure ✓ Encourage scheduled toileting rounds - to (myasthenic crisis) enhance bowel and bladder function ✓ Suctioning, careful feeding, proper position for Diagnostic Findings eating - to manage swallowing difficulties ✓ Patches on eye - restrict visual input in eye only Acetylcholinesterase Inhibitor Test to prevent the brain from getting two images o Most common o Is performed by administering endrophonium Myasthenia Gravis (MG) chloride. − Autoimmune disease which affects the myoneural Endrophonium chloride (Tensilon) or Tensilon Test junction that causes weakness of voluntary muscles - stops acetylcholine breakdown making acetylcholine − Myoneural junction – neural connection between the available for binding in myoneural junction. motor nerve and muscle o Administered via IV − Uncommon o 30 secs after administration: ✓ Facial muscle weakness and ptosis − Women are more affected than men should resolve for about 5 mins − Purely motor disorder ✓ Represents a positive test ✓ Confirms the diagnosis o Side effects: bradycardia, asystole, bronchoconstriction, sweating, cramping. ✓ Atropine as antidote Ice Test o For patients with cardiac problems or asthma o Apply ice pack on pts eye for 1 min 3 | JK MARIA  o Ptosis should temporarily resolve ✓ Corticosteroids (prednisone) Repetitive Nerve Stimulation (RNS) − Decreases the amount of antibody o A decrease in successive action potentials in production patients with MG. − Daily for 1-2 months o An electrophysiological study ✓ Azathioprine Single-Fiber Electromyography (EMS) − Inhibits T-lymphocytes and B cell o Detects a delay or failure of neuromuscular proliferation transmission o Uncomfortable for patients − Decreases the activity of the body’s MRI immune system o Detects enlarged thymus gland due to − Adverse effects: leukopenia possible hyperplasia (decreased WBC), hepatotoxic ✓ IVIG Medical Management − Used to treat exacerbations No cure − Involves administration of antibodies Treatment do not stop the production of acetylcholine that body can’t make on its own receptor antibodies. − Complications: Headache, migraine, Goals: aseptic meningitis, and flu-like o Improve function symptom o Reduce and remove circulating acetylcholine ✓ Avoid Procaine receptor antibodies. − Exacerbates Myasthenia gravis Management: − Procaine is usually use as o Anticholinesterase medications o Immunosuppressive therapy anesthesia by dentist. o Intravenous immunoglobulin (IVIG) ✓ Therapeutic plasma exchange o Therapeutic plasma exchange (plasmapheresis) o Thymectomy − Used to treat exacerbations Anticholinesterase Medications − Remove plasma and its components o Pyridostigmine bromide w/ the use of large-bore double- ✓ First line of treatment, with fewer lumen catheter, blood cells and signs and symptoms. antibodies are separated then ✓ Inhibit breakdown of Acetylcholine plasma substitute are reinfused, this ✓ Increase availability of Acetylcholine temporarily reduces circulating at the neuromuscular junction antibodies. ✓ Dosage is gradually adjusted, ✓ Thymectomy usually 4x a day. − Surgical removal of the thymus o Complications (if there are changes in the gland dosages) − Since patients with myasthenia ✓ Myasthenic crisis (underdosage) gravis have enlarged thymus gland – there is exacerbation of the − Only treatment that can result in disease; there is severe generalized complete remission that occurs in muscle weakness, respiratory approximately 35% of patients with muscle weakness and bulbar myasthenia gravis. weaknesses which may result to respiratory failure. Nursing Management ✓ Cholinergic crisis (overdosage) – ✓ Teaching strategies to conserve energy - rest, rare but may also result in minimize walking, maintain good sleep patterns respiratory failure ✓ Minimize risk of aspiration ✓ Tensilon test - to determine crisis − Coincide mealtime with peak effect of complication medication because dysphagia should be ✓ Pyridostigmine bromide controlled first (neostigmine) - for relief of signs − Rest before meals and symptoms of myasthenic crisis − Sit upright when eating, soft diet to facilitate ✓ Atropine (anticholinergic) - if swallowing exacerbations of signs and ✓ Visual problems symptoms due to cholinergic crisis − Tape eyes – to prevent corneal damage when o Immunosuppressive Therapy eye does not close completely due to ptosis ✓ Goal: to reduce the production of − Artificial tears acetylcholine receptor antibodies that can cause the disorder 4 | JK MARIA  NCMB 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER FINALS 3RD YEAR NURSING WEEK 14 - Management of Patients with Neurologic ↓ Dysfunction Axonal loss and leads to interruption of nerve conduction ↓ Guillain Barre Syndrome (GBS) Remyelination − AKA idiopathic polyneuritis Schwann cells - generate the myelin sheath in the − An autoimmune demyelinating disease of the PNS PNS, whereas Oligodendroglial cells produces myelin which results in an acute, rapid segmental sheath in the CNS. demyelination of peripheral nerves and some cranial o Remyelination nerves which products an ascending weakness. ✓ Schwann cells are spared from the − In Guillain Barre Syndrome, the weakness is usually damage symmetrical and bilateral affectations. ✓ Allows remyelination – because If your myasthenia gravis is having a set up or Schwann cells are not damaged pattern of descending weakness or ✓ Takes months or years descending paralysis, GBS has an ascending ✓ But often recovery is incomplete weakness. Clinical Manifestations If your myasthenia gravis starts the weakness in brain, in GBS it starts in muscle and PNS demyelination peripheral nerve. o Ascending weakness - Muscle weakness in In GBS the weakness usually symmetrical the legs, may progress upward (symmetrical, and bilateral affectations. bilateral) − The cause of GBS is unknown but this sometimes o Hyporeflexia, areflexia (absence of reflexes) triggered by respiratory infection and stomach flu, but ✓ NOTE: In patients with GBS, most often antecedent precursor is viral infection. Hyporeflexia, areflexia, and − Viral infection – this is the cause of GBS but not weakness may progress to necessary the cause, if the patient just suffered or tetraplegia (paralysis of the lower encounter GBS, they have viral infection prior to GBS and upper body) − Most Common Infectious Agent: o Dyskinesia – pt unable to execute voluntary Campylobacter jejuni movement Cytomegalovirus o Paresthesia - numbness, tingling, pricking, Epstein–Barr virus (EBV) pins and needles sensation Mycoplasma pneumoniae CN demyelination H. Influenzae o Blindness (CN II) o Bulbar muscle weakness (CN IX) – can Zika virus result to manifestations of dysphagia, inability Pathophysiology of the client to clear secretions o Autonomic demyelination (CN X) – includes NOTE: GBS is a result of immune system attack on the tachycardia, bradycardia, hypertension or peripheral nervous system myelin. This myelin contains protein, orthostatic hypotension and the attack on the peripheral nervous system myelin will Does not affect cognitive function or LOC result into inflammatory demyelination. The trigger of GBS is an infectious agent. It occurs after a virus Diagnostic findings infection; cause is related to molecular mimicry. History of viral illness in the previous week – ↓ Cause is related to molecular mimicry or the organism that suggest the diagnosis if manifestations of GBS are causes the damage contains amino acids or proteins that are present similar to the proteins found in the peripheral nerve myelin. Serum lab tests are not useful ↓ Elevated protein in CSF – may be a sign of a tumor, This will prevent the immune system from distinguishing between bleeding, trauma, nerve injury or nerve inflammation in the two proteins (the proteins of the organism and the proteins of the brain the myelin sheath), resulting in the immune system attacking the PNS myelin. Vital capacity changes, (-) inspiratory force – ↓ suggest impending neuromuscular respiratory failure This promotes infiltration of macrophages and other agents, which my result to death which can lead to inflammation and destruction of the PNS myelin. ↓ Medical Management Once inflammation has occurred, along with the destruction of PNS myelin and demyelination of the myelin sheath in the PNS, it A medical emergency leads to axonal loss and interruption of nerve conduction. If respiratory is impaired 5 | JK MARIA  o Mechanical ventilation Parkinson’s Disease (PD) Due to weakness and immobility - it may cause − A slowly progressing neurologic movement disorder venous thromboembolism, deep vein thrombosis and (that may eventually lead to disability). pulmonary embolism. o Anticoagulants − Affects men more than women o Antiembolic stockings − Usually appear in 50 years of age and early To directly affect the PNS myelin manifestations occur in 30 years of age o Therapeutic plasma exchange − 2 forms: ✓ It involves the removal of plasma 1. Idiopathic (most common) the cause is and its contents. unknown. ✓ Once removed, blood cells are 2. Secondary form (known or suspected) separated from antibodies, and then − Risk factors plasma substitute is reinfused to Age remove the previously circulating Environment antibodies in the circulatory system. Heredity o Intravenous Immunoglobulin (IVIG) Pathophysiology Due to autonomic dysfunction o ECG monitoring – needed because of affectation in the vagus nerve (CN X) o Alpha-adrenergic blocking agents – for manifestations of hypertension and tachycardia Terazosin, prozasin o Increase the amount of IVF Nursing Management Monitor for changes in VC and negative inspiratory force – to prevent GBS from resulting to respiratory failure Destruction of dopamine storage cells in the substantia o Vital capacity – ability of the lungs to handle nigra in the basal ganglia of the brain. oxygenation ↓ Decreased levels of dopamine that leads to the o Decreased in VC and (-) inspiratory force – degeneration of the dopaminergic nigrostriatal pathways patient is at risk for respiratory failure which is important to the control of complex body Maintain adequate ventilation movement. o O2, mechanical ventilation ↓ Enhance physical mobility Degeneration of the dopaminergic nigrostriatal pathway. o PROMEs – at least twice a day ↓ Imbalance of excitatory (ACH) and inhibiting (dopamine) o Position changes neurotransmitters which is more on excitatory. o Anticoagulation administration ↓ o Antiembolic stockings – prevent embolism Impaired control of refined movements; and uncontrolled o Padding of bony prominences – to prevent complex body movements. pressure injury ↓ NOTE: Under nutrition occurs because of inefficient Tremors, rigidity, bradykinesia, postural instability. parasympathetic activity. This leads to manifestations of decreased peristalsis, which may lead to a Dopamine - is a neurotransmitter produced by neurons complication of paralytic ileus. located in the substantia nigra of the midbrain of the Maintain adequate nutrition basal ganglia. o IV fluids, parenteral nutritional o It plays several roles in the body, such as its involvement in reward-motivated behavior, Another possible complication is ineffective lactation, memory, and sleep regulation. communication due to bulbar weakness, wherein the o The most distinct role of dopamine regarding patient has difficulty talking or speaking (dysphonia) Parkinson's disease is in movement, as the Maintain effective communication manifestations of Parkinson's disease are o Picture cards, eye/blink system distinctively notice in the patient's control of Patients with GBS are faced with a sudden and body movements. potentially life-threatening disease. They may Acetylcholine - is excitatory while dopamine is experience feelings of fear and anxiety. inhibitory. The loss of dopamine results in more Decreased fear and anxiety excitatory than inhibitory neurotransmitters. o Diversional activity o If excitatory neurotransmitter is more o Referral to support group dominant, this will lead in impaired control of 6 | JK MARIA  refined movements and uncontrolled complex Dysphagia and drooling – patient is placed at risk for body movements choking and aspiration. o The noticeable body movements include Psychiatric changes – may be related to the disorder tremors, rigidity, bradykinesia (slowness of or due to biochemical abnormalities movement), and postural instability. o Depression, anxiety, dementia, hallucinations, psychosis Clinical Manifestations Autonomic symptoms Parkinson’s disease has a gradual onset and o Seborrhea (skin breakdown), sweating, symptoms progresses slowly orthostatic hypotension, constipation, urinary retention, sexual dysfunction 4 Cardinal Signs: Diagnostic Findings 1. Resting Tremors − Fingers moves as if rolling a pill between Laboratory and imaging tests are not helpful in the fingers (pill-rolling tremor) diagnosis of PD. − This is evident when the extremities are at Diagnosis is made from rest or motionless, and it becomes apparent o Patient history with purposeful movement and during sleep. o Presence of 2 of the 4 cardinal signs − Present in majority of patients at the time of ✓ If the patient shows 2 of the cardinal diagnosis signs it can be diagnosis PD 2. Rigidity Levodopa Trial − Characterized by resistance to passive limb o Confirm diagnosis when symptoms are movement (assisted movement) relieved − Passive movement can cause cogwheel Medical Management rigidity (jerky movement) − Stiffness of arms, legs, face, and posture are No medical or surgical approaches in current use common with rigidity. prevent disease progression 3. Bradykinesia (Akinesia) Goal − Common feature of Parkinson’s disease o Control symptoms − Slowing of active movement o Maintain functional independence - they − Patients take longer to complete activities can perform ADL such as rising from a sitting position or turning Pharmacologic treatment in bed o Antiparkinsonian meds – used to restore 4. Postural Instability balance between dopamine and the − Head bent forward and walks with propulsive cholinergic activities of acetylcholine gait. o Levodopa The gait is caused by forward flexion ✓ Most effective, mainstay of of the neck, hips, knees, and elbows treatment − Patient walks faster and faster trying to move ✓ Converted to dopamine in the feet forward under the body’s center of the basal ganglia which gravity produces relief Shuffling gait – places the patient ✓ But because levodopa can increase risk for falls, be metabolized before it reaches the brain, that Other Clinical Manifestations means the effectiveness will be decrease carbidopa Visual problems it usually added Olfactory changes o Carbidopa Hypokinesia - abnormally movement it occurs ✓ Added to levodopa to after the tremor. prevent levodopa from Freezing phenomenon metabolism prior it reaches o A transient inability of the client to perform the brain active movement, there is a temporary Stereotactic procedure inability to move. o Deep brain stimulation (DBS) o Extreme form of bradykinesia ✓ Involves surgical implantation of an Micrographia (small handwriting) - patient cannot electrode into the brain. Stimulation perform skills using the hands (decreased dexterity) of the electrode can either increase Masklike, expressionless faces dopamine release or block Dysphonia – characterized by soft slurred speech, low anticholinergic release. pitch, and less audible speech ✓ Improve tremor and rigidity 7 | JK MARIA  Thalamotomy and Pallidotomy - are ablative procedures that involve the removal and destruction of tissues. Formerly used to treat symptoms, they are rarely used today due to the procedure’s permanent destruction to brain tissues. Nursing Management Administer medication as ordered o Antiparkinsonian medication which is levodopa and carbidopa. Provide safe environment o Side rails on bed, rails and handlebars on toilet, no scatter rugs, spring-loaded chair (to make it easier for the pt to get up) Provide measures to increase mobility o AROMEs and PROME, stretching, assistive devices, suggest thinking of something to walk over if the client freezes Improve communication abilities o Read aloud, listen to own voice, pronounce each syllable clearly Maintain adequate nutrition o Cut food into small pieces, small-frequent feedings, allow time for meals – to prevent aspiration and to prevent difficulty of swallowing. 8 | JK MARIA  NCMB 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER FINALS 3RD YEAR NURSING WEEK 15 - Musculoskeletal System o However, the underlying padding if not waterproof can pose a problem if Orthopedic Nursing exposed to water and may result in Cast excoriation of the skin or formation of a pressure sore − A rigid external immobilizing device that is molded to Fiberglass is more expensive than Plaster of the contours of the body. Paris, and for this reason is often not the initial Purposes: cast of choice following trauma or surgery. o When removal may be necessary Permit mobilization of the patient while restricting because of swelling or wound movement of a body part inspection. Apply uniform pressure on encased soft tissue o Fiberglass casts can leave sharp To immobilize a reduced fracture edges and may cause breakdown of To correct a deformity the skin Principles in applying plaster cast: Padding materials: Generally speaking, the joints proximal and distal to the 1. Wadding sheet area to be immobilized are included in the cast 2. Roll of cotton stockinette Provide for maximal comfort & alleviation of complications Contraindications Application of padding is the first step in the procedure Pregnancy (growing size of abdomen, may have Maintain desired position throughout cast application edematous legs and feet) Use caution in handling of the cast until it has set and Skin disease (lesions, vesicles, infection, inflammation) become hardened o It can be applied as a combination, like Care of Patient on Cast stockinette & sheet wadding. The duration of keeping the body/part of it in cast is at o Apply it to include the joint above & joint below least one month (may vary among patients) the injured part Factors that influence the duration are: o Apply it in circular motion & mold it o Age of the patient o Support it with the palm o Part of the body affected 2 Types of Cast Materials o The degree of injury or affection of the part 1. Plaster of Paris (gypsum sulfate) Nursing Care on Patient’s with Cast A high-quality gypsum impregnated onto an During the entire period that the patient is in cast, your open weave fabric material. responsibility is focused on the: It has been the most common choice for 1. Neuro-vascular checks immobilization for many years. − The color, motion, temperature & It is relatively inexpensive, pliable and easy to sensation of toes/fingers should be mold, smoothing to conform almost exactly to observed every 30 minutes for the extremity several hours (longer if there is It starts to set in 5-7 minutes however it may much edema) and then regularly take up to 48 hrs. for the plaster cast to dry every 3 hours completely 2. Circulatory impairment o During this time, the wet cast should − Results in symptoms of coldness, be supported by a pillow and edema cyanosis, pain, & finally handled with the palms of the hands numbness in the toes / fingers to prevent denting the cast. − Patients in arm & leg cast should be o Walking on a cast before it is fully set able to move & feel each toe / finger, will cause the same problem because the same nerve does not 2. Fiberglass innervate each one- All toes & Is usually a knitted fabric impregnated with a fingers should be checked polyurethane resin, which hardens on Preservation of the efficiency of the cast exposure to water in a matter of minutes Maintenance & promotion of the integrity of the system It only takes a few seconds in water to initiate of the body the chemical reaction Maintenance of the cleanliness of the cast It takes approximately 30 minutes to dry completely, making weight-bearing and use of Points to remember the casted limb possible much sooner ✓ After the cast removal, support the part with pillow, Fiberglass casting materials have water- maintaining the same position that existed in the cast resistant properties. 9 | JK MARIA  ✓ Move the extremity gently It is important to place the pin correctly to ✓ Observe the skin for any abrasions & plaster sores avoid injury to vessels, nerves, joints & growth ✓ Wash skin w/ mild soap followed by application of oil plates and lanolin as prescribed Equipment’s: Traction Orthopedic Bed − It is the act of pulling & drawing which is assisted with Thomas Splint with Pearson attachment counter traction. Rest splint Purposes: Slings of variable sizes Paper clips or safety pins To reduce fracture Ropes - different length To reduce pain & muscle spasm Short - for the thigh To provide immobilization Long - for the traction To maintain good body alignment Longest - for the suspension For support Weights and Bags To prevent further deformity/correct deformity Suspension weight - is 1/2 lighter than the weight of Principles of Skeletal Traction: the traction. Traction weight - approximately 10% to of the Position of the patient should be in Dorsal Recumbent patient’s body weight or Supine Position Foot rest - to prevent foot drop Avoidance of friction o Instruct the patient to flex his unaffected leg Weights should be hanging freely while holding on the trapeze. Observe for signs of wear and tear on ropes and bags o Help him slowly to the stretcher. Rope should run freely along the grove of the pulley Musculoskeletal System Knots should be away from the pulley − Composed of the bones, joints, tendons, muscles, 3 Basic Types of Traction ligaments, & bursae of the body. 1. Manual Traction Bursae of the body - these are sacs that are The hands are used to exert a pulling force on located in between joints that are fluid filled. the bone which is to be realigned. o It assists us during the movement. Generally, this is reserved only for very stable o The bursae of the body are fractures or dislocations prior to splinting or important to reduce the friction. immobilization in a cast It also may be used prior to the application of Major Function: skin or skeletal traction or surgical reduction − Protection The pulling force is applied by the hands of For vital organs such as the lungs, brain and the operator. heart. o It is a temporary measure It reduces the damage of vital organs that is sometimes employed in handling enclosed in Musculoskeletal system neck injury when a cervical spine is − Framework fractured. Support body structures It is also used to apply the necessary pull to an extremity when cast is being applied − Mobility Musculoskeletal systems make mobility 2. Skin Traction possible. Strips of tape, mole-skin, or other type of Musculoskeletal system is the one that make commercial skin traction strips are applied us move. directly to the skin Traction boots for leg traction & pelvic belts for − Thermoregulation Heat produced during movement spinal disorders are included. It regulates temperature Treatment of children’s fractures & adult fractures/dislocations that require only a − Venous return moderate amount of pulling force for a Musculoskeletal systems facilitate venous relatively short period return during position changes, PROMEs and o Buck’s Extension (Most common) AROMEs. - femur and hip affection. Venous return is the blood flow of our body. It 3. Skeletal Traction moves from the heart specifically to the right atrium. Apply skeletal traction by placing a metal pin through the metaphyseal portion of the bone − Reservoir of immature blood cells & minerals & apply weight to the pin Calcium, Phosphorus, Magnesium, Fluoride The pulling force is applied directly to the Production of blood cells can be found in the bone using pins & wires such as: bone marrow. o Kirshner's wire The majority of our calcium is in the bone o Steinman's pin approximately 99% of Calcium. o Vinki's skull retractor o Crutch field tongs 10 | JK MARIA Assessment of Musculoskeletal: ✓ Apply ice if there is bleeding or edema Indicators of Peripheral Neurovascular Dysfunction ✓ Antibiotics as prescribed 6 P’s Neurovascular Assessment - Electromyography assessment of CMS (circulation, motor, sensation) o Provide information about electrical potentials of muscles and nerves o Circulation: o Evaluate weakness, pain, disability 1. Pulse o Involves insertion of needle electrodes 2. Pallor o Nursing Consideration: 3. Poikilothermia - capillary ✓ Determine patient if taking refill: > 3 secs anticoagulants or has skin infections o Motion: 4. Paralysis (and weakness) Muscle Biopsy o Sensation: 5. Pain (relenting), pain on o Muscular disorders passive stretch o Metabolic defects of muscle 6. Paresthesia (absence of o Infections of the muscles feeling) o Difference between nerve and muscle disorder Diagnostics: o Nursing Consideration: ✓ No fasting Bone X-ray Arthrogram/Arthrography o Determine bone density, texture, erosion, widening, narrowing, sign of irregularity o Identify the cause of unexplained joint pain o Nursing Consideration: and progression of joint disease ✓ Removing jewelries (blocks o Involves injection of contrast material into the anatomy) joint cavity ✓ Instruct to remain still (to avoid blurry ✓ (+) TEAR if contrast agent leaks out images) from the joint cavity ✓ If PCP, if female client is pregnant o Nursing Consideration: ✓ Determine allergy to contrast dye CT scan & MRI ✓ Notify PCP if female patient is o Visualize, assess tumors injury to soft tissues, pregnant ligaments, tendons ✓ Remove jewelries o Nursing Consideration: Arthroscopy ✓ Determine allergy to IV contrast ✓ Remove metal containing objects o Allows direct visualization of a joint ✓ Credit card informations can be o Treats tears, defects, and disease process erased (due to MRI) o Nursing Considerations: ✓ Nicotine patch, NGT transdermal, ✓ Pre-op clonidine transdermal have thin layer − Consent of aluminum − Do not consume any food or fluid for 8-12 hours Bone Scan − Patient may be instructed o Detect bone cancer, osteomyelitis, fractures, to shave the joint area aseptic necrosis − Hospital gown o Monitor progression of bone disease ✓ Post-op o Can diagnose disease before it can be − Elastic bandage is worn for identified in x-ray 2-4 days o Nursing Consideration: − Keep joints extended and ✓ Consent elevated ✓ Determine allergy to isotopes − Monitor neurovascular ✓ Inform PCP if female client is status pregnant − Avoid strenuous activity of ✓ Empty bladder prior to bone scan the joint ✓ Drink 4-6 glasses of water after bone − Exercise must be approved scan by the PCP ✓ Observe for signs of complications Bone Biopsy ✓ Fever, excessive bleeding, swelling, o Determine structure & composition of the numbness, cool skin. bone marrow, bone muscle, synovium o Involves excision of bone tissue using needle Arthrocentesis o Nursing Consideration: o Also known as joint aspiration ✓ Offer assurance of pain meds or o Obtain synovial fluid sedative, pre-op & post-op o Purpose: ✓ Monitor site of insertion of ✓ Relieve pain complications ✓ Analyze synovial fluid 11 | JK MARIA  o Nursing Consideration: o Epiphyseal - treatment through the epiphysis ✓ Offer assurance that pain meds will o Greenstick - one side of bone is broken, the be administered other is bent ✓ Apply ice on the operative site o Impacted - a bone fragment is driven into Fractures another bone fragment o Transverse - fracture straight across the − A complete or incomplete disruption in the continuity of bone shaft bone structure o Oblique - fracture at an angle across the − Descriptions bone Complete fracture - break across the entire o Pathologic - fracture that occurs through an cross-section of the bone area of a diseased bone Incomplete fracture - break is through only a o Spiral - twists around the shaft of the bone part of the cross-section of the bone o Stress - fracture that results from repeated Comminuted fracture - break produces loading of bone and muscle several bone fragments − Causes Direct blows, crushing forces, sudden twisting motions, extreme muscle contractions − Complications Soft tissue edema, hemorrhage, joint dislocations, ruptured tendons, severed nerves, damaged blood vessels − Types o Closed fracture o Simple fracture o Does not cause a break in the skin o Open fracture Clinical Manifestations: o Compound or complex fracture Acute pain - more intense when spasms occur o Skin or mucous membrane wound Loss of function - depends on the integrity of bones extends to the fracture bone where muscles are attached o Classifications 1. Type I Deformity - displacement, angulation, rotation of the ✓ A clean wound fracture extremity less than 1 cm Shortening of the extremity - due to compression of long and simple the fracture bone, or overlapping of the distal and fracture pattern proximal site of the fracture 2. Type II Crepitus - a crumbling sensation when extremity is ✓ A larger wound w/ gently palpated minimal soft Localized edema and ecchymosis - due to trauma, tissue damage, no bleeding into tissues flaps or avulsions Muscle spasm and tenderness 3. Type III Emergency Management: ✓ Most severe, highly If suspected with a fracture contaminated, o Immobilize thru adequate splinting first has extensive o Check neurovascular status before and after tissue damage splinting o Intra-articular fracture If open fracture o Fracture extends into the joints of a o Cover wound w/ sterile dressing bone o Never attempt to reduce the fracture o MRI or arthroscopy confirms the Medical Management: diagnosis o Often leads to osteoarthritis Reduction o Restoration of fracture fragments to anatomic − Specific types alignment and positioning o Avulsion - fragment of bone has been pulled o Nursing considerations away from its main body by a tendon and its ✓ Secure consent attachment ✓ Administer analgesics as prescribed o Compression - bone has been compressed ✓ Handle the affected extremity gently o Depressed - fragments are driven inward 12 | JK MARIA  Closed reduction Nursing Management o Involves manipulation, manual traction, Closed fracture percutaneous pinning o Control of edema and pain o Involves application o cast, splint or another o Exercises on the unaffected side device to reduce fracture o Proper use of assistive devices o Xray to verify correct alignment Open fracture o Traction may be used o IV antibiotics and tetanus toxoid Open reduction o Wound irrigation and debridement o Involves a surgical approach w/ the use of o Temp check internal fixations (pins, wires, screws, plates, o Elevate affected extremity nails, rods) o Neurovascular check o Open reduction internal fixation (ORIF) Complications ✓ Most common orthopedic surgical o Shock (hypovolemic or traumatic) procedure used to treat severe ✓ Prevent further hemorrhage, restore fracture BV and circulation Immobilization ✓ Relieve pain o Accomplished by external or internal fixation ✓ Proper immobilization o Methods of external fixation o Fat embolism syndrome (FES) ✓ Bandages, casts, splints, continuous ✓ Hypoxia, tachypnea, tachycardia, tractions pyrexia ✓ External fixators ✓ Petechiae on chest External fixators ✓ Free fat urine o Devices that manage fracture o Compartment syndrome o Purposes ✓ Complicated fracture of the Compartment Syndrome humerus, femur, tibia, pelvis − Compartment - is an area of the body encased by a ✓ Correct defects, treat nonunion, bone or fascia which contains muscles, nerves and lengthen limbs blood vessels. ✓ Provide skeletal ability for severe − Characterized by elevation of pressure within an comminuted fracture (crush or anatomic compartment that is above normal perfusion splintered) pressure. o Involves surgical insertion of pins through skin That pressure can compromise the circulation into the bones w/ attached of external frame and function of tissues that may lead to cell o Types death, necrosis, permanent dysfunction ✓ Roger-Anderson External Fixator − The body has 46 compartments and 36 are located in (RAEF) the extremities ✓ llizarov external fixator − Most common in young adults ✓ Delta external fixator − Causes: o Nursing management (post-application) ✓ Elevate the affected extremity to the Edema level of the heart Bleeding ✓ Cover sharp points w/ caps Restrictive cast ✓ Assess neurovascular status every Fractures 2-4 hours o Most common cause ✓ Clean pin site o Tibial fracture has the highest risk ✓ Check for signs of infection Clinical Manifestations: ✓ Isometric and active exercises ✓ Never adjust the clamps Pain o Cardinal signs o Severe pain and out of proportion to the injury o Deep and burning pain Management: Bivalving o Cast is cut in half longitudinally o To relieve pressure and allow inspection of the skin Elevate extremity no higher than the heart level - to maintain arterial perfusion “E” fasciotomy 13 | JK MARIA  o The fascia is cut open to relieve pressure o The symptoms are most occurring in o If pressure is not relieved and circulation is not weight-bearing joints restored NOTE: There are no systemic symptoms Monitor neurovascular status associated with osteoarthritis − Onsets: Pressure Injuries Begins in 30 years − Tissue anoxia and ulcer due - to pressure from cast Peaks between 50-60 years or inappropriately applied brace which can lead to NOTE: Osteoarthritis can affect younger tissue anoxia or pressure injury patients also. − Most susceptible areas are those with bony − Risk factors: prominences Increased age, obesity, previous joint Heel, malleoli, dorsum of the foot, head of damage, mechanical injury, anatomic fibula, anterior surface of the patella deformity, genetic and hormonal factors Medial epicondyle of the humerus, ulnar styloid Clinical Manifestations: Clinical Manifestations: Joint pain – aggravated by movement of exercise and relieved by rest. Pain and tightness Stiffness – usually occurs in the morning (lasts for 30 Warm area on cast - suggests tissue erythema or mins). redness Functional impairment – an individual cannot perform Skin breakdown ADLs completely. Tissue necrosis Other Manifestations: Management: o Enlarged affected joint – most often occurs in weight-bearing joints (such as hips, knees, Univalving – application of cast on a single tube cervical, and lumbar spine). wherein all sides are closed o Decreased ROM Bivalving – the cast is cut half longitudinally o Heberden’s nodes (DIP) Windowing – cutting a portion of a cast to create an opening to allow for inspection, access and possible ✓ Distal interphalangeal joint treatment abnormality ✓ Common sign Disuse Syndrome ✓ Upon palpation, you may notice small-hard bony lumps located in the − Muscular atrophy and loss of strength due to distal interphalangeal joint. immobilization rom cast, splint, or braces o Bouchard’s nodes (PIP) - abnormalities or Management: lumps that occur at the proximal interphalangeal joint. Instruct the client to perform isometric contraction o Crepitus - may be present through palpation o Performed hourly while awake - to promote over the knee. muscle strength and reduce weakness. o Mild joint effusion - a sign of inflammation o Isometric contraction – is done by o Boutonniere deformity instructing the pt to contract muscle without a o Swan-neck deformity significant movement of the extremity or underlying bone. Joint Disorders Assessment and diagnostic tests: Osteoarthritis (OA) Blood tests and synovial fluid analysis are not useful Xray − A non-inflammatory degenerative disorder of the joints o Narrowing of joint space and the most common form of joint disease o Osteophyte formation − Also known as degenerative joint disease ✓ Osteophyte – bone spurs that − Classifications: protrude into the joint space, leading Idiopathic (primary) – there is no prior to narrowing joint spaces. disease related to the osteoarthritis. o Dense, thick subchondral bone Secondary - osteoarthritis results from a ✓ Subchondral bone – bony plates previous joint injury or inflammatory disease. where articular cartilage is attached. − Distinguishing factors: OA does not involve autoimmune or Medical and Nursing Management: inflammation Goal: Decrease pain and