NCM 116 Week 1 PDF

NCM 116 WEEK 1 Care of Clients with Alterations in Coordination ANATOMY PHYSIOLOGY ANATOMY AND PHYSIOLOGY REVIEW SKELETAL SYSTEM Functions Divisions Types of Bone Tissues Types of Bone Cells Classification Bone Healing FUNCTIONS (F-A-P-P-S) Framework of the body Assist in body m...

NCM 116 WEEK 1 Care of Clients with Alterations in Coordination ANATOMY PHYSIOLOGY ANATOMY AND PHYSIOLOGY REVIEW SKELETAL SYSTEM Functions Divisions Types of Bone Tissues Types of Bone Cells Classification Bone Healing FUNCTIONS (F-A-P-P-S) Framework of the body Assist in body movement Protects vital organs Production of red blood cells Storage of minerals DIVISIONS Axial Skeleton Appendicular Skeleton DIVISIONS Axial Skeleton composed of 80 bones; involving the following vertical and central axis of the body cranial (8) and (14) facial bones vertebrae – composed of 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused into 1); and 4 coccyx (fused into 1) vertebrae ribs – composed of 12 pairs (7 pairs of true bones, 3 pairs of false ribs, 2 pairs of floating ribs) hyoid bone sternum Appendicular Skeleton composed of 126 bones, involving the following Upper extremity – clavicle, scapula, humerus, radius, ulna, carpal, metacarpal, & phalanges Lower extremity – pelvis, femur, patella, tibia, fibula, tarsal, metatarsal, & phalanges CRANIAL BONES FACIAL BONES VERTEBRAE RIBS UPPER EXTREMITY LOWER EXTREMITY BONE TISSUES Compact Bone/Dense Bone Also known as cortical bone Forms the hard external layer of all bones Surrounds the medullary cavity or bone marrow Provides strength and protection to the bones Spongy Bone/Cancellous Bone Forms the inner layer of all bones Softer compared to compact bone Reduces the density of bone Allows the end of the bones to compress at times when stresses are encountered by the bone BONE CELLS Osteoblasts Bone-forming cells Synthesize and secrete both the organic (calcium, phosphate)(responsible for hardness and resistance) and inorganic (collagen fibers)(responsible for tensile strength and flexibility) part of the extracellular matrix of the bone tissue Osteocytes Mature bone cells and main cells Osteoclasts Large bone cells responsible for removing bone structure by releasing enxyms and acids that dissolve the bone Play an important role in bone remodeling Osteoprogenitor cells Has the ability to produce daughter cells that would differentiate into osteoblasts. Important in the repair of fractures BONE CELLS CLASSIFICATION OF BONES Long bones Longer than they are wide Mostly compact bone with spongy bones at the ends Bones of the limbs except the patella, the wrist, and the ankle bones, are long bones Flat bones Thin, flattened and usually curve Have two thin layers of compact bone sandwiching a layer of spongy bone Most bones of the skull, the ribs and sternum are flat bones Short bones Cube-shaped Mostly spongy bones with an outer layer of compact bone Wrist, patella, and ankle bones Irregular bones Bones that does not fit one of the preceding categories Mostly spongy bones with an outer layer of compact bone Vertebrae, pelvis, facial bones, hyoid bone BONE HEALING Hematoma Blood vessels rupture leading to bleeding and clot formation Inflammation Inflammatory cells (macrophages, neutrophils, lymphocytes) migrate to the site of injury releasing cytokines and growth factors Growth factors recruit fibroblasts, osteoblasts, chondrocytes Soft callus formation Fibroblasts and chondrocytes form soft callus Angiogenesis begins to restore blood supply Hard callus formation Osteoblasts replace soft callus with hard callus Calcium and phosphorus deposition occurs, increasing bone rigidity Remodeling Osteoclasts resorb excess bone Osteoblasts lay down new bone to restore original shape and strength BONE HEALING ALTERATIONS IN COORDINATION Injuries Fracture Sports Injury Joint Disorders Rheumatoid arthritis Osteoarthritis Gouty Arthritis Carpal Tunnel Syndrome Degenerative Osteoporosis CARE OF CLIENTS WITH FRACTURE FRACTURE Break or interruption in the continuity of the bone CAUSES Direct Force – bone absorbs more stress that it cannot endure from the impact of a solid object such as from direct blow or fall from a height or a crushing injury from vehicular accidents Indirect Force – bone breaks at a site different from where the force was actually applied such as twisting force that usually causes spiral fractures Powerful Muscle Contractions – highly developed muscles contract so violently that muscle tears from bone Pathologic Decay – bones are weakened by diseases such as osteoporosis and becomes susceptible to fracture even with a minimal movement Repetitive Forces – those caused by running which can cause fractures of the foot, ankle, tibia or hip CLASSIFICATION OF FRACTURES Closed fracture (Simple fracture) – disruption in the community of the bone without skin breakage Open fracture (Compound fracture) – there is bone disruption with skin breakage and involvement of the underlying soft tissues leading directly into the fracture site Incomplete fracture – a fracture involving only a portion of the cross section of the bone, usually undisplaced Complete fracture – a fracture involving the entire cross section of the bone, usually displaced CLASSIFICATION OF FRACTURES PATTERNS OF FRACTURES Transverse – fx straight across the bone; usually caused by a force applied directly to the site where the fracture occurs Oblique – fx occurring at an angle across the bone Spiral – fx twisting around the shaft of the bone Comminuted – fx splintered into several fragments Depressed – fx in which fragments are driven inward (seen frequently in fractures of the skull and facial bones) Compression – fx in which bone has been compressed (seen in vertebral fractures) Greenstick – fx in which one side of a bone is broken and the other side is bent (occurs in children whose bones are soft and yielding) PATTERNS OF FRACTURES Fatigue/Stress – bone breaks after repeated stress (associated with soldiers who may break bone during prolonged marching) Impacted – fractured surfaces are driven together or wedged into other bone fragment Segmental – bone break in which several large bone fragments separate from the main body of a fractured bone; the ends of the fragments may pierce the skin, or may be contained within the skin Longitudinal/Fissure – fx run along the length of the bone; does not typically break the bone into several pieces PATTERNS OF FRACTURES PATTERNS OF FRACTURES PATTERNS OF FRACTURES CLINICAL MANIFESTATIONS OF FRACTURES Pain/tenderness (aggravated by motion and increases in intensity until immobilized) Edema/Swelling (after 24 hours) Deformity Crepitus (grating sound as bone ends rub together) Ecchymosis (after 24 hours) Shortening of the limb d/t muscle spasm Loss of function X-ray – confirmatory test TREATMENT Notes Immediate immobilization of the bone Bone should never be attempted to straighten; “splint it as it lies” Prevention of shock and hemorrhage Primary aim of treatment is to establish a sturdy union between the broken ends so that the bone can be restored to continuity To ensure proper healing without deformity or loss of function, the surgeon must bring two broken ends together in proper alignment and then immobilize until healing is complete Reduction of the fracture – procedure of bringing the two fragments of bone into proper alignment Stabilization of the fracture – process of securing and supporting broken bone fragments to ensure proper alignment and immobilization during the healing process TREATMENT Phases in the Management of Fracture (4Rs) Recognition Phase – assessing the type of fracture and its s/sx; done initially through x-ray Reduction Phase – putting back the bone to its proper alignment Retention Phase – maintaining the alignment using immobilization devices and supplies such as cast, brace, traction, implants or fixators Rehabilitation Phase – putting and helping the patient achieve the optimum level of functioning after having the retention phase TREATMENT Reduction Closed Reduction – bone is manipulated into alignment; no surgical incision is made Open Reduction – done after a surgical incision is made through the skin and down to the bone at the site of the fracture Stabilization Internal fixation External fixation Casts, splints, braces Traction TREATMENT Internal Fixation Use of pins, nails, screws, metal plates to stabilize the position of the two broken ends External Fixation Use of a device composed a sturdy external frame to which are attached pins that have been placed into the bone fragments TREATMENT TREATMENT TREATMENT Cast used for stabilizing a fracture after a closed reduction externally applied and molded to the contours of the body made up of layers of plasters, bandages, fiberglass or other non-plaster materials Permits mobilization while restricting movement of a body part TREATMENT Braces Medical device made of rigid materials such as hard plastics, metal, leather and soft materials such as spandex, fabrics, Velcro or straps designed to support, maintain good body alignment Splint Medical device used to immobilize and support an injured body part, typically a bone, joint, or soft tissue. TREATMENT TREATMENT Traction An act of pulling or drawing in association with a counter traction Indications Reduce/immobilize fractures Relieve muscle spasm Relieve pain Prevent/correct deformities Types Skin Traction – bandage (mole skin, or a foam traction boot) is applied to the limb below the site of fracture, and then pull is exerted on the limb Skeletal Traction – surgeon inserts pins, wires, or tongs directly to the bone at a point distal to the fracture so that the force of pull from the weights is exerted directly on the bone Buck’s Traction TRACTIONS Buck’s Traction exerts straight pull on affected extremity; temporary intervention to immobilize the leg in patient with a fractured hip shock blocks at the foot of the bed produce counter traction and prevent the patient from sliding down in the bed Has a horizontal weight Can only immobilize one bone Turn client towards unaffected side Check for pressure sore on the heel of the foot and signs and symptoms of thrombophlebitis Bryant Traction TRACTIONS Bryant Traction Both legs are raised at 90 degrees angle to bed. Because the weight of the child is not adequate to provide counter traction For fracture of the femur and hip dislocation Buttocks must be slightly off the mattress. To enhance efficiency of the weight as counter traction Knees slightly flexed. Russell Traction TRACTIONS Russell Traction Knee is suspended in a sling attached to a rope and pulley on a Balkan frame, creating upward pull from the knee (vertical traction) Weights are attached to the foot of the bed creating a horizontal traction Has horizontal and vertical weights Used to treat fracture of the femur and immobilizes more than one bone Allows patient to move about in bed more freely and permits bending of the knee Hips should be flexed at 20 – 30 degrees. Foot of the bed usually elevated to provide counter traction Asses back of the knee for pressure sores; and s/sx of thrombophlebits Head Halter Traction TRACTIONS Head halter traction Attached to weights that hang over head of bed Used for soft tissue damage or degenerative disease of the cervical spine to reduce muscle spasm and maintain alignment Pelvic Traction Crutchfield Tong Balanced Skeletal Traction (BST) COMPLICATIONS OF FRACTURE Osteomyelitis Hypovolemic shock Nonunion, delayed union, malunion Fat embolism Venous thrombosis Compartment syndrome COMPLICATIONS OF FRACTURE Osteomyelitis Bacterial infection of the bone Infection may reach bone through open wound, through the blood stream or by direct extension from infected adjacent structures Signs/Symptoms Sudden onset with severe pain and marked tenderness at the site High fever with chills, swelling of adjacent soft parts, headache, and malaise Sequestrum (necrosis of bone tissue) Diagnostic: Elevated WBC (infection); Elevated ESR (inflammation) COMPLICATIONS OF FRACTURE Osteomyelitis Management Analgesics, antibiotics Dressing changes, sterile technique Maintain proper alignment and change position to prevent deformities Immobilization of affected area Surgery if needed Incision and Drainage of bone abscess Sequestrectomy – removal of dead infected bone and cartilage COMPLICATIONS OF FRACTURE Hypovolemic shock Due to massive bleeding Frequently noted in trauma patients with pelvic fractures or in patients with open femoral fracture in which the femoral artery is torn by bone fragments COMPLICATIONS OF FRACTURE Hypovolemic shock Management Stabilize fracture to prevent further hemorrhage Restoring blood volume and circulation Relieving pain Proper immobilization COMPLICATIONS OF FRACTURE Nonunion Failure of the ends of the bone to unite Presence of fibrocartilage in between the bone fragments; no bone has been formed Malunion Failure of the ends of a fractured bone to unite in normal alignment Signs/symptoms Persistent discomfort Abnormal movement COMPLICATIONS OF FRACTURE Nonunion Management Internal fixation – to align bone ends Bone grafting – promotes bone growth Electrical bone stimulation – enhances mineral deposition which promotes bone growth COMPLICATIONS OF FRACTURE Fat Embolism Rare but serious Occurs in fractures of bones with an abundance of marrow (long bones, pelvis, ribs) Fat globules partially or completely occludes blood vessel Can lead to acute respiratory distress syndrome (ARDS) Signs/Symptoms Change in mental status Respiratory distress, tachypnea, crackles, wheezes Rapid pulse, fever Petechiae COMPLICATIONS OF FRACTURE Fat Embolism Management Stay with the patient High Fowler’s position Oxygenation Contact the physician immediately Anticipate hydration via IV and correction of acidosis Intubation and mechanical ventilation if supplemental oxygen is inadequate COMPLICATIONS OF FRACTURE Venous Thrombosis Veins of the pelvis and lower extremities are vulnerable to thrombus formation after fracture, especially hip fracture Immobility, traction, and casts may contribute to venous stasis Management Compression stockings ROM exercises Anticoagulant drugs COMPLICATIONS OF FRACTURE Compartment Syndrome Restriction of blood flow that occurs in one or more muscle compartments of the extremities Results from fractures of arms or legs where closed compartments are present Anatomic compartments is an area of the body encased by bone or fascia (fibrous membrane that covers and separates muscles) Human body has 46 compartments, and 36 of these are located in the extremities Compartment contains blood vessels, nerves, muscles which are enclosed by fascia, which is inelastic COMPLICATIONS OF FRACTURE Compartment Syndrome Caused by internal and external pressures that seriously restrict circulation to the area External pressures – dressings or casts that are too tight Internal pressures – inflammation and edema COMPLICATIONS OF FRACTURE Compartment Syndrome Signs and Symptoms Deep, throbbing, unrelenting pain which continues to increase despite administration of opioids, and seems out of proportion to the injury Pain that intensifies with passive ROM (hallmark sign) Management Assess for 5 Ps or 6 Ps Pain Pallor Pulselessness Paresthesia Paralysis Poikilothermia (cold to touch) COMPLICATIONS OF FRACTURE Compartment Syndrome Management Elevation at the heart level is the key in preventing compartment syndrome Notify physician immediately to prevent nerve and muscle damage Bivalving of cast (split through all layers of the material) Remove tight dressings or cast Fasciotomy with delayed closure of wound, 3 – 5 days after surgery to allow edema of the contents of the compartment to subside COMPLICATIONS OF FRACTURE CARE OF CLIENTS WITH CAST CARE OF CLIENTS WITH CAST FIBERGLASS CASTS PLASTER OF PARIS CASTS Synthetic resin fiberglass fabric (hardens when Gypsum (calcium sulfate hemihydrate) (hardens exposed to water) when mixed with water) Lighter in weight Heavier in weight Stronger and more durable Less stronger and less durable Water-proof Absorbs water and weakens and disintegrates Dries quicker (within 10 – 15 minutes_ Dries longer (within 48 hours, longer if large cast) CARE OF CLIENTS WITH CAST Carry the newly-casted body part with palms of the hand or flat surface of the extended fingers. To prevent indentation and pressure against the tissue under the cast which can lead to pressure sore Elevate the body part with pillow support. To prevent edema and minimize swelling Expose the cast to dry. Dry Plaster of Paris cast appears white, shiny, hard and resonant. Sensation of heat as the cast is drying is normal. Do not covered cast with a blanket or towel while it is drying. Retained heat can burn the client CARE OF CLIENTS WITH CAST Keep cast clean and dry. Advised not to used sharp objects to scratch under the cast. These can tear the skin, leaving an open break for bacteria to enter. Use hair- dryer on cooler setting if at home, or use a large syringe and forcefully direct air under the cast Observe “hot spots” & musty odor or drainage from the cast. These are signs of infection “Petal” the edges of the cast to smoothen the areas by applying adhesive tapes to maintain skin integrity CARE OF CLIENTS WITH CAST Do neurovascular checks. The following findings distal to cast application indicate the cast is too tight. Skin color – pallor, cyanosis Skin temperature – cold skin Sensation – numbness, tingling Mobility – inability to move the body part Pulse – absence of pulse Windowing is done facilitate observation under the cast. It is also done to assess pulse or to prevent “cast syndrome” Cast syndrome may occur if the client has body cast. It is manifested by bloated feeling, prolonged nausea, repeated vomiting, abdominal distention, vague abdominal pain, shortness of breath. Caused by compression of the duodenum between the aorta and superior mesenteric artery CARE OF CLIENTS WITH CAST Bivalving is done for wound care or x-rays or for when the cast is too tight or when healing process has occurred. Involves splitting the cast Never ignore complaints of pain from the patient in a cast because of the possibility of a problem Pain due to fracture is relieved by immobilization Pain due to edema can be controlled by elevation COMPLICATIONS ASSOCIATED WITH CASTS Compartment syndrome Pressure ulcers Disuse syndrome – muscle atrophy and loss of strength due to immobilization CARE OF CLIENTS WITH TRACTION CARE OF CLIENTS WITH TRACTION Keep the patient in the center of the bed. Slipping down in bed results in ineffective traction Keep the body part in traction in a straight line. Misalignment causes pain Weights should be freely hanging. If the weights are resting on the bed or on the floor, the purpose of traction is defeated. Weights must never be removed unless a life threatening situation occurs Assess neurovascular status (6 Ps) Advise used of overhead trapeze to prevent using elbows and heel when moving to prevent skin breakdown Monitor pin site insertion for infection. Daily wound care. CARE OF CLIENTS WITH TRACTION Promote exercise which includes pulling up the trapeze, flexing and extending feet, ROM exercises. To prevent muscle weakness and muscle mass loss Encourage to increase food rich in fiber, protein, vitamin C and calcium; increase fluid intake Provision of supportive therapy Spiritual aspect Diversional activities POTENTIAL COMPLICATIONS Pneumonia d/t accumulation of pulmonary secretions. Provide bronchial tapping and teach deep breathing exercises Bedsore. Ensure proper positioning, skin care and lifting buttocks UTI d/t urinary retention due to CBR and lack of fluids. Increase OFI, provision of urinal/bedpan Constipation d/t lack of fluids, immobility, lack of privacy. Provision of privacy, increase OFI, high fiber diet Pin Site infection d/t contamination of pin site dressing, lack of aseptic technique. Do daily wound care Contractures d/t immobility and pain. Encourage ROMS, Provision of exercises. WALKING ASSISTIVE DEVICES FOR ASSITIVE DEVICES FOR WALKING Cane The client must hold cane on the unaffected hand. The cane and the affected leg are advanced together. To shift the weight unto the cane. The height of the cane should be hip level ASSITIVE DEVICES FOR WALKING Walker Instruct client to use “lift and walk” technique (lift the walker forward, then make few small steps toward the walker Height should be hip level ASSITIVE DEVICES FOR WALKING Crutches Assure proper length The distance between the crutches and axillae should be 2 to 3 fingerbreadths. To prevent crutch palsy Elbows should be slightly flexed when hand is on bar (30 degrees) Weight must be borne by palm of the hands not by the axillae to prevent crutch palsy Gaits for Crutch-walking Four point gait: right crutch  left foot  left crutch  right foot Two point gait: right crutch and left foot  left crutch and right foot Three point gait: both crutches and affected leg  unaffected leg Swing-to gait: advance both crutches, swing the body so that the feet will be to the level of the crutches Swing-through gait: advance both crutches, swing the body so that the feet will be past the level of the crutches Going up and down the stairs “Up with the good; down with the bad” When going up the stairs, advance the good leg first, followed by the bad leg and the crutches. When going down the stairs, advance the bad leg and the crutches first, followed by the good leg. Note: The bad leg should always be with the crutches to provide support