NUR 212 Notes PDF

Unit 2 Modules 2 (Metabolism: Osteoporosis) & 3 (Mobility: Hand & Foot Disorders, Muscular Dystrophy, Osteomalacia, Osteomyelitis, Scoliosis, Amputations) Bone Metabolism Review: ○ Metabolism: overturn, absorption and use of bone cells and nutrients; classified...

Unit 2 Modules 2 (Metabolism: Osteoporosis) & 3 (Mobility: Hand & Foot Disorders, Muscular Dystrophy, Osteomalacia, Osteomyelitis, Scoliosis, Amputations) Bone Metabolism Review: ○ Metabolism: overturn, absorption and use of bone cells and nutrients; classified by osteoblasts and osteoclasts ○ Nutrients Carbohydrates, fats, proteins ○ Metabolism Energy, cell repair ○ Hormones Chemical messengers that exert controlling effects on cells of the body Regulate growth, reproduction, F/E balance ○ Catabolism (all metabolic processes that tear down biomolecules (osteoclasts)) vs. Anabolism (process of building up new biomolecules) (osteoblasts)) Aging Bones ○ Decrease bone mass and minerals ○ Decrease calcium resorption Thinner bones = increased risk for fractures Slow resorption of interior of long bones Slow production of new bone on the outside surface of bones ○ Vertebrae shorten and intervertebral disks thin; kyphosis (shortening and hunchback) ○ Cartilage on bone surfaces in joints deteriorate (leads to osteoarthritis) and bone spurs may occur (limits mobility) Changes Related to Aging ○ Bone structure changes (caused by expansion and resorption) ○ Osteopenia: decreased bone density (can lead to osteoporosis) ○ Cartilage degeneration (can lead to arthritis) ○ Atrophied muscle tissue (increased exercise can slow atrophy) ○ Decreased coordination and ROM ○ Loss of muscle strength ○ Gait changes ○ Slowed movement ○ Increased fall risk Osteoporosis ○ Chronic metabolic disease in which bone demineralization results in decreased density and subsequent fractures - issue w/ metabolic process of bones ○ “Silent disease” - don’t see effects until someone has typically fallen and broken something ○ Osteoclastic activity is greater than osteoblastic activity (breaking down more rather than building) ○ Most common in: postmenopausal, Caucasian women ○ PREVENTION IS KEY!!! Prevent falls, encourage weight bearing exercise, encourage calcium intake, encourage adequate hydration and nutrition ○ 3 types: Primary: occurs in postmenopausal women (r/t decreased estrogen, causing increased bone resorption); men over 50 Secondary: r/t other medical conditions, drug therapy, tobacco use, ETOH use, or prolonged immobilization Regional: happens in one specific region of the body; r/t trauma or prolonged immobilization of one area (ex: broken arm) ○ Risk Factors Nonmodifiable Age > 50 Family hx Hx of low trauma fx after 50 Modifiable Low body weight, thin build Chronic low calcium or vitamin D Excess or deficient protein intake (too much protein binds to calcium, and if excreted, can lose excess calcium) Estrogen (promotes activity of osteoblasts; if low, osteoclastic activity occur) or testosterone deficiency Gender confirmation surgery (affects hormones, so increases risk; after 12 months of replacement, risk can decrease) Smoking and high ETOH intake Sedentary lifestyle Excessive caffeine (slows bone repair) or carbonated beverage (high amounts of phosphorus can eat away at bones, and also binds to calcium which can lead to excess excretion) consumption ○ Screening - DEXA scan Who should have a bone density test? Women age 65 or older Men age 70 or older If one breaks a bone after 50 Women of menopausal age with risk factors Men aged 50-69 w/ risk factors A bone density test may also be necessary if you have any of the following: An x-ray of your spine showing a break or bone loss in your spine Back pain w/ a possible break in spine Height loss of ½ inch or more w/in a year  Total height loss of 1 ½ inches from your original height ○ Secondary Osteoporosis Medical conditions that may be associated with osteoporosis: Diabetes - HUGE Hyperthyroidism Hyperparathyroidism - excess PTH = excess breakdown Cushing’s syndrome Growth hormone deficiency Metabolic acidosis Female hypogonadism Rheumatoid arthritis Prolonged immobilization Bone cancer Cirrhosis HIV/AIDS Medications: Aluminum Anticonvulsants Cytotoxic drugs Glucocorticoids - decreased metabolism in the gut Immunosuppressants Lithium LT heparin use Progesterone Tamoxifen (SERM) - blocks estrogen and can increase risk of fx TPN ETOH Thyroid hormones ○ Clinical Manifestations Loss of height Progressive spinal curvature “Dowager’s Hump” Low back pain Fractures - typical dx factor Most common in lower back, wrist, or hip Secondary manifestations Constipation - decreased calcium or specific multivitamins being taken, compression of intestines Reflux - stomach gets pushed up, and gastric secretions make their way back up Respiratory complications - compresses chest cavity, SOB, increased risk for pneumonia ○ Diagnostic Imaging  X-rays - usually w/ fractures, shows bone density loss (shows when 25- 40% of bone loss occurs) Bone mineral density (BMD) DEXA Scan - gold standard: Dual-energy x-ray absorptiometry Spine, hip, or wrist; quick and can be completed in a few minutes; has less radiation exposure Can remain clothed, but must remove any metal objects ○ Fine w/ pacemakers Must stop calcium supplements 24 hrs prior ○ Can cause skewed results cDXA (central DXA) (spine and hip) vs. pDXA (peripheral DXA) (forearm, wrist, heel, etc) pQUS (peripheral quantitative ultrasound densitometry) Peripheral ultrasound to look at bones that may be superficial Not as precise, but can indicate increased risk MRI FRAX - fracture risk assessment tool Assesses 10 year fracture risk ○ DEXA T-Score Based on standard deviation Normal: BMD is within 1 SD of a “young normal” adult (T-score at - 1.0 and above) Low bone mass (“osteopenia”): BMD is between 1.0-2.5 SD below that of a “young normal” adult (T-score between -1.0 and -2.49) Osteoporosis: BMD is 2.5 SD or more below that of a “young normal” adult (T-score at or below -2.5) Patients in this group who have already experiences one or more fractures are deemed to have severe or “established” osteoporosis ○ Diagnostic Labs - no definitive dx labs Serum calcium - low or normal Vitamin D - low or normal Alkaline phosphatase - usually normal unless if they’ve had a fracture Phosphorus - high or normal Urinary calcium - detects if they’re having early bone loss via early calcium binding to protein and being excreted; not common Serum protein (albumin) Thyroid function tests - rules out hyperthyroidism or hyperparathyroidism Serum and urinary bone turnover markers - not common; provides bone formation activity and bone resorption information ○ Treatment  Priority problem: potential for fractures due to weak, porous bone tissue Pharmacological treatment Diet therapy Increase vitamin B, D, and calcium intake If they have a fracture - increase vitamin C, iron and protein intake as well Decrease ETOH, caffeine, and carbonated beverages Exercise Muscle strengthening exercises - to help protect the bones Low impact, weight bearing exercises (WALKING) Avoid high impact activities (bowling, skydiving, horseback riding, gardening, etc) Pain mgmt Orthotic devices Back brace, wrist brace, etc. Psychosocial Address anxiety, fears May become obsessed with preventing falls Be encouraging and talk to family as well ○ Helping with chores, home safety, exercising together, educating about diet and medications, etc. Community resources ○ Pharmacology Calcium supplements 1000 mg/day for women 19-59 and men 19-70 Safe upper limit: 2500 mg/day Take with 6-8 oz of water S/E: constipation, kidney stones (ask about hx) Vitamin D supplements (1200 mg/day 51+ and men 71+) Promotes calcium absorption Recommended: 800 international units/day Can develop hypercalcemia if too much is taken and absorbed Bisphosphonates - most common; hinders bone resorption by inhibiting osteoclast activity; effects rapidly increase after first 2 years of taking these, then plateaus after 2 years Make sure calcium and vitamin D are within range S/E: GI related effects (ulcers, esophageal irritation, dysphagia), osteonecrosis of the jaw (visit dentist frequently; will need baseline visit and dentist needs to be aware of this, needs to have exams every 6-12 mo)  Bone scan will need to be done; if improvement occurs, may be able to stop treatment and then have another scan within 2-3 years ○ Alendronate (Fosamax) - PO Take meds first thing in the AM on an empty stomach with a lot of water; NOTHING ELSE! Need to remain sitting or standing at least 30 minutes after taking it ○ Risedronate (Actonel) - PO Take meds first thing in the AM on an empty stomach with a lot of water; NOTHING ELSE! Need to remain sitting or standing at least 30 minutes after taking it ○ Ibandronate (Boniva) Newer bisphosphonates: bone scan will need to be done; if improvement occurs, may be able to stop treatment and then have another scan within 2-3 years IV Zoledronic acid (Reclast) ○ Once a year treatment via IV infusion ○ May eventually see every other year ○ Big concern: jaw necrosis IV pamidronate (Aredia) Estrogen agonists/antagonists Raloxifene (Evista) ○ Mimics effects of estrogen in the bones ○ S/E: blood clots, increased hot flashes, mood swings Monoclonal antibodies/RANKL inhibitors Denosumab (Prolia) ○ Very expensive ○ Prevents protein from activating receptors, decreasing bone loss and increasing bone mass ○ SQ injection given 2X/year Calcitonin Synthetic hormone For postmenopausal women Extracted from glands of salmon ○ Make sure they’re not allergic to fish! Slows bone breakdown (but can also decrease calcium; will need to be monitored), increases bone density Works best in the spine Parathyroid hormone-related protein drugs - injectable PTH; postmenopausal women and men w/ osteoporosis; giving this in low doses decreases resorption, which allows to be giving in hyperPTH Teriparatide (Forteo)  Abaloparatide (Tymlos) ○ Caregiver Teaching: Fall Prevention Major risk factors: Delirium Dementia Immobility Muscular weakness Hx of falls Visual or hearing deficits Current medications Environmental Malnutrition Agitation Remove rugs Adequate stair rails and grab bars Shower/bath access Use of orthotic devices Hand & Food Disorders ○ Dupuytren’s Contracture A gradual thickening and tightening of tissue under the skin in the hand Usually develops over years; progressive Starts as knots in palm, then turns into rope-like cords Pulls in ring finger and can eventually pull in pinky finger Exact cause unknown; commonly seen in older euromen and diabetics Risks: ETOH, smoking, diabetes, nutritional deficiencies, overuse, and some seizures meds If tx is impaired, surgical release is an option w/ a fasciotomy; will typically wear a brace while healing ○ Ganglion Cyst Small, round, fluid-filled sac growing out of the tissues surrounding a joint Sometimes on foot or ankle as well “Bible bumps” - can be smashed with a bible Usually forms once fluid leaks around a joint or tendon May be painful or not, swelling; eventually grow in size Cause unknown; seen a lot in athletes (volleyball players), trauma to the wrist, RA TX: can disappear on their own, can attempt w/ aspiration (not usually fully successful), I&D surgery to get to the root, may need brace, for 48 hrs after: no strenuous activity and monitor for s/s infection ○ Hallux Valgus (Bunion)  Great toe drifts laterally and the first metatarsal head becomes enlarged As deviation worsens, becomes more painful More common in women b/c of high heels Causes: poor fitting shoes, osteoarthritis, RA, obesity, genetic component TX: custom-made shoes for support, bunion splint, surgery if severe enough (bunionectomy: cut off overgrowth of bone, realign, and fuse together; may use screws and wires; same day surgery; assess neurovascular status and monitor for s/s infection; will wear a boot and use crutches or a walker for 6-12 wks after; partial weight bearing only) ○ Hammer Toe Dorsiflexion of metatarsophalangeal (MTP) joint w/ plantar flexion of the proximal interphalangeal (PIP) joint next to it Can worsen over time, can develop corns and calluses on bottom or top side of toe; very painful TX: surgical (similar to bunionectomy; partial weight bearing only) ○ Plantar Fasciitis Inflammation of the plantar fascia Stabbing pain, much worse w/ weight bearing Seen unilaterally, but can be seen bilaterally TX: conservative tx (rest and ice, massage), supportive shoes, strap feet to support the arch (brace), calf stretches, NSAIDS/steroids, endoscopic surgery to remove any inflamed tissue ○ Carpal Tunnel Syndrome (CTS) Very common Median nerve compression - median nerve is what moves the fingers Loss of grip strength Chronic presentation Associated with RA r/t inflammation in wrist Repetitive stress injuries (typing, the way you sleep, yoga, pilates, tennis, adolescents (texting, video games, etc.) Genetics Assessment and diagnostics Pain - may radiate up arm, shoulder, or into chest Numbness Paresthesia Motor changes - starts w/ weak pinch Inspection Palpation Phalen maneuver ○ Wrist flexion test  ○ Hold arm upright and put back of hands together Tinel’s sign ○ Tap on median nerve and if they start to feel a shock through the hand or wrist, it’s positive X-ray, MRI, ultrasound Nerve conduction study Treatment Goal: relieve nerve compression Medications ○ NSAIDs ○ Steroids ○ Diuretics (diabetes, pregnancy, etc) Immobilization via splint or brace Surgery ○ Endoscopic carpal tunnel release (ECTR) - has longer periods of pain and numbness post op, so less desirable ○ Open carpal tunnel release (OCTR) ○ Synovectomy Carpal Tunnel Release Post-Op Care ○ Monitor VS ○ Monitor dressing ○ Elevate extremity ○ NV checks q hour ○ Pain relief Should resolve within 24-48 hrs with endoscopic ○ Wrist splint ○ Lifting restrictions No heavy objects for 4-6 weeks Hand movements are restricted, so may need help with ADLs ○ Home care May experience discomfort for up to a month Can reappear Muscular Dystrophy ○ A group of genetic diseases that cause progressive weakness and loss of muscle mass ○ Usually develops during childhood ○ Most pts will need a wheelchair and may eventually affect breathing and swallowing ○ Different types: Duchenne Becker Limb-Girdle  Facioscapulohumeral Myotonic Congenital Distal Emery-Dreifuss Oculopharyngeal ○ Duchenne & Becker MD X-linked disorders that differ only in severity Dystrophin gene involved Usually limited to males S/S: may be masked early; muscle weakness when learning to walk, ride a bike, climb stairs; frequent falls, waddling gait, lordosis (inward curvature of spine), Gower’s sign (trait of rising from sitting or squatting position); pseudohypertrophy (false overgrowth of muscles; can appear extremely large r/t excess fatty infiltration and may feel like wood); cardiomyopathy (weakened heart muscles), cognitive impairment Duchenne: dystrophin is completely absent Most severe Onset: 2-6 y.o. Complete loss of mobilization by age 12 Survival past 20 years old is rare Becker: dystrophin is reduced Less severe DMD Onset: adolescent or early adulthood ○ Diagnostics Physical exam, neuro exam, mobility exam Primarily dx by a blood test Look for dystrophin genetic mutation Prenatal testing is now an option Genetic testing/DNA testing Important to know if parents are carriers Muscle biopsy If a family hx of MD is known, this can be skipped over Neurological tests To rule out other disorders Serum creatinine kinase (extremely high in first few years before seeing s/s) Indicates excessive muscle wasting Myoglobulin (extremely high in first few years before seeing s/s) Protein that carries oxygen to the muscles ○ Treatment No cure Many current clinical trials  Primary goal: maintain optimal functioning Secondary goal: prevent contractures Physical therapy Corticosteroids (can give for 6 mo-2 yrs) Decreases respiratory issues Stretching, strength and muscle training, breathing exercises, ROM exercises Surgery Release contractures PEG tube placement r/t swallowing issues Respiratory and cardiac problems Palliative care - s/s management (NOT HOSPICE) Noninvasive ventilation (CPAP, BiPAP) Trach placement MIE (mechanical insufflation-exsufflation) - mechanical coughing for the patient; done by RT; safe for daily use Extensive cardiac evaluation FAMILIES SHOULD BE INVOLVED IN EVERY ASPECT OF THEIR CARE! Provide lots of parental support, emotional support, psychosocial support, financial support, etc. Osteomalacia ○ Softening of bones r/t deficiency in vitamin D or malabsorption of vitamin D ○ Called “rickets” in children (more common in peds and second-world countries) ○ Risk factors: Decreased sunlight to skin exposure Dietary deficiency in vitamin D (vegan diet, lactose intolerance) Malabsorptive syndromes (those who have had gastrectomies or have Crohn's disease) (vitamin D is absorbed by the small intestine) Dark skin Obesity Elderly Medication that may precipitate vitamin D deficiency (certain seizure medications) Renal or hepatic disease (can interfere with calcitriol aka the activated form of vitamin D) ○ Clinical Manifestations - can present pretty late Hypocalcemia Pain and weakness (especially in arms, legs, and spine) Pain worse at night or when they put pressure on their bones Waddling gait Decreased muscle tone Fractures  Bow legs - classic in pediatrics Pigeon chest - classic in pediatrics Restless at night - more common in pediatrics Fever - more common in pediatrics ○ Diagnostics X-ray - look for any generalized bone demineralization, but can also show no change at all Bone mineral density scan - evaluate how much damage has been done Labs - REQUIRED Blood tests - vitamin D (very low) and calcium (typically low or normal), alkaline phosphatase (low) Urine tests (same as blood) ○ Treatment Supplements - vitamin D, calcium, phosphorus 50,000 international units of vitamin D2 daily 50,0000 international units of Vitamin D3 daily Given for 8-12 weeks, redraw labs, and then given 800-2000 units/day Increase sunlight exposure Increase dietary intake of vitamin D Salmon, tuna, mackerel, egg yolks, beef liver, fortified milk, fortified cereals, yogurt, orange juice, cheese Corrective braces Surgery to correct bone deformities Routine lab draws - vitamin D and calcium Osteomyelitis ○ Severe infections of the bone and surrounding tissues Usually starts somewhere else, but can start from within the bone Can result from injury, especially open fractures ○ Requires immediate intervention; limb threatening ○ Most common cause: bacteria (especially Staphylococcus Aureus) ○ Infection Cycle: Pathogen invasion → tissue inflammation → edema formation d/t vascular leakage spreading into surrounding tissues → decreased blood flow to bone and pus is released → bone ischemia that leads to bone necrosis → superimposed infection takes place and bone abscess occurs Osteoblasts may try to work to create a matrix of new bone over the site, which locks in the infection ○ Classification  Exogenous - from outside the body (ex: IV drug use, open fracture) Endogenous - carried by bloodstream (ex: infection from somewhere else in the body, bacteremia, nonpenetrating trauma, UTIs in lower vertebrae or pelvic bones) Contiguous - from skin of adjacent tissue (ex: gum infection getting into facial bones) ○ Acute vs. Chronic Acute - lasts 4 weeks or less; MAY need to be treated longer Chronic - lasts 4 weeks or longer; think diabetic ulcer wounds ○ Assessment VS - fever expected with acute (usually above 101); elderly may present confused rather than w/ a fever; immunocompromised may not present w/ fever Pain (constant, localized), tenderness, and inflammation - all gets worse w/ movement S/S infection Possibly more fatigue and redness? Vomiting and dehydration Limping or hesitation of use of affected limb Malaise/fatigue Drainage (usually more w/ chronic) ○ Diagnostics Labs - elevated WBCs, elevated ESR and CRP Blood cultures - complete before ABX; tells best ABX to use Wound cultures - complete before ABX; tells best ABX to use X-ray - sometimes good early on, but not always accurate Needle aspiration of the bone - determines organism present Open bone biopsy - not common Radionuclide bone scans - determines changes in perfusion via injection of radioactive substance MRI - best indicator! Shows damage, fluid, distinguishment between soft tissue and tissue damage ○ Treatment Antibiotic therapy Acute - at least 4-6 weeks w/ multiple types; usually IV administration ○ Can be sent home w/ a PICC line and infuse at home w/ a home health nurse or go to an infusion center PICC care instructions: how to clean it, clean hub prior to injection, s/s of infection, being gentle around the arm, wearing a sleeve over it Not IV drug users!!! Home vs. outpatient  Contact precautions/infection control Gown and gloves! Wound care Wound care/irrigation, ABX solutions on wounds Pain control Hyperbaric O2 therapy Over-oxygenation to treat anaerobic infections (Staphylococcus aureus infections) Sent into hyperbaric chamber with 100% O2 Usually outpatient care Surgical intervention Sequestrectomy ○ Removal of dead bone (sequestrated bone) ○ Allows for revascularization of that area; may need to graft to replace that area PMMA beads ○ ABX beads placed directly next to the bone and slowly dissolve and release medication into bone over the course of 6 weeks Bone grafts ○ Replacing dead bone with healthy bone Muscle flaps ○ If there’s a bony defect, muscle can be flipped over to cover the wound Amputation - when everything else has failed Amputation ○ Congenital - at birth Part isn’t fully formed or is missing R/t decreased blood flow in utero ○ Surgical vs. traumatic Surgical (elective) - used as last resort when other treatments have failed; majority of amputations - usually lower extremities Traumatic - caused by trauma (especially MVA, occupational accidents, and combat injuries) - usually upper extremities ○ Risk factors: DM PVD Arteriosclerosis Infection Cancer Dysfunction ○ Trauma ○ Field Care Emergency care in the field:  ABCs Salvage the body part if possible ○ Clean, wrap in dry sterile gauze or cleanest cloth possible, seal body part in tight seal bag and put it on top of ice Promote perfusion ○ Don’t detach any semi-perfusing parts; maintain as well as possible Prevent hemorrhage ○ Apply pressure and elevate ○ Using a tourniquet isn’t the first choice due to cutting off perfusion to the rest of the area that may still be perfusing Hospital ASAP ○ Surgery Goal: restore the arm (replant), amputated part needs to go to anatomical site, and preserve function and image of part Depends on severity and location of trauma When coming into the hospital, know the time of injury up until the time the body part was put on ice (warm ischemia time); then know the cooling time until arriving at the hospital (cool ischemia time) The longer the time, the less likely to replant the body part Provide lots of patient education on compliance, rehabilitation, hospitalization, and possible follow up reconstructions May get blood transfusions depending on severity IMPORTANT: DO NOT REDUCE PERFUSION! Avoid tight clothing, ice, and smoking If not able to complete, a revision or complete amputation will be complete with a skin or muscle flap Contraindications: if it won’t take, if the pt is unwilling to comply, ○ (Pre) Amputation - Assessment Health hx Subjective ○ Pain, feelings, story, etc. Objective ○ VS, assessment, neurovascular check, s/s infection, contracture Medications Psychosocial (concerns, reactions, needs, etc) Common: bitterness, hostility “I’d rather die than lose my leg” - appropriate response: “do you know all of your other treatment options?” “I understand your response”, “let’s address it”, “tell me more about it”, etc. Knowledge deficits ○ Diagnostics Ankle-brachial index (ABI) Helps determine if they have any arterial disease; usually ordered by vascular specialist Calculated by divided ankle systolic pressure by brachial systolic pressure (both arms, then the affected limb, then divide) Doppler ultrasound Measures the speed of perfusion in the extremity Laser doppler flowmetry Also assesses speed of blood flow Measures the speed of perfusion as well Transcutaneous oxygen pressure (TcPO2) Measures how much oxygen is traveling to the affected limb ○ Amputation Surgery Goals Successful healing Function reservation Prosthetic ability (if possible) - helps w/ function and appearance Approach depends on body part and damage extent: Standard amputation - removal of limb, anchor muscles to end of bone and then cover with skin; if using a prosthetic, will need a good padding of tissue for sitting comfortably and bone protection Osseointegration - amputation is complete with a steel rod at the end of the bone Interdisciplinary teams - case mgmt, PT, OT, psychiatry, vascular, orthopedics, surgical team (techs, nurses, aide), plastic surgeons, prosthetic team ○ Amputations of Lower Extremities Partial foot amputation - removal of part of the foot (toe, midfoot, syme) Syme ankle disarticulation - removing the foot after separating it from the lower leg at the ankle Below the knee amputation - removing the food and part of the lower leg by cutting across the bones of the lower leg (tibia and fibula) Knee disarticulation - removal of the lower leg by separating it from the upper leg at the knee Above the knee amputation - removal of the lower leg, knee, and part of the upper leg by cutting across the upper leg bone (femur) Hip disarticulation -removal of the entire leg by separating it from the pelvis at the hip joint Pelvic amputation, or hemipelvectomy - removal of the entire leg and part of the pelvis ○ Amputations of Upper Extremities Partial hand amputation - removing part of the hand  Wrist disarticulation - removing the hand after separating it from the lower arm at the wrist Below the elbow amputation - removing part of the lower arm by cutting across the bones of the lower arm (radius and ulna) Elbow disarticulation - removing the lower arm after separating it from the upper arm at the elbow Above the elbow amputation - removing the lower arm, elbow and part of the upper arm by cutting across the upper arm bone (humerus) Shoulder disarticulation - removing the entire arm after separating it from the shoulder Forequarter amputation - removing the arm and part of the shoulder (shoulder bones could include the clavicle and scapula) ○ Amputation: Surgery Complications Hemorrhage - especially if traumatic amputation Infection - at incision site or possible osteomyelitis High risk: chronic smokers, diabetics, elderly, immunocompromised people Impaired mobility Neuromas - a bundle or tangle of nerves that develop into a very sensitive tumor; more common in upper extremity amputations; can be surgically removed, but likely to come back Flexion contractures Phantom limb pain ○ Phantom Limb Pain Occurs frequently - comes from area of amputated limb Common in those who had pain prior to amputation surgery REAL PAIN!!! Multiple triggers Touching the stump, significant changes in temperature or barometric pressure, illness, increased anxiety or stress, simple routines (ex: going to the bathroom) Interference with ADLs Treatment: PT, massage, heat, TENS unit, mirror therapy Pharmacological treatment: Calcitonin IV - reduces phantom limb pain Beta blockers - constant, dull, aching pain ○ Typically we give propranolol Anticonvulsants - sharp, burning pain from nerves ○ Gabapentin and pregabalin Antispasmodics - helps with muscle spasms and/or cramps ○ Baclofen Opioids Antidepressants ○ Duloxetine (Cymbalta)  NMDA receptor antagonists - used for typically dementia ○ Flexion Contractures Muscle or tendon shortening d/t permanent or semipermanent soft tissue hardening Typically in the knee or hip May prevent use of a prosthetic limb Prevention is key: Exercises, splinting, firm mattress, prone position q3-4 h for 20-30 mins at the time, ROM exercises, no pillow under the knee ○ Post-Op Interventions Assess and maintain tissue perfusion Pain mgmt Prevent infection, promote wound healing Improve mobility Prosthesis preparation Promotion of body image Lifestyle adaptations ○ Prosthetics Pre-op Preparation - teach about exercises, meet with prosthetic maker prior to surgery, get any necessary ambulatory devices and practice with them prior to surgery Post-op Prevent secondary disabilities Proper fitting can take weeks Stump conditioning/shrinking - only takes a few days; has to be worn 24 hrs/day to condition for prosthetic Rehabilitation Education - come off for sleep and showering (only used for ambulation), examine stump every single day, clean every single day with mild soap and water, no special creams or ointments, look for any s/s of infection, will need to wrap stump in figure eight style at least 3X/day Scoliosis - lateral S shaped curve of the spine ○ Cause is unknown ○ Seen in some patients with cerebral palsy and muscular dystrophy ○ Genetic component present ○ Usually gets worse during growth spurts in adolescence, so diagnosed in adolescence ○ Most cases are mild; if severe, can be disabling and affect the amount of space in the chest, causing respiratory complications ○ Assessment S/S may include  Uneven shoulders One shoulder blade appears more prominent than the other Uneven waist One hip higher than the other One side of the rib cage jutting forward One side of ribs and side stick out more than the other A prominence on one side of the back when bending forward Breathing problems Back pain Back problems ○ Diagnosis Physical exam Adams forward bend test ○ Bend over and reach arms outward, looking at the ribcage and back Plumb line test ○ Quick visual check ○ If positive, it will fall to the left or the right Scoliometer ○ If there’s a rib hump, they will use this to measure the size of the hump Confirmed with: X-ray - determines exactly where spine is affected Ultrasound - if more underlying issues MRI - if more underlying issues ○ Treatment Close monitoring with x-rays Brace (TLSO - can be adjusted as they grow; not helpful after adolescence; worn 18-23 hrs/day) Surgery Spinal fusion ○ Fusing the vertebrae together to prevent them moving independently instead of growing in the wrong directions Expanding rod - usually done if progressing rapidly at a young age ○ Rods adjust and growth with the child, keeping the spine as straight as possible ○ Every 3-6 months, rods will need to be changed ○ Look for s/s of infection, complications, pain, bleeding, nerve damage, etc. Vertebral body tethering ○ Procedure w/ small incisions, placing screws along the outside of the abnormal curve and put a flexible cord in between to straighten out the spine ○ Beneficial with growth  ○ Look for s/s of infection, complications, pain, bleeding, nerve damage, etc. ○ Goal: prevent long term complications Unit 5 Module 9 (Legal Issues: Whistleblowing, Obligation to Report, Risk Management), Module 12 (Healthcare Systems/Evidence-Based Practice: Allocation of Resources, Resource Utilization, Community Preferences), Module 12 (Health Policy: Types of Reimbursement (Medicare, Medicaid, & Private Pay)) Stakeholders in Healthcare ○ Providers (all HC professionals) View quality of healthcare in a technical sense via accuracy of a diagnosis, getting the right treatments and using them, and achieving good health outcomes for patients ○ Employers Focus on wanting to keep costs down and getting employees back to work ASAP after any health issues/complications ○ Payers Insurance companies Focus on cost effectiveness of care ○ Patients Just want compassionate, good care and clear communication from HCPs ○ Biggest issues with stakeholders: 1: between patients and employers Patients want their employers to provide a variety of health coverage options that can be customized to fit their needs and fit to pay most of the insurance costs Patients also hope to have the most choices with the least amount of out-of-pocket expense vs. employers want to keep costs down, have patients only seek necessary treatment, and recovery quickly to get back to work at full capacity 2: between providers and payers Providers want to provide the best service that they can, using the latest and most accurate testing and treatments; also want to provide preventative care, even if insurance doesn’t cover it Payers want providers to stick to a clear, evidence-based diagnostic plan and reach an accurate diagnosis and treatment plan that has the fewest visits and the least number of tests, minimizing costs Human Error ○ Truths: Everyone commits errors  Human error is generally the result of circumstances beyond the control of those committing the errors (unless intentional) Systems or processes that depend on perfect human performance are inherently flawed ○ What we can do to help prevent: Root cause analysis teams Ergonomics Risk management teams ○ Reasons for Human Error Communication failure (ex: minimized report at shift change) Lack of effective training (ex: new EKG machines without any inservice/training) Memory lapse (ex: colleague asks for help and you forget about it) Inattention (ex: distractors like personal phones, TVs, computers, work phones, alarm fatigue from monitors and IV pumps) Poorly designed equipment (ex: small space to administer meds in front of computer in patient room) Fatigue (ex: sleep deprivation, long shifts) Ignorance (ex: not knowing the things you should know, like when to change out IV tubing) Noisy work conditions (ex: talking at or around the pyxis) Other personal or environmental factors (ex: personal texts/calls, pulling meds for all of your patients, being hungover/under the influence) Risk Management ○ A function of administration of a hospital or other health facility directed toward identification, evaluation, and correction of potential risks that could lead to injury to patients, staff members, or visitors and result in property loss or damage ○ How do we gather information about risk? Incident reports (variance reports/occurrence reports/near- misses/near-hits) Root cause analysis Tool used to identify strategies for preventing errors and improving safety; plays a key role in creating an environment that fosters safety ○ Goals: find out what happened, why it happened, and how we can prevent it from happening again Key features: ○ Interdisciplinary approach (Nursing, CNA, HCPs, etc.) ○ Involvement of key players (providers and patients) ○ Systematic investigation (going to continuously ask why throughout every stage)  ○ System-focused and identifies changes that may need to be made ○ Impartial **Sentinel events (event resulting in injury or death) vs. never event (an event that should’ve never happened)** EX: pt suicide on facility grounds, baby abduction, wrong site surgery ○ Incident/Variance/Unusual Occurrence Report Part of risk management Agency’s record of an accident/incident occurring within the agency that’s designed to collect adequate information to assist personnel in preventing future incidents/occurrences Can also be used in legal cases to gather information before a trial…but do NOT place an incident report in the patient’s chart!!!! It is meant for quality improvement, NOT legal cases! Do’s & Don’ts No opinions regarding blame and/or liability No assumptions, conclusions, or blame DO report the facts completely and accurately Use direct quotes where possible Identify names (first, last) and ID data for client, client’s HC members, and witnesses Chart location, date and time of incident Mention equipment or medication involved Variance Examples Patient injury Unexpected death Equipment malfunctions (ex: programming an IV pump to run NS 1000 mL at 75 mL/hr but the entire bag runs over the course of 1 hour) Adverse reaction to therapy or care Violence Environmental issues/emergencies (fire, spill, hazardous structure, etc) Medication variances (not available/not given, med error, given at wrong time, wrong route, wrong dose, wrong med) Staff not available Patient leaving AMA Patient/visitor falls Family/patient refusing care Orders not being carried out Incorrect order from doctor Witnessing ○ Unethical/dangerous behavior  ○ Incompetent practice ○ Risk Management Process Identify Analyze Rectify hazards Prevent future harm ○ Strategies for Risk Management Purchasing insurance ID exposure, types, where they occur, frequency and level of risk Implementing practices to protect against undue risk Implementing organization programs to prevent occurrence of risky events Incident reports Staff education Data collection Investigating incidents ASAP after they occur Monitor prevention strategies ○ Nurse Manager’s Role in Risk Management Identifies and reports unusual occurrences Identifies all potential risks Reduce the fears of punishment for acknowledging, reporting, and/or discussing the error Shares information with only the people that are needed/necessary Recognizes staff efforts to help improve system or organizational failures Monitors threats to client safety on an ongoing basis ○ What are some examples of high risk issues in healthcare? Medication administration complications Equipment malfunction Surgical site complications Falls Infections (CAUTIs, CLABSIs) Diagnostic errors Patient hand-off communication error ○ What are we doing about it? QSEN (Quality and Safety Education for Nurses) 6 core competencies: patient centered care, teamwork and collaboration, evidence based practice, quality improvement, safety and informatics Ensures competency to make a well-rounded nurse that knows about safety and is able to provide better patient care cause of it Joint Commission (JCAHO) Developed national initiatives ○ National safety goals, sentinel event and alert systems  Set accreditation standards ○ Come into the hospital every year to make sure that everything is appropriate and safe Focuses on reducing risks and promoting patient safety ○ Preventing pressure ulcers, wrong-site operation, infections, falls, med errors, etc. ○ Risk management vs quality management Risk management - more problem focused; identifies the problem and asks how we can fix the problem Quality management - more problem prevention focused; focuses on how to prevent the problem ○ Performance & Quality Indicators Variance tracking Identifies variances and analyzes them to improve performance Core measures Standardized measures of quality Addresses peds and geriatrics populations, diseases (pneumonia, sepsis, HF), organizational measures (those used in the ED or ICU) Outcome measures Explore and study outcomes of patient care (length of stay, MRSA infection rates, effectiveness of fall risk screenings for those who are at risk) Whistleblowing ○ Whistleblower Protection Act of 1989 offers protection to employees that report serious misconduct by their employers to federal authorities ○ Whistleblowing: Action taken by a nurse who goes outside of the organization for the public’s best interest when the organization fails to follow procedures regarding safety and client care The act of misconduct must violate state or federal law/rule and the employer must be aware that the activity/policy is a violation Employer must be given written notice by the nurse and time to correct the issue Protection is granted by OSHA if the nurse acts in good faith Allocation of Resources & Access to Care ○ Review: pg 180 in cherry textbook (allocation of scarce resources and organs), pg 119 (care coordination and how to reduce service duplication and waste), pg 120, box 7.14 (how to reduce costs as a provider) ○ Resource allocation: How a resource is allocated/provided to clients or communities when there are not enough of the resource for everyone who needs it  EX: Affects organ transplants and vaccine distribution Need to address: length of hospital stays, services offered, costs of services, access to care, etc. Factors affecting: hospital and clinic locations, transportation options, ease of making appointments, clear instructions, insurance vs. no insurance vs. limited insurance, etc. ○ Provider Performance Goal is cost-effective, high quality care Indicators of performance Member satisfaction data Complaint and grievance reports Visit wait-times Mammography rates Number and types of procedures performed Rehospitalization numbers Monitoring agencies: Agency for Health Research & Quality (AHRQ), Hospital Safety Score.org (HSS) Reimbursement ○ Types of reimbursement Medicare Funded by the federal government Coverage for: ○ 65+ y.o. ○ < 65 w/ certain disabilities ○ People of all ages w/ ESRD requiring hemodialysis or a transplant 4 parts: ○ A - hospital insurance (premium free if individual or spouse paid medicare taxes for at least 10 years; pays for hospice, home health, and SNF placement as well) ○ B - medical insurance (monthly premium, deductible and 20% copayment required in order for this to cover the rest of the cost; includes doctor services, outpatient care, home health, preventative services) ○ C - medicare advantage plans (HMO or PPO) (includes A, B and D; allows beneficiaries to enroll in private health insurance programs (HMO) approved by medicare; needs payment for each enrollee but must pay any out of pocket expenses) ○ D - medicare prescription drug coverages (run by private insurance companies approved by medicare; lower costs and protect against higher costs in the future) Medicaid  Funded on a federal and state level ○ Lower income states receive more federal funding than higher income ○ Income alone doesn’t determine eligibility Available to certain low-income individuals and families ○ Blind, pregnant, age, disabled, income/resources, demographics, citizenship status ○ Eligible for medicaid if child is a US citizen or lawful immigrant (based on child status, not the parent) (for lawful immigrant: must figure it out after 5 years) Medical and dental coverage ○ Kids have mandated dental coverage, but not adults State Child Health Insurance Programs (SCHIP) ○ Must provide certain coverages to receive federal funding Health coverage for kids