NCMB316 Lec Final 2023 PDF

NCMB316 LECTURE: Exam Week 18 BSN 3RD YEAR 2ND SEMESTER FINAL 2023...

NCMB316 LECTURE: Exam Week 18 BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Bachelor of Science in Nursing 3YB Professor: Dr. Potenciana A. Maroma Final Topics: - Usually occurs in the older population: sxs occur during Parkinson’s Disease, Multiple Sclerosis, and the 5th decade of life some diagnosed at age 30 Myasthenia Gravis - Affects men more frequently than women Guillain Barre Syndrome, Amyotophic Lateral - Cause: UNKNOWN; predominantly idiopathic Sclerosis, and Huntington’s Disease - but sometimes disorder is postencephalitic, toxic, Musculoskeletal System: Anatomy and Physiology, arteriosclerotic, traumatic, or drug induced ( reserpine, Diagnostic Tests, and Disorders methyldopa [Aldomet], haloperidol [Haldol], Eyes: Anatomy and Physiology, Diagnostic Test, and phenothiazine ) Disorders - Dxtic tests: not helpful …PET used only for evaluating Ears: Anatomy and Physiology, Diagnostic Test, and levodopa uptake = diagnosed clinically from patient’s hx, Disorders presence of 2 of the 3 cardinal sxs, neuro examinations Assessment findings PARKINSON’S DISEASE, MULTIPLE SCLEROSIS, AND Tremor: MYASTHENIA GRAVIS - mainly of the upper limbs Parkinson’s Disease (PD) - "pill-rolling" - The basal ganglia are a collection of nuclei deep to the - resting tremor; most common initial symptom white matter of cerebral cortex. Rigidity: cogwheel type - The name includes: caudate, putamen, nucleus Bradykinesia: slowness of movement accumbens, globus pallidus, & substantia nigra. Fatigue Stooped posture; shuffling, propulsive gait Difficulty rising from sitting position Masklike face with decreased blinking of eyes Quiet, monotone speech Emotional lability, depression Increased salivation, drooling Cramped, small handwriting Autonomic symptoms: - excessive sweating - constipation Pathophysiology - seborrhea Disorder causes degeneration of the dopamine-producing - decreased sexual capacity neurons in the substantia nigra in the midbrain - lacrimation Dopamine influences purposeful movement Nursing interventions Depletion of dopamine results in degeneration of the basal Administer medications as ordered ganglia. 1) Antiparkinsonian: Levodopa (Dopar, Larodopa) - Increases level of dopamine in the brain; relieves tremor, rigidity, and bradykinesia - Side Effects: anorexia; nausea and vomiting; postural hypotension; mental changes such as confusion, agitation, and hallucinations; insomnia; renal damage; cardiac arrhythmias; dyskinesias (purposeless involuntary movements that may be hyperkinetic =rapid and repetitive) - Contraindications: o avoid multiple vitamin preparations containing vitamin B6 (pyridoxine) and foods high in vitamin B6 (tuna, pork, dried beans, salmon) Parkinson’s Disease (PD) / Paralysis agitans o avoid Tyramine rich foods ( cheese, yogurt, - A progressive disorder with degeneration of the nerve cells coffee, raisins, sausage, red wine, beer)=may in the basal ganglia resulting in generalized decline in cause hypertensive crisis muscular function; disorder of the extrapyramidal system o administer with food or snack to decrease GI (neural network located in the brain that is part of the irritation. motor system involved in the coordination of movement) J.A.K.E 1 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 2) Carbidopa (Sinemet): prevents breakdown of dopamine Major types in the periphery and causes fewer side effects. 1) Relapsing-remitting MS (RRMS) = 85%of cases 3) Antiviral: Amantadine (Symmetrel): - relapses develop over 1-2 weeks & resolve over 4-8 - used in early/mild cases to reduce rigidity, tremor, months then returns to baseline. and bradykinesia - 50% may develop secondary progressive MS within 10 - act by releasing dopamine from neuronal storage yrs; 90% develop it within 25 yrs sites 2) Progressive-relapsing MS (PRMS) = 5% of cases 4) Anticholinergic: Benztropine mesylate (Cogentin), - absence of remission & client’s condition does not procyclidine (Kemadrin) return to baseline - inhibit action of acetylcholine - progressive, cumulative sxs & deterioration occur over - used in mild cases or in combination with Levodopa several yrs - relieve tremor and rigidity 3) Primary progressive MS (PPMS) = onset tend to be bet - side effects: dry mouth, blurred vision, constipation, 40&60 years of age urinary retention - steady, gradual neurologic deterioration w/o remission 5) Dopamine agonist: Bromocriptine mesylate (Parlodel) of sxs - stimulates release of dopamine in the substantia - progressive disability with no acute attacks nigra 4) Secondary progressive MS (SPMS) - often employed when Levodopa loses effectiveness - begins with RRMS course that later becomes steadily 6) Tricyclic antidepressants given to treat depression progressive 7) Antihistamines have mild central anticholinergic & - attacks & partial recoveries may continue to occur sedative effects & may reduce tremors Diagnostic tests: Provide a safe environment. CSF studies: increased protein and IgG (immunoglobulin) - Side rails on bed; rails and handlebars in toilet, bathtub, EEG: abN and hallways; no scatter rugs CT scan: increased density of white matter - Hard-back or spring-loaded chair to make getting up MRI: shows areas of demyelination easier Symptoms: Provide measures to increase mobility. 1st sx: visual disturbances: blurred vision, scotomas - Physical therapy: active and passive ROM exercises; (patchy blindness), diplopia stretching exercises; warm baths Impaired sensation: touch, pain, temperature, or position - Assistive devices. If client "freezes," suggest thinking of sense; numbness, tingling something to walk over. Impaired motor function: weakness, paralysis, spasticity Improve communication abilities: instruct client to Impaired cerebellar function: scanning speech, ataxic gait, practice reading aloud, to listen to own voice, and nystagmus, dysarthria, intention tremor enunciate each syllable clearly. Euphoria or mood swings Maintain adequate nutrition. Bladder: retention or incontinence - Cut food into bite-sized pieces. Constipation - Provide small, frequent feedings. Sexual impotence in the male - Allow sufficient time for meals, use warming tray. Nursing interventions Promote optimum mobility. Multiple Sclerosis (MS) - Muscle-stretching and strengthening exercises - An immune-mediated progressive demyelinating disease of - Walking exercises to improve gait: use wide-based gait the CNS which results in impaired transmission of nerve - Assistive devices: canes, walker, rails, wheelchair as impulses necessary - Typically present in young adults 20-40 Administer medications as ordered. - Affects women more than men - For acute exacerbations: corticosteroids (ACTH [IV], - More frequent in cool or temperate climates prednisone) to reduce edema at sites of - Cause UNKNOWN; may be a slow-growing virus or possibly demyelinization of autoimmune origin - For spasticity: baclofen (Lioresal), dantrolene - Characterized by remissions and exacerbations (Dantrium), diazepam (Valium) Pathophysiology - Beta interferon (Betaseron) for relapsing-remitting MS 1) Sensitized T cells that would typically cross the blood-brain patients barrier to check for antigens in the CNS and then leave; in Prevent injury related to sensory problems. MS would remain in the CNS - Test bath water with thermometer. 2) Promote infiltration of other agents that damage the - Avoid heating pads, hot-water bottles. immune system - Inspect body parts frequently for injury. 3) Immune system attack leads to inflamm that destroys - Make frequent position changes. myelin and oligodenroglial cells Prepare client for plasma exchange (to remove antibodies) if indicated J.A.K.E 2 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Plasmapheresis Assessment findings - This treatment — also known as plasma exchange — is a Ptosis, diplopia , dysphagia, Extreme muscle weakness, type of "blood cleansing" in which damaging antibodies are increased with activity and reduced with rest (identifying removed from your blood. characteristic) - Plasmapheresis consists of removing the liquid portion of Masklike facial expression your blood (plasma) and separating it from the actual Weak voice, hoarseness blood cells. Diagnostic tests - The blood cells are then put back into your body, which Tensilon test: IV injection of Tensilon provides manufactures more plasma to make up for what was spontaneous relief of symptoms (lasts 5-10 minutes) removed. - It's not clear why this treatment works, but scientists believe that plasmapheresis rids plasma of certain antibodies that contribute to the immune system attack on the nerves. Myasthenia Gravis (MG) - A neuromuscular disorder in which there is a disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular junction (PNS), causing extreme muscle weakness - Highest between ages 15-35 for women, over 40 for men. - Affects women more than men - Cause: thought to be autoimmune disorder whereby Electromyography (EMG): amplitude of evoked potentials antibodies destroy acetylcholine receptor sites on the decreases rapidly postsynaptic membrane of the neuromuscular junction. Presence of anti-acetylcholine receptor antibodies in the - Voluntary muscles are affected, especially those muscles serum innervated by the cranial nerves. Medical management - The first noticeable symptoms of myasthenia gravis may be weakness of the eye muscles, difficulty in swallowing, or Drug therapy slurred speech. a) Anticholinesterase drugs: neostigmine bromide (Prostigmin), pyridostigmine bromide (Mestinon), edrophonium chloride (Tensilon) - block action of cholinesterase and increase levels of acetylcholine at the neuromuscular junction - side effects: excessive salivation and sweating, abdominal cramps, nausea and vomiting, diarrhea, fasciculations (muscle twitching) b) Corticosteroids: prednisone. - used if other drugs are not effective - suppress autoimmune response Administer anticholinesterase drugs as ordered. - Give medication exactly on time. - Give with milk and crackers to decrease GI upset. - Monitor effectiveness of drugs: assess muscle strength and vital capacity before and after medication. - Observe for side effects. Promote optimal nutrition. - Mealtimes should coincide with the peak effects of the drugs: give medications 30 minutes before meals. - Check gag reflex and swallowing ability before feeding. - Provide a mechanical soft diet. - If the client has difficulty chewing and swallowing, do not leave alone at mealtimes - Keep emergency airway and suction equipment nearby. Monitor respiratory status frequently: rate, depth; vital capacity; ability to deep breathe and cough Observe for signs of myasthenic or cholinergic crisis. J.A.K.E 3 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Provide nursing care for the client with a thymectomy. GUILLAIN BARRE SYNDROME, AMYOTOPHIC LATERAL Assessment findings SCLEROSIS, AND HUNTINGTON’S DISEASE Mild sensory changes; in some clients severe GUILLAIN BARRE SYNDROME (GBS)/ Polyradiculoneuritis misinterpretation of sensory stimuli resulting in extreme discomfort Clumsiness: usually first symptom Progressive motor weakness in more than one limb (classically is ascending and symmetrical) Cranial nerve involvement (dysphagia) Ventilatory insufficiency if paralysis ascends to respiratory muscles Absence of deep tendon reflexes Diagnostic tests - CSF studies: increased protein - EMG: slowed nerve conduction Medical Management Considered as medical emergency patient is managed in the ICU Mechanical ventilation if respiratory problems present Plasmapheresis to reduce circulating antibodies Continuous ECG monitoring to detect alteration in heart rate and rhythm Propranolol to prevent tachycardia Atropine may be given to prevent episodes of bradycardia during endotracheal suctioning and physical therapy. Nursing interventions Maintain adequate ventilation. Check individual muscle groups every 2 hours in acute phase to check for progression of muscle weakness. Assess cranial nerve function: check gag reflex and swallowing ability; ability to handle secretions; voice. J.A.K.E 4 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Monitor vital signs and observe for signs of autonomic Fasciculations("muscle twitch") – a small, local, dysfunction such as acute periods of hypertension involuntary muscle contraction visible under the skin fluctuating with hypotension, tachycardia, arrhythmias. DTRs becomes brisk and overactive Administer corticosteroids to suppress immune reaction Respiratory insufficiency as ordered. 25% of patients: weakness starts in the muscles supplied Administer antiarrhythmic agents as ordered. b the cranial nerves = difficulty talking, swallowing and Prevent complications of immobility. ultimately breathing Promote comfort (especially in clients with sensory Death usually occurs as a result of infection, respiratory changes) failure, or aspiration and generally occurs about 3 years Promote optimum nutrition. after the onset of the disease. Few patients survive for - Check gag reflex before feeding. longer periods. - Start with pureed foods. Medical Management - Assess need for nasogastric tube feedings if unable to Drugs swallow. - Riluzole (Rilutek)-glutamate antagonist; slows deterioration of motor neurons Amyotrophic Lateral Sclerosis (ALS) - Baclofen (Lioresal)/ Diazepam (Valium) -used to control - A disease of UNKNOWN cause in which there is loss of spasticity that interferes with ADL motor neurons in the anterior horns of the spinal cord & the - Quinine -relieve muscle cramps motor nuclei of the lower brain stem NGT feeding - Onset occurring usually in the 5th or 6th decade of life Cervical esophagostomy or gastrostomy to prevent - Leading theory: overexcitation of nerve cells by aspiration & for long-term nutritional support neurotransmitter glutamate leads to cell injury and Mechanical ventilation if hypoventilation develops neuronal degeneration. Nursing interventions Pathophysiology Provide nursing measures for muscle weakness and 1) Motor neurons in the anterior horns of the spinal cord and dysphagia. motor nuclei of lower brainstem dies. Promote adequate ventilatory function. 2) Muscle fibers that they supply undergo atrophic changes. Prevent complications of immobility. 3) Neuronal degeneration may occur in both upper and lower Encourage diversional activities; spend time with the client. neuron system Provide compassion and intensive support to client/significant others. Provide or refer for physical therapy as indicated. Promote independence for as long as possible. Huntington’s Disease (HD) / Huntington’s Chorea (Dance) - A chronic, progressive, hereditary disease of the nervous system that results in slow progressive involuntary choreiform movement and dementia - Onset occurs between the ages of 35 & 45 years, though 10% of patients are children - Affects men and women of all races - Transmitted as an autosomal dominant genetic disorder: each child of a parent w/ HD has a 50% risk of inheriting the illness Pathophysiology 1) Premature death of cells in the striatum, (caudate & Diagnostic tests putamen) of the basal ganglia (for control of movts) Diagnosed on the basis of the signs & sxs 2) + loss of cells in the cortex (for thinking, memory, No clinical or lab test are specific for this disease perception & judgment) EMG- may indicate reduction in the # of functioning motor 3) + loss of cells in the cerebellum (for coordination) units 4) Cells’ destruction results in lack of GABA & AcH MRI – may show high signal intensity in the corticospinal 5) A ↓ in GABA & Ach (both excitatory neurotransmitters tracts -differentiates it from a multifocal motor neuropahy leads to brisk, jerky, purposeless movements, particularly Symptoms the hands, face tongue and legs which the client is unable Progressive weakness and atrophy of the muscles of the to stop arms, trunk, or legs Dysarthria, dysphagia Spasticity J.A.K.E 5 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Arthrocentesis Bone x-ray - observations of bone density, alignment & swelling, & intactness are made - conditions of joints like: size of the joint space, smoothness of articular cartilage & synovial swelling can be determined - Nursing considerations: inform client that there is low radiation exposure & not dangerous - Accdg to researches, GLUTAMINE –building block for remove all jewelry protein abnormally collects in the cell nucleus, causing instruct to remain still during the filming process cell death inform the health care provider if pregnant ---pregnant - Reason that the protein destroys only certain brain cells is women and children are more sensitive to the risks of UNKNOWN the x-ray, a protective shield may be worn over areas Diagnostic tests not being scanned (like pregnant abdomen, testes, clinical presentation of characteristic sxs ovaries) (+) family hx Bone Scan CT & MRI - may show atrophy of the caudate nuclei once the dse is well established 2 Main Symptoms 1) Progressive mental status changes leading to dementia – significant loss of intellectual abilities such as memory capacity, severe enough to interfere with social or occupational functioning 2) Choreiform movements (rapid, jerky movements) in the limbs, trunk & facial muscles - Other sxs: Emotional disturbance: fits of anger, suicidal depression, impaired judgment & memory, hallucinations, delusions & paranoid thinking 3 stages Onset of neurologic or psychological sxs ↑ng dependence on others for care Loss of independent functions - Death follows from complications such as choking, fall, - Done to evaluate damage to the bones, detect cancer that infection, pneumonia or heart failure and generally has spread (metastasized) to the bones, and monitor occurs 10-20 years after onset of the disease. conditions that can affect the bones (including infection Medications and trauma). 1) Phenothiazine – blocks dopamine receptors - A bone scan can often detect a problem days to months 2) Reserpine – depletes presynaptic dopamine earlier than a regular X-ray test. 3) Tetrabenezine – reduces dopaminergic transmission "cold" spots - areas that absorb little or no amount of Nursing interventions tracer appear as dark which may indicate a lack of Frequent assessment/ evaluation of patient’s motor signs blood supply to the bone (bone infarction) or the Interact with the patient in a creative manner presence of certain types of cancer. Learn how this particular patient expresses need and want "hot" spots - areas of rapid bone growth or repair, absorb increased amounts of the tracer and show up as MUSCULOSKELETAL SYSTEM: ANATOMY AND bright. This may indicate the presence of a tumor, a PHYSIOLOGY, DIAGNOSTIC TESTS, AND DISORDERS fracture, or an infection. Musculoskeletal System - Bone scan of the spread of prostate cancer - Diagnostic tests: - Nursing considerations: Bone X-ray BEFORE: o Consent form CT scan & MRI o Tell your doctor if you are pregnant Bone Scan / Nuclear Scan / Scintigraphy o Limit your fluids for up to 4 hours before the test – Bone biopsy because you will be asked to drink extra fluids after Muscle biopsy the radioactive tracer is injected (about 4 to 6 Electromyography (EMG) glasses of water to help eliminate any of the Arthrogram/ Arthrography radioactive substance that does not collect in your Arthroscopy bones. J.A.K.E 6 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 o Empty your bladder – to prevent any radioactive Muscle Biopsy urine from blocking the view of your pelvic bones during the scan o patient may want to bring some reading materials or a project to pass the time during the waiting period – they have to wait 1 to 3 hours after the radioactive tracer is injected before their bone scan is done o remove any jewelry that might interfere with the scan o may need to take off all or most of their clothes, depending on which area is being examined AFTER: o some soreness or swelling may develop at the - May be done to identify or detect: injection site= relieved by applying moist, warm Muscular disorders such as muscular dystrophy or compresses to the arm congenital myopathy o encourage the client to increase fluid intake to Metabolic defects of the muscle facilitate urinary excretion – isotope excreted in the Infections that affect the muscles urine and feces within 48 hours; not harmful to Difference between nerve and muscle disorders others - More than one needle insertion may be needed to get a Bone Biopsy large enough sample. - Nursing considerations: no fasting or other special preparation is usually necessary for closed biopsy aftercare is the same as bone biopsy Electromyography - to tell the difference between cancerous and non- cancerous bone tumors and to identify other bone problem - The sample of bone can be removed by: Inserting a needle through the skin and directly into the bone (closed, needle, or drill biopsy); local anesthetic; IV pain medication and sedative may be given. Making an incision through the skin to expose an area of the bone (open biopsy); general anesthesia, spinal - Measures electrical potential associated with skeletal anesthesia or nerve block is given for this procedure. muscle contraction - Nursing considerations: - Nursing considerations: Before: Before: o Consent form o Consent form o For a closed biopsy (needle biopsy), no special o Avoid using any creams or lotions on the day of the preparation is needed. Before the test, you will be test – no other special preparation is usually asked to undress and put on a hospital gown. You necessary- will be awake during the procedure. You may go After: home shortly after a closed bone biopsy is done. If o The muscle may feel tender or bruised for a few you have received a sedative, you may need to stay days=rest; ice longer and have someone drive you home. Arthrogram / Arthrography o For an open biopsy, certain preparation is needed. Do not eat or drink anything for 8 to 12 hours before the biopsy. You can resume normal eating after the procedure. If an open biopsy is done, you may need to stay in the hospital overnight. After: o a bandage will be placed over the biopsy site o keep the biopsy site covered, elevated for 24 hrs. and dry for 48 hours. o ice packs can prevent the development of hematoma o monitor for edema, bleeding & pain J.A.K.E 7 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 - During arthrography, a contrast material is injected to reveal the presence of hemarthrosis (bleeding into the enable the radiologist to study the joint space that appears joint cavity) which suggests trauma or tendency to on the x-ray image. bleed - Nursing considerations: verify the presence of an infection, identify the notify physician if patient is pregnant causative agent, and follow the progress of antibiotic remove jewelries therapy generally, you can resume your usual activities inject medications into the joint space, such as an anti- immediately inflammatory agent (e.g. cortisone) Arthroscopy - Nursing considerations: Before: consent form After: o Compression bandage post procedure, it may take about 5 -10 mins. o Rest joint for 8-24 hrs. o Take acetaminophen, ibuprofen, or some other relatively mild pain killer for a day or two after the procedure o Instruct client to notify physician if fever or swelling occurs - Both as diagnostic test and surgical procedure Musculoskeletal Disorders - endoscopic examination of various joints Inflammatory conditions - articular cartilage abnormalities can be assessed, loose (Synovitis, Tendonitis/ Tendinitis, Bursitis) bodies can be removed - Treatment: - large bore needle is inserted into the joint under GA or local Rest of the extremity anesthesia Intermittent ice & heat - Nursing considerations: NSAIDs Before: - Arthroscopic synovectomy – a surgery in which the o consent form swollen lining of the joint is removed using arthroscope to o do not consume any food or fluid for 8-12 hours see inside the joint like the knee. before the procedure Traumatic conditions (Contusions, Strains & Sprains) o you may be instructed to shave your joint area 1) Contusion o given a sedative before leaving for the hospital - A soft tissue injury produced by blunt force, such as o hospital gown blow, kick or fall After: - many small blood vessels rupture and bleed into soft o limit activity for 1-4 days, walking w/o weight bearing tissues = ecchymosis / bruising is usually permitted - sxs; pain, swelling & discoloration o elastic wrap is worn for 2-4 days - resolves in 1-2 weeks o elevate extremity and place ice on the site - There are three types of bruises: Arthrocentesis (Closed Joint Aspiration) a) Subcutaneous – beneath the skin, b) Intramuscular – within the belly of the underlying muscle c) Periosteal – bone bruise - Bruises can last from days to months, with the bone bruise being the most severe and painful. - Reasons for Procedure: Diagnose and/or treat a painful, swollen, fluid-filled joint diagnose the specific type of arthritis occurring within a joint like rheumatoid arthritis (RA) check for crystals in the joint fluid, which could be a sign of gouty arthritis (GA) / gout J.A.K.E 8 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 If sprain is severe, like torn muscle fibers & disrupted ligaments: o Surgical repair o Cast mobilization Neurovascular status (circulation, motion, sensation) of the injured extremity is monitored frequently. After the acute inflamm stage (24-48 hrs), heat may be applied intermittently, for 15-30 mins, 4x a day to relieve muscle spasm & to promote vasodilation, 2) Strain absorption & repair. - a “muscle pull” Depending on the severity of the injury, passive & - caused by improper use, overuse, overstretching or active exercises may begin in 2-5 days. excessive stress Severe sprains may require 1-3 wks of - microscopic, incomplete muscle tears w/ some immobilization. bleeding into the tissue Joint Dislocation - sxs: soreness, sudden pain, local tenderness on - A condition in which the articular surfaces of the bones muscle use forming the joint are no longer in anatomic contact - traumatic dislocations are orthopedic emergencies bec the associated joint structures, blood supply & nerves are distorted & severely stressed - if not treated immediately, avascular necrosis & nerve palsy may occur - s/sxs: pain, change in contour of the joint, change in the 3) Sprain length of extremity, loss of normal mobility, change in the - injury to the ligaments surrounding a joint that is caused axis of the by a twisting motion - dislocated bones - blood vessels rupture & edema occurs - x-ray confirms the dx & shows any assoc fracture - sxs: joint is tender & movt becomes painful - pain ↑ during the first 2-3 hrs. after the injury bec of swelling and bleeding - x-ray is needed to R/O bone injury - On the outside of the ankle, there are three main ligaments which help to stabilize the ankle: Anterior talofibular Posterior talofibular Calcaneofibular Structural defects (Scoliosis, Kyphosis, Lordosis) - The front band (anterior talo-fibular ligament) is most 1) Scoliosis commonly injured during severe sprains. - Scoliosis is a curving of the spine. - Management: - The spine curves away from the middle or sideways. R – rest = to prevent addtnal injury & promote healing I – ice = moist/ dry cold applied intermittently for 20- 30 mins during the first 24-48 hrs after injury produces vasoconstriction bleeding, edema & discomfort C – compression = elastic compression bandage controls bleeding, reduces edema & provides support for the injured tissues E – elevation = controls swelling J.A.K.E 9 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 2) Kyphosis - Kyphosis is a curving of the spine that causes a bowing of the back, such that the apex of the angle points backwards leading to a hunchback or slouching posture. 3) Lordosis - Lordosis is excessive curvature in the lumbar portion of the spine, which gives a swayback appearance. - Fractures are characterized by their CAUSE: 1) Pathologic /Spontaneous fracture – occurs after minimal trauma to a bone that has been weakened by disease. ex. client with bone cancer or osteoporosis 2) Fatigue/ Stress fracture – results from excessive strain or stress on the bone 3) Compression fracture – produced by loading force applied to the long axis of cancellous bone. Often occur in the vertebrae of clients with osteoporosis - Clinical manifestations: Pain – continuous & ↑ ses in severity until bone Spinal instrumentation – is the use of metal implants fixed to the spine to improve spinal deformity while the fusion matures. fragments are immobilized Loss of Function – fx of muscles depends on the integrity of the bones to w/c they are attached Deformity – displacement, angulation or rotation of fragments either visible or palpable Shortenng –due to the contraction of muscles attached above & below the site Crepitus –caused by rubbing of bone fragments against each other Swelling as a result of trauma & bleeding into the tissues; Discoloration may not develop for several hrs after the injury Fracture - 4 R’s Management of Fracture - A break or disruption in the continuity of a bone 1) Recognition - Classification of fractures: 2) Reduction by the extent of the break - Closed Reduction 1) Complete Fracture – involves a break across the - Open Reduction entire cross-section of the bone 3) Retention 2) Incomplete Fracture – the break occurs through only - Fixation (internal/ external) part of the cross-section of the bone - Cast by the extent of associated soft-tissue damage - Traction 1) Closed / Simple – does not cause a break in the skin - Braces & Splints 2) Open / Compound / Complex – one in w/c the skin or - Bandage mucous membrane wound extends to the fractured 4) Rehabilitation bone - Fracture Reduction - Specific types of fracture: the procedure by which a fractured bone is realigned in normal position it can be either closed or open 1) Closed reduction - refers to realigning bones without breaking the skin J.A.K.E 10 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 - It is performed with manual manipulation and/or o relieving patient’s pain traction and is commonly done with some kind of o provide adeq splinting anesthetic (LA or GA). o protect patient from further injury & other - cast or splint may be applied after complications 2) Open reduction Fat Embolism - primarily refers to surgery that is performed to - most freq in young adults (20-30 y.o.) & elderly w/ realign bones or fragments proximal femur fractures - may be treated with internal fixation devices - fat globules may move into the blood bec. - cast or traction may be applied after the o marrow pressure >capillary pressure procedure o cathecolamines ↑by the patient’s stress rxn Fractures with little or no displacement may not require mobilize fatty acids ►promote devt. of fat any form of reduction. globules in the bloodstream - An internal fixation device may be used to keep fractured - fat globules (emboli) occlude small blood vessels bones stabilized and in alignment. The device is inserted that supply the lungs, brain, kidneys, etc surgically to ensure the bones remain in an optimal - onset of sxs is rapid ,occurring w/in 24-72 hrs position during and after the healing process. - but may occur up to a week after injury - An external fixation device – commonly used in children. Clinical Features When the skin over the fracture has been damaged. a) Pulmonary features: respiratory insufficiency occurs Provides more freedom of movement than with traction in 75% of patients with FES presenting with dyspnea, - Stages of bone healing tachypnea, and fine inspiratory crackles 2-3 days after injury. The chest x-ray is often normal initially but bilateral fluffy shadows develop as respiratory insufficiency worsens → ARDS b) Cerebral features: neurological features often precede pulmonary features by 6-12 hours. Patients often present in an acute confusional state. Seizures and decorticate posturing have also been seen in FES. Fortunately, almost all neurological deficits are reversible. c) Cutaneous features: due to embolisation within the dermal capillaries. This produces a petechial rash in 1) Within 48-72 hrs after the injury , hematoma (a localized the conjunctiva, oral mucous membrane and skin swelling filled with blood) forms at the site of the folds of the upper body, especially the neck and fracture because bone is extremely vascular blood axilla. The rash appears within the first 36 hours and supply to and within the bone usually diminishes bec. of is self-limiting, disappearing completely within 7 the injury causes an area of bone necrosis days. 2) Dead cells prompt the migration of fibroblasts and Treatment: Notify MD immediately. Support respiratory osteoblasts to the fracture site / inflammatory process system 3) Formation of fibrocartilage=providing foundation for Compartment syndrome bone healing within 3 days -2 weeks 4) Due to vascular & cellular proliferation fracture site is surrounded by callus= a new vascular tissue within 2-6 weeks. Callus formation is the beginning of a nonbony union 5) As healing continues, callus is transformed from loose, fibrous tissue into bone within 3weeks- 6 months 6) Excess callus is resorbed 7) Healing, consolidation & remodeling continues up to a year Fracture Healing Complications Tx: 2 CATEGORIES: o Notify MD immediately (bec delay may result in 1) Early permanent nerve & muscle damage or even Shock necrosis) - Hypovolemic shock resulting from hemorrhage o Elevation of extremity to the heart level - May occur in fractures of extremities, thorax, pelvis o Release of restrictive devices like dressings or cast or spine >>if it doesn’t relieve pain w/in 1 hr - Tx: o Fasciotomy may be needed o restoring of blood volume &circ J.A.K.E 11 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Auto-immune Disorders Systemic Lupus Erythematosus (SLE) DVT THROMBOEMBOLISM PULMONARY EMBOLUS - Prevalence is 100 per 100,00 persons DIC - occurs 10x more freq in women INFECTION - 2-3x times more prevalent among people of color, 2) Late including African-Americans, Hispanics, Asians, and - DELAYED UNION = occurs when healing does not occur Native Americans @ a normal rate for the location & type of fracture Pathophysiology - assoc w/ distraction (pulling apart) of bone fragments, Combination of: systemic or local infection, poor nutrition or Genetic comorbidity; eventually, the fracture heals Hormonal (evidenced by the usual onset during the - NONUNION = failure of the ends of the fractured bone childbearing yrs bet 15-40 y.o) to unite Environmental factors (sunlight, thermal burns) - problems include infection, interposn of tissue bet. The Chemical or drug-induced: bone ends, inadq immobilization or manipulation that Hydralazine (Apresoline), procainamide (Pronestyl), disrupts callus formation, excessive bone gap, limited isoniazid (INH), chlorpromazine (Thoraxine) & some bone contact, impaired blood supply ► avascular antiseizure medications necrosis - Tx: internal fixation, bone grafting, electrical bone stimulation or combination of these - MALUNION=heal incorrectly Avascular Necrosis - occurs after a fracture w/ disruption of blood supply esp in femoral neck fractures - also seen in dislocations, bone transplantation, prolong high dosage corticosteroid therapy, chronic renal dse, sickle cell anemia, etc - sxs: pain, limited movt, decrease sensation - x-ray: Ca loss & structural collapse - Tx: bone grafts, prosthetic replacement or arthrodesis ( joint fusion) - Onset may be insidious or acute. - SLE may remain undiagnosed for yrs. - Clinical features: involves multiple body systems J.A.K.E 12 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Systemic Manifestations patients w/ serious forms of SLE who have not Musculoskeletal Sys responded to conservative therapies - arthralgias (joint pain) & arthritis (synovitis) is a common Nursing management presenting sx Instruct patient abt the importance of continuing - joint swelling, tenderness & pain on movt are also common, prescribed meds. freq accompanied by morning stiffness Addresses the changes & side effects likely w/ the use of Skin these meds. a) Subacute cutaneous lupus erythematosus – Remind patient of the importance of monitoring bec of the papulosquamous or annular polycyclic lesions high risk for systemic involvement including renal & b) Discoid lupus erythematosus – chronic rash that has cardiovascular effects. erythematous papules/ plaques & scaling & can cause Rheumatoid Arthritis (RA) scarring & pigmentation changes - CAN OCCUR @ ANY AGE, USUALLY 25 & 55 Y.O. c) Acute cutaneous lesion – butterfly-shaped rash across the - 2-3x greater incidence in women bridge of the nose & cheeks & most familiar occurring in < - Pathophysiology: half of patients 1) T- & B- cell proliferation. Angiogenesis in synovial lining. - Lesion worsen during flare ups (exacerbations) & provoked 2) Neutrophil accumulation in synovial fluid. Cell by sunlight or artificial UV light proliferation. No cartilage invasion - oral ulcers may also occur 3) Synovitis. Early pannus (proliferation of synovial tissue) Cardiac invasion. Degradation of cartilage. - pericarditis is the most common 4) Subchondral bone (bony plate that support the articular Renal cartilage) erosion. Pannus invasion of cartilage. Laxity - screening: serum creatinine levels & urinalysis of ligaments. - may lead to HPN Clinical manifestations: Kidney involvement - may vary, depends on the stage & severity of the dse. - leading cause of death - CLASSIC: joint pain, swelling, warmth, erythema & lack of - renal biopsies show progressive changes within the fx glomeruli: - upon palpation: joints reveal spongy or boggy tissue glomeruli slightly irregular – minimal lupus nephritis - begins w/ small joints in the hands, wrists & feet Further glomerular changes; shows clinical signs of progresses to the knees, shoulder, hips, elbows, ankles, renal impairment – focal/mild lupus nephritis cervical spine & temporomandibular joints 50% of glomeruli are affected; client is in renal failure – - BILATERAL & SYMMETRIC diffuse/ severe proliferative nephritis - JOINT STIFFNESS ESP IN THE MORNING LASTING FOR >30 CNS MINS - widespread, encompassing the entire range of neurologic - IMMOBILIZATION FOR EXTENDED PERIODS = RESULTS TO dses CONTRACTURES, CREATING SOFT TISSUE DEFORMITY - neuropsychiatric presentations as demonstrated by - SYSTEMIC: fever, wt loss, fatigue, anemia, lymph node Subtle changes of in behavior patterns or cognitive enlargement, Raynaud’s phenomenon ( cold- & stress- ability induced vasospasm causing episodes of digital blanching Depression or cyanosis) Psychosis - ADVANCED: NODULES ARE PRESENT Diagnostic Tests Nontender & movable in the subq tissues Hx, physical examination & blood tests appear over bony prominences like elbows; vary in size BUT NO SINGLE LAB TEST CONFIRMS SLE & disappear spontaneously Medical Management: Other extra-articular features: neuropathy, scleritis, - There is no cure for SLE. pericarditis, spenomegaly & Sjögren’s syndrome ( dry - TX is aimed to manage the disease aggressively until eyes & dry mucous membranes. remission. NSAIDs for minor clinical manifestations. Corticosteroid=single most impt. medication available o topically to promote fading of the skin lesions o low oral doses for minor dse activity o high doses or IV doses for major dse activity Anti-malarial agent called hydroxychloroquine (Plaquenil) for cutaneous, musculoskeletal & mild systemic features of SLE Immunosuppressive agents (alkylating agents & purine analogs) bec of its effect on immune function & for J.A.K.E 13 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Medical Management: Degenerative/ Metabolic Disorders 1) Early-Stage RA Osteoarthritis (OA) - education, balance of rest & exercise & referral to community agencies for support - sx control within the first 2 yrs of dse onset - more aggressive pharmacologic approach earlier in the dse. - COX-2 inhibitors = a class of NSAIDs; cyclo-oxygenase blocks enzyme involved in inflammatory process while leaving intact the enzyme involved in protecting the stomach lining ► less likely to cause gastric irritation & ulceration - most common & frequently disabling of the joint disorders - antirheumatic agents: antimalarials, gold, - Classification: penicillamine or sulfasalazine initiated early 1) Primary / Idiopathic – no prior event or dse related to OA - if sx appears to be aggressive ( x-ray: early bony 2) Secondary – resulting from previous joint injury or erosions) = methotrexate to pain, tender & swollen inflammatory dse joints ►improve the quality of life distinction is not always clear 2) Moderate, Erosive RA - formal program w/ occupational & physical therapy OFTEN BEGINS DURING 30s AND PEAKS BET. 50s & - medication program is reevaluated periodically w/ 60s appropriate changes made = cyclosporine an @ 75 YEARS, 85% OF POPULATION HAS X-RAY OR immunomodulator may be added CLINICAL EVIDENCE OF OA but only 15%-25% 3) Persistent, Erosive RA experience significant sxs - reconstructive surgery when pain cannot be relieved by Pathophysiology: conservative measures; cannot be performed during 1) Risk factors: ↑ age, obesity, previous joint damage, dse flares repetitive use (occupational/ recreational), anatomic Synovectomy – excision of the synovial membrane deformity, genetic susceptibility Tenorrhaphy-suturing a tendon 2) Affects the articular cartilage, subchondral bone & Arthrodesis-surgical fusion of the joint snynovium Arthroplasty-surgical repair & replacement of the 3) Combination of cartilage degradation, bone stiffening & joint reactive inflamm of synovium occurs - systemic corticosteroids for unremitting inflamm or Clinical manifestations: pain or needs “bridging” medication while waiting for Primary: the slower dse-modifying antirheumatic agent - pain due to an inflamed synovium, stretching of the (methotrexate) to begin working joint capsule or ligaments, irritation of the nerve - local injection of corticosteroid for severely inflamed endings, bursitis, tendonitis & muscle spasm joint - JOINT STIFFNESS MOST COMMONLY EXPERIENCED IN 4) Advanced, Unremitting RA THE MORNING OR AFTER AWAKENING & LASTS end product: uric acid > metabolized by Elevated serum uric acid level the body and excreted === GOUT, uric acid is not excreted Joint x-rays which show damage consistent with gouty > urates form > goes to the joints arthritis - There are recurrent attacks of the pain and swelling of the joints. J.A.K.E 15 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Medical Management Osteoporosis Drug therapy is the primary component of management for - a metabolic disease in which bone demineralization results clients with gout. Acute gouty attacks, inflamm subsides in decreased density and subsequent fractures= BONES spontaneously within 3-5 days. BECOME PROGRESSIVELY POROUS, BRITTLE & FRAGILE 1) Acute gout - Often referred as “silent disease.” …because bone loss - combination of colchicine (Colsalide, Novocolchicine) occurs without symptoms. & NSAIDs such as indomethacin (Indocin, - "You may not know that your bones have become porous Novomethacin of ibuprofen (Motrin, Amersol) (not as dense) until a sudden strain, bump, or fall causes a - IV colchicine works within 12 hrs. fracture." - client takes oral meds until inflamm subsides, usually - Most often affected bones: wrist, hip, vertebral column 4-7 days - 40-45% of a woman’s bone mass is lost during her life 2) Chronic gout span. - Uricosuric agents: Probenecid (Benemid, Benuryl)  urinary excretion of uric acid; prevents tophi formation - Allopurinol (Zyloprim) is the drug of choice when patient has or at@ risk for renal insufficiency or renal calculi ; xanthine oxidase inhibitor = interrupts the breakdown of purines before uric acid is formed ; use is limited bec of the risk for toxicity - Aspirin is avoided because it inactivates the effects of the drug- - Corticosteroids may be used in resistant cases Nursing Management - Bone density test being done at the ankle using a Patients are encouraged to restrict consumption of foods peripheral device. high in purines, esp organ meats & limit alc intake; maintain N body wt In acute episodes: pain management is essential Diet and gout Purines (specific chemical compounds found in some foods) are likely to be broken down into uric acid. - Foods to limit (very high in purines): Beef Pork Lamb Seafood - Bone density (DEXA) measurements to assess overall bone Yeast (used in beer and bread) health status. Alcoholic beverages, particularly beer - These low energy Xray tests will be used to measure the Bacon bone mineral density (BMD) of both hips, the lumbar spine Liver (both AP and lateral views). - Foods to eat occasionally (moderately high in purines, - These DEXA tests usually require 20 to 30 minutes for but may not raise your risk of gout): completion. Asparagus, cauliflower, mushrooms, peas, spinach Management: Whole-grain breads and cereals Drug Therapy: HRT (Hormone replacement therapy) Chicken, duck, ham, and turkey - has been used as a primary prevention strategy for Kidney and lima beans reducing bone loss in the postmenopausal woman - Dairy products that may lower your risk of gout: - long-term effects: high woman’s risk of breast cancer, Low-fat or skim milk cardiovascular dse & stroke Low-fat yogurt - conjugated estrogens/ medroxyprogesterone (Prempro, - Foods that are safe to eat (low in purines): Premphase) use are carefully evaluated by the health Green vegetables and tomatoes care provider & client Fruits and fruit juices PTH Breads and cereals that are not whole-grain - approved tx for both men & women Butter, buttermilk, cheese, and eggs - self-administered, daily subq injection teriparatide Chocolate and cocoa (Forteo) Coffee, tea, and carbonated beverages - stimulates new bone formation = increasing BMD Peanut butter and nuts - monitor for s/sxs of hypercalcemia: fatigue, anorexia, n&v, constipation, polyuria J.A.K.E 16 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Calcium - Ca alone is not a tx but an impt part of a prevention program to promote bone health - OTC supplements like calcium carbonate (Tums/ Oscal) ; calcium citrate (Citracal) - Taken with foods & 6-8 ozs of water Vitamin D - for optimal Ca absorption in the intestines - 400-800 International Units/day Treatment Biphosphonates Oral supplements of vitamin D, calcium, and phosphorus - inhibit bone resorption by binding with crystal elements may be given depending on the underlying cause of the in bone, esp spongy, trabecular bone tissue disorder. - 3 BPs: alendronate (Fosamax), ibandronate (Boniva) & Larger doses of vitamin D and calcium may be needed for risedronate (actonel) are commonly used for the people with intestinal malabsorption. prevention & management of osteoporosis - side effects: not common but when it occurs, they tend Mineral calcium – calcium is essential for the formation to be serious and maintenance of bones and teeth, blood clotting, = esophagitis & esophageal ulcers esp if the tablet is normal heart beat and hormone secretion. Food sources of not completely swallowed calcium include diary products, green leafy vegetables and = s/sxs: chest pain; d/c drug & call their doctor salmon and sardines. - early AM with 8 ozs of water & wait 30 mins before Vitamin D – the body itself makes vitamin D when it is eating exposed to the sun. cheese, butter, margarine, fortified - c/i to clients with poor renal fx, gi reflux dse (GERD) cereals are food sources of vitamin D. SERMs (Selective Estrogen Receptor Modulators) - newer class of drugs designed to mimic estrogen in Infectious Disorders some parts of the body while blocking its effect Osteomyelitis elsewhere It became infected by one of 3 MODES: - raloxifene (Evista) 1) Extension of soft tissue infection (infected pressure or vascular ulcer, incisional infection) Calcitonin 2) Direct bone contamination fr bone surgery, open fracture - thyroid hormone that inhibits osteoclastic activity, thus or traumatic injury (GSW) decreasing bone loss 3) Hematogenous (bloodborne) spread fr other sited of - IM or subq salmon calcitonin (refrigerated); intranasally infection (infected tonsils, boils, infected teeth, upper resp Miacalcin = preferred bec it improves compliance, infections). Typically occurs in a bone area of trauma or minimizes side effects & is convenient ; alternate lowered resistance. nostrils to prevent s/e like nasal mucosal irritation - salmon calcitonin may  its effect are use for 2 or more years = requires holiday from this tx Diet Therapy Increase Ca & vit D intake; alcohol & caffeine discouraged If w/ fracture: protein, vit C & iron intake Exercise Plays a vital role in pain management & cardiovascular fx together with the physician , PT prescribes exercises for strengthening the abdominal and back muscles which improve posture & provide improved support for the spine, deep breathing General weight-bearing exercise program= walking for 30 mins 3x a week, swimming, biking High-impact recreational exercises (horseback riding, bowling) are avoided bec it may cause vertebral compression Osteomalacia - At high risk: - Osteomalacia is softening of the bones, caused by not Poorly nourished having enough vitamin D, or by problems with the Elderly metabolism (breakdown and use) of this vitamin. Obese - These softer bones have a normal amount of collagen that Impaired immune system gives the bones its structure, but they are lacking in w/ chronic illness (DM, RA) calcium. w/ long term steroid therapy J.A.K.E 17 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Clinical Manifestation to prevent pathologic fracture= internal fixation or 3 MODES external supportive devices may be needed A. Extension of soft no sxs of septicemia Nursing Management tissue infection Relieving pain B. Direct bone swollen, warm, painful & tender to Improving physical mobility contamination touch Controlling infectious process C. Hematogenous onset is sudden Teaching self-care (bloodborne) sxs of septicemia: chills, high fever, Pott's Disease spread PR, general malaise - Tuberculosis (TB) of the backbone is not common, but is =systemic sxs overshadow the local sxs still seen in poor communities, especially in children. ►as infection extends into the cortex of - It is the most common form of tuberculosis of the bone. the bone - It is important to recognize and treat it early, before infected area has constant, pulsating damage to the backbone causes nerve damage and pain that intensifies w/ movt bec of paralysis. pressure of the collecting pus+ it is - Signs swollen & extremely tender It begins little by little-often without pain at first. Patient w/chronic osteomyelitis presents w/ continuously A bump develops in the backbone. This is because the draining sinus; experiences recurrent periods of pain, front part of one or more vertebrae is destroyed and inflamm, swelling & drainage = low-grade infection thrives collapses. in scar tissue bec of its reduced blood supply The child has trouble bending over to pick things up. Diagnostic test - Prevention 1) Acute consists of early diagnosis and treatment of - Early X-ray: soft tissue swelling tuberculosis, and in the fight against poverty. - After 2 wks X-ray: areas of irregular decalcification, Vaccination against TB may also help. bone necrosis, periosteal elevation & new bone - It is a presentation of extrapulmonary tuberculosis that formation affects the spine, a kind of tuberculous arthritis of the - Bone scan (isotope-labeled WBC scan) & MRI help w/ intervertebral joints. early definitive dx - It is named after Percivall Pott (1714-1788), a London - Wound & Blood culture studies: to identify appropriate surgeon. antibiotic therapy - Scientifically, it is called tuberculous spondylitis. 2) Chronic - The usual sites to be involved are the lower thoracic and - X-ray: large, irregular cavities, raised periosteum, upper lumbar vertebrae. sequestra or dense bone formations - In adults, disc disease is secondary to the spread of - Bone scan: to identify areas of infection infection from the vertebral body but in children it can be a - ESR & WBC count: N; may present w/ anemia assoc w/ primary site, as the disc is vascular in children. chronic infection - SXS: - Abscess Culture to identify infective organism & Back pain appropriate antibiotic therapy Fever Treatment Night sweating Acute: IV antibiotic therapy (Staph-sensitive to Anorexia semisynthetic penicillin & cephalosporin) RTC, continues Weight loss up to 3-6 weeks then orally for up to 3 months (taken w/o Spinal mass, sometimes assoc with numbness, tingling, food) or muscle weakness of the legs If patient did not respond to antibiotics: surgically exposed, Diagnostic Test pus & necrotic tissue removed, area is irrigated w/ sterile blood tests - elevated ESR saline soln, antibiotic-impregnated beads may be placed in tuberculin skin test the wound for 2-4 weeks, IV therapy continued radiographs of the spine Chronic: IV antibiotics + surgical debridement bone scan - SEQUESTRECTOMY-removal of enough involucrum to CT & MRI of the spine remove sequestrum bone biopsy - SAUCERIZATION-sufficient bone is removed to convert Late complications: a deep cavity into a shallow saucer closed suction irrigation system may be used to Vertebral collapse resulting in kyphosis remove debris for 7-8 days Spinal cord compression w/ large defect= cavity may be filled w/ vascularized Paraplegia (so called Pott's paraplegia) bone transfer or muscle flap J.A.K.E 18 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 Prevention: symptoms are intermittent. They will commonly occur BCG vaccination at night or when driving. Improvement of socio-economic conditions Many people will describe waking up in the night with Prevention of HIV and AIDS their hands feeling dead or numb, some say that their Patients who have a positive PPD test (but not active fingers feel like sausages. tuberculosis) may  their risk by properly taking medicines Holding the wrists bent will also bring on the problem. to prevent tuberculosis - The best way of making the diagnosis is on the history, To effectively treat tuberculosis, it is crucial that patients however sometimes that is not enough. take their medications exactly as prescribed. - There are several tests that can be done: Tinel's sign is performed by briskly tapping a nerve, the Therapy: median nerve at the wrist. (+) = results in shooting Non-operative - antituberculous drugs electric-like sensations in the distal distribution of the Analgesics nerve Immobilization of the spine region by rod (Hull) Phalen's test is performed by asking the patient to hold Surgery may be necessary, especially to drain spinal her wrist in maximum flexion. (+) = if the thumb and abscesses or to stabilize the spine finger becomes numb Carpal tunnel syndrome (CTS) Nonsurgical Treatment Activities that are causing your symptoms need to be changed or stopped: Avoid … - repetitive hand motions - heavy grasping - holding onto vibrating tools - positioning or working with your wrist bent down and out - smoking Lose weight if you are overweight. - The carpal tunnel is an opening through the wrist to the A wrist brace will sometimes decrease the symptoms in hand that is formed by the bones of the wrist on one side the early stages of CTS. A brace keeps the wrist in a resting and the transverse carpal ligament on the other. position, not bent back or bent down too far. - This opening forms the carpal tunnel. - The median nerve passes through the carpal tunnel into the hand. - It gives sensation to the thumb, index finger, long finger, and half of the ring finger. - Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. - Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment. - This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. - Actually, many people develop this condition regardless of the type of work they do. - any condition that makes the area inside the carpal tunnel smaller or increases the size of the tissues within the tunnel = can lead to symptoms of CTS. - Example: after a wrist fracture or dislocation, the area inside the tunnel can also be reduced, if the bone pushes into the tunnel A traumatic wrist injury may cause swelling and extra pressure within the carpal tunnel - First symptoms of CTS Gradual tingling and numbness in the area J.A.K.E 19 of 31  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023 EYES: ANAPHYSIO, DIAGNOSTIC TEST, AND DISORDERS Anatomy and Physiology - Protected by: bony orbits & pads of fat surrounding each eye dorsally eyelids & eyelashes which close over the eyes lacrimal apparatus/ glands lubricating & washing off foreign particles conjunctiva which lines the eyelids & covers exposed scleral surface Anti-inflammatory medications may also help common 1) The cornea is the clear surface of the outer eye which can OTC medications such as ibuprofen and aspirin oral be damaged by infections. steroid medications 2) The iris gives the eye color. High doses of vitamin B-6 3) The pupil is the black hole within the iris that lets light into the eye. It changes size in response to light levels, among Cortisone injection may help ease symptoms and can aid other things. the doctor in making a diagnosis 4) The lens is the internal focusing element of the eye, it is Open release procedure involves simply cutting the curved on both sides. The clear lens becomes cloudy when transverse carpal ligament. a cataract forms. Endoscopic carpal tunnel release 5) The conjunctiva is the thin lining of the inside of the eyelid. It extends over the front of the white part of the eye. 6) The retina is the light sensitive part of the eye. 7) The optic nerve. In glaucoma, the rise in fluid pressure in the eye damages the nerve fibers entering the optic nerve from the retina. - Wall of the eyeball is composed of 3 layers: 1) Outer fibrous protective layer - Posteriorly = sclera, the ‘white of the eye’ with firm tough connective tissue - Anteriorly = cornea, ‘window of the eye’ a forward continuation of the sclera, transparent & avascular