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Types of Bones

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Title: Types of Bones


1
Types of Bones
  •    Long bones femur
  • Short bones somewhat cubed- shaped
    as in the phalanges
  •    Flat bones broad surface for muscular
    attachment or protection of organs (skull, ribs,
    shoulder blades, sternum.
  •    Irregular bones wrist, vertebrae

2
Functions of Bones
  • Support protect body tissues and organs
  • Provides the skeletal framework of the body
  • Provides movement through the attachment of
    muscles
  • Storehouse for minerals CA 99 makeup
    of bones PO4 90 Po4
  • Production of blood cells) which takes place in
    the bone marrow

3
Diarthrodial/Synovial Joints
  • -  Ball socket i.e. shoulder hip which
    permits movement in any direction
  • - Hinge i.e. elbow movement along one plane
    allows flexion extension
  • -  Condylar functions like a hinge joint but
    can
  • rotate slightly
  •  

4
Synovial Joint Capsule
  • Fibrous connective tissue covers the ends of
    bone.  Ligaments and tendons reinforce the joint
    capsule
  • Bundles of rich, white fibrous tissue are
    supplied with nerves. Nerves are sensitive to
    rate and direction of motion, compression,
    tension, vibration and pain
  • Blood vessels, and lymphatic vessels.
  •  

5
Skeletal Muscles
  • Primary Function
  • Provides voluntary movement
  • Maintains posture
  • Body Movement contraction relaxation

6
Skeletal Muscles
  • Points of Attachment
  • Point of Origin attachment of muscle to a more
    stationary bone
  • Point of insertions attachment to a more
    movable bone

7
Head to Toe Assessment
  • Health History
  • Musculoskeletal disorders
  • Nutritional status
  • Pain History
  • ADLs, endurance, assistive devices
  • Medications prescription and OTC

8
Assessment Skills
  • Inspection symmetry, body alignment, function,
    skin changes, swelling, deformity, contractures,
    gait, non-verbal indication of pain
  • Palpation Skin temperature, swelling, nodules,
    masses, Crepitus
  • Joint Structure ROM
  • Muscle mass strength (atrophy, flaccidly,
    spasticity, paralysis)

9
Connective Tissue Disorders
  • Rheumatoid Arthritis
  • Osteoarthritis
  • Lupus Erythematous
  • Gout

10
Rheumatoid Arthritis
  • Autoimmune connective tissue disorder
    characterized by inflammatory destructive changes
    in the joints
  • Systemic disease Inflammatory changes can
    affect skin, heart, lungs, eyes, blood vessels
    nerves

11
Etiology of Rheumatoid Arthritis
  • Autoimmune theory Normal antibodies become
    autoantibodies (RH Factors) and attack the
    tissue.
  • Genetic Factor 2-3 times with family Hx
  • Virus Epstein-Barr
  • Stressful events

12
Stages of Joint Deterioration
  • Stage 1 Initiation - Some changes in the
    synovial lining no loss of functional capacity
  • Stage 2 Immune Response Joint swells
    thickens. Functional capacity impaired
  • Stage 3 Inflammatory Progressive involvement of
    blood vessels. Limited ADL
  • Stage 4 Destructive Granulation tissue hardens
    (Pannus). Leads to ankylosis. Confined to bed or
    wheel chair

13
Assessment Data
  • Subjective
  • - Stiffness especially in a.m. or after
  • inactivity
  • - Proximal joint pain in the fingers
  • - Fatigue, weakness, 2-3 weight loss, low
    grade fever

14
Assessment Data
  • Objective Manifestations
  • - Swollen, reddened, warm joints
  • - Weak hand grasp
  • - Deformities (late stages)
  • Swan Neck
  • Ulnar Drift
  • Boutonnière (buttonhole)
  • Rheumatoid Nodules
  • Vasculitis, Sjogrens Syndrome

15
Diagnostic Tests
  • Blood Tests
  • - Rheumatoid Factor
  • - Antinuclear Antibody Titer
  • - Erythrocyte Sedimentation Rate
  • - CBC WBC

16
Diagnostic Tests
  • Radiographic determines cartilage erosion, joint
    space narrowing, bone cysts
  • - Arthrography- x-ray with contrast medium
  • - Arthroscopy endoscopic exam of joint
  • - Arthrocentesis needle aspiration of
  • synovial fluid

17
Nursing Care Arthroscopy Post-procedure
  • Assess Neurovascular status (Sx. of
    thrombophlebitis)
  • Monitor for bleeding or leakage at site
  • Assess for pain, edema, redness
  • Ice for swelling, mild analgesic pain

18
Pain Management
  • Prescribed Drug Therapy on timely basis
  • Rest periods
  • Warm shower, hot packs
  • Avoid sudden, jarring of joint
  • Warn clients about quacks (miracle cures)

19
Impaired Physical Mobility
  • Exercise joint, but not beyond pain
  • Positioning body alignment
  • Support joints for optimal function
  • Assistive Devices proper fit instruction

20
Self-care Deficit
  • Routine that includes pacing activities
  • Encourage sleep routine
  • PT for conditioning
  • Occupational Therapy Assistive devices

21
Drug Therapy
  • Salicylates (ASA)
  • NSAIDs (Advil, Indocin, Toradol, naprosyn)
  • Side effects/Precautions
  • Tinnitus, GI distress, prolonged bleeding. Give
    with food, milk. Avoid anti-coagulants

22
Drug Therapy
  • Side effects/Precautions
  • GI (do not crush enteric coated) give after
    meals or with food
  • Dizziness, Diarrhea, headache, rash

23
Drug Therapy
  • Glucocorticoids (dexamethasone, hydrocortisone,
    prednisone.)
  • Side Effects/Precautions
  • Depression, euphoria, anorexia, nausea,
  • weight gain, bruising. Taper dosage when
    discontinuing.

24
Drug Therapy
  • Slow-acting Antirmalirial drugs (plaquenil)
  • Side Effects/Precautions
  • Retinal edema, GI disturbance
  • Toxic Gold Salts (solganol, myochrysine)
  • Side Effects/Precautions
  • Dizziness, flushing, metallic taste, skin rash
    assess CBC UA prior to administration

25
Drug Therapy
  • Cytoxic Drugs (Methotrexate, Imuran, Cytoxan)
  • Side Effects/Precautions
  • Pneumocystis Carni pneumonia, mouth sores, bone
    marrow suppression, hepatotoxicity

26
Degenerative Joint Disease (Osteoarthritis)
  • Non-inflammatory disease of the weight bearing
    joints (hips, knees, spine, hands)
  • Incidence in post-menopausal women
  • Risk Factors age, obesity, overuse of joints,
    trauma (fractures, sports injuries)

27
Osteoarthritis
  • Pathophysiology Articular cartilage becomes
    yellow opaque, joint space narrows, bone spurs
    (osteophyte), cysts
  • Symptoms Joint pain / diminishes on rest
    crepitus (grating sensation) Joint enlargement,
    Herberdens nodes, Bouchards nodules, decrease
    ROM, joint effusion

28
Osteoarthritis
  • Diagnostic Tests X-rays of joints indicates
    narrowing of joint spaces CT Scan MRI of
    spine Bone Scan
  • Differential features of RA DJD
  • OVERHEAD Table 24-1

29
Osteoarthritis
  • Medical Management
  • Drug therapy for pain (NSAIDs), muscle
    relaxants(Flexeril), injection of cortisone
  • Rest immobilization with splint, brace, sleep
    (8 hours/night)
  • Position of joints to maintain alignment avoid
    contractures
  • Heat hot packs, PT diathermy
  • Exercise walking, water aerobics

30
Osteoarthritis
  • Surgical Management
  • Hemiarthroplasty one part of a joint is
    replaced, i.e. head of femur
  • Total Hip replacement Head of femur the
    acetabulum replaced
  • Total Knee replacement both articular surfaces
    of the knee replaced
  • Interphalangeal joint replacement

31
Total Hip Replacement
  • Preoperative Care Skin preparation, IV
    antibiotics, education re nature of prosthesis,
    mobility restrictions, exercises
  • Types of Prosthesis
  • - Cemented 10 year life
  • - Uncemented bone growth occurs into the
    metallic surfaces within 6-12 weeks

32
THR - Postoperative
  • Pain control
  • Wound drain assessment
  • Neurovascular Assessment
  • Activity bed rest with abduction splint or
    pillow, OOB with PT (NO hip flexion 90) weight
    bearing dependent on type of prosthesis
  • Use of walker crutches - cane

33
THR - Potential Complication
  • Thromboembolism
  • Subluxation - Hip Dislocation
  • Neurovascular Compromise
  • Hemorrhage

34
THR Hip Precautions
  • Avoid hip flexion 90
  • Avoid low, soft chairs
  • Avoid excessive trunk flexion in reaching
  • Maintain hip adduction
  • No leg crossing at knee
  • Use raised toilet seat

35
Total Knee Replacement
  • Preoperative Care similar to THR
  • Postoperative Care
  • - Pain control
  • - Wound drain assessment
  • - Neurovascular Assessment
  • - Elevate leg on Pillow for comfort
  • - Head of bed elevated for comfort
  • - Continuous Passive Motion Machine

36
TKR - Potential Complications
  • DVT pulmonary emboli
  • Prosthetic Dislocation
  • Infection

37
Lupus Erythematous
  • Definition Autoimmune disease involving diffuse
    inflammatory changes in vascular connective
    tissue
  • Pathophysiology Antigen-antibody interactions
    results in deposits of immune complexes in
    tissues cells that damage the organs and or
    blood vessels

38
Discoid Lupus
  • Cutaneous manifestations butterfly
  • rash on face
  • Risk Factors Sun exposure intensifies
  • Treatment Cortisone creams, sun screens 30
    SPF, avoid sun at peak hours

39
Systemic Lupus
  • Organs affected Heart, lungs, kidney, Brain,
    blood vessels, joints
  • Systemic symptoms Fatigue, myalgia, joint pain,
    low grade fever, anorexia
  • System specific symptoms Tachycardia, chest
    pain, poteinuria, hip knee necrosis, psychosis,
    seizures

40
Laboratory Tests of SLE
  • Skin biopsy scrapings of skin cells
  • Immune tests RF, ANA, Sed Rate
  • CBC (pancytopenia), Sed Rate, Cardiac Liver
    Enzymes

41
Pharmacological Management Lupus
  • NSAIDS
  • Cortico-steroids
  • Immunosuppresive Agents

42
Nursing Care - Lupus
  • Pain Management
  • Encourage rest periods
  • Decrease protein in diet (kidney involvement) and
    sodium restriction (fluid retention)
  • Referral Local National Lupus Foundation

43
Potential Complications Lupus Erythematous
  • Vasculitis
  • Cardiopulmonary pericarditis, pleural effusion
  • CNS psychosis, seizures, peripheral
    neuropathies
  • Avascular Necrosis

44
Gout
  • Definition Systemic disease involving pain
    inflammation of joints due to urate crystal
    deposits
  • Pathophysiology Inbalance of purine metabolism
    kidney function
  • Incidence Middle aged men

45
Types of Gout
  • Primary Inherited defect in purine metabolism
  • Secondary Disease i.e renal, diuretic therapy
    chemotherapeutic agents

46
Clinical Manifestations of Gout
  • Asymptomatic phase Elevated Uric Acid
  • Acute Phase Sustained elevated Uric Acid
    causing extremely painful, swollen, and reddened
    joint
  • Chronic Phase Urate crystal deposits appear in
    cartilage, synovial membranes, tendons, soft
    tissues

47
Drug Therapy - Gout
  • Acute Phase Colchicine, NSAIDS
  • Chronic Phase Allopurinol (Benemid)
  • Colbenemid
  • Avoid aspirin diuretics

48
Diet Therapy - Gout
  • Low purine (avoid organ meats, shellfish, oily
    fish with bones
  • Avoid Alcohol
  • Increase fluid intake to 3,000 cc/day
  • High alkaline ash foods citrus fruits and
    juices, certain dairy products

49
Other Connective Tissue Disorders
  • Polymyalgia Rheumatica
  • Anklosing Spongylitis (Marie-Strümpell Disease)
  • Sjögrens syndrome
  • Lymes Disease
  • Fibromyalgia

50
Osteoporosis
  • Types
  • Primary - Bone loss related to loss of estrogen
    in menopausal women and low testosterone levels
    in men
  • Secondary Bone loss related to disease process
    (hyperthyroidism, renal failure, GI malabsorption
    problems

51
Pathophysiology Bone Remodeling
  • Resorption Worn out bone cells are removed by
    bone-resorbing cells called osteoclasts
  • Formation New bone is laid down by bone-forming
    cells called osteoclasts

52
Incidence/Risk Factors Osteoporosis
  • Age
  • Race
  • Gender
  • Life Style
  • Diet
  • Heredity

53
Prevention of Osteoporosis
  • Exercise weight bearing types
  • Diet modifications
  • Calcium intake OTC i.e. Tums, Oscal, Calcium
    carbonate, Dietary supplement

54
Clinical Manifestations Osteoporosis
  • Height loss
  • Vertebral deformities
  • Restricted movement
  • Back pain
  • Fractures

55
Diagnostic Tests Osteoporosis
  • Laboratory serum calcium, Vitamin D,
    phosphorus, alkaline phosphatase
  • Radiological X-ray, CT Scan, MRI
  • - Dual energy x-ray absorptiometry

56
Medical Management Osteoporosis
  • Drug Therapy
  • Estrogen replacement Premarin
  • Calcium supplements
  • Bone resorption inhibitor Fosamax
  • Vitamin D

57
Nursing Management Osteoporosis
  • High Risk for Injury Prevention of falls and
    fractures
  • - safe environment
  • (non-skid slippers, shoes, clean spills, avoid
    scatter rugs, lighting, access to items for ADL,
    hand rails, Avoiding lifting heavy objects, use
    of walker, cane.)

58
Nursing Management Osteoporosis
  • Impaired Physical Mobility
  • Increase mobility to level of independence in
    ADL
  • Interventions
  • - Physical therapy program (strengthening
    weight bearing exercises)
  • - Occupational Therapy (Adaptive Devices)

59
Nursing Management Osteoporosis
  • Pain Management - Reduce alleviate pain
  • Interventions
  • - Drug Therapy - opiod, non-opiod Analgesics,
    muscle relaxants, Anti-inflammatory agents
  • Use of heat
  • Orthotic devices braces, splints

60
Other Metabolic Degenerative Bone Disorders
  • Osteomalcia
  • Pagets Disease
  • Herniated Nucleus Pulposus
  • - Laminectomy
  • - Spinal Fusions

61
Fractures
  • Definition Interruption in normal bone
    continuity, which is accompanied by soft tissue
    injury
  • Classification
  • - Simple or closed
  • - Open or compound

62
Fracture Patterns
  • Oblique Line of Fx. Angled
  • Transverse Across the bone
  • Longitudinal Length of bone
  • Spiral Twisting or rotation of bone
  • Comminuted broken in 2 places
  • Impacted Fragments driven into each other
  • Displaced or Avulsed torn away by a ligament or
    tendon

63
Classification by Anatomical Location
  • Humerus
  • Tibia, Fibula
  • Pelvis
  • Hip
  • Skull
  • Mandible
  • Ribs
  • Vertebrae

64
Stages of Bone Healing
  • Hematoma
  • Granulation
  • Callus Formation
  • Osteoblastic Proliferation
  • Bone Remodeling
  • Complete Healing

65
Bone Healing Problems
  • Delayed Union - 6 months to a year
  • Nonunion -
  • Malunion Bone healed in state of deformity

66
Assessment of Fractures
  • Subjective Data History, complaints of pain,
    loss of sensation, movement
  • Objective Data Warmth, edema, ecchymosis,
    neurovascular impairment, splinting, anxiety, fear

67
Emergency Care
  • Inspect area
  • Control bleeding
  • Immobilize/splint
  • Prevent shock
  • Transport safely to ER

68
Nursing Diagnoses
  • Acute Pain
  • Risk for Neurovascular Dysfunction
  • Risk for Infection
  • Altered Mobility
  • Activity Intolerance

69
Complications of Fractures
  • Shock
  • Neurovascular Compromise
  • DVT Pulmonary Emboli
  • Aseptic Necrosis
  • Acute Compartment Syndrome
  • Fat Embolism Syndrome
  • Osteomyelitis

70
Shock
  • Etiology Hemorrhage into damaged tissues,
    especially thorax, pelvis, extremities
  • Treatment Control bleeding and restore blood
    volume

71
Neurovascular Compromise
  • Etiology Damage to nerves from fragments of
    bone, pressure from casts, splints, traction
  • Treatment 6 Ps Pain, Pulslessness,
    Paresthesia, Pallor, Paralysis, Poikothermia

72
Fat Embolism Syndrome
  • Etiology Release of particles of fat into the
    blood stream from the yellow marrow at site of
    injury
  • Risk Factors Fx. of long bones, multiple fx.,
    high serum glucose or cholesterol level

73
DVT Pulmonary Emboli
  • Etiology Immobility, trauma, surgery
  • Risk Factors Incidence in fractures of the lower
    extremities Smoking, obesity, Heart Disease
  • Treatment Anticoagulants

74
Avascular Necrosis
  • Etiology Loss of blood supply to bone
  • Risk Factors Hip fractures or any fracture where
    this bone displacement
  • Treatment Surgical joint replacement

75
Compartment Syndrome
  • Etiology Massive compromise in circulation from
    external (Tight, bulky dressings, casts)
    internal (blood fluid)
  • Treatment Immediately loosen any tight
    dressings MD can bivalve cast
  • Surgery Decompression fasciotomy for edema and
    bleeding

76
Osteomyelitis
  • Acute infection in another part of the body
    invades bone tissue or occurs from penetrating
    trauma
  • Chronic Infection persists especially in a
    patient with compromised circulation

77
Medical Management of Fractures
  • Closed Reduction immobilization Manual
    traction to align the bone
  • External Fixation Percutaneous placement of
    pins implanted into bone
  • - Kronner 4-Barr Compression Frame
  • - Hex-Fix External device for tibial fractures
  • - Halo Traction Cervical spinal fractures

78
Nursing Care External Fixation
  • Teach patient patient to grasp frame when moving,
    rather than limb
  • Frequent observation neurovascular assessments
  • Pin Care Note symptoms of infection
  • Assess for loosening or shifting of devices

79
Casts
  • Purpose Immobilze, correct deformity, allow
    early mobility, provide support protection
  • Types Plaster of Paris Fiberglass

80
Plaster Cast Care
  • Instruct that cast will feel warm
  • Handle cast with palms of hands
  • Turn client q 1-2 hours for drying
  • Elevate on pillow î than heart
  • Pedal rough edges with moleskin
  • Inspect q 4-8 hours drainage, cracking, odor,
    alignment fit

81
Cast Complications
  • Circulatory impairment
  • Peripheral nerve damage
  • Impaired skin integrity
  • Pneumonia, DVT, Constipation
  • Compartment Syndrome
  • Cast Syndrome Body cast
  • Fracture blisters

82
Traction
  • Definition Pulling force that is applied to part
    of an extremity while a counter traction pulls in
    the opposite direction
  • Purpose Reduce Fracture, immobilize, decrease
    pain muscle spasm, correct deformities, stretch
    tight muscles

83
Types of Traction
  • Continuous or Running Bucks, Russell
  • Circumferential Pelvic
  • Cervical
  • Suspension or Balanced Thomas Ring
  • Skeletal Steinmann pins, Kirschner wires,
    Crutchfield tongs

84
Nursing Assessment
  • Equipment weights, pulleys, ropes, Balkan
    frame
  • Mobility
  • Skin integrity
  • Neurovascular
  • Gastrointestinal
  • Urinary

85
Fractured Hip
  • Incidence Prevalent women 65 200,000
    annually by age 80 1 in 5
  • Risk Factors Falls, osteoporosis, age related
    changes in balance

86
Anatomy of Hip
  • Head of femur
  • Acetabulum
  • Femoral neck
  • Greater trochanter
  • Lesser or sub-trochanter

87
Types of Hip Fractures
  • Femoral Neck displaced, impacted, comminuted
  • Intertrochanteric (Intracapsular, Extracapsular)
  • Subtrochanteric

88
Signs Symptoms of Hip Fractures
  • Pain hip or thigh
  • Adduction, external rotation
  • Shortening of leg
  • Inability to move or bear weight

89
Surgical Intervention
  • Total Hip Arthroplasty
  • - Cemented allows full weight bearing
  • - Uncemented Full weight bearing not
    permitted for 6-8 weeks
  • ORIF Intramedullay rods, plates, compression
    screws allows early ambulation

90
Post-operative Care - ORIF
  • Bedrest 1st day OOB with walker
  • HOB î 35 - 40
  • Avoid hip flexion 90
  • Trochanter roll for hip alignment
  • Pillow splint when turning (per MD)
  • Isometric exercises
  • Pain control narcotic analgesics

91
Complications ORIF
  • DVT, PE
  • Hemorrhage
  • Infection
  • Subluxation or dislocation

92
Carpal Tunnel Syndrome
  • Definition compression of the medial nerve in
    the wrist
  • Etiology Repetitive motions, wear tear,
    Fracture of wrist
  • Symptoms Pain, paresthesia, difficulty in
    grasping

93
Diagnostic Tests CTS
  • Phalens wrist flexed back to back results in
    paresthesia 60 seconds
  • Tinels Tapping over the median nerve pain,
    tingling, numbness or inflating a BP cuff will
    result in same SX.
  • X-ray
  • EMG

94
Interventions CTS
  • Non-invasive wrist support, immobilization with
    splint, frequent breaks, cushion grippers on
    pencils pens, Rest, Ice, Heat,
    Anti-inflammatory agents
  • Invasive Cortisone Injections, Surgery
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