Chapter_023.pptx

Chapter 23

Musculoskeletal Function

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Diseases of musculoskeletal system are usually not fatal but can lead to chronic pain and disability.

May cause impairments in ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs)

When dependence occurs, can result in loss of self-esteem, perception of decreased quality of life, and depression

Introduction

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Muscle mass, tone, and strength decrease

Elasticity of ligaments, tendons, and cartilage decreases

Bone mass decreases

Intervertebral disks lose water, narrowing the vertebral space.

Posture and gait change leading to shift in center of gravity.

Age-Related Changes in Structure and Function

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Musculoskeletal system affected in numerous ways by aging process

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All the changes may cause pain, impaired mobility, self-care deficits, and increased risk of falls for older adults.

One-third of people age 65 or older have falls each year.

Moderate to severe injuries included hip fractures, lacerations, and traumatic brain injury.

Falls are the most common cause of accidental death.

Fall experience causes a fear of falling.

Consequences of Changes in Structure and Function

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Common problems and often result in loss of functional ability

May occur because of trauma to bone or joint, or may be the result of pathologic processes

Falls are a common cause.

Most common fractures are hip, the proximal femur, Colles (wrist), vertebral, and clavicular.

Fractures

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Most disabling type of fracture for older adults

25% patients with hip fractures die within 1 year after injury.

Complications of hip fractures generally related to immobility.

Classified by location: intracapsular, extracapsular

Affected extremity is externally rotated and shortened with tenderness and severe pain.

Hip Fracture

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Assess hips and lower extremities for evidence of fracture such as shortening of the extremity, and abnormal rotation.

Assess for presence of tenderness, swelling, or ecchymosis and pain with movement.

Obtain VS and level of consciousness.

Can you name six nursing diagnoses for hip fracture?

Hip Fracture: Assessment and Diagnosis

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Pain, resulting from the discomfort from the muscle and bone trauma

Decreased mobility, resulting from immobilization of the fracture and the healing process

Potential for reduced skin integrity, resulting from immobilization required for healing

Potential for infection, resulting from inadequate wound healing, compromised nutrition, and effects of immobility

Inadequate bathing/dressing/feeding/toileting self-care, resulting from discomfort and decreased mobility

Inadequate home maintenance, resulting from decreased independence and recovery period needed for fracture healing

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The patient will do the following:

Report minimum discomfort and an adequate level of pain control

Remain free from postoperative complications, such as altered skin integrity and wound infection

Adhere to the prescribed physical therapy regimen

Participate in physical and occupational therapies

Safely demonstrate use of assistive devices for mobility and ADLs

Return to the preinjury level of independence with appropriate support and assistive devices

Hip Fracture: Planning and Expected Outcomes

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Assess and stabilize medical conditions and hip fracture.

If surgical intervention: keep patient comfortable and hydrated and prevent complications of immobility during pre-op period

Postoperative: monitoring of VS, I&O, and mental status (watch for delirium)

Turning, deep breathing, and coughing

Monitor for signs of infection and bleeding

Assess movement, circulation, and sensation

Provide safety, comfort, and maintain their sense of independence and identity.

Maintain proper hip alignment to prevent dislocation.

Prevent constipation.

Appropriate patent teaching.

Hip Fracture: Intervention

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Successful achievement of expected outcomes will allow patient to return to preinjury level of function.

Should be successful in meeting goals of therapy

Should report minimum pain at the fracture or surgical site and intact skin integrity

Muscle strength, joint movement, level of mobility, and degree of safety while performing ADLs should be continually evaluated.

Hip Fracture: Evaluation

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Fracture of distal radius as a result of reaching out with open hand to break fall.

Immediate pain, local edema, swelling, and visible deformity from displacement of distal bone fragment

Treatment: closed reduction and immobilization with forearm splint or cast.

Elevate extremity and perform neurovascular assessment to monitor for complications.

Instruct patient to actively move thumb and fingers to improve venous return and decrease edema.

Colles Fracture

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Occurs after fall on outstretched hand or on fall to shoulder

Point tenderness, local edema, and crepitus

Shoulder noticeably deformed, dropping downward, forward, and inward

Treatment: reduction of fracture and immobilization with a sling or cast

Monitor for neurovascular complications, elevate extremity, and instruct patient to actively move hand and fingers.

Clavicular Fracture

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Casting materials include plaster of Paris or synthetic materials such as fiberglass.

Instruct to keep casts dry; keep extremity elevated to level of heart to decrease edema; maintain movement of extremity to prevent muscle atrophy and joint stiffness.

Assess for potential areas of skin irritation or breakdown; neurovascular assessment; control pain with medication; prepare patient for self-care and prevent complications.

Casts and Cast Care

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Degenerative joint disease; noninflammatory disease of joints characterized by progressive articular cartilage deterioration and formation of new bone in joint space

When joint cartilage lost, two bone surfaces come into contact with each other, resulting in joint pain.

Most common type of arthritis

Causes: age, trauma, lifestyle, obesity, and genetics are predisposing factors.

Osteoarthritis (OA)

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Joints most commonly affected: distal interphalangeals, carpometacarpal joint, first metatarsophalangeal joint, proximal interphalangeals, knees, hips, and spine

Gradual onset aching joint pain; pain occurs with activity and relieved with rest; stiffness after periods of inactivity that resolves with activity

Crepitus may be heard and felt with range of motion in affected joints; affected joints have decreased range of motion.

Bony enlargements, Heberden nodes, may be seen on the distal interphalangeals, and Bouchard nodes may be seen on the proximal joints.

OA Presentation

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History of problem: the onset, location, quality, and duration of the joint pain and precipitating factors

Questions about drugs used to relieve pain, including prescription and OTC agents and nonpharmacologic interventions

Inspect affected joints for pain, tenderness, swelling, redness, crepitation, and range of motion

Can you name three nursing diagnoses for OA?

OA: Assessment and Diagnosis

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Pain resulting from inflammation and deterioration of the joint cartilage

Reduced mobility as a result of lower extremity joint stiffness

Inadequate self-care as a result of limitations in joint movement and strength

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The patient will do the following:

Verbalize an improved level of comfort with activities

Successfully use various adaptive devices in maintaining independence in ADLs and IADLs

Demonstrate safe use of assistive devices for ambulation

Demonstrate an understanding of the use of orthotics

OA: Planning and Expected Outcomes

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Instruct on joint protection and energy conservation.

Educate on heat and cold therapy, nonsteroidal antiinflammatory drugs, topical gels, and injected steroids.

For surgical patients (severe pain and increasing disability)

Preoperative period: educate about surgical procedure, its risks, potential complications, and postoperative course

After surgery: prevent complications, relieve surgical pain, and assist patient in achieving higher level of function and activity

OA: Conservative Intervention

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The main indications for surgery are severe pain and increasing disability.

Preoperative period: educate about surgical procedure, its risks, potential complications, and postoperative course

After surgery: prevent complications, relieve surgical pain, and assist patient in achieving higher level of function and activity, monitor for complications: DVT, joint or wound infection, blood loss, nerve injury, joint dislocation, and surgical pain

Rehabilitation begins within 24–48 hours and includes muscle strengthening and range-of-motion exercises.

Occupational therapy provides instructions for independence in daily activities.

OA: Surgical Intervention

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Successful achievement of expected outcomes for patient with osteoarthritis are to relieve pain and restore function.

Conservative measures will improve mobility and increase comfort.

The patient needs to understand the expected outcomes, as well as the risks associated with surgical procedures.

Understanding the disease process and treatment measures will assist an older adult in maintaining function and independence.

OA: Evaluation

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The most frequently encountered, clinically important degenerative spinal disorders in the aging population

Bony overgrowth of facet joints of vertebrae leads to narrowing of spinal canal and possible compression of nerve roots.

Most frequently seen in lumbar region at levels L3 and L4

Leads to progressive back pain and possible weakness of lower extremities

Spinal Stenosis

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Assessment focuses on patient’s symptoms

Identify exact location of pain or numbness, the duration of the symptoms, and successful pain relief measures.

Assess comfort levels during routine ADLs.

Can you name four nursing diagnoses for spinal stenosis?

Spinal Stenosis: Assessment and Diagnosis

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203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Report a minimum or tolerable level of pain

Demonstrate improved mobility and tolerance of activity

Incorporate a plan for lifestyle modifications that includes activity and rest

Demonstrate safe use of assistive devices and make necessary environmental changes to promote safety

Spinal Stenosis: Planning and Expected Outcomes

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Nursing care depends on severity of spinal cord narrowing, patient’s state of health, and degree of pain and immobility.

Instruct patient to allow sufficient periods of rest and to limit activities that produce pain.

Initiated pain relief measures and evaluate for their effectiveness using assessment scales

Offer other measures like heat or cold applications, massage therapy, relaxation techniques, and position changes while in bed.

Spinal Stenosis: Intervention

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Patient’s ability to perform ADLs independently with minimum discomfort should be evaluated by self-report and observation.

Effectiveness of pain relief measures should be discussed with patient and changes made when medications have lost effectiveness.

Reinforce instructions about precautions and activities for patients undergoing epidural injections or surgical procedures.

Spinal Stenosis: Evaluation

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Chronic, systemic, inflammatory, autoimmune disease that causes joint destruction and deformity and results in disability

Starts with the proximal interphalangeals, metacarpophalangeals, and wrists when the synovial membrane becomes inflamed and thickens, and production of synovial fluid is increased (pannus)

Pannus tissue result in decreased joint motion, deformity, and finally ankylosis, or joint immobilization.

Onset gradual, and course is one of remissions and exacerbations

Rheumatoid Arthritis (RA)

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Symptoms: painful, stiff joints, decreased range of motion in joints, joint swelling, and deformity

Morning joint stiffness which lasts from 30 minutes to 6 hours

Affected joints are warm and swollen.

Joint deformities include ulnar deviation of the wrists, boutonnière deformity caused by contractures of the distal and proximal interphalangeal joints, and swan-neck deformity caused by contractures of the distal interphalangeal joint.

RA Presentation

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Family history and constitutional symptoms, including fever, anorexia, weight loss, fatigue, and duration of the joint stiffness

Physical exam of affected joints

System assessment of the eye for scleritis and corneal ulcers, lungs for pneumonitis, and heart for pericarditis

Can you name six nursing diagnoses for RA?

RA: Assessment and Diagnosis

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The patient will do the following:

Maintain normal joint motion in affected joints, with minimum deformities

Experience adequate pain control of inflammation

Maintain optimal functional status

RA: Planning and Expected Outcomes

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Educate to cope effectively with chronic nature of disease.

Discuss pain management, maintenance of self-care activities, promotion of safe mobility, methods of joint protection and precautions, and management of overall health.

Provide information about resources that are available.

Teach about action, side effects, and special precautions related to the specific drugs.

RA: Intervention

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Older adult with rheumatoid arthritis should experience minimum discomfort and be able to maintain acceptable level of function and mobility.

Active participation by patient in activities to prevent joint deformities; patient should experience less deformity, increased comfort levels, and understanding of disease process.

RA: Evaluation

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Result of elevated levels of serum uric acid

Joint inflammation caused by sodium urate crystals in joint

Most commonly affected joint is the great toe.

Can be acute or chronic

Affected joint becomes hot, reddened, and tender; pain can be severe and interfere with mobility, self-care, and functional abilities; chills and fever may be present.

Gouty Arthritis (Gout)

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History of symptoms

Assess for of warmth, swelling, cutaneous erythema, and severe pain in the affected joint, fever, chills, and malaise and presence of tophi

Identify risk factors or conditions that may predispose patient to development of gout.

Can you name three nursing diagnoses for gout?

Gout: Assessment and Nursing Diagnosis

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203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Verbalize increased comfort and pain relief with the use of appropriate analgesics and nonsteroidal antiinflammatory drug (NSAID)

Be able to verbalize understanding of the disease process

Incorporate appropriate diet modifications and lifestyle changes

Modify his or her activity and rest pattern based on limitations imposed by the pain

Incorporate health practices to minimize recurrent attacks

Gout: Planning and Expected Outcomes

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Provide pain relief measures and prevention of recurrent attacks of gout.

Educate about role of dietary habits should be provided.

Consult with dietician to educate on avoiding a diet with purines, alcohol, and weight reduction if obese.

Encourage fluids to prevent kidney stones.

Gout: Intervention

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Patients should be able to maintain healthy lifestyle, incorporating changes suggested during treatment.

Pain management should allow patients to participate fully in ADLs and allow full mobility.

Gout: Evaluation

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Which of the following is associated with gout? (Select all that apply.)

Crepitation

Joint become severely deformed

High uric acid levels

Symptoms include fever and malaise.

Avoiding alcohol may help

Treatment may involve joint surgery.

Quick Quiz!

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ANS: C, E

Answer to Quick Quiz

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Common in postmenopausal women

Reduction in bone mass and loss of bone strength

Causes: renal or hepatic failure, hyperthyroidism, hyperparathyroidism, type I diabetes mellitus, rheumatoid arthritis, and chronic kidney disease

Risk factors: heredity and genetic predisposition, lifestyle factors, and age

Risk factors that can be modified with lifestyle changes involve calcium intake, exercise, cigarette smoking, and consumption of alcoholic beverages.

Osteoporosis (1 of 2)

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Frequently no clinical symptoms appear until fractures occur.

Initial complaint may be back pain or fatigue.

Bone densitometry commonly done with dual-energy x-ray absorptiometry (DEXA)

Labs: CBC, serum calcium, serum phosphorus, alkaline phosphatase, and urinary calcium obtained to differentiate osteoporosis from other diseases that may cause bone loss

Osteoporosis (2 of 2)

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Directed at minimizing bone loss and preserving current level of bone mass

Patient education is critical for prevention and risk reduction.

Changing lifestyle risk factors, nutritional counseling, and pharmacologic management are strategies used to prevent osteoporosis.

Adequate calcium intake or supplements

Weight-bearing and resistance exercises

Pharmacological treatments

Osteoporosis Management

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Family health history and determination of risk factors, level of exercise, alcohol and caffeine intake, and smoking

Assess age of onset of menopause, lifelong intake of calcium, history of fractures, presence of pain, and history of falls.

Physical examination for the presence of kyphosis, gait impairments, muscle weakness, and cognitive impairments

Can you name five nursing diagnoses for osteoporosis?

Osteoporosis: Assessment and Diagnosis

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The patient will do the following:

Demonstrate taking precautions at home and in the community to prevent falls and activities that may result in fractures

Report an adequate level of pain control in the presence of bone fractures

Consume nutritional supplements, food products, and medications recommended or prescribed for meeting dietary needs, as evidenced by a diet log

Verbalize acceptance of changes brought about by the disease and an understanding of the treatment and prevention of further deformities

Osteoporosis: Planning and Expected Outcomes

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Education about disease process, strategies to prevent further injury or deformity, and measures to promote decreased loss of bone

Emphasize identification and minimization of controllable risk factors.

Recommend exercise programs that will place some stress on bones.

Teach about pain management modalities.

Osteoporosis: Intervention

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Patient should describe measures to decrease potential for further bone loss, as well as measures to maintain a safe living environment.

Patient will be able to participate in regular exercise programs and to identify resources available for prevention of disease.

Osteoporosis: Evaluation

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Inflammatory disease of bone in which both osteoclasts and osteoblasts proliferate

Recent evidence supports theory that viral infection of osteoclasts causes disease.

Onset is insidious.

Involves pelvis, femur, skull, tibia, and spine

First symptom is bone pain not relieved with rest and movement.

Prognosis is not favorable because of complications that may develop: pathologic fractures and loss of hearing related to changes in the temporal bone, possible cord compression and paralysis related to overgrowth of the spinal vertebrae

Paget Disease

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Health history and family history of disease

Assess for warmth, deformity, pain, and erythema over long bones; assess range of motion in joints; and evaluate presence of any weakness, ataxia, or hearing loss

Can you name four nursing diagnoses for Paget's disease?

Paget’s Disease: Assessment and Diagnosis

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Pain, resulting from bone deformity and possible joint involvement

Reduced mobility, resulting from bone deformity, fracture, or pain

Potential for injury, resulting from limitations of mobility and altered bone metabolism

Distorted body image, resulting from deformities and disturbance in function

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The patient will do the following:

Achieve a satisfactory comfort level with pain management techniques and medications

Modify the home environment and take precautions in the community to prevent injuries

Verbalize an understanding of the chronic nature of the disease and appropriate therapies

Make positive coping statements related to a potential altered body image

Paget’s Disease: Planning and Expected Outcomes

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Educate regarding the disease and treatment

Manage pain strategies

Assess safety and mobility issues

Consult with physical or occupational therapists

Paget’s Disease: Intervention

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Documentation of patient’s ability to perform ADLs and understanding of importance of therapy for prevention of pain, deformity, and loss of function

Evaluate need for adaptive equipment.

Paget’s Disease: Evaluation

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Infection of bone that can be either acute or chronic

Symptoms of osteomyelitis associated with a bone injury are localized pain, tenderness on palpation, erythema, warmth to the touch, and edema.

Symptoms of osteomyelitis associated with infected pressure ulcers are subtle changes in mental status, low-grade fever, and increased purulent wound drainage which may go unnoticed until sepsis occurs.

Has as good prognosis if treated early; if first sign is sepsis then poor prognosis

Osteomyelitis

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Focus assessment on identifying risk factors predisposing patient to osteomyelitis.

Examine preexisting wounds or infections carefully.

Monitor vital signs and diagnostic test results.

Assess oral cavity.

Can you name three nursing diagnoses for osteomyelitis?

Osteomyelitis: Assessment and Diagnosis

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203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Report minimum discomfort and adequate pain control

Verbalize an understanding of the need for long-term therapy to eliminate infection

Demonstrate safe and independent mobility

Exhibit intact skin surfaces and no evidence of further infection

Osteomyelitis: Planning and Expected Outcomes

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Use sterile technique during dressing changes and following strict wound precautions.

Teach importance of completing course of oral antibiotics, methods of preventing infection, and specific techniques of wound management.

Allow patient to make informed decisions about care and consult with therapeutic recreation specialists.

Consulted with physical and occupational therapists to provide individualized exercise programs that promote optimal function and prevent disability

Osteomyelitis: Intervention

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Patients should participate fully in all aspects of care.

Any wounds or other potential sources of infection should show progressive healing.

Patient should verbalize understanding of chronic nature of treatment, and documentation should include patient’s involvement in wound care or antibiotic therapy.

Osteomyelitis: Evaluation

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PVD, infections, neoplasms, and traumatic injury may lead to lower extremity amputation.

Atherosclerosis and diabetes predisposing factors in development of foot or extremity ulcers

Osteomyelitis with bone destruction results in amputation of extremity.

Amputation

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Before surgical procedure, assess to determine presence of other diseases and their effect on function

Focus on mobility and self-care ability

Assess affected limb determining peripheral pulses, temperature, sensation, and movement

Note characteristics of ulcer or gangrenous area

Ascertain feelings about impending surgical procedure and how amputation will affect health and lifestyle

Can you name six nursing diagnoses for amputation?

Amputation: Assessment and Diagnosis

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203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Report pain relief with the administration of analgesics

Demonstrate acceptance of body image changes

Have an incisional area that remains clean and without evidence of infection

Safely perform self-care activities within his or her activity and energy expenditure limitations

Amputation: Planning and Expected Outcomes

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Education is important in preventing amputation.

Teach about promptly notifying health care provider for changes in temperature, sensation, and color; if sore develops, prompt treatment must be sought.

Teach methods to protect lower extremity from injury.

Amputation: Intervention

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Preoperative: provide extensive information about surgical procedure, including the purpose of amputation, potential use of a prosthesis, and rehabilitation program

Postoperative: provide routine postoperative care and monitor carefully for complications that may be the result of preoperative health problems; provide pain relief measures and monitor for side effects; manage stump dressings

Amputation: Surgical Intervention

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Rehabilitative care starts immediately after surgery with application of dressing, when patient’s condition is stable, physical therapy begins.

Assist patient with accepting body image changes.

Prosthetic fitting and adaptation

Not all older adults are candidates for prostheses.

Delayed prosthetic fitting takes place when stump is healed and well shaped.

The physical therapist and prosthetist instruct the older patient in the use of the prosthesis.

Amputation: Rehabilitation Intervention

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Based on achievement of expected outcomes: exhibiting positive outlook about body changes, performing self-care and other activities safely and adequately, and experiencing pain relief over time

Documentation of activities critical for multidisciplinary evaluation of the older patient’s progress

Amputation: Evaluation

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The nurse is caring for a patient with an amputation. Give three or more important nursing interventions necessary for proper recovery and adjustment postoperatively.

Quick Quiz!

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ANS: Answers may vary but should include pain medication, preventing complication, stump dressings and education, and rehabilitation.

Answer to Quick Quiz

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Chronic inflammatory condition—sudden onset of muscle stiffness and aching in neck, shoulders, and hip girdle

Cause unknown

Symptoms: muscle stiffness present in morning and lasts more than 1 hour

Constitutional symptoms such as fever, malaise, anorexia, and weight loss may be present.

Treated with NSAIDs and steroids

Polymyalgia Rheumatica (PMR)

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History of patient’s symptoms, physical examination, and functional assessment are important in determining the effect of disease on functional abilities.

Can you name five nursing diagnoses for PMR?

PMR: Assessment and Diagnoses

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The patient will do the following:

Report pain relief with initiation of treatment

Correctly describe pharmacologic therapy—purpose, action, and side effects of drugs

Establish an activity and rest pattern based on limitations imposed by the disease

Incorporate effective coping strategies in disease management

Correctly state the treatment rationale and prognosis

PMR: Planning and Expected Outcomes

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Provide patient with information about disease and treatment plan

Monitor for development of side effects

PMR: Intervention

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Pain management is necessary for the older patient to perform ADLs, evaluate the patient’s understanding of the drugs and their side effects.

Providing appropriate education about the disease and symptom management

Documentation of education, pain assessment, and functional abilities is important for ongoing planning and care of patient.

PMR: Evaluation

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Often overlooked in assessment and care

Foot problems, especially pain, are common.

Foot problems may cause an unsteady gait and may result in falls.

Painful feet can be result of congenital deformities, weak structure, injuries, and diseases.

Foot Problems

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Thickened and hardened dead or hyperkeratotic tissue that develops over bony protuberances

Cause localized pain

Caused by ill-fitting or loose shoes that constantly place pressure on bony prominences

Treatment: warm water soaks used to soften corns before gentle rubbing with pumice stone or callus file; gentle debridement by a podiatrist, moleskin or cotton pads are placed over areas of rubbing and pressure

Corns

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Dead tissue found on plantar surfaces of the feet

Form under metatarsal heads

Aging changes of decreased toe function and decreased fat padding contribute to development.

Treatment same as for corns

Calluses

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Arthritis and other age-related changes such as ligament and tendon atrophy predispose older adults to bunions.

Bony protuberances on side of great toe

Great toe rubs against shoe, bursa becomes inflamed, resulting in bursitis and pain.

Treatment: soft leather shoes that are flat and wide and lace up; NSAIDs may be prescribed to reduce inflammation and pain; surgical interventions used after conservative treatment has failed

Bunions

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Deformity of the second toe—clawlike position

Causes: improperly fitted shoes, muscle weakness, and arthritis

Symptoms: pain and burning on bottom of foot and problems walking in shoes

Treatment: metatarsal arch support, orthotics, splints, and passive manual stretching of proximal interphalangeal joint; surgical correction is done if conservative treatment is ineffective

Hammertoe

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Onychauxis; hypertrophic nails; can cause nail bed ulcers, infection, and pain

Onychomycosis: fungal infection of toenail; white, yellow, or brown nails with simple scaling or totally destroyed

Predisposing factors: moisture, poor footwear, recurrent trauma, and diabetes

Treatment: topical antifungals generally used for several months

Nail Disorders

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Educate about predisposing factors, prevention, and treatment of onychomycosis and need for ongoing foot care, including inspection of feet for signs of infection and application of medication.

Foot Problems Patient Education

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Idiopathic muscle cramps without muscle weakness are common.

Affect the calf or foot muscles, producing plantar flexion of the foot or toes

Occur most frequently at night during sleep.

May be prevented by stretching the affected muscles for several minutes at bedtime.

Stretching will generally relieve the discomfort.

Muscle Cramps

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