�MUSCULOSKELETAL AND REHAB STUDY GUIDE�
�Chs: 44 (MS), 45 (MS), 47 (MS), 7 (Rehab), 67 (Male Reprod.)�
Final Exam 12/06/2022 @ 10am
( Ca = Calcium, P = Phosphorus)
1. Musculoskeletal system structures:
a. Bones
b. Joints
c. Skeletal Muscles
d. Supporting Structures
2. Musculoskeletal system function?
a. Provides framework for the body & allows the body to be weight bearing
b. Supports the surrounding tissues (e.g., muscle & tendons)
c. Assist in movement thru muscle attachment & joint formation
d. Protects vital organs, such as the heart & lungs
e. Manufactures blood cells in red bone marrow
f. Provides storage for mineral salts (e.g., calcium & phosphorus)
3. How many bones are in the musculoskeletal system?
206
4. Two ways bones can be classified
a. Shape:
i. Long → femur, shaft or diaphysis, epiphyses , weight bearing
ii. Short → phalanges
iii. Flat → scapula
iv. Irregular → carpal bones (wrist)
v. Sesamoid → patella
b. Structure:
i. Cortical → dense, compact
1. Haversian system-structural unit
a. is a complex canal network containing
microscopic blood vessels that supply nutrients
& oxygen to bone & lacunae (small cavities that
house osteocytes)
b. osteocytes (bone cells)
c. canals run vertically w/in the hard cortical bone
tissue
ii. Cancellous → Large spaces/trabeculae, red marrow, yellow
marrow
1. contains large trabeculae (large spaces)filled w/ red &
yellow marrow
2. Hematopoiesis (production of RBCs) occurs in red
marrow
3. Yellow marrow contains fat
4. note*: Volkmann canals connect red bone marrow
vessels w/ the haversian system & periosteum
iii. Periosteum → outer layer, osteogenic cells
1. osteoblasts (bone forming cells, think “baby” bone
cells)
2. osteoclasts (bone destroying cells)
iv. Matrix → collagen, mucopolysaccharides, Calcium salts (carbonate & phosphate)
5. Composition of bone (see above)
a. Cortex = outer layer
i. dense compact bone tissue
b. Medulla = inner layer
i. spongy, cancellous tissue
c. bone is VERY vascular, each bone has a main
nutrient artery, which enters near the middle
of the shaft & ranches into ascending &
descending vessels
6. Other stuff to note:
a. the vessels supply the cortex, the marrow, &
the haversian system
b. very few nerve fibers are connected to bone;
sympathetic nerve fibers control dilation of blood
vessels
c. sensory nerve fibers transmit pain signals experienced
by the pt who have primary lesions of the one, such as
bone tumors
7. Musculoskeletal differences among various ethnic groups
idk how to highlight “Accounts for decreased incidence of OA” under AA & “increased incidence OA”
underChinese
8. Bone Resorption → process by which osteoclasts break down tissues in bone & release the minerals, resulting in
transfer of Ca from bone tissue to blood
9. Minerals & Hormones involved in Bone Growth & Metabolism
*Note → Ca & P have an inverse relationship
Calcium (Ca)
● bone accounts for 99% of Ca in the body
● when serum levels of Ca &/or P levels are altered calcitonin & PTH work to maintain
equilibrium
● As Ca levels rise, P levels decrease
● If/when Ca in the blood is decreased, the bone (which stores Ca), releases Ca into the
bloodstream in response to PTH stimulation
Phosphorus (P)
● bone accounts for 90% of P in the body
Calcitonin
● produced by thyroid gland
● decreases serum Ca concentration if its above normal level
● inhibits bone resorption & increases renal excretion of Ca & phosphorus as needed to
maintain balance in the body
Vitamin D (& its
metabolites)
● transported by blood to promote absorption of Ca & P from small intestines
● also seem to enhance PTH activity to release Ca from bone
● decrease in Vitamin D levels can cause osteomalacia (softening of bone) in the adult
Parathyroid
Hormone (PTH)
● when Ca levels are lowered PTH secretion increases & stimulates bone to promote
osteoclactic activity & release Ca into the blood
● reduces renal excretion of serum Ca & facilitates its absorption from the intestine
● if Ca levels increase PTH secretion diminishes to preserve the bone Ca supply
● this is an example of the feedback loop system of the endocrine system
Growth
Hormone (GH)
● secreted by anterior lobe of pituitary gland
● responsible for increasing bone length & determining the amount of bone matrix formed
during puberty
● during childhood an increase results in gigantism, whereas decrease results in dwarfism
● in adult, increase causes acromegaly, which is characterized by one & soft-tissue deformities
Adrenal
Glucocorticoids
● regulate protein metabolism, either by increasing or decreasing catabolism to reduce or
intensify the organic matrix of bone
● also aid in regulating intestinal Ca & P adsorption
Estrogens
● stimulate osteoblastic activity & inhibit PTH
● when estrogen levels decline at menopause, women are susceptible to low serum Ca levels &
increased bone loss (osteoporosis)
Androgens
● such as testosterone in men, promote anabolism (body tissue building) & increase bone mass
Thyroxine (T4)
● principal hormone secreted by thyroid gland
● increases rate of protein synthesis in all types of tissues, including bone
Insulin
● works w/ GH to build & maintain healthy bone tissue
10. At what age does bone resorption
increase?
a. Book says “later years”
b. Google says→ anywhere from 40-50
yrs
11. Three types of joints:
a. Synarthrodial → completely
immovable
i. ex: cranium
b. Amphiarthrodial → slightly moveable
i. ex: pelvis
c. Diarthrodial → synovial, freely moving
i. ex: elbow, knee
ii. synovial joints most common in body, & only type lined w/ synovium (a
membrane that secretes synovial fluid for lubrication & shock absorption)
12. Function of joints
a. space in which two or more bones come together
b. provides movement & flexibility in the body
13. Three types of muscles
a. Smooth
i. non-striated, involuntary, controlled by ANS
b. Cardiac
i. striated, involuntary, controlled by ANS
c. Skeletal
i. striated, voluntary, MOVEMENT, controlled by PNS & CNS
14. Ligaments v. tendons
a. Tendons → connect muscles to bone
i. tough, fibrous
b. Ligaments → attaches bone to bones at joints
15. Osteopenia = softening of bone
16. Musculoskeletal physiological changes that occur as we age
17. Detailed information that should be obtained from the
musculoskeletal history & physical
a. Pt hx →
i. accidents/illness, lifestyle/drugs
ii. previous or current illness → MVA/trauma/falls,
sports related activities, diabetes, as about
ability to perform ADLs
iii. current lifestyle → weight bearing exercises,
high impact sports, tobacco use, alcohol intake
iv. occupation → manual labor, computer reader,
prolonged standing, athletes
v. allergies → dairy products?
vi. medications → steroids, herbs, vitamins &
minerals, supplements
b. nutrition hx
i. weight gain/loss, recall food intake, protein, vitamin D & C, obesity
c. family & genetic risk → helps identify disorders w/ a familial or genetic
tendency
d. current health problems
i. most common reports: impaired COMFORT & impaired MOBILITY
ii. date & time of onset
iii. factors that exacerbate
iv. S/S
v. helpful measures
vi. assess PAIN (COMFORT)
1. acute/chronic, with movement? pain level? pain quality?
location? duration? describe in own words
vii. Is weakness proximal or distal?
1. Proximal weakness (near the trunk of
body) may indicate myopathy (a
problem in muscle tissue), whereas
distal weakness & impaired sensory
perception (esp. lower extremities) may
indicate neuropathy (a problem in
nerve tissue)
e. general inspection
i. posture & gait
1. standing & walking
2. curvature of spine
3. length, shape, symmetry of extremities
4. balance, steadiness, & length of stride
a. antalgic giant
b. lurch
ii. mobility & functional assessment
1. PT/OT
2. need for assistive/adaptive devices
3. ROM
4. review musculoskeletal assessment
from health assessment
iii. Crepitus → grafting sounds
iv. Effusion → fluid accumulation
v. Spinal Alignment → scoliosis
vi. Genu Valgum → “knock-knee”
vii. Genu Varum → “bow-legged”
viii. the pt with hip joint pain usually experiences it in the
groin or has pain that radiates to the knee or lower
back
18. Important components of a neurovascular assessment
a. begin w/ injured side & compare one
extremity w/ another
b. palpation of pulses
i. What if pulses are not palpable? → get
a doppler
c. Sensation, movement, color, temp., pain
19. Important questions to ask a patient prior to an MRI
a. Is the pt pregnant? Not me. Fuck that lol, Not my ass anymore
b. does the pt have ferromagnetic fragments or implants, such as older style aneurysm clips?
c. does the pt have a pacemaker, stent, or electronic implant?
d. does the pt have CKD (Gadolinium contrast agent causes severe systemic complications if the kidneys
do not fxn)
e. can the pt lie still in supine for 45-60 min (may need to be sedated)
f. does the pt need life-support equipment available?
g. can the pt communicate clearly & understand verbal communication?
h. did the pt get any tattoos more than 35 yrs ago? (if so, metal particles may be in the ink)
i. is the pt claustrophobic? (ask for closed MRI scanners)
20. Arthroscopy
a. What it is → a fiberoptic tube inserted into a joint for direct visualization of the ligaments, menisci, &
articular surfaces of the joint
b. the knee & shoulder are most commonly evaluated
c. Priority post-procedure care:
i. Assess NV status q1hr or per protocol
ii. monitor: distal pulses, warmth, color, CFT, pain, movement, sensation
21. At what age is peak bone mass achieved? 30
22. Osteoporosis
a. Etiology→ lack of Ca
i. most common type = primary
ii. lifestyle:
1. lack of exercise
2. diet excessive in → caffeine, protein intake (Atkins diet),
alcohol & tobacco use, exercise, dieting, carbonated
beverages
iii. environment → lack of exposure to sunlight
b. Patho → osteoclast activity > osteoblast activity
i. results in decreased bone mineral density (BMD)
1. Estrogen does not build bone, but does prevent bone loss
ii. results in thin, fragile bone tissue & at risk for fractures, “silent
thief”
iii. secondary→ (chart to the right)
1. result of a medical condition such as hyperparathyroidism,
long term corticosteroid use, prolonged immobility, regional
limb mobilized from cast, injury, or paralysis
c. Risk Factors:
d.
Health
Promotion &
Maintenance:
i.
Build
strong bones
as a young
person, teach
pt to decrease
modifiable risk factors
e.
f.
g.
h.
i.
j.
ii. adequate vitamin D → fatty fish (Mackerel, tuna), fortified milk,
beef liver, egg yolks, cheese
iii. limit carbonated beverages, smoking cessation
iv. importance of exercise → weight bearing, walking 30 min 3-5
times/week is the single most effective method for prevention
v. avoid activities that cause jarring such as horseback riding
Prevention: Goal is PREVENTION
i. increase Ca in diet (dairy products, dark leafy greens)
ii. increase Vitamin D → dietary intake, sun exposure (5
min/day), supplements
iii. Foods high in Vitamin D (see above) plus swordfish, chicken, liver,
fortified/enriched cereals & bread), & D3 supplements for all adults
iv. Read Labels
v. Lactose intolerant or Vegan
1. soy, rice milk, tofu, fortified w/ Vit. D
Common bone fracture sites → wrist, femur, vertebra
Important physical assessment components:
i. Health Hx:
1. pt w/ increased risk factors are at an increase risk for falls!
2. perform fall risk assessment: (high risk)
a. delirium, dementia, immobility, muscular weakness, hx of
falls, visual or hearing deficits, current drugs
ii. Musculoskeletal Assessment:
1. inspect & palpate vertebral column
a. “dowager’s hump”, kyphosis, pt states “I have gotten shorter”, assess height/weight
2. assess pain
a. bending, stooping, lifting, worse w/ activity
b. if accompanied by tenderness, think compression
vertebral fracture
c. ask pt to locate all painful areas, pain w/ or w/out
movement, swelling, malalignment
d. assess for fractures→ most common = wrist,
femur, vertebra
Psychosocial assessment:
i. may associate w/ menopause → fear of getting older, fear of
becoming less dependent
ii. Quality of Life (QOL) → pain, insomnia, depression,
fallophobia
iii. assess→ concept of body image, social interaction, sexuality,
self-esteem
Treatment → is to slow the progression & based on cause
i. bone building drug →Teriparatide (Forteo) SubQ 2 years
1. for pts who don’t respond well to Bisphosphanates
ii. Bisphosphonate maintenance following therapy
iii. Estrogen Agonist/Antagonist → raloxifene (Evista)
iv. others→ parathyroid hormone, calcitonin, RANKL inhibitor, combination
Diagnosis:
i. DXA (Dual X-Ray Absorptiometry) → best tool for measuring bone
density
1. pDXA = peripheral DXA, heel, forearm, finger
ii. no definitive test; men & women > 50 (high risk) → yearly serum Ca & Vit
D3 levels
iii. rule out secondary osteoporosis → serum Ca, Vit. D, & P levels, urine Ca,
protein measurements, thyroid tests
iv. imaging (others) → conventional x-ray (decreased bone density & fractures), qualitative CT scan, MRI
k. Fall risk interventions (a lot of repeat):
i. pt education → prevention/slow progression; reduce chance of fractures
ii. nutrition therapy → increase Ca & vitamin D, low-fat dairy, fruits & veggies, increase fiber, decrease
alcohol (women 1 drink/day; men 2/day) & caffeine
1. fractures → adequate protein, vitamin C, & iron for healing
2. lactose intolerant → soy, rice water, fruit juice, cereals, & bread fortified w/ Ca & vit D
iii. lifestyle changes, exercise (swimming & yoga), avoid tobacco, avoid scatter rugs
iv. Ca & Vitamin D3 supplements
1. Not treatment (prevention)
2. Calcium carbonate (Os-Cal), Calcium citrate (citracal), D3
3. Best to take w/ food, 6-8 oz water, drink plenty of fluids to prevent stones
23. Bisphosphonates
a. MOA: slow bone reabsorption
b. Examples → alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), IV (Reclast)
c. Important teachings:
i. dental exam before beginning therapy
ii. take early AM on empty stomach w/ 8oz water
iii. wait 30-60 min in upright position
iv. call provider for chest discomfort/esophageal irritation
v. pts w/ poor renal fxn, hypocalcemia, GERD should not take
24. Evista (raloxifene)
a. MOA: binds to estrogen receptors & mimic estrogen, reduces bone resorption & incidence of vertebral
fractures
b. S/E: hot flashes, leg cramps, joint pain, flu-like symptoms, N/D, swelling in arms & legs
c. teach s/s of VTE
25. Foods high in vitamin D (look above, I’m not re-writing it)
26. Osteomalacia (rickets in kids)
a. Patho: loss of bone related to vitamin D
deficiency
i. softening of the bone → inadequate
deposits of Ca & P in bone matrix
ii. normal remodeling is disrupted
iii. calcification does not occur
b. Risk Factors:
27. Paget’s disease (metabolic bone disease)
a. Patho→ osteitis deformans
i. chronic metabolic disorder
ii. one remodeling (turnover)
iii. increased resorption → weak bones, enlarged bones,
disorganized growth
b. Risk factors:
i. men > women
ii. Age > 50 yrs
iii. european heritage
c. S/S:
i. may be asymptomatic
ii. pathologic fractures may be the presenting clinical manifestation
iii. may report warmth/redness at affected site
iv. skin may be flushed and warm
v. bone pain, aching, deep, worse w/ pressure & at night
vi. posture/stance → may have decreased height, bowing of legs
vii. skull → soft, thick, enlarged
viii. sensory changes → may have changes in vision, swallowing, hearing, & speech
1. ATI says hearing loss not vision loss
d. Surgical Tx: joint replacement
e. Non-Surgical Tx:
i. Aspirin or NSAIDs for pain (ibuprofen aka Motrin)
ii. application of heat & gentle massage
iii. relaxation techniques
f. Impaired Mobility:
i. consult PT for exercise
program
ii. non-impact → pain, danger
of fracture
iii. strengthening & weight
bearing
iv. ROM w/ gentle stretching
g. Teach diet rich in Ca &
Vitamin D (same as
osteoporosis diet)
h. Refer pt to Paget Foundation
28. Osteomyelitis
a. What it is: Bone infection or inflammation of bone caused by infection
i. bacteria = most common, viruses, fungi, & parasites
b. Risk Factors:
i. trauma
ii. secondary infection (most commonly staph)
iii.
iv. blood-borne (hematogenic) → results from bacteremia, underlying
disease, long term IV catheters (hickman), non-penetrating trauma, IV
drug abusers, hemodialysis
v. continuous→ from infection in adjacent tissues, poor dental hygiene,
staph
vi. exogenous→ organisms that enter body from outside, open
fracture
c. Acute v. Chronic S/S:
Acute
Chronic
● Fever > 101
○ Confusion in older
adults
● Swelling around affected
area
● Bone pain, constant,
localized, pulsating, worse
w/ movement
● Elevated WCs
○ life threatening
bacteremia → Septic
Shock
● Ulceration of skin
● Sinus tract formation
● Localized pain
● Drainage from the affected
area
● Normal or slightly elevated
WBCs
● IV ABX 4-6 wks
● IV ABX > 3 months,
followed by oral
d. Non-surgical Tx:
i. ABX ASAP for Acute!!
1. more than 1 ABX sometimes
& take on time
2. take full course
3. observe for actions, s/e,
toxicity, & teach when to
contact HCP
ii. Contact Precautions
1. copious wound drainage
2. severe infections
iii. Wound Care
1. ABX Continuous or intermittent irrigation
2. Pack ABX eads into wound
3. may use clean technique for “dirty wounds”
4. standard precautions at home
iv. Pain Management
v. Hyperbaric Oxygen → high concentration O2 diffuses into tissues
e. Surgical Tx:
i. Sequestrectomy
1. debride necrotic tissue, leaves large cavity
2. may need one grafts
3. allows revascularization
ii. Microvascular bone transfer
1. large skeletal defects
2. bone graft using pts fibula or iliac crest
iii. Amputation
iv. Nursing Care: (similar to any post-op care)
1. Frequent NV assessment → pain, movement, sensation, warmth, temp, distal pulses, CFT
2. Elevate affected extremity
3. Psychosocial care → esp. amputations!
29. Benign bone tumors
a. Often asymptomatic & may be discovered on routine x-ray scans or cause of a pathologic fracture
b. Cause is unknown
c. Classifications:
i. Chondrogenic → from cartilage
ii. Osteogenic → from bone
iii. Fibrogenic → fibrous tissue; most often seen in children
iv. Giant cell tumor (osteochondroma) → uncertain origin, aggressive, can spread to lungs, most
commonly seen in pts in their 30’s
1. onset usually in childhood but not diagnosed until adulthood
2. can be a single growth or multiple
3. femur & tibia most often involved
d. Treatment → surgery to remove the tumor
30. Malignant Bone tumors
a. Primary → begin in bone
i. often occurs in pts 10-30 yrs old & makes up small
percentage of bone cancers
ii. exact cause unknown but genetic & environmental
factors are likely causes
b. Secondary → originate in other tissue & metastasis to bone
i. metastatic lesions often occur in older aged pts &
account for most bone cancers in adults
31. Metastatic Bone Tumors (not a question she put on this but thought it was important)
a. primary tumors of the breast, prostate, kidney, thyroid, & lung are “bone seeking”
b. “Seeds” carried thru bloodstream
c. fragility fractures are MAJOR concern
d. Chondrosarcoma
i. S/S → dull pain & swelling for a long period of time
ii. destroys bone & calcifies
iii. middle aged older adults
e. Fibrosarcoma
i. gradual onset
ii. S/S → no specific symptoms, pain w/ no palpable mass
iii. metastasizes to lungs
iv. usually middle aged men
32. Osteosarcoma
a. Primarily occurs → distal femur
i. most common PRIMARY
b. S/S → acute pain, swelling, warmth in affected area (bc blood flow to site increases)
i. center of tumor is sclerotic from increased osteoblastic activity
ii. periphery is soft, extending thru bone cortex in a classic “sunburst” appearance, visible on x-ray
iii. often metastasizes & results in death
iv. previous radiation
33. Ewing Sarcoma
a. MOST MALIGNANT!!!!!!
b. children & young adults in their 20’s
c. S/S: pain, swelling, low grade fever, leukocytosis, anemia, extends to soft tissue
i. pelvic involvement = poor prognosis
ii. death from metastasis to lungs & other bones
d. Labs that are elevated & why:
34. TNM staging system
a. T → tumor size & number
b. N → cancer cells in lymph nodes?
c. M → metastasis? spread to distant sites?
35. Bone cancer
a. Surgical tx:
i. usually reduced or removed with surgery & may be combined w/ radiation or chemotherapy
1. Pre-op care
a. chemo/radiation
b. psychological support
c. assess level of
understanding
d. spiritual support
e. teach what to expect
post-op
2. Operative
a. total joint replacement
b. metallic implants
c. allografts
d. try to salvage the limbs
3. Post-op
a. may have pressure dressings for several days &/or cast
b. ROM asap → PT/OT, assistive/assistive devices
c. may need assistance w/ ADLs
d. NV checks
e. observe for hemorrhage!! → allograft
f. emotional support
g. promote physician-pt relationship
b. Non-Surgical Tx:
i. Pain Relief!!!
ii. Drug Therapy:
1. chemotherapy
2. Biologic agents → stimulate immune system
3. Biophosphates → protect bones/prevent
fractures
iii. Radiation Therapy
1. may be palliative
2. external
3. brachytherapy
iv. Interventional Therapy → Microwave Ablation (MWA)
36. Ganglion cysts
a. round, benign cyst in wrist or foot joint or tendon
b. synovium surrounding tendon degenerated allowing tendon sheath to
become weak & distended
c. S/S → painless on palpation, fluids can be aspirated, can rapidly appear
& disappear
d. Tx → cortisone injections; large cyst may be removed
e. Teachings → avoid strenuous activity for 48 hours post-op & report s/s of
inflammation to surgeon
37. Hallux valgus v. Hammertoe
Hallux valgus
● Great toe drifts laterally
Hammertoe
● Dorsiflexion of any metatarsophalangeal (MTP)
● first metatarsal becomes enlarged resulting in bunion
● as deviation worsens, bony enlargement causes PAIN
● women > men
joint w/ plantar flexion of the proximal
interphalangeal (PIP) joint next to it
● 2nd toe most often
● as worsens, corns develop
● Causes:
○ poorly fitted shoes
○ osteoarthritis
○ rheumatoid arthritis
○ family hx
● Treatment:
○ custom shoes if not a surgical candidate
○ Bunionectomy
● Treatment:
○ corrected w/ osteotomies
○ crutches until FWB (full weight bearing)
allowed several weeks after surgery
● Bunionectomy:
● Osteotomy:
○ one foot at a time
○ cutting bone (& sometimes adding bone tissue)
○ screws & wires often inserted to stabilize bones in
to reshape or realign bones
great toe & first metatarsal
○ PWB w/ orthopedic boot
■ 6-12 wks recovery time (blood flow to foot less
than other body parts)
38. Plantar fasciitis
a. Patho → inflammation of plantar fascia (arch of foot)
i. middle-aged & older adults/athletes (runners)
ii. Obesity is a contributing factor
b. S/S → severe pain in arch of foot, worsens w/ weight bearing
c. Treatment → Rest, ice, stretching, strapping of foot, good shoes, orthotics
i. NSAIDS
ii. Endoscopic surgery
39. Scoliosis repair
a. < 50 degree curve → moist heat, pain medication, exercise
b. > 50 degree curve → SOB, fatigue, OA, severe back pain, may require surgery
c. Post-op care → anxiety, pain
i. assist pt w/ standing, sitting up, walking for first time
ii. collaborate w/ PT
iii. teach wound management at home
iv. avoid twisting & lifting
v. may return to work/school in 3-6 wks
40. Fractures:
Incomplete → break thru part
Simple (closed) → no break in skin, no visible wound
Open (compound) → bone breaks thru skin at moment of injury
Greenstick → cracked on one side, & can be bent on the other
i. an incomplete fracture; most commonly seen in kids
ii. called greenstick because it looks similar to what happens when you try to break a “green” branch on a
tree- wtf?
e. Spiral→ the break partially encircles the
bone, most commonly a long bone, occurs
from a twisting force
f. Displaced (complete) → break across the
entire cross-section of bone (width)
g. Impacted → broken ends of the bone are
jammed together by the force of the injury;
one fragment goes into another
h. Oblique → a break that runs at an angle
across the bone; breaks diagonally
i. Comminuted→ a break or splinter of the
bone into more than 2 fragments; occur after
high impact trauma (ex., MVA)
j. Fatigue (stress) → excessive strain; most
commonly seen in athletes from repeated
stress to bones
k. Compression → common fracture of the
spine or d/t osteoporosis; exactly what it
means “compressed”
l. Pathologic (fragility) → bone weakened by disease;
m. Transverse → bone broken at right angle to the bone’s axis, may be displaced
a.
b.
c.
d.
41. Stages of bone healing
42. Factors that can delay bone healing
a.
b.
c.
d.
e.
f.
g.
severity of trauma
type of bone injured
gender (women have loss of estrogen after menopause)
chronic diseases (arteriosclerosis)
infection
nutrition (Ca, P, Vitamin D, Protein)
Ischemic or avascular necrosis
43. Acute Compartment syndrome
a. what it is → a serious, limb-threatening condition that results from a complication of a fracture
b. etiology:
i. increased pressure within one or more compartments (that contain muscle, blood vessels, & nerves)
reduces circulation to the lower leg or forearm
c. Patho:
i. sometimes referred to ask ischemia-edema cycle
ii. slide → inelastic tissue surrounding muscle, blood vessels, & nerves
iii. capillaries within the muscle dilate which raises capillary (arterial) & venous pressure, capillaries
become more permeable d/t release of histamine by the ischemic muscle tissue & venous drainage
decreases; as a result, plasma proteins leak into interstitial fluid space & edema occurs
iv. edema increases pressure on nerve endings & causes severe pain
v. perfusion to the area is reduced & further ischemia results
d.
e.
f.
g.
vi. sensory perception deficits or paresthesia generally appears before changes in vascular or motor signs
Causes → can be from internal or external source, but fracture is present in most cases
i. external pressure → tight, bulky dressings & cast
ii. internal pressure → blood or fluid accumulation (common source), burns, or massive IV infiltration
S/S (6 P’s) → Pain, Pallor, Pressure, Paralysis, Paresthesia, Pulselessness
i. color of tissue pales & pulses weaken but rarely disappear
ii. palpably tense
iii. acute severe pain w/ passive motion of the extremity
Treatment:
i. fasciotomy → surgeon cuts thru the fascia to relieve pressure & tension on vital blood vessels &
nerves; wound remains open & heals from inside out; surgeon usually closes wound w/ a skin graft in
several days
Long-term problems → infection, persistent motor weakness, contracture, myoglobinuric renal failure,
amputation
44. Hypovolemic shock
45. Fat Embolism Syndrome v. Venous Thromboembolism
Classification
Fat Embolism Syndrome (FES)
Venous Thromboembolism (VTE)
Patho
● Fat globules released from yellow marrow
into blood stream (12-14 hours after
injury/illness)
● Globules clog blood vessels
● impairs oxygen perfusion
● long bone fractures or fracture repair (hip
fracture)
● occlusive blood clot (thrombus) that obstructs
blood flow in an artery or vein
● potential complications → coronary,
cerebrovascular, pulmonary (PE), and venous
thrombosis
● includes both DVT & PE
● Virchow’s Triad: Stasis of Blood,
Hypercoagulability, Endothelial injury
Risk Factors
● Men 20-40 yrs
● older adults 70-80 yrs greatest risk
● cancer/chemo
● surgery > 30 min
● smoking
● obesity
● heart disease
● prolonged immobility
● oral contraception
● history of VTE
● older adults (hip fracture)
S/S
● Early:
○ altered mental status!! VERY
EARLY
○ hypoxemia
○ dyspnea
○ tachypnea
○ chest pain
○ headache
○ lethargy/agitation/confusion
○ vision changes
● Altered Mental Status!!!
● hypoxemia
● dyspnea
● difficulty breathing
● lightheadedness
● fainting
● coughing up blood
● sudden or gradual pain, warmth, redness,
tenderness of skin
● chest pain
Treatment
46.
○ seizures
● Late:
○ Petechiae (classic) on neck, arms,
chest, abdomen
■ measles-like rash
○ death
● leg cramps
● bedrest
● gentle handling
● oxygen
● hydration via IV
● steroid therapy
● fracture immobilization
● elevate affected extremity
● compression stockings/SCDs/TED hose
● Drugs (anticoagulants DOC)
○ IV unfractionated Heparin
○ LMWH (Enoxaparin [Lovenox])
○ Warfarin (Coumadin)
○ Oral→ Rivaroxaban (Xarelto), Apixaban
(Eliquis), Dapigatran (Pradaxa)
● Surgical→ thrombectomy, IVC filter
Complications of Tissue & Bone Infection
Complication
Ischemic/Necrosis
Delayed Wound Healing
Complex Regional Pain
Syndrome (CRPS)
● Aseptic or avascular
necrosis
● Blood supply to bone
interrupted
● Death of bone tissue
● Common in hip fractures
● Surgical repair of fractures
can cause (Hardware
interferes w/ circulation)
● Long term corticosteroid
therapy (ex.: Prednisone)
● Fracture not healing within 6
months
● Nonunion (never achieves
union)
● Malunion (heals incorrectly)
● Common in tibial, pathologic
fractures
● Casts/traction
● Older pts
● Results in chronic
pain/immobility/deformity
● severe, chronic pain
● CNS & PNS dysfunction
● Fractures & other
musculoskeletal injuries
(common in feet & hands)
● ANS: changes in color, temp.,
sensitivity of skin, diaphoresis,
edema
● Motor: Paresis, muscle spasms,
loff of fxn
● Sensory: intense burning pain,
intractable
● Priority Management = Pain
Relief
● Meds: Topical analgesics,
antiepileptics, antidepressants,
corticosteroids, bisphosphonates,
analgesics, maybe chemical
nerve block
● Surgical: sympathectomy
● collab w/ PT (ROM)
● gentle skin care/minimal
stimulation
● assist pt w/ coping
47. Primary Assessments of Patients with Fractures
a. History → severe pain (delay interview)?, cause? events leading to injury, drug history, medical history,
occupation? activity level (runner?, Colles’ fracture of wrist?)?
b. Physical → assess all body systems, VS, (respiratory status, pneumothorax), skin color, LOC, urine, pain,
bone alignment, ecchymosis, subq emphysema, swelling (NV checks)
c. Psychosocial → depends on extent of injury, assess feelings, coping, support systems
d. Labs/Imaging:
i. none specific
ii. check H&H (may be decreased)
iii. may have elevated ESR d/t inflammatory process
iv. may have elevated Ca & P levels (during healing, bone releases elements into blood)
v. Standard X-ray, CT/MRI
48. Important Assessments of Patients in Splints & Casts
Classification
Casts
Assessments
● rigid device that holds bone fragments in
place after reduction
● early mobility
● reduces pain
● synthetic materials (weigh less):
○ fiberglass (most common)
○ plaster of paris (24 - 72 hr drying
time)
● may have window for wounds, drains, pulse
assessment
● Bivalve option cut lengthwise in 2 pieces
● Arm:
○ may have ice first 24-48 hrs.
○ teachings:
■ elevate above heart
■ use sling when out of bed
■ alleviate fatigue caused by weight
of cast
■ sling should distribute weight to
shoulders & trunk, not just neck
■ some HCP prefer no sling for first
few days
■ encourage normal movement
● Leg
○ allows mobility & requires to use
ambulatory aids (crutches)
○ may be cast shoe, sandal, or boot
attached to a rubber walking pad if
weight bearing allowed
○ teachings:
■ elevate affected leg on several
pillows to reduce swelling
■ may use ice for first 24 hrs
● Body
○ Body → encircles trunk, not usually for
adults
○ Spica → encases portions of trunk & 1
Splints
● flexible materials, allow room for swelling w/out
decreased arterial perfusion
● preferred over casts
● upper-extremity:
○ non-weight bearing so splint may be sufficient
○ Elastic Bandages → scapula (shoulder), Clavicle
(collar bone)
● padded boots/shoes for foot or toe fractures, allows
weight bearing, have velcro straps
or 2 extremities
○ Potential Complications:
■ skin breakdown, respiratory
dysfunction, constipation, joint
contractures
■ cast syndrome → partial or
upper intestinal obstruction,
abdominal distention, epigastric
pain, N/V
Planning &
Taking
Action
● teach purpose before application
● check skin integrity
● warn pts of heat if Plaster-of-Paris used
● check for edema & s/s of infection if applicable
○ handle w/ palms of hands until dry
○ turn q2hr
○ cloth pillow
● Perineal area of cast may be covered in
plastic
● fracture pans → do not contaminate cast
w/ urine or feces
● NV checks q1hr first 24 hrs → insert a
finger between cast & skin
● teach to report s/s of infection, circulation
problems, peripheral nerve damage
● observe cast for drainage → report
immediately sudden increases in drainage
or change in cast integrity, if cast becomes
too loose & needs replacement
● cast should only be odorous when wet
49. Bucks (skin traction) v. Skeletal Traction
classification
Bucks (Skin)
Skeletal
● use of velcro boot, belt, or halter secured around
affected leg
● primary purpose: to decrease painful muscle
spasms that accompany hip & proximal femur
fractures
● weight is used as a pulling force
● limited to 5 - 10lbs. to prevent injury to the skin
● may be used to help decrease pain & muscle
spasms!
● screws, wires, tongs (Crutchfield) are
surgically inserted directly into the bone (e.g.,
femoral condyles for distal femur fractures)
● allow the use of longer traction time &
heavier weights
● 15 - 30lbs.
● aids in bone realignment but impairs pt’s
mobility
● Pin care!!!
50. Assessments of patients on traction
a. DO NOT remove weights w/out a prescription
i. inspect all ropes, pulleys, knots every 6-8 hours
ii. check weights
b. DO NOT rest weights on floor
i. DO NOT lift manually
ii. weights should hang freely
iii. teach UAP
c. Inspect skin at least every 8 hours
i. remove belt or boot q8hr if possible for skin inspection
d. severe pain
i. weights may be too heavy
ii. pts may need realignment
e. Assess NV status q1hr for first 24 hours then per prescription (usually q4hr)
51.Surgical Options for Treating Fractures
a. Pre-Op → teach pt & family what to expect; Care similar to any pt
undergoing general or epidural anesthesia
b. Pre-op alternative to opioids is fascia iliaca compartment block (FICB) which
avoids risk to femoral artery & vein
c. Open Reduction w/ Internal Fixation (ORIF)*** big one for fractures!
i. allows surgeon to directly view fracture site
ii. common for hip fractures!!
iii. operative
1. Early mobility!!
2. metal pins, screws, rods, plates, or prostheses to immobilize FX during healing
3. May remain or be removed later, depends on FX location & type of hardware
d. External Fixation
i. operative
1. pins or wires inserted thru skin & affected bone
2. allows early ambulation & exercise
3. minimal blood loss
4. risk for pin site infection (osteomyelitis)
a. pt usually given Ketorolac in PACU
52.Post-Op Care for External Fixator
a. Care similar for any pt undergoing surgery
b. reduce inflammation & pain
c. External Fixator (soft tissue damage/open fractures)
i. observe pins for S/S infection/inflammation (heat, erythema, swelling, pus/drainage, pain)
ii. clear fluid drainage first 48-72 hours normal & expected
iii. Assess for disturbed body image
iv. teach pt alterations in clothing may be required while fixator in place
*Slides 109-113*
53.Distal radius fractures & Hip fractures
a. Distal Radius Fractures (DRF)
i. most common upper extremity fracture
ii. older-standing level fall (Colles’)
iii. Colles’ → when you attempt to break a fall by landing on heel of
outstretched hand when wrist is extended
iv. Nursing →
1. remove jewelry on affected hand/wrist before edema worsens
2. perform frequent NV checks on affected upper extremity (pay
special attention to presence of decreased sensory perception
such as numbness &/or decreased movement)
3. assess for nerve compression (esp. radial & median nerves)
4. immobilize affected wrist/hand
5. elevate affected upper extremity
6. apply ice to the affected area
7. manage pain
v. most common treatment is closed reduction after initial stabilization
vi. HCP realigns bone ends while pt is moderately sedated & a splint is
applied & held in place w/ elastic bandages; splint may be replaced
several days later with a cast after edema decreases
vii. more complicated DRF, an ORIF w/ pins & plates may be performed
b. Hip Fractures
i. most common injury in older adults; Osteoporosis biggest risk
factor
ii. high mortality rate; may die w/in 1 year
iii. hemiarthroplasty →
prosthesis for femoral
neck or femoral head
fractures)
iv. Intracapsular → within
joint capsule
v. Extracapsular →
outside of joint capsule
vi. Femoral neck → ischemic or avascular vascular
necrosis
vii. TOC → ORIF
1. may have Buck’s traction before
surgery to decrease pain associated w/
muscle spasms
2. Pain management/bedrest if pt not
candidate for surgery
3. IV morphine for pain (not
Demerol!!!!)
54. Complications of hip fractures
a. Acute Confusion/Delirium
i. Monitor for falls
ii. ask family or visitors to alert nurse if pt is trying to get out of bed
b. Immobility
i. pressure injuries
ii. atelectasis
iii. VTE
iv. ambulate w/ assistance day after surgery
v. carefully inspect skin (heels)
c. Hip Dislocation after Surgery
i. keep operative leg in alignment
ii. pillows & abduction device
iii. assess skin or pressure
iv. NV checks
55. Different levels of amputations (above knee, below knee, etc)
a. most are elective d/t PVD
b. Lower-extremity (LE) amputations are much more common than upper
extremity amputations
c. upper extremity amputation → trouble w/ ADLs, more incapacitating
d. AKA→ above the knee
e. BKA → intense efforts are made to preserve knee joints
f. Syme & midfoot→ most of foot removed but the ankles the remain
i. Syme = amputation thru ankle joint
ii. common for PVD pts
iii. advantage of this over BKA is that weight bearing can occur
without use of prosthesis & w/ reduced pain
g. Toe → Big toe most common toe to be amputated which is significant
d/t the effects on balance, gait, & “push-off” ability during walking
h. Hip disarticulation → removal of the hip joint
i. Hemipelvectomy → removal of half of the pelvis w/ the leg
j. the higher the level of amputation the greater the energy required for mobility
.
56. Physical & Psychosocial Assessments of Patients with an Amputation
a. Physical
i. NV status in extremity to be amputated
ii. check circulation in both legs
iii. assess skin color, temp., sensation, pulses in affected & unaffected extremities
iv. observe/document any discoloration of skin, edema, ulcerations, presence of necrosis, & hair
distribution
v. CFT may be difficult → use skin near nail beds
b. Psychosocial
i. never underestimate loss
ii. evaluate psychological preparation (response correlates w/ progress)
iii. assess for altered self image
iv. loss of independence
v. refer to chaplain, spiritual leader, social worker, counseling services
vi. assess pt & family coping
vii. explore cultural beliefs
viii. veterans
57. Care of a traumatic amputation
a. Call 911, assess ABCs
b. Examine amputation site & apply direct pressure to
bleeding
c. Elevate extremity above heart
d. Do not remove dressing
e. Pre-hospital care for parts (usually finger):
i. Wrap in dry sterile gauze (if available) or clean cloth
ii. Place in watertight, sealed plastic bag
iii. Place the BAG in ice water, never directly on ice, 1
part ice & 3 parts water
iv. Avoid contact between water & finger
v. Do not remove any semi-detached parts
vi. Send part to hospital w/ pt
58. Management of phantom limb pain (PLP)
a.
b.
c.
d.
e.
opioid analgesics are not as effective
IV infusions of calcitonin during week after amputation
then PCP can prescribe meds that are patient specific
Slides → U/S therapy, massage, heat, biofeedback, relaxation, hypnosis, psychotherapy
IV calcitonin, infusions, BBs (constant dull, burning pain), antiepileptics (knife-like, sharp burning pain),
Antispasmodics (muscle spasms, cramping)
59. Nursing care for Impaired Mobility in Pt w/ an amputation? How are flexion contractures
prevented?
a. Firm mattress
i. essential for preventing contractures from leg amputations
ii. prone q3-4hrs for 20-30 min
iii. teach ROM, turning q2hr, & use of trapeze
b. Collab w/ PT to begin exercise ASAP
i. crutches
ii. learn before surgery if possible
c. CPO (certified prosthetist-orthotist)
i. residual limb needs to be shaped & shrunk
ii. rigid dressings
60. How to Prepare the Residual Limb for a Prosthesis
a.
b.
c.
d.
Reapply bandage every 4-6 hours
figure 8 wrapping prevents restriction of blood flow
decrease tightness while wrapping distal → proximal
anchor bandage to the highest point after wrapping
61. RICE, Describe?
a.
b.
c.
d.
e.
Rest
Ice
Compression
Elevate
See gray box
62. Carpal tunnel syndrome
a. Causes:
i. excessive hand exercises
ii. metabolic & connective tissue diseases
iii. women > men; children too d/t computers & electronic devices
iv. often dominant hand
v. repetitive stress injury → most common; occupational, excessive pinching/grasping, golf/tennis,
computer work
b. Patho:
i. Median nerve of wrist compressed
ii. pain & numbness
iii. chronic problem
c. S/S
i. numbness
ii. paresthesia
iii. weak pinch
iv. clumsiness
v. difficulty w/ fine movements
vi. wrist swelling
vii. can progress to muscle weakness & wasting which can impair self-management
d. Diagnosed → made based on history, report of hand pain, & numbness
i. Phalen’s Maneuver/Test → produces paresthesia in the median nerve distribution (palmer side of
the thumb, index & middle fingers, & half of the ring finger) w/in 60 seconds as a result of
increased internal carpal pressure
1. pt is asked to relax wrists into flexion or place back of hands together at same time
2. positive phalen’s test = CPS
ii. Tinsel’s Sign → light tapping of irritated median nerve elicits paresthesia in the distribution of
nerves
e. Nonsurgical Tx:
i. immobilization
ii. teaching
iii. NSAIDs
iv. May inject corticosteroids
v. splint/brace (neutral position or slight extension)
vi. OT
f. Surgical Tx:
i. Same day surgery
ii. removes cause of nerve compression
iii. Post-Op:
1. Monitor vitals
2. check dressing for drainage & tightness
3.
4.
5.
6.
7.
elevate hand
NV status q1hr immediate post op
teach to restrict heavy hand movement 4-6wks.
report numbness, increased pain
may need assistance w/ self-management during recovery
63. Rotator cuff injuries
a. Rotator cuff of shoulder stabilizes head of humerus
during abduction
b. Causes → falls, throwing a ball, heavy lifting,
repetitive movements
c. S/S:
i. shoulder pain
ii. cannot maintain abduction
iii. pain more intense at night & w/ overhead
activities
d. Treatment
i. NSAIDs
ii. Steroid injections
iii. PT → U/S, Electrical Stimulation, Ice, Heat
iv. Immobilization
v. Surgical repair
�Rehab Lecture�
1. Goal of rehabilitation
● To return the best possible physical, mental, social, vocational, & economic capacity
2. Different rehabilitation settings
Inpatient Rehabilitation Facilities
(IRFs)
● free-standing rehab hospitals
● skilled units w/in a hospital
○ ex.: Mobile Infirmary Rotary Rehab
Skilled Nursing Facilities (SNFs)
● part of a hospital or long-term care facility
● admitted for 1-3 weeks
○ ex.: Mobile Infirmary LTAC Unit & Nursing Homes
Ambulatory Care Rehabilitation
● outpatient clinics for pts requiring less-intensive services
such as outpatient PT, OT, wound care, etc.
Home Rehabilitation
● for pts who are able to rehabilitate to independence or who
have a caregiver & a home w/out environmental barriers
● Provided by home health agencies (PT, OT, wound care, IV
infusions)
3. Role of each member on the rehab team
Physiatrist
-Physician’s Assistant
Nurses & Assistants
● Physicians who specialize in rehabilitative medicine
● oversee the rehabilitation medical POC from emergency dept, ICU, telemetry
unit, & med-surg unit into the community
● is the attending physician at the IRF w/ consultation from general practitioners.
May also provide consultation in the SNF
● Physician assistant (PA) → works under the supervision of the physician
● advocates for the pt & family
● creates therapeutic rehab milieu
● provides & coordinates whole-person pt care in a variety of health care settings,
including home
● collaborates w/ the rehab team to establish expected pt outcomes to develop POC
● coordinates rehab team activities to ensure implementation of the POC
● acts as a resource to the rehab team who has specialized knowledge & clinical
skills needed to care for pt w/ chronic & disabling health problems
● communicates effectively w/ all members of rehab team, including pt & family
● plans continuity of care when the pt is discharged from health care facility
● evaluates effectiveness of the interprofessional POC for the pt & family
Physical Therapist (PT) ● aka physiotherapist
● intervene to help the pt achieve self-management by focusing on gross
MOBILITY skills (e.g., facilitating amulation & teaching the pt to use an assistive
device such as a walker)
● may also teach techniques for performing activities such as transferring (e.g.,
moving into & out of bed), emulating, & toileting.
● in some settings PTs play a major role in providing wound care & cognitive
retraining
● Physical therapist assistants may be employed to help the PT
Occupational Therapist ● work to develop the pt’s fine motor skills used for ADL self-management such as
those requiring eating, hygiene, grooming, & dressing
(OT)
● also teach pts how to perform independent living skills such as cooking &
shopping
● to accomplish these outcomes, OTs teach skills related to coordination (e.g., hand
movements) & cognitive retraining
● Occupational therapist assistants (OTAs) may be available to help the OT
Speech-Language
Pathologist (SLP)
● evaluate & retrain pts w/ speech, language, or swallowing problems
● some pts, especially those who have experienced a head injury or stroke, have
difficulty with both speech & language
● those who have had a stroke may also have dysphagia, SLPs provide screening &
testing for dysphagia, if the pt has this problem, the SLP recommends appropriate
foods & eating techniques
● speech language pathologist assistants (SLPAs) may be employed to help the SLP
Restorative Aids
● in long term care settings, may enhance the therapy team to continue rehab
therapy POC when therapist are not available
Recreational/Activity
Therapist
● help pts continue or develop recreation or leisure interest to bring meaning to the
person’s life
● these activities may also contribute to strengthening fine motor skills
Cognitive Therapist
● usually neuropsychologist
● work primarily w/ pts who have experienced a stroke, brain injury, brain tumor,
or other condition resulting in cognitive impairment
● computer programs are often used to assist w/ cognitive retraining
Registered Dieticians
● ensure the pt meets their nutritional needs.
● plan a pt specific diet
Social Worker
● promotes community reintegration of the pt & acceptance of the disability or
chronic condition(s)
● helps pt identify support services & resources including financial assistance
Spiritual Care
Counselor
● specialize in spiritual assessment & care & are able to address the needs of a wide
array of pt preferences & beliefs
Pharmacist
● collaborate w/ other members of the health care team to ensure the pt receives the
most appropriate drug therapy, if required
● oversee the prescription & preparation of medications & provide the
interprofessional team w/ essential info regarding drug safety, interactions, &
s/e’s
Clinical Psychologist
● asses & diagnoses mental health/behavioral health or cognition issues resulting
from the disability or chronic condition
● helps both pt & family identify strategies to foster coping
4. Functional Index Measure (FIM)
● a measure of disability; assess & grade functional status of
a person based on level of assistance he/she requires
● measures:
○ ability to perform ADLs
○ ability to perform IADLs (instrumental activities of
daily living)
○ sphincter control
○ transfers
○ locomotion
○ communication
○ social cognition
5. Vocational counselor
● helps with job placement, training, or further education
● work-related skills are taught if the pt needs to change
careers d/t disability
● if the pt has not yet completed high school, tutors may help
w/ completion of the requirements for graduation
6. Best practices for using canes & walkers
● Canes:
○ apply transfer belt around pt’s waist
○ guide the pt to standing
○ be sure the cane is at the height of the pt’s wrist when arm is placed
at his/her side
○ place cane in pt’s strong hand
○ ensure the pt is well balanced
○ teach pt to move in this sequence:
■ move cane & weaker leg forward at the same time
■ move stronger leg one step forward
■ check balance & repeat the sequence
● Walkers:
○
○
○
○
○
apply transfer belt around pt’s waist
guide pt to standing position
remind pt to place both hands on walker
ensure pt is well balanced
teach pt to move in this sequence:
■ lift the walker
■ move the walker about 2 feet forward,
& set it down on all legs
■ while resting on the walker, take small
steps
■ check balance & repeat the sequence
7. Safe patient handling practices
●
●
●
●
Maintain a wide, stable base w/ your feet
put the bed at correct height
keep pt in front of you
keep pt close to your body
8. Complications of immobility
●
●
●
●
●
●
●
●
●
●
●
contractures
footdrop
constipation
DVT
confusion
infection
neurogenic bladder
neurogenic bowel
calculi
pneumonia
pressure ulcers
9. How can foot drop be prevented? (per google, thank you mayo clinic)
● use a padded splint or boots and using exercises like ankle pumps
● perform passive or active ROM exercises as possible/tolerated
10. Neurogenic v. Spastic Bladder, Neurogenic v. Spastic Bowel; treatments for each
Classification:
Reflex/Spastic Bladder (overactive)
Flaccid Bladder (underactive)
Patho:
● upper motor neuron injury
● bladder fills, transmits impulses to the spinal
cord, but pt cannot perceive sensation
● Complications: urinary frequency &
incontinence
● lower motor neuron injury
● bladder fills, transmits impulses to spinal cord,
but d/t injury impulses are not interpreted
correctly & bladder doesn't contract
● Complications: urinary retention & overflow &
post void residual urine
Techniques to
re-establish
voiding
patterns:
● triggering techniques (stroking inner thigh,
massaging peno-scrotal area, pinching
posterior aspect of glans penis)
● drug therapy (idk why its on here twice)
● intermittent catheterization
● consistent toileting schedule
● indwelling catheter (as a last resort!)
● drug therapy w/ antispasmodic agents
(oxybutin)
● **be careful w/ older adults on
antispasmodics; report hallucinations or
delirium to HCP asap
● Valsalva & Crede maneuver
● increased fluids
● intermittent catheterization
Classification:
Reflex/Spastic Bowel (overactive)
Flaccid Bowel (underactive)
Patho:
● upper motor neuron injury
● damage to nerves which result in a loss of
the ability to feel when rectum is full
● Complications: defecation w/out warning
● lower motor neuron injury
● damage to nerves which result in anal
sphincter being loose or flaccid
● defecation is infrequent & in small amounts
Techniques to reestablish
defecation
patterns:
●
●
●
●
●
●
●
●
●
●
●
●
triggering mechanisms (digital stimulator)
high fiber diet
increased fluids
laxative use
consistent toileting schedule
manual disimpaction
triggering mechanisms
increased fluids
high fiber diet
suppository
consistent toileting schedule
manual disimpaction