Muscular-Skeletal
Lecture 3
Amputation
• Pg 1080
Amputation
• “removal of a body
part, often an
extremity”
Amputation
• Common Causes
– Peripheral Vascular
Disease (PVD)
– Trauma
– Osteomyelitis
– Tumor
• osteosarcoma
Which of the following type of
amputation is the most
common?
A. Upper extremity
B. Lower extremity
Amputation
• Reason
– Relieve symptoms
– h function
– h quality of life
• Which of the following is the
preferred type of amputation
A. AKA
B. BKA
Amputation
• Most distal point
Amputation
Nursing Assessment
• Pre-op
– Neurovascular status
• CMS
• Doppler
• Ultrasound
Amputation
Nursing Assessment
• Pre-op
– Function
– S&S of infection
• C&S
• Lymph nodes
– Psych. status
Amputation
• Complications
– Hemorrhage
– Hematoma
– Infection
– Skin breakdown
– Edema
– Phantom limb pain
– Contracture
Table Question
• What would you identify as the priority
nursing diagnosis for a client who is postop BKA?
Nrs Dx: for Amputation
•
•
•
•
•
•
Acute pain
Disturbed sensory perception
Impaired skin integrity
Grieving
Self-care deficit
Impaired physical mobility
Acute Pain
Nrs Dx: Acute Pain
•
•
•
•
•
Opioid
Evacuation
Δ position
Sandbag
Distraction
Nrs Dx: Altered Sensory Perception
•
•
•
•
h activity
Rehab
Distraction
Rx
– Analgesics
– Tricyclic antidepressants
– Anticonvulsants
Nrs Dx: Impaired skin integrity
• Gentle
• Aseptic tech.
• Diet
– h protein
– vitamins
• Residual limb shaping
– Elastic dressing
– Cast
Which of the following techniques is correct for
obtaining a wound culture specimen from a surgical
site?
A. Thoroughly irrigate the wound before
collecting the specimen.
B. Use a sterile swab and wipe the crusty
area around the outside of the wound.
C. Gently roll a sterile swab from the center
of the wound outward to collect drainage.
D. Use a sterile swab to collect drainage from
the dressing.
NURSING ALERT
• If the cast or elastic dressing comes off, the
residual limb must be immediately wrap
with an elastic compression bandage. If
not, excessive edema will develop leading
to a delay in rehabilitation.
• Notify the surgeon so that another cast can
be applied promptly
Nrs Dx: Impaired body image
Nrs Dx: Grieving
•
•
•
•
•
•
Relationship of trust
Pt. care for limb
Independence
Realistic goals
Support systems
Referrals
Nrs Dx: Self Care Deficit
• Practice
• Nursing impact
Nrs Dx: Impaired physical mobility
• Prevent contractures
• Avoid
– Abduction
– External rotation
– Flexion
• Prone*
• ROM
• Upper body exercises
Nursing Alert
• The residual limb should not be
placed on a pillow because a
flexion contracture of the hip
may result.
A client hospitalized with MRSA (methicillinresistant staph aureus) is placed on contact
precautions. Which statement is true
regarding precautions for infections spread
by contact?
A. The client should be placed in a room with
negative pressure.
B. Infection requires close contact; therefore, the
door may remain open.
C. Transmission is highly likely, so the client
should wear a mask at all times.
D. Infection requires skin-to-skin contact and is
prevented by hand washing, gloves, and a
gown.
A client who is admitted with an above-theknee amputation tells the nurse that his
foot hurts and itches. Which response by
the nurse indicates understanding of
phantom limb pain?
A. "The pain will go away in a few days.“
B. "The pain is due to peripheral nervous system
interruptions. I will get you some pain
medication."
C. "The pain is psychological because your foot is
no longer there."
D. “The pain and itching are due to the infection
you had before the surgery."
The primary reason for rapid
continuous rewarming of the area
affected by frostbite is to:
A. Lessen the amount of cellular
damage
B. Prevent the formation of blisters
C. Promote movement
D. Prevent pain and discomfort
You are assigned to care for a patient with a Below
the Knee Amputation (BKA). Among the patient’s
orders is one which states that the patient should
be placed in the prone position twice daily. The
nurse knows that the reason for this is:
A. Changing the patient’s position will help to
prevent skin breakdown
B. To observe the stump for signs of infection
C. To assist the patient in doing ROM (Range of
Motion) exercises
D. To stretch the flexor muscles and prevent
flexion contractures
Small Group Questions
1. Look at the list of complications associated
with an amputation. Identify ways to assess
for each complication and treatment.
2. Describe the assessment of a patient going
into surgery for a non-traumatic BKA.
What is the number one reason people
go to their doctor?
A. Respiratory infection
B. Back pain
C. Ear infection
D. Head aches
E. Complaint of symptoms assoc. with heart
attacks
What is the number TWO reason
people go to their doctor?
A. Complaints of arthritis in the hands
B. Back pain
C. Ear infection
D. Head aches
E. Complaint of symptoms assoc. with heart
attacks
Low Back Pain
• Pg 1117
Low Back Pain
• Multiple causes
Spinal Column
• Vertebrae
• Intervertebral disk
Intervertebral disks
• Youth
– Cartilage
– nucleus pulposus
• Age
– Cartilage 
• Dense
• △ Shape
Term
Cervical
Thoracic
Lumbar
Sacrum
Coccyx
# vertebrae
7
12
5
5 (fused)
3
Body area
Neck
Chest
Low back
Pelvis
Tailbone
Abrv.
C1 – C7
T1 – T12
L1 – L5
S1 – S5
Spinal Column
• Facet joints
• Ligaments
• Muscles
Spinal Curves
• Shock Absorbers
http://www.spineuniverse.com/anatomy/cervi
cal-spine-anatomy-animation
Disk degeneration
• Most common areas
– L4 – L5
– L5 – S1
Disk protrusion
• AKA
– Herniated nucleus
pulposus
– “Slipped disk”
•  pressure on the
nerve
•  “Radiating” pain
• “Sciatica”
Low Back Pain
S&S
• Acute
– < 3 months
• Chronic
– > 3 months
Low Back Pain
S&S
• Muscle spasm
• i Lumbar curve
If a paravertebral muscle is in
spasm, how would you describe
the muscle tone?
A. Atonic
B. Flaccid
C. Increased muscle tone
D. Decreased muscle tone
Low Back Pain
Assessment
•
•
•
•
Hx & PE
Reflexes
CSM
Pain.
Low Back Pain
Medical Management
• If no serious problem 
• No additional testing
• for 4 weeks.
Low Back Pain
Medical Management
• Self-limiting
– 4 wks
• With
– Rx
– Rest
– Relaxation
Medical Management: Rx
• Analgesics
– Acetaminophen
– NSAIDs
• Muscle Relaxants
– Cyclobenzaprine
(Flexeril)
– S/E
• Drowsiness
Medical Management: Rx
• Tri-cyclic
Antidepressants
– Amitriptyline (Elavil)
Low Back Pain
Medical Management
• Rest
• No
– Twisting
– Bending
– Lifting
– Reaching
Low Back Pain
Medical Management
• Bed rest
– 1-2 days
• Δ position frequently
• No sitting > 50 min.
• Gradual
Nonpharmacologic Interventions
• Relaxation
– Heat
– Spinal manipulation
Low Back Pain
Nursing interventions
• Assess pain 
–i
analgesics
• Mattress
– Firm
– No sag
• Lumbar flexion
Low Back Pain
Nursing interventions
• h activities gradually
• Low stress exercise
• 2 wks  abd. & trunk
exercises
• Improve posture
Good body mechanics: Standing
•
•
•
•
•
•
•
Short duration
1 foot on a stool
⌀ high hills
⌀ flexion
Shift wt
Stand on cushion
⌀ Lock knees
Good body mechanics: Sitting
• Short duration
• Chair
– Straight back
– Arm rests
•
•
•
•
Knees h than hips
Back support
i extension
Alt. sitting / walking
Good body mechanics: Lifting
• NEVER BEND AT THE
WAIST!
• Bend knees
• Squat
• Hold item close Lift
with your legs
No-No’s!
• Bending at the waist
• lifting without bending
knees
• twisting and lifting
• Slouching
• Holding breath when
lifting
Carpal Tunnel Syndrome
• Pg 1078
Carpal Tunnel Syndrome
• “Entrapment
neuropathy”
•
http://video.about.com/ergonomics/C
arpal-Tunnel-Syndrome.htm
Carpal Tunnel Syndrome
Pathophysiology
• Median nerve
• Compressed
Carpal Tunnel Syndrome
Etiology
• Men vs Women?
– Women
• Age?
– 30-60
• Risk Factor
– Repetitive
movements
Carpal Tunnel Syndrome:
S&S
• Pain
– Night
• Paresthesia
• ? weakness
Carpal Tunnel Syndrome
Assessment & Dx
• Tinel’s sign
– Percussing over the
median nerve 
• Tingling
• Numbness
• Pain
– Test = +
Carpal Tunnel Syndrome
Tx
• Corticosteroids
• Wrist splint
Carpal Tunnel Syndrome
Surgery
•
•
•
•
Open nerve release
Endoscopic laser
Local anesthetic
Cut carpal ligament

Small Group Questions
1. What medications are frequently prescribed to a
clinic with acute low back pain? What are their
actions
2. What are the 3-R’s of Low Back pain treatment?
3. Mr. Jones is suffering from acute back pain, what
would you advice him to do? (What would your
teaching plan include)?
4. Describe the pathophysiology of carpal tunnel
syndrome.
5. Demonstrate how to perform the Tinel sign.
Osteoporosis:
• Pg. 1089
Osteoporosis:
Pathophysiology
Bone resorption
osteoclasts
Bone formation
osteoblasts
Osteoporosis:
Pathophysiology
Bone Resorption > Bone formation = i bone
mass
Osteoporosis:
Pathophysiology / Hormones
• Age related changes
• i Calcitonin
– Resorption
•i
– Formation
•h
Osteoporosis:
Pathophysiology / Hormones
• Age related changes
• i Estrogen
– Resorption
• Inhibits
Osteoporosis:
Pathophysiology / Hormones
• Age related changes
• h PTH
– Resorption
•h
– Formation
•i
Osteoporosis:
Pathophysiology
•
•
•
•
Porous
Brittle
Fragile
Fx easily
• http://www.youtube.co
m/watch?v=rHyeZhcoZc
Q
Osteoporosis
• > 10 million Am.
Have osteoporosis
• 33.6 million have
osteopenia
• Men vs Women
– Men < Women
Osteoporosis
S&S
Fractures may be the first
clinical manifestation of
osteoporosis
Osteoporosis
Most Common Fx
• Compression
– Thoracic spine
– Lumbar spine
• Hip
• Colles
– wrist
Osteoporosis
S&S
•
•
•
•
Collapsed vertebra
Asymptomatic 
Kyphosis 
i height
•  protruding abdomen
•  Pulm. insufficiency
Osteoporosis
Risk Factors
• Age
• Men vs Women
– WOMEN
• Small framed vs. large
framed
– Small framed
• Caucasian vs. Asian
– Asian
Osteoporosis
Risk Factors
• Nutritional factors
– Adequate Cal.
– Calcium
– Vit. D
Osteoporosis
Risk Factors
Physical Activity stimulates bone
formation & remodeling
Osteoporosis
Risk Factors
• Immobility
Osteoporosis
Assessment
• X-ray
– Lumbar
• Biconcave
– Thoracic
• Wedge shaped
Osteoporosis
Assessment
• Bone densitometry
– Detect bone mineral
density (BMD)
• http://www.youtube.com/watch?
v=heTObdmOU8o
Osteoporosis
Medical management
• PREVENTION!!!!!!
• Diet
– Calcium
• h
– Vitamin
• D
• Exercise
– Weight bearing
Osteoporosis
Prevention
• Lifestyle
– Alcohol
– Smoking
– Carbonated
drinks?
– Caffeine
Osteoporosis
Medical Management
• Rx
– Calcium
• 1,000 mg/day
Osteoporosis
Medical Management
• Rx
– Calcium
• 1,000 mg/day
– Vit. D
• 600 IU/day
– Vit. C
• 2,000 mg/day
Osteoporosis
Medical Management: Rx
•
•
•
•
Calcium Supplement
Caltrate / Citracal
Split dose
S/E
– Abd. distention
– Constipation
Osteoporosis
Medical Management: Rx
• Bisphosphonates
• Action
– i bone resorption
– h bone density
• Nrs implications
–
–
–
–
–
AM
Water
NPO (ā & ṗ)
Hold Ca+
⌀ lye down
Osteoporosis
Medical Management: Rx
• Estrogen
replacement
Osteoporosis
Medical Management: FX
• Colles Fx
• Distal Radius
• D/T
– Fall on open hand
• Reduced
• Active ROM
Osteoporosis
Medical Management: FX
• Hip
• ORIF
Osteoporosis
Medical Management: FX
• Compression Fx of
vertebrae
• Conservative*
• If acute pain
– Vertebroplasty
Osteoporosis
Nrs Process
• Acute Pain
– D/T compression fx
• Rest
–
–
–
–
–
Supine
Side-lying
△ position frequently
Flex knees
No twisting
• h activity as pain i
Osteoporosis
Nrs Process
• Risk for constipation
• D/T
– Immobility
– Meds
• Assess
– Intake
– BS
– BM
Osteoporosis
Nrs Process
• Risk for constipation
• Fiber
–h
• Fluids
–h
• Rx
– Stool softeners
Paget’s Disease
• Page 1093
Paget’s disease
Pathophysiology
•
•
•
•
•
•
Rapid Bone Turnover
h # of osteoclasts 
h bone resorption
F/B
h osteoblast activity 
Bone replacement
Paget’s disease
Pathophysiology
• Disorganized bone
replacement
• Vascular
• Weak
•  Pathologic fractures
•  bowed legs 
– Misalignment
– Pain
Paget’s disease
S&S
• Insidious
• Deformity
– Skull
– Pelvis
– Femur/tibia
• Pain
• Warm
• Fx
Paget’s Disease
Assessment & Dx
• Serum Ca+
– Normal
• X-ray
• Bone scan
• Bone biopsy
Paget’s Disease
Medical Management
• Pain
– Rx
• NSAIDs
• Gait
– Assistive devices
– Shoe lifts
– PT
• Wt. control
Paget’s Disease
Medical Management: Rx
• Calcitonin
• Action
– i bone resorption
– i osteoclasts
• Route
– Sub q
– Nasal
Paget’s Disease
Medical Management: Rx
• Bisphosphonates
• Action
– i bone turnover
Paget’s Disease:
Nrs Management
• Teaching
Osteomalacia
• Page 1093
Osteomalacia
• AKA
– Adult Rickets
• Deficit or impaired
absorption of
– Ca+
– Vit. D
Osteomalacia
S&S
• Pain
• Difficulty △
positions*
• Weak*
• Waddle*
• Kyphosis
• Pathologic fx
Osteomalacia
Medical Management
• Rx
– Calcium
– Vit. D
– Bisphosphonate
– Calcitonin
Small Group Questions
1. What is the pathophysiology of Osteoporosis?
2. What effect do the hormones calcitonin, estrogen and
PTH have on bone remodeling?
3. What are Bisphosphonates? What advice would you give
to a client with these?
4. What is a Colles’ fracture? What is a compression fx (of
the vertebrae)
5. What is the pathophysiology of Paget’s Disease and
Osteomalacia?
6. How are Paget’s Disease and Osteomalacia similar and
how are they different?
During a home visit, a client with AIDS tells the
nurse that he has been exposed to measles.
Which action by the nurse is most appropriate?
A. Administer an antibiotic
B. Contact the physician for an order for
immune globulin
C. Administer an antiviral
D. Tell the client that he should remain in
isolation for 2 weeks
A client is discharged home with a
prescription for Coumadin (sodium
warfarin). The client should be instructed
to:
A. Have a Protime done monthly
B. Eat more fruits and vegetables
C. Drink more liquids
D. Avoid crowds
Following an amputation, the
advantage to the client for an
immediate prosthesis fitting is:
A. Ability to ambulate sooner
B. Less chance of phantom limb
sensation
C. Dressing changes are not necessary
D. Less edema