MUSCULOSKELETAL DISORDERS

The musculoskeletal system

The musculoskeletal system consists of the bones, muscles, ligaments and tendons. Function:
The function of the musculoskeletal system is to:

protect and support the internal structures and organs of the body allow movement give shape to the body produce blood cells store calcium and phosphorus Produce heat.

The skeletal system The skeletal system is comprised of bones and joints and provides the basic supporting structure of the body. It consists of the joined framework of bones called the skeleton. The human skeleton is made up of 206 bones.

Bones Bone is a dry, dense tissue composed of a calcium-phosphorus mineral and organic matter and water. Bone is covered with a living membrane called the periosteum. The periosteum contains bone-forming cells, the osteoblasts. The centre of bone contains marrow where blood vessels, fat cells and tissue for manufacturing blood cells are all found.

There are four main shapes of bones:

flat e.g. ribs irregular e.g. vertebrae short e.g. hand (carpals) long e.g. upper arm (humerus)

 Joints A joint is an area where two or more bones are in contact with each other. Joints allow movement. The bones forming the joint are held together by ligaments. There are 3 types of joints: 1. fibrous or immovable e.g. skull 2. cartilaginous or slightly moveable e.g. vertebrae 3. synovial or freely movable: a. ball and socket e.g. hip b. hinge e.g. elbow. c. gliding e.g. carpals at wrist d. pivot e.g. radius and ulna Movement There are certain terms that are used to describe the movement of bones:

abduction - movement away from the body adduction - movement towards the body flexion - bending a limb towards the body extension - extending a limb away from the body rotation - movement around a central point

The muscular system The muscular system allows us to move and you will need to learn about the muscles of the body in order to understand how this system contributes to the overall design of the human body. The human body is composed of over 500 muscles working together to facilitate movement. It is very important to understand the muscular system and how it works in conjunction with the skeletal system to allow us to move and maintain our posture. The major function of the muscular system is to produce movements of the body, to maintain the position of the body against the force of gravity and to produce movements of structures inside the body.

Structure Tendons attach muscle to bone. There are 3 types of muscles: 1. skeletal (voluntary) muscles are attached to bone by tendons 2. smooth (involuntary) muscles control the actions of our gut and blood vessels 3. cardiac muscle in the heart

 LABORATORY/DIAGNOSTIC TESTS
blood tests ESR(Elevated in SLE and arthritis) Rheumatoid factors (+ in rheumatoid arthritis) Lupus erythematosus cells (LE cells) Antinuclear antibodies (ANA) (+ in rheumatoid arthritis) Anti DNA (+ in SLE) C reactive protein ( + in rheumatoid arthritis) Uric Acid (elevated in gout) Minerals o Calcium -decreased levels in osteomalacia, osteoporosis. -increased levels in bone tumors, healing fractures, Pagets disease. o Alakaline Phosphate -elevated levels in bone cancer, ostoeporosis, osteomalacia, Pagets disease. o Phosphorus -increased levels in healing fractures, bone tumors. Muscle enzymes o Aldolase -elevated in muscle dystrophy, dermatomyositis. o AST o CK (Creatinine Phosphokinase) -elevated in traumatic injuries o LDH (Lactic Dehydrogenase) -elevated in skeletal muscle necrosis, extensive cancer.

X-rays (Roentgenography) Done primarily to detect bone fractures Bone scan Measures radioactivity in bone 2 hours after IV injection of a radio isotope; detects bone tumors, osteomyelitis. Nursing care o Patient must void immediately before procedure o Patient must remain still during scan.

 Arthroscopy Insertion of fiberoptic scope into a joint to visualize it, perform biopsies or remove loose bodies. Performed in OR under sterile technique Nursing care o Pressure dressing for 24 hours o Patient must limit activity for several days Arthrocentesis: removal of synovial fluid, blood or pus from a joint. Myelography Lumbar puncture is done to withdraw a small amount of CSF, which is replaced with a radiopaque dye; used to detect tumors or herniated intravertebral discs. Nursing care pretest -consent form must be signed. -check for iodine allergy -keep on NPO after liquid breakfast. o Nursing care post test -if dye has been completely removed (oil dye), keep patient flat for 12 hours. -if dye has not been completely removed (water based dye- Amipaque), keep head of bed elevated (30-40 degrees) to prevent causing meningeal irritation and seizures. -if water based dye is used, put patient on seizure precautions and do not administer any phenothiazine drugs. Electromyography (EMG) Measures and records activity of contracting muscles in response to electrical stimulation; differentiate muscle disease from motor neuron dysfunction. Explain procedure to patient and prepare him for discomfort of needle insertion.

COMMON MUSCULO-SKELETAL INTERVENTIONS

RANGE OF MOTION EXERCISES (ROM) Types o Active done by the patient. Increases and maintain muscle tone and joint mobility.

o Passive done by the nurse without help from the patient, maintains joint mobility only. o Active assistive patient moves body part as far as possible and nurse completes exercise or stronger arm and leg perform exercise to weaker arm and leg. o Active resistive contraction of muscle against an opposing force; increases muscle power . Isotonic exercises Involve change in both muscle length and tension. Isometric exercises Active exercise through contraction / relaxation of muscle no joint movement length of muscle does not change. Patient increases tension in muscle for several seconds and then relaxes. Maintains muscle strength and sizes.

ASSISTIVE DEVICES FOR WALKING Cane o Types single, tripod cane, quadripod cane. o Patient must hold cane in hand opposite affected extremity. Advance cane as the affecred leg is moved forward. Walker o Hip level o Lift and walk o Positioned at the back when going up the stairs o Positioned in front when going down the stairs Crutches o Assure proper length -with patient standing: top of the crutches is 2 inches below the axilla and the tip of each crutch is 6 inches in front and to the side of the feet. (2 inches forward, then 4 inches to the side). -patients elbows should be slightly flexed when hand is on bar ( 30 degrees). -weight must not be borne by axillae, but on palms of the hand to prevent crutch palsy. o Crutch gaits -four point gait. Advance right crutch followed by the left foot, then left crutch followed by the right foot. -two point gait. Advance right crutch and left foot together, then the left crutch and the right foot together.

-three point gait. Advance both crutches and affected leg together, followed by the unaffected leg. None or little weight- bearing is allowed. -swing to gait. Advance both crutches, swing the body so that the feet will be at the level of crutches. -swing through gait. Advance both crutches, swing the body so that the feet will be past the level of the crutches. o Going up and down the stairs -up with the good (good leg first, then bad leg and crutches). -down with the bad (bad leg and crutches first, then good leg).

CARE OF THE CLIENT WITH CAST Carry with palms of the hand. Elevate with pillow support. Expose to dry Keep clean and dry Observe hot spots and musty odor. Maintain skin integrity petalling Do neurovascular checks: o Skin color o Skin temperature o Sensation o Mobility o Pulse Windowing to facilitate observation of the cast. Bivalving if cast is too tight/ healing process has occurred. It is splitting of the cast.

CARE OF CLIENT WITH TRACTION Traction o The act of pulling associated with counterpull. Purposes o Reduce/immobilize fractures o Relieve muscle spasm o Relieve pain o Prevent/correct deformities

 Types o Skin traction Bucks traction Exerts straight pull on affected extremity, temporary to immobilize the leg in patient with a fractured hip. Shock blocks at the foot of the bed produce counter traction and prevent the patient from sliding down in bed. Has a horizontal weight Turn towards unaffected side, with 2 pillows in between legs. Check for pressure sore at the heel of the feet and signs and symptoms of thrombophlebitis. Russell traction Knee is suspended in a sling attached to a rope and pulley on a Balkan frame, creating upward pull from the knee. Weights are attached to the foot of the bed creating horizontal traction Used to treat fracture of the femur Allows patient to move about in bed more freely and permits bending of the knee joint. Hip should be flexed at 20 degrees; foot of bed usually elevated by shock blocks to provide countertraction. Assess back of the knee for pressure sores. Check for signs and symptoms of thrombophlebitis. Bryant traction Both legs raised at 90 degrees angle to bed because the weight of the child is not adequate to provide countertraction. Used for children under 2 years and 30 pounds to treat fractures of the femur and hip dislocation. Buttocks must be slightly off the mattress. To enhanced efficacy of the weight as countertraction. Knees slightly flexed. To prevent hyperextension deformity. Cervical traction Cervical head halter attached to weights that hang over head of bed.

Used for soft tissue damage or degenerative disc disease of cervical spine to reduce muscle spasm and maintain alignment. Usually intermittent traction, elevate head of bed to provide countertraction. Pelvic traction Pelvic girdle with extension straps attached to ropes and weights used for low back to reduce muscle spasm and maintain alignment. Usually intermittent, patient in semi-fowlers position with knee gatched 20-30 degrees angle, secure pelvic girdle around iliac crests. Encourage to use overhead trapeze. Skeletal traction traction applied directly to the bones using pins, wires, or tongs (crutchfield) that are surgically inserted, used for fractured femur, tibia, humerus, cervical spine. Balanced suspension traction Produced by a counterforce other than the patients weight Extremity floats or balances in the traction apparatus. Patient may change position without disturbing the line of traction. Thomas splint with Pearson attachment Used with skeletal traction in fractures of the femur; hip should be flexed at 20 degrees. Use footplate to prevent footdrop Check pressure at the inguinal area (groin).

PRINCIPLES IN THE CARE OF THE CLIENT WITH TRACTION The line of pull should be in line with the deformity. There should be an adequate countertraction. Apply traction continuously. Allow the weights to hang freely. Turn the client as indicated. Avoid friction. Pin site care for skeletal traction: -cleanse and apply antibiotic ointment.

-do neurovascular check -prevent complications of immobility.

DISORDERS OF THE MUSCULOSKEKETAL SYSTEM

TRAUMA Strain damage to tendon due to twisting motion. Sprain damage to ligament due to twisting motion. Subluxation partial disarticulation (amputation or separation at a joint) Dislocation complete disarticulation (amputation or separation at a joint) Fracture any impairment in the bone integrity. Types of fracture: Complete fracture: A fracture marked by complete fragmentation of the bone. Incomplete fracture: In this, the two pieces of the bone, resulting from the fracture partially avulsed from each other; the portions are radially joined to some extent. This happens when the pattern of laceration does not segment the bone completely. Oblique fracture: A type of fracture where the fissure runs diagonal to the axis of the bone. Transverse fracture: A fracture caused is right angled to the axis of the bone. Spiral fracture: A section of the bone has endured luxation.

 Simple fracture: Also known as a closed fracture, it is a fracture where the bone suffers breakage; however, it does not puncture, or pierce through the epidermis. Compound fracture: Also known as an open fracture, this form of bone trauma is characterized by luxation of the bone, with it being exposed to contamination. This is dangerous as the plausibility of contracting an infection is dense. Impacted fracture: It is a closed fracture which occurs when pressure is applied to the two extremities of the bone, causing it to split into two fragments that jam into each other. This type of fracture is a common resultant of motor collisions and falls.

 Stress fracture: It is a common overuse injury. It is most often seen in athletes who run and jump on hard surfaces, such as runners; ballet dancers; and basketball players. Traumatic Fracture: Normally, people suffer from a traumatic fracture as a result of them having performed an activity that subjected the bone to enduring excessive pressure, stress, or a deep impact -- for instance, a fall, or a vehicular accident. A person, governed by good health and body constitution, too, may suffer from such a fracture. Pathological Fracture: Certain medical conditions, such as osteopenia, osteoporosis, bone marrow cancer, bone cyst, or inherited bone disorders debilitate the bones to such an extent that a superficial impact, too, may cause the bones to fracture. These fractures are different from normal fractures, in that the impact involved in causing the fracture is rather superficial. A break in the bone, endured when the bone is either declared morbid, or abnormal is termed pathological fractures. Assessment Pain, aggravated by motion, tenderness Loss of motion Edema Crepitus Ecchymosis

 Shortening of the limb Obvious deformity X-ray reveals fracture Collaborative management Traction Reduction o Closed reduction through manual manipulation followed by application of cast (with external fixation) (CREF). o Open reduction through surgery (with internal fixation) (ORIF). Cast Monitor for disorientation and confusion in the elderly. This may result from stress of fracture, unfamiliar surroundings, coexisting systemic disease, cerebral ischemia, etc. Neurovascular checks Prevent complications of immobility Encourage use of trapeze to facilitate movement Analgesics Care of clients with open reduction Check dressings Empty hemovac Assess LOC Turn q 2 hours Turn to unoperative side only Place 2 pillows between legs while turning and lying on side Measures to prevent thrombus formation o Elastic hose o Dorsiflexion of foot o Anticoagulants such as aspirin o Encourage quadriceps setting and gluteal setting exercises Observe for adequate bowel and bladder function Assist patient in getting in and out of bed on first and second post op day. Avoid weight bearing until allowed. Provide care for the patient with a hip prosthesis if necessary (similar to care of patient with total hip replacement). Complications of fracture Hypovolemic shock Fat embolism Compartment syndrome A compartment contains blood vessels, nerves, muscle which are enclosed by fascia. Collaborative management of compartment syndrome o Extremity elevated above the level of the heart

o Notify physician o Remove tight dressing or cast o Surgery: fasciotomy with delayed primary closure of wound. 3 -5 days after to allow edema of compartment to subside. Peroneal nerve palsy Avascular necrosis Delayed union or nonunion or malunion Total hip replacement Replacement of both acetabulum and head of femur with prostheses. Indications Rheumatoid arthritis or osteoarthritis causing severe disability and intolerable pain. Fractured hip with nonunion. Nursing interventions Provide routine post op care In addition to routine post op care Maintain abduction of affected limb at all times with abductor splint or 2 pillows between legs Prevent external rotation by placing trochanter rolls along hip Prevent hip flexion Head of bed flat if ordered. Raise head of bed 20 30 degrees for meals if ordered; use abductor splint or two pillows between knees while turning and lying on side. Get patient out of bed 2 4 days post op. Avoid weight bearing until ordered. Avoid adduction and hip flexion do not use low chair. Teach client o Prevention of adduction of affected limb and hip flexion o Do not cross legs o Use raised toilet seat o Do not bend down to put on shoes or socks o Do not sit in low chairs o Assess signs of wound infection o Exercise program as ordered o Partial weight bearing only until full weight bearing allowed; use three point crutch walking gait. RHEUMATOID ARTHRITIS Chronic systemic disease characterized by inflammatory changes in joints and related structures. Occurs in women more than men (3.1); peak incidence between 20 and 40 years of age. Cause unknown May be autoimmune process or may be genetic

 Predisposing factors include fatigue, cold, emotional stress, infection peripheral joints of hands; also commonly involves wrists, elbow, shoulder, knees, hips, ankles and jaw. If unarrested, affected joints progress through four stages of deterioration: synovitis, pannus formation, fibrous ankylosis and bony ankylosis. Assessment Fatigue, anorexia, malaise, weight loss, slight temperature elevation. Painful, warm, swollen joints with limited motion, stiff in morning and after periods of inactivity. Crippling deformity in long standing disease. Muscle weakness secondary to inactivity. History of remissions and exacerbations. Some patients have other manifestations: subcutaneous nodules, eye, vascular, lung, or cardiac problems. Sjogerns syndrome o Excessive dryness of the eyes, mouth and vagina. Feltys syndrome o Leukopenia o Splenomegaly Severe anemia Collaborative management Bed rest during acute pain Passive ROM exercises of joints Splint painful joints Heat and cold application o Cold application during acute pain; 20 minutes at a time. Warm bath in the morning. To relieve morning stiffness. Protect from infection. Well balanced diet Physical therapy Surgery o Osteotomy Surgical removal of a wedge from the joint. o Synovectomy Removal of synovia. o Arthrolasty Replacement of joints with prostheses. o Pharmacotherapy -aspirin mainstay of treatment, has both analgesic and anti inflammatory effects. -nonsteroidal anti inflammatory drugs (NSAIDs): Indomethacin (Indocin) Phenylbutazone (Butazolidin) Ibuprofen (Motrin)

Fenoprofen (Nalfon) Naproxen (Naprosyn) Sulindac (Clinorel)

-gold compounds (chrysotherapy) Injectable form: sodium thiomalate (Myochrysine). Aurothioglucose (Solganal); given IM once a week; takes 3 6 months to become effective. Oral form: auranofin (Ridaura); smaller doses are effective; diarrhea is a common side effect. -corticosteroids (intra articular injections) OSTEOARTHRITIS (HYPERTROPHIC ARTHRITS) Chronic nonsystemic disorder of joints characterized by degeneration of articular cartilage. Women and men affected equally, incidence increases with age. Also related to obesity and joint trauma. Weight bearing joints spine, knees, hips, and ends of fingers are most commonly affected. Assessment Pain aggravated by use and relieved by rest. Stiffness of joints Heberdens nodes bony overgrowth at terminal interphalangeal joints. Decreases ROM, crepitation. Collaborative management Assess joints for pain and ROM Relieve strain and prevent further trauma to joints. o Cane or walker when indicated. o Posture and body mechanics, avoid excessive weight bearing and continuous standing. o Physical therapy to maintain joint mobility and muscle strength. o Promote comfort/relief of pain (analgesics and NSAIDs). o Joint replacement as needed. GOUT Disorder of purine metabolism. Precipitation of urate crystals in the joints (tophi). Causes inflammation and pain. Occurs most often in males; familial Manifestations Joint pain, redness, heat, swelling, great toe and ankle most commonly affected. Headache, malaise, anorexia. Tachycardia, fever, tophi in outer ear, hands and feet.

 Uric acid elevated (blood/urine). Collaborative management Drug therapy o Acute attack colchicines (discontinue if diarrhea or N & V occur); NSAIDs Indocin, Butazolidin o Prevention uricosuric agents -Probenecid (Benemid), sulfinpyrazone (anturane); increase Renal excretion of uric acid. -Allopurinol (Zyloprim) inhibits uric acid formation. -encourage fluids to 2,000 to 3,000cc/ day when giving antigout drugs to Prevent formation of kidney stones. Low purine diet o Foods to avoid Organ meats Shellfish Legumes Sardines Salted anchovies Mushrooms Herring Sweetbreads Consomm Beer / wine SYSTEMIC LUPUS ERYTHEMATOSUS Chronic multisystem, collagen disorder Causes Unknown Autoimmune Drugs Viral Genetic Increase in females / 15 to 40 of age Precipitated by: Pronestyl Phenergan Apresoline Dilantin INH Quinidine Diagnostic tests Cbc Pancytopenia

 Increase ESR ANA Anti DNA (most specific) LE factor Assessment Weakness Anorexia Malaise Fatigue Joint pains Fever Oral / nasopharyngeal ulcerations Alopecia Photosensitivity Butterfly rash over the nose and cheeks Peri neuropathy Seizures Psychoses Renal / CNS / cardiopulmonary involvement With remissions / exacerbations 10 years survival (50 %) Collaborative management Rest relieve muscle and joint pains ROM exercise Prevent infection Avoid exposure to sunlight o Sunblock o Long sleeved clothings o Hats o Sunglasses Increase calcium, increase CHON diet Pharmacotherapy o ASA o Steroids o NSAID o Anti malarial o Cytotoxic agents (Cyclophosphamide / Methotrexate) OSTEOMYELITIS Acute or chronic infection of the bone and surrounding soft tissues, most commonly caused by Staphylococcus Aureus Infection may reach bone through open wound (compound fracture, surgery); through the bloode stream or by direct extension from infected adjacent structures.

 Assessment Malaise, fever Pain and tenderness of bone, redness and swelling of bone, redness and swelling over bone. Difficulty with weight bearing. Drainage from wound site may be present; necrosis of bone tissues (sequestrum). Diagnostic tests o CBC WBC may be elevated o ESR may be elevated Collaborative management Analgesics Antibiotics Dressing change sterile technique Maintain proper body alignment and change position frequently to prevent deformities Immobilization of affected part Psychologic support Surgery if needed o Incision and drainage of bone abscess. o Sequestrectomy removal of dead, infected bone and cartilage. o Bone grafting after repeated infections. HERNAITED NUCLEUS PULPOSUS (HNP) Protrusion of nucleus pulposus (central part intervertebral disc) into spine causing compression of spinal nerve roots. Occurs most often in men. 4th and 5th intervertebral spaces in the lumbar region most commonly affected. Predisposing factors: Heavy lifting or pulling and trauma Degeneration Congenital predisposition

Rupture of intervertebral disc

Protrusion of nucleus pulposus

Compression of spinal nerves

 Assessment Lumbosacral disc o back pain radiating across buttock and down leg (along sciatic nerve). o Weakness of leg and foot on affected side. o Numbness and tingling in toes and foot. o Positive straight leg raise test; pain on raising leg (Lasegues sign). o Depressed or absent Achilles reflex. o Muscle spasm in lumbar region. Cervical disc o Shoulder pain radiating down arm to hand weakness of affected upper extremity, paresthesia and sensory disturbances. Diagnostic tests o Myelogram o MRI Collaborative management Conservative o Bed rest on a firm mattress with bed boards. o Traction o Drug therapy Anti inflammatory agents Muscle relaxants (e.g. Robaxin) Analgesics o Local application of heat and diathermy. o Corset for lumbosacral disc; cervical collar for cervical disc. o Epidural injections of corticosteroids. o Prevents complications of immobility. Surgery o Chemonucleolysis Chymopapain (Papaya derivative) into disc to reduce size pressure on affected nerve root. Used as alternative to laminectomy in selected cases. Pre op care for patient receiving chomonucleolysis -Cimetidine (Tagamet) -Diphenhydramine HCl (Benadryl) q 6 hours to prevent allergic reaction -corticosteroids before procedure

Post op care for patient receiving chemonucleolysis. -observe for anaphylaxis -Observe for less serious allergic reaction -monitor for neurologic deficits (numbness or tingling in extremities or inability to void).

Laminectomy Surgical excision of part of posterior arch of vertebrae and remoal of protruded disc. Nursing interventions preoperative Routine pre op Teach patient log rolling and use of bedpan Nursing interventions postoperative Routine post op care Positioned as ordered o Lower spinal surgery: flat o Cervical spinal surgery: slight elevation of head of bed o Proper body alignment cervical spinal surgery: avoid flexion of neck and apply cervical collar. o Turn patient q 2 hours Use log rolling Pillows between legs while on side o Assess for complications Monitor sensory and motor status 2 4 hours With cervical spinal surgery: assess swallowing, coughing, check for respiratory distress; suction and tracheostomy set at bedside Check dressing for hemorrhage, CSF leakage, infection. Promote comfort o Analgesics as ordered. o Additional comfort measures and positioning. o Assess for adequate bowel and bladder function; q 2- 4 hours for bladder distention. o Prevent constipation Prevent complications of immobility Assist with ambulation o OOB (out of bed) day after surgery. o Brace or corset if ordered o If patient is allowed to sit, use straight back chair and keep feet flat on floor.

 Patent teaching and discharge planning Avoid: o Acute hip flexion (bending, stooping, crossing the legs, sitting on low chair). o Prolonged sitting / standing o Running jogging, horseback riding o Heavy lifting of more than 2 lbs. Back strengthening exercises o Prone position o Walk in seawater Lie in side lying with hip flexion Wound care Good posture and proper body mechanics (bend knees, not the back) Activity level as ordered Recognition and reporting of complications such as wound infection, sensory or motor deficits.

CARPAL TUNNEL SYNDROME (TNS) It occurs when the median nerve at the wrist is compressed by thickened flexor sheat, skeletal encroachment, edema of tissue mass. It is commonly due to repetitive hand activities. Assessment Pain Numbness, paresthesia Thumb, first and second fingers affected (+) Tinels sign (tingling sensation on percussion of inner wrist). Collaborative management Wrist splints Avoid repetitive flexion of the wrist. NSAIDs Carpal canal cortisone injections Surgical release of transverse carpal ligament.

 DUPUYTRENS CONTRACTURE A flexion deformity of the fourth and fifth fingers, sometimes the middle finger this is progressive contracture of the palmar fascia. It is caused by an inherited autosomal dominant trait. Spinal fusion Fusion of spinous processes with bone graft from iliac crest to provide stabilization of spine. Nursing interventions Pre op care (same as laminectomy). Post op care o Position: lower spinal fusion keep bed flat for first 12 hours, then may elevate HOB 20 30 degrees, keep off back for first 48 hours. o Cervical spine fusion elevated HOB slightly, assist with ambulation o Usually OOB 3 4 post op days, apply brace before OOB, apply special cervical collar for cervical collar for cervical fusion. o Promote comfort may have considerable pain from graft side. Advise patient that brace will be needed for 4 months and lighter corset for 1 year after surgery. o It takes 1 year for graft to become stable. o No bending, stooping, lifting, or sitting or prolonged periods for 4 months. o Walking w/o excessive tiring is good; diet modification will help prevent weight gain from activity. Amputation of a limb Surgical procedure done for peripheral vascular diseases if medical management is ineffective. It may also be done in trauma. Types -Guillotine -Closed/Flap Nursing interventions preoperative Establish open and honest communication. Offer support and encouragement and accept patients response of anger / grief. Discuss: o Rehabilitation program and use of prosthesis. o Upper extremity exercise such as push ups in bed. o Crutch walking o Amputation dressing / cast o Phantom limb sensation as a normal occurrence.

 Observe stump dressing for signs of hemorrhage and mark outside of dressing so rate of bleeding can be assessed (tourniquet at bedside). Prevent edema Raise extremity with pillow support for first 24 hours. Prevent hip / knee contractures Avoid letting patient sit in chair with hips flexed for long periods of time. Have patient assumes prone position several times a day and position hip in extension. Avoid elevation of stump after 24 hours; keep stumps adducted with the unaffected leg. Pain medication as ordered (Phantom limb pain) Ensure that stump bandages fit tightly and are applied properly to enhance prosthesis fitting. Initiate active ROM of all joints, crutch walking and arm / shoulder exercises. Provide stump care Inspect daily for signs of skin irritation Wash thoroughly daily with warm water and bacteriostatic soap; rinse and dry thoroughly, avoid use of irritating substances such as lotions, alcohol, powders. Wear woolen stump socks, avoid nylon socks. Put on prosthesis upon arising and keep it on all day (to reduce stump swelling) Continue prescribed exercises (to prevent weakness); push stump against hard surface, e.g. foot stool with to toughen it for better prosthesis fitting. DONTS ON THE STUMP Hang stump over the bed. Sit in wheelchair with stump flexed. Place pillow under hip or knee. Place pillow between thighs. Rest AK stump on crutch handle. Abduct AK stump.

PAGETS DISEASE (Osteitis Deformans) Increased rate of bone tissue breakdown by osteoclasts followed by excessive abnormal bone formation by the osteoblasts. The diseased bone is weak and prone to fracture. Usually affects femur, tibia, lower spine, pelvis, and cranium. Cause Unknown More common in male, -40years of age. Manifestations Bone pain Bone deformity Pathologic fractures Nerve compression Diagnostic tests Elevated serum Ca Anemia Increased alkaline phosphatase Increased hydroxyproline (24 hours urine specimen) Collaborative management Analgesic / anti inflammatory agents (ASA / NSAIDs) Calcitonin / Etidronate to retard bone absorption Cytotoxic Antibiotic (Mithracin) to decrease s. Ca, hydroxyproline, s. alkaline phosphatase.