การพยาบาลผู้ป่วย Orthopedic

4/3/2020

Nursing care of 2
Orthopedic patients
1
Asst. Prof. Dr. Saranya Chularee

Institute of nursing,
Suranaree University of Technology

1

Outlines

» Review of musculoskeletal system
» Nursing care of patients with inflammation and

infection of bone & joint : Rheumatoid arthritis, Gouty

arthritis, Septic arthritis, Osteomyelitis

» Nursing care of patients with degenerative of bone :

Osteoporosis, Osteoarthritis (Hip & knee) , Herniated nucleus
pulposus

» Nursing care of patient with fracture: Fracture, Cast,

Traction, Internal & external fixation, Amputation

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4/3/2020

Learning outcomes 3
4
» Describe the pathology of inflammation and infection of bone &
joint (Gouty arthritis, Rheumatoid arthritis, Septic arthritis,
Osteomyelitis).

» Describe the pathology of degenerative of bone (Osteoporosis,
Osteoarthritis, herniated nucleus pulposus).

» Determine nursing diagnosis for patient with orthopedic problems
(inflammation & infection of bone & joint, degenerative of bone,
fracture).

» Have skills to seek and select credible evidence-based practice for
planning.

» Discuss of issues and apply the nursing process, research and local
wisdom for nursing care of orthopedic patient

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Review of Musculoskeletal
system

Asst. Prof. Dr. Saranya Chularee

Institute of nursing,
Suranaree University of Technology

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Anatomy of musculoskeletal system

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Nursing care of
Orthopedic patients
: Inflammation & Infection

• Rheumatoid arthritis
Gouty arthritis
• Septic arthritis
Osteomyelitis
•

Asst. Prof. Dr. Saranya Chularee •

Institute of nursing,

Suranaree University of Technology

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Rheumatoid arthritis

» Rheumatoid arthritis is a chronic inflammatory disorder that can
affect more than just your joints.

» An autoimmune disorder, rheumatoid arthritis occurs when your
immune system mistakenly attacks your own body's tissues.

» Signs and symptoms of rheumatoid arthritis may include:

⋄ Tender, warm, swollen joints
⋄ Joint stiffness that is usually worse in the mornings

(morning stiffness both sides> 30 m) and after inactivity
⋄ Fatigue, fever and loss of appetite

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5

» Early rheumatoid arthritis tends to 4/3/2020
affect your smaller joints first —
particularly the joints that attach 11
your fingers to your hands and your
toes to your feet. 12

» As the disease progresses, symptoms 6
often spread to the PIP joint, wrists,
knees, ankles, elbows, hips and
shoulders.

» In most cases, symptoms occur in the
same joints on both sides of the
body.

Note: PIP= proximal interphalangeal joint

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» Rheumatoid arthritis can affect
many non-joint structures,
including: Skin, Eyes, Lungs,
Heart, Kidneys etc.

» Over time, rheumatoid
arthritis can cause joints to
deform and shift out of place.

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Rheumatoid arthritis & Osteoarthritis

» Osteoarthritis, the most common form
of arthritis, involves the wearing away of
the cartilage that caps the bones in your
joints.

» Rheumatoid arthritis, the synovial
membrane that protects and lubricates
joints becomes inflamed, causing pain and
swelling.

» Joint erosion may follow.

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Rheumatoid arthritis (RA) Osteoarthritis (OA) 14

Patho Inflammation of Synovial membrane, Degeneration of cartilage from
destruction of bone, tendon, ligament, wear & tear, bone spur formation

Cartilage

Effect of Symmetrical joint in proximal Often only one side of body
joint interpharyngeal joint (PIP), wrist, affected in hands, spine, knees
knee & hips

Sign & - Edema, erythema, heat, pain, - Localized pain, Stiffness of
joint , Heberden’s node
Symptom tenderness
- Morning stiffness , Rheumatoid - No systemic sign

nodule, fatigue, muscle aches & - Other organ involvement is
fever absent**(differentiation
between OA&RA)
- Systemic manifestations occurs

- Vasculitis may be responsible for a
variety of systemic complications

- Potential complication: infection,
osteoporosis

Cooper, K &Gosnell, K. (2015). Adult health Nursing.7th eds. St.Louis, Missouri, Elsevier Mosby.

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Rheumatoid arthritis Osteoarthritis (OA)

(RA)

Age Children nearing Ages 45-90 yr.

adolescence, adult 20-50 yr.

Sex Female > male 3:1 Male & female equally

Investiga - Rheumatoid factor (RF) - X-ray

te positive (85% of patient with RA) -No specific lab

- ESR  abnormalities
- C-reaction protein

- CBC: Anemia

- Joint fluid RF positive (80%

of patient with RA)

Cooper, K &Gosnell, K. (2015). Adult health Nursing.7th eds. St.Louis, Missouri, Elsevier Mosby. 16

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Investigation

» Hx: risk factors

⋄ Sex : Women > men to develop rheumatoid arthritis.
⋄ Age : can occur at any age, but it most commonly begins in middle age.
⋄ Family history : heredity.
⋄ Smoking : Cigarette smoking increases risk of developing rheumatoid

arthritis.
⋄ Environmental exposures : Some exposures such as asbestos or silica

may increase the risk of developing rheumatoid arthritis.
⋄ Obesity : People — especially women age 55 and younger — who are

overweight or obese appear to be at a somewhat higher risk of
developing rheumatoid arthritis.

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Investigation

» PE:
⋄ Joint pain, redness & swelling (Both sides)
⋄ Joint stiffness (examining by rang of motion)
⋄ Loss of joint function (examining by reflex &
muscle strength)
⋄ Deformities
⋄ Maybe have rheumatoid nodule

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Investigation 9

» Laboratory & special test
⋄ ESR  (F 0-20 mm/hr, M 0-15 mm/hr)
⋄ Rheumatoid factor (RF) +ve
⋄ Anti-citrullinated peptide antibodies (ACPA) +ve
⋄ Antinuclear antibody (ANA) titer & C-reactive
protein (CRP) 
⋄ CBC : Anemia →Chronic RA
⋄ Synovial fluid : WBC > 5,800-12,900
cell/Cumm3 (Lymphocyte)

สมาคมรูมาตซิ มั่ แหง่ ประเทศไทย. (2557). แนวเวชปฏิบตั เิ พ่ือการวินิจฉยั และการดแู ลรักษาโรคข้ออกั เสบรูมาตอยด์.

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Investigation 4/3/2020

» Laboratory & special 19
test
⋄ X-Ray : hand & feet 20
→ marginal bone
erosion

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Henrique da Mota, et al., (2011). 2011 consensus of the Brazilian Society of Rheumatology for diagnosis and early assessment of
rheumatoid arthritis. Revista Brasileira de Reumatologia. 51(3), https://doi.org/10.1590/S0482-50042011000300002

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CLASSIFICATION
CRITERIA OF RA

Henrique da Mota, et al., (2011). 2011 consensus of the Brazilian Society of Rheumatology for diagnosis and early assessment of
rheumatoid arthritis. Revista Brasileira de Reumatologia. 51(3), https://doi.org/10.1590/S0482-50042011000300002

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Treatment

» Rest by Splint / cast
» Physical therapy : low impact exercise (Yoga)
» Hot compression reduce stiffness, cold compression reduce

inflammation
» Medication:

⋄ NSAID / Tramadol / Tramadol + acetaminophen (S/E: peptic ulcer)
⋄ Prednisolone (S/E: Low immune, Osteoporosis )
⋄ Anti-inflammatory agent : Antimalarias (S/E- GI & retina), Gold salt (S/E-

hepatitis, renal failure, stomatitis), Antineoplastic drug (S/E- N/V,
stomatitis, headache)
⋄ Disease – Modifying anti – Rheumatic Drugs [DMARDs] : Methotrexate 5-
10 mg/wk, 4-12 wk, Sulfasalazine 1-2 g/d 4-12 wk,

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Treatment

Synovectomy
Arthrodesis / Arthroplasty

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Rheumatoid arthritis diet 12

» Omega-3 fatty acids : Anti-inflammation diet
⋄ Salmon, tuna, chia seeds, flax seeds, walnuts

» Antioxidants, such as vitamins A, C, E and selenium, may
also help reduce inflammation.
⋄ berries, such as blueberries, cranberries, goji berries,
and strawberries, dark chocolate, spinach, kidney
beans, pecans

» Fiber may help reduce inflammatory responses
⋄ soy products, berries, green tea, broccoli

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Nursing care plan

» Pain related to inflammatory phase.
» Low self esteem related to negative self-evaluation

about self or capacities.

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Nursing care of
Orthopedic patients
: Inflammation & Infection

o Rheumatoid arthritis
o Gouty arthritis
o Septic arthritis
o Osteomyelitis

Asst. Prof. Dr. Saranya Chularee

Institute of nursing,
Suranaree University of Technology

26

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Gouty arthritis

» Gout is a kind of arthritis caused by a
buildup of uric acid crystals in the joints.

» Uric acid is a breakdown product of purines
that are part of many foods we eat.

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Risk factors

» Diet: rich in meat & seafood and drinking beverages sweetened with fruit sugar
(fructose) increase levels of uric acid

» Obesity : produces more uric acid and have a more difficult time eliminating
uric acid.

» Medical conditions: untreated high blood pressure & chronic conditions such
as diabetes, metabolic syndrome, and heart and kidney diseases.

» Certain medications: The use of thiazide diuretics and low-dose aspirin also
can increase uric acid levels.

» Family history of gout

» Age and sex : more often in men. After menopause, however, women's uric
acid levels approach those of men.

» Recent surgery or trauma: Experiencing recent surgery or trauma has been
associated with an increased risk of developing a gout attack.

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Sign & Symptom

» Asymptomatic hyperuricemia

» Acute gouty attack :

⋄ abruptness of onset
⋄ morning acute monoarthritis: Ankle & big toe
⋄ Provoking factors: injury, stress, purine-rich food (such as red meats, organ

meats, and certain fish), alcohol drinking, certain medicine (such as diuretics
& cyclosporine)

» Inter-critical period ระยะสงบ

» Chronic tophaceous gout

⋄ Hard lumps called tophi : joints and the skin and soft tissue surrounding them
⋄ Chronic kidney disease

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Pathology 15

» Gout is caused by too much uric acid in the
bloodstream and accumulation of urate crystals in
tissues of the body.

» Uric acid crystal deposits in the joint cause
inflammation of the joint leading to pain, redness,
heat, and swelling.

» Uric acid is normally found in the body as a
byproduct of the way the body breaks down certain
proteins called purines.

» Causes of an elevated blood uric acid level
(hyperuricemia) include genetics, obesity, certain
medications such as diuretics.

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Pathology 31

» An abnormality in handling uric acid and crystallization
of these compounds in joints can cause attacks of
⋄ painful arthritis,
⋄ kidney stones,
⋄ blockage of the kidney filtering tubules with uric acid
crystals, leading to kidney failure.

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Investigate

» Hx: seeking for precipitate cause
» PE: pain, redness, heat, and swelling of joint, fever,

anorexia, fatigue
» Lab:

⋄ Uric acid  (M: > 7 mg%, F: > 6 mg%)
⋄ ESR  (M: 0 – 15 mm/hr, F: 0 – 20 mm/hr, C: 0 – 1 mm/hr)
⋄ WBC 
⋄ Synovial fluid : urate
⋄ X-ray : urate

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Treatment

» Drugs to relieve gout pain include:
⋄ Relife gout attacks : Colchicine (Colcrys, Mitigare)
⋄ Nonsteroidal anti-inflammatory drugs (NSAIDs), such as
aspirin (Bufferin), ibuprofen (Advil, Motrin), and naproxen
(Aleve)
⋄ Steroids: corticosteroids

» Drugs that prevent gout attacks include:
⋄ Drug to reduce uric acid production: xanthine oxidase
inhibitors like allopurinol (Lopurin, Zyloprim)
⋄ Drug to excreta uric acid: probenecid (Probalan),
benzbromarone

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Nursing care

» Pain related to disease process.
» Deficit knowledge, related to lack of information.

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4/3/2020

Nursing care of
Orthopedic patients
: Inflammation & Infection

o Rheumatoid arthritis
o Gouty arthritis
o Septic arthritis
o Osteomyelitis

Asst. Prof. Dr. Saranya Chularee

Institute of nursing,
Suranaree University of Technology

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Septic arthritis

» Septic arthritis is a painful infection in a joint.
» Caused by bacterial, viral or fungal infections.
» Bacterial infection with Staphylococcus aureus (staph)

is the most common cause. (Staph commonly lives on
even healthy skin).
» Septic arthritis can develop when an infection, such as
a skin infection or urinary tract infection, spreads
through your bloodstream to a joint

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Investigate

» Hx: Injury or infection, risk in children & elderly adults, People with

open wounds, pre-existing conditions such as cancer, diabetes, intravenous
drug abuse, and immune deficiency disorders

» PE:

⋄ Discomfort and difficulty using the affected joint (especially, lower
extremities→ can’t walk).

⋄ The joint could be swollen, red and warm.
⋄ Fever, anorexia

» Lab:

⋄ X-ray , Ultrasonography
⋄ Hemoculture
⋄ Erythrocyte sedimented rate (ESR)
⋄ Synovial fluid

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Treatment

» Joint drainage
⋄ Needle (In some cases)
⋄ Scope procedure : arthroscopy
⋄ Open surgery and drainage

» Antibiotic drugs
⋄ Select the most effective medication by
H/C (2-6 weeks)

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Nursing care

» Pain related infection involvement in knee joint

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Nursing care of
Orthopedic patients
: Inflammation & Infection

o Rheumatoid arthritis
o Gouty arthritis
o Septic arthritis
o Osteomyelitis

Asst. Prof. Dr. Saranya Chularee

Institute of nursing,
Suranaree University of Technology

40

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Osteomyelitis

» Osteomyelitis is an infection in a bone.

» Most cases of osteomyelitis are caused by staphylococcus
bacteria.

» Signs and symptoms of osteomyelitis include:
⋄ Fever
⋄ Swelling, warmth and redness over the area of the
infection
⋄ Pain in the area of the infection
⋄ Fatigue

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Risk factors

» A weakened immune system, due, for example, to
chemotherapy or radiation treatment, malnutrition,
dialysis.

» Circulatory problems, as a result of diabetes, peripheral
arterial disease.

» A deep puncture wound or a fracture that breaks the skin
» Surgery to replace or repair bones.

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Pathology

» Bone is normally resistant to infection.

» Bone infection may result from the treatment of trauma,
which allows pathogens to enter bone and proliferate in the
traumatized tissue.

» Some important factors in the pathogenesis of osteomyelitis
include the virulence of the infecting organism, underlying
disease, immune status of the host, and the type, location,
and vascularity of the bone.

» Common site: femur, vertebras

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Pathology

» Sequestrum : necrotic bone
that is embedded in the pus/
infected granulation tissue.

» Involucrum : new bone laid
down by the periosteum
(surrounds the sequestra).

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Investigate

» Hx : posttraumatic injury (expose to bone), Septicemia from

infectious disease, such as pneumonia, urinary tract infection

» PE :

⋄ Acute:

⋄ Pain that worsens with activity
⋄ Swelling, metaphyseal tenderness, warmth at the

infection site
⋄ Restricted movement of affected part→ Defect

⋄ Chronic:

⋄ Painless, Swelling
⋄ systemic sign (fever, fatigue, anorexia, lethargy or

irritability)

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Investigate 46

» Lab:

⋄ WBC 
⋄ Erythrocyte sedimented rate(ESR) (>40 mm/hr) & C-reactive

protein (CRP) 
⋄ Hemoculture Positive
⋄ Bone c/s Positive ESR 
⋄ X-ray : Sequestrum & Involucrum
⋄ Computed Tomography (CT): position of Sequestrum (if x-ray

unclear)

⋄ Bone scan :(seeking for primary source)
⋄ MRI : (better than bone scan)

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Treatment

» Antibiotic 4-6 wk (intravenous) and oral ATB follow
or combination

⋄ Straph.a. → Cloxacillin, Rifampicin
⋄ Strep. → Penicillin G

» Surgery
⋄ Draining
⋄ Debridement

» Immobilization

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Nursing care

» Pain related to infection in tibial area
(preoperative period) / incision pain / Soft tissue
trauma of surgery

» Possible increase infection related to opened
wound at …

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4/3/2020

Nursing care of Orthopedic patients
: Degeneration

o Osteoporosis
o Osteoarthritis
o Herniated nucleus pulposus

Asst. Prof. Dr. Saranya Chularee
Institute of nursing,

Suranaree University of Technology

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Osteoporosis

» A disease characterized by low bone mass and structural
deterioration of bone tissue, leading to bone fragility and
an increased risk of fractures of the hip, spine, and wrist.

» Osteoporosis is often called a silent disease because
bone loss occurs without symptoms

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Risk factors

» Risk factors you cannot change:

⋄ Sex : Women have less bone tissue and lose bone faster
than men because of the changes that happen with
menopause.

⋄ Age : The bones become thinner and weaker as you age.
⋄ Body size : Small, thin-boned women are at greater risk.
⋄ Ethnicity: White and Asian women are at highest risk >

African American.
⋄ Family history

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Risk factors 52

» Risk factors : can change:

⋄ Sex hormones : low estrogen ⋄ Medication use : such as
level (menopause), and low glucocorticoids and some
testosterone level in men can
bring on osteoporosis. anticonvulsants can lead
⋄ Anorexia nervosa : (fear of to loss of bone density and
weight gain) fractures.

⋄ Calcium and vitamin D ⋄ Lifestyle : inactive lifestyle

intake : more prone to bone ⋄ Cigarette smoking

loss. ⋄ Alcohol intake

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Pathology 53
54
Low intake of Ca Decrease Menopause →
decrease estrogen
calcitonin production

→ decrease osteoclast

1,25 dihydroxy vit.D  Bone → cytokines (interleukin
I; IL-1, interleukin 6; IL-6, tumor

necrosis factor; TNF-L)

Parathyroid excrete

PTH to blood

circulation osteoclast

(Imbalance of osteoblast &

osteoclast)

Decrease bone mass

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Investigate

» Hx: chronic pain, fracture, risk factors

» PE: Kyphosis

» Lab:
⋄ X-ray
⋄ bone mineral density (BMD)

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Bone mineral density (BMD) 4/3/2020
analysis
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Cosman F, de Beur S, LeBoff M, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 2014;25(10):2359– 2381. Erratum in:
Osteoporos Int 2015;26(7):2045–2047.

World Health Organization. WHO Scientific Group on the assessment of osteoporosis at primary health care level: summary meeting report. May 5–7,
2004. Available at: www.who.int/chp/topics/ Osteoporosis.pdf. Accessed December 27, 2017.

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Treatment

» Therapeutic medications: including:

⋄ Reduce osteoclast : bisphosphonates; calcitonin;
estrogen (hormone therapy);

⋄ Produce osteoblast : vit D 800 IU/day + CA
1,200 mg/day

» Orthopedic management: lumbar support or
brace

» Exercise: not only improves your bone
health, but it increases muscle strength,
coordination, and balance

» Nutrition: calcium and vitamin D are needed
for strong bones and for your heart, muscles,
and nerves to function properly

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Nursing care

» Pain related to disease process.

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4/3/2020

Nursing care of Orthopedic patients
: Degeneration

o Osteoporosis
o Osteoarthritis
o Herniated nucleus pulposus

Asst. Prof. Dr. Saranya Chularee
Institute of nursing,

Suranaree University of Technology

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Osteoarthritis

» Osteoarthritis : OA
» Degenerative joint disease : DJD
» Osteoarthrosis
» Hypertrophic arthritis

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Osteoarthritis : OA

» OA is the most common chronic joint condition.
» OA occurs most often in older people, although

it can occur in adults of any age.
» The most commonly affected areas of the body

include the: hands, fingertips, knees, hips,
spine

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Signs & Symptoms 31

» Pain
» Tenderness (discomfort when pressing on

the area with your fingers)
» Stiffness (Decreased range of motion)
» Inflammation (swelling, red, pain, warmth)
» Joint instability
» Other symptoms: muscle weakness, bone

spurs, and joint deformity

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Investigate

» HX: Pain, Tenderness, Stiffness, inflammation, Joint

instability

» PE:

⋄ Creaking or grating of the joint – known as crepitus
⋄ Bony swelling
⋄ Excess fluid
⋄ Restricted movement
⋄ Joint instability
⋄ Weakness or thinning of the muscles that support the joint.

» Lab: usually normal

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Treatment

» Relief pain:

⋄ Warmth (reduce pain) & cold compress (reduce swelling &
discomfort) 20 mq 2hr.

⋄ Splint or brace to support painful joint.
⋄ Walking aids.

» Physical therapies: strengthens the muscles around your joints and

may help relieve stiffness.

» If obesity: to get weight loss.

» Alternative treatment: Fish oil, green tea, ginger, glucosamine,

massage therapy, Diet for reducing inflammation- Vit C, D, beta-
carotene, Omega3

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Osteoarthritis of the Knee 65

» The etiology of knee OA is
multifactorial and includes

⋄ generalized constitutional factors e.g.,
aging, sex, obesity, heredity, and
reproductive variables.

⋄ local adverse mechanical factors (e.g., joint
trauma, occupational and recreational
abuse, alignment, and postmeniscectomy)

⋄ geographic factors

Ronn, K., Reischl, N., Gautier, E., Jacobi, M. (2011). Current surgical treatment of knee osteoarthritis. 26, doi : 10.1155/2011/454873

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Surgery for Osteoarthritis of

» Surgical treatment the Knee

options:

⋄ Arthroscopic debridement
⋄ Cartilage repair surgery
⋄ Osteotomy with axis-

correction
⋄ Unicompartmental or total

knee arthroplasty (TKA)*

Ronn, K., Reischl, N., Gautier, E., Jacobi, M. (2011). Current surgical treatment of knee osteoarthritis. 26, doi : 10.1155/2011/454873

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Knee arthroplasty

» Joint arthroplasty is a well-accepted, safe, and cost-
effective method for treatment of advanced knee OA

Unicompartmental arthroplasty Total knee arthroplasty

Ronn, K., Reischl, N., Gautier, E., Jacobi, M. (2011). Current surgical treatment of knee osteoarthritis. 26, doi : 10.1155/2011/454873 68

67 34

Nursing care

» Patient education
» Pain assessment & Pain management

⋄ Cold compression- reduce inflammation
⋄ Hot compression- increase blood circulation

» Risk assessment & management

⋄ Nutrition- Obesity
⋄ Posture & position

» Exercise: Yoga, Tai Chi, local dance
» Knee support
» Assistive device: walkers, cane

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Nursing care

» Postoperative complication : Fat emboli,
Thrombophlebitis, joint dislocation

⋄ Observe sign of fat embolism: fever, tachypnea,
tachycardia, dyspnea

⋄ Observe sign of thrombophlebitis: pain, phlebitis
⋄ Observe sign of joint dislocation: increasing

knee pain
⋄ Elevate affected patient’s leg in 48 hr. and then

lie on your leg.
⋄ Exercise affected patient’s leg: ankle pumping,

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Nursing care of Orthopedic patients
: Degeneration

Asst. Prof. Dr. Saranya Chularee o Osteoporosis
Institute of nursing, o Osteoarthritis

Suranaree University of Technology o Exercise for Knee OA
o Herniated nucleus pulposus

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Range of motion exercise

Exercise 1 repeat 5-10 time per side, 2-4 cycle

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Exercise 2 repeat 5-10 time per side, 2-4 cycle

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Exercise 3 repeat 5-10 time per side, 2-4 cycle

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Strengthening and endurance exercise

Exercise 4 - 5 repeat 5-10 time per side, 2-4 cycle

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Exercise 6 repeat 5-10 time per side, 2-4 cycle

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Exercise 7 Tighten for 3-5 seconds and rest repeat 5-10 time per side,
2-4 cycle

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Closed kinetic chain exercise

Exercise 8 up & down 5-10 time, 2-4 cycle

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Nursing care of Orthopedic patients
: Degeneration

Asst. Prof. Dr. Saranya Chularee o Osteoporosis
Institute of nursing, o Osteoarthritis

Suranaree University of Technology o Exercise for Knee OA
o Herniated nucleus pulposus

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Hip osteoarthritis

» The causes of osteoarthritis of the hip are
not known.

» Factors that may contribute include
⋄ joint injury
⋄ increasing age
⋄ being overweight

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Surgery for Hip osteoarthritis 40

» Hip preservation surgeries: These are

operations that prevent damaged cartilage
from wearing down further. They include:
⋄ Hip osteotomy
⋄ Hip arthrotomy
⋄ Hip arthroscopy
» Joint fusion (arthrodesis): he pelvis and
femur are surgically connected with pins or
rods to immobilize the joint.
» Total or partial joint replacement surgery:
⋄ Total hip replacement surgery
⋄ Partial hip replacement

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Nursing care

» Postoperative complications

⋄ Pain
⋄ Infection
⋄ Pressure sore / Pressure injury
⋄ Dislocation of the hip joint with prosthesis
⋄ Thrombophlebitis
⋄ Pulmonary embolism

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Dislocation of the hip joint with prosthesis

» Monitor in 3 month.
» Maintain affected joint in prescribed position and

body in alignment when in bed (Avoid hip flexion
beyond 60 degrees for approximately 10 days; beyond
90 degrees for 2-3 months)
» Use pillows between the legs (for legs spread) all the
time for 2-3 months.
» Avoid positioning on the operative side

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Thrombophlebitis

» Venous thrombophlebitis occurs in the lower extremities.
» It may also occur in superficial veins, which usually is not life

threatening, or it may happen in a deep vein, which can be life-
threatening because clots may travel to the bloodstream and cause
a Pulmonary embolism.
» Risk factor can lead to the development of deep vein thrombosis (DVT)
which includes:
⋄ Venous stasis- blood flow is decreased, as in immobility
⋄ Hypercoagulability- most commonly in clients with deficiency fluid

volume, pregnancy, oral contraceptive use, smoking,
⋄ Vessel wall injury- secondary to venipuncture, trauma, and

surgery.

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Thrombophlebitis

» Providing information regarding disease condition,
treatment, and prevention.

» Assessing and monitoring anticoagulant therapy.
» Providing comfort positioning the body and

encouraging exercise
» Maintaining adequate tissue perfusion.
» Preventing complications.

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Pulmonary embolism

» Pulmonary embolism (PE) is a common disorder that is
related to deep vein thrombosis (DVT).

» PE refer to the obstruction of the pulmonary artery or one
of its branches by a thrombus that originates somewhere
in the venous system or in the right side of the heart.

» Symptoms of pulmonary embolism
⋄ Dyspnea
⋄ Chest pain
⋄ Tachycardia
⋄ Tachypnea

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Pulmonary embolism

» Assess for signs of hypoxemia and monitor the
pulse oximetry values.

» Monitoring thrombolytic and anticoagulant
therapy through INR or PTT.

» Turn patient frequently and reposition to improve
ventilation-perfusion ratio.

» Encourage ambulation and leg exercises to prevent
venous stasis.

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Rehabilitation

» Early postoperative exercises
» Increase circulation to your legs and feet, which is

important for preventing blood clots.

⋄ Ankle Pumps 5-10 m.

⋄ Ankle Rotations 5 times in each direction

⋄ Bed-Supported Knee Bends 10 times.

⋄ Buttock Contractions 10 times

Total Hip Replacement Exercise Guide. https://orthoinfo.aaos.org/en/recovery/total-hip-replacement-exercise-guide/

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Patient & family education

» Explain prescribed activity restrictions and necessary
lifestyle modification because of impaired mobility.

» Teach the proper use of assistive devices, as
indicated.

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Rehabilitation 4/3/2020

» Abduction exercise 10 times 89

» Quadriceps set 10 times 90

» Straight leg raises until your thigh 45
feels fatigued

Total Hip Replacement Exercise Guide. https://orthoinfo.aaos.org/en/recovery/total-hip-replacement-exercise-guide/

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Rehabilitation

Standing Exercises
» Standing knee raises: hold for 2 or 3 counts

and put your leg down, Repeat 10 times.
» Standing hip abduction: hold for 2 or 3

counts and put your leg down, Repeat 10
times.
» Standing hip extensions: hold for 2 or 3
counts and put your leg down, Repeat 10
times.

Total Hip Replacement Exercise Guide. https://orthoinfo.aaos.org/en/recovery/total-hip-replacement-exercise-guide/

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Going up and down the stairs

Total Hip Replacement Exercise Guide. https://orthoinfo.aaos.org/en/recovery/total-hip-replacement-exercise-guide/

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Nursing care of Orthopedic patients
: Degeneration

o Osteoporosis
o Osteoarthritis
o Herniated nucleus pulposus

Asst. Prof. Dr. Saranya Chularee
Institute of nursing,

Suranaree University of Technology

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Herniated nucleus pulposus: HNP

» Herniated nucleus pulposus is prolapse of an intervertebral disk
through a tear in the surrounding annulus fibrosus.

» A spinal disk has a soft, jellylike center (nucleus) encased in a
tougher, rubbery exterior (annulus).

» A herniated disk, which can occur in any part of the spine, can
irritate a nearby nerve.

» Depending on where the herniated disk is, it can result in pain,
numbness or weakness in an arm or leg.

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Anatomy 47

» The rubbery disks that
lie between the
vertebrae in your spine
consist of a soft center
(nucleus) surrounded
by a tougher exterior
(annulus)

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Pathology

» Disc herniation is a consequence of degenerative
changes in the annulus;

» Those changes are age-related adaptive
modifications in the disc structure.

» Annulus fissures predispose to a weakness, which
allows disc material to bulge or migrate outside
the annulus margins.

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Sign & symptoms

» Pain is usually the chief complaint and back
pain is typically relieved by bed rest.
⋄ Neck, Arm & leg pain
⋄ Numbness or tingling
⋄ Weakness
⋄ or without symptoms.

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Risk factors

» Weight : Excess body weight causes extra stress on the disks in
your lower back.

» Occupation : People with physically demanding jobs have a
greater risk of back problems. Repetitive lifting, pulling,
pushing, bending sideways and twisting also can increase your
risk of a herniated disk.

» Genetics : Some people inherit a predisposition to developing
a herniated disk.

» Smoking : It's thought that smoking lessens the oxygen supply
to the disk, causing it to break down more quickly.

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Investigate

» HX : Neck, Arm & leg pain, Numbness or weakness and risk

factors

» PE:

⋄ Straight leg raising test positive (bilateral if disk
herniation is central)

⋄ Decrease pain sensation
⋄ Decrease abduction of fingers of lower extremities

(Examining with muscle strength)
⋄ Deep tendon Reflex 

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Investigate

» Lab:

⋄ X-rays.
⋄ CT scan - cross-sectional images of your spinal

column and the structures around it.
⋄ MRI - can be used to confirm the location of the

herniated disk and to see which nerves are affected.
⋄ Myelogram - show pressure on your spinal cord or

nerves due to multiple herniated disks or other
conditions.

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Treatment

» Bed rest
» Physical therapy to help reduce pain
» Medications: Relief pain:

⋄ Acetaminophen (Tylenol, others) ibuprofen (Advil, Motrin
IB, others) or naproxen sodium (Aleve).

⋄ Cortisone injections (If doesn't improve with oral
medications)

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