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HEAD INJURY Associated injuries:

• Any damage to the head as a  Facial and skull fracture

result of trauma  Vertebral or carotid artery
• Also known as Traumatic Brain dissection
Injury (TBI)  Spinal cord injury
• Disruption of normal brain  Soft tissue injuries
function due to trauma (blunt
or penetrating injury). TBI is classified from mild to severe
according to Glasgow Coma scale
• Neurologic deficits result from (GCS) score
shearing of white matter,
ischemia, and mass effect  Mild TBI – GCS 13 to 15 with
from, hemorrhage and loss of consciousness up to 15
cerebral edema of surrounding minutes
brain tissue  Moderate TBI - GCS 9 to 12
with loss of consciousness up
to 6 hours
Types of Brain Injuries:
 Severe TBI – GCS 3 to 8 with
1. Concussion loss of consciousness longer
2. Cerebral contusions than 6 hours

3. Brain stem contusion 2 Forms of TBI

4. Epidural hematoma 1. Primary injury

5. Subdural hematoma  consequences of direct contact
to the head/ brain during the
6. Diffuse axonal injury
instant of initial injury 
contusions, lacerations,
external hematoma, skull
Common causes of TBI:
fractures
1. Falls (48%)
 Focal brain injury from sudden
2. Motor vehicle crashes (14%) movement of the brain within
the cranial vault
3. Being struck by objects (15%)

4. Assaults (10%)

 children up to 4 years old,

adolescents, and adults (65
yrs. and older)  most likely
to sustain

 Higher in males than for

females
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 Skull fracture

2. Secondary injury  A break in the continuity of

the skull caused by forceful
 Evolves over the ensuing
trauma
hours and days after the initial
injury May occur with or without
damage to the brain
 Results from inadequate
delivery of glucose and oxygen Classified by type
to the cells
 Linear (simple) – break in the
PHATOPHYSIOLOGY: continuity of the bone

Monro-Kellie hypothesis or Monro-  Comminuted – a splintered or

Kellie doctrine multiple fracture lines

Cranial vault has 3 main  Depressed – occurs when the

components: brain, blood, and CSF bones of the skull are
forcefully depressed downward
 Cranial vault is a closed
system By location:

 If any of the 3 components  Frontal

increases in volume, at least 1
 Temporal
of the other two must
decrease in volume or the  Basal skull fracture
pressure will increase

 Any bleeding or swelling within

the skull increases the volume Open skull fracture – scalp
of contents within the skull laceration or tear in the dura (from
increase ICP bullet or ice pick)

 If the pressure increases can Closed skull fracture – the dura is

cause displacement of the intact
brain through or against a ASSESSMENT FINDINGS:
rigid structure of the skull 
and 1. Disturbance in the level of
consciousness (LOC) from slightly
 will cause blood flow drowsy (concussion) to unconscious
restrictions to the brain
thereby decreasing O2 a. Acute subdural hematoma
delivery and waste removal   Persistent unconsciousness or
cells within the brain become deteriorating LOC progressing
anoxic ischemia, infarction, to decerebrate or decorticate
irreversible brain damage, and posturing
brain death
 Decorticate posturing – loss
 Scalp Injury – a minor injury of motor control by the
 Large avulsion (tearing) of cerebral cortex
the scalp – life-threatening;  hands/ wrist is flexed
true emergency
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 Upper arm adducted ALERTS:

 Elbows flexed Signs of Increase ICP

 Thighs and knees are • Altered LOC

internally rotated
• Abnormal pupil responses
 Plantar flexion of feet
• Vomiting

• Widened pulse pressure

 Decerebrate posturing –
 Bradycardia
brainstem dysfunction
 Hyperthermia
 Upper arm-adducted
ALERTS:
 Elbows extended
Regard every px who has a brain
 Wrist pronated
injury as having a potential spinal
 Hands flexed cord injury, especially patients under
the influence of alcohol at the time of
 Plantar flexion of feet
injury, which may mask the nature
and severity of the injury.

b. Chronic subdural hematoma – DIAGNOSTIC EVALUATION:

may present gradually with
1. CT scan – identifies and
irritability and seizure
localizes lesions, cerebral
2. headache, vertigo, agitation, edema, and bleeding
restlessness
2. Skull and cervical spine X-rays
3. CSF leakage at ears (otorrhea) – identify fracture and
and nose (rhinorrhea) which displacement
indicates skull fracture
3. Neuropsychological tests
4. Contusions about eyes (raccoon during the rehabilitation phase
eyes) and ears (battle sign) determine cognitive deficit
indicating skull fracture
THERAPEUTIC and
5. Irregular respirations PHARMACOLOGIC
INTERVENTIONS:
6. Cognitive deficit
1. Maintenance of airway,
7. Pupillary abnormality breathing, and circulation
8. Sudden onset of neurologic a. Intubate for GCS <8
deficits (comatose)

9. Otorrhea (leakage of CSF from b. Placement of nasogastric tube

ear) – indicates posterior fossa with intubation to prevent
skull fracture aspiration

10. Rhinorrhea – (leakage of CSF c. Oxygen as needed to maintain

from nose) – indicates anterior partial pressure of arterial
fossa skull fracture oxygen (PaO2) >100 mm Hg;
maintain partial pressure of
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arterial carbon dioxide SURGICAL INTERVENTION:

(PaCO2) between 35 to 45mm
1. Surgery may be necessary for
Hg (avoid use of
evacuation of intracranial
hyperventilation)
hematomas, debridement of
d. Maintain systolic blood penetrating wounds, the
pressure >90mm Hg through elevation of skull fractures,
use of vasopressors and subdural tapping to remove
albumin fluid or repair of CSF leaks

e. e. Maintain normovolemia; 2. Shunting to relieve persistent

treat symptomatic anemia fluid build-up with subdural
with packed RBC and iron hematoma
supplements
NURSING INTERVENTIONS:
f. f. Treat symptomatic
A. Monitoring:
arrhythmias
1. Maintain ICP monitoring, as
2. Management of increased ICP with
indicated, and report
osmotic diuretics, corticosteroids,
abnormalities
mechanical hyperventilation or
barbiturates to induce coma 2. Ma studies; maintain a
neurologic flow sheet to track
3. Antibiotics to prevent infection in
changes in cranial nerve,
open skull fractures or penetrating
sensory, motor, and reflex
wounds.
function
4. Management of sympathetic
3. Monitor results of serial serum
storming with medications, such as
and urine electrolyte and
oxycodone (opiate), propranolol
osmolality (K and Na
(beta-adrenergic blocker), clonidine
imbalances are common)
(alpha-adrenergic antagonist)
dantrolene (muscle relaxant), 4. Monitor hemodynamic
gabapentin (antiepileptic), and measurements to guide fluid
bromocriptine (dopamine receptor replacement; monitor urine
agonist) output.
 Sympathetic storming may be  Excessive dilute urine
triggered by suctioning, indicates Diabetes Insipidus
turning, hyperthermia, or loud
noises  concentrated urine indicates
SIADH (Syndrome of
5. Treatment of hypernatremia (due Inappropriate Anti-diuretic
to Diabetes insipidus, dehydration, Hormone)
diaphoresis) with fluid replacement
5. Monitor for anemia (decreased
6. Treatment of hyponatremia (due hemoglobin and hematocrit) and
to cerebral salt-wasting or SIADH) by infection (elevated WBC)
monitoring daily fluid status, fluid
restriction, oral salt replacement, 6. Monitor respiratory rate, depth,
and I.V. saline 0.9% or 3% (240 to and pattern of respirations; report
500 ml) over 3 to 5 hours any abnormal pattern such as
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CHEYNE-STOKES respirations or  Avoid neck flexion

periods of apnea
 Avoid hip flexion (which may
EMERGENCY ALERT!!! reduce venous drainage)

 Monitor for signs of  Prevent straining

sympathetic storming:
 Spread out care evenly over a
 Diaphoresis 24-hour period so px is not
overstimulated at any time.
 Tachycardia
7. Feed the px as soon as possible
 Tachypnea
after a head injury and administer
 Hypertension histamine-2 blockers to prevent
gastric ulceration and hemorrhage
 Hyperthermia from gastric acid hypersecretion
 Agitation 8. If the px is unable to swallow,
 Dystonia provide hyperalimentation, then
enteral feeding after bowel sounds
 REPORT immediately and try have returned
to identify and eliminate
triggers  Caloric needs of the head-
injured px increase by 100%
7. Maintain constant vigilance of to 200%
agitated patients confined or bed and
avoid the use of restraints if possible  Consult a dietitian to institute
nutritional support within the
SUPPORTIVE CARE: first 2 to 3 days after injury to
1. Maintain a patent airway; assist support the recovery process
with intubation and ventilatory 9. Elevate the head of the bed after
assistance if needed feedings and check residuals to
2. To facilitate respirations, turn the prevent aspiration.
patient every 2 hours and encourage  Check glucose level and give
coughing and deep breathing insulin as directed to prevent
3. Replace I.V. fluids as indicated. hyperglycemia
Avoid rapid changes in electrolytes 10. provide stimulation of all sensory
which may precipitate cerebral avenues. Orient the px to the time
edema and place
4. Apply firm pressure over the 11. Observe the px for fatigue or
puncture site for subdural tap, and restlessness from overstimulation
observe for drainage on the dressing
12. Warn the family regarding
5. Suction the px as needed; restlessness and combativeness that
hyperventilate the px before may occur during recovery from
suctioning to prevent hypoxia brain injury
6. Institute measures to prevent 14. Pad rails and wrap hands in mitts
increased ICP or other neurovascular if the px is agitated
compromise
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Starwin B. Panes

15. Investigate for physical sources b. Formed by the synovial

of restlessness, such as membrane, which lines the joint
uncomfortable position, and signs of capsule
urinary tract infection or pressure
c. Lubricates the cartilage
ulcers
d. Provides a cushion against shocks
16. Provide adequate light and
reorient frequently if the px is D. Muscles
hallucinating
1. Characteristic of muscles
17. Perform passive range-of-motion
exercises to release motion tension a. Made up of bundles of muscle
from inactivity fibers

18 avoid sedatives to avoid b. Provide the force to move bones

medication-induced confusion and c. Assist in maintaining posture
altered state of cognition
d. Assist with heat production
19. Review with the family the signs
of increased ICP

20. Teach the family therapeutic use

of touch, massage, and music to
calm the agitated px

1. Characteristic of joints

b. Allow movement between bones

b. Formed where 2 bones join

2. Process of contraction and
c. Surfaces are covered with relaxation
cartilage.
a. Muscle contraction and relaxation
d. Enclosed in a capsule (synovial require large amounts of adenosine
joints) triphosphate.
e. Contain a cavity filled with b. Contraction also requires calcium,
synovial fluid (synovial joints) which functions as a catalyst.
f. Ligaments hold the bone and joint c. Acetylcholine released by the
in the correct position. motor end plate of the motor neuron
g. Articulation is the meeting point of initiates an action potential.
2 or more bones. d. Acetylcholine is then destroyed by
2. Synovial fluid acetylcholinesterase.

a. Found in the synovial joint capsule e. Calcium is required for muscle

fiber contraction and acts as a
catalyst for the enzyme needed for
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the sliding-together action of actin i. Complete the screening

and myosin. process per agency policy.

f. Following contraction, adenosine Arthrocentesis

triphosphate transports calcium out
1. Description: Arthrocentesis is used
to allow actin and myosin to separate
to diagnose joint inflammation and
and allow the muscle to relax
infection.
Diagnostic Tests
a. Arthrocentesis involves aspirating
A. Radiography and magnetic synovial fluid, blood, or pus via a
resonance imaging needle inserted into a joint cavity

1. Description: Radiography and b. Medication, such as

MRI are commonly used corticosteroids, may be instilled into
procedures to diagnose the joint if necessary to alleviate
disorders of the inflammation
musculoskeletal system.
Interventions
Interventions
a. Ensure that informed consent has
a. Handle injured areas carefully been obtained.
and support extremities above
b. Apply an elastic compression
and below the joint
bandage post procedure as
b. Administer analgesics as prescribed.
prescribed before the
c. Use ice to decrease pain and
procedure, particularly if the
swelling
client is in pain.
d. Pain may worsen after aspirating
c. Remove any radiopaque and
fluid from the joint; analgesics may
metallic objects, such as
be prescribed.
jewelry.
e. Pain can continue for up to 2 days
d. Ask the client if she is
after administration of corticosteroids
pregnant; MRI may be
into a joint.
contraindicated in pregnancy.
f. Instruct the client to rest the joint
e. Shield the client’s testes,
for 8 to 24 hours post-procedure.
ovaries, or pregnant abdomen.
g. Instruct the client to notify the
f. The client must lie still during
HCP if a fever or swelling of the joint
a procedure.
occurs
g. Inform the client that
Arthroscopy
exposure to radiation from
radiography is minimal and 1. Description: Used to diagnose and
not dangerous. treat acute and chronic disorders of
the joint.
h. The health care provider
(HCP) wears a lead apron if a. Arthroscopy provides an
staying in the room with the endoscopic examination of various
client having radiography. joints. b. Articular cartilage
abnormalities can be assessed, loose
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bodies removed, and the cartilage c. It is used to diagnose metabolic

trimmed. bone disease and to monitor changes
in bone density with treatment.
c. A biopsy may be performed
during the procedure. d. Inform the client that the
procedure is painless.
Interventions
e. All metallic objects are removed
a. Instruct the client to fast for 8 to
before the test.
12 hours before the procedure.
2. Quantitative ultrasound
b. Ensure that informed consent is
obtained. a. Quantitative ultrasound evaluates
the strength, density, and elasticity
c. Administer pain medication as
of various bones, using ultrasound
prescribed post-procedure.
rather than radiation.
d. Assess the neurovascular status of
. Inform the client that the procedure
the affected extremity.
is painless
e. An elastic compression bandage
E. Bone scan
should be worn post procedure for 2
to 4 days as prescribed. Description:

f. Instruct the client that walking 1. A bone scan is used to identify,

with weight-bearing usually is evaluate, and stage bone cancer
permitted after sensation returns but before and after treatment; it is also
to limit activity for 1 to 4 days as used to detect fractures.
prescribed following the procedure.
a. Radioisotope is injected
g. Instruct the client to elevate the intravenously and will collect in areas
extremity as often as possible for 24 that indicate abnormal bone
hours following the procedure and to metabolism and some fractures if
place ice on the site to minimize they exist.
swelling for 12 to 24 hours post-
b. The isotope is excreted in the
procedure.
urine and feces within 48 hours and
h. Advise the client to notify the HCP is not harmful to others
if fever or increased knee pain occurs
Interventions
or if edema continues for more than
3 days post-procedure. a. Food and fluids may be withheld
before the procedure.
D. Bone mineral density
measurements b. Ensure that informed consent has
been obtained.
1. Dual-energy x-ray absorptiometry
c. Remove all jewelry and metal
a. Dual-energy x-ray
objects
absorptiometry measures the bone
mass of the spine, wrist and hip d. Following the injection of the
bones, and total body. radioisotope, the client must drink
32 oz of water (if not
b. Radiation exposure is minimal.
contraindicated) to promote renal
filtering of the excess isotope.
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e. From 1 to 3 hours after the e. Mild analgesics can be used for

injection, have the client void to the pain.
clear excess isotope from the bladder
before the scanning procedure is RHEUMATOID ARTHRITIS
completed
A. Description
f. Inform the client of the need to lie
1. Rheumatoid arthritis is a chronic
supine during the procedure and that
systemic inflammatory disease
the procedure is not painful.
(immune complex disorder); the
g. Monitor the injection site for cause may be related to a
redness and swelling. combination of environmental and
genetic factors.
h. Encourage oral fluid intake
following the procedure. 2. Rheumatoid arthritis leads to the
destruction of connective tissue and
 No special precautions are synovial membranes within the
required after a bone scan joints.
because only a minimal
amount of radioactivity exists 3. Rheumatoid arthritis weakens the
in the radioisotope used for joint, leading to dislocation and
the procedure permanent deformity of the joint

F. Electromyography (EMG) 4. Pannus forms at the junction of

synovial tissue and articular cartilage
Description: EMG is used to evaluate and projects into the joint cavity,
muscle weakness. causing necrosis.
a. Electromyography measures 5. Exacerbations of disease
electrical potential associated with manifestations occur during periods
skeletal muscle contractions. of physical or emotional stress and
b. Needles are inserted into the fatigue.
muscle, and recordings of muscular 6. Vasculitis can impede blood flow,
electrical activity are traced on leading to organ or organ system
recording paper through an malfunction and failure caused by
oscilloscope. tissue ischemia.
Interventions B. Assessment
a. Ensure that informed consent is 1. Inflammation, tenderness, and
obtained. stiffness of the joints
b. Instruct the client that the needle 1. Moderate to severe pain, with
insertion is uncomfortable. morning stiffness lasting
c. Instruct the client not to take any longer than 30 minutes
stimulants or sedatives for 24 hours 2. Joint deformities, muscle
before the procedure. atrophy, and decreased range
d. Inform the client that slight of motion in affected joints
bruising may occur at the needle 3. Spongy, soft feeling in the
insertion sites. joints
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Starwin B. Panes

4. Low-grade temperature, 7. Apply paraffin baths and

fatigue, and weakness massage as prescribed

5. Anorexia, weight loss, and 8. Encourage consistency with an

anemia exercise program.

6. Elevated ESR and positive 9. Use joint-protecting devices.

rheumatoid factor
10. Avoid weight-bearing on
7. Radiographic study showing inflamed joints.
joint deterioration
F. Self-care
8. Synovial tissue biopsy reveals
1. Assess the need for assistive
inflammation
devices such as raised toilet
C. Rheumatoid factor seats, self-rising chairs,
wheelchairs, and scooters to
1. Blood test used to assist in
facilitate mobility
diagnosing rheumatoid
arthritis 2. Work with an occupational
therapist or HCP to obtain
2. Reference interval: Negative or
assistive or adaptive devices.
< 60 units/mL D. Medications:
Combination of pharmacological 3. Instruct the client on
therapies includes NSAIDs, alternative strategies for
disease-modifying antirheumatic providing activities of daily living.
drugs (DMARDs), and
Client Education for
glucocorticoids
Rheumatoid Arthritis and
D. Medications: Degenerative Joint

 Combination of  Assist the client to identify and

pharmacological therapies correct safety hazards in the
includes NSAIDs, disease- home.
modifying antirheumatic drugs
 Instruct the client on the
(DMARDs), and glucocorticoids
correct use of assistive or
E. Physical mobility adaptive devices.

1. Preserve joint function.  Instruct the client on energy

conservation measures.
2. Provide range-of-motion
exercises to maintain joint motion  Review the prescribed exercise
and muscle strengthening. program.

3. Balance rest and activity.  Instruct the client to sit in a

chair with a high, straight
4. Splints may be used during
back.
acute inflammation to prevent
deformity.  Instruct the client to sit in a
chair with a high, straight
5. Prevent flexion contractures.
back.
6. Apply heat or cold therapy as
prescribed to joints.
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Starwin B. Panes

 Instruct the client to use only 4. Encourage the client to wear

a small pillow when lying street clothes
down.
I. Surgical interventions
 Instruct the client on
1. Synovectomy: Surgical removal of
measures to protect the joints.
the synovia to help maintain joint
 Instruct the client regarding function
the prescribed medications.
2. Arthrodesis: Bony fusion of a joint
 Stress the importance of to regain some mobility
follow-up visits with the health
3. Joint replacement (arthroplasty):
care provider.
 Surgical replacement of
G. Fatigue
diseased joints with artificial
 1. Identify factors that may joints; performed to restore
contribute to fatigue. motion to a joint and function
to the muscles, ligaments, and
 2. Monitor for signs of anemia
other soft tissue structures
and administer iron, folic acid,
that control a joint
and vitamins as prescribed.

 3. Monitor for medication- OSTEOARTHRITIS

related blood loss by testing (DEGENERATIVE JOINT
the stool for occult blood. DISEASE)
 4. Instruct the client in A. Description
measures to conserve energy,
such as pacing activities and 1. Osteoarthritis is marked by
obtaining assistance when progressive deterioration of the
possible. articular cartilage.

 H. Disturbed body image 1. 2. Osteoarthritis causes bone buildup

Assess the client’s reaction to and the loss of articular cartilage in
the body change. 2. peripheral and axial joints.
Encourage the client to 3. Osteoarthritis affects the weight-
verbalize feelings. 3. Assist bearing joints and joints that receive
the client with self-care the greatest stress, such as the hips,
activities and grooming. 4. knees, lower vertebral column, and
Encourage the client to wear hands
street clothes
4. The cause of primary
H. Disturbed body image osteoarthritis is not known.
1. Assess the client’s reaction to the Risk factors include trauma, aging,
body change. obesity, genetic changes, and
2. Encourage the client to verbalize smoking.
feelings. B. Assessment
3. Assist the client with self-care 1. The client experiences joint pain
activities and grooming. that diminishes after rest and
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Starwin B. Panes

intensifies after activity, noted early 6. Provide a bed or foot cradle to

in the disease process. keep linen off of feet and legs until
inflammation subsides.
2. As the disease progresses, pain
occurs with slight motion or even at 7. Instruct the client on the
rest. importance of moist heat, hot packs
or compresses, and paraffin dips as
3. Symptoms are aggravated by
prescribed.
temperature change and climate
humidity 8. Apply cold applications as
prescribed when the joint is acutely
4. Presence of Heberden’s nodes or
inflamed.
Bouchard’s nodes (hands)
9. Encourage adequate rest.
5. Joint swelling (may be minimal),
crepitus, and limited range of motion D. Nutrition
6. Difficulty getting up after
1. Encourage a well-balanced diet.
prolonged sitting
2. Maintain weight within normal
7. Skeletal muscle disuse atrophy
range to decrease stress on the
8. Inability to perform activities of joints.
daily living
E. Physical mobility
9. Compression of the spine as
1. Instruct the client to balance
manifested by radiating pain,
activity with rest and to participate in
stiffness, and muscle spasms in 1 or
an exercise program that limits
both extremities
stressing affected joints.
C. Pain
2. Instruct the client that exercises
1. Administer medications as should be active rather than passive
prescribed, such as acetaminophen and to stop exercise if pain occurs.
or topical applications; if
3. Instruct the client to limit exercise
acetaminophen or topical agents do
when joint inflammation is severe
not relieve pain, NSAIDs may be
prescribed. Muscle relaxants may F. Surgical management
also be prescribed for muscle
spasms, especially those occurring in 1. Osteotomy: The bone is resected
the back. to correct joint deformity, promote
realignment, and reduce joint stress.
2. Prepare the client for
corticosteroid injections into joints as 2. Total joint replacement or
prescribed. arthroplasty

3. Position joints in function position a. Total joint replacement is

and avoid flexion of knees and hips. performed when all measures of pain
relief have failed.
4. Immobilize the affected joint with
a splint or brace until inflammation b. Hips and knees are replaced most
subsides. commonly.

5. Avoid large pillows under the head c. Total joint replacement is

or knees. contraindicated in the presence of
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Starwin B. Panes

infection, advanced osteoporosis, or  Cigarette smoking

severe joint inflammation.  Early menopause
 Excessive use of alcohol
OSTEOPOROSIS
 Family history
A. Description  Female gender
 Increasing age
1. Osteoporosis is a metabolic  Insufficient intake of calcium
disease characterized by bone  Sedentary lifestyle
demineralization, with loss of calcium  Thin, small frame
and phosphorus salts leading to  White (European descent) or
fragile bones and the subsequent Asian race
risk for fractures.
B. Assessment
2. Bone resorption accelerates as
bone formation slows. 1. Possibly asymptomatic

3. Osteoporosis occurs most 2. Back pain that occurs after lifting,

commonly in the wrist, hip, and bending, or stooping
vertebral column.
3. Back pain that increases with
4. Osteoporosis can occur palpation
postmenopausal or as a result of a
4. Pelvic or hip pain, especially with
metabolic disorder or calcium
weight-bearing
deficiency.
5. Problems with balance
5. The client may be asymptomatic
until the bones become fragile and a 6. Decline in height from vertebral
minor injury or movement causes a compression
fracture.
7. Kyphosis of the dorsal spine, also
Primary osteoporosis known as “dowager’s hump”

a. Most often occurs in 8. Degeneration of lower thorax and

postmenopausal women; occurs in lumbar vertebrae on radiographic
men with low testosterone levels studies

b. Risk factors include decreased 1. The client with osteoporosis is

calcium intake, deficient estrogen, at risk for pathological fractures.
and a sedentary lifestyle.
C. Interventions
Secondary osteoporosis
1. Assess risk for and prevent injury
a. causes include prolonged in the client’s personal environment.
therapy with corticosteroids,
a. Assist the client to identify and
thyroid-reducing medications,
correct hazards in his or her
aluminum-containing antacids,
environment
or antiseizure medications.
b. Position household items and
b. Associated with immobility,
furniture to ensure an unobstructed
alcoholism, malnutrition, or
walkway.
malabsorption
c. Use side rails to prevent falls.
Risk Factors for Osteoporosis
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Starwin B. Panes

d. Instruct in use of assistive devices 4. Secondary gout involves

such as a cane or walker. excessive uric acid in the blood
caused by another disease.
e. Encourage the use of a firm
mattress. B. Phases

2. Provide personal care to the 1. Asymptomatic: Client has no

client to reduce injuries. symptoms but serum uric acid level
is elevated.
a. Move the client gently when
turning and repositioning. 2. Acute: Client has excruciating pain
and inflammation of 1 or more small
b. Assist with ambulation if the client
joints, especially the great toe.
is unsteady.
3. Intermittent: Client has
c. Provide gentle range-of-motion
intermittent periods without
exercises.
symptoms between acute attacks.
d. Apply a back brace as prescribed
4. Chronic: Results from repeated
during an acute phase to immobilize
episodes of acute gout
the spine and provide spinal column
support. a. Results in deposits of urate
crystals under the skin
3. Provide the client with instructions
to promote optimal level of health b. b. Results in deposits of urate
and function. crystals within major organs,
such as the kidneys, leading to
a. Instruct the client in the use of
organ dysfunction
correct body mechanics.
C. Assessment
b. Instruct the client in exercises to
strengthen abdominal and back 1. Swelling and inflammation of
muscles to improve posture and the joints, leading to
provide support for the spine. excruciating pain

4. Administer medications as 2. Tophi: Hard, irregularly shaped

prescribed to promote bone strength nodules in the skin containing chalky
and decrease pain. deposits of sodium urate

GOUT 3. Low-grade fever, malaise, and

headache
A. Description:
4. Pruritus from urate crystals in the
1. Gout is a systemic disease in skin
which urate crystals deposit in joints
and other body tissues. 5. Presence of renal stones from
elevated uric acid levels
2. Gout results from abnormal
amounts of uric acid in the body. D. Interventions

3. Primary gout results from a 1. Provide a low-purine diet as

disorder of purine metabolism. prescribed, avoiding foods such as
organ meats, wines, and aged
cheese.
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Starwin B. Panes

2. Encourage a high fluid intake of 2. Comminuted: The bone is

2000 mL/day to prevent stone splintered or crushed, creating
formation. numerous fragments.

3. Encourage a weight reduction diet 3. Complete: The bone is

if required. separated completely by a
break into 2 parts.
4. Instruct the client to avoid alcohol
and starvation diets because they 4. Compression: A fractured
may precipitate a gout attack. bone is compressed by other
bone. Depressed: Bone
5. Increase urinary pH (above 6) by
fragments are driven inward.
eating alkaline ash foods (i.e., green
beans, and broccoli). 5. Greenstick: One side of the
bone is broken and the other
6. Provide bed rest during acute
is bent; these fractures occur
attacks, with the affected extremity
most commonly in children.
elevated.
6. Impacted: A part of the
7. Monitor joint range-of-motion
fractured bone is driven into
ability and appearance of joints.
another bone.
8. Position the joint in mild flexion
C. Assessment of a fracture of an
during acute attack.
extremity
9. Protect the affected joint from
1. Pain or tenderness over the
excessive movement or direct
involved area
contact with sheets or blankets.
2. Decrease or loss of muscular
10. Provide heat or cold for local
strength or function
treatments to the affected joint as
prescribed. 3. Obvious deformity of the affected
area
11. Administer medications such as
analgesic, anti-inflammatory, and 4. Crepitation, erythema, edema, or
uricosuric agents as prescribed. bruising

FRACTURE 5. Muscle spasm and neurovascular

impairment
A. Description:
D. Initial care of a fracture of an
A break in the continuity of the bone
extremity
caused by trauma, twisting as a
result of muscle spasm or indirect 1. Immobilize the affected extremity
loss of leverage, or bone with a cast or splint.
decalcification and disease that
2. Assess the neurovascular status of
results in osteopenia.)
the extremity.
B. Types of fractures
3. Interventions for a fracture:
1. Closed or Simple: Skin over Reduction, fixation, traction, cast
the fractured area remains
If a compound (open) fracture
intact
exists, splint the extremity and cover
the wound with a sterile dressing.
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Starwin B. Panes

E. Reduction restores the bone to b. It provides proper bone

proper alignment. alignment and reduces muscle
spasms.
1. Closed reduction is a nonsurgical
intervention performed by manual 2. Interventions
manipulation.
a. Maintain proper body
a. Closed reduction may be alignment.
performed under local or general
b. Ensure that the weights hang
anesthesia.
freely and do not touch the
b. A cast may be applied following floor.
reduction.
c. Do not remove or lift the
2. External fixation is the use of an weights without an HCP’s
external frame to stabilize a fracture prescription
by attaching skeletal through bone
d. Ensure that pulleys are not
fragments to a rigid external support
obstructed and that ropes in the
pulleys move freely.

e. Place knots in the ropes to

prevent slipping.

f. Check the ropes for fraying.

a. External fixation provides

more freedom of movement
than with traction.

b. Monitor pin stability and

provide pin care to decrease
infection risks.

c. Risk of infection exists with

both fixation methods.

d. External fixation is commonly

used when massive tissue
trauma is present. H. Skeletal traction
G. Traction A. Description
1. Description a. Traction is applied mechanically to
a. Traction is the exertion of a the bone with pins, wires, or tongs.
pulling force applied in 2 b. Typical weight for skeletal traction
directions to reduce and is 25 to 40 lb (11 to 18 kg).
immobilize a fracture.
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Starwin B. Panes

2. Interventions c. Not more than 8 to 10 lb (3.5 to

4.5 kg) of weight should be applied
a. Monitor color, motion, and
as prescribed.
sensation of the affected extremity.
d. Elevate the foot of the bed to
b. Monitor the insertion sites for
provide the traction.
redness, swelling, drainage, or
increased pain. 4. Russell’s skin (sling) traction:

c. Provide insertion site care as 5. Pelvic skin traction is used to

prescribed. relieve low back, hip, or leg pain or
to reduce muscle spasms
3. Cervical tongs and a halo fixation
device: a. Apply the traction belt snugly over
the pelvis and iliac crest and attach it
Skin traction
to the weights.
A. Description:
b. Use measures as prescribed to
1. Skin traction is applied by using prevent the client from slipping down
elastic bandages or adhesive, foam in bed.
boot, or sling.
Balanced suspension traction
2. Cervical skin traction relieves
A. Description
muscle spasms and compression in
the upper extremities and neck. a. Balanced suspension traction is
used with skin or skeletal traction.
a. Cervical skin traction uses a head
halter and chin pad to attach the b. Used to approximate fractures of
traction. the femur, tibia, or fibula

a. Use powder to protect the ears c. Balanced suspension traction is

from friction rub. produced by a counterforce other
than the client.
b. Position the client with the
head of the bed elevated 30 to 2. Interventions
40 degrees, and attach the
a. Position the client in a low Fowler’s
weights to a pulley system
position on either the side or the
over the head of the bed.
back.
3. Buck’s (extension) skin traction is
b. Maintain a 20-degree angle from
used to alleviate muscle spasms and
the thigh to the bed.
immobilize a lower limb by
maintaining a straight pull on the c. Protect the skin from breakdown.
limb with the use of weights
d. Provide pin care if pins are used
a. A boot appliance is applied to with the skeletal traction.
attach to the traction.
e. Clean the pin sites with sterile
b. The weights are attached to a normal saline and hydrogen peroxide
pulley; allow the weights to hang or povidone-iodine as prescribed or
freely over the edge of bed. per agency policy

Casts
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Starwin B. Panes

1. Description: Plaster, fiberglass, or k. Teach the client to keep the cast

air casts are used to immobilize clean and dry.
bones and joints into correct
l. Instruct the client in isometric
alignment after a fracture or injury. 2
exercises to prevent muscle atrophy.
2. Interventions
Monitor a casted extremity for
a. Keep the cast and extremity circulatory impairment such as pain,
elevated. swelling, discoloration, tingling,
numbness, coolness, or diminished
b. Allow a wet plaster cast 24 to 72
pulse. Notify the HCP immediately if
hours to dry (synthetic casts dry in
a circulatory compromise occurs.
20 minutes).
VI. Complications of Fractures
c. Handle a wet plaster cast with the
palms of the hands (not fingertips) A. Fat embolism
until dry
 A fat embolism originates in
d. Turn the extremity every 1 to 2 the bone marrow and occurs
hours, unless contraindicated, to after a fracture when a fat
allow air circulation and promote globule is released into the
drying of the cast. bloodstream.

e. A hair dryer can be used on a cool  Fat embolism can occur within
setting to dry a plaster cast (heat the first 48 to 72 hours
cannot be used on a plaster cast following the injury and clients
because the cast heats up and burns with long bone fractures are at
the skin). the greatest risk for the
development of a fat
f. Monitor closely for circulatory
embolism.
impairment; prepare for bivalving or
cutting the cast if circulatory  Findings are similar to those
impairment occurs. noted with pulmonary
embolism and include
g. Petal the cast or apply moleskin to
restlessness, hypoxemia,
the edges to protect the client’s skin;
mental status changes,
maintain smooth edges around the
dyspnea, tachypnea,
cast to prevent crumbling of the cast
tachycardia, and hypotension.
material.
 In addition, a petechial rash
h. Monitor for signs of infection such
may present over the upper
as increased temperature, hot spots
chest and neck.
on the cast, foul odor, or changes in
pain  The HCP is notified
immediately while initiating
i. If an open draining area exists on
emergency care.
the affected extremity, the HCP will
make a cutout portion of the cast  The client is maintained on
known as a window, for assessment bed rest and is repositioned
and wound care purposes only as necessary and gently.

j. Instruct the client not to stick

objects inside the cast.
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Starwin B. Panes

 Oxygen is administered and IV b. Sudden onset of dyspnea and

hydration is administered to chest pain
prevent hypovolemic shock.
c. Cough, hemoptysis, hypoxemia, or
 Vital signs and respiratory crackles
status are monitored closely
3. Interventions
and the client is prepared for
intubation and mechanical a. Notify the HCP immediately if
ventilation if necessary. signs of emboli are present.
 Medications may also be b. Administer oxygen and other
prescribed for the client. prescriptions; intravenous (IV)
anticoagulant therapy may be
 The nurse then documents the
prescribed.
event, actions taken, and the
client’s response.

PRIORITY NURSING ACTIONS

Fat Embolism in a Client Following a

Fracture

1. Notify the health care provider

(HCP).

2. 2. Administer oxygen.

3. 3. Administer intravenous (IV)

fluids as prescribed.

4. 4. Monitor vital signs and

respiratory status.

5. Prepare for intubation and

mechanical ventilation, if necessary,
as indicated by arterial blood gas
values

6. Follow up on results of diagnostic

tests such as chest x-rays or
computed tomography (CT) scans.

7. Document the event, actions

taken, and the client’s response.

B. Pulmonary embolism

1. Description: Pulmonary embolism

is caused by the movement of
foreign particles (blood clot, fat, or
air) into the pulmonary circulation.

2. Assessment

a. Restlessness and apprehension

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