section name header

Information

  1. IMMOBILITY: Impaired physical mobility or limitation of physical movement may be accompanied by a number of complications that can involve any or all of the major systems of the body. Regardless of the cause of immobilization, there are a number of conditions that arise primarily as a complication of immobility. These are discussed in Table 6-34. Complications of Immobilization .
    1. Types of immobility:
      1. Physical—physical restriction due to limitation in movement or physiological processes (e.g., breathing).
      2. Intellectual—lack of action due to lack of knowledge (e.g., mental retardation, brain damage).
      3. Emotional—immobilized when highly stressed (e.g., after loss of loved person or diagnosis of terminal illness).
      4. Social—decreased social interaction due to separation from family when hospitalized or when alone, as in old age.
    2. Risk factors:
      1. Pain, trauma, injury.
      2. Loss of body function or body part.
      3. Chronic disease.
      4. Emotional, mental illness; neglect.
      5. Malnutrition.
      6. Bedrest, traction, surgery, medications.
    3. Assessment:
      1. Subjective data: psychological/social effects of immobility:
        1. Decreased motivation to learn; decreased retention.
        2. Decreased problem-solving abilities.
        3. Diminished drives; decreased hunger.
        4. Changes in body image, self-concept.
        5. Exaggerated emotional reactions, inappropriate to situation or person; aggression, apathy, withdrawal.
        6. Deterioration of time perception.
        7. Fear, anxiety, feelings of worthlessness related to change in role activities (e.g., when no longer employed).
      2. Objective data: physical effects of immobility:
        1. Cardiovascular.
          1. Orthostatic hypotension.
          2. Increased cardiac load.
          3. Thrombus formation.
        2. Gastrointestinal.
          1. Anorexia.
          2. Diarrhea.
          3. Constipation.
        3. Metabolic.
          1. Tissue atrophy and protein catabolism.
          2. BMR reduced.
          3. Fluid/electrolyte imbalances.
        4. Musculoskeletal.
          1. Demineralization (osteoporosis).
          2. Contractures and atrophy.
          3. Skin breakdown.
        5. Respiratory.
          1. Decreased respiratory movement.
          2. Accumulation of secretions in respiratory tract.
          3. O2/CO2 level imbalance.
        6. Urinary.
          1. Calculi.
          2. Bladder distention, stasis.
          3. Infection.
          4. Frequency.
    4. Analysis/nursing diagnosis:
      1. Impaired physical mobility related to specific client condition.
      2. Impaired skin integrity related to physical immobilization.
      3. Urinary retention related to incomplete emptying of bladder.
      4. Constipation related to inactivity.
      5. Risk for disuse syndrome related to lack of range of motion.
      6. Bathing/hygiene self-care deficit related to musculoskeletal impairment.
      7. Sensory/perceptual alteration related to complications of immobility.
      8. Body image disturbance related to physical limitations.
    5. Nursing care plan/implementation:
      1. Goal: prevent physical, psychological hazards.
        1. Apply nursing measures to promote venous flow, muscle strength, endurance, joint mobility, skin integrity.
        2. Assess and counteract psychological impact of immobility (e.g., feelings of helplessness, hopelessness, powerlessness).
        3. Help maintain accurate sensory processing to prevent and lessen sensory disturbances.
        4. Help adapt to altered body image due to increased dependency, sensory deprivation, and changes in status and power that accompany immobility.
        5. Offer counseling when sexual expression is impaired.
      2. Goal: health teaching: how to prevent physical problems related to immobility (e.g., anticonstipation diet, range of motion, skin care); teach activities while immobile that encourage independence and provide sensory stimulation.
    6. Evaluation/outcome criteria:
      1. Minimal contractures, skin breakdown, muscle atrophy, or loss of strength.
      2. Interest in self and environment; positive self-image.
      3. Returns to optimal level of physical activity.
  2. FRACTURES: disruptions in the continuity of bone as the result of trauma or various disease processes, such as Cushing's syndrome or osteoporosis, that weaken the bone structure.
    1. Types (Figure. 6.13. Types of Fractures and Terminology):
      1. Open or compound—fractured bone extends through skin and mucous membranes; increased potential for infection.
      2. Closed or simple—fractured bone does not protrude through skin.
      3. Complete—fracture extends through entire bone, disrupting the periosteum on both sides of the bone, producing two or more fragments.
      4. Incomplete—fracture extends only partway through bone; bone continuity is not totally interrupted.
      5. Greenstick or willow-hickory stick—fracture of one side of bone; other side merely bends; usually seen only in children.
      6. Impacted or telescoped—fracture in which bone fragments are forcibly driven into other or adjacent bone structures.
      7. Comminuted—fracture having more than one fracture line and with bone fragment broken into several pieces.
      8. Depressed—fracture in which bone or bone fragments are driven inward, as in skull or facial fractures.
      9. See also VI. TOTAL HIP REPLACEMENT, Physiological Integrity.
    2. Methods used to reduce/immobilize fractures:
      reduction or setting of the bone—restores bone alignment as nearly as possible.
      1. Closed reduction—manual traction or manipulation. Usually done under anesthesia to reduce pain and muscle spasm. Maintenance of reduction and immobilization is accomplished by casting (fiberglass or plaster of Paris).
      2. Open reduction—operative procedure utilized to achieve bone alignment; pins, wires, nails, or rods may be used to secure bone fragments in position; prosthetic implants may also be used.
      3. Traction reduction—force is applied in two directions: to obtain alignment, and to reduce or eliminate muscle spasm. Used for fractures of long bones. May be:
        1. Continuous—used with fractures or dislocations of bones or joints.
        2. Intermittent—used to reduce flexion contractures or lessen pain and muscle spasm.
        3. Applied as follows:
          1. Skin—traction applied to skin by using a commercial foam-rubber Buck's traction splint or by using adhesive, plastic, or a moleskin strip bound to the extremity by elastic bandage; exerts indirect traction on bone or muscles (e.g., Bryant's, Buck's extension, head, pelvic, Russell's) (Figure 6-14. Types of Skin and Skeletal Traction, parts A through E ).
          2. Skeletal—direct traction applied to bone using pins (Steinmann), wires (Kirchner). Pin is inserted through the bone in or close to the involved area and usually protrudes through skin on both sides of the extremity. Skeletal traction for fractured vertebrae accomplished with tongs (e.g., Crutchfield tongs, Gardner-Wells tongs) (see Figure 6-14. Types of Skin and Skeletal Traction, parts F through H ).
        4. Specific types of traction:
          1. Cervical—direct traction applied to cervical vertebrae using a head halter or Crutchfield, Gardner-Wells, or Vinke tongs that are inserted into the skull (see Figure 6-14. Types of Skin and Skeletal Traction, parts C and G ). Traction is increased with weights until vertebrae move into position and alignment is regained. After reduction is obtained, weights are decreased to the amount needed to maintain reduction. Weight amount is prescribed by physician.
          2. Balanced suspension—countertraction produced by a force other than client's body weight; extremity is suspended in a traction apparatus that maintains the line of traction despite changes in the client's position (e.g., Russell's leg traction, Thomas' splint with Pearson's attachment) (see Figure 6-4. Interpretation of Normal Cardiac Cycle, parts E and F ).
          3. Running—traction that exerts a pull in one plane; countertraction is supplied by the weight of the client's body or can be increased through use of weights and pulleys in the opposite direction (e.g., Buck's extension, Russell's traction) (see Figure 6-4. Interpretation of Normal Cardiac Cycle, parts B through E ).
          4. Halo—an apparatus that employs both a plastic and metal frame; molded frame extends from axilla to iliac crest and houses a metal frame. The struts of the frame extend to skull and attach to round metal (halo) device. The halo is attached to skull by four pins—two located anterolaterally and two located posterolaterally. They are inserted into external cortex of the cranium (see Figure 6-4. Interpretation of Normal Cardiac Cycle, part H ). Used to immobilize the cervical spine following spinal fusion, give some correction to scoliosis before spinal fusion, and immobilize nondisplaced fracture of spine.
      4. Immobilization—maintains reduction and promotes healing of bone fragments.
        Achieved by:
        1. External fixation:
          1. Casts—types:
            1. Spica—applied to immobilize hip or shoulder joints.
            2. Body cast—applied to trunk.
            3. Arm or leg cast—joints above and below site included in cast.
          2. Splints, continuous traction.
          3. External fixation devices (Charnley)—multiple pins/rods through limb above and below fracture site, attached to external metal supports. Client able to become ambulatory.
        2. Internal fixation—pins, wires, nails, rods (see VI. TOTAL HIP REPLACEMENT, Physiological Integrity, and VII. TOTAL KNEE REPLACEMENT, Physiological Integrity).
    3. Assessment:
      1. Subjective data:
        1. Pain, tenderness.
        2. Tingling, numbness.
        3. Nausea.
        4. History of traumatic event.
        5. Muscle spasm.
      2. Objective data:
        1. Function: abnormal or lost.
        2. Deformities.
        3. Ecchymosis, increased heat over injured part.
        4. Localized edema.
        5. Crepitation (grating sensations heard or felt as bone fragments rub against each other).
        6. Signs of shock.
        7. Indicators of anxiety.
        8. X-ray: fracture—positive interruption of bone; dislocation—abnormal position of bone.
    4. Analysis/nursing diagnosis:
      1. Pain related to interruption in bone.
      2. Impaired physical mobility related to fracture treatment modality.
      3. Risk for injury related to complications of fractures.
      4. Knowledge deficit (learning need) regarding cast care, crutch walking, traction.
      5. Constipation related to immobilization.
      6. Risk for impaired skin integrity related to immobility or friction from materials used to immobilize the fracture during healing.
    5. Nursing care plan/implementation:
      1. Goal: promote healing and prevent complications of fractures (Table 6.35. Complications of Fractures).
        1. foodImageDiet: high protein, iron, vitamins to improve tissue repair; moderate carbohydrates to prevent weight gain; no increase in calcium to prevent kidney stones (decalcification and demineralization occur when client is immobilized).
          1. Encourage increased fluid intake, to prevent kidney stones.
          2. pillImagePrevent or correct constipation through increasing bulk foods, fruits, and fruit juices, or using prescribed stool softeners, laxatives, or cathartics as necessary.
        2. Provide activities to reduce perceptual deprivation—reading, handcrafts, music, special interests/hobbies that can be done while maintaining correct position for healing.
      2. Goal: prevent injury or trauma in relation to:
        1. Fracture care:
          1. Maintain affected part in optimum alignment.
          2. Maintain skin integrity; check all bony prominences for evidence of pressure q4h and prn, depending on amount of pressure.
          3. Monitor: circulation in, sensation of, and motion of (CSM) affected part q15 min for first 4 hours; q1h until 24 hours; q4h and prn, depending on amount of edema (Table 6.36. Assessing Injured Limb: CSM).
          4. Maintain mobility in unaffected limb and unaffected joints of affected limb by active and passive ROM; prevent footdrop by using ankle-top sneakers.
        2. Skin traction:
          1. Maintain correct alignment:
            1. If tape or moleskin is used, shave extremity and apply benzoin to improve adherence of strip and reduce itching.
            2. Check apparatus for slippage, bunching; replace prn.
          2. Prevent tissue injury:
            1. Check all bony prominences for evidence of pressure: q15 min for first 4 hours; q1h until 24 hours, q4h and prn, depending on amount of edema.
            2. Nonadhesive (e.g., Bryant's ) traction may be removed q8h to check skin.
        3. Skeletal traction:
          1. Maintain affected part in optimum alignment:
            1. infoImage Ropes on pulleys.
            2. Weights hang free.
            3. Elevate head of bed as prescribed.
            4. Check knots routinely.
          2. Maintain skin integrity:
            1. Frequent skin care.
            2. Keep bed linens free of crumbs and wrinkles.
          3. Prevent infection: special skin care to pin insertion sites three times daily. Keep area around pins clean and dry. Use prescribed solution for cleansing.
          4. Monitor circulation in, sensation of, and motion of affected part (see E. 2. a. Fracture care (see above), and Table 6-36. Assessing Injured Limb: CSM, Physiological Integrity).
          5. Maintain mobility in unaffected limb and unaffected joints; prevent footdrop of affected limb.
        4. Running traction(see Figure 6-4. Interpretation of Normal Cardiac Cycle, Types of Skin and Skeletal Traction):
          1. infoImageKeep well centered in bed.
          2. Elevate head of bed only to point of countertraction.
          3. No turning from side to side—will cause rubbing of bony fragments.
          4. Check distal circulation frequently.
          5. Frequent back care to prevent skin breakdown.
          6. Fracture bedpan for toileting.
          7. Avoid excessive padding of splints in groin area to prevent tissue trauma.
        5. Balanced suspension traction(see Figure 6-4. Interpretation of Normal Cardiac Cycle, part F, Types of Skin and Skeletal Traction):
          1. Maintain alignment and countertraction:
            1. infoImage Ropes on pulleys.
            2. infoImageWeights hang free.
            3. Elevate head of bed as prescribed.
            4. Check knots routinely.
          2. infoImageMay move client, but turn only slightly (no more than 30 degrees to unaffected side).
          3. Heel of affected leg must remain free of the bed.
          4. infoImage20-degree angle between thigh and bed.
          5. Check for pressure from sling to popliteal area.
          6. Provide foot support to prevent footdrop.
          7. infoImageMaintain abduction of extremity.
          8. Check for signs of infection at pin insertion sites; cleanse three times daily as ordered.
          9. If tape or moleskin is used, shave extremity and apply benzoin to improve adherence of strip and reduce itching.
        6. Cervical traction (see Figure 6-4. Interpretation of Normal Cardiac Cycle, Types of Skin and Skeletal Traction):
          1. May be placed on specialized bed (e.g., Stryker frame).
          2. infoImagePosition: maintain body alignment.
          3. Keep tongs free from bed, and keep weights hanging freely to allow traction to function properly.
        7. Halo traction:
          1. Several times a day, check screws to the head and screws that hold the upper portion of the frame, to determine correct position.
          2. pillImagePin sites cleansed three times daily with bacteriostatic solution to prevent infection.
          3. infoImageMonitor for signs of infection.
          4. Position as any other client in body cast, except no pressure to rest on halo—pillows may be placed under abdomen and chest when client is prone.
          5. Institute ROM exercises to prevent contractures.
          6. Turn frequently to prevent development of pressure areas.
          7. Allow client to verbalize about having screws placed in skull.
          8. Postapplication nursing care same as pin insertion for other traction.
        8. External fixation devices:
          1. Pin care same as for skeletal traction.
          2. Teach clothing adjustment.
          3. Teach to adjust for size of apparatus.
        9. Internal fixation devices:
          1. Monitor for signs of infection/allergic reaction to materials used for maintenance of reduction (drainage, pain, increased temperature).
          2. Position as ordered to prevent dislocation.
        10. Casts:
          1. Support drying cast on firm pillow; avoid finger imprints on cast.
          2. infoImage Elevate limb to reduce edema.
          3. Prevent complications of fractures as listed.
          4. Closely monitor circulation (blanching, swelling, decreased temperature); sensation (absence of feeling; pain or burning); and motion (inability to move digits of affected limb).
          5. Be prepared to notify physician or cut cast if circulatory impairment occurs.
          6. Protect skin integrity: avoid pressure of edges of cast; petal prn.
          7. Monitor for signs of infection if skin integrity impaired.
      3. Goal: provide care related to ambulation with crutches.
        1. Teach appropriate gait (Table 6.37. Teaching Crutch Walking).
        2. Measure crutches correctly (Table 6.38. Measuring Crutches Correctly).
          1. Subtract 16 inches from total height; top of crutch should be 2 inches below the axilla.
          2. Complete extension of the elbows should be possible without pressure of axilla bar into the axilla.
          3. Handgrip should be adjusted so that complete wrist extension is possible.
          4. Instruct in correct body alignment:
            1. Head erect.
            2. Back straight.
            3. Chest forward.
            4. Feet 6 to 8 inches apart, wide base for support.
      4. Goal: provide safety measures related to possible complications following fracture (see Table 6-35. Complications of Fractures ).
      5. Goal: health teaching.
        1. Explain and show apparatus before application, if possible.
        2. Pin care at least once daily to prevent granulation and cellulitis.
        3. Correct position for rest/sleep and prevention of injury with halo traction—no pressure on halo.
        4. Purpose of cast: to immobilize, to support body tissues, to prevent or correct deformities.
        5. Teach signs and symptoms of complications to report related to cast care (i.e., numbness, odor, crack/break in cast; extremity cold, bluish).
        6. Isometric exercises for use with affected joint.
        7. Safety measures with crutches:
          1. Weight-bearing on hands, not axilla.
          2. Position crutches 4 inches to side and 4 inches to front.
          3. Use short strides, looking ahead, not at feet.
          4. Prevent injury: if client begins to fall, throw crutches to side to prevent falling on them; body should be relaxed.
          5. Check for environmental hazards: rugs, water spills.
    6. Evaluation/outcome criteria:
      1. No injury or complications related to apparatus or immobilization (e.g., infection, tissue injury, altered circulation/sensation, dislocation).
      2. Bone remains in correct alignment and begins to heal.
      3. Demonstrates elevated limb position to relieve edema with casted extremity.
      4. Lists complications related to circulation or neurological impairment and infection.
      5. Begins to use affected part.
      6. Demonstrates correct technique for ambulation with crutches—no pressure on axilla, uses strength of arms and wrists.
      7. No falls while using crutches.
  3. COMPARTMENT SYNDROME: an accumulation of fluid in the muscle compartment, resulting in an increase in pressure that reduces blood flow to the tissues. Can lead to neuromuscular deficit, amputation, and death.
    1. Pathophysiology: inability of the fascia surrounding the muscle group to expand to accommodate the increased volume of fluid → compartment pressure increases → venous flow impaired → arterial flow continues, increasing capillary pressure → fluid pushed into the extravascular space → intracompartment pressure further increased → prolonged or severe ischemia→ muscle and nerve cells destroyed, contracture, loss of function, necrotic tissue, infection, release of potassium, hydrogen, and myoglobin into bloodstream.
    2. Risk factors:
      1. Fractures.
      2. Burns.
      3. Crushing injuries.
      4. Restrictive bandages.
      5. Cast.
      6. Prolonged lithotomy positioning.
      7. Ischemic injury (arterial or venous injury).
    3. Assessment:
      1. Subjective data:
        1. Severe, unrelenting pain, unrelieved by narcotics and associated with passive stretching of muscle.
        2. Paresthesias.
      2. Objective data:
        1. Edema; tense skin over limb.
        2. Paralysis.
        3. Decreased or absent peripheral pulses.
        4. Poor capillary refill.
        5. Limb temperature change (colder).
        6. Ankle-arm pressure index (API) decreased; 0.4 indicates ischemia (see Chapter 11. Reduction of Risk Potential, Doppler ultrasonography, Reduction of Risk Potential).
        7. Urine output—decreased (developing acute tubular necrosis); reddish-brown color.
    4. Analysis/nursing diagnosis:
      1. Pain related to tissue swelling and ischemia.
      2. Risk for injury related to neuromuscular deficits.
      3. Impaired physical mobility related to contracture and loss of function.
      4. Risk for infection related to tissue necrosis.
      5. Altered urinary elimination related to acute tubular necrosis from myoglobin accumulation.
      6. Body image disturbance related to limb disfigurement.
    5. Nursing care plan/implementation:
      1. Goal: recognize early indications of ischemia.
        1. Assess neurovascular status frequently (q1h): skin temperature, capillary refill, peripheral pulses, mobility, and sensation.
        2. Listen to client complaints; report suspected complications.
        3. Report nonrelief of pain with narcotics.
        4. Recognize unrelenting pain with passive muscle stretching.
      2. Goal: prevent complications.
        1. infoImageElevate injured extremity initially; if ischemia suspected, keep extremity at heart level to prevent compensatory increase in blood flow.
        2. Avoid tight bandages, splints, or casts.
        3. Monitor intravenous infusion for signs of infiltration.
        4. Prepare client for fasciotomy (incision of skin and fascia to release tight compartment).
    6. Evaluation/outcome criteria:
      1. Relief from pain; normal perfusion restored.
      2. Neurovascular status within normal limits.
      3. Retains function of limb; no contractures or infection.
      4. Compartment pressure returns to normal (<20 mm Hg).
      5. No systemic complications (e.g., normal cardiac and renal function, acid-base balance within normal limits).
  4. OSTEOARTHRITIS: joint disorder characterized by degeneration of articular cartilage and formation of bony outgrowths at edges of weight-bearing joints.
    1. Pathophysiology: excessive friction combined with risk factors → thinning of articular cartilage, narrowing of joint space, and loss of joint stability; cartilage erodes, producing shallow pits on articular surface and exposing bone in joint space. Bone responds by becoming denser and harder.
    2. Risk factors:
      1. Aging (>50).
      2. Rheumatoid arthritis.
      3. Arteriosclerosis.
      4. Obesity.
      5. Trauma.
      6. Family history.
    3. Assessment:
      1. Subjective data:
        1. Pain; tender joints.
        2. Fatigability, malaise.
        3. Anorexia.
        4. Cold intolerance.
        5. Extremities: numbness, tingling.
      2. Objective data:
        1. Joints:
          1. Enlarged.
          2. Stiff, limited movement.
          3. Swelling, redness, and heat around affected joint.
          4. Shiny stretched skin over and around joint.
          5. Subcutaneous nodules.
        2. Weight loss.
        3. Fever.
        4. Crepitation (creaking or grating of joints).
        5. Deformities, contractures.
        6. Cold, clammy extremities.
        7. Laboratory data: decreased Hgb, elevated WBC count.
        8. Diagnostic tests: x-ray, thermography, arthroscopy.
    4. Analysis/nursing diagnosis:
      1. Pain related to friction of bones in joints.
      2. Bathing/hygiene self-care deficit related to decreased mobility of involved joints.
      3. Risk for injury related to fatigability.
      4. Impaired physical mobility related to stiff, limited movement.
      5. Impaired home maintenance management related to contractures.
    5. Nursing care plan/implementation:
      1. Goal: promote comfort: reduce pain, spasms, inflammation, swelling.
        1. pillImageMedications as prescribed.
          1. Nonsteroidal antiinflammatory agents: aspirin (Ecotrin), acetaminophen (Tylenol), ibuprofen (Motrin), indomethacin (Indocin), corticosteroids, nabumetone (Relafen), naproxen (Naprosyn).
          2. Antimalarials: chloroquine (Aralen), hydroxychloroquine (Plaquenil), to relieve symptoms.
        2. Heat to reduce muscle spasms, stiffness.
        3. Cold to reduce swelling and pain.
        4. Prevent contractures:
          1. Exercise.
          2. Bedrest on firm mattress during attacks.
          3. Splints to maintain proper alignment.
        5. infoImageElevate extremity to reduce swelling.
        6. Rest.
        7. Assistive devices to decrease weight-bearing of affected joints (canes, walkers).
      2. Goal: health teaching to promote independence.
        1. Encourage self-care with assistive devices for activities of daily living (ADLs).
        2. Activity, as tolerated, with ambulation-assistive devices.
        3. Scheduled rest periods.
        4. Correct body posture and body mechanics.
      3. Goal: provide for emotional needs.
        1. Accept feelings of frustration regarding long-term debilitating disorder.
        2. Provide diversional activities appropriate for age and physical condition to promote comfort and satisfaction.
    6. Evaluation/outcome criteria:
      1. Remains independent as long as possible.
      2. No contractures.
      3. States comfort has increased.
      4. Uses methods that are successful in pain control.
  5. RHEUMATOID ARTHRITIS: chronic, systemic, collagen inflammatory disease; etiology unknown; may be autoimmune, viral, or genetic; affects primarily women ages 20 to 40 years; present in 2% to 3% of total population; follows a course of exacerbations and remissions.
    1. Pathophysiology: synovitis with edema → proliferation of various blood material (formation of pannus) → destruction and fibrosis of cartilage (fibrous ankylosis); calcification of fibrous tissue (osseous ankylosis) (Figure. 6.15. Rheumatoid Arthritis).
    2. Assessment:
      1. Subjective data:
        1. Joints: pain; morning stiffness; swelling.
        2. Easily fatigues; malaise.
        3. Anorexia; weight loss.
      2. Objective data:
        1. Subcutaneous nodules over bony prominences.
        2. Bilateral symmetrical involvement of joints: crepitation, creaking, grating.
        3. Deformities: contractures, muscle atrophy.
        4. Laboratory data: blood: decreased—hemoglobin/hematocrit; RBCs; increased—WBCs (12,000 to 15,000), sedimentation rate (>20 mm/hr), rheumatoid factor. Positive antinuclear antibody titer.
    3. Analysis/nursing diagnosis:
      1. Pain related to joint destruction.
      2. Impaired physical mobility related to joint contractures.
      3. Risk for injury related to the inflammatory process.
      4. Body image disturbance related to joint deformity.
      5. Self-care deficit related to musculoskeletal impairment.
      6. Risk for activity intolerance related to fatigue and stiffness.
      7. Altered nutrition, less than body requirements, related to anorexia and weight loss.
      8. Self-esteem disturbance related to chronic illness.
    4. Nursing care plan/implementation:
      1. Goal: prevent or correct deformities.
        1. Activity:
          1. Bedrest during exacerbations.
          2. Daily ROM—active and passive exercises even in acute phase, 5- to 10-minute periods; avoid fatigue and persistent pain.
          3. Heat or pain medication before exercise.
        2. pillImageMedications: aspirin (high dosages); nonsteroidals; steroids; antacids given for possible GI upset with ASA, steroids; disease-modifying antirheumatics (methotrexate, hydroxychloroquine, sulfasalazine).
        3. Fluids: at least 1,500 mL liquid daily to avoid renal calculi; milk for GI upset.
      2. Goal: health teaching.
        1. Side effects of medications: tarry stools (GI bleeding); tinnitus (ASA).
        2. Psychosocial aspects: possible need for early retirement; financial hardship; loss of libido; unsatisfactory sexual relations.
        3. Prepare for joint repair or replacement if indicated.
    5. Evaluation/outcome criteria:
      1. Remains as active as possible; limited loss of mobility; performs self-care activities.
      2. No side effects from drug therapy (e.g., GI bleeding).
      3. Copes with necessary lifestyle changes; complies with treatment regimen.
  6. TOTAL HIP REPLACEMENT: femoral head and acetabulum are replaced by a prosthesis, which is cemented into the bone with plastic cement. Performed to replace a joint with limited and painful function due to bony alkalosis and deformity, caused by degenerative joint disease or when vascular supply to femoral head is compromised from a fracture. Goal of the surgery: restore or improve mobilization of hip joint and prevent complications of extended immobilization.
    1. Risk factors:
      1. Rheumatoid arthritis.
      2. Osteoarthritis.
      3. Complications of femoral neck fractures—avascular necrosis and malunion (Table 6.39. Fractures of the Hip).
      4. Congenital hip disease.
    2. Analysis/nursing diagnosis:
      1. Risk for injury related to implant surgery.
      2. Knowledge deficit (learning need) regarding joint replacement surgery.
      3. Impaired physical mobility related to major hip surgery.
      4. Pain related to surgical incision.
      5. Risk for impaired skin integrity related to immobility.
    3. Nursing care plan/implementation:
      1. Preoperative:
        1. Goal: prevent deep vein thrombosis or pulmonary emboli.
          1. Antiembolic stockings.
          2. Increase fluid intake.
        2. pillImageGoal: prevent infection: antibiotics as ordered, given prophylactically (Cefazolin).
        3. Goal: health teaching.
          1. Isometric exercises—gluteal, abdominal, and quadriceps-setting; dorsiflexion and plantar flexion of the feet.
          2. Use of trapeze.
          3. Explain position of operative leg and hip postoperatively to prevent adduction and flexion.
          4. Transfer techniques—bed to chair and chair to crutches; dangle at bedside first time out of bed.
          5. Assist client with skin scrubs with antibacterial soap.
      2. Postoperative:
        1. Goal: prevent respiratory complications.
          1. Turn, cough, and deep breathe.
          2. Incentive spirometry.
        2. Goal: prevent complications of shock or infection.
          1. Check dressings for drainage q1h for first 4 hours; then q4h and prn; may have Hemovac or other drainage tubes inserted in wound to keep dressing dry.
          2. Monitor I&O and vital signs hourly for 4 hours, then q4h and prn.
        3. Goal: prevent contractures, muscle atrophy: initiate exercises as soon as allowed: isometric quadriceps, dorsiflexion and plantar flexion of foot, and flexion and extension of the ankle—sequential compression device while in bed.
        4. Goal: promote early ambulation and movement.
          1. Use trapeze.
          2. Transfer technique (pivot on unaffected leg); crutches/walker.
          3. infoImageInitiate progressive ambulation as ordered; ensure maximum extension of leg when walking.
          4. pillImageAdminister anticoagulation therapy as ordered (warfarin immediately postoperatively) to prevent deep vein thrombosis and pulmonary emboli.
          5. Recognize early side effects of medications and report appropriately.
        5. Goal: prevent constipation.
          1. Increase fluid intake.
          2. Use fracture bedpan.
        6. Goal: prevent dislocation of prosthesis.
          1. infoImageMaintain abduction of the affected joint (prevent external rotation); elevate head of bed, turn according to physician's order. When turning to unaffected side, turn with abduction pillow between legs to maintain abduction.
          2. Buck's extension or Russell's traction may be applied (temporary skin traction).
          3. Plaster booties with an abduction bar may be used.
          4. infoImageWedge Charnley (triangle-shaped) pillow to maintain abduction between knees and lower legs.
          5. infoImageProvide periods throughout day when client lies flat in bed to prevent hip flexion and strengthen hip muscles.
          6. Report signs of dislocation: anteriorly—knee flexes, leg turns outward, leg looks longer than other, femur head may be felt in groin area; posteriorly—leg turns inward, appears shorter than other, greater trochanter elevated.
        7. Goal: promote comfort.
          1. Initiate skin care; monitor pressure points for redness; back care q2h.
          2. Alternating pressure mattress; sheepskin when sitting in chair.
        8. Goal: health teaching.
          1. Exercise program with written list of activity restrictions.
          2. Methods to prevent hip adduction.
          3. Avoid sitting for more than 1 hour: stand, stretch, and walk frequently to prevent hip flexion contractures.
          4. infoImageAdvise not to exceed 90 degrees of hip flexion (dislocation can occur, particularly with posterior incisions); avoid low chairs.
          5. Teach alternative methods of usual selfcare activities to prevent hip dislocation (e.g., avoid: bending from waist to tie shoes, sitting up straight in a low chair, using a low toilet seat).
          6. Avoid crossing legs, driving a car for 6 weeks.
          7. Wear support hose for 6 weeks to enhance venous return and avoid thrombus formation.
    4. Evaluation/outcome criteria:
      1. Participates in postoperative nursing care plan to prevent complications.
      2. Reports pain has decreased.
      3. Ambulates with assistive devices.
      4. Complications of immobility avoided.
      5. Able to resume self-care activities.
  7. TOTAL KNEE REPLACEMENT: both sides of the joint are replaced by metal or plastic implants.
    1. Analysis/nursing diagnosis (see VI. TOTAL HIP REPLACEMENT, Physiological Integrity).
    2. Nursing plan/implementation:
      1. See VI. TOTAL HIP REPLACEMENT, Physiological Integrity.
      2. Goal: achieve active flexion beyond 70 degrees.
        1. infoImageImmediately postoperatively: may have continuous passive motion (CPM) device for flexion-extension of affected knee. Maximum flexion 110 degrees
        2. Monitor drainage in Hemovac (q15 min for first 4 hours, q1h until 24 hours; q4h and prn while Hemovac in place).
        3. pillImageAnalgesics as ordered for pain.
        4. While dressings are still on: quadriceps-setting exercises for approximately 5 days (consult with physical therapist for specific instructions).
        5. After dressings removed: active flexion exercises.
        6. Avoid pressure on heel.
    3. Evaluation/outcome criteria:
      1. No complications of infection, hemorrhage noted.
      2. ROM of knee increases with exercises.
  8. AMPUTATION: surgical removal of a limb as a result of trauma or circulatory impairment (gangrene). The amount of tissue amputated is determined by the severity of disease or trauma and the ability of the remaining tissue to heal.
    1. Risk factors:
      1. Atherosclerosis obliterans.
      2. Uncontrolled diabetes mellitus.
      3. Malignancy.
      4. Extensive and intractable infection.
      5. Result of severe trauma.
    2. Assessment (preoperative):
      1. Subjective data: pain in affected part.
      2. Objective data:
        1. Soft tissue damage.
        2. Partial or complete severance of a body part.
        3. Lack of peripheral pulses.
        4. Skin color changes, pallor → cyanosis → gangrene.
        5. Infection, hemorrhage, or shock.
    3. Analysis/nursing diagnosis:
      1. Impaired physical mobility related to lower-limb amputation.
      2. Body image disturbance related to loss of body part.
      3. Pain related to interruption of nerve pathways.
      4. Anxiety related to potential change in lifestyle.
      5. Knowledge deficit (learning need) related to rehabilitation goals.
    4. Nursing care plan/implementation:
      1. Goal: prepare for surgery, physically and emotionally.
        1. Validate that client and family are aware that amputation of body part is planned.
        2. Validate that informed consent is signed.
        3. Allow time for grieving.
        4. If time allows, prepare client for postoperative phase (e.g., teach arm-strengthening exercises if lower limb is to be amputated; teach alternative methods of ambulation).
        5. Provide time to discuss feelings.
        6. Prepare surgical site to decrease possibility of infection (e.g., shave, scrub as ordered).
        7. Discuss postoperative expectations.
      2. Goal: promote healing postoperatively.
        1. Monitor respiratory status q1–4h and prn: rate, depth of respiration; auscultate for signs of congestion; and question client about chest pain ( pulmonary emboli common complication).
        2. Monitor for hemorrhage; keep tourniquet at bedside.
        3. pillImageMedicate for pain as ordered—client may have phantom limb pain.
        4. infoImageSupport stump on pillow for first 24 hours; remove pillow after 24 hours to prevent contracture.
        5. infoImagePosition: turn client on to stomach to prevent hip contracture.
        6. ROM exercises for joint above amputation to prevent joint immobilization; strengthening exercises for arms, nonaffected limbs, abdominal muscles.
        7. Stump care:
          1. Early postoperative dressings changed prn.
          2. As incision heals, bandage is applied in cone shape to prepare stump for prosthesis.
          3. Inspect for blisters, redness, abrasions.
          4. Remove stump sock daily and prn.
        8. Assist in rehabilitation program.
    5. Evaluation/outcome criteria:
      1. Begins rehabilitation program.
      2. No hemorrhage, infection.
      3. Adjusts to altered body image.
  9. GOUT: disorder of purine metabolism; genetic disease believed to be transmitted by a dominant gene, characterized by recurrent attacks of acute pain and swelling of one joint (usually the great toe).
    1. Pathophysiology: urate crystals and infiltrating leukocytes appear to damage the intracellular phagolysosomes, resulting in leakage of lysomal enzymes into the synovial fluid, causing tissue damage and joint inflammation.
    2. Risk factors:
      1. Men.
      2. Age (>50).
      3. Genetic/familial tendency.
      4. Prolonged hyperuricemia (elevated serum uric acid).
      5. Obesity.
      6. Moderate to heavy alcohol intake.
      7. Hypertension.
      8. Abnormal kidney function.
    3. Assessment:
      1. Subjective data:
        1. Pain: excruciating
        2. Fatigue
        3. Anorexia.
      2. Objective data:
        1. Joint: erythema (redness), hot, swollen, difficult to move; skin stretched and shiny over joint.
        2. Subcutaneous nodules, tophi (deposits of urate) on hands and feet.
        3. Weight loss.
        4. Fever.
        5. Sensory changes, with cold intolerance.
        6. Laboratory data:
          1. Serum uric acid: increased significantly (6.5 mg/100 mL in women, 7.5 mg/100 mL in men) in chronic gout; only slightly increased in acute gout.
          2. WBC count: 12,000 to 15,000/mm3.
          3. Erythrocyte sedimentation rate: >20 mm/hr.
          4. 24-hour urinary uric acid: slightly elevated.
          5. Proteinuria (chronic gout).
          6. Azotemia (presence of nitrogen-containing compounds in blood) in chronic gout.
        7. Diagnostic tests: arthrocentesis, x-rays.
    4. Analysis/nursing diagnosis:
      1. Pain related to inflammation and swelling of affected joint.
      2. Impaired physical mobility related to pain.
      3. Knowledge deficit (learning need) related to diet restrictions and increased fluid needs.
      4. Altered urinary elimination related to kidney damage.
    5. Nursing care plan/implementation:
      1. Goal: decrease discomfort.
        1. pillImageAdminister antigout medications as ordered:
          1. Treatment of acute attacks: colchicine, phenylbutazone (Butazolidin), indomethacin (Indocin), allopurinol (Zyloprim), naproxen (Naprosyn), corticosteroids (prednisone).
          2. Preventive therapy: probenecid (Benemid), sulfinpyrazone (Anturane). These drugs are not used during acute attacks.
        2. infoImageAbsolute rest of affected joint → gradual increase in activities, to prevent complications of immobilization; at the same time, rest for comfort.
      2. Goal: prevent kidney damage.
        1. Increase fluid intake to 2,000 to 3,000 mL/day.
        2. Monitor urinary output.
      3. Goal: health teaching.
        1. foodImageNeed for low-purine diet during acute attack (see Purine-restricted diet, Common Therapeutic Diets, Chapter 9. Physiological Integrity: Basic Care and Comfort—Nutrition, Special Diets).
        2. Importance of increased fluid in diet.
        3. Signs and symptoms of increased progression of disease.
        4. Dosage and side effects of prescribed medications.
    6. Evaluation/outcome criteria:
      1. Swelling decreased.
      2. Discomfort alleviated.
      3. Mobility returned to status before attack.
      4. Laboratory values return to normal.
  10. LUPUS ERYTHEMATOSUS (LE): chronic inflammatory disease of connective tissue; may affect or involve any organ; vague etiology, but genetic factors, viruses, hormones, and drugs are being investigated; occurs primarily in women ages 18 to 35 years. Two forms: discoid lupus erythematosus (DLE) affects skin only, and systemic lupus erythematosus (SLE) affects multiple organs.
    1. Pathophysiology: possible toxic effects from immune complexes deposited in tissue (antibodyantigen trapping in organ capillaries)—fibrinoid necrosis of collagen in connective issue, small arterial walls (kidneys and heart particularly) → cellular death, obstructed blood flow.
    2. Assessment:
      1. Subjective data:
        1. Pain: joints.
        2. Anorexia; weight loss.
        3. Photophobia; sensitivity to sun.
        4. Weakness.
        5. Nausea, vomiting.
      2. Objective data:
        1. Fever.
        2. Rash: butterfly distribution across nose, cheeks.
        3. Lesions: raised, red, scaling plaques—coinlike (discoid).
        4. Ulceration: oral or nasopharyngeal.
        5. Laboratory data:
          1. Blood: increased LE cells; decreased—RBCs, WBCs, thrombocytes. Positive antinuclear antibody (ANA) titer.
          2. Urine—hematuria, proteinuria (nephritis).
    3. Analysis/nursing diagnosis:
      1. Risk for injury related to possible autoimmune disorder.
      2. Pain related to joint inflammation.
      3. Risk for activity intolerance related to extreme fatigue, anemia.
      4. Body image disturbance related to chronic skin eruptions.
      5. Altered nutrition, less than body requirements, related to anorexia, nausea, vomiting.
      6. Altered oral mucous membrane related to ulcerations.
    4. Nursing care plan/implementation:
      1. Goal: minimize or limit immune response and complications.
        1. Activity: rest; 8 to 10 hours' sleep; unhurried environment; assist with stressful activities; ROM to prevent joint immobility and stiffness.
        2. pillImageSkin care: hygiene; topical steroid cream as ordered for inflammation, pruritus, scaling.
        3. Mouth care: several times daily if stomatitis present; soft, bland, or liquid diet to prevent irritation.
        4. foodImageDiet: low sodium if edematous; low protein with renal involvement.
        5. Observe for signs of complications:
          1. Cardiac/respiratory (tachycardia, tachypnea, dyspnea, orthopnea).
          2. GI (diarrhea, abdominal pain, distention).
          3. Renal (increased weight, oliguria, decreased specific gravity).
          4. Neurological (ptosis, ataxia).
          5. Hematological (malaise, weakness, chills, epistaxis); report immediately.
        6. pillImageMedications, as ordered:
          1. Analgesics.
          2. Anti-inflammatory agents (aspirin, prednisone) and immunosuppressive drugs (azathioprine [Imuran], cyclophosphamide [Cytoxan]) to control inflammation.
          3. Antimalarials for skin and joint manifestations.
      2. Goal: health teaching.
        1. Disease process: diagnosis, prognosis, effects of treatment.
        2. Avoid precipitating factors:
          1. Sun (aggravates skin lesions; thus, cover body as much as possible).
          2. Altering dosage of medications.
          3. Pregnancy (requires medical clearance).
          4. Fatigue, stress.
          5. Infections.
        3. Medications: side effects of immunosuppressives and corticosteroids.
        4. Regular exercise: walking, swimming; but avoid fatigue.
        5. Wear Medic Alert bracelet.
    5. Evaluation/outcome criteria:
      1. Attains a state of remission.
      2. No organ involvement (e.g., no cardiac, renal complications).
      3. Keeps active within limitations.
      4. Continues follow-up medical care—recognizes symptoms requiring immediate attention.