13
Rehab Quiz 2 Review
TBI, & musculoskeletal, stroke & brain tumors
- Rheumatoid arthritis & pt education
2.
Hip fractures (several questions)
- S & s
- Treatment
- Risk factors post op
Fractures of the Hip
Hip fracture is the most common injuries in older adults and one of the most frequently seen injuries in any health care setting or community. It has a high mortality rate as a result of multiple complications related to surgery and prolonged immobility. Osteoporosis is the biggest risk factor for hip fractures (see Chapter 53). This disease weakens the upper femur (hip), breaks, and then causes the person to fall. The number of people with hip fracture is expected to continue to increase as the population ages, and the associated health care costs will be tremendous.
CONSIDERATIONS FOR OLDER ADULTS
Teach older adults about the risk factors for hip fracture including physiologic aging changes, disease processes, drug therapy, and environmental hazards. Physiologic changes include sensory changes such as visual acuity and diminished hearing; changes in gait, balance, and muscle strength; and joint stiffness. Disease processes like osteoporosis, foot disorders, and changes in cardiac function increase the risk for hip fracture. Drugs, such as diuretics, antihypertensives, antidepressants, sedatives, opioids, and alcohol are factors that increase the risks for falling in older adults. Use of three or more drugs at the same time drastically increases the risk for falls. Throw rugs, loose carpeting, inadequate lighting, uneven walking surfaces or steps, and pets are environmental hazards that also cause falls.
The older adult with hip fracture usually reports groin pain or pain behind the knee on the affected side. In some cases, the patient has pain in the lower back or has no pain at all. However, the patient is not able to stand. X-ray or other imaging assessment confirms the diagnosis. Hip fractures include those involving the upper third of the femur and are classified as intracapsular (within the joint capsule) or extracapsular (outside the joint capsule). These types are further divided according to fracture location (Fig. 54-8). In the area of the femoral neck there is concern with disruption of the blood supply to the head of the femur, which can result in ischemic or avascular necrosis (AVN) of the femoral head. AVN causes death and necrosis of bone tissue and results in pain and decreased mobility. This problem is most likely in patients with displaced fractures. Prompt surgical repair can prevent this complication and decrease pain.
The treatment of choice is surgical repair, when possible, to allow the older patient to be out of bed and ambulatory. Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm. Depending on the exact location of the fracture, open reduction with internal fixation (ORIF) may include an intramedullary rod, pins, prostheses (for femoral head or neck fractures), or a compression screw.
Epidural or general anesthesia is used. Figs. 54-9 and 54-10 illustrate examples of these devices. Occasionally a patient will be so debilitated that surgery cannot be done. In these cases, nonsurgical options are Buck's traction, pain management, and bedrest to allow natural fracture healing (Altizer, 2005; Watters & Moran, 2006).
Patients usually receive PCA morphine or other opioid or epidural analgesia after surgery. Chapter 5 discusses the nursing care associated with these pain management modalities in detail. The patient begins ambulating with assistance the day after surgery to prevent complications associated with immobility (e.g., pressure ulcers, atelectasis, venous thromboembolism). Early movement and ambulation also decrease the chance of infection and increase surgical site healing.
EVIDENCE-BASED PRACTICE
What are the major factors that influence functional status after hip surgery?
Folden, S., & Tappen, R. (2007). Factors influencing function and recovery following hip repair surgery. Orthopaedic Nursing, 26(4), 234-241.
The purpose of this small descriptive study was to determine which factors predicted the functional ability of patients who had hip repair surgery by 3 months after hospital discharge. Previous studies had suggested many contributing factors, including age, balance, cognitive ability, gender, fatigue, pain, and complications from surgery. Functional status before surgery had also been found to be a factor.
A convenience sample of 73 men and women was evaluated by self-report in an inpatient rehabilitation setting after hospital discharge and again in 3 months. Balance and cognitive ability before surgery were the best predictors of recovery and return to baseline functional status. Fatigue also played a role. Men reported higher functional levels than women and were more likely to return to their presurgical activities. The authors concluded that gender did influence recovery from hip repair surgery.
Level of Evidence—6. This research was a small descriptive study using a convenience sample.
Commentary: Implications for Practice and Research. Although this study was descriptive, it confirmed previous findings of other researchers about which factors predict return to functional ability among patients having hip repair. Physicians can use this information in making decisions about who are the best candidates for surgery. Nurses and rehabilitation therapists can use these findings to plan interventions to improve balance and reduce fatigue as patients recover from surgery during their rehabilitation period.
Patients who have an ORIF are at risk for hip dislocation or subluxation. Be sure to prevent hip adduction and rotation to keep the operative leg in proper alignment. Regular pillows or abduction devices can be used for patients who are confused or restless. If straps are used to hold the device in place, check the skin for signs of pressure. Perform neurovascular assessments to ensure that the device is not interfering with arterial circulation or peripheral nerve conduction.
Special considerations for the patient having a hip repair also include careful inspection of skin including areas of pressure, especially the heels. Use of Buck's traction and periods of bedrest before surgical intervention can increase the risk for pressure injury in this area within 24 hours. Be sure that the patient's heels are up off the bed at all times. Inspect the heels and other high-risk bony prominence areas every 8 to 12 hours. Delegate turning and repositioning every 1 to 2 hours to unlicensed assistive personnel (UAP), and supervise this nursing activity. Other measures to decrease the risk for pressure ulcers are described elsewhere in this text and in fundamentals textbooks.
Other nursing and interdisciplinary care is similar to that described for fracture in other sites. Specific interventions are similar to those for total hip replacement (see Chapter 20).
Many patients recover fully from hip fracture repair and regain their functional ability. However, some patients are not able to return to their pre-fracture ADLs and mobility level. These patients usually do not return to their homes and are placed in long-term care facilities. Folden and Tappen (2007) conducted a small descriptive study that identified predictors for patients who are likely to fully recover. They found that balance and cognitive ability were the best predictors (see the Evidence-Based Practice box above).
- Risk factors for elderly r/t osteoporosis & osteoarthritis
Although the exact etiology of primary OA has not been identified, the disease may be triggered by aging, genetic changes, obesity, smoking, and/or trauma.
Other factors that can lead to OA are obesity and smoking. Obesity causes joint degeneration, particularly in the knees. Smoking leads to knee cartilage loss, especially in patients with a family history of knee OA. This finding shows a geneenvironment interaction in the cause of knee OA (Ding et al., 2007).
Trauma to the joints from excessive use or abuse predisposes a person to OA. Certain heavy manual occupations(e.g., carpet laying, construction, farming) cause high-intensity or repetitive stress to the joints. The risk of hip and knee OA is also increased in professional athletes, especially football and soccer players, runners, and gymnasts. Lack of exercise can contribute to muscle loss. Muscle tissue helps support joints, particularly those that bear weight (e.g., hips, knees).
In a small percentage of people, congenital anomalies, trauma, and joint sepsis can result in secondary OA. For example, injuries from motor vehicle accidents can cause OA in later years. Certain metabolic diseases (e.g., diabetes mellitus, Paget's disease of the bone) and blood disorders (e.g., hemophilia, sickle cell disease) can also cause joint degeneration. Inflammatory joint diseases such as rheumatoid arthritis can lead to secondary OA.
OSTEOPOROSIS
Pathophysiology
Osteoporosis is a chronic metabolic disease in which bone loss causes decreased density and possible fracture. It is often referred to as a “silent disease” because the first sign of osteoporosis in most people follows some kind of a fracture. The hip, spine, and wrist are most often at risk, although any bone can fracture (National Osteoporosis Foundation, 2007a).
Bone is a dynamic tissue that is constantly undergoing changes in a process referred to as bone remodeling. Osteoporosis and osteopenia (low bone mass) occur when osteoclastic (bone resorption) activity is greater than osteoblastic (bone building) activity. The result is a decreased bone mineral density (BMD). BMD determines bone strength and peaks between 25 and 30 years of age. Before and during the peak years, osteoclastic activity and osteoblastic activity work at the same rate. After the peak years, bone resorption activity exceeds bone-building activity, and bone density decreases. BMD decreases most rapidly in postmenopausal women as serum estrogen levels diminish. Although estrogen does not build bone, it helps prevent bone loss. Trabecular, or cancellous (spongy), bone is lost first, followed by loss of cortical (compact) bone. This results in thin, fragile bone tissue that is at risk for fracture (National Osteoporosis Foundation, 2007b).
Standards for the diagnosis of osteoporosis are based on BMD testing that provides a T-score for the patient. A T-score represents the number of standard deviations above or below the average BMD for young, healthy adults. Osteopenia is present when the T-score is at −2 1 and above −22.5. Osteoporosisis diagnosed in a person who has a T-score at or lower than −22.5. Medicare reimburses for BMD testing every 2 years in people age 65 years and older who (National Osteoporosis Foundation, 2007c):
• Are estrogen deficient
• Receive long-term steroid therapy
• Have hyperparathyroidism
• Are being monitored while on osteoporosis drug therapy
The exact pathophysiology of osteoporosis is unclear, but two broad theories of disease development have been advocated. First, osteoporosis may result from increased osteoclastic (bone resorption) activity and decreased osteoblastic (bone building) activity related to changes in hormone levels or other disease processes. This theory has resulted in treatment directed toward measures to prevent rapid bone resorption. The second theory is that osteoblasts, or bone-forming cells, may have a shortened life span or may be less efficient in the patient with osteoporosis.
Osteoporosis can be classified as generalized or regional. Generalized osteoporosis involves many structures in the skeleton and is further divided into two categories, primary and secondary. Primary osteoporosis is more common and occurs in postmenopausal women and in men in their seventh or eighth decade of life. Even though men do not experience the rapid bone loss that postmenopausal women have, they do have decreasing levels of testosterone (which builds bone) and altered ability to absorb calcium. This results in a slower loss of bone mass in men, especially those older than 75 years. Secondary osteoporosis may result from other medical conditions, such as hyperparathyroidism; long-term drug therapy, such as with corticosteroids; or prolonged immobility, such as that seen with spinal cord injury (Table 53-1). Treatment of the secondary type is directed toward the cause of the osteoporosis when possible.
Regional osteoporosis, an example of secondary disease, occurs when a limb is immobilized related to a fracture, injury, or paralysis. Immobility for longer than 8 to 12 weeks can result in this type of osteoporosis. Bone loss also occurs when people spend prolonged time in a gravity-free or weightless environment (e.g., astronauts). The United States and other countries are studying this problem during trips into space.
Etiology and Genetic Risk
Primary osteoporosis is probably caused by a combination of risk factors and genetic changes (Chart 53-1). Peak bone mass is achieved by about 30 years of age in most women. Building strong bone as a young person may be the best defense against osteoporosis in later adulthood (National Osteoporosis Foundation, 2007a). Young women need to be aware of appropriate health and lifestyle practices that can prevent this potentially disabling disease.
TABLE 53-1 Causes of Secondary Osteoporosis
DISEASES/CONDITIONS
• Diabetes mellitus
• Hyperthyroidism
• Hyperparathyroidism
• Cushing's syndrome
• Growth hormone deficiency
• Metabolic acidosis
• Female hypogonadism
• Paget's disease
• Osteogenesis imperfecta
• Rheumatoid arthritis
• Prolonged immobilization
• Bone cancer
• Cirrhosis
• HIV/AIDS
• Chronic airway limitation
DRUGS (CHRONIC USE)
• Corticosteroids
• Heparin
• Anticonvulsants (phenobarbital, phenytoin)
• Ethanol (alcohol)
• Drugs that induce hypogonadism (decreased levels of sex hormones)
• High levels of thyroid hormone
• Cytotoxic agents
• Immunosuppressants
• Loop diuretics
AIDS, Acquired immune deficiency syndrome; HIV, human immune deficiency virus.
Chart 53-1 BEST PRACTICE FOR PATIENT SAFETY & QUALITY CARE
Assessing Risk Factors for Primary Osteoporosis
Assess for:
• Age 65 years and older in all women
• Age 75 years and older in men
• Family history of osteoporosis
• History of low-trauma fracture after age 50 years
• Caucasian or Asian ethnicity
• Low body weight, thin build
• Chronic low calcium intake
• Estrogen or androgen deficiency
• Women with other risk factors
• Smoking history
• High alcohol intake
• Lack of physical exercise or prolonged immobility
Primary osteoporosis most often occurs in women after menopause as a result of decreased estrogen levels. Women lose about 2% of their bone mass every year in the first 5 years after natural or surgical (ovary removal) menopause. For women of any age who do not take estrogen replacement, the risk for osteoporosis increases.
In addition, body build seems to influence who gets the disease. Osteoporosis occurs more often in thin, lean-built European-American and Asian women, particularly those who do not exercise regularly. Obese women can store estrogen in their tissues for use as necessary to maintain a normal level of serum calcium. Weight-bearing exercise reduces bone resorption (loss) and stimulates bone formation. Prolonged immobility produces rapid bone loss.