Nanda Nursing Diagnosis For Chest Pain

>> okay, so we left off at vte. we did fat embolus, right?>> yes. >> what are those 5 psthat you're looking for? >> (indistinct speaking). >> pain, pulse, pallor,parestesia, paralysis. that all five of 'em?>> yes. >> all right. what're you lookin' at it for? >> neurovascular-->> neurovascular checks,

because... >> you wanna makesure (indistinct). >> yup, you wanna makesure of circulation. bottom line, that simple. where's mindy?>> she's sick. >> sick of what? me?(audience laughing) okay. better check my email, right?

i dunno about you, but i've hadsome issues with grading-- the grading center trying to seeyour grades, and has everybody able to see theirgrades, and view? okay, maybe it wasjust my computer. something about cacheor catches, or... i have no idea what that is. >> cache.>> catch? all right. i couldn't catch my grades.

>> you probably just haveto delete your cache out of your internet.>> yes, somethin' like that. did i know how to do it? no.(chuckling) so yeah, if you have issues,make sure i get an email. i put up thereabout the, uh... brain-dead. um... your last camtasia.

the accessible one. what do you call it? it's got printed? >> closed caption.>> closed caption. does anybody useclosed caption here? >> mmm-hmm.>> all right. did you check it yet? >> no.>> all right. i need an email sooner thanlater if you want it in optimum

form, because i need to submitit, have it redone, and there might be issues withstatic in there. >> there is.>> don't worry about it. >> there is.>> there is static. well, there's staticon the original. on three and four. >> (indistinct speaking).>> (indistinct speaking). >> for tuesday's class?>> yeah, a little. >> is it audible?>> yeah.

>> then, that's not an issue. i'm talkin' about can you not--so nobody's really done the closed caption yet? >> i did, and there are partswhere you cannot hear it, but-- >> you can't hear it. is there wording,or they can't-- >> we can't hear you forquite a period of time. >> quite a period of time. i'll resubmit it and have itdone, but it's probably gonna

take at least a week. so that's why i need toknow like right away. if there's an issue with any ofthe setups, so i can find either an older version or some otherway around it to fix it so that you guys can get theformat that you like. okay? is everybody nice,warm, and cozy? because i'm sweatin'my butt off. >> got a coat?

>> (indistinct speaking).>> i'll stand by the window. won't give you too much light. hang on a minute, let me do thisreal quick and i'll put this back down. oh, man. i need some upper body strength. the sun is nice? okay, well-- all right. somebody with some upperbody strength, please.

>> it's not so nice whenthe cold air starts coming in-- >> shoot, can you--i'll stand right here. >> you want itclosed more than that? >> yeah, close ita little bit. thanks. thank you for thatupper body strength. i'll sit right here. as i drench. man.

what do you do if ifall and i don't get up? >> (indistinct speaking).>> where is it? where is that aed? anybody ever look for it? >> (indistinct speaking).>> the health lab? >> there's on in the gym.>> it's down there. >> gym's a little far away. if you really wantme dead, that works. okay, so we talkedabout fat embolism.

we're gonna look at thedifference between fat embolism and vte. if somebody's got one or theother, you're not really gonna know, diagnostically, unlessthey're on the morgue table. but you do need to know whatthings to look for, right? so i'm holdingyour hand here. you've got that nice page 13,14 up there for venous thrombus event. or venous thrombus embolus.

however you see it designated. so that is the newterm for the dvt. you're gonna still see dvtused a lot by old farts in the medical setting. docs that don't wanna learn. but that is-- and you'll seesome new residents that have not learned the new terminology, soyou can go in there and teach them something. how about that?

"doctor so-and-so, do you meanvenous thrombus event or venous "thrombus embolus? "do you realize that all deepveins are not the only places "where you can get a thrombus?" blood clots form in theintimal mining of a large vein. and they came up with dvt ordeep vein because it quite often is in a iliac vein inthe leg or the pelvis. but it can be anywhere in there. can be a deep vein,can be superficial.

can be in a lot ofdifferent areas. so it can lead to apulmonary embolis. so your risk factors aremore commonly, very commonly post-trauma patients. what other type ofpatients would you see? anybody? >> (indistinct speaking).>> who? >> strokes.>> strokes? what else?

>> basically anybody that's notmovin', right, like they are at home, up walkin' around. what type of patientswould that be? >> elderly.>> elderly. especially those elderliestakin' those drives down to florida and don't wanna takethat stop, because that male in the car driving just doesn'twanna stop, and the wife's saying, "i gotta pee."(laughing) and then, he'll stop,and he's gotta pee,

'cause he's gotta stand up topee, because of his bph, right? but that's the issue. people that just wanna getsomewhere and they don't wanna take the time to getup and walk around. so that's some education you cando on the elderly population, right? for all your snow-- what dothey call 'em, snow birds? snow bunnies? okay, snow bunnies,snow birds.

think about your church-->> snow bunny's a skier. >> (laughing) so think aboutyour churches, okay? the people that are in yourchurches or your community settings that areleaving for the winter. that's a little extra somethingwhen you're checking their blood pressure before they go. just to say, you know, "don'tforget-- make frequent stops, "get up, walk around, stop forcoffee, and then two hours "later, that coffee filtersthrough your body, and you can

"stop and makeanother stop." so it's important. and that's another thing whyyou-- in a hospital setting-- who is our veryuncooperative-- what's anotherthing to call her? i don't know what else to-->> (indistinct speaking). >> what's her name? mrs. cc? >> (indistinct speaking).>> yeah.

mrs. cc who didn't feel likedoing much of anything, right? and what did she run into? she ran into bigissues there, right? so not only did she getthe proper education maybe. maybe she just didn't understandwhat risks she was at, or maybe she just didn't care. maybe she had a death wish. >> sarah said shewas fat and lazy. >> okay, that's a littlesubjective, sarah.

(all laughing) but anyways, you know, maybethey just don't have enough education, okay? try to give them thebenefit of the doubt. anyways. so you're responsible for givingthem that education, right? you can only lead a horse towater, is another way of looking at it. so it's very important thatyou are able to identify this

population that are at risk. and what can youdo to prevent it? we are even currently in thehospital nursing staff, have to give our doctors a littlereminder via the computer to make sure that they order somesort of dvt vte prophylaxis. omg. who's makin' the big bucks here? and why do i haveto remind them? when i'm havin' a hardtime remembering, myself.

but anyways, it's actuallybuilt into our system right now. we actually had to go throughsome mandatory training, because this is so important. and it's basic. it's like knowing what is anormal blood pressure range. this is something that has to betaught to everybody comin' into the hospital, and hasto be followed up. there has to be some sortof prophylaxis on board. anybody know what type ofprophylaxis i'm talkin' about?

>> compression stockings. >> compression stockings,ted hose, or scds. >> an ankle pump?>> doing an ankle pump, yup. you can do that bydorsi plantar flexion. you would have to do thatfor a couple minutes every hour while awake. >> pharmacologic.>> pharmacologic. like? >> (indistinct speaking).>> heparin, sub-q heparin.

what kinda dosing wouldyou see for sub-q heparin? >> 5,000.>> how much? >> (indistinct speaking).>> 5,000 units. how often? >> (indistinct speaking).>> every eight hours. could be--yup, yup. it could be, if it's 5,000units, if you have for somebody that's 70 kilos, orapproximately 150 pounds versus a 300-pounder, might you see howyou're dosing for heparin sub-q?

absolutely. might be somebody 7,500. or where one person mighthave 5,000 units sub-q bid. another one mighthave it 5,000 q8. depends what are the riskfactors for developing this, and somebody mentioned lovenox. so, definitely lovenox. what kinda dosing doyou see for lovenox? >> so, 30 milligramssub-q daily?

>> yes. >> okay, for approximately200-pound lady. you might also see 40 milligrams. so that's kinda yourrange for lovenox. and that's usually daily dose. and that's sub-q. all right? so, the types of thingsthat you look at. what else do i wannalook at for there?

so your precursors. venous stasis there. what type of people mighthave venous stasis? >> or sluggish bloodreturn to the heart. >> bed rest?>> people on bed rest. >> chf?>> chfers, yup. their pump's not workin' verygood, so that blood's not circulating realwell, or consistent. who else?

thinkin' over time. chfers or anybody on heartfailure, right, so circulation. who else has circulation-->> (indistinct speaking). >> what kind?>> the elderly. >> elderly, yep. >> severe varicose veins.>> varicosities, right? varicose veins. >> (indistinct speaking).>> paraplegics, sure. because they'renot moving, right?

you get contractures,and that muscle wasting. >> people with diabetes?>> absolutely. ding ding ding ding. diabetes, and how common isthat becoming in our obese population? more common, right? because we're all eating-- atleast i am-- eating way too much and not paying attention, andnot doing enough exercise. yeah, two miles aday is not enough.

so you have some sort of problemwith decreased blood flow. right? you can also have up therethat is blood vessel injury. so, i apologize if i amabbreviating too much, but that's blood vessel injuryfor one reason or another. you know, you got injury,bruising-- i remember another story from-- where wasit that i lived near? morley, mi. a guy whacked his leg-- ican't remember why or how.

i think he was cuttin'down a tree or somethin'. hit his leg-- calf. went to bed that night. never woke up. he was in his 40s. he had-->> blood clot. >> yup, blood clot. killed him in his sleep. nice big old hematomain that calf.

so he had definitely had somesort of injury to that blood vessel, right? massive hematoma. and it was probably thesize of maybe my fist. you know, it was justswollen and hard in his leg 'cause he hit itand injured it. you know, for whatever reasonthat you have blood vessel injury. could be chemicallyinduced, could be, you know,

pathophysiologically induced,but-- altered coagulation for one reason or another. people that havegenetic issues, right? that they can haveproblems with that. increasing production ofplatelets and clotting in an attempt to maintain homeostasis. you could have some reasonthat's causing your blood to clot in order to stop bleeding,like your body picks up that i'm losing hemoglobin for one reasonfor another, could be a genetic

reason. think about factor viiideficiency-- a kid that fell and bruised a joint or something. and his blood's startin' toclot, or tryin' to heal because they're starting to bleed quick,so the body's trying to react and maintain homeostasis, sothen they're gonna use up the platelets, so they could begoing to the wrong place and clotting in the wrong area. it could be altered coagulationfrom somebody that's sick.

and their immune system'sstarting to break in and have issues with that. you know, anything that'sheading you down that path of dic. so it could be strep, pneumonia,going into a bacteremia where the infection isgoing into your blood. yeah, sarah, what you got?>> what's dic? >> disseminated intravascularcoagulation, where you just used up all your clotting factorsand now you're hemorrhaging.

that could be--sepsis can happen. it can happen in a hemorrhagingsituation-- a motor vehicle accident, traumas. >> (indistinct speaking).>> is it, what? >> can you say itone more time? >> disseminatedintravascular coagulation. so this altered coagulationcould be for a variety of different reasons. so when you get somebody that'shaving some issues, then you

gotta start thinking about this. what's workin' in the body? what can be affected? and what do i have to doabout it, what do i have to be thinking ahead and anticipating? so your signs and symptoms. do i have diagnosis up there? okay, yup, okay. signs and symptoms--remember mrs. cc?

the person may have those, orthey may not, may only have a part of it. so they may have some swelling. what if they weigh300 pounds or 500 pounds? are you necessarilygonna see it? maybe not. okay, so they may have all thosesymptoms or maybe just part, but think about if they'recomplaining of a pain in that area, in their calf orsomething, then what do i have

to be thinking of? what might cause them? "well, mrs. cc, you haven'tbeen getting out of bed. "that's an issue. "we're gonna do something aboutthat, we're gonna order a "doppler ultrasound." they may wanna take a peak witha little tiny ultrasound, like you do with your pulse oximeter. you know, the little dopplerthat you check pulses with?

well, this is just a bigger one. same thing--does the same thing. and you'll see on these dopplerultrasounds that they can do at the bedside, they'll just runit right up and down the leg and the tech can see right on therewhere there's an issue with circulation. so that can be doneright at the bed side. they may have to do somethingmore invasive like a venogram or an mri, especially if you'relooking at a showering of blood

clots, where it might've brokefree and it's just showering going everywhere, and they'restarting to have mild symptoms, but you're having symptoms indifferent areas, like a tia, and i'm getting short of breath, andwhat the heck's going on with this person? are they trying to have a strokeand a pe at the same time? it happens. and it happens, isee it with traumas. so your prevention, you wannause anticoagulants, right?

we wanna prevent-- anybody thatcomes into the hospital that's not gonna be moving around,unless it is for some reason they can't haveheparin or lovenox, they've gotta have something. throw scds on 'em. if they're trauma and they can'thave it on one leg, because they just had a orif of their tibiaon their left leg, well then, doggone it, we gottafind something else. maybe we can do sub-q heparinif they don't want lovenox.

maybe we're gonna do those goofylittle, they call 'em dpfs that they tap the bottom of yourfoot, and i've seen spectrum health use that. it's more like a last ditch,and i'm trying to think. plexipulses. anybody know what those are? yeah, they're pretty muchuseless as far as evidence-based practice. but they still use 'em.

you see 'em used more often ifthere is a really high risk that person getting a thrombus. think about somebodythat's pregnant. what if maybe they can't have--a pregnant person that was in a trauma, you know, and she'sgot broken legs or somethin', and they're worried. you know, they're gonnatry whatever they can, 'cause something'sbetter than nothing. and you gotta have at least oneof the three-- something going

on-- because if you don't havesomebody with ted hose on scds or heparin or lovenox, if youdon't have something on board, and that person gets a vteand/or dies, and/or walks around or medicaid gets a whiff ofthat, and they end up gettin' a vte, holy cow, areyou open for trouble. you're gonna get fined. somebody's gonna get fired. somebody's gonna getdinged somewhere. something's gonna happen.

the worst of all, the bottomline is patient safety. you don't want thatperson dying, okay? you don't want 'emgetting complications. so. early, early immobility. think about that. get 'em up and movin', right? don't have somebodysittin' in a chair all day. every two hours, yougotta move position.

that patient should beturning every two hours. if they can't move bythemselves, then you are responsiblefor moving 'em. if they refuse, you areresponsible for giving them this complication in education. like i said, you canlead a horse to water. you're responsible forgiving them that information. they have to be able tounderstand what you're saying, so watch for people with englishis a second language or has no

language at all. do you have to getan interpreter? so if they're not listening andnot following your instructions, why not? if they're competent, andyou've given 'em the information appropriately, they can make abad choice, get a blood clot and die. that's their choice. but if for some reason, you'renot giving 'em that information

appropriately, that'syour responsibility. it falls on your licenseand your shoulder. it's your responsibility ifyou're going into nursing to follow through. i can't help it ifyou're too busy. that's not an excuse. so you need to make sure thatpatient's turned and moved every two hours. if they're up in a chair, theyshouldn't be up in a chair more

than two hours. have them stand up, march inplace, walk around, go to the bathroom. they should be changingposition every two hours. so if you in your practice,where you work now, or you're a student, and you see thatthey've been sitting in the same position all morning, you needto be doing something about it, i think that's about all i haveto say about that, except for treatment, bed rest.

you're gonna see differenceshere in the timeline. you might see sooner-- they'remobilizing people with blood clots much sooner. so it depends howbad the clot is. what else is goingon with the patient? i'm seeing people dischargedwith blood clots before this time period now. so it could be five to sevendays, if it's significant. yeah, christian?

>> once you know they have ablood clot, wouldn't you wanna immobilize them so itdoesn't break free? >> moving 'em mightbreak it free. >> so how is that safe? >> they could getanother embolism. >> it's very possible. depends on the risk factors. how big is the blood clot? what reason did theblood clot form?

how quickly is thebody breaking it down? this five to seven days wasbased on how quickly the body starts breaking down, a normalperson with normal clotting factors, right? that's how long it takes thebody to start breaking it down appropriately, so that it'ssmall enough, and you've got an anticoagulant of some sort onboard or something preventing further clots from forming. five to seven days for it to getsmall enough and no other ones

forming, that that person canstart getting up and moving around. it's ultimately thephysician's decision, okay? when i worked in the er, oh man,back in the early 200s, we had somebody came inwith a blood clot. boom, bed rest,"don't you dare move." if a tech accidentally got 'emup, and either i didn't tell them, or they forgot, oh mygosh, i had a physician down my throat immediately.

it's like, "why didthat patient move?!" because if you're up walkin'around, you're contracting that calf muscle. so they did not wantthat at that time. nowadays, i've seen patientsup on the med-surg floors. they will put themon a heparin drip. they will followtheir ptts and inrs. get them appropriatelyanticoagulated through a heparin drip.

and then, they will switch 'emover to either lovenox, that they can give themselves ashot at home, or coumadin. if they're on coumadin, thenthey have to watch their pts, or partial thromboplastin times. and they have to go in and getblood tests for that to make sure that they're nottoo anticoagulated or not anticoagulated enough. so you gotta go in for periodicblood tests for that, and then they send 'em home sooner.

but it depends on the patient,what's wrong with 'em, why did they get the blood clot, howquickly is it being broken down, how safe is it tohave 'em go home. so it just depends onthe patient nowadays. and you'll see that heparin,all it does is keep more clots from forming. it's not gonna breakdown the current clot. if you need to break down theircurrent clot, then you gotta go to thrombolytics like alteplase.

and usually what you're gonnasee is those are the types of patients that cometo me from the er. they come in with a cold,blue extremity, in extreme pain, 'cause it's anacute occlusion. and what they're usually doingis they go to o.r. right now, and a vascular surgeon goes andshoves this nice, huge catheter in their groin. and they'll stick it in theirright groin, and then they'll thread it down into the left legwhere the clot is, and they'll

literally drip thisalteplase right on that clot. and that's usually arterial. and they will usually also haveheparin dripping at the same time to prevent moreclots from forming. those types of patientshave to be monitored. usually, if they have thatsheath, then they have to go to the icu. yes? >> why do they go in theleft to get to the right?

>> just because of positioning. they don't wanna clude that areaany more than it already is. so they're gonna stick a hugesheath in there, and then thread the catheter, which is muchsmaller, to the other side. they don't wanna clude thatarea anymore than it already is. and then, they're gonna dripthat alteplase on it, 'cause that alteplaseis a clot buster. it will actuallybreak down the clot. okay?>> how do they keep from--

if it breaks down,smaller pieces could go-- >> it's breaking down thatclot and dissolving it. >> okay.>> okay, so is there a chance pieces could break off? yes, but it's low risk. >> don't they doscreens, too, like-- >> filters? >> especially with traumasor people coming in that are having frequentpulmonary emboli,

if you have a high riskfactors, they'll do what's called a inferiorvena cava umbrella. i still see that done, not asfrequently as they used to. and i'm not sure why, if it'sjust because it's a mechanical thing and it works for so long,or you know-- i've never heard of one being-- yeah, i haveseen one being replaced. not very often. maybe one in 30 years thati recall being replaced. but an inferior vena cava.

does everybody know what asteamer looks like, those collapsible steamersfor vegetables? >> well, flip it upsidedown like an umbrella. >> (indistinct speaking).>> yep. and it's got like little,little, little, little tiny holes in it. but all it is is like anumbrella, and it's put right in the inferior vena cava tocatch any clots from the lower extremities.

>> and then, it's coated withsome anticoagulant, right? >> nowadays it should be. anything artificial that theystick in your-- like stints, when they do like casts, oropening up like the anterior arteries in your kidneys or yourheart or your brain, they're coated with anticoagulants. so that you don'tend up clotting. sometimes the bodylooks at that, "is this somethin' foreign?

"do i need to clot around it?" you know, it's an unevenpart, too, in that vessel. but good point, matt. thanks for bringing that up. so, i think that's all ihave to say about that now. so that's an important topic. (sirens in distance) so remember, we're talkin'--(sirens wailing) holy cow, you guys are loud.

>> yeah, why don't weclose the window? >> sorry, i'm just to the pointwhere i'm not dripping anymore. oh, let's see. where were we? we are on infection, right? complications. these are complicationsof fractures, right? hot dog. love cutting things inhalf in between two days.

so, you're gonna have infectionmostly with compound fractures, right? i talked about this on tuesdayabout osteomyelitis, or an infection in that bone, howimportant that is, how long-term of an issue that it is. it can affect you life-long. you have iv antibiotics,you have a slow healing process. it's a chronic condition. so, it's not a goodthing to have happen.

and you can have that withtraumas, compound fractures, docs doing surgery that, forsomehow for some reason, those orthopods, orthopedic surgeons,that have poor technique, or somebody, you know, messed upand they get infection in the bone, that's a life-long issue. do you have a question? >> once it gets in the bones,it's almost like-- chronic. it's almost like getting-- ithink of it in relation to mrsa. once you get it, you're alwayscolonized with it, and then it

can flare up the next timeyou get an infection. somethin' similar to that. so if you can relate it to that. it's just chronic. it's very hard to get ridof and deal with long-term. delayed or nonunion, i think wetalked about this a little bit already, but where you haveprolonged healing, the bones beyond the usual time period,or no healing at all for one reason or another.

you have risk factors includingfor delayed union or nonunion, could be like poor nutrition. alignment, infection,or necrosis. if it's not healing, you know,is it an alcoholic that's got poor nutrition, or you know,somebody that lives on the streets-- yes, my lagirl, allison, what? >> treatment, yes. sorry-- yeah, catchme on that stuff. anemia, right?

because you don't have enoughhemoglobin circulating. so think about, what are thecomorbidities of the elderly, so that not only do they run intoanemia more often, for multiple factors, but then what aretheir bones like, you know? so, could be a lot of issues. it could be somebody thatdoesn't have good healing, and then it wasn't followed, or theydidn't start their antibiotics in time, and then you endedup with necrotic tissue or infection because of that.

holy cow, does thatrun ya into trouble. yup. any comorbidity--diabetes, heart failure. anything that's gonnaprevent healing. it could be just the physicianthat didn't do a good job of alignment. it could be somebody that didn'tseek treatment early enough. prolonged reductiontime, you know? for whatever reason.

you know, maybe they had otherlife-threatening injuries that had to be taken care of first. so now they have to deal withthe complications of not taking care of, you know, puttin'this bone in alignment. you can have infectionor necrosis, not only for antibiotics, but what if therewas an issue with circulation to it? you know? it could also get necrotic,or infection because of that.

casted wrong. gave you that example. my granddaughter. a lot of times, if somebodyisn't sedated or sitting quiet enough when they're casting--like if they're casting, a lot of times it could be a newresident that didn't do it right, or an intern-- gotta makesure that if you're workin' on this hand-wrist, that that thumbis pointed upward, rather than having it like this when they'retryin' to wrap it or put the

cast on. you know, it could just be thetechnician's lack of experience. so you're lookin' atsix weeks for healing. age is up there, right? immunosuppression. or how badly the bone'sdamaged, you know? the more damage you have, themore you gotta consider how long it's gonna heal, right? treatment might be surgery,might have to be bone-grafting

or debriding, you know,if it's necrotic. you go in, and somebody had anopen compound fracture, and they were in a mud, dirt, youknow, road grime, whatever. tree bark. for whatever got in there,they might have to kinda debride that out. yeah, matt?>> nope. >> are you-- oh, okay. so just think about that, thetype of things that they have to

deal with-- yes? >> i was thinkingabout (indistinct). >> oh, huge. and they talked about-- theysaid people that had minor injuries are now running intomajor complications, because the minor injuries werenot addressed, right? so i'm sure you'veseen a lot of this. >> they had it on the new lastnight-- some doctors were rerouted from a trip tomexico to the philippines.

they only had one littlesheet to-- you know, trying to cut 24 squares. they don't have enoughmedical supplies. >> sure. >> some sort of antibiotic. >> yeah, they couldonly give them one dose. >> i guess, if that'swhat's keeping you alive. thank you, erica. anything else-- oh, treatment.

oh, electrical bone stimulator. anybody ever heardor used one of those? know anybody? it's like a tens unit. they'll put it on both sides ofthe fracture to stimulate the bone to grow faster and heal. those osteoclasts, osteoblasts. remember, look at the-- in youroutline, for the section there's a gazillion vocabulary.

make sure you look throughthose, so that you know what those mean. sometimes, they'll use those. i have not actually seen one. i just know they exist. and reflex sympatheticdystrophy is that complex regional pain syndrome. i might have mentionedthis a little bit before. it's a poorlyunderstood condition.

the signs and symptoms arethat persistent pain and hyperesthesias, which is, youtouch their skin and it's like you just stabbed them. they're just hypersensitivityto any stimulus. they have swelling, changes incolor, texture, temperature, and decreased motion. had a colleague of mine that hadthat develop for her-- i think i mentioned that already--for two reasons. she had knee replacementsand developed that.

so her foot, i think itwas always feeling cold. and then, she had an epidural,and that screwed her up even more. and she had pain. and i remember shehad a lot of swelling. yeah, allison? >> (indistinct) older peopleare more at risk for that? >> good question. and that's what i see.

because i do see more females,maybe it's the location of the sensors, because i see more menabout kevin's age that have the most pain for open heartsurgery, and maybe it's in their chest area. because we don't have anyexplanation for that, either. and we surmise, and there's noevidence to back it up, that there's just more sensors, nerveendings in that area for them at that age. so i don't have a goodexplanation for that same thing.

but i do see itmore often in women, that sympathetic dystrophy. so, if somebody does findinformation on that, please share. so any of thosethings can occur. the problem is that thetreatment, there's not a whole heck of a lotyou can do for it. they might do nerve blocks. they might try things likeneurontin or lyrica, that are

meant for other reasons,but they also work for this. don't you also see women havemore-- is it women that are more apt to have fibromyalgia? do you see that, too? so maybe it might be the sametype-- just the way the nerves are innervating. this colleague of mine,she actually had that nerve stimulator. she also had it implanted.

she had tens unit. it tried blocking the painstimulus going to the brain, so that she would feel less pain. and she had to pay forthat out of her pocket. i think she had to go out ofstate to have it implanted. but it was withinthe united states. i remember that. it just wasn't done here. the docs didn't wanna touch her.

trying to think of what else. there's other types of--we'll talk about it more, where they'll go in and do-- forcertain nerve-related issues, they'll go in andliterally cut the nerve. but i haven't seenit done for this. >> (indistinct speaking).>> sympathetictomies. >> have you seen itdone for this, though? >> yeah, and then they--i have seen it done. (indistinct speaking)>> okay.

>> people who got them done--if we saw them, it had worked. >> right, right...because, yeah. do you know what the stats were? were there quite a few of 'emcoming back that had it done? >> there wasn't very manyof them that had it done. >> that had it done, okay. well it's-- you know.>> i mean, not that we saw. >> okay. >> (indistinct speaking).>> the blocks, right.

been there. but, nope, i haven't. luckily, the blocksworked for me. and i went in before they got'em contaminated with fungus. that was a drag. that clinic got shutdown, the manufacturer. >> and it was only...>> a small amount. >> small amount.>> yup. so think about, what does anursing care for fractures and--

think about prevention. whenever, you know-- canyou prevent fractures? you try, right? once you get the fracture, howdo i prevent complications? try to get your brainin that mode, okay? so what is the nursingcare and management? you've got pain. so always ask that patientto describe the pain. remember how important itwas in knowing that pain?

what is the trend of that pain? is it consistentwith the problem? or is it giving you ideas ofsomething else goin' on, right? could it be that they'redeveloping a vte? or a pe, or a fat embolis? are they the showering clots,and now they're getting abdominal pain because you'veclotted up their superior mesenteric arteryto their bowel? or are they starting to get tiasymptoms, and "i'm getting the

"worst headache of my life"? could be that you're startingto use up all your clotting factors, and now they'restarting to bleed, and now they're getting the worstheadache of their life with a brain bleed insteadof a brain clot. gotta start thinkin' that way. you gotta start thinkin'about what are the possible complications, andhow do i prevent 'em, and how doi act on 'em?

so pain is very important. know what the trend--what are the characteristics of that pain? is it normal for this situation,or do i have to start thinkin' about other things? use that pain scale. if you can't use the pain scale,find some other way to measure it, right? everybody's done a painnursing care plan, right?

everybody's got a successfullypassed pain nursing care plan, otherwise, getsomebody that has. so impaired physicalmobility, right? are things barrier-free? do they need assistive devices? do they need a cane or a walker? do you have a little old ladyfrom world war ii that's got, you know, maybe two feet widewith newspapers and magazines and all her tchotchkes and allthe stuff that one might need

some day in my life, you know,up in her home, you know, and how am i gonna fitcrutches through there? what other type of environmentdo they have at home that you're sending them back to? they got an alcoholic son thatbeats 'em up, or, you know, what is that environment, you know? are they alone andthey shouldn't be? think about that stuff. impaired tissue perfusion andneurovascular compromise, right?

remember those five ps. i can't shove that downyour throat enough. how often should you becheckin' for that stuff? how often should yoube checkin' for this? every hour or every time youwalk in that room, right? eyeball it. they got a cast,they got that leg. how's that pain doin'? remember, your painreassessment, right?

and what is theirresponse to the trauma? that includes psychosocial. yes, 102, that iwould have failed. do i check, do i make sure thatthat little old fella that's got his dog at home and nobodytakin' care of it, or his parakeet or whatever? i can't stress that enough. i mean somebody, if they losehope, or they have a home situation-- they'regonna lose their home--

you know, theymight just give up. "this is just one more thing onmy plate that i can't handle "no more. "i just give up." and you'd be amazed-- itdoesn't matter what age. you can lose somebody veryeasily that just gives up. at any age. and how does thatimpact their home? do they have somebody takingcare of the bills for 'em?

do you have to send 'em toextended care facility and tell 'em this is just for a shorttime, or do you have to get somebody involved and managecare to help them cope with, "i can't go back home. "i have to go to extended carefor life, the rest of my life." that's a huge impact. you take somebody's home awayfrom 'em, you take away their ability to drive. you kinda wannacurl up and die.

that's a huge impact,psychologically. so think healthpromotion, right? you wanna maintaingood bone health. got milk? yeah, that commercial'sthere for a reason. you've gotta have the calciumintake when you're young so that, once you hit menopause,you're kinda up a creek. think aboutweight-bearing exercises. avoid obesity andlosing your balance.

exercise and toning. it just becomesharder to move. so these are huge healthpromotion options that you're lookin' at. think about any communityimpact that you can have. you are a population that isgonna be really strongly needed out in the community. so, yeah, some of you are erjunkies, adrenaline junkies, you wanna work the eror wherever-- icus.

that's fine. but you may or may not be therefor your entire life span for the nursing career. there's gonna be a hugeneed out in the community. these are huge impacting optionsthat you're gonna help to prevent people fromgetting breaks, fractures, and/or complications. yeah. so huge, nursinghealth promotion.

think about your churches,your community centers. give back to the communityonce you get outta debt. it will happen someday. i promise. nursing diagnoses. number one. pain's a good one. >> impaired mobilityshould be up there. you betcha.

>> risk for infection,you betcha. >> risk for disturbedsensory perception. psychologically, physically? physically? okay, so that has to do withyour sensory neurovascular dysfunction. but also, you take a olderperson with a neck or other fracture, their pelvis, andyou pull 'em out of their normal environment and stick 'em inthe hospital and give 'em drugs,

they're gonna havea psychological drug- and stress-induced psychosesmaybe, right? >> depending where it is,(indistinct). >> sure, sure, absolutely. i think we got all of'em in there, right? did we talk about all those? >> what about coping?>> coping's huge. coping's huge. very good.

i like that one. see, i would've failed 102--let me borrow your pen. that's a good one. thank you. oh, he's got a crushed bone. i hate when that happens. bummer. you gotta get onthat commercial. take my phone, please.(laughing)

so... home care. cast care. how to shower, howto monitor the skin. do i have to put aplastic bag on it, wrap some ducktape around it? i dunno-- whatever,whatever they do. you can't get thecast wet, remember? either it's gonnastink or dissolve.

>> i went to walgreen's lastweek looking for a heating pad and there was this productwhere it shows this very excited, very happy women,with like a cast on her arm. and it's like a foam ring thatgoes around, and then this plastic sleeve, and she'slike sitting on the edge of the bath tub. so they do make-->> like a sleeve? well, how about that? and it's a foam ring?

what is it, kinda just-- thefoam ring is right up against the skin?>> yup. >> like a gasket.>> like a gasket! there ya go. >> maybe it's a mechanic that'snow a gazillionaire, right? >> "i'm gonna make amillion bucks off of this." probably more. excellent idea. so it's at walgreen's.

there ya go,and now ya know. your community intervention. (laughing) so you gotta check the edgesaround the cast, right? you wanna monitor that skin. because a lot of times-- i hadmy son, he was in a spica cast. it was like, went around hiswhole torso here and then went down the leg. so you had to be really carefulin that poor little kid's groin

area, or when he went to bed. and that any edge of that cast--not only the circulation within, but also that the edgesweren't getting' raw. sometimes, i've seen people uselike mole, sheepskin or moleskin to put on the edge. but just be careful. you know, 'cause sometimes theedges can be a little rough. sometimes, you canask 'em to fix-- you know, help withthat a little bit.

but watch for pressureand friction, okay? think about casts that go downinto the extremities, right? be very careful for circulation. make sure you follow thedoc for weight-bearing. when am i supposed towalk on this, when not? you weight-bear too soon,you're gonna cause damage, and you know, yourhands and your feet are very preciousextremities. once they're gone,they're gone.

so if you walk on it too soon,it's not gonna heal right, and you're sol. so make sure that theyunderstand the importance of not weight-bearing any soonerthan what they're told. give that bonetime to heal, okay? range of motion to theunaffected joints, right? so if i've got a broken wrist,you know you can still do the fingers, you can stilldo the elbow, whatever. make sure thatmoving is goin' around.

you keep that mobility. don't wanna end up having afrozen shoulder or something just 'cause you'reafraid to move that arm. remember, don't forget toelevate to decrease swelling and pain. what other thingsthat you have to-- when does dischargeplanning start? on admission. i want that so hard-wired inyour brain that you don't even

think about it,you just do it. because they'renot at this point. they're justtask-oriented. i know you're task-orientedright now because you're so focused on, "oh my gosh, i gottaknow how to do a straight cath, "and i haven't had thatchance," but you know what? you gotta look atthe bigger picture. are they gonna be able togo back to their original environment?

what types of things do ineed to make them safe in that environment, okay? do they need a niceelevated toilet seat? all right, they don't have it,how do i get it for 'em? what community resources do weneed to tap into to have that safe environment, or do we haveto go through the government and start looking at other things? do they have to go toextended care for a while? what do they need to get throughthe system as fast and safely as

possible and get 'em to theiroptimum level of functioning in the optimum safeenvironment, right? does that make sense? do they need a wheelchair? do they need a wheeled walker? or whatever. onward-- amputations. you guys can read this. i don't have to read it to you.

this is forty-what? >> 48.>> 48. what happened to 47? holy cow, all right. c'est la vie. gosh-- gotta borrowyour pen again. sorry, kevin.>> not a problem. >> 48. so, amputation's a partial ortotal removal of a body part

resulting from a traumaticevent or a chronic condition. this is a nice good picture forthose of you that do really well with pictures. this gives youthe whole idea. you got stump care. you got to elevate thatstump for the first 24 hours after that. especially with anabove-the-knee amputation. what do you think that that'sgonna do, after about 24 hours?

what do you think not havingthat weight-bearing, and stretching that flexor muscle--what do you think that's gonna wanna do? it's gonna wanna contract. yup, that muscle'sgonna wanna flex. so you need to keep thatstretched out and down, so that it will fit into aprosthesis and work. you've seen people thatare paralyzed, you know. divers.

what happensto that muscle? gets atrophied, right? doesn't wanna work. but immediately after, what'sgonna happen is that's gonna wanna pull right up. it's gonna wanna do this. so think about, what do ihave to do to maintain that extension? keep that extremity stretchedout until we can get it fixed up

for a prosthesis. you're gonna wanna make sure youwrap that-- see how that's got a nice kind of a cone shape to it? you wanna make sure that thatdressing's on there to help facilitate that forming, so thatit'll fit into a prosthesis. they might want to-- and thinkabout that, if they chopped it right off, if it was a traumaticamputation, like that guy i told you that got crushed. think about the bone.

can you imagine coming rightdown on your bone all the time, how much that would hurt? so they probably quiteoften will go back. they might have to revise itlater, or they might do it during that initial surgery. but they might cut that bone alittle bit shorter and actually bring a flap of skin around, sothat your suture is not right on the tip. so that the suture is moreup here, either anterior or

posterior. so you're kinda wrapping thatarea, so you got regular skin that you're puttin'that pressure on. you know, a lot less painful. you know, if you don't have anincision that you're putting that pressure on, less of achance of that friction and pressure causingskin breakdown. so you kinda wantthat flap in there. it works really well.

it just depends on the personand the type of surgery and why they did the amputation. because it could be atraumatic amputation. it could be somebodywith-- my uncle-- i know the weirdest people.(all laughing) my uncle, god rest his soul, wasa smoker, world war ii soldier in germany in the winter withboots, and developed burgis disease. so poor circulationin the extremities.

so they didn't get to changetheir socks every day. they marched for days and daysand days in this ice and snow. ended up losing one leg rightat the end of the war in '45 and then developed diabetes on topof all this, and heart failure, because of the diabetes andthe genetics, that he had poor genetics. so he ended up gettingthe other leg cut off. where was i going with this? >> (indistinct speaking).>> oh, okay.

so chronic conditions.(laughing) here's an example of chronicconditions that can lead you to have an amputation. but i'll tell you that guypopped in his prosthesis and eventually both, and he'd walkaround me, and you couldn't keep that guy down for nothin'. the heart failurekilled him in the end. so, think about thatwith amputations. you've gotta find a way--nowadays, usually in acute care

settings, they get physicaltherapy, occupational therapy involved right away. because you gotta keepthat stretched out. how else do you think you couldkeep somebody stretched out? >> range of motion.>> range of motion, okay. yeah, sarah. >> no, i'm not seeing that. not seeing that. what else could you do?

>> get out of bed.>> get out of bed, okay. so you get out of bed. how would that stretchthat extremity? how would you keep thatstraight by getting out of bed? >> stand up.>> stand up. so you're gonna do somerange of motion on that. that would include range. how else could youstretch that out? >> strap it to the--interesting.

>> (indistinct speaking).>> that's a good thought. strap a belt around it,you know, get somebody up and walkin'. of course, that would bekinda weird, 'cause-- no, that's gangnam style--(all laughing) that was almost insane. yeah, i dunno howthat would work. your whole pelvis wouldbe going at the same time. you know, people with brokenleg, they'll do that.

they'll swing through. so keep it straight. so that's a possibility. what if they are inbed for a while? >> how would youstretch that out? how would you extend? >> (indistinct speaking).>> say again? >> (indistinct speaking).>> very good! prone!

lay over on yourbelly for a while. well, change positions,but you gotta be specific. because laying on your side,you're still gonna flex, right? and i didn't hear whatwent with that, sorry. but yeah. prone. think if you're out in a podunkhospital where they don't have physical therapy out there,really aggressively workin' with them, flip 'em over.

but that's gonna be moreprobably-- that first 24 hours, you wanna elevate itfor the swelling, right? you might evenuse ice and stuff. you can use iceongoing, right? for even pain management. but after that, you wannaget that stretched out as much as possible. what are you thinking, kevin? >> why not?

make sure they're breathing. prevent contracture at thejoint above the amputation. phantom limb pain. i find that people-- and i thinki mentioned this under the pain section-- that brain remembersthe effect that they had prior to that limb being removed, andif it was pain, it seems like that's what they'regonna remember. my foot, my leg hurts,even though it's gone. so they'll do that mirror-typetherapy, and stuff like that,

to help retrainthe brain. they might use stuff likeneurontin or lyrica to try to help with that. the type of regularanalgesics that you can use. immediately post-op, you know,you're gonna use your stronger drugs, right? if you're doing an amputation,right, in the hospital, you can monitor their breathing, youcan throw a pulse ox on 'em. then you wean 'emdown for home.

discourage semi-fowler's. you don't wanna have themsitting in a wheelchair all day long, right? you need to make sure thatthey're moving every couple hours. prevent furthercomplications, right? you wanna watch thatcirculation there. or bleeding. did they miss a small arteryor vein or something, and

something's leaking into thetissue and you end up with this massive bruising? yes, my la friend? it's not allison, it's "l." >> lindsay.>> lindsay! >> saturday morning startedcomplaining of a lot of pain at the stump. so the nurse kept lookin'at it, lookin' at it. couple hours and it just keptswelling and swelling, and she's

like, "something'snot right." they paged the surgeonmultiple times. when he finally came, she saidhis stump was like three times the size it was that morning. and so, the surgeon, he's like,"well i wanna try something." he pops two staples out. digs his hand in there, andblood is like just a volcano coming out of there. he had a massive hematomaon the bottom of his stump.

>> so blood goes-->> he went back to surgery. >> yup, absolutely. was it a venous bleed?>> i don't know. we had to transfer him upto pacu at like 7:20 and we left at 7:30.>> okay. >> so i don't reallyknow what happened. >> so, a small vessel bleed. you said it was two weeks?>> it was about two weeks. >> so that's kind ofa ways out, right?

blood wants to godependent, right? so it's gonna drain down. so she said it wasposterior, right? maybe it was a stitch that brokewhen they sutured the vessel, and it was a friable areathat just broke loose. you know, maybe he was doingsome aggressive therapy or somethin' and it popped. could be anything. could've been a small venousthat took a while, and then all

of a sudden-- or it could'vebeen something that was bleeding that the initial swelling hadkind of tamponaded it off, you know, squeezed it so tight, andthen as the swelling went down and the tissue was healing,popped it open and it started leaking spontaneously. could've been any of those. could've beenany of those. so pay attention. that's a perfectpicture, lindsay.

so that could be aweek, two weeks out. so pay attention, all right? you're gonna watch for comfort,mobility, circulation, right? you're gonna assess for skinbreakdown, make sure they move. you're gonna watch that stump,especially as they're starting rehab, if you're workin' in arehab area, in an extended care where they're startin' tolearn to use the prosthesis. watch to make sure that youdon't end up with a skin ulcer. what's that gonnado to their rehab?

if they can't put thatprosthesis on, right? be careful. remember alcohol dries, andyou don't want it too soft, 'cause you want it tobe kind of in between. because-- i dunno if youactually want a callous, but you just want, you know, astrong tissue that's not gonna be susceptibleto friction. encourage client to wear hisprosthesis when he gets it. up all day to preventthat stump swelling.

because once it swells, likeif you take it off for a little while, it's gonna behard to put it back on. >> i was just wondering, 'causeyou have above the knee and you have below the knee.>> uh-huh. >> but it says discouragewith above the knee. is there anything else that'sdifferent in the care between below and above? >> well, when you have it abovethe knee, you're more apt to have that flexion happen muchfaster than below the knee.

you have much more mobility andfunctionality below the knee. so just depends how muchof the tissue's taken off. but your contracture's muchquicker with above the knee. because oncethat knee's gone. speed. causes. peripheral vascular disease orperipheral arterial disease can be a major cause. you have that poor circulationgoing to the tissue, not getting

that oxygen tothe tissue, right? think of your chroniccomorbidities like diabetes, as kevin mentioned. chronic high bloodpressure, hypertension. smoking. how well does oxygen get toyour tissues with smoking? that can be chronic or acute. trauma's usually the major causeof upper extremity amputation. think about other things causingtrauma like frostbite, burns, or

being electrocuted. i've seen electrocution wherethat literally blown off parts of fingers and hands,parts of the feet. because you know you usuallyhave an entrance and an exit wound withelectrocution. i had a young nurse. she's probably inher late 30s now. she was working with sailboatsout on the shoreline, and the mast hit a power line,and she got electrocuted.

she had part ofher neck taken out. she lost her thumb. i think it blew out her hand,or it went through her hand and blew out her neck--i forget. but she lost her whole thumb. they ended up puttin' her toe,her big toe, up here, so that she could have dexterity. yeah, i think that'sthe way it went. i can't remember.

but she was lucky to be alive. she had a trach for a while. she had some severe burns. she ended up being the managerof the burn unit for, i dunno, five years. five, ten years. but she came in as a burnpatient, you know, a young college student, and that madeher wanna be a nurse, because of the care that theburn nurses gave her.

so, and she's verycompassionate. very awesome, awesome lady. underlying causes canbe acute or chronic. it's interruption inthe blood flow, right? your goals are gonna be toalleviate the symptoms-- if you're bleeding or they'reperipheral vascular disease, you gotta watch forpain or sores. you wanna maintaina healthy tissue. if it's open, it'scalled that guillotine.

you're gonna see thatmore often for infection. they might wanna do thatshort-term, and then later go back and close it up. but they may, if they do aguillotine, they might have to watch for infection. that might be areason why they do it. but usually,i'm seeing them, they eventuallywanna do that flap. you wanna basically haveincreased functional outcome.

that's your goal. and for the site healing, veryimportant, watch for that stump to heal, right? you're gonna assess thecirculation, your five ps, all that good stuff. >> maintain. mtn is maintain. i mean i know whatguillotine is, but-- >> chop!

chop straight off. you're gonna see all the fascia,you're gonna see the muscles, you're gonna see the bone. they're only gonnado that short-term, and they'regonna wrap it. they're gonna, like,you'll see, like this. and you'll have yourbone right in the middle. it's just chopped right off. think about a ct scan,slice of a ct scan.

it's gonna be chopped right off. and they're gonna monitor this. this will be wrapped--packed and wrapped. but they're monitoring this. they're watchingfor necrosis here. i've only heard of that usuallywith infection-related where they know that they'vegotta go back and reassess. okay, it's justguillotine chopping. >> no, no, no, it's usuallyfor infection monitoring.

they've had an infection. think of the strep bug. what is that called? gas gangrene. >> (indistinct speaking).>> no. gosh, come on. it's strep, it's strep. it eats your tissue. >> (indistinct speaking).>> necrotizing fasciitis!

boom-- chop it off. they're gonna monitoring. good job. >> (indistinct speaking).>> good job. necrotizing fasciitiscan kill ya really fast. that's an example where i couldsee that they would do this, 'cause it's short-term. they're gonna have togo in and close that. because what they're gonna dois they're gonna wanna cut this

bone shorter, and then takethis tissue and wrap it. >> oh.>> does that make sense? lemme see what else. what slide are we on here? do i have rigid compressionanywhere on there? yes. you're gonna wanna do that. that wrap, that'sgoing usually-- i've got a picture of it.

i don't know if it'sin your lab manual. or you can google it. where they're gonna start-- theymight start, bring one down, but they're gonna wrap it,like a figure eight. and it's gonna be firm, and it'sgonna be compression, so you might have a dressing on thevery end for a little while. if you've got a guillotine,you're gonna have compression on there anyways. they might just use foamtape for short-term.

but once you have that flap andthat stump, you're gonna do that figure eight, and it's gonnabe a figure eight because it's gonna pull and keepit from swelling, okay? to make that cone shape. there should be pictures. if you can't find it, let meknow, and i'll find you one. >> there's a picturein the book. there you go--thank you, sheena. what page?>> 1329.

>> 1329. so, you wanna prevent infectionand minimize edema to get them up. stand 'em up very soon aftersurgery with a temporary prosthesis until theyget a permanent one done. because you don't want 'em tolose that sense of balance, especially above the knee. i mean you can lose part of yourfoot and still have big issues with sense of balance.

it's very important. and some people will get apermanent prosthesis implanted. usually younger people. you want the stump that'swrapped-- ace wrapped to allow that cone shape. prevent edema. that's applied fromdistil to proximal. i talked about not elevatingafter the first 24 hours. you're gonna prone 'em.

flexor muscles are strongerthan extensor muscles. so that's why you'reso prone to flex. and once you start getting thatcontracture, it's much harder to fit that prosthesis and getit to function appropriately. so you will need physicaltherapy and occupational therapy if you can. your complications involve... infection, right? you got delayed healing.

if the circulation isn't good,it's gonna take much longer to heal. they can end up withchronic stump pain. that's why they'llcut that bone shorter. you want that flap if you can. you don't want that pressurefrom the bone right on the edge, let's see, you canhave that phantom pain. remember, it'svery real, very difficult totreat with narcotics.

they usually need neurontinor lyrica might help. might. don't forget aboutcontractures, okay? especially withabove-the-knee amputations. range of motion. avoid sitting forprolonged periods. holy cow. think of nursingdiagnosis, page 1331. physical, psychosocial.

you got pain, grief, alteredbody image, mobility issues, risk for infection,and skin integrity. >> (indistinct speaking).>> coping! yes, get that one in there. onward-- repetitiveuse injuries. carpal tunnel syndrome. that's compression of themedian nerve in the wrist. symptoms are numbness andtingling of the thumb, index finger.

pain interfering with sleep,because of the positioning and the weakness of the hand. and when they do surgery,they're just gonna make a bigger tunnel. sometimes you'll get to wearthat nice split at night. bursitis. what have we got here,what am i missing? is it on there? bursitis?

okay, inflammationof the bursa. enclosed sac betweenyour muscles. tendons, especially in theshoulder, hip, knee, and elbow. symptoms involve joint istender, hot, red, swollen with pain upon flexionof the joint. both of my surgeries, myshoulders, when they went in there, they just sucked out allthe bursa, 'cause it was just beet-red and inflamedall the time. so -itis...inflammation, right?

collaborative pain care for allthese types of tissue injuries are pain relief,increasing mobility. you're gonna use nsaids todecrease the inflammation. steroid injectionsinto the area. you can have that doneusually twice a year. do you know ofanything else, matt? >> and it feels really good. you just wanna get your clawson the ceiling and scream. some people have to be sedated.

to me, that's another injectionand somebody to drive me home. so treatment is conservative. you can do immobilizedwith splinting, a sling for a shoulder. remember, rest, ice. sometimes you might alternatethe heat and the ice. remember, you're gonnado a chest-- not a chest-- you're gonna do an x-ray torule out bone injury, right? if you need surgery, you'regonna do an incision to remove

the inflamed bursa or make atunnel bigger for the carpal tunnel, right? if you're gonna do somesort of invasive surgery. you're gonna look at acute painand impaired physical mobility. because if they're taken out,if they're messin' with your shoulder, or down here, it'sreal common to get what's called a frozen shoulder. so you wanna get that swellingdown as quickly as possible if you're doing a surgicalintervention and get that joint

moving as quickly as youcan as well as you can, 'cause the longer you get outfrom the intervention, the less chance of improving mobilityover a long period of time. nursing care. pain relief, increasedmobility, right? anything else? >> when you increase mobility,how do you put that together with resting andavoiding activity? >> time.

time frame. initially, you want to rest. and it depends, if you'rein conservative treatment, initially with the injury,they're gonna rest it, give it time, nsaids, like whenyou have a tendonitis, you can't go back to your swing ofthe hammer every, you know, 50 million times a day. they might say you gotta takea week off, rest it, right? or might be longer.

could be a month. might be six weeks. but you've gotta give thatinflammation in that area, what is it called,a hammer elbow? or-->> (indistinct speaking). >> tennis elbow. i think tennis-- is tennison the top of the elbow, and hammer's on the bottom? it's one or the other.

but you know you canaffect both areas. you gotta rest it. you can't go back to thatrepetitive use all the time. you gotta give it a period oftime to rest with nsaids to take down the inflammation, give ittime for that tendon to heal. >> so then, when would youincrease mobility then? (indistinct speaking). >> eventually, hopefully. they might tell you tofind a different job.

if you keep going back to therepetitive use, and you keep getting the same injury fromthat type of work, you gotta find a different job. if you can find a way to workyourself into it, and it was just, you know, something that idid, like i was workin' a lot of overtime, and that's whatgot me into trouble, then i'll just do it buti won't do overtime. and you can stay in that, andyou might end up having the same problem down the line,but at least you can work

a little bit longer. >> with the injury, yougotta rest it initially. then you work with the correctdrugs to correct the problem, and then you start mobilityand range of motion. range of motion is usuallyfirst, and then you start strengthening the area, okay? because, especially once youthink of surgery, you gotta give that two, three daysof swelling to go down. they'll usually giveyou a cryo cuff.

you know, with the ice. and i put mine on much longerthan i was supposed to. or have that sub-q, that on-qpump that i told you guys about. best thing since sliced bread. where you had a lidocaine orsome sort of local anesthetic dripping in therefor five days. i took mine for the max. and, you know, i was-- you know,so that i could start gentle range of motion,'cause otherwise,

you end up with afrozen shoulder. i think i got prettygood range with that. so it just depends. you know, you gotta do-- thinkabout that 24 to 48 hours after surgery, and then they give youmild range of motion, exercises, and as that heals, then youstart strengthening, okay? did i answer your question?>> kind of. >> kind of-- okay, what elsedo you need clarified? >> well, it says toincrease the mobility,

but that's whatcaused the problem. >> mobility could be range. not necessarily therepetitive-- yeah. >> (indistinct speaking).>> yes. is that more clear?>> yes. okay, impaired mobility,nsaids, treatment, x-ray-- okay, surgery. okay, home care. rehab.

avoid activities thatincrease the risk of redevelopingthe injury. i think i alreadymentioned that. onward-- osteoarthritis. degenerative disorders. big clue up here. degenerative means what?>> it gets worse. >> hmm?>> gets worse. >> gets worse with?>> time.

and as it's getting worse,it's not gonna get better. it just graduallygets worse. there's no goingback at this point. maybe stem cells will dosomethin' with that, i dunno. so osteoarthritis, akadegenerative joint disease is the most commonform of arthritis. gosh, what happened here? loss of articular cartilage andhypertrophy of the bones at the articular margins.

where you're bendin'. you know, where the knee boneconnects to the, you know, elbow bone connectsto the, you know. arm bone? i dunno. arm bone connectsto the shoulder. i dunno--somethin' like that. anyways, wherethey come together. articulate.

all right, so... chapter 40. most common form, males aremore often than females until menopause orapproximately age 55-ish. then, the incidence istwice as high in females. just because ofthat calcium deal. do i have risk factors up there? i do? yes-- age.

so think if you're unfortunateenough to have it in your genetics to have issues,you run into it younger. i been on arthritis medicationsfor well over 20 years. and i'm maxed out on what i cantake, other than chemo drugs. don't wanna go there. excessive weight, especiallyin the hip or knee. think about that extra weighton your joints, and your joints say, "man, losesome weight there. "take some weight off me.

"i'll live longer." inactivity. think about strenuous,repetitive exercise like sports. you know, think about yourtennis players, your football players, and,you know, runners. what does that do toyour joints, man? just kills ya. hormonal factors. so your pathophys involves,that's cartilage lining the

joint degeneratesor falls apart. just basicallywear and tear. >> they're not sure--they're guessing autoimmune. joint space narrows, becausethe cartilage is gone. you can alsodevelop bone spurs. remember those osteophytes a lotof times are what builds into those spurs. they form along theedges of the bones. they cause painand limit mobility.

you'll see spurs mostoften in fingers. i get 'em in my shoulder,along the articulating edges. get 'em in your spine. they can get'em anywhere. your symptoms-- the onset isgradual and slowly progresses. it is pain and stiffnessin one or more joints. in your nursing diagnosis,would that be, you know, a self-care deficit? i can't make a fist.

if i don't take my drugs, ican't pull somebody up in bed. i can't even hold a coffee cup. the pain possibly can bereferred to other areas. it's just that stiffness. it just depends howfar it radiates. you could have decreased rangeof motion, and you'll hear sometimes-- oh gosh, i remembersometimes helping a little old lady turn in bed, and i'll grabtheir wrist right here, and you hear that grindingof the bones.

that's called crepitus. it's just a reallycreepy feeling. so it's another term where youmight hear that term "crepitus." remember, you hear it in--or at least my students know-- a crepitus can be a sub-qemphysema or air under the tissue when you have a leak inyour lung tissue, and it feels like rice krispies whenyou touch the chest. that's another crepitus term. you can have bony overgrowththat causes joint enlargement.

you see people with like-- oh,what is the name of that guy? he's a famous actorin-- say again? who?>> (indistinct speaking). >> elephant man--i don't know. >> did anybody see that"snow dog" movie? the guy that endedup being the father of the african-americangentleman? i think he was a famousdentist or somebody. ah, shoot.

if you didn't see it, youwon't know what i mean. he had arthritis so bad,his hands were just terribly deformed. he kinda walkedaround like this. >> that rheumetides more often,but my 90-year-old aunt has joints about this bigfrom osteoarthritis, yep. collaborative care. you wannarelieve the pain. the pain-- think about peoplethat wanna shake their hands,

you know? you wanna be able to completeyour activities of daily living, you know, doinghousehold chores. you wanna hopefully try tomaintain function of mobility as long as possible. so when you're first startingout, think about the medications that you can use. remember, this is achronic condition. do you have swellingand inflammation?

however, it might startmildly, so start mildly. tylenol is strictlya painkiller, right? is it gonna doanything for swelling? no. however, things aregonna get worse. if you can control it, this isone of those things where it kinda messes with your brain,but when you're working with a chronic condition like this,initially it might just be a painkiller.

because they're eventuallygonna get maxed out, and there's nothin' you can do for 'em. so just try. will tylenolwork for now? maybe it'll workfor a year or two. >> this week, at the hospital,an elderly woman has had osteoarthritis in her backfor however many years. and so, she's alwaystaken aspirin. well now, she has a gi bleed,because she's takin' the aspirin

for so many yearsfor her back. so she kinda-->> oops. >> --screwed herself.>> well, for so many years. but for so many years. and maybe she could've caughtthat gi bleed a little bit sooner by paying attention tothe pain in her gut, right? and then, switched overto something else. but aspirinis a salicylate. you have anti-inflammatory,plus pain control.

so it, you know, might work. but you have to look at other,you know, as her other risk factors are increasing,you have to look at. so she's probably gonna have toshy away from nsaids altogether, but you can try this. maybe they'll have to dosomething and watch her. what can they dofor her permanently? are they gonnacauterize that gi bleed? is it somethin' theyhave to watch for?

was she doing somethingelse that also affected it? so they have to weigh thoserisks and benefits of what they can do for that arthritislong-term now, that she can't take the aspirin. so she's past-- they might trytylenol for a while, just for pain control versus anyanti-inflammatory effects, but try that for a while, until atleast that gut heals up, right? and then they're gonna have tolook at what else can they do. they might try paraffinwax treatments.

you know, if it's just her handsthat are botherin' her, but she said it was her back. so maybe they mighttry other things. physical therapy for a while. "suck in the gut, tuckin the butt" type thing. but physical therapy--strengthening that core will help. a lot of that is stayingconsistent with that. all the physical therapists intown know me at spectrum health.

i have to go in forthat gibbs slap. you're supposed to bedoing x, y, z, remember? so i'm noncompliant. so i just need thatreinforcement of, this is what you're supposed to be doing. so that's what-- you start withtylenol, then you have to go the nsaids, and then you end up withsteroids, but that accelerates cartilage destruction, andthat's why they'll only do that injection maybe acouple times a year.

in your back,they might do it. you can only have it so often. so just depends. so conservative treatment, isthat strengthen the area around the area of the injury,because you can't prevent the degenerative process, but youcan strengthen the muscles around it tosupport it, right? so think about it that way. do they need helpwith ambulation?

canes or walkers. weight loss. analgesics,anti-inflammatory meds. then if you have to go in forsurgery, then you're talkin' about arthroscopy,arthroplasty. you might have to have atotal joint replacement. might have that nice stay atblodgett there, where they do all that bone stuff. you'll see a total jointreplacement, total hip

replacements, or thr. you can do thatwith the knees, it can be done forthe shoulders. i'm avoiding that. sometimes they'll doit with the elbows. knees are morecommon than hips. they'll talk about more rehabon that when you go into next class, too. so complementary therapiesthat you can run into are the

bioelectromagnetic therapythat supports the knees. that's like that magnets--copper bracelets, things like that. hang on a minute. don't go there yet. elimination of night shadesor family foods-- that's like potatoes, tomatoes. is it on that last slide?>> yes. >> sorry, my bad.

peppers, eggplant, tobacco. you end up-- oh gosh, what isit-- somehow involves alkaloids and calcium bone loss, and idon't know all the information behind those foods. think about the nutritionalsupplements that you need-- glucosamine and chondroitinif you can tolerate it. there's herbaltherapies and vitamins. if anybody's got any othersuggestions, we'll take it. you can do osteopathicmanipulation to improve range of

motion sometimes. and don't forget yoga. nursing care-- promote comfort,give their drugs, medications, warm mattress pad to keep thejoints more mobile, but be careful that they don'tfall asleep with them. maintain mobility. my mom went to do thewarm water at the ymca. she took classes there. assist with adaptionof lifestyle.

they might need help at home. remember gripper slippers,to keep 'em from slipping? anybody ever watch--i think i told you this. what's the name of that? clint eastwood. "gran torino." where the daughter-in-law walkedin with a big phone and the gripper thing. "this'll make it easierfor you to grab things."

did you see him growl? just like my dad. so they might need help withthat, and they might need a little bit of acceptance andtime to think about, yeah, that's really what they need,other than 20 years too soon for clint eastwood. so our nursing diagnosisincludes chronic pain, right? impaired physical mobility. think about those little oldladies-- "no, let's not go

"shopping at shipshewana," unless you reallywant a wheelchair. my 93-year-old aunt, icannot twist her arm enough. she will not take a wheelchair. she just won't goto certain things. really, she's got the brains toknow that, "i've gotta return "from howeverfar i walk to." some people don'tthink that way. and then, they endup gettin' somewhere

and they can't get back. self-care deficit. you know, do they need along-term care facility, and the coping skills that theyneed to deal with that. onwards to lower back pain. hope you went pottybefore we started. i was hopin' for a break here. low back pain is most oftendue to strain of muscles and tendons of the back caused byabnormal stress or overuse.

you need to rule outdegenerative disc disease and herniated intervertebral disc. you'll find some people call ita slipped disc, a ruptured disc, herniated which is aherniated nucleus pulposus. you'll find that over 90% ofpeople will have complaint of back pain at sometime in their life. pathophys. it varies with the cause. local pain can be caused bycompression or irritation of the

sensory nerve. might be associated withdisc disease or arthritis. just think, as that arthriticjoint increases in size, it might be pinchin' on a nerve, oron space that is needed by the disc, okay? so it's gonna startbulgin' that disc. you can have radicular painwith a herniated disc. what happens with that isthat it pinches that nerve. well, how far doesthat nerve go?

how far does thatnerve innervate? i'm pinching on a nervesomewhere between l4 and l5, and between l5 and s1. what type of thingsdoes that affect? i have to remember to suck in mygut and tuck in my butt, so my toes don't go numb. when somebody has lower backpain, what else is in that part of your body that you gotta payattention to that it can affect? >> (indistinct speaking).>> urinary, and your bowels.

am i gonna be a happy camperif i've gotta wear a diaper? so lower back pain issomething to pay attention to. >> (indistinct speaking).>> yes, kate? >> does radicular painmean that it radiates? >> yeah, it's like, it mayradiate or that's gonna show up somewhere down theline from that nerve. sometimes, i have pain that'llwrap around and go all the way down my leg. sometimes, it's just ifeel numbness in my toe.

>> okay, there you go. it'll show that, okay? you can have itaggravated by movement. could be coughing orsitting, just position. muscle spasm you can have-- thepain can be dull and it can be accompanied by normal posture,if i've got a really bad back spasm, you might see me walkin'like this, or somethin'. you know, thinkabout muscle spasm. it's gonna keep you from,you know, your normal--

i'm not gonna be joggin'in a marathon, right? although they probably do. but i'm talkin'chronic, right? clinical manifestations. mild discomfort tochronic debilitating. there's a box in your book thatgives you some good information on that. you can have alteration in gait,neural involvement, loss of bowel and bladder function,and varying degrees of pain.

your diagnostic tests areconservative treatment for approximately four weeks. they might have youup walkin' around. limit your lifting to lessthan five or ten pounds. don't pick up yourkids or your grandkids. things like that, okay? don't pick up that50-pound bag of dog food. x-rays-- remember,x-rays show bone, not soft-tissuedamage, right?

you could see a compressionfracture, congenital problems. think about how quickly somebodymight tolerate a set of x-rays versus a ct scan they can do inlike five minutes, so they can determine a bony structure. mri is gonna take longer, butit's gonna show soft-tissue injury along with that. the mris take usuallyabout 30 minutes. meds. think about nsaids.

pain clinic for epidural steroidinjections or adjuvant meds are like muscle relaxants. they may or may not help. they'll help with muscle spasm. or like with an acute flare-up. that might help. i avoid 'em becausethey put me to sleep. you try and stay away fromnarcotics unless it's an acute that is just totallydebilitating, because it's

basically aband-aid approach. yes, if it's a trauma, you mightneed it short-term, but i'm talkin' like if i have aflare-up, i'm not gonna take narcotics. if you go in to get a pain shot,'cause you can't move or walk, you know, they might give youa shot and send you home with a six-pack of vicodin. but that's just short-term. it's just a band-aid.

it doesn't fix the problem. it's just a short-term fix. so, ongoing, i'm not gonna takevicodin every day because my toe's going numb. or because i have alittle bit of back pain. there are peoplethat live on vicodin. but how good is that gonna helpwhen that injury flares up even more? they're gonna need that baselinedrug, plus they're gonna need

somethin' stronger, like ifthey fell down some steps or somethin'. conservative treatment. limited rest andearly mobilization. think about somebodywith back pain. they're gonna liedown initially. you're gonna have a low fowler,so your knees are gonna be bent up, maybe a pillowunderneath the knees. remember when you do yourabdominal assessment?

how you had that? you can use the knee gatch onthe hospital bed or throw a pillow under their knees. if they're laying on their side,they might want a pillow between the knees to maintainalignment of the pelvis. because if i'mstretching my trochanter, i'm usually ina lot of pain. you'd have to shoot me to keepme in bed in the hospital. knock me out.

because i'm gonna be that personon that like, every four hours, "give me my drugs." where are we? back pain, knee gatch, okay. application ofheat and ice. thin and flat. you can alternate those, right? no more than 15 minutes ofice or 30 minutes of heat. otherwise, you end up with theopposite effect-- the ice starts

to cause pain, or it'sjust not working as well. physical therapy-- massage,gentle stretching, initially. you're gonna learn tostrengthen those muscles. remember, the core or thearea around the injury. nursing care plans-- acute pain,deficient knowledge, risk for impaired adjustment. how well are they coping withnot being able to run marathons anymore? back pain with a herniated disc.

rupture the cartilagesurrounding the disc with protrusion of thenucleus pulposus. you might have radicular pain,or pain that's, you know, radiating down to another areafrom the back to the leg along that nerve route. matt said we got somepictures coming up. common sites are l4, l5, orc5 and c6 up in your neck. the outer annulus fibrosus andthe inner part of the nucleus pulposus-- you can see thisright here in these stages of

herniation. so you can see,this is degeneration. this can happen over time, itcan be acute, like in a crush think about this thing like adonut-- a jelly donut-- here's your jelly, here's theouter part of the donut. so this can happen over time. you got a little fissurein there, a little crack. but it's starting to bulge,you're gonna start feelin' that pressure on the nerve.

or it can totally herniate orsequestration when you lose that. when it bulges like this,just think whenever it's going outside of its normal spot, youmight end up having pressure on other areas. so that's when you mightstart feeling the pain. l4, l5, you think ofthat sciatic area. and that's what can radiate downand around and down your leg. but if this happens over time,your symptoms can develop

gradually. if this happens abruptly, wherei bent over and boom, i had that instantaneous pressure from myarthritic areas around, just kind of pushed that jelly donut,squished that puppy out, and/or bulged it and gotthat instant-- ugh! and it's acute andit's very painful. if this happens, and you havethat instant compression, because these are your cushionsin between your vertebrae. those are your cushions.

you wanna keep those donutsintact as much as you can. when you bulge it like this overabout a period of three months, 12 weeks or so, this wouldusually kind of dehydrate and then you'll still have this parthere, so you have some cushion left, but that'll dehydrate. but you still have somethingseparating your vertebrae. this is where yourun into trouble. because once that herniates, youusually end up draggin' a leg behind ya.

it's like, "oh, i've got suchacute pain that i can't walk," or, "i got nerveinvolvement to where "i've got mobilityissues now." and they've gotta go in, andthey've gotta fix that right away, because thatcan become permanent. so you have to either relievethe symptoms, or they can become permanent, all right? you don't wanna keep pressureon the nerve long-term. so this is the nucleuspulposus, is your jelly.

you don't wanna lose that. so we'll talk alittle more about it. where do i wannago with that? >> (indistinct speaking).>> is it 56? oh, okay. you can look at this in your owntime, but you can see wherever that nerve is, the differentareas of your body it can impact. this is a and p.

i threw it up there justfor your information. here's your dermatomes. so if you pinch a nerve here,look where it affects. pinch a nerve here,what does it affect? don't forget thatbowel and bladder. gradual herniation. oh, as far asthe herniation. sorry. didn't wanna miss that.

i mentioned that you can doa gradual herniation, right? that's wherei'm at right now. osteoarthritis is a good,nasty reason for that. you have developed a slow onsetof pain and neural deficits, and i showed you that one picture ofthat annulus, where it was-- you see that crack in there? you can have somethinglike this happen over time. and you'll see people like methat will sometimes-- think about a cat that wantsto curve their back.

i'm trying to do that to openthat up, to try and get that pressure off that nerve. so manifestations--lumbar disc. you have recurrent episodesof pain in the lower back with radiation to thebuttocks and the leg. you have pressure on the sciaticnerve, and you have to watch for bladder dysfunction. motor deficits. weakness of various muscles.

you can end up with foot drop,because you end up with that peroneal nerve being involved inthe anterior part of your tibia. you can have sensory deficitsor paresthesias with numbness and tingling. think about a cervical disc. think about where is the areabeing involved, and what does it affect? with your cervical, youcan have pain in your shoulder, arm, neck--

(student sneezes)bless you. neck pain in the shoulder. i said neck pain in theshoulder, arm, neck. paresthesias or abnormalsensations or muscle spasms. so think about what area isbeing affected, and how much can it affect. you know, how bad is thecompression, and how much jelly are ya losin' orbeing protruded? usually, they're gonnado a mri, ct scan.

they might just do a plain x-rayif you've never had one done before, because they wannasee the abnormalities in the bone structure. think about if you'vehad a prior trauma. if you've had plates and screws,reconsider what are they made of, can they have an mri done? non-ferrous metal is okay. or, you know, iron. remove from the body-- make sureif somebody's going in for an

mri, you take allthat jewelry off. external watches, rings,glasses, earrings. think about, do they have stintsor clips involved, if they had a old brain aneurism that wasclipped years ago, what are those clips made out of? fillings, usually in your teethdon't have iron in 'em, so they're usually okay. are the people claustrophobic? can they tolerate it?

do you have to give'em some sedation? there's bigger mris builtfor bigger people nowadays. they might also do an emg, tocheck the electrical activity of the muscles at rest withvoluntary contractions. they wanna know whatmuscles groups are affected. they also mightdo a myelogram. that's where they inject dyeinto the subarachnoid space. medications-- analgesics. painkillers, right?

nsaids, muscle relaxants. most commonly prescribed aregonna be your skelexin, robaxin, flexeril. maybe some valium. mother's little helpers fromthe '50s for anti-anxiety. make sure you do the teachingthat's involved with these drugs. treatment. conservative fortwo to six weeks.

they'll do this approach first. decrease your activity, takeyour drugs, physical therapy, and mild exercises. alternative therapiesinclude acupuncture. those are triggers torelease endorphins. acupressure. that's what there pressure withthe fingers, not needles, right? or massage toimprove blood flow. do we have surgery up there?

laminectomy-- removal of part ofvertebral lamina to relieve the pressure on the nerve enabledto get at the herniated disc. they're actually able to dosome of this stuff out-patient. discectomy, orremoval of the disc. and it's usually removal ofthe herniated nucleus pulposus. you only remove the rupturedportion if you can, 'cause remember that's all you have,that's all the cushion you have. they try not to remove total,otherwise your vertebrae are gonna come right ontop of each other.

decompressive laminectomy is alaminectomy with removal of the arthritic bone spursand additional bone. sometimes requiresa spinal fusion. and they can do thatwith your own autograft, which means "self." and they'll usually take it offthe hip off the crest of your iliac crest. but they'll use-- my aunt marysaid, "they built me a ladder." you know, so they took some boneout of her hip and rebuilt her

spine. and they'll usuallyfuse those spots. you know, it's permanent. you're not asflexible in that area. okay, does thatmake sense? were you gonna saysomethin', matt-- what? >> well, there's also somethingcalled a nucleoplasty. >> nucleoplasty? >> where they actually take aprobe and they go into the disc

and they heat it up, and thatheating up reduces the pressure inside the disc, and sothe bulge can go back in. >> and it's called, again? >> nucleoplasty.>> nucleoplasty. so they stick, like--is it like a-- >> it's like an electrodethat heats up. >> i'm trying to think. is that fiber optic, or-->> nope. it's just a little-->> okay, so you got a probe that

goes right into thenucleus, heats it up. that's interesting. let's boil it for a little bitand decrease it down a little bit, boil it. so they're trying to decreasethe bulge in the disc. very interesting. cool...cool stuff. should've had that done. if they're gonna dodecompressive lami,

they're usually in the hospitalfor two to three days. some of you've cared forpatients with what's called a spondylolisthesis. they have a decompressivelami with a lumbar fusion. those patients aregonna wear a back brace. it's firm in the back,sometimes softer in the front. they're gonna wear itevery time that they're up. for about three months. a lot of times, thesepatients will go to rehab.

and anytime you have-- and itdepends-- make sure you watch your orders. it might be-- any time thatthey're more than 45 degrees, they might haveto have it on. when my aunt had her backsurgery, they had her up out of bed the next dayat age 89 or 90. they had this brace on, andshe was up walkin' around. but make sure thatyou check your orders. can i have 'em up 30 degreeswithout the brace?

if i'm up at 45, and they'reeating, do i have to have the brace on, or is it only when igot 'em sitting at the side of the bed or out of bed? so make sure you look at yourkardexes, and make sure you're givin' the propertreatment for that patient. safer to go through the-- okay,so if you're doing a cervical fusion. before i do that, when thosepeople are like that-- 80, 90 years old-- and they'vegot something that they

have to really watch that typeof stabilization, they usually will go to rehab first. cervical fusions are usuallydone anterially, because there's less chance of causing traumaversus going posterior. and it's more convenient. the disc can be reached withoutdisturbing the spinal cord, the nerves, and the strongmuscles of the back. you wanna avoid cuttin' intothose muscles if you can. the cervical vertebrae aresmaller, and they always fuse it

if they go in. bone for fusion-- cervical cancome from a cadaver which is called allograft. your own bone i mentioned isautograft from the iliac crest. it'll grow cells--say again? >> that's on the next slide.>> okay, let me go to that. losin' my voice, man. cadaver-- allograft. so autograft, you got growthcells and protein, so it'll

obviously heal alittle bit faster. you might hear for an anteriorcervical fusion, also called an acf. the bone does not heal aswell if the patient smokes. sometimes, the surgeon might usea metal plate to support the bone, 'cause it doesn'twanna heal as well. you can see incision oneither side sometimes. just depends onphysician preference. you try to spare the nervesof the voice or your pharynx.

usually home within 24 hours. oh man, i'm almost done. (coughing) we're obviously notgettin' to neuro. no nsaids, 'cause it can causebleeding, interferes with bone healing, and no smoking'cause it delays-- >> i need-- we gottafinish this, guys, 'cause we'reway behind. i'm lookin' for anything.

ha! oh, this is what i-- seei didn't have my coffee. >> do you want a cough drop? >> might take ya upon that in a minute. so are we on nursingdiagnosis yet? >> no.>> next slide. >> you guys can read. acute pain. incisional pain.

think if they've gotextra implants or plates. chronic pain they might haveto be dealing with, 'cause especially when you're lookin'at back surgery, there's no guarantee it's gonna work. constipation. remember, narcotics? lower back pain dueto meds, inactivity. hurts to sit on atoilet seat, even. limited mobility.

especially if they do a fusion,they'll have to wear a brace, but eventually it willget better mobility. my aunt was ableto do just fine. self-care deficit-- especiallyin the elderly, they usually have to go to rehab. difficulty just bendingover to tie shoes. for about three months, there'susually three to six months for healing. immediate post-op lumbar lami.

there's concerns-- you payattention if they've got numbness or tingling, 'cause you might have a problemwith swelling in that area, and it could be a medical emergency,'cause you gotta do something to alleviate that or it'sgonna become permanent. so you watch for numbness andtingling in the feet and legs. cervical, you'relookin' at the hands. you know, just think of whereverit is and below that point. and look up your terms--spondylolisthesis is the bones

in the spine slip on eachother-- most common l4, l5. spondylolysis is a smallfracture in the back spine. you'll see thatcommonly in l5 to s1. that's common in athleteswith hyperextension movements. i see that. fusion arthrodesis. we talked aboutallograft, autograft. and that's all i got to say.